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Dynamic Chiropractic – May 23, 1990, Vol. 08, Issue 11

Comments Regarding Practice Management Consultants

By Editorial Staff

Acquiring the knowledge and skills needed to run a practice successfully is certainly a legitimate goal for every chiropractic student. Unfortunately, the tightly packed college curriculum leaves little time to provide adequate and effective practice management instruction.

Also, learning priorities for students facing state board examinations following graduation tend to discourage immediate attention to the business side of chiropractic. Thus a vacuum exists that attracts a variety of consultant types eager to profit from the legitimate need that fledgling DCs have for expert assistance in setting up and operating a sound practice. Most (but not all) of these consultant types appear to work from a base designed exclusively to profit themselves at the expense of the young DC, and even more seriously, at the ultimate expense of the profession and the consumer.

Using tactics bordering on the illegal and patently unethical, some of these consultants woo the future DC with false and illusionary claims, complex and unilateral agreements and then foster a sense of political disaster if one doesn't sign up for their particular program. Naively, many students and recent graduates fall for this line. Tragically, the vast majority who sign with the self-serving consultant soon discover their mistake and seek ways to get out of an onerous contract.

Answers to this problem are difficult to find. Colleges (including LACC) could do more, but would have to extend and reorganize the curriculum to provide really effective practice management experiences. Students could be helped to be more discerning in seeking assistance from field consultants. The profession and its responsible media partners could continue to speak out about the harm that the unethical consultants bring to chiropractic consumers and to the public image that so many doctors of chiropractic work to improve. Chiropractic must be viewed as a responsible profession concerned with quality health care, delivered in a fair and ethical manner. Too many of the practice management consultants destroy that image in their eagerness for profit at the expense of the profession.

Students need help; there is no question about that. But, they need help from ethical, responsible sources that care deeply about chiropractic and the role chiropractic plays in the health care system of society.

E. Maylon Drake, Ed.D.
President of the Los Angeles College of Chiropractic Whittier,

Frankly, I am opposed to students signing contracts with practice management organizations while they are still in school. At the present time, I do not know what percentage of chiropractic students sign such contracts, but my opinion is that they would be better served by finishing their education and either entering into an associateship or opening their own office before they commit to the expenditure of even more money than is already owed, as a result of their student loans.

I have the opportunity to speak with many of my recent graduates, and I am happy to know that certainly a significant number of them have managed to open successful practices without spending the money that is oftentimes apparently required by the practice management organizations. I am still of the old-fashioned belief that genuinely caring for people and their needs results in a return of caring on the part of the patient. Perhaps, doctors who start out this way do not become financially successful as quickly as others, but I remain convinced that they become financially successful in the long view and become highly respected, successful, and stable citizens of their communities.

J. F. Winterstein, D.C.
President, The National College of Chiropractic
Lombard, Illinois

Your specific question relates to students signing contracts with such firms, while still in chiropractic college. While I agree, students are adults and intelligent people and are capable of signing contracts for themselves, they are also at a point of great vulnerability and often make their choices on a relatively limited information base. Like many things in life, the saving caveat emptor -- let the buyer beware -- applies. I fear students sometimes don't know what they are buying, nor what the real cost will be.

Thank you for the opportunity to respond on this issue.

Gerard W. Clum, D.C.
President, Life Chiropractic College-West
San Lorenzo, California

In response to your letter of March 14th, Texas Chiropractic College has a policy of encouraging its students not to sign a contract with any practice management consultant until they have completed their chiropractic education. Futhermore, entrepreneurial activity, "practice management for profit," is not allowed to occur in general assemblies.

Lewis W. Ogle, Ed.D.
President, Texas Chiropractic College
Pasadena, Texas

By the nature of being "students," I would prefer not to see students entering into practice management contracts prior to graduation. Unfortunately, this is occurring and often to students without the business savvy and experience necessary to make an educated decision in this area.

This phenomena is due, in part, to the "evangelical" nature of some of these practice management organizations. Regardless of the success of the efforts of the chiropractic colleges in this area, there will always be students susceptible to these high energy, "fast road to success" sales techniques (and sales techniques are what they are, in spite of their objections).

Unfortunately, practice management firms are, in part, filling a void as yet inadequately filled by formal chiropractic education. While we at New York Chiropractic College have in the past offered some practice management instruction in the 7th and 10th trimesters, it has been difficult to "find more time" in the schedule. But, we are committed to making more time, and our new curriculum offers over 120 hours of instruction in this area, including course work in: Patient Communications, Patient and Office Management, and Small Business Management.

We, at the New York Chiropractic College feel a responsibility to provide our graduates with a solid foundation from which to build their reputations as doctors. We are interested in preparing them not only in the clinical and technical areas, but in the areas of people and patient relations, business and practice management skills, and in discovering how they can better serve their communities.

Kenneth W. Padgett, D.C.
President, New York Chiropractic College
Old Brookville, New York

As educators, we believe that management consultants should assist doctors in providing quality services to the public and maximizing the management skills of the business aspects of the practice. Unfortunately, we see too many consultants emphasize making money. Financial aspects of practice are important, i.e., charging appropriately for service, insurance management and educating patients about cost of services, for example. Ideally, if consultants assist the chiropractor in providing better services, better patient education and better business management, increased income would be a natural by-product.

We do not support the practice of students developing contractual agreements with practice management consultants. Students are not always knowledgeable about the consequences of signing such contracts. This can result in a detrimental experience due to the financial and other long-term obligations. New graduates may find themselves implementing unethical or questionable practices to meet practice consultants' protocol and their own financial indebtedness.

The forces of the marketplace today: increased competition, current third-party reimbursement, and the lack of consensual chiropractic procedure -- are increasing the influence of and need for management consultants.

Attending a few seminars prior to graduation for planning, selection, and starting a practice should not necessitate a long-term contractual arrangement. After graduation, the new doctor can make a more responsible and informed decision for the kinds of additional services he may need in his practice for better serving patients and the community.

At Northwestern, our Business and Practice Management Department provides two courses and requires a project during the last term preceptorship program. These broaden the knowledge base and sharpen the students' business skills. During these courses, students also receive information needed to make an informed decision about management consultants and contracts.

It should be stressed that state associations should provide "new doctor" programs which assist recent graduates in starting their practices. This much needed service to the new doctors would coincidentally reinforce the benefits of state association memberships. It also provides a uniform body for a profession that historically is peopled by "rugged individualists" and not group or hospital practices.

Donald M. Cassata, Ph.D.
President, Northwestern College of Chiropractic
Bloomington, Minnesota

For years I have been concerned about the entrepreneurs within and outside our profession, who market their educational or quasi-educational services to our students. A comparison could be made with this scenario: While John Doe is attending the University of Bora Bora Medical School, the amazing Dr. "X" sends a letter to the student's school address, or his apartment, or floods the campus of Bora Bora with leaflets announcing Dr. "X's" approach to removal of the appendix. The next day, student John Doe receives advertisements from the amazing Dr. "Y" encouraging him to take his seminar on how to manage patients better who have had their appendices removed. Further, to better the management of these cases, they (Dr. "Y's" group) can help the medical doctor to see more patients and make more money; and, after all, isn't that what it's all about -- making money? Does this sound incredible, familiar, or both?

Now, I believe in the great American free enterprise system. If you have a product or service that is valuable to society, you have the right to let the marketplace of society procure it or not procure it. Education, for thousands of years, has survived and prospered in the marketplace. Its vehicle for delivery to the public has been schools. Schools spend millions of dollars to create and maintain a service and the result of that service is called an educated individual. That individual can then go forth with that education, make a more significant contribution to society than he or she may have otherwise. Schools meet rigorous standards of accreditation imposed on them by a society which seeks a quality assurance. Schools that have survived have earned the reputation of maintaining an acceptable level of quality assurance as seen by state and federal governments and society, in general. There is no quality assurance on the product or services of private entrepreneurs -- no accreditation, no millions of dollars spent to buy buildings, hire faculties, pay their salaries and fringe benefits, no accountability for outcomes, and no measure of outcomes on the basis of an examining board. They present a weekend seminar and are not around on Monday morning to answer questions from their students, that may later arise. They are often perceived by students as all-knowing demigods who walk on water and, more importantly, help them to become rich.

Colleges are powerless to prevent their students from attending these seminars. Usually, these attempts succeed in enhancing the image of these entrepreneurs. So these private entrepreneurs are bad guys with nothing of value for students or chiropractors? Not necessarily so. They are sometimes individuals who have valuable contributions to make to chiropractic education. There is an avenue open to those people and it's called the Continuing Education Faculty of a chiropractic educational institution. Courses are evaluated by a committee, approved by the college, and presented by the now faculty member for the institution. They are compensated by the institution, and herein lies one of the deterrents in the mind of an entrepreneur and would-be Continuing Education Faculty member. More money can be made as a private entrepreneur than as a faculty member. Entrepreneurs enjoy that best of two worlds. They enjoy teaching and sometimes have something of value to teach and don't have to live on a faculty salary. Some colleges have opened their arms to entrepreneurs by offering an objective evaluation of their work and compensation agreements that make it attractive for them to join a Continuing Education Faculty. Often, the institution offers options permitting them to retain their "free-agency status" while also working for the school. This is a matter of institutional policy.

Most colleges, however, feel a responsibility to their students to not only advise them as to the credibility of seminar content, but also on the most appropriate timing in their educational sequence for such a course/seminar. Some entrepreneurs do not share this commitment to those who attend their seminars. Whether they are freshmen, sophomores, juniors or seniors -- it doesn't matter. All seminar fees are happily received.

Asking students at any level of their chiropractic education to sign a contract for educational services, to me, is exploitation in its purest form. I have served the profession as an educator for 30 years. I have sadly witnessed the exploitation of my colleagues and our students more so from within our profession than from outside. The well-known philosopher, Pogo, once said, "We have met the enemy and he is us!" As our profession matures, maybe we can get a handle on the exploitation -- maybe. Before we can mature, we must first recognize that the need exists to mature. Colleges need to recognize that weaknesses within their curriculums open doors for entrepreneurs. We need to strengthen the business management aspect of our educational package. Of what value is it to graduate chiropractors with strong clinical skills, but weak in business management? Entrepreneurs need to know that they can become a part of Continuing Education faculties and work with us to better prepare our graduates. They also need to be advised that we, the profession, will not tolerate exploitation or sub-quality course offerings. Students need to know that their schools have an obligation to focus their thinking during education and that we do not take this obligation lightly. And, finally, we are all in this together and will continue to be equal partners in the success or demise of this profession we love.

Donald P. Kern, D.C.
President, Palmer College of Chiropractic
Davenport, Iowa

When I am made aware of students being subtly induced into signing a contractual agreement with a practice management group while they are in the first year of their studies, it causes me great anger and much disappointment in the unethical behavior of these perpetrators.

Most students at that level are too naive to realize how very inappropriate this maneuver is -- certainly not in their best interest.

In their course of study, they will be exposed to practice management, as well as patient management. They will have more opportunities to visit offices, talk with practicing doctors, serve in a preceptorship arrangement, study the pros and cons of different practice management courses offered, etc.

Their clinical and management judgement will be honed to that grade level of expertise; they will be more capable of making informed decisions.

Many graduates wisely decide on a mentor for practice guidance, only after they have started practice -- being very cautious to not compromise their own integrity.

It is a disgrace to our profession to have individuals so willing to take advantage of the unwary.

Beatrice B. Hagen, D.C., F.I.C.C.
President, Logan College of Chiropractic
Chesterfield, Missouri

I feel pretty sure everyone knows, very well, my opinion of this,"10 to 25 percentage of gross income, plus a built-in guarantee whether any consultant produces results or not," is just outside of fraud, and any DC, regardless of how strapped he might be, is next door to insanity to sign one. Most of these huge, spontaneous, unreasonable income increases are based on solicitation and/or overutilization and overcharging; and this has never been a part of the instructions of the Parker School for Professional Success.

James W. Parker, D.C.
Founder and President,
Parker College of Chiropractic

It is the goal of Palmer-West to present a program that fills the needs of our graduates in the important area of practice management. Our present program is much improved over the one earlier offered and we are confident that it will improve even more in the future. There is, however, considerable thoughtful speculation that because of senior year academic, clinical and licensure pressures and requirements, no matter what practice management program is offered in the college environment, students cannot be optimally receptive during this critical time in their education. This may or may not be the case; in any event it remains the responsibility of the college to present the best possible program.

A recent survey of Palmer-West alumni indicated that approximately 18.5%, nearly one in five, of our graduates do associate themselves with practice management organizations at some time after they leave school. This causes one to arrive at the inescapable conclusion that, until such time as the college reaches its goal of providing the ideal program, there is a need for the practice management organization.

With this in mind, several questions present themselves:

  • Exactly what is the need?
  • How is the need now being filled?
  • To the extent the need is being filled, how well is it being filled?
  • Does the means by which the need is now being filled effectively and ethically well serve the chiropractic patient, the chiropractic doctor, and the chiropractic profession?

A comprehensive answer to these and other related questions require analysis and discussion beyond the time and space available here. I do, however, have some thoughts on the matter that hopefully would be constructive rather than add to the tedious parade of public and private colleague and college bashing -- characteristic of our profession.

Chiropractic education in the United States, like many of the educational enterprises in this country, has its origins in the entrepreneurial spirit of the last century. This is a fact and there is no reason not to be proud of it.

Entrepreneurial enterprises, when they prosper, often are abused by the over-zealous and sometimes greedy activities of competitive players. Serious and ethical participants in such entrepreneurial fields have historically sought protection from these abuses by joining together in professional association which espouse high ethical and behavioral standards. Open membership based on adherence to publicized association standards then distinguish members from others not willing or able to meet and/or uphold the standards.

This is precisely the origin of the educational phenomenon know as accreditation. While accreditation had its beginnings in the mid 19th century, it took until 1971 to reach chiropractic education. It was then, and only then, that chiropractic education began the long climb toward membership in the larger community of professional higher education. It may not be a coincidence that this same decade, the 1970s, marked both the advent of a willingness on the part of chiropractic colleges to adhere to commonly agreed upon standards and the beginning of a period of incredible growth in public acceptance of chiropractic care and a similar growth in the number of young people choosing chiropractic as a career. It would seem that high standards may very well be an essential ingredient of success. This brings us back to the subject of practice management organizations.

It appears there is a need for practice management skill enhancement. It also is apparent that there exists significant dissatisfaction and mistrust on the part of many in the profession concerning the strategies and tactics used by some of the practice management programs as they foster the achievement of their definition of that nebulous thing called success. On the other hand, I have talked with a number of leaders of well-known practice management organizations and invariably they profess dedication and support of high and ethical methods. They indicate the bad actions of a small minority who have damaged the reputation of the many. This may very well be the case. If it be true, then the answer seems extremely simple.

Practice management organizations could utilize a time honored American solution. They could form a professional association. If formed, the association should have standards of ethics -- high standards of ethics. Chiropractic patients and chiropractors deserve them. The standards should be created and maintained by broad input and continued oversight from the profession and public at large. The standards should be directed at both the management of ethical and successful practice management organizations and the management of ethical and successful clinical practices. The formation of such an umbrella organization, with publicized standards against which practitioner clients could make judgements about the advice they receive, would go a long way toward building confidence and alleviate existing dissatisfaction, misunderstanding and mistrust. Additionally, it could serve the profession by making available a reliable needed service. Like the almost explosive number of positive benefits that accrued to the profession as a result of chiropractic college accreditation in the 70s, such an organization could assist the profession in taking the high road to success and could have a similar impact on the 90s.

In the meantime, a goal of the colleges must be the continued improvement of programs that increase the ability of graduates to ethically, competently, and, of course, successfully enter practice.

John L. Miller, D.C.
President, Palmer College of Chiropractic-West
Sunnyvale, California

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