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?
Table of Contents
3. Canadian Report: 1994
On Attitudes Toward Chiropractic
For The ACA: 1992 By Clayton Davis & Associates 5. New Zealand Report: 1993
Understanding the Market Qualitative Report
“I wouldn’t want my daughter to marry one.”
The Role And Image Of Chiropractic Services
By Jerome F. McAndrews, DC
–Mr. George McAndrews
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,
- Public relations is the effort of a corporation to promote goodwill between itself and the public.
- Marketing is the packaging of a product or service, i.e., appearance, price, distribution, etc.
- Advertising is to describe in some medium a product or service in order to induce the public to buy it.
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:
- The tendency to view them as being “results oriented”—such reasons accounting for 28% of total mentions. Again, the younger and older ends of the age spectrum particularly note this factor, these people being of the view that they are “fantastic,” that here is “almost nothing they can’t cure or at least relieve the pain for.” 14% make mention of the fact that they do get results, and significant results at that, from their chiropractor. This is followed by 10% who go so far as to say that a chiropractor has “cured,” if not rectified their problem. Such problems range from headaches, bronchitis, to recurring pain—these people then, placing particular faith in the value of chiropractors.
- A tendency to perceive them as specialists within the “skeletal” area—this accounting for 28% of all mentions. Such an attitude is more prevalent amongst 25-44 year olds. 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.” Their specialty lies in “skeletal” problems—these being practitioners that work with bones daily, who are “trained to help with skeletal problems.” Such people note that their methods within the area of manipulation “work,” that their massages are great,” this then underpinning their specialty in back complaint, neck complaints, and even certain sporting injuries.
- Their perceived quality of care and service—this accounting for 13% of all mentions. It is a recurring theme within the area of alternative practitioners that they appear more caring (amongst those who have used them) than GPs today, being highly concerned for the patient they are treating, very attentive and supportive, in addition to taking the time to listen to the problems of their patient. This then gives rise to a feeling that they are genuinely more interested in the patient, and not just in the number of patients they can get through in a day.
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%).
Predisposition to using a chiropractor in the future
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.
Incidence of seeking help/advice from various health care practitioners
Back pain (34%) sufferers sought care from:
- 55% MDs
- 25% PTs
- 37% DCs
- 9% DOs
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 Image Of Chiropractic
- People are aware of chiropractic on a superficial level
- They used words like “neck-cracking,” “bone-crunching,” and “manipulation.”
- Negative perceptions of chiropractic are influenced by misinformation, superstition, bias, and ignorance.
- Attitudes were based almost entirely on some mix of rumor, innuendo, hearsay, mythology, misconception, preconception, and ignorance.
- Inhospitable climate: hostile, unfriendly, suspicious, skeptical, or cautiously curious.
- Most common conditions for chiropractors—low back, sciatica, headaches, spine, joint problems.
- Chiropractic patients are no better informed than non-patients or detractors.
- Chiropractic is the treatment of last resort.
- Rarely are opinions of chiropractic based upon rational decision making.
- Positive perceptions—humanistic, non-invasive, treating cause vs. Symptom, chiropractors listen to their patients.
- A very special relationship can exist between a DC and patients—this can form the foundation to build a larger patient pool—patient is involved in his own cure.
Pitfalls to be avoided
- Very things that make chiropractic appealing are the very things that may impede its growth—perception of being “natural”, “positive”, “hands-on” and “personal” translates as a “promise,” and creates a high degree of expectation, a partnership, a form of involvement, in short, a meaningful relationship.
- If that “promise” is not kept, creates feeling of abandonment and disappointment, which explains why some of the criticism is so harsh, even among people who’ve been helped.
Negative perceptions of chiropractic
- Negatives are linked to the appeal as well—unrealistic expectations.
- Chiropractic carries a “burden”—psychological stress, fear, anxiety, disorientation, unknown quantity.
- Chiropractic is isolated from mainstream; aids in suppressing public awareness and knowledge
- 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.
- Without that sense of relationship, once the alleviation of pain is accomplished, on-going treatment is perceived as superfluous and costly.
- “The love of the quick-fix” describes the appeal of chiropractic.
- The assumptions of healing, long-term care, or prevention are hardly considered.
- To some extent, and perhaps unwittingly, chiropractors may contribute to or reinforce the quick-fix notion.
- Many of ex-chiro patients complained of an “assembly line” feeling rushed, unappreciated, unwanted psychologically—tends to create cynicism.
Chiropractic as enigma
- Little information about chiropractic has reached the public—they do not understand it—what they don’t understand, they disparage.
- 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.
Chiropractic sans imprimatur
- No “Good Housekeeping seal of approval,” therefore, chiropractic is not quite “legitimate.”
- No general imprimatur or sanction given to chiropractic by anyone; without govt sanction, chiropractic is suspect or considered renegade.
Chiropractic: the disavowed profession
- Majority of MDs and PTs do not recommend chiropractic to their patients accomplishes three things: isolation from mainstream healthcare services, suppresses public awareness and knowledge of chiropractic, creates negative incentive.
- “I don’t think chiropractors can prove anything. If they could, doctors would recommend them.”
Chiropractic: the terminator
- Some people fear chiropractic treatment—pain, permanent spine disorders, conditions worsened; terrified of the popping sounds of treatment, strokes.
Chiropractic: the unknown
- “All chiropractors are the same, do the same thing.”
- “No two chiropractors are the same, they all do something different.”
- Chiropractic remains largely unknown although everyone has heard of it.
- What people do not know tends to come from anecdotal hearsay, and much is deprecatory or prejudicial.
- Chiropractors do not do enough to educate their own patients, never mind the rest of society.
- 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.
- To the average person, chiropractic’s response appears to be absent.
Chiropractic: economic implications
- People do not place a high value on chiropractic.
- User fees act as a disincentive or form of punishment, akin to a “sin tax.”
- Chiropractic community must develop more effective communications programs and skills in order to: inform and educate; create awareness; improve visibility and recognition; and manipulate public opinion.
- In that way, three important advances will be accomplished: the perceived value will escalate and psychological impact of the actual dollar cost will be reduced; more people will consider chiro treatment a valid alternative to medicine; and governments will be pressured by public opinion into re-evaluating chiropractic.
Chiropractic and peer group pressure
- What other people think matters greatly to many people.
- Some would not seek chiro care because they could not face the criticisms and admonitions they knew would come their way.
- “Friends think you’re weird.”
Chiropractic and the issue of trust
- 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.
- “Chiropractors say or believe illogical things” not common canon of understanding or not scientifically proven.
- “All chiropractors think they can cure you, they will never refer you to someone else—not even another chiropractor.”
- “Many offices are old-fashioned, unprofessional in appearance.”
- “Chiropractors become impersonal, especially once the treatment is established.”
- “Chiropractors don’t have a code of ethics like MDs do.”
- “Many chiropractors claim to have the solution to all problems.”
Chiropractic and the fear of intimacy
- Especially acute among women, this syndrome has to do with “invasion of privacy” and in part it has definite sexual implications.
- Some men do not like or want to be touched, some homophobic, some ashamed of their bodies, concerned about body odors, others embarrassed at the idea of being sexually aroused by a female practitioner.
- Some women fear intimacy, being hurt or abused.
- “I didn’t expect him to be right on top of me. I felt my space was being violated.”
- There is a hint from some that a fear of being manipulated, literally and figuratively, may be associated with these feelings.
Chiropractic: limited application
- Chiropractic has limited application, primarily dealing with back and spine.
- Ailments such as earaches, stomachaches, asthma are not associated, despite some success stories.
- “You think back, you think neck, not other things.”
The counter-trend: alternative health care
- Only a distinct minority are actively involved in this counter-trend, but the vanguard of a change that will continue.
- Much of this new belief is compatible with chiro philosophy and practice, but conspicuously absent is an awareness that chiro is in the vanguard of this “revolution” in healthcare.
- Implicit in all the research findings is not just that people haven’t heard about chiro, 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?”
- Younger consumers are more prone to alternative approaches.
- Women are more willing to try chiropractic despite forces aligned against it.
Chiropractic vs. Medicine: David & Goliath in modern dress
- 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.
- The research argues, however, that this is not the most promising approach to the marketplace; and, at any rate, this is precisely what chiropractic has been doing for the past century.
- 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.
- In only a very few instances were chiropractors sought out first or voluntarily.
- It is only after the traditional treatment of medications and bed rest proved ineffective or too slow, or because of an antipathy toward the medications, or because of the threat of surgery that chiropractic was considered.
- Word of mouth is the primary means of advertising.
The image of the medical profession
- People are critical of medicine until a serious health problem arises.
- Medical profession has significant authority in matters of illness.
- Life without medicine is unthinkable or incomprehensible.
- Against this “tradition,” against the essential nature of medicine stands the chiropractor. His or her only weapon: literally, bare hands.
- What people do not know, question or fear about medicine is minimized.
- What people do not know, question or fear about chiropractic is exaggerated.
The issue of prevention
- The research suggests that prevention is no more closely associated with chiropractic than it is with medicine.
- A dichotomy exists between chiropractic’s aspirations and its accomplishments as a profession. Both patients and DCs tend to view chiropractic in terms of “crisis management,” the fast and effective relief of pain, the rapid restoration of mobility.
- A program must be developed to engender public trust and confidence.
- Patients are looking for guidance in their struggle for self-sufficiency and self-determination. They need an ally. They need a counselor. They need a reasonable alternative. Could that be in the future of chiropractic?
Chiropractor: perceptions and attitudes
- The image of chiropractic has improved and continues to improve; public confidence continues to develop, primarily through word-of-mouth recommendations regarding successful treatments.
- Old barriers remain strong; most people remain uninformed, make false assumptions, or are somewhat biased; a social stigma is till attached to chiropractic; many people ear chiropractic treatment, it is still often the treatment of last resort.
- The trend toward recognition and acceptance of alternative health care is an asset.
- In the public’s mind, chiropractic is limited to back pain; this lingering impression is primarily the fault of the chiropractic profession.
- There is some improvement in attitudes toward chiropractic within the medical profession, especially among younger doctors; but medical establishment still openly hostile.
- Full or partial user fees have economic impact on chiropractic, they are a great detriment and disincentive; and, primarily for three reasons: they limit the use of care, they provide users with an excuse to leave treatment early, they lend legitimacy to the arguments of critics and detractors overall, and they depress business.
- Divisions within the chiropractic community are political rather than ideological, messy and counter-productive.
- Despite the differences, a communications program would be supported.
Chiropractors on chiropractors
- 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.”
- Majority of DCs feels the profession is still defensive and thereby forced into being reactive rather than being proactive and demonstrating alternative healthcare leadership.
- They, and the public, would like someone to act as both guide and catalyst.
- Most striking is the intensity of conviction respondents bring to their arguments. Almost all are saying that chiropractic and its leadership cannot afford to be complacent; they are also saying confidence and conviction are the roads to pride and legitimacy.
- Behind these positions is a yearning for “equality,” a desire to be on the inside and not the outside looking in.
- Opinions regarding the medical profession fall into two camps: confrontation and those who favor ignoring. The latter group is in the majority.
- Consensus exists that there is far too much internal discord; almost all believe there are too many rifts, internecine struggles, and self-seeking factions vying for influence tearing at the fabric of chiropractic. The causes may be philosophical, but the effects are strictly political in the view of most.
- The situation is perceived to be inappropriate for those seeking to convince the public of their professionalism; this internal strife is seen to be destructive, counter-productive, and indirectly a negative influence on patients and the general public, not because the public is at all aware of it, but because it diverts focus and energy from the critical issue of promoting the benefits of chiropractic in an organized and sustained way.
- “We all must unite despite our differences to advance the profession.”
Definition of chiropractic
- Regardless of philosophy or technique, all discussed chiropractic with a fervor and dedication that can only be described as deeply humanistic. On one end were a few DCs who spoke of chiropractic in metaphysical and mystical terms or as a way-of-life; on the opposite end were a few who considered chiropractic as kind of “pseudo-scientific,” very pragmatic, or almost “mechanical” in its focus. Most DCs seemed somewhere in between.
- Regardless of where they stood, all of them think of their profession as a kind of “calling,” and all of them believe chiropractic can benefit the health and well-being of all citizens.
Philosophy & Technique
- Four principle categories of DCs as relates to the union of philosophy and technique:
- “straight”—those DCs who limit their treatments to back, spine, and neck; and who use only traditional hands-on adjustments
- “mixer”—those 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.
- “progressive straight”—those who believe in broader applications of chiropractic, but who rely on hands-on manipulation
- “progressive mixer”—those who believe in broader applications, and who use other therapies, techniques, devices or instruments.
- The large majority are “activists”—impatient for change, wanting to see more proaction from their leadership, wanting more progressive or more tolerant attitudes from their leadership as well.
Prevention vs. Crisis Management
- Whereas the public did not mention prevention in the context of chiropractic philosophy or treatment, chiropractors themselves placed considerable emphasis on it.
- They were quick to admit that building a practice on prevention is a philosophical dream, a fond wish, rather than an immediate reality. Many believe that preventive care is the wave of the future and chiropractic should be in the vanguard of it.
- In addition to regular chiropractic care which keeps the spine and nerve system in good condition, most DCs include exercise, diet, and the proper use of the body as part of the program.
The Association: repository for unused opportunities or catalyst for change?
- There is a restlessness, combativeness among chiropractors, an eagerness to bring about change that more closely resembles revolution than evolution.
- Most DCs feel either the association does not play enough of a conciliatory role vis-à-vis the rifts that plague the profession, or that it is itself responsible for exacerbating the problem.
- There is a lack of leadership in activity promoting an understanding of chiropractic among the public or important opinion leaders.
- “We don’t need more brochures and pamphlets. We need organized exposure to the public.”
- Clearly, this is an instance in which the membership feels it is ahead of its leaders.
- Needs are: identity & image; position; and reputation.
- Identity is the visual representation of chiropractic by way of logos, signatures and their control systems as a way of ensuring the maintenance of identity standards.
- Image refers to the impressions that most frequently combine to shape public perceptions of and spontaneous reactions to the association and the profession
- Position is the unique place that chiropractic occupies vis-à-vis the competition in the public view. A preemptive position is one that is difficult for the competition to usurp or replace.
- Reputation can best be understood as the sum and substance of the association’s and chiropractic’s philosophy, ethical and moral principles, and actual behavior in the public arena as it is perceived.
- Public affirmations of additional applications of chiropractic should be postponed until chiropractic’s identity and image position and reputation can be more firmly established.
- A coordinated strategic communications and public relations program should be developed, on going, 5 years minimum in programs and built on achievement.
Identity & Image
- The significant features that distinguish chiropractors from physicians are: hands-on treatment, humanistic positive approach to healing, the personal relationship between chiropractor and patient, and the aspect of “natural” health maintenance and wellness.
- The identity chosen to represent the association and its members should reflect progressive concepts of health and wellness as a strategy to shape public attitudes and perception.
- The identity must also help “legitimize” the chiropractic profession; it is essential to create a national communications standard that will provide consistency of identity among all state associations, and it is essential to establish a single and unequivocal identity for chiropractic in the minds of the public as soon as possible.
- The identity program should constitute the initial effort of the association toward the fulfillment of its goals and objectives to overcome the apparent lack of familiarity with chiropractic by the public.
- It may be necessary to publicize a flurry of activity that establishes the moral and professional authority of the association, such as
- Developing and regulating standards and practices
- Involvement or sponsorship of scientific research
- Involvement or sponsorship of continuing education
- Relationship to chiropractic education
- Mediating role in representing chiropractic before the medical establishment, legislators, and government agencies.
- It is critical that the public perceive that the association is a real organization and professional, and doing things that benefit the public, patients, and chiropractors across the country.
- The association needs to confirm indirectly that it is parallel to that of the AMA in stature and role.
- Initial image phase should lean heavily on public relations activities, especially those on an editorial nature. Use should be made of print and electronic news and information media. Articles and press releases should be placed in newspapers, magazines, and on radio and TV news and information programs.
The first year’s activities should include:
- Development and implementation of an identity program
- The cooperative buy-in to the identity program by state associations
- The establishment of the association as advocate for all associations and chiropractors
- Initial planning for a coordinated advertising, public relations, and educational program aimed at schools, civic groups, libraries, and sports groups.
- There should be spokespersons for chiropractic on the lecture circuit in schools, colleges and universities, and participate in civic and public interest debates and round-table discussions.
- Simultaneously, 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. “Natural” should be treated not as a noun or adjective, but as an action word. In that way, “natural” becomes a continuation of the initial strategy with action as the common thread; and second, it suggests that chiropractic natural healing is an active and dynamic enterprise with potentially broader scope.
- A parallel and complimentary phase of image building should include the premise that chiropractic means responsible, personal, compassionate, drug-free, and participatory treatment. This is how to “define” chiropractic (as opposed to the definition of the association) in the minds of the public, and this elucidation will contribute to positioning strategies as well.
- A possible theme for this strategy might be: The Art & Science Of Chiropractic. Under the science of chiropractic talk about the fact that it is: responsible, knowledgeable, tested and proven, drug free, non-invasive, etc. Under the art of chiropractic talk about the fact that it is: personal, compassionate, hands-on, participatory, etc.
- The Art & Science Of Chiropractic theme should be implemented through a series of succinct and sharply focused “position papers” that will be distributed throughout the print media; and to all organizations, public or private, that have a vested interest in health care/public health, education, sports and athletics, public policy, etc.
- It is also recommended to do the same with videotape that can dramatize features of chiropractic discussed in previous recommendations.
- In addition to the above effective but traditional methods of communication, it is recommended that the association consider inter-active communication methods [like videos and the internet], which are by their very nature are representative of the participatory and personal essence of chiropractic.
- Individual chiropractors could use the videos and printed materials in a more neighborly and sociable way to explain chiropractic informally. It is also imperative to the long-term success of the program that effective communications activities have a grass roots origin and appeal. Information must flow from the bottom as well as from the top.
- It is necessary to establish a pre-emptive position for the association and chiropractic—one that is solitary and defensible, so that over the course of the next five years, and even beyond, the position is not only etched into public consciousness, but is also free to prosper because it cannot be successfully challenged to displaced.
- 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. Above all else, it would be counter-productive for the association or the chiropractic community to be perceived as being on the defensive in any way—or even to be perceived as struggling for equality.
- The positioning strategies begin with the premise that chiropractic is a full and equal partner among health care providers.
- It is recommended that in public, at least, the association and the chiropractic community should ignore the medical hierarchy and any other critics.
- A major issue raised is the public’s apparent lack of awareness of the extent of formal education and training which chiropractors must successfully undergo in order to be certified as doctors. It is incumbent upon the association to educate the public through public relations and strategic communications programs regarding the high standards of chiropractic today.
- First, chiropractors must be positioned as professionals, as doctors of chiropractic. In fact, it is strongly urged that in all instances, formal and informal, in private or mass communications, chiropractors refer to themselves as doctors of chiropractic. It is well established that “doctor” is synonymous with post-graduate education and professionalism. Those associations must be hammered home.
- Secondly, chiropractic should be cast in a leadership role vis-à-vis alternative health care. Emphasis should be placed on chiropractic’s 100-year old tradition of alternative methodology and its modernity—all in the same breath. That type of juxtaposition is an effective communications tool.
- Third, 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.
- In other words, it is recommended that chiropractic’s documented success in treating spine, back, neck, and joint problems should be chronicled in terms of physiological and psychological benefits to patients, and as well as in terms of the economic advantages as per the Manga study.
- 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.
- 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.
- 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.
- A significant part of sculpting reputation will be emphasizing chiropractic’s efficacy. In this contest, it is urged that specific ailments and injuries not become the focus. That is part of positioning. Instead, it is recommended that the association stress the relationship between chiropractic and the spine, the relationship between the spine and the nervous system, and the relationship between the nervous system and general good health.
- This is, in musical terms, a natural progression, and even an untrained ear can hear it. In the same way, most people will grasp the significance of these relationships, and a more concrete and positive understanding of chiropractic will result.
- Regarding efficacy, a public relations program should be initiated in which third party testimonials are given by famous sports figures and other celebrities who have benefited from chiropractic treatment.
- Under reputation, it is essential to talk directly about partnership, the very special and personal relationship that distinguishes chiropractic from traditional medicine; about the inter-relationship between patient and chiropractor; about self-reliance and self-determination as values chiropractic endorses; and about the importance of a positive attitude toward healing and health.
- Chiropractic’s stance on matters to preventative health care are extremely important in the long run, but not in the immediate future, in our opinion. Due to the fact that it is a difficult concept to “sell” it must take a back seat temporarily to more pressing issues—those previously discussed.
- If communications progress keeps pace with expectations, and many of the identity and image, position, and reputation goals have been met, then in year three, four, or five the issue of prevention can be addressed. Further, it is suggested that prevention is precisely where chiropractic can take a strong and justifiable leadership position and make a major contribution to health care.
- In the view of the authors of this report, communications programs relating to reputation—and some key programs relating to image and position—should consist primarily of printed materials that can be distributed by individual chiropractors, by state associations, and by the national association to opinion leaders at all levels of influence, to educators and educational institutions, to libraries, to the insurance industry, to workman’s compensation boards, to legislators and government agencies, to medical groups, to physiotherapists, to health food stores etc. In a staged program, of course, not all at once.
- Careful assessment, too, should be made of more innovative communications techniques such as inter-active videos and CDs, video games [The Subluxator], direct marketing, video-conferencing, computer-driven information services such as prodigy and CompuServe, etc. For example, chiropractic’s “hands on” involvement with its patients can translate brilliantly into inter-active devices that underscore self-determination.
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:
- New associations and organizations are forming by the handful, as are new publications.
- Chiropractic entrepreneurs, many of them unethical in their motives or designs of products and services offered, are proliferating.
- Charges for chiropractic procedures are increasing by leaps and bounds to a point where chiropractic may no longer be costs effective.
- Insurance rip-off schemes are increasing.
- Personal advertising is not only becoming more frequent, more competitive and more aggressive, but also much of it is unprofessional, unethical and misleading.
- Less and less time is being given by practitioners to hands-on treatments of patients and more time is being devoted to the presentation of non-traditional procedures.
- There seems to be an increase of those elements of the profession who somehow feel inclined to combine chiropractic with fringe and cultist philosophies.
- Highly sophisticated practice-building schemes are spreading, some packaged under the label of “research.”
- Self-proclaimed chiropractic spokespersons and public relations experts are popping up on the scene, many of which appear to be emotionally unstable and detrimental to the image of chiropractic.
- Emphasis seems to be fasts moving from a service-dedicated professional to a money-dedicated practitioner.
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.
The rise or fall of chiropractic is now in the hands of the ACA.
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:
- Control of mission: a strategic planning process
- Control of message: from a public perception, there are two totally different chiropractic professions
- Control of spokespersons: too many self-proclaimed experts
- Control of entrepreneurs and opportunists: the numbers of purveyors of questionable devices and get-rich-quick courses are increasing.
- Control of competitive threats: PTs who want to get into chiropractic’s business of SMT—this poses a major threat to chiropractic
- Control of education: SCASA was a good case in point of what can happen when a situation gets out of control.
- 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.
- Control of priorities: there is so much to do, it’s easy to get off track. The most common mistake is to try to press is position in a court of law with legally weak evidence.
- Control of research: natural areas for research with high consumer interests would be in automotive seating, auto accidents, work problems, sports injuries and performance, posture and learning, structural problems related to modern technology, trends and lifestyles, benefits of utilizing both chiropractic and medical procedure in combination for various ailments, etc.
- Control of relationship with government and special interest groups: sporadic and defensive rather than consistent and offensive, ACA must control the flow of information and personal contacts with these groups; establish relationships of respect and cooperation, not those of constantly asking for favors and attacking well-entrenched programs and issues; should be involved during planning and development phases, so not in position of defense and retaliation.
- There is no point to developing ideas, programs, materials, promotions or positions on issues if you do not have the resources to communicate them properly to the required parties.
- Therefore, it is important for the ACA board to realize and fully understand that communications must be a high priority item—both in terms of budget and manpower. Unless the ACA recognizes that and puts all its programs into the proper perspective with enough communications (public relations) furl to power them and enable successful implementation, the ACA’s programs are doomed to failure.
- This realism must be understood: that ideas alone do not make for success. If there was a weakness in the entire strategic planning exercise, it was that it was a forum for uncontrolled dispersion of a myriad of ideas without the slightest chance that the great majority could be implemented. Little concern was placed on budgetary and manpower restrictions, and how they could be overcome. Little guidance led to the recognition that success is 10% innovation and 90% implementation, that ideas are a dime a dozen and that where most organizations fail is in their ability to fully and aggressively implement programs.
- Now that all the ideas and plans have been presented, the question is how will the ACA implement them, fund them, disseminate them, and communicate them?
- The greatest failing that ACA has experienced in the past has been its inability to fully dedicate itself as an organization to squeezing all the juice of opportunity out of every project and effort.
- Public relations and communications seem always to become the ideal victim to cuts when overspending is done in other areas. Communications involves soft costs spread out over the entire year, so when nine months go by and there is a cash crunch, pr appears to be a likely place to save. The fallacy of this approach is that without the communications mechanism and full implementation of the communications plan, the investment in any program is wasted.
An association must maintain its fiscal stability, but pr experience also dictates that:
- An association is a service organization, not a financial institution. Therefore, its goal should be to spend money to insure the success of its programs, and to serve its shareholders (members) not to “save” money.
- Marketing is essential to every company, organization or profession, and unless the entity is willing to invest in itself, it cannot expect growth or success.
- While the ACA is a democratic organization, it should function the same way as does a major corporation. The board is responsible for its success, and its decisions should be based on what is considered for the welfare and profit of its shareholders. In this respect, it should be decisive and strong, not succumb to the whims of some small group.
- Members of an organization should be willing to pay their fair share. While dues, tax and assessment are never welcomed, they need to be done when appropriate. Members and the profession are never hesitant to clamor for more services. How do they expect to get them if they don’t pay for them?
- The biggest mistake any organization can make is to skimp on communications (public relations), for this is the element that creates the image and the identity. It also sells the “shareholder” who is not privy to inside information on the quality of the organization’s leadership. The best programs in the world will not be recognized if their availability and benefits are not communicated. One doesn’t have to look far in our society to recognize that exciting packaging and aggressive promotion is essential for success.
- Following on the heels of the last statement, it is not enough to do something; it must be done as well as possible. Too often the association is penny-wise and dollar foolish. The ACA should not waste money, but it should make each of its investments fully productive. As an association, it cannot be recognized as productive and successful it if does not work constantly to portray a quality image.
Communications is a science
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:
- The better they know you, the more they’ll like you—providing you deserve it. Organizations often feel that their “poor image” stems from a general lack of knowledge of their activities.
- Change yourself—it’s easier than changing the public. The public will never change its thinking about you unless you, on your own, reform any questionable policies and practices.
- Speak the language of action. If you want to be listened to, support your words with actions. Words, themselves, are hollow.
- Weary not in well-doing. Public opinion takes time to develop. Don’t give up good programs if they don’t meet with immediate public recognition. Give them time to build.
- Truth rides the storm; half-truth and falsehood blow away. Always base public relations programs on truth. There is simply no substitute.
- Put your heart where your money is. Money alone can’t buy favorable public opinion. Back up your money with personal participation. The public will get the message.
- You may like cake, but you can fish better with worms. You must tell your story in terms of public’s needs, and not your own. If you have an abstract idea to put across, bait the hook with human interest, not self-interest.
- People interest people most. People want to hear about other people, they’re less interested in a firm or organization. Express things in terms of human interest.
- Watch that log—it may be a crocodile. Clever or easy solutions rarely work. Before taking any public stand, an organization must thoroughly examine all the ramifications.
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?
Is the ACA equal to it?
Important areas of concentration
- Senior citizens—by 2009, one in every 3 persons will be 50 years or older and number over 100 million, controlling $130 billion in discretionary income, and deeply concerned about health.
- Women—women make the overwhelming majority of health decisions and physician selection decisions.
- Sports—if there is an area where chiropractic seems to have a natural fit, it is in sports. It is easy for athletes to accept and easier for media to recognize, and it makes for a good story.
- Industry—the science of ergonomics is opening for chiropractic not only in terms of health, but also production and cost containment.
- Hospitals—economic squeeze to fill beds, the Wilk decision has cut the monopolistic noose around the hospitals’ necks, positive media exposure and a favorable experience for referrals between DCs and MDs, and patients requesting chiropractic care are advantages to the hospital and benefits to patients.
- Managed care—chiropractic cannot afford to overlook the growth of managed care—it is here to stay and growing.
- Government—the ACA must be at the planning table when programs are in their developmental stages; they must be able to provide intelligent and reliable input.
- Other markets and needs—there are numerous groups that need to be influenced, such as children, teachers, researchers, community leaders, other professionals, and many others.
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.
- To put the ACA and chiropractic in a power position by controlling, channeling and disseminating information and knowledge.
- To clearly identify chiropractic as to what it is, what it does, how it differs from medicine, and what benefits it provides for various elements of society as well as the individual.
- To more fully present the cost benefits of non-hospitalization but at the same time make inroads into hospitals and show administrators and boards the advantages of chiropractic staff privileges and the hospital.
- To more fully associate with emerging trends, issues and legislation. To give chiropractic a mainstream image, as opposed to an extremist identity.
- To broaden the ACA’s demographic exposure—to more fully cover children and senior citizens; men and women; white collar and blue collar workers; special occupations and sports. But to target in on special opportunities, special markets and special interest audiences with messages with which they can easily identify.
- To maximize broadcast coverage on both a national and local basis with appearances by and interviews of chiropractic leaders.
- To establish a one-voice communications source for chiropractic. The ACA must be considered as the credible voice of chiropractic. The message and the spokesperson must be consistent in focusing on issues related to priority programs.
- To gain a more personal relationship with media by letting them experience chiropractic; within the doctor’s office, the educational institution, research facilities and special utilizations.
- To build more confidence about the future with graduating students, give them ore guidance and assistance. To alleviate their dependency on entrepreneurs peddling practice-building courses.
- To continue to place emphasis on the doctor of chiropractic as a “family physician,” and thereby create an image that the DC is (1) a primary physician, and (2) a physician who treats all age groups, and (3) a physician who maintains a close and personal relationship with the family unit.
- To take a consumer advocacy approach to protect the patient. This would involve public information about the dangers of overuse of medications, anti-steroid campaigns, and the recommendation that “it never hurts to get a second opinion.”
- To exert chiropractic’s authority in areas that are obviously chiropractic subjects, such as: scoliosis, posture, whiplash, sports and occupational back problems. To depict the doctor of chiropractic as a total health authority.
- To motivate both the doctor of chiropractic and the medical doctor to build a better personal relationship and strive towards a team effort for the benefit of the patient.
- To motivate the DC to become more involved in community affairs and expose himself to a wider audience.
- To motivate high standards of performance among chiropractors through the communication of ethics and professional practice information and the display of acceptable role models.
- To establish a professional image of progressiveness, good leadership and unity. To continue to be ahead of other professions in public efforts that hinge on new waves of ideas and styles.
- To set high standards of public relations and advertising. To try to deter non-professional or hard-sell approaches by providing high quality materials for those doctors who wish to advertise.
- To maintain a clear and recognizable distinction between public service material and materials prepared for paid advertising use, so as not to violate the confidence of media.
- To help; the DC to become more sophisticated toward public relations and provide him/her with adequate tools.
- To make both the individual dc and the state and local association more fully aware of the ACA’s resources of materials and induce greater use of ACA-produced materials. To induce the use of universal message.
- To promote more cooperation between state and local organizations, and encourage more dependence on ACA. To make ACA the authority and the source.
- To make the most of the public relations budget and create an external and internal atmosphere that makes it appear that it is far larger than the actual budget.
- To direct a portion of the ACA’s overall public relations program, whenever possible, toward special needs and special projects conducted by councils, commissions and committees.
- To better merchandise ACA as a viable, needed organization that not only services its members efficiently, but also is the sole vehicle with which chiropractic as a profession can achieve its goals and move confidently into the 21st century.
- To portray the ACA’s leadership as aggressive, bright, conscientious and the most qualified to carry the banner for chiropractic.
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.
- Most people don’t realize that what they like is not what necessarily motivates others, and the worst mistake they can make is to judge by their own likes and dislikes.
- Most people don’t realize that it is wasteful and non-productive to haphazardly seek time and space. It takes a plan and a strategy.
- Most people don’t realize that there is no panacea for gaining instant recognition and approval. It takes time and patience.
- Most people don’t realize that you can’t get the job done with a one-shot splurge. It takes a balanced blend of media used on a consistent basis.
- Most people don’t realize that one medium is not necessarily better than the other. A medium is just a tool with which to get the message out, and its use is dependent upon the strategy, the plan and the needs of the program.
- Most people don’t begin to understand the enormity of programs and the size of budgets utilized by national corporations with which they compare their own marketing attempts. We are talking about hundred of millions of dollars.
- Most people don’t know that even free exposure is not really free because it takes money to create the tools and administer the program.
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.
That is our job: to distribute information as effectively and as economically as we can in order to spread the knowledge and truth about chiropractic.
Understanding the Market
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:
- Chiropractic does not involve drugs. The majority of respondents took a pragmatic attitude to the use of drugs. Their concern was not with the use or non-use, but with their effect on treatment. Some reservations were expressed that pain killers could make the identification of a complaint more difficult and so inhibit treatment.
- Chiropractic is natural: As with ‘holistic’, the term ‘natural’ was not spontaneously associated with chiropractic. It also carried negative connotations implying the denial of technology such as x-rays. Such devices were identified with the benefits of modern medicine and the greater ability to diagnose complaints, thus use of technology was preferred over ‘natural.’
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.’
- Chiropractic needs to promote itself as more than just specializing in ‘bad backs.’ It should promote its ability to treat a wide range of problems. Although, caution needs to be exercised to avoid ‘promising’ cures leading to loss of credibility. The ‘bad back’ is an ailment the target market does not relate to positively. It is linked with ‘bludgers’ or those not willing to pull their weight in society or the work force. Therefore, a profession that focuses exclusively on this complaint is likely to covertly represent a similar stigma to that of its patients.
- The majority of chiropractic experienced cited word of mouth as the current form of advertisement. Personal recommendations of friends and acquaintances as to the relief afforded by chiropractic provided evidence of achieving the desired goal; a cure.
- Overall, some respondents were aware of advertising by chiropractors, others were not. But there was little content awareness through advertising—what chiropractic could involve or its philosophy.
- A major issue for all groups was the promotion of information detailing what actually is chiropractic. There was felt to be very poor understanding of this both among those who had used chiropractors and the general public. This specific information was recommended to be aimed at those who were already aware of chiropractic but wanted to find out more.
- The chiropractic profession was not felt to sufficiently promote the successes of those who had undergone treatment.
- There was considerable consensus that chiropractors required to get ‘on side’ with GPs working with them to achieve the recommended status PTs were currently seen to enjoy among GPs.
- Moreover, it was felt advertising should promote chiropractic through general health education; teaching people how to avoid injury or illness. In regard to general TV or radio advertising it was felt that directly promoting chiropractic could cheapen the image of the profession. Therefore advertising of an educative nature was more appropriate. “I remember the ad ‘Don’t use your back like a crane’ a few years ago and that stuck in everybody’s mind. It was a simple ad and probably generated a lot of business.”
- Back ailments are topical not only for sufferers but non-sufferers as well. This existing interest provides a ready-made channel for information about the back and back problems. Furthermore, this should promote spinal problems as amenable to a permanent cure, rather than a temporary measure, through chiropractic.
- Chiropractic needs to overtly communicate more than ‘bad back’ syndrome, as it was not a positive. Naturally, unrealistic claims of cure would reduce credibility.
- Promote the use of technically advanced treatment and diagnostic aids to dispel any residual myths of chiropractic being fringe or outdated while it also emphasized that the use of technology ensured the best possible diagnosis and treatment.
- Standard charges must be communicated and a part of expected consumer rights. Those who had used chiropractors noted that charges varied and advocated the introduction of a standard charge.
- A formal qualification register should be published to increase the perception of DCs as reputable professionals to create a greater sense of confidence.
- Promote chiropractors role in both accepting and if necessary referring patients. “Chiropractors shouldn’t try to persevere with a problem that is non-reparable.”
- Information available on treatment expectation. Those who had not been to chiropractors wanted information about what to expect, what could happen and what medical procedures could occur. It was felt there was insufficient knowledge in the community as to what actually occurred.
- It was also felt that it should be made clear if treatment would occur on the first visit or would this be an examination only. This was an important issue for people in pain who wanted instant relief.
- Respondents expected a DC to fully inform them what the exact problem was, how it would be treated and how long this would take. In other words, giving patients some standard with which to independently assess the progress of treatment.
- Promote the presence of a governing or regulatory body. The ability to lodge a formal complaint was felt to give confidence in the profession’s ability and integrity. The grounds and how to lodge a complaint should be widely advertised.
- Provide a booklet including ancillary services available for chiropractic patients. The booklets could contain cash discount incentives so that the information would be kept as well as encouraging an appointment.
- Advertise in the Yellow Pages. A minority of respondents were interested in undergoing chiropractic treatment. These respondents were likely to approach a particular chiropractor on the basis of convenience or individual advertising.
“I wouldn’t want my daughter to marry one.”
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.
Code Of Ethics
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?
- Are we willing to sacrifice credibility by allowing the 10% of our freaks and cultists to over-state our scope?
- Are we willing to soil our image by falling on the sword over vaccines, homeopathy, hair analysis or other non-chiropractic issues?
- Are we willing to remain marginalized because we show low professional ethics with the “anti-anything medical” and “anything goes” attitude that allow some DCs to run amok?
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.
- 30% have used chiropractic care
- 10% had used chiropractic care in the past year
- 66% have used only MD services
- Chiropractic patients are generally older, poorer, less educated, more rural, blue collar, more physically active, and in poorer health than MD patients
- 13% of MD visits were for ms disorders, 80% of DC patients were MSDs
- 74% of all respondents think that DCs contribute to a healthy society
- 68% think that DCs should be covered by health insurance
- 62% think DCs should be able to treat patients in hospitals
Source of information
- 49% of Pennsylvanians receive their information about chiropractic primarily through friends and relatives
- Only 12% through publications and reports
- Only 3% learn about the profession through advertising
Patient perception of treatment
- Patients rated DCs higher than MDs on personal attention, waiting time, and cost of visits
- MDs and DCs received almost identical ratings on general patient satisfaction and effectiveness 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:
- 18% of respondents think that DCs employ medications in their treatment
- 25% of respondents think that DCs are members of the AMA
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
- The chiropractic-advertising insert was widely recalled. After about one month, 6 in 10 of the respondents indicated that they recalled the supplement in the April issue of Reader’s Digest.
- Exposure to the information resulted in a considerable improvement in positive perceptions of chiropractors. Descriptions of chiropractors as “highly trained individuals” and as “trustworthy and honest” increased by 67%; as “caring and concerned” increased by 56%; and as “competent and qualified” increased by 55%.
- Respondents demonstrated an increased awareness of chiropractors and their role in health care program after reading the insert. Nearly one half of the respondents were aware that chiropractic was an effective method of treatment for many types of health problems, an increase of nearly 80%. Two-thirds of the respondents indicated a new awareness that chiropractic was included in government and private health care programs and that chiropractic is an approach to health that utilizes the body’s inherent natural recuperative powers.
- Nearly 6 in 10 of the post-test sample reported that either they or someone in their household had, at one time, visited a chiropractor. Nearly one quarter of these had household members currently using a chiropractor.
- Satisfaction with chiropractors among those who have used them is relatively high. Nearly 8 in 10 of these respondents indicted that they are very or somewhat satisfied with their experience.
- The percentage of respondents who indicated that hey were likely to recommend going to a chiropractor to a friend increased significantly as a result of exposure to information in the insert. More than one half of the respondents who read the insert indicated that they were likely to make such a recommendation.
- After reading the advertising insert, one half of the respondents reported that people visit chiropractors for relief of back pain or headache tension/pain. Nearly one quarter cited chiropractors as alternatives to conventional medical treatment and medication.
- Awareness of “adjustment” as a chiropractic procedure increased by 27% after reading the ad insert. More than three quarters of the respondents indicated that they were aware of the procedure, most frequently describing it as the alignment of the vertebrae or manipulation of the spine.
ASSOCIATION OF CHARACTERISTICS WITH VARIOUS PROFESSIONS
- The perception of chiropractors was shown to improve as a result of exposure to the advertising insert in spite of this improvement, however, one should note that chiropractors are still less likely to be described with these positive terms than are MDs, dentists, optometrists, orthopedists, or physical therapists. Chiropractors are about equally likely to be described positively as are podiatrists, though are far more positively perceived than are faith healers.
- While respondents in the post-test group were generally more likely to associate the positive descriptive terms with chiropractors than were the pre-test respondents, this difference was not significant for the terms “ethical/conscientious” (17%) or “well recognized (12%).”
- While fewer than 2 in 10 (18.5%) of the pre-test respondents considered chiropractors to be “highly trained individuals,” 3 in 10 (30.9%) of the post-test respondents described chiropractors in this way. This represents a 67% increase in likelihood of describing a chiropractor in this way.
- While more than one in 10 (13.5%) of the pre-test respondents considered chiropractors to be “trustworthy/honest,” more than 2 in 10 (22.5%) of the post-test respondents described chiropractors in this way. This represents a 67% increase in likelihood of describing a chiropractor in this way.
- While more than one in 10 (14.5%) of the pre-test respondents considered chiropractors to be “competent/qualified,” more than 2 in 10 (22.5%) of the post-test respondents described chiropractors in this way. This represents a 55% increase in likelihood of describing a chiropractor in this way.
- While nearly 2 in 10 (16%) of the pre-test respondents considered chiropractors to be “caring/concerned,” one quarter (25%) of the post-test respondents described chiropractors in this way. This represents a 56% increase in likelihood of describing a chiropractor in this way.
AGREEMENT WITH STATEMENTS ABOUT CHIROPRACTORS
- Respondent awareness of the training and licensing requirements for chiropractors demonstrated a considerable change from the pre-test to the post-test (an increase of 15.3% and 25.8%, respectively.
- Respondent awareness of the inclusion of chiropractic in health care programs also demonstrated a sizeable change from pre-test to post-test (an increase of 22.7%)
- “Chiropractors are skillful in treating neuro-musculo-skeletal problems such as disc and other back and neck disorders, postural problems, and conditions of the joint.” Pre-test = 56.5%; post-test 77.5%
- “Chiropractic assists the body to repair itself utilizing its own natural ability.” Pre-test = 54%; post-test = 69%
- “Chiropractic is an effective method of treatment for many other types of health problems.” Pre-test = 25%; post-test = 45%
- “The chiropractor is a Family Physician.” Pre-test = 21.5%; post-test = 40%
- “Chiropractors are members of hospital staffs.” Pre-test = 19.5%; post-test = 28.4%
USAGE OF CHIROPRACTORS
- Fewer than half of the pre-test respondents indicated that they or some one in their household had visited a chiropractor. Significantly more of the post-test group, 6 in 10, indicated such a visit in the past.
- While the overall usage of chiropractors was greater in the post-test group, current usage of chiropractors did not differ between the two groups. About 1 in 5 of the respondents in both groups indicated that they or someone in their household was currently using a chiropractor.
- “No, have never been to a chiropractor.” Pre-test = 55%; post-test = 40%
- “No, not currently seeing a DC” among those who have ever been to a DC: Pre-test = 75.6%; post-test = 73.8%
SATISFACTION WITH CHIROPRACTORS
- 8 in 10 of the pre-test group who had experience with a chiropractor indicated that they were either “very” or “somewhat” satisfied with their chiropractor.
- 7 in 10 of the post-test group who had experience with a chiropractor indicted that they were either “very” or “somewhat” satisfied with their chiropractor. This difference between the two groups was not significant, however.
- “Not too satisfied.” Pre-test = 6.7%; post-test = 13%
- “Not at all satisfied.” Pre-test = 12%; post-test = 10.7%
LIKELIHOOD OF VISITING A CHIROPRACTOR
- More than one-quarter of those who had never been to a chiropractor in the post-test group indicated that they were either “very” or “somewhat” likely to visit one. This is significantly more than in the pre-test group.
- “Not too likely.” Pre-test = 30%; post-test = 39%.
- “Not at all likely.” Pre-test = 55.5%; post-test = 25.6%
LIKELIHOOD OF RECOMMENDING A CHIROPRACTOR
- More than half of the respondents in the post-test group indicated that they were “very” or “somewhat” likely to recommend a chiropractor to a friend. This is significantly more than were willing to make such a recommendation in the pre-test group.
- “Not too likely.” Pre-test = 19.5%; post-test = 23%.
- “Not at all likely.” Pre-test = 41.5%; post-test = 22%.
WHY PEOPLE VISIT CHIROPRACTORS
- Respondents generally considered that people visited chiropractors when they have backaches or other back problems. While half of the pre-test group cited this reason for visiting a chiropractor, only 1 in 3 of the post-test group cited this reason.
- About 1 in 5 of both the pre-test group and the post-test group cited relief from headache pain and tension as a reason for visiting a chiropractor.
- Condition Pre-test% Post-test% Change%
- Back problems/backaches 50% 31% -18
- Muscle/joint pain 18 6 -12
- Relief from pain/headache tension 18 20 -2
- Got no help from MDs 13 14 +1
- Prior to surgery 2.5 2.9 0.4
- Help without medication 2.0 7.4 5.4
- To straighten bone structure 1.5 1.0 -0.5
- Lower cost than MD 1.0 1.5 0.5
- Other 10.5 14.7 4.2
- Don’t know 9.5 2.0 -7.5
- No answer 2.5 6.4 3.9
WHAT CHIROPRACTORS DO FOR PATIENTS
- Pre-test respondents were most likely to cite alignment of spine/bones, relief of pain and massage of sore muscles as the principle services which chiropractors perform for patients. Respondents in the post-test group were also likely to cite “make body adjustments” as a major service of chiropractors.
- Condition Pre-test% Post-test% Change%
- Align spine/bones 43 30.9 -12.1
- Relieve pain 25 25.5 0.5
- Relax/ massage sore muscles 19 14.7 -4.3
- Use heat/ exercise therapy 6 0.5 -5.5
- Make body adjustments 0 16.7 16.7
- Relieve pressure on nerves 0 3.9 3.9
- X-ray 3 2.9 -0.1
- Help without medication 0 2.9 2.9
- Other 7.5 7.3 -0.2
- Nothing 3.5 1.5 -2
- Don’t know 11.5 2.0 -9.5
- No answer 1 9.3 8.3
ADJUSTMENT-AWARENESS AND DEFINITION
- While 6 in 10 of the pre-test respondents were aware of the term “adjustment” as it applied to the field of chiropractic, significantly more of the post-test respondents were aware of this term.
- Respondents described “adjustment” as the alignment of vertebrae or the manipulation of the spine.
- “Yes, aware of adjustment.” Pre-test = 61%; post-test = 77.5%
- “No, not aware of adjustment.” Pre-test = 39%; post-test = 19.6%.
WHAT IS ADJUSTMENT? (among those who are aware of adjustment)
Pre-test % Post-test% Change%
- Alignment of vertebrae 50.8 34.2 -16.6
- Adjustment /manipulation of bones 36 16 -20
- Manipulation of muscles 8 6 -2
- Manipulation of spine 0 24.7 24.7
- Relieve pressure on nerves 0 12 12
- Other 3.3 3.8 0.5
- Don’t know 8.2 2.5 -5.7
- No answer 2.5 10.8 8.3
A Treater Of Conditions
A Professional Who Evaluates?
You Be The Judge
Jerome f. McAndrews, DC
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?
- I. Avoidance of health problems
- a. Get annual complete physical examinations/diagnoses
- b. Be educated on what constitutes minimal proper nutrition
- c. Attain and retain an appropriate, minimal level of physical conditioning
- d. Avoid:
- 1. Smoking
- 2. Alcohol except in amounts established as appropriate
- 3. Injuries:
- i. At work
- ii. In automobiles (wear seat belts at all times)
- 4. Chemical toxicity exposure
- i. Insecticides
- ii. Other
- e. Be cautious in everyday work and home activities
- i. Lift properly
- ii. Sit properly
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
- i. Choose your doctor carefully
- ii. If pregnancy-related, ask for an explanation as to the relative seriousness of the finding
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
- g. The most critical part of your wellness regimen is the annual checkup. By being faithful to this process you will help to avoid more serious problems now or in later life.
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
JC Smith, MA, DC
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:
- In treatment of mechanical neck and low-back pain:
McMorland G – J Manipulative Physiol Ther – 2000 Jun; 23(5): 307-11
- Migraine Headaches
Tuchin PJ – J Manipulative Physiol Ther – 01-Feb-2000; 23(2): 91-5
- Low Back Pain
Anderson GB – N Engl J Med – 1999 Nov 4; 341(19): 1426-31
- Cervicogenic Headache
Alix ME – J Manipulative Physiol Ther – 1999 Oct; 22(8): 534-9
Millea P & Holloway R – Amer Family Physician – 2000 Oct; 62(7)
- Mechanical Thoracic Spine Pain
Schiller L – J Manipulative Physiol Ther 2001;24:394-401
- Neck Pain
Hoving, Koes et al – Ann Intern Med. 2002;136:713-722
- Chronic Whiplash Symptoms
Khan S, Cook J, Gargan M, et al. – J Ortho Med 1999;21(1):22-25
- Infantile Colic
Kemper KJ – J Pediatr – 2001 Sep; 139(3); 467
- Otitis Media
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
- Childhood Asthma Balon J, Aker P et al – NEJM – 1998 Oct; 339 (15) 1013-1020
- Jet Lag Straub W, Spino M et al – J Manipulative Physiol Ther 2001;24:191-8
- Scoliosis Lantz C, Chen J – J Manipulative Physiol Ther 2001;24:385-93
Toward a New Philosophy in Chiropractic
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.
Chiropractic’s First 100 Years—An Inch-By-Inch Progress
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
- Developing and regulating standards and practices
- Involvement or sponsorship of scientific research
- Involvement or sponsorship of continuing education
- Relationship to chiropractic education
- Mediating role in representing chiropractic before the medical establishment, legislators, and government agencies.
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.
What Are We Selling?
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.
Chiropractic’s Glass House
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.
A New Approach to Marketing Chiropractic
“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.”
- Invite all the practice management firms the ACA endorses (Kats, Dallas Humble, Breakthrough Coaching) to give one-hour presentation to the Boot Camp.
- Invite the ACA leadership to speak on practice ethics.
- Invite the presidents of the various ACA Councils to enlighten these attendees to the various types of practices available.
- Invite the ACA Staff to inform all about the HIPAA, Medicare, and general insurance issues.
- Invite NCMIC Staff to inform all about risk management and malpractice insurance.
- Invite ACA-approved venders to elaborate on their wares.
Public Relations—the introduction of our product
- National News Issues Commentaries: We desperately need a spokesman/woman to present our views on national news shows such as Fox and MSNBC on important political matters such as Patients’ Bill of Rights, Managed Care, DoD bill, Medicare, the Trend to Alternatives, Scoliosis Screening for Kids, and any topic that comes into the national spotlight such as the recent announcements that the US ranked 72nd in the WHO rankings for population health or that the IOM announced the 98,000 deaths from medical mistakes. Without such a spokesman, our profession is not seen as a cultural authority on anything despite the recent trend to alternative health care, which many so-called progressive MDs have gladly co-opted from us.
- Create Controversy: “The Disk Theory is Dead” should be heralded from every source. The NEJM in a recent article (2/2001) by Richard Deyo, MD, indicated that 97% of back pain was “mechanical” in nature, ie, joints and muscles. Only 1% had to do with disk problems and 2% was referred pain from a diseased organ. The AHCPR guideline states “surgery has been found to be helpful in only one in 100 cases of low back problems.” Yet the public still believes the “slipped disk” concept fostered by unethical surgeons. We need a campaign to debunk this notion and instead teach the public, “You don’t slip disks, but you do slip joints.”
- Chiropractic Cost Savings: We need to propose that Americans are paying more in insurance premiums because these companies promote back surgeries because they work on a cost-plus basis, so the more they pay, the more they can charge in premiums. This is especially true in workers’ comp insurance companies. It’s a big rip-off both clinically and financially, but no one is making this known to the public. This could be the focal point of “demand management” by consumers, but we need to educate them on this invalid disk theory first.
- PSAs on national TV to imprint a positive image of our profession, including the AHCPR and Manga studies that endorsed SMT over surgery and PT; and the Duke Study on headaches should be heralded.
- Image Ads: DCs in the News: Beth Larson, Olympic athlete; Bill Morgan, Capitol DC; LeRoy Perry, DC to the stars; Alan Sokoloff, Raven’s DC; other Olympic and notable DCs from around the country.
- Celebrity testimonials: like Barry Bonds, Tiger Woods.
- Charity events sponsored by DCs.
- Guests on national and local talk shows.
Marketing—the packaging of our product
- Standardization of our services and claims: The new ACA should establish guidelines of care, including length of care, type of care, traditional vs. experimental care, specialty care, etc.
- Damage control of negative ads, eg, free spinal exams, Killer Subluxation ads; the new ACA should go on record by admonishing tacky ads.
- Distribution of positive ads approved by the associations to supply field docs with tasteful ads.
Advertising—the specific selling of our product
- PSA ads on local TV and radio; Tag every PSA with the ACA’s web site
- Infomercials on cable access TV are inexpensive and effective.
- Yellow Page Ads—stop the insanity of large ads with free services; ask the telephone companies to categorize our profession by specialties or methods.
- Co-op ads with vendors, NCMIC, ASHN, other insurance companies promoting chiropractic care and alternative health care.
- Email newsletters to patients and other interested parties; and lists of all patients to be used in political matters to muster support.
- Web site standardization to avoid hyperbole and free services.
- Introduce an equivalent to WebMD.com, such as www.webchiro.net as web site to interact with cyberspace folks who want questions asked.
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:
- Low back pain strikes millions of people each year, and research from the US and around the world shows spinal manipulation by doctors of chiropractic is the best form of treatment for most cases.
- LBP is the leading on-the-job injury, and spinal manipulation is the best form of care according to health experts.
- You don’t slip discs, but you can slip spinal joints. Health experts agree that disc problems are not the cause of most back pain, and that manipulation can help these painful conditions.
- Avoid back surgery! According to the US federal guideline on LBP, surgery is helpful in only one in 100 cases of LBP. Health experts agree that spinal manipulation is the first avenue to use for these painful injuries.
- According to a recent article in the New England Journal of Medicine, 97% of low back pain is mechanical in nature, one percent is due to disk problems, and two percent is referred pain. If your back aches, there a good chance your chiropractor can help you without drugs or surgery.
For the headache theme, this might include:
- Still suffering from headaches? A study by Duke University has shown spinal manipulation is the best form of treatment for muscular-tension headaches. See your local chiropractor and avoid the side effects from chronic drug use. Feel better naturally with safe and effective spinal manipulative therapy.
- Have headaches changed your life? Give chiropractic care a chance to help you feel better. Researchers at Duke University have shown spinal manipulation is safer and more effective than drugs or other forms of care for tension headaches.
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.
- During the NCLC, we could arrange for dozens of picketers on the Capitol steps to bring attention to chiropractic. This will definitely get the media’s attention and hopefully kick start consciousness rising among the media about their boycott of chiropractors. Placards could include catchy phrases like: “End the boycott of chiropractors in hospitals”; “Freedom of choice for patients”; “Lower insurance costs with chiropractic care”; “Stop unnecessary back surgeries”; “Slipped disks are a fallacy”; “Only 1 in 100 back problems need surgery”; “Chiropractors: the leaders in alternative health care.”
- Capitol Hill Chiropractor: make available tapes, books and educational brochures.
- Email newsletters to all legislators
- Continuing education of legislative aides.
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.