For the clinician, the first and foremost issue is competence. It begins in our student days with diligent study of the basic and clinical sciences, takes on a more focused and intensive development during our internships, and should continue to progress throughout the practice years. Competence derives partly from the volume of clinical experience we accumulate over time, but it also involves staying abreast of the best information our science has to offer (e.g., JMPT). The doctor whose attitude is, "the spine hasn't changed since I graduated," shortchanges themselves, as well as their patients. The spine hasn't changed, but I can assure you that our understanding of the body, of the way it functions and malfunctions, and of the options available to patients, has grown in innumerable and unpredictable directions since I left my alma mater.
Are you interested in success? Then be mindful that patients have built-in antennae when it comes to clinical competence. Their appraisal of your knowledge and skill either gives them confidence or turns them off. Today's patients are better educated than ever, and can easily jump on the Internet to learn more about any diagnosis or treatment plan they've received. If they enter the DC's office and do not get their questions answered adequately, they will move on. If you're not keeping up with the literature, you risk falling behind in your practice. Unfortunately, the reading habits we did (or didn't) develop during college have led to a great deal of unevenness among clinicians.
The patient's impression of who you are and what you're about starts with the office itself. It is a truism that the first impression is a lasting one. The environment you offer is a reflection of yourself, and if the office is not up to speed, that probably means the doctor is not up to speed. My grandfather, a successful farmer, used to say, "You can tell how successful a farmer is by the way his barnyard looks." His observation was absolutely correct. A fancy office is not essential, but it must be clean, comfortable and efficiently arranged. One of the worst things is out-of-date magazines in the waiting room. I could go on forever about the physical plant, but let's continue.
The patient's initial and continuing impression of the service you offer depends importantly on the staff members you employ. I suspect that more practices have failed because of poor or inadequate staff performance, rather than the doctor's demeanor or practice style. Unfortunately, the typical practitioner has foggy notions, at best, about hiring a staff person. Yet, today's chiropractic assistant (CA) is no longer someone who merely fills a dead-end job - although all too often, practitioners treat them and pay them as such.
With all of the insurance problems the typical office faces today, the CA has become one of the most important parts of the team. The successful doctor will develop the moxy to choose and train assistants who are competent in managing cash flow, as well as patient flow. In light of estimates that as much as 38 percent of the doctor's accounts receivable are never even billed to the patient or the insurance company, the specter of mismanagement is vivid. Are you interested in success? Then you must learn the business side of your practice, and you must thoughtfully hire and supervise those who manage your money.
Now comes the part of this discussion that makes me cringe: ethics. The ethical dimensions of clinical practice cover more terrain than I have space to discuss, but there are a few haunting problems that cry out for review. Most discouraging is the overuse of chiropractic services. I've been in the position of testifying before state senate subcommittees when insurance companies produced evidence of gross overutilization. It is impossible to explain away what 2 percent of the practitioners in the field will not stop doing. Yet, we have gurus out there who actively preach chiropractic-without-end. Yes, there are cases in which extended care is justified based upon periodic review of circumstances, but just as surely, there are patients whose cases need to be closed. Just last month in Arizona, we endured a seminar that taught young practitioners how to manipulate the Mercy Conference clinical practice guidelines1 in order to get 80 office calls from each patient. What a travesty! Such malarkey, intended to wrest big bucks from naïve clinicians, is sure to get the young doctor into trouble in the long run. This is a major issue for the profession and the patients we serve. If we don't step up to the plate and take responsibility for this problem, we should not expect the respect accorded to professionals.
We have another significant ethical dilemma brewing in our discipline. The explosion in health care technology has created a revival of hucksterism that preys upon the young and naïve in our profession, and therefore, upon our patients. New equipment, novel theories and untested techniques proliferate, each with its own promise of remarkably better outcomes or dramatically increased patient flow. Innovation has much to be admired, but innovation without investigation is the scourge of this profession.
My advice to the doctor, whether novice or seasoned clinician, is that you ask one simple question before purchasing any clinical equipment or technique: "Where are the validity studies?" When I spoke at the Parker seminar in Las Vegas a year ago, I voiced my intention to visit the vendor hall to ask for validation papers from the folks selling various diagnostic instruments. Sadly, I found not one who could offer any validity papers from a scholarly journal. In my opinion, manufacturers and vendors have a responsibility to provide hard evidence to back up their claims. And it's not enough that a marketer says some method or apparatus has been "clinically tested." Clinically tested usually means the method has not been scientifically investigated. Meaningful data are found in peer-reviewed journals of chiropractic science. Are you interested in success? Then you must learn your way around the literature, or resign yourself to gullibility and second-class citizenship in your own profession.
Chiropractors are increasingly likely to be called into court to justify their practice methods. As a technique entrepreneur, I know this only too well. Activator Methods, Inc., has repeatedly defended our practitioners, and believe me, both the doctors and our company are mightily pleased to provide rigorous studies to the defense counsel. We've had a slogan at Activator for many years: "Don't let the sales get ahead of the science." I'm also happy to report that several of the chiropractic colleges have recently established "technology assessment committees" to protect their students from this very problem. As well, many of the colleges are re-evaluating their technique curricula, using evidence from peer-reviewed scientific journals where available.
Let me close this sermon by dispelling a myth. In over 40 years as a doctor, I've been through the "cash only" practice in my early years, the "insurance practice" of the 1980s, the "HMO practice" of the 1990s, and now the "managed care" regimens of the new millennium. During each of these times, there have been people who complained about not being able to achieve or sustain a successful practice. I think that's hooey, and my informal survey of the profession suggests to me that if you're going to be successful, you can be successful during any era. It's a matter of character!
- Haldeman S, Chapman-Smith D, Petersen DM (Eds.): Guidelines for Chiropractic Quality Assurance and Practice Parameters. Gaithersburg MD: Aspen, 1993.
Arlan Fuhr, DC
Click here for previous articles by Arlan Fuhr, DC.