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General Health - Professional and risk considerations for the nutrition practitioner

By David Balen Cert PFS, MAQ

The business, legal and political landscape facing a newly qualified professional.

I will try not to give you indigestion.  However, should this occur there are, as you know, many good products available to help you! If any of my article causes stress or discomfort, do feel free to discontinue and / or reach for the herbal tea…

We know that the future is never certain and that “protection of the public” or “fairness” is the main driver of so many pieces of legislation, which have emerged over the years. While paternalistic at times and possibly applied with misplaced zeal, disempowering, rather than protecting, the underlying driver is a sound, ethical regard for others and their wellbeing - the creation of a “fairer” society.  There are a number of books available which deal with the legal  

framework affecting Nutrition practitioners in some detail2 and, of course, the web will deliver you megabytes of such information. It is important to understand or refresh your knowledge of this subject, as it underpins everything we all do professionally.

Happily, nutritional practitioners are being perceived more and more by the outside world as valid health professionals. The recent backlash against natural approaches focuses on difference and the need for objective proof in this, far from objective, multi-dimensional universe. In particular, nutritional therapy, homeopathy, chiropractic, and self-care by the public using natural products have come in for attack from the evidence- based fundamentalists1.

There are signs that the various professions are slowly becoming more transparent and accountable. As nutritional therapists continue to progress with integrity and professionalism, much can be - and is being - done to offset public suspicion and cynicism. The natural therapy movement, per se, has routinely presented a somewhat fragmented image to the government and the public, hence the history of attempts to regulate or homogenise the various eclectic and specialist factions. From the various regulatory initiatives, the Complementary Natural Healthcare Council (CNHC) has emerged and it remains to be seen what effect this and other regulators may have in the UK for nutritional therapists. While voluntary self-regulation is laudable in some respects, it can be no substitute for the self-regulation that the individual demonstrates in terms of their professionalism, communication styles and attitudes and behaviour on a day-to-day basis. The claims and complaints markedly increased after chiropractors and osteopaths achieved statutory regulation. One must hope that this will not be replicated if self-regulation gathers momentum.

In my corner of the therapy universe, we deal with a substantial number of therapists of all kinds. We see how events can lead to problems and are shaped by style and communication. I will try to share a little of my experience and advice with you here, to aid self-reflection and, hopefully, to help you to reduce potential complaints, plus how to deal with them if they arise. The well-grounded health professional explores risk, embraces change and is not wrong-footed by it.

The current background, and media and professional attitudes

As insurance specialists, we are intimately involved when things go wrong, but I do not believe that all is doom and gloom. There is much to be positive and grateful about. While there is a much greater public and media acceptance of your work and status, there has inevitably been greater public scrutiny and some backlash. Media articles about medical, health, political or legal issues seem guaranteed to attract public attention and interest. It is a potent mixture. As we know there are “quack busters” and rationalists galore, who get much publicity and support and who, at times, rigidly adhere to a dogma unworthy of the genuine open-minded glories of enquiring science over the last 300 years or so. 

I believe these elements feed via the media into aspects of society where already “consumer is king”, further supported by recent legislation.  Insecurity, scepticism and negativity, materialistic values and diminished self-responsibility or self-care in health have been exposed, examined or exacerbated. In exploring the negative side of society in this way, I could be accused of offering a somewhat simplistic view, but I believe this caustic soup, which has cooked over the last 20 years, fuelled by the blame culture, has produced a much more litigious society and a greater claims culture. This is what we, at Balens, have to deal with on a daily basis.

The “no win-no fee” aspect of the legal profession has made it much easier to sue and has been fed by a sustained marketing campaign inviting people to consider no-cost litigation. Balens have seen complaints and claims rise significantly overall, in frequency and cost, over the last 20 years. While we have managed to drive down malpractice insurance costs over the years (in the early 1990s premiums were typically £150-200 for £500,000 cover!), this is largely because the main bulk of our client-base, including nutritional therapists, has not, historically, had frequent or costly complaints or claims.

Over the last six years we have handled 10 cases, largely notifications not resulting in payments, other than in some instances a return of the client’s fees. These notifications resulted from behaviour or communication issues, lack of trust, dissatisfaction with the advice, some adverse reactions to supplements recommended and disciplinary hearings defence, as well as the occasional, potential allegation of negligent advice. We have heard of a large claim payment previously, involving a death of a client who was on a weight loss programme and being supervised by a nutritional therapist (not insured through us). While the figures overall are encouraging, the premium totals are low, so one large claim can write off years of profit for an insurer and we cannot be complacent - these are not easy times and claims can surface years after the treatment.

The practitioner starting up will need people-handling and communication skills, a professional attitude and willingness to embark on a journey I like to call “Financial Therapy”, to ensure they can run and develop the practice so that it supports them! Any disinclination of therapists to embrace the need to run a successful business is understandable. It is less interesting, liberating or creative than their chosen vocation and can plug into all sorts of personal issues. Having traversed life, initially from being an amateur dropout and musician in the 1960s, then a yoga teacher, and healer in the early 70s, while opting into society and being a businessman for 40 years - I know from experience this stuff, while vital, isn’t always easy! 

When you have a practice, however ethically and idealistically motivated, you are running a business: a vehicle for the exchange of goods and services for (hopefully!) money and, as such, need quality information and a willingness to tackle thorny issues, such as record-keeping, cash flow and regular attention to mundane detail. How you communicate with the outside world (as well as what you say when you talk to yourself) is crucial.

These are still aspects of practice that are not usually prioritised and often sit uncomfortably because they are least understood, interesting or valued. Newly-qualified practitioners, who have never run a business before or who have not been self employed, do have a steep learning curve ahead of them.  Unfortunately, we don’t have space in this article to go into the psychology and practicalities of that little leg of the journey, nor any of the other many business aspects.

Instead I will concentrate on what I feel lies at the all-important core of many of the complaints we see against natural medicine practitioners - good quality communication.           

Communication and the therapeutic relationship

All therapists need good communication and listening skills to build that vital therapeutic relationship. When clients come to see you in pain, when chronically ill or just for general lifestyle advice, they may be worried and anxious about themselves and so their ability to communicate and listen could be impaired. From a therapist’s point of view, we have to be absolutely clear that we have the right information and skills to meet their needs and also that the client is clear about the advice we are planning to give, before during and after the process. Patients will listen to their feelings and what you communicate via the tone of voice. They usually know if you are for them (or think they know) within the first few minutes of the session / contact - so this time is crucial!

Many problems, in our experience, are due to a momentary or sustained period of communication mismatch between the parties concerned, leading, at times, to a lack of trust or a distorted view of each other’s intentions and / or actions. However, some research in the USA showed that medical professionals who had good communication skills and who were more likely to laugh and be funny during the session seemed to get less complaints. The difference was (and is) HOW they talked to their clients! 

Patient dissatisfaction - imagined or real - can lead to a…

- REQUEST FOR A REFUND

- FORMAL COMPLAINT TO YOUR PRACTICE

- COMPLAINT TO YOUR PROFESSIONAL BODY

- COMPLAINT TO YOUR REGULATORY BODY

- LEGAL ACTION FOR REDRESS OR CRIMINAL ACTION, IN EXTREME CASES

A complaint is not a moan but an indication that there may be a threat of taking things further, or that the client wants to get something from the complaint - not always financial in our experience. 

From our experience in many disciplines, we can summarise some of the key potential problem areas as follows:

Here is a list of some key points that you may care to reflect upon or revisit. An audit trail of the communication between you (in brief) needs to be kept in the notes, so that you tell the story in a way which could be comprehensible to someone else (including the patient, who can see them upon request). Insurers need this in order to defend you.

  • Listen well to the client and do not make assumptions.
  • Feedback to client what you have heard and understood, so if you have it wrong they can correct you.
  • Remember the client could well be anxious or have other emotional issues not known to you and, therefore, find difficulty telling their story or giving the complete picture.
  • Explain clearly what it is that you are intending with the treatment, ask them if they understand and what they have understood. Communicate your treatment or advice plan so the client knows what is involved, timescales, costs of products, etc.
  • Do not promise the client a particular outcome or create expectations in order to generate trust or loyalty.
  • Any procedure or technique that carries known risks needs to be explained and consent given, either verbally or otherwise. This may need to be renewed as the treatment cycle progresses.
  • Clients need to know, if new to your therapy, briefly how it works and what may be involved. Record this briefly in your notes.
  • Be respectful and get advice, if necessary, regarding the treatment of clients from different cultures, religions, races. Your behaviour and communication style may need to adapt and be different. You may need a chaperone or translator.
  • How do you deal with difficult patients? They provide us with much food for thought and self reflection.
  • Projection and transference - you are the person who will wave a magic wand and cure them. How do you deal with that and not get caught in being drawn away from your natural approach?
  • The seduction of being complimented can distract you. 
  • The mindset of the client may mean they may not hear the risks, or entertain the fact that it may not work or, indeed, make them feel worse initially. Don’t get caught in their projection, where you become the bad one because you haven’t lived up to their projection or an illusory view of you. Find a way of dealing with clients which protects you from that. Think through a script, which covers all of these eventualities.
  • Open questions are good to keep the dialogue flowing and helping to avoid embarrassing silences. Silences can be very profound, but not all clients feel comfortable with that.   
  • In the event of you finding yourself deviating and behaving differently from normal, then something at an unconscious level is going on - it may mean transference is happening.
  • If you are not sure what psychological patterns or processes such as transference and projection are, then it would pay you to explore these further.
  • Tell us or your adviser at the first intimation of a complaint which feels like it may go further.
  • It is OK to apologise. An apology is no longer considered a tacit admission of liability and can engender goodwill. Many patients / clients, in these situations, want to be heard, want an apology or believe that they don’t want anyone else to have to go through what they did.
  • Failure to notify an insurer can result in claims being refused.
  • Remember the client may have had a bad day, or feel offended or fobbed-off.
  • The client may be rude or unpleasant but maintain goodwill. A client needs to be heard, not argued with.
  • Make sure clients are aware of the complaints procedure.
  • Phone a client if they don’t show up for an appointment to understand why or defuse a situation.
  • Complaining of pain or symptoms worsening is not necessarily a complaint, but if they start to blame you and become negative, it is.

Manage difficult situations as follows:

Don’t panic!  

Dialogue up to a point to maintain goodwill but then tell client you need time to consider further and you will respond. Give them a time frame for this.

Don’t admit liability, or that you are insured, or promise to pay.

When a refund is requested, contact us or your usual advisor for a disclaimer and instructions.

Don’t beat yourself up, as prolonged self-doubt can be corrosive.  None of us are perfect - there is always room for improvement! We can and do make mistakes - learn and move on.

Try to be objective about your styles or habits which could leave you vulnerable to complaints - it can be devastating when a complaint is received and could negatively affect your practice on many levels.

The ideal potion for success (whatever that may mean for you) is to blend a rich therapeutic brew with good business skills, being aware of risk, yet going forward with confidence.

David is an insurance adviser, broker and qualified independent financial adviser, running the largest independent insurance Brokerage for Natural Medicine Professionals and Organisations in the UK and Ireland. He is involved at national level in the healing movement and is a busy Trustee of two healing / education charities and the British Holistic Medical Association. 


Article References

1. For an excellent rebuttal of the evidence-based position see: the British Holistic Medical Association Journal article “The Campaign against CAM: - a reason to be proud” by Harold Walach Volume 6 issue 1 May 2009 ISSN 1743-9493 Complementary Medicine and the Law Stone & Matthews 1996 978-0-19-825971-8 2. An Ethical Framework for Complementary and Alternative Therapists Julie Stone ISBN: 978-0-415-27900-0 (paperback) 978-0-415-27890-4 (hardback) 978-0-203-99398-9 (electronic) See also CAM Library: http://www.cam.nhs.uk/cgi-bin/koha/opac-detail.pl?biblionumber=26&shelfbrowse_itemnumber=25

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