Person-centered care is respectful of and responsive to individual patient preferences and needs, ensuring patient values guide all clinical decisions.(1) Person-centeredness principles are core elements of chiropractic care. For example, the American Chiropractic Association’s Code of Ethics includes several tenets consistent with this definition.(2) However, agreeing with person-centered principles may be easier than applying them in practice.
Opportunities or Improvement
Stuber et al., reported results from a study assessing person-centered care in two chiropractic practices in Canada. Person-centeredness was measured using a scale, with higher scores indicating a more person-centered approach. Chiropractic care was rated highest for problem solving and patient activation. In these practices, chiropractic care typically included a multidimensional approach. Both internal and external factors affecting chronic conditions were considered and patients were engaged in therapeutic activities outside the clinical visit.
This study also identified two distinct opportunities for improvement. 1) the practices did not employ systematic goal setting. The absence of standardized processes to ensure patient goals were understood prevented the opportunity to tailor care to meet them. 2) Treatment planning typically consisted of the doctor suggesting an approach, followed by patient consent. This process is perhaps the most common across all health disciplines. However, a more person-centered approach is when treatment options are offered, details about each are explained, and patients are asked about their thoughts and choices.(3)
In a study conducted by Hjerstrand et al., chiropractic patients in Sweden were interviewed about experiences with care. While some participants described care consistent with person-centered principles, some did not. For example, some participants expressed that chiropractors did not offer information to help explain why certain types of care were being used or recommended. This lack of information presented an impediment to shared decision making.
Other participants described chiropractic care that did not address patient preferences. One participant stated: “…At that point they sort of wanted me to keep coming, even though I felt done and I didn’t want to. I felt like I could manage on my own.” This quote brings up several questions such as:
- Did the doctor seek to clarify patient goals?
- Was supporting self-management capacity considered important by the doctor?
- Were treatment options offered?
- Were treatment recommendations explained?
- Were patient thoughts and choices (i.e., preferences and values) discussed?
Given, the application of person-centered care principles can be challenging, a question arises: What resources can practitioners access to support it? Fortunately, there is a body of research literature on the topic.
Five Steps
An article authored by Belton et al., in the journal Chiropractic & Manual Therapies offers unique insight into patient experiences with chronic pain.(4) This publication uses a narrative to describe how a wide range of providers, including chiropractors, failed to listen, reassure, build a positive therapeutic relationship, and validate the experience of chronic pain for a patient. The authors include both educational material for clinicians and practical examples of person-centered care, applicable to chiropractic practice. One highlight of this article includes clear and concise explanations of a five-component process to guide consultations.
Each component is described through the voice of a person with chronic pain. Each description is then followed by brief summaries of evidence explaining why these elements are both person-centered and therapeutic. The article also contains clear recommendations to help practitioners apply them.
For example, recommendations to enhance understanding the history of a problem include:
- Asking open-ended questions.
- Encouraging patients to tell their own story without interruption.
- Confirm your understanding of what matters to patients by repeating and rephrasing.
- Avoid chasing hypotheses while patients are telling their story.
- Allow patients to express emotions, concerns, and problems that go beyond your perceived scope. This doesn’t mean you must address these therapeutically, but they may be key to understanding a problem and moving forward with effective care.
Recommendations to avoid potentially harmful generic reassurance include:
- Avoiding communication that everything will be okay. This kind of reassurance can often generate an effect opposite from what was intended.
- Recognize that stating “nothing is wrong” isn’t reassuring either.
Recommendations to ensure patients are validated include:
- Being explicit about believing patients.
- Acknowledging pain and suffering experienced by patients.
- Communicating that distress is a completely normal reaction to a problem.
The article authored by Belton et al., is short, easy reading, and highly informative for practitioners. It is the type of article I recommend reading entirely, and not just once. As an open access publication, it is available to everyone with an internet connection. The description here is not intended to distill the article into essential points. Rather, to offer enough information to point readers to the full article, which contains important context.
The scientific literature offers several examples of person-centered chiropractic care. There are also numerous examples showing this ideal isn’t universally met. Fortunately, there are resources to help support a process of continual improvement.
Dr. Vining is associate dean of clinical research, as well as a professor, at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic, in Davenport, Iowa.
References
1. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century [Internet]. Washington (DC): National Academies Press (US); 2001 [cited 2022 Apr 5]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK222274/
2. Code of Ethics [Internet]. ACA Today. [cited 2022 Dec 27]. Available from: https://www.acatoday.org/about/code-of-ethics/
3. Stiggelbout AM, Pieterse AH, De Haes JCJM. Shared decision making: Concepts, evidence, and practice. Patient Educ Couns. 2015 Oct;98(10):1172–9.
4. Belton J, Birkinshaw H, Pincus T. Patient-centered consultations for persons with musculoskeletal conditions. Chiropr Man Ther. 2022 Dec 9;30(1):53.
