The Clothing Question

patientclothingAmid the sweeping plains of Davenport, Iowa, chiropractic pioneer B.J. Palmer insisted on performing his adjustments on the clean slate of a bare back. Though the profession’s philosophy and techniques remain based on the same roots tended by B.J., the trappings of Chiropractic have changed significantly since Palmer’s heyday. Despite a deep well of shared tradition, today’s high-volume practices are a long way from the turn-of-the-century tent clinics where the profession was born.

While wool coats, corsets and intricate undergarments ruled the day in Palmer’s age, modern advancements in fiber construction and indoor climate control have led to more simplified fashions with the development of thinner, more comfortable fabrics. Since loose-fitting cotton blends have grown to dominate modern wardrobes, the spine has become more accessible and there is less need for patients to wear backless gowns during adjustments.

“You have to keep in mind that B.J. was heavily involved in research and teaching, which require examining and displaying just about every part of the back,” says Bob Braile, D.C., owner of Braile Chiropractic in Marietta, Ga. “His work was very different from running a general practice where you see patients you already know. When I was in school, they [required] us to gown everyone, but in practice it’s not really a [necessity].”

Despite some chiropractors’ reservations about incorporating gowns into daily practice, other practitioners prefer the uniformity, familiarity and ease of gowning patients. “It’s always nice if a patient is dressed in loose-fitting clothing,” says Susan Sharkey, D.C., director of LIFE’s Campus Center for Health and Optimum Performance. “I used to gown my patients and suggest they wear gym clothes and a sports bra underneath.”

Sharkey oversees the University’s student clinic, where chiropractors-in-training wear clinic jackets over casual clothes, making them easily identifiable and professional in appearance. “In student clinic, our patients are students and they usually wear whatever they wear to class,” says Sharkey. “But outside the clinic, patients’ dress is really up to the [practicing] chiropractor. Dress code tends to be technique-specific and certain doctors may use instrumentation that requires direct access to the [bare skin over the] spine.”

While most chiropractic students are familiar with adjustment techniques and what to wear during an appointment, adjusting the general public presents an entirely new set of challenges for budding chiropractors. “It really depends on the technique you’re utilizing, but most students are able to palpate the spine without having actual skin-to-skin contact,” says Steven Mirtschink, D.C., director of Life University’s outreach program, where student interns practice their skills on approximately 90,000 patients a year, ranging from the poorly dressed to the well heeled. “The outreach program treats patients with a high complexity of issues, including chronic disease and fractures, who might not receive primary care regularly. Student interns really practice their communication skills to determine how to best work with their patients.” Whenever possible, patients wear their own clothes, since the open-office concept of the outreach clinic is not conducive to the privacy issues associated with several patients wearing open-backed gowns in the same room.

After graduating and setting up their own practices, fledgling chiropractors must determine the kind of practice they want and demonstrate the dress code through their own personal appearance. “Clothing presents a problem when it is distracting, inappropriate or gets in the way of a chiropractor’s ability to do his job,” says Braile. “Long earrings and necklaces and long pieces of cloth like belts and sashes can get caught up in the springs of the table and high heels can puncture the upholstery.”

Phil Librone, D.C., an associate professor in Life University’s Clinical Science Department, says restrictive clothing can also hamper a chiropractor’s ability to diagnose a problem or lessen the effectiveness of an adjustment. “Short skirts present a problem because patients have to bend and lay on the adjustment table and tight jeans make it difficult to palpate and perform certain orthopedic and neurological tests. Chiropractors often watch patients walk and high heels and thick-soled shoes can affect a patient’s gait and make their problems more difficult to diagnose,” says Librone, who advocates that chiropractors set the tone by wearing professional slacks, ties and neutral-colored dress shirts or modest blouses. “Doctors can dress in jeans and a T-shirt if they want, but it may hurt the impression they give off, and a professional dress code sets the standard for patients in the practice.”

Besides the chiropractor and his staff leading by example, socioeconomic factors and regional climate often factor into the patient dress code debate. While Braile experiences few dress code problems at his Marietta-based office, when his practice was located in Florida, patients would often come in from the beach wearing nothing but a T-shirt and a swimsuit.

“My office is located in an upper-middle class area and most of my patients come straight from work wearing nice slacks or jeans and polo shirts,” says Librone. “Sometimes people don’t know what chiropractors do so they dress inappropriately, or they come in from an emergency situation wearing whatever they’ve got on because they’re experiencing extreme pain, and sometimes it’s just the way they dress and they don’t know any better. So I put a gown over the exposed area, or two gowns if I have to. Most people figure it out on their own and they say, ‘Oh, I shouldn’t have worn this.’”

Adjustment Hindrances

While adjusting frequent patients can be done over thin, loose clothing, most chiropractors keep gowns in their offices to perform initial examinations and conduct X-rays. “A chiropractor must first inspect the area of chief complaint,” says Librone. “If patients are experiencing lower back pain, they must lift their [clothing] so the chiropractor can examine the area. If that is not possible to do modestly, then the patient can put on a gown, but the inspection must be conducted skin-to-skin.” While Braile maintains the neck should always be accessible for skin-to-skin contact during an adjustment, he believes chiropractors should consider gowning their patients during initial examinations: “Most offices conduct the initial examination in a private room with the door [cracked] for the purposes of checking things over and talking with patients about health issues that might be private.”

Since most chiropractors perform adjustments over clothing, there is a growing trend toward open adjustment areas in chiropractic offices. “It really depends on the practice, but doctors who have open adjustment areas like their patients to have a shared experience of chiropractic care, and it allows them to educate more than one patient at a time,” says Mirtschink.

Creating Comfort

Despite the camaraderie of an open office, many chiropractors and patients still prefer the confines of a private office. “All of my rooms have doors because I am privy to very personal information and I want that exchange to be done with the utmost privacy and security,” says Librone. “I personally don’t like open offices because each time you sit on an adjusting bench you get an update from the patient—whether they’re feeling better, worse or different. Patients sometimes let you know they can’t make their next appointment because a family member is sick, and no one else needs to hear or observe that. The most important thing is documenting private patient history—that guides everything you do.”

While chiropractors don’t need to perform direct touch during every adjustment, whenever the situation arises—particularly with new patients—good communication is key. “As long as you inform the patient and say ‘I’m going to be examining your upper back,’ it establishes a rapport and lets patients know they always have control over what happens to them,” says Sharkey. “The most important part of Chiropractic is finding and clearing a subluxation, but letting patients know what to expect is an important part of making them feel comfortable and respected.”

To help ease patient apprehension about exposure and direct touch, Librone often lightens the atmosphere by saying, “‘I have a designer gown for you to wear.’” On occasion, “I have had several female patients who felt very uncomfortable with being touched because they were assaulted by men in the past, so I always make sure I have a female assistant in the room and I always tell a patient what I’m going to do, when I’m going to do it and why I’m doing it. If they say stop for any reason, it’s important to listen. If they ask why I’m doing something, I let them know that in order for me to address their problem, I need to see the area where it’s hurting.”

If a chiropractor needs to gown a patient and a patient is hesitant, particularly if their previous chiropractor never gowned them, Mirtschink advocates telling patients, “‘This is just like when you go to a health care provider like a medical doctor.’ As long as you are talking to the patient about their health and lifestyle—topics that show your concern for them—it might take a week or two, but they’ll come around to your way of practicing and respect the order of your office.”

For Braile, who keeps his stash of comfy dress slacks and button-down shirts at his office, chiropractic clothing is a departure from the ragged jeans that typify his ranching and motorcycling lifestyle. “I’m not a clinic jacket guy by any stretch,” he says, “and patient clothing is not a big concern as long as it doesn’t interfere with what I’m doing. My goal is to perform the best adjustment I can, and it is best if I can work interference-free—I don’t want to be thinking about anything else—and that includes clothing.”