Are You a Bagel or a Donut?

Freakonomics, co-authored by University of Chicago economist Steven Levitt and New York Times journalist Stephen Dubner, examines a unique business model. A company delivered bagels (including cream cheese) and donuts to office buildings. They left the food, a price list and a lockbox. An honor system was used to collect payment. At the end of the day, they would come back and collect the money from the lockbox and the leftover food. The company maintained a database of more than 12 years and 75,000 bagel and donut deliveries.

Levitt and Dubner analyzed the data and found that on average, 90 percent of the posted price of the food eaten was paid. The honesty of the people taking the food was surprising, as business analysts who were consulted prior to the company starting this business model predicted that it could not succeed.¹

Another significant study findings was that customers were less honest if more donuts were consumed. Levitt / Dubner suggest that people perceive the price of donuts as less fair than the price of bagels. Thus, they think bagels are of greater value. When people can decide how much to pay for something, the amount they will pay is based on how much value they place upon it.¹

This leads me to ask, are you a bagel or a donut? Do your patients think you are of high value or low value? Likewise, does society as a whole think that we (chiropractors) are high value or low value? How do you see yourself and how do we see our profession?

As we watch office-visit payments from third-party payers creep lower and lower, one might wonder what value the public places on our services and whether that value is as low as the MCOs are willing to pay. If you think, using this analogy, that you are a bagel, but accepting donut fees for service, what message are you sending?

The great Jewish sage Hillel wrote: "If I am not for myself, then who will be for me? And if I am only for myself, then what am I? And if not now, when?" We need to keep our personal welfare in mind, yet one cannot only think of oneself – and in fact, professionalism dictates that we always put the patient first. However, as I've taught my students for years, if you can't make a living in practice, then your patients, who you care so much for, will be left seeing the second-best chiropractor in town. Thus, there is an altruistic element of being able to maintain financially one's practice.

I think the time is now for each of us to reassess our value. This is an issue of self-esteem. I believe that professionally, we have pretty big egos – after all, we are helping ease the suffering of other humans using just our hands, not a drug that took $100 million to develop. However, with those big egos, we don't seem to have the greatest self-esteem.

Low self-esteem manifests within our profession in multiple ways – for example, our penchant for providing definitive answers about the nature of a patient's complaint and what we do. I was recently at a seminar during which a neurosurgeon noted that one of his teachers said to never make a diagnosis (that's definitive); make a hypothesis. We know the evidence is equivocal about the nature of the problem we treat with an adjustment, yet there is very good evidence that our primary intervention can be effective in many conditions. A person with high self-esteem would have no problem stating that fact instead of hiding behind definitive statements that are not supportable in the literature.

I believe that for the sake of our patients, it is critical to ensure that the public sees us as bagels, not donuts. We have to strive to marginalize those members of our profession who, by putting themselves first, give our profession a bad name. Likewise with those whose commitment to the past doesn't let them progress their knowledge and skills to present-day standards. If D.D. Palmer could change his theory about chiropractic three times in his short time with our profession,² we can't sit still and keep espousing theories from a century ago that aren't consistent with the science. To be bagels, we have to make sure our profession is actually highly valuable to be highly valued by all.

References

1. Levitt S, Dubner S. White-collar crime writ small: a case study of bagels, donuts, and the honor system. Am Econ Rev, 2006;96(2):290-4.
2. Keating JC. "D.D. Palmer's Forgotten Theories of Chiropractic." Association for the History of Chiropractic; presentation to CMCC, Feb. 18 , 1995.