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Dynamic Chiropractic – July 1, 2002, Vol. 20, Issue 14

The Path of Professionalism

By Ronald Feise, DC
Hardly a week goes by when we don't hear about at least one embarrassing chiropractic practice-building gimmick, and about colleagues using unethical marketing ploys to bring in new patients. They use unsubstantiated diagnostic tests to convince patients of the need for treatment, schedule them for more visits than necessary, and use many other schemes motivated solely by financial gain.

Some chiropractors are making their fortunes using spurious marketing practices, while others are struggling using more traditional means. Sadly, the unprofessional and fraudulent marketing ploys of a few practitioners are tainting our profession's image and endangering its future.1 Needless to say, protocols like these can quickly erode our credibility. But professional marketing strategies can also enhance our professional image and simultaneously boost the financial success of our practices.

The Path to Prosperity Can Be Paved with Professionalism

Given this state of affairs, practitioners may feel that they must choose between two paths - the noble road to mediocrity, and the shameful one to riches. However, one need not make such a choice. You can be honorable and successful by aligning your practice protocols with the best evidence of the day and implementing effective professional marketing strategies. In light of the growing demand for chiropractic services, your chances for success in these endeavors are greater than ever before.

Growing Demand and Opportunity

Complaints of neck and back pain represent significant health problems for Western industrialized countries.2-7 The estimated combined annual cost in America for neck and back pain exceeds $100 billion, of which at least one-third is for health care.2-8 Thus, tremendous financial resources are being allocated to spinal conditions. Although the majority of these conditions are still treated by MDs, the tide is beginning to shift.

Over the last two decades, great strides have been made in the public's acceptance of chiropractic. Chiropractic use has increased from about four percent of the U.S. population in 19809 to an estimated 11 percent in 1997,10 and it is expected to increase even further. This progress has been due largely to improvements in the quality and quantity of chiropractic research, and the growing use of professional, ethical marketing strategies.

Health care observers have noted that the chiropractic profession's strength (the treatment of spinal complaints) is the medical profession's weakness. Although researchers have found that most patients who visit chiropractors are seeking treatment for spinal conditions,11 approximately three times as many patients visit medical professionals for such conditions.12 Interestingly, many primary care providers are not interested in treating spinal pain,13 and more than two-thirds of general practitioners say they would be interested in receiving information about chiropractic.14,15 Therefore, our profession is poised at the brink of a tremendous opportunity.

The Need for Collaboration

As the demand for chiropractic increases, so does the need for collaboration with medical providers.15 Although good communication between various health care professionals has been shown to be a consequential variable for maintaining high standards of patient care,16 communication remains lacking between chiropractors and medical doctors.17-19 Chiropractors have been unable or unwilling to communicate with MDs because, frankly, we haven't known what to say or how to say it.

Obviously, we need to narrow the communication gap if we are going to seize the opportunity for collaboration. But our communication must be based upon scientific literature, and it must be made in the context of a planned, professional marketing strategy. One such strategy among the many available to savvy, ethical chiropractors is a medical referral program.

Mastering Collaborative Communication

Although MDs may only occasionally turn to the scientific literature for evidence to support their own established interventions, they are adamant about requiring such evidence for complementary and alternative treatments. This double standard, previously exposed by Cooperstein,20 is probably fueled by the fact that these approaches fall outside of the traditional medical paradigm and, until recently, have had little research supporting their use.

Before we can effectively and credibly communicate with our medical colleagues, we must align our practice protocols with the best available evidence. Doctors who have successfully forged collaborations with MDs are those who:

  1. use a comprehensive case history coupled with specific low-tech, high-touch exam techniques;

  2. utilize a biopsychosocial evaluation, including "yellow flag" screening;

  3. avoid expensive high-tech procedures that often produce numerous false positives and false negatives;

  4. provide treatment schedules driven by reliable and valid outcome measures like the Functional Rating Index;21 and

  5. educate their patients regarding proven lifestyle strategies, including nutrition, exercise and smoking cessation.

Chiropractors armed with scientific knowledge and protocols will be in a position to articulate the benefits of chiropractic in the "language" our medical colleagues understand. Such peer-to-peer communication lays the foundation for initiating a successful medical referral program and for teaching MDs the nature of our paradigms. Although the secrets for implementing such a program can be learned, successful execution depends on conscientious, dedicated effort, and a commitment to professionalism and science.


Not all marketing strategies require chiropractors to abandon our ethics or professionalism. We can be both honorable and financially successful if we align our protocols with the evidence and employ effective professional marketing strategies. Not only will this approach elevate our profession and our practices to new levels of success, but it will benefit our patients!


  1. Keating JC, Hansen DT. Quackery vs. accountability in the marketing of chiropractic. Journal of Manipulative & Physiological Therapeutics 1992;15:459-70.
  2. Borchgrevink GE, Lereim I, Royneland L, Bjorndal A, Haraldseth O. National health insurance consumption and chronic symptoms following mild neck sprain injuries in car collisions. Scand J Soc Med 1996;24:264-71.
  3. Bovim G, Schrader H, Sand T. Neck pain in the general population. Spine 1994;19:1307-9.
  4. Chrubasik S, Junck H, Zappe HA, Stutzke O. A survey on pain complaints and health care utilization in a German population sample. Eur J Anaesthesiol 1998;15:397-408.
  5. Cote P, Cassidy JD, Carroll L. The Saskatchewan Health and Back Pain Survey. The prevalence of neck pain and related disability in Saskatchewan adults. Spine 1998;23:1689-98.
  6. Urwin M, Symmons D, Allison T, Brammah T, Busby H, Roxby M, Simmons A, Williams G. Estimating the burden of musculoskeletal disorders in the community: The comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis 1998;57:649-55.
  7. Waddell,G. Low back pain: A twentieth-century health care enigma. Spine 1996;21:2820-2825.
  8. Frymoyer JW, Durett CT. The economics of spinal disorders. In: Frymoyer JW (ed). The Adult Spine: Principles and Practice, 2nd ed. Philadelphia: Lippincott-Raven 1997:143-50.
  9. Von Kuster T. Chiropractic Health Care: A National Study of Cost of Education, Service, Ntilization, Number of Practicing Doctors of Chiropractic and other Key Policy Issues. Washington, D.C. The Foundation for the Advancement of Chiropractic Tenets and Science, 1980.
  10. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler RC. Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey. JAMA 1998;280:1569-75.
  11. Coulter ID, Hurwitz EL, Adams AH, Genovese BJ, Hays R, Shekelle PG. Patients using chiropractors in north America: Who are they, and why are they in chiropractic care? Spine. 2002;27:291-8.
  12. Media General Chiropractic Survey. Richmond, Virginia, February 2002.
  13. Schers H, Wensing M, Huijsmans Z, van Tulder M, Grol R. Implementation barriers for general practice guidelines on low back pain: A qualitative study. Spine 2001;26:E348-53.
  14. Brussee WJ, Assendelft WJ, Breen AC. Communication between general practioners and chiropractors. J Manipulative Physiol Ther 2001;24:12-6.
  15. Langworthy JM, Birkelid J. General practice and chiropractic in Norway: How well do they communicate and what do GPs want to know? J Manipulative Physiol Ther 2001;24:576-81.
  16. Peters R. Steun voor intercollegiale communicatie [Support for communication between colleagues]. Med Contact 1995;50:746-7.
  17. Jamison J. Chiropractic's functional integration into conventional health care: some implications. J Manipulative Physiol Ther 1987;10:5-10.
  18. Matthews A, Langworthy J. Anticipating Change: An Opinion Survey of the Membership of the British Chiropractic Association in the Year of the Chiropractors Act. Reading, England: British Chiropractic Association; 1996.
  19. Mainous AG, Gill JM, Zoller JS, Wolman MG. Fragmentation of patient care between chiropractors and family physicians. Arch Fam Med 2000;9:446-50.
  20. Cooperstein R. American Back Society Meets in Las Vegas, Part I. Dynamic Chiropractic 1999;17:24,30, 46.
  21. Feise RJ, Menke JM. Functional rating index: A new valid and reliable instrument to measure the magnitude of clinical change in spinal conditions. Spine 2001;26:78-87.

Ronald J. Feise,DC,CEBC
Fort Collins, Colorado

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