Why Wellness?

By K. Jeffrey Miller, DC, DABCO

Wellness is the hottest buzzword in chiropractic these days. Everyone seems to be talking about it and committed to the principles behind it. At least the chiropractors are talking and committed.

I'm not too sure about the chiropractic patients. Wellness care sounds like a good idea. Unfortunately, I just don't think it is going to work as well as we think.

I realize I will catch a great deal of flack for this opinion. It isn't that I don't want wellness care to work. I just don't think we can overcome all of the obstacles to the idea. I offer the following as the reasons for my opinion.

• A Consumer Union study of gyms and health clubs several years ago revealed that of every 100 people who joined these facilities, 75 never returned after the third week. Only five are still attending by the end of the year. Everyone knows exercise is good for them, but few follow through.
• An ad for a certain exercise machine claims the machine provides a complete workout in only four minutes. Obviously, the machine addresses the common claim by many that they lack the time to exercise. The ad also states that 92 percent of people who own exercise equipment and 88 percent of people who own gym memberships don't exercise. I cannot help but wonder what percentage of people who own this machine exercise, since you only have to use it for four minutes. I also wonder how many people own this machine, as it costs more than $14,000.
• A study conducted by Michigan State University and published in Archives of Internal Medicine, April 2005, looked at "healthy Americans." The criteria for "healthy" was someone who does not smoke, eats right (five or more fruits and vegetables per day), maintains normal body weight and exercises (30 minutes most days). In the end, only 3 percent of Americans qualified as healthy.
• Study after study shows Americans are overweight or obese. In 2000, data from the National Center for Health Statistics showed 63 percent of Americans to be overweight and 31 percent to be obese. The October 2002 issue of the Journal of the America Medical Association also showed the percentage of obese Americans to be 31 percent.
• A study at Boston's Massachusetts General Hospital, published in Radiology in August 2006, related that the quality of X-rays and other diagnostic imaging studies in America has decreased due to patient size. This is significant, considering the advances in imaging technologies in recent years. Technology is not able to adequately compensate for patient body fat.
• A friend of mine was seeing more than 1,300 maintenance patient visits per month when he retired from practice, which is remarkable. But all success is relative. He had more than 14,000 new patients during his career. The 1,300 wellness patients represent only 9 percent of the total number of patients he treated in his career.
• Chiropractors have been trying to get insurance carriers to pay for maintenance care for decades. The wellness movement will push this agenda even harder. The odds of the carriers paying for wellness/maintenance care are slim. Why? Consider the study of "healthy Americans" mentioned above. The study looked at diet, smoking, weight and exercise. It did not look at subluxations. Subluxations and chiropractic care aren't even on everyone's radar. Only chiropractors and a small percentage of chiropractic patients think chiropractic care is necessary for optimum health. As I said above, everyone knows exercise is good for you, but how many people know that adjustments are good for you? And even if they figure it out, as with exercise, how many are going to follow through?
• A lack of insurance coverage, whether it is for acute, chronic or maintenance care, is a major deterrent to patients following through with care. Does wellness have a wallet?
• The vendors selling wellness to the chiropractic profession know their customers. They are selling to people who by virtue of being associated with the chiropractic profession already understand the wellness concept. The vendors are the wholesellers. Their customers (the chiropractors) are, in turn, attempting to resell the concept and materials to a completely different customer, the patients. Patients don't think like chiropractors. Remember the numbers above: 5 percent exercise, 3 percent considered healthy and 9 percent on maintenance? The wholesellers selling to the chiropractors leave the chiropractors with the impression that the patient will love their wares just as much as the chiropractors do, and that the wares will sell themselves. Not true. What motivates chiropractors and what motivates the American public are not the same in the majority of cases.
• The difference in what motivates chiropractic patients and what motivates the American public is a big pitfall for chiropractic students. Students spend their time surrounded by fellow "believers"- professors, other students, administrators, vendors, guest speakers and seminar speakers. Almost everyone they encounter loves chiropractic and wellness. Graduation and the pursuit of private practice suddenly cast the new doctor into the sea of "unbelievers." It can be a rude awakening.
• If asked, the average patient would agree that exercise, eating right, not smoking and maintaining proper body weight are logical and important. Despite their agreement, it does not mean they will take action.
• A television commercial for the osteoporosis medication Boniva has actress Sally Field talking about how a friend of hers is inconvenienced by taking another osteoporosis medication once a week. Sally, of course, is only taking Boniva once a month. The commercial emphasizes Boniva's monthly dosage over the other medications weekly dosage, as though swallowing a single pill once a week is an unbearable hardship. Can you imagine what would happen to the poor dear if she had to exercise, eat right and see the chiropractor once a month? How could she bear it?
• It is not the nature of Americans to exert ourselves if we don't have to. We have become used to thinking that no matter how much we let ourselves go, modern health care will jump in and save us at the last minute. After all, this happens every night on the evening news. The latest medical miracle is always big news and while these news segments are meant to inform, they also give the public a false sense of security.
• Most Americans would rather watch a television program they are not interested in, rather than go to the trouble of getting up to change the channel if the remote control is not handy. Patients who would get up and change the channel are the same 5 percent who are "working out" by changing the channel at the gym.

Wellness sounds good, like the idea of world peace sounds good, but is either realistic? Has chiropractic chosen the hardest row to hoe? Is the hardest row to hoe the best route to increasing chiropractic utilization in America? Must we always take the road less traveled in order to prove ourselves? For a profession that has always swum upstream and struggled for recognition, aren't there easier routes to take?

There are other options. A good one was provided last year by Steve Troyanovich, DC. Dr. Troyanovich's idea was to offer patients a choice between pain-based care and corrective care that leads to maintenance or wellness care. I thought the idea was reasonable. I practiced for more than 17 years and thought the idea would work well for the general population.

I have brought this idea up at seminars as an instructor and it appalled some. They felt it was selling chiropractic short. They felt it is our responsibility to always offer the optimum plan of care. I agree, but Troyanovich's recommendation did not avoid offering the best possible plan of care. It offered the best option and a lesser choice.

Some chiropractors only offer the best possible plan of care (corrective care plus maintenance) and refuse to accept a case if the patient will not agree to that plan. No other options are offered. It is an all-or-nothing deal. They have every right to do this and run their practices the way they choose. But what happens to patients whose life circumstances and/or financial situation will not allow them to follow the optimum plan?

If a patient enters a chiropractic office in pain and can only follow through with relief care, they leave without help or drop out of care as soon as the pain is reduced. In either situation, the patient is not likely to return to that chiropractic office and may not return to chiropractic at all. The patient either leaves mad because the doctor would not help, or leaves feeling guilty and embarrassed because they could not follow through. To soothe these hurt feelings, the patient may perpetuate the old adage, "Once you go to a chiropractor, they just want you go keep going forever."Some will say this is because the patients just don't understand. Those people are absolutely right. But patients are not supposed to understand - they are patients, not chiropractors. The American public is ingrained with allopathic philosophy from their past health care experiences, the news media and countless television medical dramas.

If pain care and wellness care are offered and the patient can only follow through with pain relief, the patient still benefits from chiropractic care. They also feel welcome to return to the practice for additional pain care or wellness care if their situation changes. There is no anger, guilt or embarrassment. How can this be selling chiropractic or the patient short?

The dental profession has been successful in developing a wellness dental mentality in a large portion of the American population. They did this while always offering more than just the optimum plan. They will fix the painful cavity or abscess tooth and recommend straightening, capping, whitening and everything else. If the patient just wants to be out of pain and cannot complete the optimum course of care, they are still treated and invited to return if pain returns, or so they can finish the full plan.

Many in chiropractic hate the idea of pain care. But to most patients, this is one of our strengths. Why not focus on this strength? Wouldn't this be an easier row to hoe?

Back pain and headaches are two of chiropractic's biggest success stories and two of the most common complaints in America each year. Why not pursue these pain syndromes and introduce options initially, as Troyanovich suggests, or introduce wellness as an option after the initial course of care is underway? This second option allows time to educate the patients to the benefits of wellness care without trying to shove it down their throats right off the bat.

In business, this is known as line extension. The customer enters for one product or service and is introduced to other products and services they may want or need, once the initial transaction is underway or complete. They don't have to buy everything in the shop during their first visit.

Wellness overwhelms patients, especially those with poor health habits. A long series of adjustments is a significant change in a patient's life. Throwing in maintenance adjustments, daily supplements, home therapies, exercise and other good ideas is often too much too fast. Americans, like most people, do not handle change as well as they claim. When overwhelmed, people often shut down. Pressuring them to buy into wellness for themselves and everyone they know and love is even more overwhelming.

Wellness is a good idea, and it fits the chiropractic thinking and tradition. Moreover, the statistics listed above show the need for wellness. Unfortunately, it may be the worst choice for our profession when trying to increase utilization by the American public.

I always have been a goal-setter and believe if you are going to set goals, you should set significant ones. I also believe some goals are unrealistic and some fail when their success isn't dependent upon the people who set them, but on other people. Setting goals based on other people changing their beliefs and long-term bad habits is a huge risk. Why not meet the patients where they are and lead them? It may work much easier than trying to thrust more upon them than they are prepared for or want.

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