Articles by JCS
Ethics in Chiropractic
PURSUIT OF IMAGE
JC Smith, MA, DC
In 1992, George McAndrews wrote in the ACA Journal his opinion of chiropractic's suspect image: "I believe this is the era of image. It is time for the 'deweirdization' of the profession... An aura of 'weirdness' is the necessary consequence of some chiropractic literature, advertisements... a sampling of yellow page ads makes one wonder if chiropractors are financial advisors or health care professionals... It is time to isolate the rascals."(1)
Want to start a good argument among chiropractors? Aside from asking about which personal philosophies or techniques they prefer, try asking their opinions about advertising and free spinal exams, then watch the proverbial meadow muffin hit the fan. Indeed, free exams can be considered the bane or banquet for chiropractors, depending upon your ethics, of course. Whenever I’ve written articles about this issue, eyebrows are raised and accusations are thrown. Some comment with missionary zeal that free exams “bring in the masses,” while others speak of the low-brow ethics of this bait-and-switch scheme.
More interesting are the comments of non-chiropractors like George McAndrews who have studied our profession. Another example, Dr. Pran Manga, noted Canadian medical economist and head-author of the Manga Report, commented on this issue:
“It is clear to me that a thorough and serious review of chiropractic ethics and professionalism is in order, long overdue in fact...Chiropractors do not rate very high among health care professions for being concerned about professional ethics...I say this as one who teaches and has taught bioethics for 14 years...Chiropractors also need to take supply management seriously...the rapid growth in numbers is a concern and the two problems are interconnected…”(2)
At the 1998 ACA Convention in Vancouver, B.C., George McAndrews recounted the more memorable instances from the Wilk v. AMA antitrust case, and noted his frustration with the chiropractic profession’s inability to organize and police itself. Often when he addresses chiropractic groups, he is known to bring the local Yellow Pages and reads the inane chiropractic ads. Mr. McAndrews flatly said in Vancouver, “5 percent of you are cultists, 5 percent are freaks, and the rest of you, who offer care that uplifts the quality of life for millions of Americans, keep your mouths shut!” (3)
As Dr. Lou Sportelli mentioned in an JACA article, The Pursuit of Image, this dilemma is not restricted just to outsiders to our profession.
“Thus, a new era of professional ethics is emerging, and the chiropractic profession must recognize the challenge to meet the expectations, or suffer the consequences.” (4) Could the fact that we see less than 10% of the population be a consequence of the questionable ethics in chiropractic? Rather than blaming the incessant medical wars or a biased press for our woes, perhaps our dilemma could also be a byproduct of us shooting ourselves in the foot with tacky ads, unsubstantiated hyperbole and a split profession? Maybe our greatest enemy is us!
Mr. Mark Goodin, the ACA's former legislative consultant/lobbyist on Capitol Hill, was painfully honest in his opinion of chiropractic's self-inflicted wounds.
"That enemy, of course, is this profession itself - and those elements within it that are unwilling to deal forthrightly with the charlatans, hucksters, profiteers, and wild-eyed 'philosophers' who put their own selfish interest ahead of science and the ethical and professional demands that every true healer must shoulder.
"They pass themselves off as 'educators,' but cut corners and counsel their students with messianic appeals on ego and self-promotion. They spend their out-of-practice careers in a cause to stop legitimate reform. They bring nothing of value to the future of this profession - but will resist, oppose, reject, undercut, and nit-pick any effort to lift it up through higher accreditation, more comprehensive education, real standards of care and more ethical practice requirements."(5)
Ethical practice methods must include the patient acquisition methods commonly associated with tacky chiropractic carnival-type displays. Although many DCs have done mall shows and such, read what one astute chiropractor experienced.
“My wife and I decided to visit the local county fair. As we walked through the livestock barns which were situated beneath the grandstands, we saw the usual potpourri of vacuum salesmen, water softener sales reps, a psychic palm reader and the like. Even the ginsu knife guy was there! But lo and behold, right there, next to psychedelic candle maker was to be found a bonified chiropractor.
“I ventured closer, then, my jaw dropped in horror as I listened to
this supposed doctor telling people who were lined up waiting what
their ailments were.. How did he know this, I wondered? I had been to a
chiropractor on numerous occasions and one thing I did remember was the lengthy and thorough examination given me. But, here was a chiropractor who was offering fair patrons answers to their health questions, just by running his hand down their spines!!!! It had an uncanny resemblance to the guy guessing people's weight, just a little further down the midway.
“Yes, there was a fish bowl and people were dutifully dropping their
names in it; perhaps some potluck reward awaited them for their deed.
Yes, the ol' doc was making appointments, right there, and yes the first
visit was absolutely free; free x-rays, free exam and free treatment.
“I walked away, horrified. This wasn't what I had known chiropractic to be. I always thought it carried a degree of respect and dignity. I envisioned the day that would come when I would see people in my office, anxiously awaiting to seek my help, and me being able to comfort them, offer guidance and possibly offer resolve to their complaints.
“Now, I had questions to ask. I called people that I knew in the
profession and explained what I had seen at the fair. I asked what it
was about. One doc laughed and said, ‘What you witnessed was a product
of Sid William's shenanigans.’ He said that whatever I did, to ‘stay
away from that garbage, cause that wasn't chiropractic.’
“Well, that's been a few years and remarkably things haven't changed
much, for I can still witness the same charade just by going to a mall,
a K-Mart or the same old county fair; new faces, same parlor tricks. Some
things never change, but one thing I am so thankful for. I went to the
right school and don't have to resort to spending my Saturdays making a
mockery of my profession like the guy down the street.” (6)
On the other hand, proponents of mall shows and free exams will argue with missionary zeal of the benefits of doing such displays. Mr. Shawn Clark promotes himself as a chiropractic marketing coach and suggests the following:
“I have been a proponent of free exams…. My reason for using the free exam approach is one of education. Before you get your stake and kindling ready, let me explain how I think this is very ethical.
“I think offering a free exam/screening allows us to make people more aware of the problems they have and to educate them on potential causes and potential consequences. I do not believe this process to be inherently anti-ethical. Now, here's where I need you to really here me out. I believe that the unethical behavior is in the diagnosing. I don't care how a person hears about Chiropractic, BUT, if the practitioner is prone to telling EVERYONE they need care, that is the problem, not the free exam. If a Doctor with good intention does a screening or free exam, GREAT! But if he tells everyone he sees that they need care or else... that is a stain on the profession.
“Selling is NOT automatically villainous, and can be a very high integrity endeavor. Again, the difference is intent. If I sit down with you and honestly help you determine your needs and offer solutions when I have them, that is service. If someone lies about your needs, lies about their ability to help and applies undue pressure to get you to act, then they are a charlatan. Chiropractic IS the child of a lesser God in the healthcare world. And I say-- so be it! I have worked with many practitioners who refuse to market themselves consistently. They try to put up a self-righteous front of professionalism. With a bit of digging, this often turns out to be a cover up for apathy or fear. Yes, many Chiropractors do use methods to get attention that are counter-productive, but let's not throw the baby out with the bath water… (Well, except maybe in the case of those chicken dinners).
“However, I am concerned about the public perception of Chiropractors. I agree that we should do all we can to avoid a carnival atmosphere or a used car salesman approach. I do NOT support the various NOOPE and insurance fraud antics. Sure, the percentage of tire-kickers and wackos is higher, but it is not the only type of patient these programs generate. I'll stick by my notion that the MANNER in which the exam is offered and the integrity of the exam will make the difference between a circus and a practice.
“One of my best clients see about 300 patients a week and wants more. He has always been gun-ho about free exams. Hands coupons out like candy. I had him do a drop-off analysis to see at what point new patients were discontinuing care. 50% were dropping out after the FIRST visit! And this is a doctor who already has a good practice. He didn't need more patients, he needed a better education system.” (7)
Obviously the argument about the ethics of giving free services at shows or health fairs has proponents on both sides. Some believe “anything goes” as long as it brings in new patients, much to the chagrin of Dr. Cline. Even a proponent of free services like Mr. Clark believes there must be professional standards that distinguish the manner or intent of such patient acquisition promos.
I believe Mr. Clark hit the nail on the head with his assertion that his client “didn’t need more patients, he needed a better education system.” I assert that rather than lowering prices like K-Mart running blue light specials, the key is to increase the Value Factor of your office in the minds of patients. I advertise that I'm the only nationally certified spinal rehab facility in Georgia to make my Unique Factor in their minds. Also, once they do come in, we concentrate on the Wow Factor--giving them the best exam, teaching them more about chiropractic and health via audio-cassette tapes, health class, ChiroVision, etc. and a well-trained/versed staff who know how to manage skeptical patients with transformational management.
Free exams only scrape the bottom of the barrel, and you can't build a practice with them, instead creating a frustrating turnstile practice. Even lowering prices only attracts Cost-Conscious patients, not Health-Conscious ones. After all is said, it’s your reputation that attracts patients, not your prices.
How you position yourself in your community to be the “best” chiropractor rather than the “cheapest” depends upon your communication skills/methods rather than a particular technique or the pricing issue. As Bill Gates wrote about in his book, Business @ the Speed of Thought, they use non-price criteria to attract customers. In this Information Age, people are seeking understanding of their health problems/solutions as much as they are seeking good prices, hence the plethora of health related web sites.
Another question every DC should ask himself is not only how to get new patients into the office, but what will you do with them once they do come in? Simply thinking your technique will wow them is like the cook thinking his recipe will win over the customer. On the other hand, it is more likely the service, the rapport, the aesthetics--these intangible, non-price criteria that will impress them
Aside from tacky ads, the DC has another problem to concern him—the mis-management of patients. Fewer than 20% of DCs put patients on a treatment plan and fewer than 10% have a health class or any patient education programs. Again, “cooks” trying to run their restaurants relying solely upon their recipes, forgetting management and “informative” marketing are the cornerstones of a healthy practice.
Rather than spending big bucks on external ads of any type, I recommend you strengthen your practice internally with “vitamins” such as patient education programs, empower staff management and comprehensive patient management before you implement any expensive outside-in promos. After all, building a practice is like building your own health—it best comes from the inside-out.
1. McAndrews, “Winning the Battle in Legislative and Regulatory Arenas,” JACA, 1992
2. Manga, Pranlal, private communication with author. June 18, 1999
3. McAndrews, George, speech before ACA Convention, Vancouver, B.C., July 20, 1998.
4. Sportelli L, In pursuit of image; chiropractic in the next millennium, JACA vol. 32, no .5, May1995. pp. 38.
5. Goodin, Mark, “Winning the Battle in Legislative and Regulatory Arenas,” JACA, July 1992, pp. 45-47.