A patient sits across from you and says yes before you've finished explaining the options. It feels efficient. It might be anything but.
Shared decision making is one of those phrases that has been absorbed into clinical language so thoroughly it risks losing its meaning. In chiropractic practice, patient expectations often arrive pre-formed — shaped by a previous practitioner, a family recommendation, or something watched at midnight on YouTube. The patient wants manipulation. They've always had manipulation. They're here for manipulation. And so the conversation becomes a formality rather than a process.
This matters clinically, not just ethically.
Clinical reasoning that doesn't incorporate the patient's values, preferences, and understanding of their own condition is reasoning conducted in partial information. A thorough orthopaedic and neurological assessment tells you what's happening in the tissues and the joints. It doesn't tell you what the patient is most afraid of, what they need to be able to do by Thursday, or what they tried six months ago that made things worse. That information changes the clinical picture. Without it, even a technically sound treatment plan may be the wrong plan for this person.
When a chiropractor moves from assessment to treatment without surfacing the patient's perspective, they're making assumptions — about what matters, about what success looks like, about what the patient can tolerate or is willing to try. Some of those assumptions will be right. Others won't surface until the patient quietly doesn't rebook.
Good clinical communication here isn't about spending longer with each patient or following a prescribed script. It's about recognising which moments in a consultation carry decision weight and slowing down at those moments. What are the plausible management options, including watchful waiting? What does each option involve and what are its limitations? What's the patient's working understanding of what's happening in their body — and is that understanding accurate enough to support a genuine choice? These aren't administrative questions. They're clinical ones. Answering them well requires the same discipline as reading an X-ray or interpreting a positive Kemp's test.
There's also something worth naming about the power asymmetry in any clinical encounter. Patients often agree because they trust you, not because they've weighed the options and chosen. That trust is valuable. It should be respected — which means it shouldn't be used as a shortcut. A patient who consents because they defer to your authority hasn't shared in the decision. They've handed it to you entirely. That places the full burden of the reasoning on the clinician and leaves the patient with little investment in the process or the outcome.
None of this is an argument against clinical confidence or clear professional guidance. Patients often want to know what you think, and telling them is entirely appropriate. The distinction is between a clinician who says here is what I recommend and why, here is what it cannot do, and what would you like to do — and one who moves forward on the assumption that agreement means understanding. The first is shared decision making. The second is a well-intentioned transaction.
The most durable clinical relationships tend to be built in the space between assessment and treatment. In the moment when the practitioner pauses long enough for the patient to become a participant rather than a recipient.
That pause is not a soft skill. It is part of the reasoning.