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2018 Epiphanies

Exit forum ID Forum Discussion 2018 Epiphanies

This topic contains 5 replies, has 5 voices, and was last updated by   Brandon Cohen DC, CSCS January 7, 2019 at 10:28 pm.

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    Adam Holen D.C.

      Since we’re all on the same journey and the forum is meant to learn from each other, I figured it’d be worth sharing your biggest takeaways, epiphanies, frustrations, or whatever from this past year.

      To have some form of structure to this, I think it’d be cool to categorize them: Diagnosis, Communication, Treatment, and Business.  Ideally, I’d like this to come more from humility because hearing how much you crushed it doesn’t give much of a learning opportunity for the rest of us.  What did you suck at, but now suck less at, essentially? So, for each category, what’s the biggest takeaway, frustration, or epiphany you had in 2018?

      Diagnosis: Make sense of everything first, it will be harder initially, but you’ll be less frustrated in the end and your message will be more honest.  We can’t help everyone directly, but getting them to the right person is just as rewarding when they understand.

      Treatment: Depth is super critical.  Not just being at the right depth, but especially the angle of depth.  Being perpendicular to the tissue makes depth seem much less ‘deep’ and keeps your hands more relaxed.  It’s best to have a mental construct of the tissue (own the anatomy), but in the end, you just have to trust your hands and feel what compresses the quickest.

      Communication: Fuckin smile. Be excited. Patients will only take your lead, so if you aren’t excited about them being there or progress, you can’t expect them to be excited either.  Separate work and personal life.  No matter what happens outside of the office, patient’s are paying for your ‘A’ game, so never let something compromise that by bringing a shitty attitude to work.

      Business: Finally having staff has been great, but training them is no joke.  Front desk staff plays an important role in whether or not people will ultimately decide to trust you with their health.  It’s not easy, but the more they own it, the easier your life will be.  It starts with you tho because like a patient, you can’t expect them to know or appreciate something unless you’ve made it important.


      Anthony Moreno

        Diagnosis– Actually making appropriate time to do it. Meaning, giving myself a minimum amount of time to realistically do an ID examination, ROF, etc… I’ve had situations where steps are cut short because patient takes an hour to fill out paperwork, or is late, or has off track questions, etc… I’ve changed to now only proceed if the step, is accomplished and move forward.

        Treatment– Slow down. Instead of throwing my hands on, have a slower approach to where in a 3min window I do a few passes with more time spent on body position, depth, tension. Even prepping the patient movement or assistants role.

        Communication – I’ve gotten down a rabbit hole a few times by talking too much. My goal is to say as little as possible but be very clear and complete.

        Not discussing $ or topics other than the patients case.

        Business – Have an informed customer contact our office, which I see requires majority of questions answered prior to visit. Only so that when they show up, they’ve already committed. This requires a better website, a trained staff, and firm process’s, which are all in the making.

        I have to learn not to care so deeply. The patient must meet me halfway.


        Christopher Stepien

          Love this Adam. TY for the prompt and reflection.

          Just wanted to acknowledge you first. Was super impressed by your humility and willingness to look at your own weaknesses last Small Group. It made me reflect and ask, “Where am I ignoring my short-comings?” So, thank you.

          Before all of the other stuff, I’m going to add one:

          Mindset: By far, my shift in mindset has made the biggest difference this past year for me.

          I went from:

          • “I still suck” –> “I am the best around” (thanks to the many small groups and seminars I attended, finally being able to trust what I feel.
          • “being frustrated at marketing and not knowing what to do” –> “I’m going to figure this shit out, then doing it.”
          • “I don’t have the energy right now” –> “I’m going to do this right now because my patients (AND I) deserve success.”

          Without the mindset shift, I don’t see how any of the rest would’ve happened.

          Diagnosis: No data points unexamined. I want to own every diagnosis. I don’t always own it, but I make a point each day to reflect on what I don’t know so things stay top of mind.

          Treatment: wax on, wax off – get those reps in.

          Communication: I’ve found that communication doesn’t matter if I know my presence is owning that they have a problem and I have the answer to solve it. Having the humility to say, “I can’t help you” also helps. I like knowing that I’m the type of person that doesn’t take on patients and let them down when they’re not better.

          Business: I’ve become really clear that I can serve way more people than I’m currently serving if I’m making a lot of money. Continuing to discount patients only left me without energy, money, and more patients I could be serving.

          But when I’m a millionaire, I can discount more people and do greater good. So I focus on the bigger picture.


          Michael Vibert

            Thanks Adam this is a great thread,

            Diagnosis: Ive finally figured out properly (I think this time) what reverse compatibility means and how to use it. Every time I review a case that is not going the way I want or thought it would I find that I haven’t conducted a proper and honest audit of the facts. The the cool thing I’m seeing with this is that it automatically teaches you to learn how to take a better, more meaningful history.

            : What haven’t I learnt. My overall feeling with treatment is that it’s like a 1000 piece jigsaw puzzle and each time you do a seminar or a small group, you get 1-5 pieces of the puzzle. The takeaway is that you have to keep training.

            Communication: Not avoiding tough or even mildly uncomfortable conversations. I’ve always had a lot of trepidation around anything that involves talking, persuading, confronting or anything that involves communication. It’s definitely the weakest part of my game. The best thing I’ve learnt this year (I think came from Carl) was that it’s so important to remember the “why” you are doing it in the first place. Because when someone’s health and future happiness is on the line, it’s easier to get out of your own way and just help the person who needs it. It’s been really good for both me and my staff. So thanks Carl.

            : This year I have started actually charging missed appointment/late cancellation fees and it’s great! I really wish I had started sooner. It just makes patients respect my time and their treatment more. Win Win, no downside.

            Mindset: I’ll have to think on this Chris.


            Adam Holen D.C.

              Thanks, Chris and thanks for sharing guys, always nice to get other perspectives to learn something new. Chris, I think your comment would summarize my mindset epiphany for 2018.

              Mindset: “Humble Confidence” – own what you’ve earned so far with your skills (diagnosis, treatment, communication) for the benefit of the patient, but always look inward to what can be done better, no matter how small. I hope the day never comes when there’s nothing (ID skill related) to improve upon because it means learning for a lifetime which is ultimately what makes it so appealing.


              Brandon Cohen DC, CSCS

                I haven’t read any of the other answers, and wanted to get mine out unbiased. I also thought this would happen 3 weeks ago. Alas, fatherhood.

                Diagnosis: Stop looking for problems you can fix. My process was to determine where they had adhesion, and where I could fix it. Stop ignoring things that don’t make sense. In all of my “hard” cases, the making sense of the things that don’t make sense is crucial in getting a complete diagnosis. The better you get at focusing on making sense of each history piece and each exam piece, the less you have to rely on response to treatment.

                Certainly, the diagnosis sheet helps, but just because there’s a (-) on the sheet doesn’t mean you can ignore it.

                Also, get the imaging. Example: Patient with a clear labral tear (and likely some rotator cuff tearing) on history and exam gets treatment (4 visits) and feels better. She still has pain with 100% range. I explain to her each visit that part of her problem is adhesion, and part is the labrum. Getting the imaging made her finally understand this wasn’t a simple thing that will just get fixed. I should have gotten it sooner.

                Treatment: Focus. After the last seminar, I wrote this on the whiteboard in my office. Its a reminder that the best I can be is when I focus on the step I’m on. If I focus on the one thing, I can do it damn well. Focus on 2 minutes to test. Focus on the results of the test. Focus on locating tissue, focus on taking depth, focus on generating tension, etc. That’s what it means to me. On a 6 hour shift, its been thus far impossible for me to be on 100 for the whole time, but I’m getting better.

                I usually catch myself early in the encounter. Not starting at a point of certainty, lazy 2 minutes to test, but when I recognize it, it makes all the difference.

                : Two things. Don’t make value assumptions for patients. It is not your job to figure out if your patient can afford care. If you think a patient needs “2 x 4 weeks to start,” and instead you recommend 1 x 4 weeks because you think they will be able to say yes easier, you are a thief. You are giving a partial solution and thinking you are doing them a favour, but are not. You are setting them up for failure in treatment, and taking their money without providing the best value you can.

                Number two. Progress parties are a big deal. It’s hard for me to have progress parties for myself. I’m not a good celebrator. I used to be the pooper of all parties, as I would spend the whole time wondering why we are celebrating. 3 of the most depressing days of my life were High School Graduation, College Graduation, Chiro School Graduation. People were all like, “High five! We did it.” I was like, “We haven’t done crap, we have to go do something now.” I’m getting better, but I still will have my best month better and not even take a breath before trying to figure out why it wasn’t better.

                So, its especially hard for me to have a progress party when it just feels like I’m doing my job. Now I focus on emphasizing the change in range. “This is great.” and when we move onto a new range taking a beat and celebrating that.

                Also, because I feel it my responsibility to bring Hamilton into this forum as much as possible. As Burr says, “Talk less, smile more.”

                Business: People are lazy. Your staff will slip as far as you let them. I have two separate front office people that work different days. I was trying to remember who I told what to. I now have a communication log that when I give them instruction, they write down, so the other one can see it. It has cut down on that.

                I don’t know what the ideal scenario is though. I currently have one working M-W and the other Th-F. One of which I have trained as a proxy assistant. The thing I like about it is that if someone is sick, or has to go out of town, there is someone who can help out. The thing I dislike is that one of them is not that great and requires much more training and super detailed information before getting things right.

                Concluding thoughts
                : The further I go down the road of ID, the harder it is to remember what it was like before. I continue to gain more certainty in the value of what we provide for people. Being so isolated from other providers, I am the only hope my patients have. When people ask how’s business, I always answer (something I stole from somebody smarter than me at some point, Dr. Brady probably), “There’s no shortage of hurt people.” The reality is that those people are best served by walking through my office doors. I know what I can fix, and what I can’t. I try to communicate reality to those who come in. One last story.

                79-year-old male with left hip pain. It’s clearly super degenerated. ROF: 90% arthritis (no imaging yet) 10% adhesion in the adductor. I told him that I could get him 10-15% better. We got a plain film through his primary care which was worse than I thought. His PCP said, “how many painkillers are you on? Let me know when you want something stronger.” He just takes OTC NSAIDS PRN. We discussed it, he still wanted treatment. This situation we did 4 visits over 2 weeks. Reduced a lot of adhesion, patient reports 25% better. He’s super happy, and we’ve discussed what his next steps are. He’s in really great shape other than the degenerated hip, and we talked about hip replacement. He’s generally inactive and currently is happy with his hip. I know we won’t get any better range, and we’ve moved him to maintenance of his >50% range, and slowly working on him to get an ortho consult (he is very proud of his no surgery record). There was a time in my career (facepalm) that I would hammer away on the capsule trying to get that range better. There was also a time in my career (double facepalm) that I would have referred him out after the history without even palpating because “it wouldn’t make a difference.” The reason’s I am okay with it is that we were able to establish expectations at the beginning, and both of us move forward with an understanding as to what we can accomplish and what we can’t.

                I received a referral from Carl yesterday (Thanks Carl!). She lives 4 hours away from me, and wants to know if there is someone closer. There’s a lot of nice guys between her and me, but I know there’s no better place for her than here. While I want her to have a convenient solution, there’s a reason I travel for treatment. I feel sorry for her, but I can only control what I can control. Our patients are fortunate to live within driving distance of us. Its not arrogance, its just a reflection of reality. At the end of the day, that’s all we need to do.

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