AJCC Jan 2000

Minimization and Maximization

by Mark Radermacher, D.C.

President of Total Practice Management

Excerpts of a recent interview

with Dr. Mark Radermacher:

 Q:    What are minimization and maximization?

A:    A brief explanation of minimization is patients thinking that their health problem is not too serious nor too life impacting. Whereas maximization is patients thinking that their health problem is very serious and very life impacting.

 Q:    Who would want to minimize their health problem?

A:    Most people don’t want to admit to having a health problem; they feel they don’t have time to be inconvenienced by a health problem. Furthermore, most people don’t think they have the money to take care of a health problem. A health problem is seen as discommodius to the extent that minimizing it seems most reasonable.

 Q:    So people pretend they don’t even have a problem?

A:    Not exactly. People minimize their problem instead of ignoring it entirely. The fact that people seek a chiropractor’s advice proves that they are aware of the existence of a health problem. Yet they want to hear that the problem isn’t serious and that it doesn’t require much time or attention. Most patients minimize their health problem to such an extent that a chiropractor could actually be led to believe that the health problem was quite insignificant.

Q:    If the chiropractor was misled, through minimization, he/she might believe the patient’s problem is less serious.

A:       Exactly. When this happens, the chiropractor might sense a lack of desire for care and may subsequently dilute his recommendations for care.

Q:    That could be dangerous for the patients.

A:    Yes it could. If patients minimized their conditions extensively enough to convince the chiropractor to believe them, the recommendations for care and follow through of care might be totally inadequate.

Q:    Do you think patients minimize with medical doctors the same way they do with chiropractors?

A:    Only in some respects. For example, patients usually minimize their problem or condition with all health professionals, this type of minimization seems universal. In contrast, patients minimize in other ways with chiropractors. People don’t think of chiropractic care as mandatory. There usually isn’t a feeling of emergency or life or death situations when entering chiropractic offices. Therefore, many patients will further minimize the situation by taking the attitude of “it’s only a chiropractor, I’m not dying or anything”. Most patients realize that a medical doctor might have some significantly bad news pertaining to their health, whereas, most patients don’t believe a chiropractor would have nearly the equivalent. This attitude further compounds the minimization problem for both patients and chiropractors.

Q:       Patients don’t believe chiropractic care is that essential?

A:    No. There are no chiropractic television series to highlight any drama. There aren’t any chiropractic emergency vehicles or chiropractic first-aid kits. There are no chiropractic emergency rooms or intensive care units; there aren’t even any chiropractic emergency numbers. It’s easy to understand why patients minimize toward the chiropractic profession, they simply don’t understand health or chiropractic and don’t see chiropractic care as mandatory.

Q:    Are there many patients with serious conditions that enter chiropractic offices?

A:    There are very many patients with serious conditions who enter chiropractic offices; however, in many instances, these serious conditions are in developmental stages.

Q:    What do you mean, developmental stages?

A:    People, in general, seem to have a serious misconception that they are either healthy or they’re sick. This is far from the truth. Healthy is defined as 100% of the bodily functions operating 100% of the time. To be totally healthy would be an uncommon moment in time. Sick is on the other end of the spectrum. To be sick is to have at least some bodily system malfunction significantly enough to drop bodily performance which could lead to disease, weaken the host allowing it to succumb to germ infiltration, or die. There are more people in the sick category than in the healthy category. But the largest group of people are in a category most are totally unaware even exists.

Q:    What category is that?

A:    The category of unhealthy. This is the category of developmental stages that often and ultimately lead to sick. Many patients enter chiropractic offices somewhere in the unhealthy category. Due to the fact that they don’t understand or even recognize the unhealthy category, they feel comfortable in justifying the attitude of minimization.

Q:    Do patients feel anything when they’re in the unhealthy category?

A:    Sure they do. On the lighter end of unhealthy, patients often feel fatigue, frustration and/or stress and on the heavier end of the unhealthy spectrum, they often feel symptoms that are indicative of the beginning stages of sick. For example, patients might first feel fatigued and stressed, then they might develop a headache and finally succumb to the flu. On a more serious level,  patients might first feel fatigued and frustrated, then they might experience dizziness and weight loss and finally end up with a type of cancer. The time this staging process can take might be a few months to many years. If more patients realized how often serious health problems, that created sickness, actually begin much earlier as only slightly noticed symptoms in the unhealthy category, they’d minimize much less.

Q:    What would they do?

A:    They would begin to maximize their conditions at all levels. They would maximize and appreciate their healthy category, when they were in it; they would maximize the unhealthy category and try to improve it, and they would maximize the sick category by realizing that it was simply a progression, overtime, that provided warning signs and opportunities. The opportunities could allow patients to get appropriate care that would effect the root of their problem, not just the symptoms.

Q: So if a patient would maximize instead of minimize, their problems would go away?

A:    Not quite. Minimization and maximization are first a state of mind, an attitude, if you would. No appropriate measurable or mechanical steps are necessarily taken because a patient is minimizing or maximizing his condition. Yet minimization often leads to little being done and maximization often leads to much more being done. If a patient is in a state of maximization and receives the appropriate type and duration of care, his body might respond to that care by healing somewhat or entirely.

Q:      Maximizing one’s condition could require quite a bit of time.

A:    More than time, maximization requires understanding, commitment, appropriate care, life style changes and time. A patient must understand his/her condition well enough to realize the effect it currently has or might end up having in his/her day to day life. If his/her symptom is advanced enough, it may currently effect his/her job, his/her relationships, his/her recreational activities or his/her household chores. Any one of these areas effected could have significant life impact. A lighter unhealthy symptom of fatigue could cause a serious accident with a heavy equipment operator or a professional driver, whereas enough fatigue might cost an executive his job because he/she begins to make inadequate decisions; fatigue could demote a secretary because work load could back up. All of these examples would be intensified if any symptom continued to progress. It’s easy to extrapolate with the other life impact areas of relationships, recreational activities and household chores. How many arguments begin because one person has a headache, how many arguments are required for some people to get divorced? How many people compete less well or not at all in golf, tennis or soccer if they have low-back pain? And how many shoulder problems, breathing problems, mid-back pains, neck pains or dizziness symptoms have affected basic household chores like cutting grass, washing windows, cleaning floors or cooking? Maximization certainly requires a significant level of understanding yet most of the understanding is simplistic correlation, that is—correlating a symptom or condition with a specific life impact effect.

Q:    You also mentioned that maximization requires commitment, appropriate care, lifestyle changes and time.

A:    Yes, consider commitment for a moment. Even though many people seem too busy to add one more activity to their unbelievably busy schedules, everything would instantly stop if they’d die. As their conditions progressed and moved them closer to death, their schedules would dramatically be affected. But everything’s relative, that’s why the 50 things a busy 30 year old does everyday makes him/her believe no one could feel busier. Yet the 5 things a busy 70 year old does everyday has him/her convinced he/she’s accomplishing as much as he/she at 30. Neither the 30 year old nor the 70 year old thinks he/she has any time to do anything else. If either develops a health problem, they’d have to maximize their understanding of it to recognize the life impact. Then they’d have to commit to certain things.

Q:    Like what?

A:    Like a type of effective care. They’d have to determine the type of care they’d need and commit to receiving and paying for that care for as long as was required. They’d also have to commit to lifestyle changes that could assist in the regaining of their health and might help to keep them healthier once they’ve regained a level of health. So you can see that maximization requires much more than time.

Q:    Can a chiropractor help his patients understand minimization and maximization?

A:    It is imperative that a chiropractor teach his patients about minimization and maximization. Perhaps the greatest challenge the chiropractor faces are in the areas of integrity and clarity. It would be inappropriate yet very easy to scare patients with life impact information. A chiropractor could exaggerate and intensify a particular life impact point. For example, a chiropractor may make a statement about a 12 year old patient such as “he’ll flunk out of school and become a degenerate if his neck isn’t adjusted today.” If the the child is experiencing mild fatigue, for example, hasn’t missed any school or suffered with grades in any class, this statement might be far too intense. Instead, the chiropractor might explain that the child needs to be adjusted today in order to continue giving his body the opportunity to heal which in turn may allow him to focus better in class and continue his solid grades. In doing so, the parent and the child may realize that getting adjusted today is part of a current and necessary routine allowing the opportunity described a moment ago. The integrity the chiropractor uses can hold the line in not underplaying or overplaying the situation in life impact. Chiropractors should be integritas enough not to alarm patients while being careful enough not to down-play a condition that requires care. There is a fine line that must be walked in order to educate and motivate a patient thereby allowing him to accept the invitation to care with alacrity. Besides the challenge of integrity, the chiropractor also faces the challenge of clarity. It is very important to use words, voice inflection and personality style versatility to the fullest extent. The patient must be communicated to with the utmost of clarity in order to obviate any misunderstanding. The clearer the chiropractor can become, the better the opportunity of understanding for the patient. The more integritas the chiropractor is, the greater the respect and trust in the patient’s eyes.

Q:    Are most chiropractors aware of the fact that the majority of patients minimize their conditions?

A:    Not really. It seems that most chiropractors believe that patients who minimize are people who just don’t care about their health. When a chiropractor hears a patient minimizing but believes, instead, that the patient simply doesn’t care, problems often arise. The chiropractor often gets upset when a patient doesn’t seem to care about his/her health. The chiropractor often makes short, cold and sarcastic statements to the patient. For example, the patient might say something like “the low back pain isn’t that bad, I just put some ice on it and I’m pretty good” the chiropractor mistakingly misses the minimization and hears not caring instead; his/her response might be “if you don’t even care about your serious low back problem, surely don’t expect me to.” The patient’s response is one of confusion and irritation. The patient usually gets a few adjustments, at most, then quits care thinking that the chiropractor was insensitive and uncaring.

Q:    So if the chiropractor doesn’t understand and recognize minimization, he/she can ruin the patient’s opportunity for care?

A:    That’s right. By not understanding or recognizing minimization, the chiropractor can lose the patient and, over time, become very bitter by believing patients just don’t care about their health.

Q:    What do you recommend a chiropractor do to improve his/her understanding of minimization and maximization?

A:    He/she must first realize that when a patient is making comments of minimization, what he/she’s actually doing is crying out for guidance and care. He/she’s scared, he/she hurts, he/she doesn’t want to have a problem and he/she’s completely unaware of what chiropractic really offers. With this realization, a chiropractor is at least in the appropriate frame of mind. If he/she then guides that patient through appropriate questions that reveal life impact, he/she often allows the patient a level of understanding that could lead toward a productive relationship that would provide care to the patient.

Q:    If the chiropractor does his/her job, as you just mentioned, might the patient still refuse care?

A:    Of course, the patient might refuse care, but the chiropractor said what he/she needed to say in a very appropriate manner. He/she then can walk away knowing that he/she did his/her job and the rest is up to the patient.

Q:    If a chiropractor became excited about the information he/she delivered to a patient, wouldn’t that automatically take the patient out of minimization and place them in maximization?

A:    No, rarely. Too many chiropractors try to get their patients excited by talking excitedly. This is a very empty approach because it is often short lived.

Q:    Why?

A:    Once the patient’s symptom is gone, excitement won’t be enough to keep him/her in a care program. Excitement requires quite a bit of energy by the chiropractor which would have been better spent on content. Chiropractors who use excitement instead of content usually have weak and irregular statistics in their practices. Eventually, the chiropractor who attempts to motivate patients with energy and excitement ends up burning out.

Q:      Minimization and maximization are very interesting and very important, are there any additional comments that could help in understanding this concept?

A:    If chiropractors fail to understand and recognize patient minimization, they’ll be frustrated in practice. They’ll be looking for new patient programs or creative billing techniques to solve their frustration problems instead of addressing the actual problem at hand. Minimization and maximization are not too difficult to understand nor are they difficult to rectify through the use of appropriate communications. Like anything else, a chiropractor needs to learn as much as possible about minimization and maximization then he/she needs to practice listening and responding to patients who are minimizing. Once the chiropractor moves the patient from a position of minimization to maximization, he/she must then attempt to maintain the maximization level of understanding. Once maximization fades away, the patient will quit care. Maximation must be used decently in order to allow ample opportunity for the patient’s body to respond to chiropractic care. The chiropractor who succeeds in helping a patient understanding his/her condition and his/her care, at a level of maximization importance, will also succeed in delivering the chiropractic care a patient requires.

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