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Chiropractic Practice Building: A Doctor’s Confession and the Report of Findings

“I’ve got to get this off my chest!”

Dear chiropractic practitioner,

Confessions are tough…Real tough. They are painful, awful things. But, sometimes a confession can set the record straight, and I want to give credit where credit is due. Before I talk about my confession though, let me say a few other things first. You may want to sit down.

You know, when I meet people in town they usually say, “Oh, yeah, I know you, you’re Dr. Jones. I’ve seen your posts with that picture of you and the two cute little girls.” Well, I’m the guy on the left. Aren’t they cute? Now do you feel like you can trust me?

Years ago, something happened to me that changed my life forever. And I would love to tell you all about it, but first I need to give you my report of findings.

I’ve correlated the findings of your examination, and I’ve put it into a package that I’m going to review and send home with you, so you’ll know what we found and what we’re going to do to help you. In the next 10 minutes or so I’m going to review what we found, explain what these findings mean, recommend a course of action and discuss the results you can expect in the future. Feel free to ask any questions as we go along.

First a quick review. You’ve come to our website suffering from an inability to recognize your complete lack of effectiveness in the treatment of headaches, ear infections, asthma, or any other condition with the possible exception of acute musculoskeletal pain involving the back. You have difficulty accepting that any treatment you offer which is effective is provided by physical therapists, minus all the “baggage”, and that nothing you offer which is unique to chiropractic is effective. You are in denial over how the majority of your profession is woefully ignorant of, or exists in a state of denial of, so many of the advancements in modern medicine, like life-saving vaccines, made since chiropractic was invented by D.D. Palmer in 1895.

Don’t worry, we have had excellent results with these sorts of problems. Well, actually, the proponents of irregular medicine tend to stick their fingers in their ears when faced with criticism and evidence that doesn’t support their world view. In fact, I’m surprised we’ve made it this far. I take that as a good sign.

To locate the specific cause of your problem, we conducted a thorough examination. Here’s what we found:

Making it as a chiropractor is hard. The numbers just don’t add up despite how CAM use is portrayed in the media and defended by proponents. Certainly some chiropractors do very well, with the median salary a few years out of training being about seventy thousand dollars a year, but because of low demand and marketplace oversaturation many practices fail. With debt that rivals physicians coming out of medical school, and families to provide for, chiropractors often turn to so-called practice building or management firms to help right the ship. Many of the methods recommended by these companies are quite shady, encouraging manipulation and misrepresentation unbecoming of a group of practitioners with a goal of being regarded as primary care practitioners.

The most recent National Health Interview Survey data on CAM use revealed that 8.6% of people polled underwent some form of manipulation in 2007, which was up from 7.5% in 2002. But these numbers aren’t really comparable. We don’t know what percentage of the patients in the 2007 data were actually seen by a chiropractor rather than an osteopath, because unlike in 2002 they did not differentiate between the two fields. Some osteopaths do continue to provide manipulation-based therapy but most practice or at least incorporate science-based practice. In fact, most osteopaths train with and practice alongside medical doctors.

The number of chiropractors in the United States is somewhere around sixty thousand based on numerous sources. There were 52,000 chiropractors in 2010 according to the Bureau of Labor and Statistics, so I will go with that, and there are currently about 316 million Americans. Based on the NHIS data it appears that about 27 million people get manipulated yearly, which works out to 500 or so people per manipulator. Again, we don’t know how many people are actually visiting a chiropractor but it is probably the majority, and we don’t know what percentage of those are regular visitors. That is not a large patient panel by any stretch of the imagination, and of course it would not be evenly distributed. Some newer practices likely have far fewer patients.

Knowing how the numbers actually break down is interesting considering some of the claims that I have come across researching the chiropractic presence on the internet. A common chiropractic meme (chiromeme) I see is bragging about large patient loads, often with numbers that hint at an ability to interact with space and time in fundamentally new ways. This is a practice-building technique. The bragging, not the manipulation of time.

Claims of seeing hundreds of patients a day, or performing millions of adjustments over a career, are common. Sharon Gormon, for instance, “has cared for thousands of patients and has performed over half a million adjustments in her career.” Over a twenty year career that works out to at least 68 adjustments a day, if she never took a day off. Even taking into account that many patients are diagnosed with multiple subluxations at the same visit it is still a hectic schedule. The ability to claim to have that degree of popularity in order to impress potential patients, while also denigrating physicians for not “treating the whole patient”, is impressive and perhaps unrivaled in the natural world.

Another chiromeme I came across recently, while perhaps not as commonplace, was still repeated word for word on several different chiropractic websites and is considerably more comical:

If you think that chiropractic is a new science, it is. However, you might be surprised to know that spinal manipulation has been utilized for a very long time. The first pictures depicting spinal manipulation were discovered in prehistoric cave paintings in Point le Merd in southwestern France. The historical cave paintings can be dated as far back as 17,500 BC.

A quick search revealed that Point le Merd is not an actual location in France or anywhere else. It is however suspiciously close in spelling to “pointe le merde”, which translates to “the very tip of the shit”. Make of that what you will.

With so few patients at their disposal, I am not surprised that chiropractors are more likely to default on student loans than any other health-related profession. It is also easy to see why so many turn to these practice-building techniques and the seminars run by companies promising to bring more patients in and increase profits. I don’t have a problem with a business trying to succeed and make enough money to feed their family and pay their debts, but I do have a problem with how it is sometimes done. The ends don’t justify the means in this case because they require deceiving patients. The evidence simply does not support the vast majority of the claims being made.

Usually these practice-building techniques come in the form of setting up information booths at local gyms or fairs, ads containing coupons for free spinal exams and pseudo-journalistic press releases run in smaller local publications. The easiest to recognize are the bogus personal testimonials placed on practice websites (1, 2, 3, 4). I’m sure you have seen these “confessions” before, but you may not have realized that they involve the use of a standard template purchased from practice-building firms. Here is a video version which hits all the high points as well. I highly recommend watching all three installments. Here is another one, just for fun.

These seemingly personal stories always follow the same pattern, with many being identical except for the picture of their adorable offspring and specific practice information. The chiropractor always sheepishly admits that he or she has something to confess and then tells the story of how they, or a family member, were injured and could only find relief in the caring hands of a chiropractor, usually after a bad experience with conventional medicine. Thus they are inspired to join the field of chiropractic.

Then comes the confession that they have been taking the credit for healing patients over the years when really it was the chiropractic all along. They simply remove roadblocks to the body’s innate healing ability. They can treat your pain, get you off your meds and save your life naturally. Check out the links above and you’ll see. And trust me there are thousands more, like this one, that are easily accessible online. I can’t help but imagine that they choose from a list of personal tragedy options, and the testimonials typically placed in the ad are likely invented as well. I could be wrong but if not then these are a very accident-prone bunch. They should probably have a special restriction on their driver’s licenses.

Many of these phony personal confessions disparage the medical profession or make questionable claims about the side effects of childhood vaccines. Or they simply complain that medical doctors only know how to push drugs and treat symptoms. Here is one that gives highly questionable medical advice such as bringing your child to the chiropractor if they are injured falling from a high place. It also contains the following gem:

However, have you ever wondered what would happen if you gave a healthy child the same medicine you give a sick child? Don’t parents usually tell their kids “don’t take drugs” if not needed because it’ll make them sick?? So it seems if drugs make healthy people sick, wouldn’t they make sick people even sicker?

Makes sense. I for one would never put a healthy child on a dopamine drip.

Another post on this particular site lists some reasons why chiropractic might not work:

Invalidating Comments: When a patient has a family member (or other close person) who is making them wrong about using chiropractic care, then those people have up-and-down results. The person is better after I treat them, but after coming in contact with that person, they are doing worse again.

I think that Dr. Erica might be on to something. I told a family just today not to speak ill of the gentamicin or it might interfere with its ability to kill bacteria. And if they just had to they should have the decency to not do it in front of the IV. I don’t think this is a chiromeme that will catch on though.

While some rogue chiropractors like Dr. Erica do sometimes go off point on their websites, virtually everything you read on a chiropractic website or in an advertisement for a chiropractic practice is part of a prepackaged practice-building scheme. The wording is carefully chosen to have the biggest impact. Every flyer or handout found in a chiropractor’s waiting room is designed to indoctrinate you so that you not only come back, you go out and spread the word. Here is a nearly ubiquitous example from a chiropractic website’s FAQ section:

Who needs to be evaluated by a chiropractor?

EVERYONE!

Anyone with a spine can benefit. Due to its positive effects on the nervous system, chiropractic can help correct many health problems.  Our clinic typically treats patients with fatigue, scoliosis, allergies, asthma, menstrual disorders, headaches, and low immune function.

Another example:

How long will you need chiropractic care?

You’ll need chiropractic care as long as you live in Hanover Park and encounter physical, chemical or emotional stress that you cannot adapt to or accommodate. Ready to get started? Call our office today.

And yet another from a different chiropractic website’s “Story of Chiropractic” page:

Ultimately, the goal of the chiropractic treatment is to restore the body to its natural state of optimal health.  In order to accomplish this, I use a variety of treatment methods, including manual adjustments, massage, trigger point therapy, nutrition, exercise rehabilitation, massage, as well as counseling on lifestyle issues that impact your health.  Since the body has a remarkable ability to heal itself and to maintain its own health, the primary focus is simply to remove those things which interfere with the body’s normal healing ability.

But these boilerplate “confessions” and FAQ sections are hardly the worst that chiropractic practice building has to offer. That would be the report of findings, or the ROF.

The ROF sounds simple enough as explained to the potential patient on many websites:

After Chiropractor Jones has had time to sit down and thoroughly analyze your exam findings, he will give you a detailed report of all findings and answer any questions including:

  1. What is causing my problem?
  2. Can you help me?
  3. What will my treatment cost?

After reviewing your health history, goals, and examining your spine and X-rays, Chiropractor Jones will discuss recommendations and notify you if  your condition requires care with other providers. Chiropractor Jones will provide the best treatment and wellness program for your needs.

Well that sounds lovely, and not much different than when I discuss a treatment plan with the family of a hospitalized child. I go over exam findings and test/imaging results that might have been obtained with the family, I explain my diagnosis and I make treatment recommendations. And I make sure that the family has all of their questions answered.

But there is more to the chiropractic ROF. In the world of chiropractic practice building, the ROF is the sales pitch. It is what all the bells and whistles of the chiropractic office, the x-rays, the neurocalometers, leg length measurements and even simple palpation of the spine are designed to lead up to. It is the chiropractor’s chance to convince the patient of the validity of what B.J. Palmer called the Big Idea. This is the notion that the subluxation is the root of all your health problems and correcting the subluxation will fix all of your health problems. Palmer imagined a world without subluxations. Lennon did not.

The ROF is also the chance to convince the patient that there is more to chiropractic than fixing the acute problem. That pesky subluxation could return at any time. Thus the patient is convinced of the need for transitioning into maintenance care. As insurance does not typically long-term chiropractic care, this tends to require cash. And naturally if you pay up front, they can pass the savings on to you. Many practice-building resources refer to the ROF as a means of achieving the “killer close.” Classy.

I learned how to discuss the nuances of a patient’s diagnosis and management by reading, role play and observation. There are a number of excellent resources for physicians to improve their ability to communicate. I am still learning after ten years of practice. Recently I’ve focused on learning how to better discuss the management of pain because my wife has transitioned into a career in pediatric palliative care and she made me do it. There is absolutely nothing wrong with the desire to hone these skills. The chiropractic ROF is clearly not the same thing.

There are a number of practice-building programs offer ROF scripts and coaching for purchase, many with claims of superiority in growing a practice, but a great deal of information is available online. There are many different approaches. This particular practice-building consultant, for instance, believes that patient autonomy is a nuisance:

When a chiropractor crosses the line from controlled office procedural and patient management into procedural exceptions and patient management decisions based on patient debate and input, that chiropractor is entering the realm of ineffective practice.

Here is a complete script. I’ve provided some of the highlights:

2. Opening statement with an assertive, We can help you!
-Susan, your radiological findings indicate that we can help you. But we have a lot of work to do.
-The purpose of your visit today is to first show you how the structural biomechanics of your spine differ from a healthy spine.
-The second goal is to give you our recommendations for relief and correction.
-Does that sound good?
-Patient responds, “Yes”

** Use a model of a spine to show the patient what a healthy spine looks like.
-Do you remember the term we use when a bone in your spine is out of alignment?
-Patient responds “Subluxation”
-If the patient doesn’t respond with, “Subluxation.” Show the patient a poster with the word subluxation on it.
-Then make the patient say it, “Subluxation”.

8. Express urgency
-If we don’t address this, what do you think will happen?
-Patient responds, “It will get worse.”
-That’s correct.
-You mentioned during the consultation you have been having difficulty working and sleeping. If your subluxations get worse, how do you think that will affect those areas of your life?
-Patient responds, “I might not to be able to work at all.”
-That is what I am concerned about.

9. Relate subluxations to the organs innervated and associated conditions
-You have a subluxation here at C1. These nerves supply your heart, pituitary gland, and lungs.
-Subluxations at this level are associated with headaches, migraines, neck  pain and stiffness, high blood pressure, anxiety, depression, insomnia and  asthma.

(Cardiopituitopulmonary depression is very serious.)

10.How long
-I can’t give you an exact date because there are many factors that play a role and impact your body’s ability to heal: what you eat, how you exercise, genetics and how much stress you are under.
-However, if we stop at relief care the hole in the roof will not be corrected.
-Corrective care for an adult with this severity of subluxations can take between 24 weeks and 24 months.
-I know that seems like a longtime, but how long does it take to straighten  teeth?
-Patient responds, “A couple years.”
-That’s correct, it takes time to move bones.

11.Find level of commitment
-Are you committed to correcting your subluxations?
-Patient responds, “Yes.”
-Are you a 100% committed?
-Patient responds, “Yes.”

12.How much
-You can pay 55 a visit for the 48 visits plus two re-x-rays. That comes to 2838.
-You can pay 239 per month for 6 months and that will include three x-rays. That comes to 1434 and saves you 444 dollar
-You can also pre-pay for the 24 weeks and receive a 15% discount. That comes to 1219 and saves you 215 dollars over the monthly plan

I’m hard on the practice of chiropractic because it involves lying to patients and parents. I realize that not all chiropractors subscribe to subluxation theories or disparage vaccines, and not all chiropractors make use of slimy practice-building schemes, but there are just not very many out there like Sam Homola. And whether they continue to make claims of effectively treating or preventing non-musculoskeletal conditions despite the reams of negative evidence is because of gullibility or guile, I do not care.

I have no doubt that there are similar tactics put into use by some medical doctors. I cringe every time I see another “health and wellness” medical spa pop up with an MD as a director. It burns me up every time a medical clinic starts offering bogus bio-identical hormone therapy or selling supplements.

I spent a long time trying to see what kind of shady practices go on in the world of pediatrics to drum up business. Outside of some reasonable discussions of website design and establishing a presence in the community, which is also something that chiropractic practice-building techniques cover, my search for the sordid underbelly of pediatrics came up empty. What I did find, using the same search terms minus the word “chiropractic”, were countless examples of pediatricians trying to make a practice better rather than a busier or more profitable.

What does having a better practice entail? Primarily it means providing better care for patients through quality improvement initiatives. It means improving efficiency, limiting the ordering of diagnostic studies like labs and imaging that aren’t supported by good evidence and incorporating more effective educational interventions for families. There is no place in the practice of medicine for the chiropractic model of practice building.

Posted in: Chiropractic

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