Articles by JCS
JC Smith, MA, DC
2002 PR AD HOC COMMITTEE
Presented March, 2003
Skeletons in the Chiropractic Closet
When Dr. Daryl Wills appointed me to the new ACA PR AD HOC Committee, I realized it was a daunting challenge that I was thoroughly unprepared to handle—after all, I’m a chiropractor, not a PR professional. After this committee’s one and rather unproductive conference call, it was obvious to me that none of the committee members were prepared to deal with this issue other than to admit the chiropractic profession desperately needs positive PR. I thought to myself this was a task best left to the professionals, but as luck would have it, I serendipitously stumbled across numerous PR reports that were given to me by Dr. Lou Sportelli and Dr. Robert Brooks.
Needless to say, these reports from around the world were eye-openers to say the least, and often very discouraging in some regards—while our patients “love us to death,” the vast majority of non-users remain skeptical, uninformed, biased, and painfully honest in their opinions about chiropractors and our care. Indeed, if there were any skeletons in the chiropractic closet, these reports from Australia, New Zealand, Canada, the USA, Oklahoma and Pennsylvania certainly shined the light of truth upon those in our profession.
After reading the ~700 pages of fascinating public polls and the corresponding advice from professional PR people, this information leads to a few conclusions that I doubt this committee or chiropractors in general will want to hear. Basically, our self-perception is dramatically different from that of many in the public sector—our target market. If we want to expand our market share as well as improve our image, identity, position, and reputation in the healthcare field, we must heed these reports. But, this begs the question: Can we face our skeletons and handle the truth, or will we ignore it all once again?
Before the new ACA embarks on any expensive PR campaign, I believe it’s essential to address the skeletons in our closet before we go to the market place with promotions that fail to address these salient issues—the fears, worries, and concerns of the potential consumers. I urge each of you to read this report of the highlights and lowlights of the public’s perceptions before we meet to discuss any possible PR campaign. We need to admit to ourselves these skeletons remain stumbling blocks to our future success and until they are corrected, any PR will simply be “throwing good money in after bad.”
I believe once we’ve all digested the invaluable insights from these reports, we will be better prepared to develop an effective strategy to implement. This project may be one of the most important efforts the new ACA will ever embark upon, but just as the new ACA has been super successful in changing the minds of Congress, I believe we can do the same to change the negative attitudes in the public. It will take time, money, and effort, and these reports will certainly give us a head start to accomplishing our goal of a larger market share and increased respect by all. We’ve got a great service to offer the world, and now is the time to address these issues forthright, change our course, re-define ourselves, and embark on the 21st century with a new identity, a reformed image, and an equal position at the healthcare table.
As Albert Einstein once said: insanity is doing the same thing repeatedly while expecting a different outcome. With the abysmally low user rate for chiropractic care, if we want to see our market share increase, obviously we must change our strategies, change our methodology, and change our attitudes about our relationship with the consumers and the medical profession. The days of the Don Quixote chiropractor fighting the many medical windmills is over. The enemy is not the AMA as much as it is ourselves. Indeed, chiropractors now more than ever need to think out of the box of old ideas, old marketing, and old self-perceptions.
It’s time NOW to address the problem of PR and chiropractic in realistic terms mentioned in these reports.
Are we up to this challenge? Can we handle the truth?
“I wouldn’t want my daughter to marry one.”
Reader’s Digest Insert
By Jerome F. McAndrews, DC
In the Jan/Feb 2003 edition of ACA Today, Dr. Daryl Wills asks in his column: “What is our message?” The ACA’s focus groups sadly confirmed: “a lack of knowledge regarding the new ACA message…”
Dr. Wills concluded:
“I am convinced that in spite of all we do, say or print, the majority of our profession does not know what a viable, pro-chiropractic, member-driven organization we have in the ACA. It is our responsibility to help the non-members and uninformed to understand why ACA is the organization to represent this profession in the future.”
To add to Dr. Wills’ concern, Mr. George McAndrews might ask: what is our image? Regrettably, the same problem exists with the public’s attitude and chiropractic in general. The following pr reports from Australia, New Zealand, Canada, Oklahoma, Pennsylvania, the Reader’s Digest, and the US mentioned the many misconceptions and problems standing between our professional image and many in the public sector.
Not only do DCs fail to understand the new ACA’s message, but the public generally also fails to understand chiropractic’s message. In fact, I was stunned at what I learned from these PR reports—the misconceptions, the skepticism, and the lack of knowledge by the vast majority of people, especially non-users. Also, many perceptions by the public were painfully honest—those gimmicks some DCs use, the mysticism some DCs profess, the bait-and-switch ads, the over-reaching claims of cure, the assembly line treatments, to name a few of the many problems cited in these reports. If these reports are accurate, our image, identity, reputation, and authority are all at great risk, and although we want to believe it’s getting better, the fact is our market share has not increased since these polls were done, in fact, with managed care our share has actually diminished.
These various studies have repeated the same warnings and suggestions that seem to have gone unnoticed by the chiropractic profession. Despite these obviously important perceptions and attitudes among the consumers from around the western world, it appears that much of it has fallen on deaf ears within the chiropractic profession. Indeed, we seem to go blindly on our way saying the same old things and doing the same practice methods as we ignore the public’s sentiments.
Perhaps chiropractic’s evolution is a stair-step situation where research, judicial, and legislative action had to come first. Hopefully once the current lawsuits are successfully completed, the new ACA will address this huge problem of PR. As you will read in these reports, a good 5-year PR campaign could undo our mistakes of the past 100 years. I was impressed at the recommendations presented, and wondered why little was acted upon by the profession’s leadership. But, as I mentioned, perhaps it’s all evolving slowing but surely.
Just for clarity, let’s define public relations, marketing, and advertising. According to the dictionary,
Remember if it’s an increase in market share we want, we need to appeal to the market we are seeking. The new ACA cannot build a campaign around something that simply will not sell—the “old chiropractic.” "New coke,” regardless of the money invested in that product, would not sell. Chiropractic has been trying to shove its philosophy and what it wants down the throats of the consumer for a century and it is not working! The consumer wants chiropractic but they want it on their terms. That is premise number one.
Regrettably, in the chiropractic profession, there is very little national PR or marketing efforts, and the main advertising effort is left in the hands of individual DCs, for better or worse. Consequently, without a constant positive impression upon the public with a good PR and marketing campaign, chiropractic takes on many different images depending upon who is advertising their particular services, leading to a great deal of confusion. As Forrest Gump may have said, “Chiropractic is like a box of chocolates; you never know what you’ll get.”
It must be made clear that the PR campaign of the future should be developed by a PR firm and not necessarily by the chiropractic profession. Indeed, since not all chiropractors are the same, nor are they selling the same service, selling chiropractic care as a whole is a difficult proposition. We lack collective "cultural authority" which is the underlying problem with the profession as a marketing issue. The various Harris polls which talk about the least trusted individuals and last is the used car salesmen, but right above them is advertising doctors: what does that tell us? Until our authority improves, we’ll remain the New Coke of healthcare. We don’t just need more PR, we need a new flavor!
Obviously the AMA and ADA enjoy high cultural authority and positive images, but neither used any advertising on their own—both had affiliated industries promoting them indirectly via drug and toothpaste ads with the message: “Buy our products and go see your local doctor/dentist.” If chiropractic could do the same, what a bonanza that would be! Nonetheless, these are challenges the new ACA must embrace as soon as possible.
I’ve paraphrased the hundreds of pages into this synopsis for your reading enjoyment. If this PR AD HOC Committee is to do its job, it’s important to learn what our PR predecessors have done—the incredible wealth of material and insight into programs and problems. I daresay I learned more about this profession than I had in 25 years in practice. It was a real eye-opener for me, and hopefully it will be just as impactful for you. Maybe if we finally listen to the consumer, we will hear what they’re telling us.
Dangar Research Group
Overall rating of the image and reputation of chiropractors
On balance, chiropractors emerge with a positive standing today, with 45% of the 18-65 year olds rating the image and reputation of chiropractors in a positive light. This proportion rises to around a half of 18-24 year olds. 15% rate their image as fair, with only 7% rating it in a negative light. Again, 34% don’t feel they know enough to comment.
The image and reputation of chiropractors would appear to be quite solid amongst those who have ever used them. It would seem once again that 18-24 year olds are particularly positive in their view, with close to 4 in 5 of those who have ever been rating their image and reputation as good to very good.
The reasons for such a positive rating center upon 3 key factors:
In addition to this, it is appreciated that chiropractors do represent an alternative—a natural way of treating an underlying cause without having to revert to drugs. 5% go so far as to state that they have complete faith and trust in chiropractors, with 4% also volunteering that chiropractors are beyond the stage of being seen as “quacks,” and that they are genuinely becoming more accepted and more recognized by the general public as “specialists” in their field.
Those who rate the image and reputation of chiropractors as “only fair” are not necessarily negative disposed. On balance, the majority offer some positive or neutral response—once again, the primary reasons for a fair rating centering upon lack of personal familiarity with them, but a recognition of the very good reports they have heard from family, friends, and associates. Where criticism is ventured however, it relates primarily to dissatisfaction with the results received—the very temporary nature of the relief (“it didn’t fix my problem for good”), and a lack of satisfaction with their “performance” (of key concern, a feeling that the chiropractor didn’t diagnose the condition correctly).
Again, it is 45-65 year olds who are more likely to have ventured some criticisms. The small minority who rated chiropractors poorly (28%) did so on the basis of a perception that they did little more than exacerbate the problem (21%), that they generally do more harm than good (11%), had no faith/don’t believe in them (14%), not impressed with the way they crack bones (11%), or are all rip offs (11%).
In total, 28% are likely to use the services of a chiropractor in the future. 25-44 year olds are perhaps the most predisposed towards using chiropractors in the future, with 45-65 year olds being most resistant. 45% of 45-65 year olds are very unlikely to use a chiropractor in the future. Not sure rated 17% overall; total unlikely rated 57% overall.
Back pain (34%) sufferers sought care from:
On Attitudes Toward Chiropractic
This research was intentionally designed as a blueprint for action. There is a clear mandate for change. Both in theory and in practice the goal of this investigation is to enable chiropractic to influence public opinion and alter public behavior toward a more authentic appreciation of chiropractic.
In this manner, the research aimed at the “truth,” not with an upper case “T”, much more modestly, but in a significant way even so. The research sought out the truth, not through describing behavior, but rather through understanding its roots—attitudes, perceptions, emotion, feelings—in short, the psychology that shapes it, or the sociology that influences it.
More specifically, the research design intensified the negatives—the dislikes, dissatisfactions, misinformation, misconceptions, biases, fears—surrounding chiropractic. The positives—the approbation, accomplishment, success—are important. They form the foundation on which to build. But, the negatives are more significant because they define the challenges to be met, the barriers to overcome—the road ahead.
There is a danger in ignoring the positive, granted, and this report will not ignore it; but, there is a danger, too, in accentuating the positive. From the point of view of increasing public awareness, acceptance, and patronage the danger is that instead of accomplishing those objectives, the tendency is to preach to the converted, or talk to yourselves, which is a waste of time.
Of course, chiropractic has both its supporters and is detractors. That is not the issue. The issue is far more profound than popularity. The medical profession—and its business partners—likewise has its supporters and its detractors. But, nobody seriously questions its authority in matters of illness or injury.
The research clearly establishes that the struggle can be summed up in three words: authority—respect—trust.
What forces in society block or prevent those achievements vis-à-vis chiropractic? How to earn them? How to keep them? Those are the quintessential issues the research addresses.
The first year’s activities should include:
Clayton-Davis & Associates
It certainly could be the golden age for chiropractic. As healthcare becomes an “open society,” the consumer will have the freedom of choice he and she deserves under the democratic system, and healthcare will become even more of a commodity subject to competition. These factors certainly show a movement toward a free market in health care. And while there has been talk for years about national health insurance, there are many indications that centralized planning may not work any better in the health arena than it does in the political arena, so that the final plan may be one that is fueled by market economics and consumer preference, rather than pure bureaucracy.
Now that chiropractic seems to be entering a golden age of acceptance, understanding and opportunity, there is a delirium within the profession that is scary. Perhaps it is similar to that following the Russian revolution or maybe that being played today in the news as the ethnic groups of the USSR become intoxicated with the thought of liberty. Chiropractic is on the edge of health care anarchy.
Let’s look at the symptoms:
The question hits home and provokes some deep thought: the triumph of chiropractic—is the profession equal to it?
The topic has not been brought up to criticize chiropractic, undermine its gains or forecast its doom. Rather, it is to present some serious cautions and to again remind the board of governors of the ACA that the ACA is the only mechanism that can control and successfully lead the chiropractic profession to reasonable and honorable goals of health service.
John F. Kennedy said a democracy must be prepared “to pay any price, bear any burden, meet any hardship, support any friend, oppose any foe, to assure the survival and success of liberty.”
If one is to apply the same thinking to chiropractic (and the ACA board of governors should), the ACA must be prepared to do the same. The need for programs that show leadership and give control are even greater now that the gates of opportunity for chiropractic have been opened than it was before when chiropractic was struggling to find a portal of entry. The big threat is no longer the AMA or government; it is not lack of exposure. It is the wrong type of exposure. It is the throngs of chiropractors who are running wildly, stepping on each other and others outside the profession, yelling and screaming with the glee of new-found liberty, but also carrying the bombs of naivety, non-cooperation and greed that could explode in their faces.
The bottom line is that while chiropractic has craved freedom for almost 100 years, and the strides it has made against unbelievable odds have been phenomenal, now that chiropractic is near its goal, chiropractors are not exerting self-control. A new generation of chiropractor doesn’t know what to do with freedom and a freer market.
Whether the ACA bargained for this position or not, it now finds itself as the one and only organization large enough, strong enough and representative enough to lead and control the profession.
Some will resent the word, “control,” but it is all-important, for without control the profession is destined to failure. Even worse, suicide.
Control can be applied in many ways. It need not be strong-arm control. In its best form, it is motivation.
Let’s look at some of the critical points of control so necessary to prevent health anarchy and insure chiropractic’s future:
An association must maintain its fiscal stability, but pr experience also dictates that:
You can’t “try” public relations because it is attractive and turn it off when funds get tight; you have to be sold on it as an essential cost of doing business. It is the on-going cost of marketing the organization, the product, the issue, and the program. It is also the means by which information is disseminated, opinions influenced and support organized.
Dr. G. Edward Pendray, a former editor of the Public Relations Journal offered nine maxims for dealing with public opinion:
This is a plea for ACA leadership to recognize the essentials for success—that without really strong, aggressive, highly creative marketing, the ACA cannot be successful. And if the ACA is not successful, who will be? Who will be there to lead chiropractic, to control and motivate practitioners in the right direction?
The challenge is:
The triumph of chiropractic:
Is the profession equal to it?
This is a communications age. At the base of it is new and quickly changing technology, new attitudes, a more transient society—a whole new generation of idea and opinion development. In health care, it has knocked the physician off his pedestal, opened new and unexplored markets and methods for providing health care, created awareness that is leading to a demand for more information and freedom of choice, forced dialogue of the various disciplines and health managers, and made conduct openly subject to criticism and evaluation. Today, you can’t hide anything—not even skeletons in the closet as so many politicians have learned.
This establishes an environment whereby the institution—any type of institution be it a corporation, association or profession, is subject to failure or success based on its ability to utilize the media. Today, quality of product or service and intent of message is not enough; the institution is decidedly dependent on its ability to control and distribute information. Having that capability gives the institution a unique advantage; not having it makes it impotent.
Most people know communications only from what they surmise it to be by watching television or noticing beautiful four-color ads sponsored by multi-million dollar national corporations in their favorite magazine. This often makes for a strong opinion, but provides little basis for recommending PR solutions to problems.
What the average person doesn’t know and doesn’t understand is what happens behind the scenes—the fact, for example, that for every consumer magazine on the newsstand, there are at least 30 special interest publications; that for every article printed in the newspaper there are at least 50 news releases that will not be printed for lack of space if not for lack of interest; for every broadcast coverage, there are at least 100 attempts at coverage that are turned away.
The average person doesn’t know that it is not so much friendship or cunning, but method that gets the job done: that news and program people are smart skeptics and will not be misled more than once.
We could go one and on describing the naivety and ignorance of most people in our information-driven society. They see the results of advertising, public relations and marketing, but don’t understand what does into it. They see only the tip of the iceberg.
This is a problem which chiropractic suffers. The field practitioner expects too much in terms of “public relations” and too many services out of the ac without being willing to invest in his/her profession and self.
This is why you have so many critics who pop up on the scene, many of them self-proclaimed but ignorant “public relations experts.” Too many of them are entrepreneurs who utilize all the tricks of demagoguery to sell their wares.
It is important that the ACA no succumb to their harassment. And just as important, it is advisable that the ACA not give them a platform for their divisive criticism.
Part of growing up and becoming a responsible organization means having a well-calculated program, supporting it, implementing it fully and not succumbing to destabilizing forces. One of the lessons both the ACA and chiropractic must learn to act, not react.
Central Market Research Associates Limited
Auckland, New Zealand
SUMMARY & IMPLICATIONS
1. Respondents Self-Perceptions of Health Care Needs: For certain types of medical problems, respondents saw themselves as being primarily responsible for decision making. Such medical problems can be characterized as being due to injury, non-critical, stable, e.g. chronic rather than acute and typically related to muscular or skeletal injury. Common examples being backaches, migraines, neck pains, recurring dislocations, torn ligaments and so forth. Although pain and discomfort might result, individuals were able to manage their injuries in terms of retaining control over their everyday lives. By definition, this “fix it” attitude excludes philosophical approaches, such as wellness. Early indicators are that the chiropractic profession must reinforce the ‘mend’ ability of chiropractic treatment and/or provide greater patient understanding if treatment is to be prolonged or unlikely to result in a long-term cure.
2. Need for Identification of Patients Complaint and Options Available: GPs were not felt to be suitably skilled to themselves treat problems of the skeletal or muscular system…those who suffered a recurring complaint were more likely to directly self refer to the perceived appropriate health care professional…Consequently, patients desired to know what type of medical specialist could be appropriate and, within the sector, who was the best within the profession. Individual chiropractors must be provided with and be willing to utilize customer service information intended not only to improve their level of performance, but also enhance overall perceptions of the chiropractic profession.
3. The Perception of Specialists: The term ‘Specialist’ referred to any health care professional who literally had specialized in an area of health care, including chiropractors, PTs, DOs, surgeons and pediatricians. The term tended to be used in reference to health care professionals dealing with injury, rather than sickness. Chiropractors and PTs were firmly perceived as mainstream specialists in the next level of health care after GPs. Chiropractors need to reinforce their existing perception as specialists. This will consolidate their position, and the associated positive perception, as a part of the orthodox medical profession. Specialists are also more likely to receive referrals as part of the mainstream/accepted medical profession.
4. Alternative Medicine: The large majority of patients were more concerned with the correction of specific problems rather than the relationship between mind and body. Therefore, alternative medicine was not generally perceived as addressing a relevant health care. Chiropractic should not try to identify with alternative health. This is not perceived as relevant by the target group to their need and so likely to act as a barrier to seeking referral.
5. Health Care Professionals Respective Roles: GPs referral to DCs: There was a strong perception that GPs often did not refer patients to DCs, preferring PTs instead. This was due to their perceived conservative attitudes and was felt not to reflect the range of treatments options these doctors should be offering. This attitude, including PGs negative comments about DCs, tended to reflect badly on themselves rather than the former, indicating for patients their reluctance to accept the chiropractic concept. The gatekeeper role was due to GPs being expected to identify skilled practitioners for patients, although such advice was taken conditionally. If such recommendations did not prove satisfactory then many patients were likely to seek other forms of treatment without further consultation with their GP. This indicates the limits to the GPs ability as a gatekeeper. GPs must recommend practitioners most likely to successfully treat diagnosed conditions to ensure their own patient loyalty…chiropractors are in a position to clearly inform GPs they are sought by increasing numbers of patients. This will further encourage GPs to provide referral to chiropractors in order to retain patients.
6. The Role of Chiropractors: The area of specialty for chiropractors was clearly that of the spinal column or back. Most individuals considered this to include the area between the waist and the neck inclusive, and more specifically misaligned vertebrae, pinched nerves and non-specific sore backs. Others also included migraines, arthritis and dislocated bones in other parts of the body. A small minority considered chiropractic to be concerned with the state of the nerves running through the spinal column, including the brain.
7. The Perceived Limitations of the Chiropractic Treatment: The majority of respondents perceived chiropractic as suitable to readjust or realign various aspects of the skeletal system. However, it was felt to be limited in its ability to provide a long-term solution to deal with damage through old age and wear. Only a minority of respondents identified chiropractic as capable of providing a long-term solution. The majority of the target market seeks quick ‘fix it’ solutions as the norm, rather than permanent solutions requiring longer-term treatment. Chiropractic treatment must concentrate on changing this attitude by educating patients that long term solutions can be achieved and hat the immediate ‘fix it’ solutions may be only temporary and so ultimately unacceptable.
8. The Role of the PT in Comparison to the DC: There was a widespread perception of PTs having primarily specialized in the treatment of muscles, while DCs primarily specialized in the skeletal system. To counter this impression, chiropractors must promote themselves as specializing in the entire area surrounding an injury, including muscle. This will reinforce the specialist perception of chiropractors and promote referral.
9. Low Recognition of the Term ‘Spinal Adjustment’ and its Implications: For the majority of patients ‘spinal adjustment’ was interchangeable with ‘manipulation’ and both were identified as resettling or aligning vertebrae or bones. The implication of this was that once resetting or aligning had occurred, there was little perception that further treatment could be required to ensure long-term stability. Given the low recognition of the term ‘spinal adjustment’, the term ‘manipulation’ should receive precedence in promotional material as it is already in common usage. This would make the techniques used in chiropractic appear more familiar and so understandable. Consequently, more confidence in the chiropractor can be developed.
10. Chiropractor-Patient Communication: Communication was identified as important, but verbal communications alone appears to be insufficient, so that the use of diagrams and models of the area under treatment was both appreciated and effective. Concern was often expressed at the seemingly short time chiropractors attended patients, especially in comparison to PTs, leading to feelings of poor value and frustration. Consequently, unless chiropractors made the effort to raise issues or possible concern patients tended to remain silent opting instead to terminate treatment.
11. Attitudes Rated as Not Very Important:
12. The Promotion of Chiropractic: In promoting themselves, chiropractors should concentrate on promotion through health education, for example, the protection of backs. This was seen as likely to attract the attention of the target group without appearing unprofessional or ‘pushy.’
Welling & Company did this poll along with the Oklahoma chiropractic research foundation in cooperation with the chiropractic association of Oklahoma in 1984 that surveyed the “attitudes toward chiropractic health care in Oklahoma” by 400 households. The results were interesting to say the least, provoking in what they revealed, and insightful as to what we should be considering in any future PR campaign.
The summary analysis included:
“As might be expected in a survey of this type, there is both good news and bad news for the survey sponsors. As is no surprise, chiropractors tend to be at the lower end of the image scale among many of the professions…but not that far behind osteopathic doctors and attorneys…to many respondents, chiropractors are seen as being fine for many people in the community, but ‘I wouldn’t want my daughter to marry one.’
“Most of the real favorable feeling toward chiropractors is, of course, among those who have experienced chiropractic medicine in the past. Those who have never been to a chiropractor, nor has anyone in their immediate family, tend to hold very negative reactions and opinions toward chiropractors on many of the factors.
“Half of those interviewed admit their knowledge of chiropractic medicine is slight or non-existent and therefore, the opinions they hold, in most cases, are built either on misconceptions or erroneous word-of-mouth. Only 10% feel they have great knowledge of chiropractic, and this is generally based on first-hand experience.
“The most common sources of any knowledge or opinions held about chiropractic tends to be, first of all, friends or relatives (38% cite this as their primary source of knowledge), followed closely by first-hand experience (34% cite this as their primary source of knowledge). A distant third in providing information around which persons form opinions about chiropractic are article or books written on the subject which 11% say forms the basis of their opinions.
“The weakest ratings held regarding chiropractors are seen not only among those which have no experience with chiropractors, but in certain demographic groups. For instance, lower ratings are received from those over 65 years of age than their younger counterparts. As a matter of fact, the younger the respondent, the more favorable he is likely to feel about chiropractors and chiropractic medicine. Those in the highest income group (over $40,000 per year) also tend to hold a lower opinion of chiropractors than do those in the middle-income groups in particular. Along the same lines, men seem to hold a lower opinion of chiropractic than do women…
“The fact that nine out of ten admit they do not have great knowledge of chiropractic medicine is somewhat confirmed by the fact that 40% indicate they have no idea as to how much education is required to become certified as a doctor of chiropractic. 38% indicate that at least four years is required, while 22% assume that less than four years is required.
“Some of the axioms around which chiropractic is structured are firmly believed in, and these are the ones which should be promoted more stringently since they will reach a higher degree of sympathetic belief. A particularly high number (over eight out of ten) agree that:
1. Once nerves are involved, almost anything can go wrong
2. Bones in the spine can pinch or get out of alignment and affect functions
Additionally, a very high number (71% to 75%) also agree that:
1. The spine can easily get out of alignment and affect functions
2. Nerves more than anything regulate function
3. There is an unseen life force that cannot function unless all is in harmony
“The fact that chiropractors are an acceptable part of the health care scene is the number one attitude which is agreed with in a list of eleven offered to respondents. Number two is the fact that most people do not have a good opinion of chiropractic. 71% feel chiropractors probably suffer under a stigma that may not be deserved. However, it should be pointed out here that a certain degree of transference may be inherent in this answer. That is, there may be those who are saying ‘my friends are prejudiced against chiropractors, but I’m not,’ when in fact, that’s not necessarily true.
“The third most agreed with factor is the opinion that chiropractors are highly underestimated regarding their benefit to the community and their patients. 60% hold or agree with this opinion to one extent or another.
“The fourth most agreed with factor overall tends to be the fact that chiropractors will try to perform more of their services than needed. Rounding out the top five is the attitude which is agreed with by nearly six out of ten, to some degree, that most doctors of all types end up treating you far more than is necessary.
“Therefore, of the top five factors or statements of attitude which were offered respondents, three of the top five tend not to be favorable toward chiropractors. These top five tend to stand out somewhat above the others on the list. Overall, of the eleven factors, only four tend to be agreed with by a majority of the respondents. However, some were presented in a negative posture and therefore, disagreement with them may in fact be favorable to chiropractors.
Favorable to chiropractors % who agree
DCs are an acceptable part of health care 86%
DCs’ benefit is highly underestimated 60%
MDs and DOs do a lot which could be done better by DCs 33%
DCs often cause more harm than good 25%
DCs are okay for some but not for me 34%
Anything a DC does, a MD can do better 22%
Visiting a dc is not socially acceptable 15%
Unfavorable % who agree
Most people do not have a good opinion of DCs 71%
DCs will try to perform more than is needed 45%
Most DCs try to treat problems they aren’t qualified for 39%
“Overall then, how is the chiropractor seen by the public? 72% feel the chiropractor is rightfully a spinal or structural specialist. Therefore, indication with this particular label will be one which is believable and is consistent also with earlier findings which show that a significant number agree that certain problems can be caused by improper alignment or spinal, structural and nerve problems.
“Only 52%, on the other hand, feel that a chiropractor is the best place to go initially for a sore back or stiff neck. Apparently, many see a chiropractor as a secondary source after visiting their MD or do if they see chiropractic as a source at all. Unfortunately, chiropractors are not seen as the first place to go with pain in general. Only 19% indicate they would think of visiting a chiropractor first regarding any pain or suspected illness.
“Along these same lines, then, to what extent are misconceptions held about chiropractors? Between 26% and 40% of the respondents tend to hold certain misconceptions about chiropractic medicine and these are the ones that probably should be addressed first in educational material.
1. DCs are expensive to visit (40%)
2. Once you start visiting a DC, you have to continue (39%)
3. DCs tend to fall short in the area of diagnosis (37%)
4. Visiting a DC is not covered by most medical insurance (30%)
5. Visiting a DC can be painful (26%)
“Nearly half indicate they would be more likely to visit a DC if the first visit were free. This appears to be an area of potential for developing new contacts for chiropractors. However, it should be pointed out here that if the public perceives that the first visit is simply a way to hook patients into some sort of a continuing program, then the first free examination will lose credibility. Therefore, before strongly pushing the free visit, it is recommended that the chiropractic association of Oklahoma or individual doctors first educate the public in the area of the continual visit or habitual visit syndrome, as well as the area of diagnostic capability of chiropractors. Once the public tends to have confidence in these two areas, then the effectiveness and impact of a free examination or initial free visit will be much more favorable.
“The impact of this 45% is particularly strong in view of the fact that only 59% of those interviewed have never been to a chiropractor. Therefore, assuming that most of those who said they would like their first visit to be free is represented by those who have never been, then over three-fourths of those who have never been to a chiropractor indicate they would be fairly strongly influenced by a possibility of a free visit or examination.
“Overall, 42% have virtually no experience with chiropractic in that neither they, themselves, nor anyone in their family has been to a chiropractor. Of all those who have been chiropractic patients, 41% indicate they make or made regular visits to their chiropractor, while 59% indicate they go to the chiropractor only when they have pain which they feel the chiropractor can address. The most prominent reason for the most current visit to their chiropractor dealt primarily with back pain, as might be expected. Nearly six out of ten who have been to a chiropractor recently indicated that back pain was the main reason, while neck pain or stiff neck was distant second at 16%. 5% indicated they went because of a headache, while 18% had various other pains which led them to seek relief from a chiropractor.
“As indicated earlier, the most significant factor dealing with selection of a chiropractor stems from recommendations by friends or relatives. 43% say the reason they first selected a chiropractor to visit rather than some other potential source was because a friend, acquaintance or relative had strongly recommended a chiropractor. A distant second in this reasoning is ‘general knowledge’ which was mentioned by 17%. 14% said their doctor recommended a chiropractor and therefore they visited one, while 10% simply said they had exhausted all other methods and turned to chiropractic as a last resort. Only small numbers indicated they visited a chiropractor in the first place because of personal acquaintance with a dc or because of advertising.
“On the other hand, when asked why they selected a particular chiropractor over others, again, the recommendation of a friend, acquaintance or relative was the strongest factor by far, with 58% pointing to that reason. 9% said they were personally acquainted with a chiropractor that they first visited, while 9% said the location of the chiropractor’s office contributed to their selection. 4% said advertising influenced them in their selection.”
Although some may discount this 1984 poll as outdated, I daresay it may not be invalid since painfully little in public relations has occurred in the meantime to change the public’s perception. Despite the recent research that shows chiropractic’s effectiveness with low back pain (AHCPR, Manga, Meade) and headache (Duke, Nilsson, Nelson), our profession has done very little to promote these endorsements—missed opportunities of huge proportions.
Although years ago the ACA under the supervision of Ira Davis created many forms of pr and advertising for its members, this effort waned and has been supplanted by individual advertising, much of which focused on the free spinal exam bait-and-switch procedures that this poll warned against doing. The lack of a nationwide TV pr program has certainly kept our status alive as the mystery science profession. Hopefully once the legal action effort is successfully done, we can turn our attention and monies toward a massive pr campaign.
Of greatest interest to me was the fact that only 4% of respondents said advertising influences their selection of a DC, while 58% were referred. As Dr. Nimmo once said, “the preferred patient is the referred patient,” and this poll verifies that point. The fact that 59% of current patients sought chiropractic care only after a relapse occurs indicated the conflict between continued maintenance care that may resemble over-utilization to them versus preventative care that the other 41% of current patients actually utilized.
Another interesting point was regarding diagnosis and scope issues—37% felt DCs did a bad job at diagnosis and 39% felt some DCs treated outside their scope. Of course, when one DC does a bad job in this regard, all are tainted. For example, on CJ Mertz’ videotape, he listed numerous conditions supposedly helped by chiropractic care, including pimples, that are simply unfounded. Mertz’ logic, as with many chirovangelists, are based on ol’ time chirovangelist axioms that “the power that made the body, heals the body,” and “the body needs no help, just no interference,” so one can assume “a body without nerve interference works better than one with nerve interference.” Fine, but where’s the actual proof?
Since the nerve system controls all function in the body, they believe, and nerve interference due to VSC is the culprit that interferes with the transmission of innate intelligence in the body, then chiropractic’s potential effectiveness is as vast as the nerve system itself. This belief system, while remotely plausible, is simply unproven and a rather simplistic extrapolation of the one cause-one correction-one cure notion. Realistically, in the many years of supposed research done at the BJ Palmer Research Clinic and the Sid E. Williams Research Clinic, neither was able to prove any of these claims.
“Improved homeostasis and resistance to dis-ease” are claimed, but without any proof that, in fact, a subluxation reduces homeostasis or innate resistance to disease. While it does sound nice, there’s just no proof, and as long as we spout unproven hyperbole, many rational prospective new patients will seek care elsewhere. Perhaps this is one big reason why the NACM has found a foothold in the media since its members are unwilling to recite the hyperbole associated with too many chirovangelists? If the ACA PR campaign is to succeed, it must appear the rational voice in chiropractic by disassociating itself with unproven claims. Besides, there's a huge market in this epidemic of back pain that's just waiting for us to help--why try to convince the public that chiropractic is a cure-all when most are already sold that we can help with NMS disorders? It's simply dumb marketing to sell chiropractic as a cure for pimples when most already believe we can help with LBP and neck problems.
After viewing Mertz’ and brooks’ videos, I asked the audience of DCs just where do we draw the line in terms of gaining credibility with the public? Obviously as long as TV infomercials like Mertz’s make all DCs appear as snake oil salesmen who blare out unproven claims and “$200 exams for only $35,” the public will continue to hold all DCs in low regard.
It’s been my contention that aside from political unity, this profession also needs a Reform platform—to admit some of our members have been over the top in terms of realistic claims, some have preached chirovangelism, and some former leaders have been among the "5% who are cultists and 5% who are freaks," as George McAndrews once mentioned.
With our hat in hand and with a contrite attitude, if our present leaders were to approach the media with this admission and pledge to follow a narrower code of ethics to stay within evidence-based guidelines for NMS conditions that we help so well, I believe the public and press would embrace us unlike ever before. If Richard Nixon and now possibly Pete Rose can apologize in order to be embraced again by the American public, why shouldn’t we chiropractors admit the errors of our past ways and do the same?
Indeed, just where do we draw the line to gain acceptance?
Just where do we draw the line on ethical behavior in order to regain credibility? This 1984 poll indicates the areas (diagnosis, treating outside our scope, free exams) that remain urgent today to improve although little has been done to ameliorate these public perceptions. If insanity is doing the same thing while expecting different results, than we certainly should be criticized for not thinking out of the box of old ideas of professional conduct.
Many newer DCs in the profession may not know the challenge by CO Watkins, DC: "let's be bold in what we hypothesize and cautious in what we claim." Regrettably, many chirovangelists like Big $id, Wrongberg, and CJ Mertz are beyond bold in what they hypothesize and egregious in what they claim—they’re simply far-out! Their hyperbole is more than enuf to invalidate what we can reasonably claim (“pimples”), which only acts to convince prospective patients that we still cannot be believed or trusted. Just where do we draw the line, or will chiropractic continue to be a belief system based on chirovangelist faith instead of clinical science/research?
Added to this hyperbole of overstatement, those “principled” straight chiropractors who refuse to diagnose anything but the VSC pose a potential danger to the public’s welfare, which certainly becomes another blow to our image and respectability, as indicated by 37% of the Oklahomans who think that DCs were short on diagnosis.
I would recommend that every state association in the ACA do a similar poll of 400 households to determine what attitudes still exist today. I imagine we’ll find the same perceptions exist since little has been done on a pr level to change the existing misconceptions. And we may find some negative attitudes are well based in actual unethical actions that give good reason to be skeptical of chiropractic. In other words, the public may not be wrong in its perceptions of chiropractic, but we may be ignorant to accept these perceptions as reality. As long as many respondents believe chiropractic may be fine for others, but "I wouldn't want my daughter to marry one," something is terribly amiss.
Whatever is found, I still wonder if the ACA, as the leader in this profession, will act upon it? Will the ACA enforce a stricter code of ethics before we implement an expensive pr campaign? Will it lay down the guidelines for evidence-based “best practices” to guide our field docs in the most clinical and cost-effective methods? Will it screen all advertisements or offer effective ones to use? Will it rein in on experimental and unproven methods? Indeed, just how much of the chiropractic circus can the ACA clean up?
Perhaps the ACA could release a code of ethics for its members to sign, and then advertise that these DCs have been given the ACA’s stamp of approval by virtue of subscribing to the highest ethical behavior in our profession. We could give ACA members a sticker for their clinic doors or receptionist window that says, “yes, I am an ACA member.” Beneath this sentence we could say, “all ACA members adhere to a strict code of ethics.”
Or will we continue to suffer from the Forrest Gump syndrome and see 66,000 DCs doing and saying 66,000 different things?
The Role And Image
Of Chiropractic Services
This study was conducted in the early 1980s by independent researchers at Penn State University. The results were based on 975 respondents, 18 years and over.
Patient perception of treatment
The important recommendation of this study is that the public must be better informed about chiropractic. There is no structured and longstanding referral network for DCs like that existing for medical specialties. Consequently, much information about chiropractic is passed informally, through friends and relatives of those who visit chiropractors. That such information is not always accurate can be shown by responses to two further questions:
Reader’s Digest Insert
Beta Research Corp
The present study is a two-phased one, addressing the Reader’s Digest subscribers’ awareness of and attitudes toward the field of Chiropractic. In the April 1988, issue of Reader’s Digest, an 8-page, full color insert was included which described Chiropractic and the role of Chiropractors in an overall health care program. By obtaining 200 subscriber information prior to this information (pre-test) and comparing with information gained from 204 subscribers after they have had an opportunity to review the information after this issue had been in the household for one month (post-test), one can measure the impact of the advertising insert on subscriber awareness and attitudes.
SUMMARY OF KEY FINDINGS
ASSOCIATION OF CHARACTERISTICS WITH VARIOUS PROFESSIONS
AGREEMENT WITH STATEMENTS ABOUT CHIROPRACTORS
USAGE OF CHIROPRACTORS
SATISFACTION WITH CHIROPRACTORS
LIKELIHOOD OF VISITING A CHIROPRACTOR
LIKELIHOOD OF RECOMMENDING A CHIROPRACTOR
WHY PEOPLE VISIT CHIROPRACTORS
WHAT CHIROPRACTORS DO FOR PATIENTS
ADJUSTMENT-AWARENESS AND DEFINITION
WHAT IS ADJUSTMENT? (among those who are aware of adjustment)
Pre-test % Post-test% Change%
A Professional Who Evaluates?
You Be The Judge
I had an opportunity in mid-1996 to go carefully through “a qualitative investigation into attitudes toward and perceptions of chiropractic in Canada”. It’s quite a document. The major title, “the image, position, and reputation of chiropractic in the health care marketplace today” seemed to cover most aspects of the public’s (and the chiropractic profession’s) perception of what constitutes “chiropractic practice.” The conclusions of the study seemed as well to parallel the situation in the United States and perhaps elsewhere.
It was very interesting and kept my attention all the way through it. It reminded me - often - of the study commissioned by BJ Palmer some forty-three years ago, which he immediately filed away because it concluded what he didn’t want to hear: chiropractors were spine doctors, and the public would rather go to an NCA chiropractor since they “seemed more like doctors.” It was known as the Saunders’ report. I later met with Mr. Saunders who was quite disappointed with the way his effort had been handled; he thought he would become known as the “Flexner” of chiropractic because his report had been so exhaustive.
There are two outstanding points, in my view, in the Canadian report: 1) the absence of much of an indication that the chiropractor is a cognitive, thinking, decision-making individual; and, 2) the seeming lack of awareness that wellness is in no way considered - by the healthcare system at large - to be in the chiropractor’s domain; he/she has long since abdicated such interest by focusing on prevention through the removal of the subluxation.
On the first point: the medical doctor’s role is most importantly thought of as where a person would first go to find out what is wrong with him/her. The treatment seems to be of secondary importance. I recently saw an advertisement from Harvard that had a paragraph describing the role of the medical physician (or of the medical center). Fully three-fourths of the paragraph had to do with patient evaluation. A relatively minor part had to do with follow-on treatment. It has been my feeling for some time - cutting to the chase, so to speak - that chiropractors almost without exception “sell” themselves as treaters of primarily the spine. They give off the aura of focusing on their palpation examination of the spine, they talk mainly of the correction (treatment) of spinal problems, or of physio-therapy treatment, and in the overall come across somewhat as a type of “hypodermic syringe” or as some other, unthinking health-related apparatus; in other words, as professionals who are extremely limited as to their focus on patient care. They are not even treaters, they are tools used to make a spinal correction. The closest the image of the chiropractor comes to evaluation is in the use of the x-ray.
I’m going to quote here some relevant comments from the study:
“Typical appraisals of chiropractic” (by chiropractors in the study):
“Chiropractic is the removal of muscle or nerve interference. It helps people reach their maximum potential. These messages are not being effectively communicated.” (not a thing here about examination, evaluation or cognitive activity on the part of the chiropractor)
“We need to back up our claims scientifically, like the 85% success rate with migraine. There’s proof, and we should promote it.” (not a thing here about evaluation). A thought: could it be that we are so accustomed to either comparing our care to medical care for an already diagnosed condition, or that we have for so many decades been the “last resort” also for an already diagnosed condition, that we simply have learned to not think about an appropriate examination of a patient? We keep hearing that “CCE requires we do so many examinations in college,” etc., but do we ever hear about the pretty hard fact that such education is often not used?
“We need to encourage more research to prove chiropractic’s effectiveness” (not a thing here about evaluation)
“There isn’t always scientific proof, but there are clinical indicators.” (clinical indicators of what? I suggest this comment has to do with clinical indicators of alleged results, and likewise says not a thing about evaluation of the patient upon presentation).
“We don’t need everything to be scientific. We know when we are helping people and how much.” (helping them with what? Have we developed a baseline of the patient’s overall health through an examination, against which we can then say - after we treat the patient - this patient has improved against the initially established baseline?).
“We can really start to help people, and this must be communicated.” (“help people….” Or first evaluate people to see what if anything is wrong with them?) (This again is about treating and in no way infers an evaluation occurred)
“I use a rather traditional treatment procedure involving mechanical wellness.” (Hard to know what this means but it raises in my mind the morass of techniques in chiropractic, all related to treatment. True, some of them claim their own special brand of palpation or what have you, but their use still gives off the aura of treatment, not evaluation. And, at best, if there is any evaluation sense at all, it has to do with spinal or other body joints, not about the health status of the patient)
“I look at chiropractic in terms of health and wellness. I’m not pain oriented or crisis management oriented.” (is there any implication of overall patient evaluation here?)
“There’s a chiropractic way of life. I live it. It’s adjustment plus diet and exercise. It’s a natural way.” (not a hint of evaluation in here.)
“We improve the quality of life for patients.” (not a thing.)
“Chiropractic explores the relationship between the spine and the nervous system. The nervous system is like an electrical system.” (not a thing.)
“We improve the quality of life for patients.” (not a thing)
“People come to a chiropractor usually to get rid of pain. I see it to better your health, to realize your full potential.” (not a thing.)
“Defining the scope of one’s practice is important, but not to narrow it only to scientific proof.” (not a thing.)
And here are the definitions of the “four principle categories of chiropractors” from the study:
a) “straight” -- those chiropractors who limit their treatments to back, spine, and neck; and who use only traditional hands-on adjustment; (obviously all related to treatment, not evaluation)
b) “mixer” -- those chiropractors who focus on the back, spine, and neck; but who use adjunctive therapies, techniques, devices, or instruments such as a holistic approach, acupressure, applied kinesiology, massage, etc.; ( all of these emphasize the action of treatment.)
c) “progressive straight” -- those chiropractors who believe in broader applications of chiropractic; but who rely on hands-on manipulation and adjustment; (treatment only)
d) “progressive mixer” -- those chiropractors who believe in broader applications; and who use other therapies, techniques, devices, or instruments. (treatment only)
Every single one of these definitions makes me want to ask the question: where is the diagnostic role of the chiropractor? Nowhere is it even hinted at. How could a patient feel comfortable in a chiropractor’s office - I mean really comfortable - when he/she feels/knows that in order to keep abreast of what is generally wrong with his health he must go back to the medical doctor? Do we feel ourselves that we could comfortably rely on chiropractors as a group in evaluating our overall, not just spinal or spine-related, health? How would each of us answer this question? What would the public say? It looks like they have repeatedly spoken: “we wouldn’t feel confident if we had a real problem as defined by society.”
I could go on with the text of the study. Virtually every word tells us the chiropractor is not an evaluator but focuses his or her attention on bones. Any diagnosis that is done is highly limited and if the patient wants to know what is wrong with him or her, they must go back to the medical doctor. Yes, I know, some chiropractors do a good job of examining the patient. But, the patient is moved more by the image of the profession than by the individual practitioner because most chiropractors - apparently supported by RAND - talk and act as if they have no interest in such things as the patient’s vital signs: temperature, pulse and respiration. I have to admit, even I was surprised that not many even took the patient’s blood pressure. If the chiropractor doesn’t take the blood pressure, should the patient feel they must return to some other doctor “who cares whether or not I die. I suppose the chiropractor’s only interest is in unthreatening things, like joints.”
I personally feel this will one day need to be addressed. The creation of an entirely new image for our profession, one that says we are interested in a patient’s non-spinal joint pain and problems, would come up against inertia, a terribly powerful force that resists all but the most powerful new or external forces. I have encountered the inertia in chiropractic many times and it has sapped the energy of all who have attempted to influence it in any significant ways, at least in the time frame we are now facing, what with the managed care juggernaut at our doorstep.
Listen to this additional paragraph from the Canadian study: “not withstanding chiropractic’s recognized specialty of treatment of back and neck problems, the identity chosen to represent…” The challenge is set forth, not to introduce patient evaluation as the new image for chiropractic, but essentially to broaden the treatment image. I do not personally believe that such an effort can pull the public’s perception of us as spine doctors into the broader role of the “physician.”
Read the following from the study: “simultaneously, (we) should embark on an image-building campaign in which chiropractic is characterized as the major provider of a natural treatment for back, neck, shoulder, and spine problems.” Where is diagnosis? Is there some danger in the minds of the public in going to a doctor who is not interested - or seems to not be interested - in the health status of the patient?
And again: “in other words, it is recommended that chiropractic’s documented success in treating (not in evaluating patients’ health problems and in treating those of them that require natural, non-invasive forms of care - my comments in parentheses) spine, back, neck, and joint problems should be chronicled in terms of the physiological and psychological benefits to patients, and as well in terms of the economic advantages as per the Pran Manga study.”
This is a very large problem and possibly defies addressing, let alone solution; but then, I think it is important that we continue to place the issue out on the table for discussion.
On point number two, wellness:
It seems clear to me that chiropractic has never penetrated the definition of the term wellness. We have been so identified with the spine, and sore backs, and have never really openly spoken out in favor of avoiding hazards to health - at least spoken out in a way that it has rubbed off on our profession’s image - such as smoking, not wearing seat belts, not exercising to maintain aerobic fitness, etc., and not consistently following good nutritional habits.
How is this for a model of wellness for chiropractic?
iii. Avoid overly repetitious movement unless interrupted by contrary movement
iv. Avoid prolonged sedentary postures by moving about at pre-planned times
F. When pain or discomfort - or negative outcomes under i.a. above results - know your options
iii. If your doctor says or infers that you should not go to a different medical doctor or to a doctor of chiropractic, be suspicious that you may be placing your health in jeopardy. Seek out your own information if this should occur
iv. If medications become part of your proposed treatment, always demand information on adverse side-effects (all drugs have them) and make your own final judgment and decision on whether the outcomes justify the treatment
A policy position on the subject of wellness could be easily developed if we could only hope to influence the profession to then adopt it. The “removal of subluxations” –contrary to what is thought by some - does not relate to the wellness movement in society.
I well remember a “think tank” that was convened several years ago. As I remember some 35 members of the profession were invited to participate. Some statements of mine at that event: we should find two thousand DCs, each of whom would pledge $40 a month for five years, to a PR campaign. This would equal $4,800,000 for the five-year period. We could vary these numbers in any direction. The problem: who would administer the fund?
The second point I raised at the “think tank”: how were we as a profession going to “sell” the notion that chiropractic is an essential service? With back pain as our focus, and with treatment as our limitation, we must seem like somewhat small potatoes. With diagnostic screening in the loop, however, we can have our cake and eat it too.
This perception problem is national and international in its scope. To view it as a problem is the first hurdle; to attempt to arrive at a consensus as to how to deal with it looms even larger. In effect, each chiropractor is a “president” of his/her own domain. He/she is not answerable to anyone. Your staff is keyed into your wants and dislikes; you run the show. To get all these entrepreneurial types to listen seriously to others - and to alter their approaches - is not easy. They are all presidents.
As one small suggestion: perhaps the profession could address the creation of a standard for the evaluation of chiropractic patients; that we could arrive at a consensus as to what constitutes a minimum “physical examination.” It would at least be a place to begin.
Finally…I am concerned - and see signs of it in many places in the country - that the window of opportunity for chiropractic may be in jeopardy. We are being tolerated in managed care because we have not found a niche that fits the system. We are still pretty much isolated “outsiders.” We must be dealt with because we are active in the system, because of the insurance equality laws, workers’ comp laws, and the various studies that give us a certain solid argument for being involved at least in the area of low back pain. The ominous signs include the 100,000-plus PTs who are now focusing on the learning of the type of spinal manipulation we do. We have the Osteopaths establishing an entirely new curriculum in their colleges that includes spinal manipulation as a required course (it was only an elective up until two years ago). Once these elements are in place - all of them answerable to and a part of the healthcare system in America - the system can move all manipulation directly to them and away from us. No longer any need to deal with the “upstart” profession. After all, “spinal manipulation” is what has been validated in most cases, not “chiropractic adjustments.”
There continues to be widespread exclusion of chiropractic data from the system. We always were, and largely continue to be, left out of the data. It would be so easy for others to lose us in the cracks. Or, better still as far as the system is concerned, displace us with the PTs and Osteopaths.
I could go on and on but I think I have made my point. And…I think the most effective thing we have available to us to do is to mount the PR campaign to turn our image into one that shows our interest in, and capabilities for, diagnosis. When you see MDs on TV, they are always wearing stethoscopes or doing something else that spells out “the evaluator of the human condition”; not, the “treaters” of conditions. They truly show themselves as the “keeper of the gate.”
I hope these comments have added to the positive side of the equation.
Summary & Recommendations
It’s obvious the new ACA has a huge PR problem that won’t go away or improve by itself. In effect, we have a great healing art shrouded in controversy and skepticism. While all the polls showed the huge support by users, the fact is there are more non-users who would never use chiropractic care as it is now packaged. Indeed, we have a huge marketing problem that needs crisis care immediately.
Presently with the news reports of the turmoil over the loss of accreditation of Life University, once again the profession as a whole has been tainted. Not only did this hurt our image when the largest chiropractic college was embarrassed, but other reports of insurance fraud, MD/DC scams, PI runners, and some DCs in the LA area using their offices as brothels certainly didn’t help our image either.
The problem is presently there is no voice of reason in chiropractic—there’s a virtual silence among all of the associations, which may explain why the NACM gets the ear of the press and government bureaucrats because it has taken the risky position to renounce the cultism, the unproven clinical methods, the over-reaching promises of cure, and they have relegated their treatment to only those evidence-based conditions that have shown to be helped via spinal manipulative therapy. Regrettably, the NACM now appears to be the voice of reason to the press, a position the new ACA must regain. But is the new ACA willing to draw the line in the sand as the NACM has?
According to Randy Ferrance, DC, MD, here’s a list of conditions that SMT may help:
McMorland G - J Manipulative Physiol Ther - 2000 Jun; 23(5): 307-11
Tuchin PJ - J Manipulative Physiol Ther - 01-Feb-2000; 23(2): 91-5
Anderson GB - N Engl J Med - 1999 Nov 4; 341(19): 1426-31
Alix ME - J Manipulative Physiol Ther - 1999 Oct; 22(8): 534-9
Millea P & Holloway R - Amer Family Physician - 2000 Oct; 62(7)
Schiller L - J Manipulative Physiol Ther 2001;24:394-401
Hoving, Koes et al - Ann Intern Med. 2002;136:713-722
Khan S, Cook J, Gargan M, et al. - J Ortho Med 1999;21(1):22-25
Kemper KJ - J Pediatr - 2001 Sep; 139(3); 467
Froehle, RM - J Manipulative Physiol Ther - 1996 Mar-Apr; 19(3);169-77
Bronfort G, Evans R - J Manipulative Physiol Ther 2001;24:369-77
Forget about adhering to the roots of BJ’s chirovangelism—the mysticism of Innate, Mental Impulses, Life Energy—terms he used to explain health because he had reportedly a poor grasp of the ANS and neurophysiology. Indeed, can anyone name one research project done by the BJ Palmer Research Institute that has prevailed the test of time? What he couldn’t explain in real terms, he used metaphysical ones instead, which has led to the birth of chiropractic cultism as we’ve seen in the world of chirovangelism led by Rev. Reggie, Big $id, and others.
If we are to reform our profession in order to improve our image and reputation, it must begin by cutting the cord to these old ideas that never were true, never did work to convince the vast majority of the public, and won’t convince anyone in the future. We must move toward a new philosophy of healthcare rather than a philosophy of chiropractic built on mysticism and cultism. Clinging to BJ’s metaphysical concepts and the 33 Principles is equivalent to medicine clinging to bad spirits and bad germs as the cause of all disease. We need a paradigm shift before we can convince the public of anything—just as Coca-Cola couldn’t continue to sell New Coke when the flavor is bad, chiropractic cannot sell the same old chiropractic package that few bought in the past.
Is it possible for the ACA to follow this research as to our scope of care as the movement in evidence-based “best practices” now suggest we do? Or will chiropractic continue to appear to the press and public as the snake oil salesman who purport to “cure you of whatever ails you”? I believe the new ACA must take a stand on these issues—our realistic scope of care; upgrade a Code of Ethics, and become public spokesmen to the media on all health issues. The new ACA must become the voice of reason in this profession, but that may require tightening our belt.
These polls have all showed that the public considers DCs as specialists in neuro-musculo-skeletal disorders. Fewer consider DCs as PCPs, GPs or family physicians. If the new ACA were to follow the research evidence it would show the media and public that there’s a new, pragmatic, voice in the chiropractic profession that doesn’t have its head in the clouds, but well-founded in the world of modern research. Obviously the old ICA and the maverick WCA will never assume the role of pragmatism, but if the new ACA fails to speak up on these issues, it will by default allow the NACM, ICA, or WCA to assume that role.
Not only would a professional PR campaign help the bottom line of all DCs, it would help immensely with all legislative efforts by improving our image, if, if, if…Before any PR campaign begins, it’s imperative for the new ACA to answer a few questions raised in the Canadian report about our Identity, Image, Position, and Reputation. In other words, before we spend millions of dollars on a PR campaign, it’s imperative we DCs undergo a paradigm shift in the way we view ourselves. If these reports are not enough to wake us all up to the facts, what will it take?
As these polls indicated, and as hard as it may be to admit to ourselves, the favorable image of DCs perceived by the public was not as family doctors or PCPs as much as we are accepted as POE for spine and spine-related disorders, as this statement from the Australian study cited:
“They are generally acknowledged as being “specialists” with their area—structural experts who perhaps “know bones, backs and how to treat them better than most GPs.”
The Oklahoma Poll also noted:
“72% feel the chiropractor is rightfully a spinal or structural specialist. Therefore, indication with this particular label will be one which is believable…”
Are we listening to the polls that tell us our position rests best, in effect, as “natural specialists for spine and spine-related disorders?”
“An important part of building reputation is to establish chiropractic’s legitimacy. And, its authority in matters relating to injury to the spine, back, neck, and joints.
It is consequential to affirm chiropractic’s expertise in spine, back, neck, and joint problems. Acknowledge expertise. This particular piece of positioning should be supported with both scientific and anecdotal validation. Chiropractic’s adeptness in these areas of injury needs to be discussed in very human terms and in hard economic terms, too.”
Or will we persist on selling unsuccessfully the PCP, family doctor concept that very few folks accept?
“Public affirmation of additional applications of chiropractic techniques, it is recommended, should be postponed for several years until chiropractic’s identity and image, position, and reputation can be more firmly established.”
Until the ACA decides to listen to the public as to what role they accept us doing, we will simply waste time and money on a futile effort to convince them and the medical profession. On the other hand, if chiropractic’s scope in healthcare is relegated as POE for NMS disorders, it will further strengthen our position as the experts in this area as the public already believes.
I realize the Davis-Clayton report urged the ACA to seek the family doctor image, but the actual public polling didn’t support this idea. The Reader’s Digest poll indicated that only 21.5% of the pre-test respondents feel DCs are family physicians. Rather than competing with MDs for the role of PCPs and GPs, strategically it would be smarter to reposition ourselves as primary access providers for NMS problems as the leaders in the diagnosis and natural solutions to the epidemic of spine and spine-related disorders. The public accepts us in this role, the MDs are also open to this role, now if we could convince ourselves that this is our niche, perhaps we can begin our recovery into acceptance.
Unbeknownst to many DCs, most medical critics are not anti-chiropractic as much as they are anti-quackery. Dr. Stephen Barrett, MD, perhaps the most notorious quack buster, has written, “I don't consider myself at war with the chiropractic profession. I am at war with quack practices. I have always supported appropriate chiropractic care.” And appropriate in his mind is restricted to NMS disorders. He also preached against unproven methods such as AK, Activator, Network, homeopathy, and the infamous, never-ending, anti-vaccine position some DCs have taken. Is the new ACA willing to draw the line to exclude these methods in order to gain credibility?
I recall a meeting I attended with the Governor’s Advisory Commission on Workers’ Compensation, and after I gave a 45-minute presentation on the clinical and cost-effectiveness of SMT for LBP cases, the first response from this crowd of executives was “We don’t want those chiropractors who think they can cure diabetes!” As long as some DCs champion these controversial issues that have nothing to do with our practices, we will continue to be viewed as fringe practitioners who speak with an illogical tongue.
According to the Canadian report, “A preemptive position is one that is difficult for the competition to usurp or replace,” and chiropractic already has a foothold in this area of NMS problems as the “natural” non-drug, non-surgical experts.
“Chiropractic is best accepted by the general public, the medical profession, and by chiropractors themselves when associated with back and neck problems. The further from this “core” approval chiropractic philosophy or treatment strays, the less its credibility and support.
“The conclusion is drawn in previous research, based on the above observation, argues for the status quo, that the best communications course for chiropractic to follow is: limit its public promotion to the treatment of back and neck injuries; invite practitioners to pursue broader applications of chiropractic among individual patients, and allow word-of-mouth recommendation to remain the primary means of advertising.”
This is where we need to target ourselves rather than appearing to be all things to all people. There’s a huge niche for neuro-musculoskeletal disorders that we should stake a claim to capture instead of appearing to be family practitioners, pediatricians, or primary care diagnosticians. While diagnostics and evaluation as POE practitioners is important, just as Dentists are portal of entry (POE) for dental issues, we chiropractors should position ourselves as POE for spinal issues. While this belt-tightening may give some DCs indigestion, it may prove best in the immediate and long term because we’ll appear more credible in the eyes of the public, press, and medical profession.
Realistically, many “straight” DCs from Palmer, Sherman or Life may find it difficult to do proper examinations and evaluations since the philosophy of those colleges has been to “detect and correct VSC” only. Of course, the CCE Standards shun this approach, which was one of the core problems with Life—improper diagnostics. As Dr. McAndrews mentioned, the focus of these colleges is on treatment, not evaluation. Until all DCs embrace differential diagnostics, we will continue to position ourselves more as therapists than doctors in the public’s mind.
“Truth rides the storm; half-truth and falsehood blow away. Always base public relations programs on truth. There is simply no substitute.”
As well, the Reputation of chiropractic needs to be address with an act of contrition on the part of the ACA. Let’s admit our mistakes in the past to the public—some DCs have over-stated our scope, some have used experimental or unproven methods, some still preach the “one cause, one cure, one correction,” and some still preach chirovangelism. If the new ACA and our profession as a whole are to appear rational to Americans, we need a tabula rasa, a clean slate, and that means apologizing for our past sins, stating our new position (“the natural leaders in spine and spine-related disorders”), and promising a new code of ethics by the members of the new ACA.
Would it be unreasonable to hold a press conference and admit our past mistakes? Is it asking too much in order to increase our Trust factor and improve our Reputation to stop with the anti-anything medical and anti-vaccine raps? While some straight DCs may object (but they belong to the ICA and WCA, not the new ACA), the majority of rational DCs would enjoy this apology to the public as a cleanse this profession needs. Otherwise, if the new ACA remains silent, we will continue to hear the following comment:
“Chiropractors say or believe illogical things” not common canon of understanding or not scientifically proven.
Indeed, if we want to push anything that’s anti-medical (which isn’t recommended by the Canadian poll), I suggest we criticize the many unnecessary and ineffective back surgeries—an issue we can prove easily, and it would save a lot of money as well as a lot of suffering. But to go off half-cocked with the anti-anything medical attitude like some of our ICA brethren just invalidates ourselves as rational health care providers.
“It would be counter-productive to go directly up against the medical community in the public arena. It would be counter-productive to challenge the medical establishment publicly on any issue at this point in time.”
Bellowing about vaccinations is equivalent to hitting our heads against an ideological wall that will never move, but certain to give us a continual headache. Ironically, the rate of clinical iatrogenesis for vaccines (smallpox) is similar to SMT—about 1-2 per million. I’ve never understood why chiropractic should champion the anti-vaccine issue when there are plenty of more credible health issues to support—such as anti-tobacco, anti-junk phoods, or wellness concepts galore. By harping on vaccines only makes us appear anti-modern and silly since most people accept vaccines as an effective weapon against infectious diseases.
While a small percentage of chirovangelists may object to any Reformation of Chiropractic, the vast majority would support it along with an intensive PR campaign touting not only our past sins, put pledging the new ACA to higher clinical standards and ethical behavior. We could give our ACA members who support this PR campaign a door sticker that reads, “YES, I am a member of the new ACA and subscribe to the highest ethical standards in the profession.” Perhaps this might offset the claim that “Chiropractors don’t have a code of ethics like MDs do.” Indeed, chiropractic ethics to many appears to be an oxymoronic statement.
One of major causes of the limited appeal is the lack of information regarding what DCs really do, can do, and for what problems or symptoms. “Chiropractors say or believe illogical things” not common canon of understanding or not scientifically proven.
“More than a touch of the occult and superstition associated with chiropractic. This attitude is reinforced by the perception that those who champion chiropractic behave as if they were part of some religious faith or creed, and are possessed of some special fervor.”
Implicit in all the research findings is not just that people haven’t heard about chiropractic, they also have not heard from chiropractic.
“We don’t know what chiropractors stand for: we don’t know what they’re about.”
“Chiropractic isn’t top-of-mind. It isn’t tangible. You don’t get little things that remind you.”
“We know they don’t believe in drugs, why aren’t they telling us what they do believe in?”
To the average person, chiropractic’s response appears to be absent. According to the Australian report:
“No one is out front leading the parade for chiropractic; no one is disseminating information about the methods and benefits of chiropractic; this hesitancy could be construed as a “lack of confidence” or as “having something to hide.”
Another sore point among users is the belief once you go to a DC, you have to go the rest of your life. While this may be true for the small percentage of patients with serious or chronic spinal injuries, most patients “just want to get fixed” and not come back until their back goes out again. While it may not make good sense to us chiropractors, it is the prevailing thought among many in the public sector, including the insurance industry. Maintenance care is not reasonable to those who don’t suffer with a permanent spinal problem, and any effort to suggest lifetime care is seen as “unscrupulous.”
According to the Canadian study:
“Most frequent and serious complaint of trust is that DCs can be unscrupulous when it comes to holding on to patients.
“DCs have not “sold” the public on their services, but have only promoted them the “wrong” way with gimmicks, including a package of treatments in advance.
“Such perceptions added to feeling part of an assembly line, or that DCs are loathe letting them stop once they have started treatments, translates into greed or pure self-interest.”
According to the Reader’s Digest poll, of 8 health professionals, DCs were rated only above faith healers and similar to podiatrists. Sadly, the pre-test polling of characteristics of DCs were shocking: highly trained = 18.5%; trustworthy/honest = 13.5%; competent/qualified = 14.5%; ethical/conscientious = 17%; caring/concerned = 16%; well recognized = 12%.
Although all these percentages increased slightly after the Reader’s Digest insert, they all remained far below the other top 6 fields (MDs, dentists, optometrists, orthopedists, PTs). This is evidence enough that our image is still sub-par, and unless we implement not only a PR program, but a Reform program to rebuild our image, these low statistics will not improve solely by our clinical expertise.
Despite BJ Palmer’s fascination with the circus and parades, his effort to expand the world of chiropractic must be seen today as a horrible failure if we analyze it from the viewpoint of market share, image, position, and reputation. In all regards, presently chiropractic ranks at the bottom of each—the facts and opinions garnered from these polls are testament to the need to completely re-invent our profession.
As the Canadian poll indicated:
“In that 100 years chiropractic has managed to inch forward in public awareness and esteem. If it continues along the same path, chances are it will only continue to inch forward over the next 100 years.”
Without question, this profession is in dire straits despite the advances on the political, legislative and research fronts because in the minds of many in the public, the bad news far outweighs the good news about chiropractic. Indeed, we must implement a professional PR campaign immediately unless we want to continue inching along at a snail’s pace.
“The association should embark on an image-building campaign in which chiropractic is characterized as the major provider of a natural treatment for back, neck, shoulder, and spine problems. “Natural” is the operative word—it means authentic and honest; it translate as “the way it was meant to be.” In effect, authority, trust, and respect are implied in it.”
“The association will want to address, very specifically and very factually, the issue of chiropractic education, training, certification, and standards and practices. This is a seminal point.”
“It may be necessary to publicize a flurry of activity that establishes the moral and professional authority of the association, such as
With the recent inclusion of chiropractic care in the military, I believe a campaign built around Dr. Bill Morgan and other military DCs would do wonders to uplift our image. First it would give chiropractic the “Good Housekeeping” approval we desperately need. It would be the imprimatur the polls indicated as important to improving our image.
“No general imprimatur or sanction given to chiropractic by anyone; without govt sanction, chiropractic is suspect or considered renegade.”
Other prominent DCs working well with the medical community could also be featured, such as Dr. Jay Triano at the Texas Back Institute, Randy Ferrance, DC, MD, Hospitalist: Internal Medicine and Pediatrics, Tappahannock, VA, and Dr. Don Murphy of the Rhode Island Spine Institute, Department of Community Health, Brown University School of Medicine. When the public sees DCs cooperating with MDs to give patients the best of both worlds, it will enhance our image and reputation immensely. Indeed, the more we can cooperate for the patients’ benefit, the less suspect or renegade we’ll appear to be.
A cooperative theme between MDs and DCs would also counteract the current regressive, biased attitude by some MDs who refuse to refer. If patients see prominent MDs referring to DCs, they will demand the same. Rather than appearing on a pedestal, any MD who refused to refer a patient with NMS to a DC would invalidate himself in the eyes of the patient.
Before the ACA and its members invest millions in a PR campaign, we must agree what we are selling before we can sell it to the public. Presently, we are the Mystery Science profession—people have little idea what we do, why we do it, or how it works. Indeed, as with medical care, most chiropractic patients subscribe to blind faith.
Part of any PR strategy is the need to clarify the different focus of chiropractic diagnosis and treatment compared to medical diagnosis and treatment for spinal disorders. Since 1934, the medical profession has adopted the slipped disk theory for back pain, thus the use of spinal surgery as its solution. On the other hand, PTs have focused on the pulled muscle concept, hence it’s focus on modalities and exercise. Of course, we DCs consider as the primary cause of spinal problems the vertebral subluxation, joint complex dysfunction, functional segmental lesions, or the chiropractic “boo-boo” as Dr. Joe Keating has humorously referred to our hard-to-describe entity.
But the problem for chiropractic remains with the public’s failure to understand that most spinal problems are “mechanical” in nature as Dr. Richard Deyo mentioned in his NEJM article (Feb. 2001) about low back pain in which he admitted that 70% are amenable to spinal manipulative therapy. The research now is filled with articles criticizing the “false positives” of disk abnormalities—as Dr. Scott Bodin from Emory University mentioned, disk abnormality is equivalent to “finding gray hair” in that it’s a natural part of the aging process. Yet back surgeons still use this false-positive diagnosis daily as reason enough to fuse the spine. Until we expose this myth, more patients will suffer with ineffective back surgery that could have been prevented by chiropractic care.
The fact that there are 137 joints in the human spine is unbeknownst to most people, including MDs, DCs, PTs, and the general public. Until we can get this fact well entrenched in the public’s mind, our diagnosis and care will not make sense. Indeed, when the public finally realizes you don’t slip disks, but you do slip joints, then our care will make sense. We need to change the focus from disks to spinal joints if our paradigm shift is to succeed.
Due to the dearth of understanding of spinal problems, the public remains confused as to which type of practitioner to seek, as this article in Spine illustrates:
Published in the February 2003 issue of Spine, the survey found that 54% of people reporting back and neck pain in the last 12 months used complementary therapies to treat their conditions. Only 37% of those surveyed consulted conventional providers. The most popular therapy was chiropractic, sought by 20% of injured people. Of those who used chiropractic techniques, 61% rated them as “very helpful.” Only 27% of the people who consulted conventional providers reported that rating.
This conceptual understanding of joint dysfunction as the major cause of spinal problems is the paradigm shift our PR strategy must incorporate. When the public finally understands that the spine is comprised of 24 little vertebrae stacked on top of 3 pelvic bones interconnected by 137 joints and covered by layers of muscles, then our manipulative therapy will be reasonable to them. Until this shift occurs, we will remain the Mystery Science profession with mystical explanations.
Secondly, are we willing to clean up our own act before we hit the road with our show?
Will the new ACA issue a new Code of Ethics to all members so we can honestly portray a new image of integrity? Or will we continue to look the other way as our colleagues advertise free exams, NOOPE, place patients on unnecessary and endless treatment schedules, and espouse “chiropractic cures all”? Just where do we draw the line?
Once we re-identify our expertise in a logical format as I’ve just mentioned, once we improve our image with a new Code of Ethics, once we position ourselves in the NMS niche, and once we improve our reputation with great ads and a commitment to ethical behavior, only after this foundation is set, then should the new ACA commence with a PR program.
Once this PR program commences, I think it is imperative that ACA members ONLY are given a window decal stating their involvement in this campaign. Although all DCs will benefit, a decal will at least tell our patients that we stand behind this effort to improve our profession’s image. “YES, I am a member of the ACA, and subscribe to its Code of Ethics.”
It will be imperative that every ACA state association holds seminars on this new PR campaign. The strategy will be laid out, the PR materials disseminated, and the empowerment of the members will commence. For the first time in a long time, the new ACA will give its members actual materials to help them succeed in an ethical manner without gimmicks.
Demand Management: An Innovative Approach To Marketing
It seems the entire world of commerce evolves around the world of marketing, yet the chiropractic profession has failed to implement this basic principle. Public relations, advertising, and marketing are terms rarely seen in chiropractic except when they cause us embarrassment, such as the “Killer Subluxation” and “Free Spinal Exam” ads which can still be found in the Atlanta phone book today. Without a professionally created ad campaign, chiropractic’s image has been mainly the function of these negative ads, newspaper editorials about runners, insurance fraud, CVAs or other unseemly issues.
Indeed, a positive, continuous ad campaign is long overdue and terribly needed if we are to change these negative impressions into positive ones. I daresay if the ACA were to implement a nationwide campaign, it would take only 3 years to turn the public’s mind around to our side. We have a great service to sell; now we need a good campaign to tell it. Without one, we will remain the Mystery Science profession, unknown to millions of Americans except for the occasional negative story.
“Demand management,” as defined by Dr. Robert Mootz in his DC article, Demand Management: The Next Big Thing? “sometimes referred to as demand moderation, is a set of behavioral change strategies directed at consumers and providers to affect how they respond to indications of injury, illness and disease. Typically, the strategies include community-wide or targeted group education to help consumers interpret signs and symptoms, learn self-care strategies, obtain ready access to diagnostic information, and in some cases, even deploy alternative "expert" access mechanisms, such as medical consultation by phone, website, or other means.
“The concept of demand management is being harnessed. Ideally, demand management is a strategy aimed at fostering informed, appropriate demands by consumers for medical and pharmaceutical interventions, with greater reliance on self-diagnosis, care, and social support. Advantages and limitations depend on the stability of the condition, the level of commitment of the consumer, and the integrity of the demand management strategies. A successful example is the public/private partnerships in diabetes education.”
Rather than waiting for the medical professionals to refer MSDs to DCs, a demand management PR campaign to educate consumers about the clinical and cost-effectiveness of SMT for this epidemic of MSDs could do wonders to circumvent the covert boycott by the medical gatekeepers. As dr. David Eisenberg found in his polls on alternative healthcare usage, the American baby-boomer generation are very smart folks who make informed decisions about their health care, and we must make our science better known to these consumers who are seeking alternative health care.
As Dr. Mootz mentioned in his article, “The distinguishing characteristic of demand management is the promotion of patient knowledge in the choices of care and providers.” Regrettably, we as a profession have failed to do so.
Unfortunately, our profession has lacked the skill to teach the public about our services with supportive research and clinical guidelines that have accrued in the last decade. Despite RAND, Manga I & II, AHCPR, and the recent Duke study on headaches, the public is unaware of these supportive studies. Nor are they aware of the plethora of research that condemns the onslaught of failed back surgery. Until we tell them, they may never know since the AMA isn’t about to tell them.
Although the last joint ACA/ICA PR effort by the Consortium ended in failure due to a few reasons (poor media choice and lack of funds), we need to learn from these mistakes and push forward. In this age of cable television and the Internet, magazine and newspaper ads seem very limited in reach, and relatively expensive for the exposure. The print media is a relatively old fashioned method that reaches few folks and is very costly, plus these ads are very limited in their content.
Until we have an ad and/or a publicity campaign on national TV, such as MSNBC or Fox News, we will continue to spend wasted money on ineffective means. Since Fox News promotes itself as giving both sides of issues, “fair and balanced” as they say, the new ACA ought to approach them with the idea that in terms of health care issues, they only give the medical point of view, never the alternative and/or chiropractic perspective.
Let me offer a few ideas along this line. Aside from external PR programs that a professional company like Davis-Clayton might do for the ACA, there are numerous internal promotions that the new ACA could do for itself.
1. Internal Promotions for Doctors’ Offices:
“No one was sure how much education and training chiropractors receive.
Little is explained to patients about their conditions, treatment, or prognosis.
Even less is explained to them about chiropractic itself: methods, history, and philosophy. Many respondents feel a “void” exists—an information and relationship void.”
v The need for a field doctor’s PR kit consisting of printed materials as Davis-Clayton did years ago as in-office promotions was a great idea. Aside from the “For Your Health” articles published by the ACA for newspaper ads or office use, the ACA could also put together an in-office brochure program that is given out at each office visit with a quick discussion by the doctor. Personally, I now have accumulated over 375 brochures that I’ve made on my own computer with a standard format that deal with chiropractic, nutritional, exercise, supplements and other health issues like junk phood. The ACA could create a series of 30-40 of its most popular brochures for an on-going distribution by doctors.
v “The preferred patient is the referred patient”: Two polls found that a very small percentage of new patients came from advertising and that the vast majority were referred from family and friends. This should be the foundation of any internal PR program for field docs. Rather than spending a lot of money on external ads, we should empower field docs with materials and methods to enhance in-office referrals.
v A very useful tool I’ve used for years is an audiocassette or CD program. I’ve made a few different ones—New Patient; Whiplash, Wellness, Progress Report, and Re-Act tapes. I hand out the NP tape to each new patient and overnight it acquaints them to my office, chiropractic care, and their responsibilities to get well. These tapes are cheap and easy to make and are more effective than any videotape I’ve ever used.
v Health Class or Back School presentation using flip charts or PowerPoint. In my Health Class, I teach patients how to avoid a back attack, a fat attack, and a heart attack. My Back School is taught by my CA who introduces patients to proper posture issues like lifting, sitting, bending, etc. as well as spinal exercises. Using PowerPoint is easy and very professional. If you want to sell the sizzle (you), such classes are essential, effective, and cheap.
2. External Promotions for Doctors’ Offices
Many polls indicated the low percentage of new patients from external advertising—4% according to the Oklahoma poll, which begs the question: why are we paying so much for external advertising when internal methods are so much more cost-effective? I believe “publicity” efforts like interviews on TV, magazine articles, etc are more effective than strictly ads because in this light DCs are cast as experts rather than salesmen. But, for exposure in the local marketplace, I suggest the following:
v The ACA could create a set of newspaper ads such as those done by TRIAD that would be small enough to be cost effective as well as professionally made.
v The ACA could distribute a PSA to doctors for their local area.
v With their laptop in hand, the ACA could create PowerPoint presentations for shows at clubs and churches.
v Another issue not addressed in our conference call was the Yellow Pages. As we all know, most DCs spend thousands each year on these ads even though they barely pay for themselves. I suggest we encourage DCs to downsize to one standard size, go in together in group ads, or just use in-column listings. As well, just as MDs and attorneys are categorized by specialties, I suggest DCs do the same since not all DCs are the same. Let’s give the public a better understanding about which DC to see for their type of problem.
3. External Promotion for the Entire Profession.
v Until chiropractic has an on-going presence on TV, we will remain the mystery science profession. I urge the ACA to develop a PSA focused on a patriotic theme, such as Born in the USA—Chiropractic; or use the military theme noting our recent success with the MHS and VA. The Derrick Parra PSA was a good idea since sports is always a popular medium to use.
v A 4-page spread in USA Today newspaper will cost almost a quarter of a million dollars, which would cover the cost of an on-going PSA throughout the year. I doubt a newspaper insert would be effective inasmuch as the Reader’s Digest inserts years ago were ineffective. All things being equal, I vote for a TV presence over the print media for a national exposure.
v Guest speakers on news shows such as Larry King, Fox News, MSNBC. We need articulate DCs in the NYC, Washington, DC, and Los Angeles areas who can comment on various health issues as they arise. The present Executive Committee comprised of Drs. Wills, Edwards and McClelland are undoubtedly the most articulate (and good looking) spokesman the ACA has had in years. The more we can get them on news shows, the better our image and reputation will be. Plus, publicity is free as opposed to expensive advertising.
v Celebrity media pitches using Olympic athletes like Derek Parra or Beth Larson, Barry Bonds, Emmit Smith or other pro athletes who swear by chiropractic care.
v Perhaps the most compelling endorsement we could use would be to promote Dr. Bill Morgan as the Capitol Chiropractor. Ask Senator Tom Harkin, Rep. Neil Abercrombie, and other chiropractic supporters among the legislators to endorse the good work of Dr. Morgan, and to speak about the inclusion of chiropractic in the military health services and VA program.
v Perhaps a more radical approach would be the Jesse Jackson method of public awareness. Just as he threatens to picket and boycott companies who he feels are racially discriminatory, why couldn’t DCs do the same? For instance, the fact that hospitals for the most part still boycott chiropractic care is a slap in our face. Imagine the ACA broaching this issue on the national level and then have the state ACA members come together in the capitol towns to picket on the steps of the largest public hospital that doesn’t include DCs with placards such as, “Stop Discrimination Against Chiropractors,” “Freedom of Choice in Healthcare,” “Patients Deserve Choice,” “Stop Unnecessary Back Surgery.” Although this idea make may some flinch, it would capture the press’ attention as well as the public and legislators. Just as the minority movement used these tactics successfully, why shouldn’t we? Imagine during NCLC to have a few dozen DCs picketing in front of the Supreme Court. The exposure would be national and raise the public’s consciousness overnight to our issues. Is this approach viable? Yes it is, as well as bold and brassy. As I mentioned, it may make some of our conservative leaders queasy, but it sure would be an instant and inexpensive method to grad the attention of the public, press, and legislators.
Internal Promotion for the Chiropractic Profession
Sadly, internal promotion has been scant albeit so important to empower the membership. Fortunately, the inclusion of ACA Today has been a good start, but there’s much more the association could be doing to promote membership in terms of renewals and to recruit new members. “Empower the Consumer” must be embraced whole-heartedly if we are to increase our numbers.
v Continue with the ACA Today insert in Dynamic Chiropractic—a great idea that will promote what the ACA is doing to all DCs.
v Expand the use of the Internet by creating a Message Board for members, a chat room like Chirosci.com to dialogue on current issues to include all members and our leadership. Regrettably, currently our leaders are only heard from on a monthly basis in the JACA or ACA Today. I suggest our state and national leaders carry on a daily dialogue via these chat rooms to share their vision, give direction, and educate members about on-going legislative needs.
v Begin an ACA Homecoming annually to promote membership, camaraderie, and to inform and empower the members. Presently the HOD meetings do this for HOD delegates, but there are nearly 10,000 non-HOD delegates who are never brought together. Although the NCLC would be an excellent location and the topics are relevant, by holding a Homecoming in Washington every time might discourage ACA members from the West Coast from attending.
v Begin state level ACA meetings to inform local ACA members of the legislative goals on the national level and to discuss statewide political issues. Presently there are no state level meetings here in Georgia (except for the annual luncheon at the GCA convention). The state rep could offer CEU credits to discuss political/legislative issues, risk management issues, research trends, and offer practice management tips and mentoring aid to new members as well as to attract new members. This would be a great opportunity to show the ACA members and non-members just what the ACA is doing for them. Also, an email mailing list could update ACA members whenever issues arise. Other than Gary Cuneo’s mailings, nothing much is sent to local members about local issues (at least here in Georgia).
v Begin the Boot Camp for new grads and students so they can avoid the pitfalls of new practitioners and avoid the high costs and questionable ethics of some practice management gurus. As the Clayton-Davis report mentioned: “Control of chiropractic careers: many grads with huge loans fall prey to get-rich-quick schemes because they seek direction about their futures but seldom get reasonable guidelines or assistance.”
Public Relations—the introduction of our product
Marketing—the packaging of our product
It seems every successful ad campaign focuses on a theme and/or slogan that the public can remember, eg, Coke Adds Life; Milk Does a Body Good. A clever ad should have a memorable slogan as the centerpiece. The problem with a slogan for chiropractic is that it’s such an odd word and nothing rhymes with it well. Old rhymes have included such slogans as “When your spine is in line, you’ll feel fine.” Trite, but cute, and something the public could remember. The Australian slogan fared well: “Don’t use your back like a crane.”
We might also consider using Backbone or Spine as the key phrases instead of chiropractic, such as “A straight backbone is the key to feelin’ good.” “Your Spine—the Key to Feelin’ Great.”
Since sex sells, we might try a line featuring a beautiful woman in a low-cut dress with a great lookin’ back, saying, “How does my back look to you? If you want to look this good, see your chiropractor too.” That ought to get their attention!
A secondary theme should include the word “chiropractic” as a tail-end phrase, such as “Brought to you by the American Chiropractic Association and your local doctors of chiropractic—the leaders in spinal care.” Or my favorite is: “You don’t know how good you can feel until you’ve had your spine adjusted by a chiropractor.” Or, perhaps, a little racy but catchy: “Chiropractic—the second best feelin’ there is!”
Realistically, since the major research supports SMT for LBP, and since this is a huge epidemic in its own right, this might be the best target to aim for. Also, with the recent headache research from Duke University, this is another plausible theme to use.
Possible text for this LBP theme could include:
For the headache theme, this might include:
For whiplash and on-the-job injuries, an ad campaign could promote the fact that SMT is safer, quicker and less costly than drugs or surgery. The only problem I’ve found with these serious injuries is that not all DCs are equipped to handle these cases, which would create dissatisfied patients who by chance ended up in a straight, non-force or low-force untraditional chiro office without any physio-therapeutics or rehab equipment. Since these serious injuries require specialized care, to avoid this inevitable problem, perhaps the ACA could conduct seminars to certify practitioners in these areas.
Obviously there’s a cost to creating a PR campaign in terms of production and the airing of these spots. Fortunately, the most impactful aspects of this campaign—publicity events—are basically free, as are the PSAs once they’re produced.
If the ACA is determined to improve its image with a positive PR campaign, it could partake in co-op advertising with other vendors, such as Foot Levelers, TRAID, NCMIC, AMI, Inc, Therapeutica pillows, mattress companies, vitamin companies, to name a few. Since we don’t have the pharmaceutical industry to advertise for us like the AMA has, the bulk of this campaign will rest with the ACA since the ICA is unreliable to help as we saw with the last advertising campaign that the ICA reneged on helping.
If and when the legal action with HCFA and the Blues finally ends, more resources would become available. Also, the ACA could tax its members a hundred dollars annually to subsidize this effort. If astute DCs and state associations understand the need to fight HCFA and the Blues, they might also see the need to support a good national PR campaign.
Aside from the lobbying efforts of the new ACA staff in Arlington, I suggest a few additional efforts to support this effort.
The new ACA needs to crow about the many recent accomplishments during the past few years. Regrettably, few field docs realize the enormity of these tasks and the huge strides the ACA has taken: HCFA, Medicare, DOD, VA, HHS, Trigon, National Blues, to name a few.
As I’ve stated before, the new ACA needs a Homecoming Happening to celebrate among current members and to recruit new members. Unlike the colleges, the ACA has not held an association-wide event to bring the members together to learn, to schmooz, and to enjoy these victories. It would stimulate old members, and entice new ones to join the new ACA by developing greater camaraderie.
The best place to have this would be the NCLC. Not only would members enjoy the sites on the Capitol, they could hear the Congress men and women praise the ACA staff for their efforts, learn of on-going challenges, and then visit with their local Reps. The ACA could also have educational seminars for CEU for non-HOD members. From within the ACA ranks many excellent speakers could present their expertise, such as the Council presidents, the ACA staff and leadership, celebrity DCs like the Capitol Chiropractor, Bill Morgan, and the Raven’s chiropractor, Alan Sokoloff, and researchers from the FCER like Tony Rosner and Mac McClelland. Perhaps the biggest draw could be a panel discussion with George McAndrews, Jerry McAndrews, Mike Pedigo, Mike Flynn, Jim Edwards, Daryl Wills, Mac McClelland, and Gary Cuneo. Instead of just a few minutes, give them 4 hours to tell it like it is. What a great show that would be!
Part of the problem within this profession is the apathy and disenfranchisement that reigns supreme among the 65% of scab DCs who just don’t know what the NEW ACA has done. By promoting this Homecoming Happening at NCLC in the ACA Today newsletters that go out in the Dynamic Chiropractic six times a year, promotion would be easy. Plus, the state ACA reps could make a hard push in their state associations’ newsletters, word-of-mouth, and emails.
We should take advice from the marketing methods of the ICA and straight camps and promote these new ACA leaders and speakers as “chiropractic superstars,” just as the Big Ea$y has done for the PCC Lyceum with the straight speakers. Instead of the straight charismatics and charlatans like Big $id, Rev. Reggie, Guy Riekeman, Fred Barge, Tedd Koren, and their ilk, the new ACA could showcase the real shakers and movers in our profession. For too long the ACA has turned its cheek in confrontations with the ICA folks, or they have taken a second seat to these charismatics. It’s time for the new ACA to put its best foot forward and showcase its best and brightest.