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Why chiropractors need to prioritise trust over thrust

Published research has concluded that patient outcomes are better when the therapeutic alliance is stronger [1] [2]. Authors in a range of health care fields have concluded that when an atmosphere of trust is created between the practitioner and the patient, a relationship is established that contributes significantly to the short- and long-term results of care.

Is this really earth-shattering news? Are we to feign surprise to learn that patients do better when they perceive that their health care provider actually cares about them as an individual human being? To those who have spent their careers in clinical practice, these revelations are, of course, anything but. Words matter, demeanour dictates and context counts. Ignore the value of any of these at your peril.

Research that looks into why chiropractic ‘works’ has long focused on the merits of particular techniques or specifics of the manipulative thrust, line of drive and contact point. Often, these elements have been studied in isolation. But while they depend on clinical skills, competency and consistent performance, how much do they actually predict optimal results or , in the wider context, satisfaction with the overall patient experience?

Being proficient is clearly fundamental to being a professional. We must be able to take a full case history, using careful questioning to elicit as much information as is necessary and is relevant to the patient before us. Our examination must be targeted to gathering further clinical information to assist us in ruling in or out our differential diagnoses. We must judiciously decide whether further investigations, such as diagnostic imaging, are justified and appropriate. Our manual care, using finely honed psychomotor skills, must be delivered competently. All of these elements are part of what it is to be a chiropractic professional.

With core competencies for chiropractic education being clearly defined by regulators and accreditation agencies, the public's expectations of chiropractors in terms of the mechanical elements of knowledge and skill are assumed in the same way that expectations of our medical colleagues are assumed.

However, over the past several years a movement has been growing, where expectations of patients and the public are so much greater than has previously been the approach of many aspects of healthcare.

As far back as 1979, Anton Antonovsky, a professor of medical sociology, described salutogenesis as the study of the origins of health and the factors that create, enhance and improve health and well-being, rather than the focus purely on factors that cause disease [3]. He considered health to be a continuously changing variable spectrum, rather than a simple dichotomy of being well or unwell.

This model accords with the World Health Organisation’s definition of health - a compete state of mental, physical and social well-being, not simply the absence of disease and infirmity - and directs us to what the World Federation of Chiropractic and others endorse as the biopsychosocial model of health.

Thankfully, there is now a focus on the biopsychosocial model in health professions generally, not just chiropractic. Holistic models of care look at multidimensional contributors to health: physical, emotional, social, spiritual, intellectual, vocational and environmental. This in turn is connected to consideration of the social determinants of health, where external factors have a significant impact on our sense of well-being.

Clinicians’ frustration with research often centres on study design and the measurement of discrete indicators rather than the reported whole-person experience. This experience materially depends on the relationship built between practitioner and patient, a relationship constructed around listening, empathy, compassion and an unwavering desire to respect individualized needs, preferences, circumstances and culture.

As chiropractors, we should prioritise trust over thrust as we pursue optimum levels of patient satisfaction and physical, mental and social well-being - the very essence of health. This involves active listening, seeking the truly understand the patient before us and arriving at decisions that will ensure the right care, for the right patient at the right time.

Research remains the currency of all health professions, including chiropractic, and we must continue to invest in advancing knowledge if we are to maintain credibility as a respected profession. But let’s not forget what constitutes a great patient experience and how those we serve measure what matters most. If we are to create a network of trust, we must never overlook the patient's perspectives on health and the myriad factors that contribute to well-being. Kindness, care, compassion and empathy must be our bedrocks.


[1] Howgego IM, Yellowlees P, Owen C, Meldrum L, Dark F. The therapeutic alliance: the key to effective patient outcome?A descriptive review of the evidence in community mental health case management. Aus NZ J Psychiatry 2003 Apr; 37(2) 169-683

[2] Lambers NM, Bolton JE. Perceptions of the quality of the therapeutic alliance in chiropractic care in the Netherlands: a cross sectional survey. Chiro Man Therap. 2016 Jun 8; 24:18.

[3] Becker, Craig M.; Glascoff, Mary Alice; Felts, W. Michael. Salutogenesis 30 Years Later: Where Do We Go from here? International Electronic Journal of Health Education, v13 p25-32 2010

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