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Machiavellian Chiropractic

machiavellianchiropractic.jpgIncreasingly as I speak to chiropractic audiences, I’m noticing an alarming trend. It’s the justification that is used to get patients to do the “right” thing. It’s as if anything is fair game if it will cause patients to get under chiropractic care.

However, the “do-gooder” attitude that prompts these patient management techniques have the effect of producing some unwanted consequences that become more obvious in light of today’s practice environment. The words and actions taught to trusting chiropractors may produce the desired result in the short term, but often end up costing far more in the form of few patient referrals and even fewer reactivations.

You might consider passing every patient procedure and every word you speak through this simple filter:

Are your words and actions ministry or manipulation?

When I use the word ministry, I don’t mean something religious. Similarly, the word manipulation doesn’t refer to a nonspecific joint mobilization. Instead, these words represent your motives; the state of your heart when saying or doing something to or for a patient. Simply put, if your words or actions serve you, that’s manipulation. If they serve the patient, that’s ministry. But here’s the rub: many chiropractors believe that saying and doing just about anything is justified if they see it as being in the patient’s best interest.

It’s not.

Using guilt, shame or fear to get patients to agree to your care plan is manipulative. Imposing office policies that serve to withhold care unless patients demonstrate perfect compliance or agree in advance to lifetime care (in yearlong chunks) is also manipulative. As is a report of findings that’s actually a sales session, replete with an emotional close or verbal sleight of hand designed to get the patient to say, “Yes!” More subtle forms of manipulation include admitting paperwork questions that ask the patient to choose “Fix care” (that attractive, enlightened patients choose) or “Patch care” (that ugly, stupid people choose).

This, and much more, is taught to legions of unwitting chiropractors. And while it often goes against the Golden Rule learned in childhood, many hold their nose and accept that it must be what it takes to have a “successful” practice. Unfortunately, this “the-ends-justify-the-means” philosophy is not only flawed, it actually turns a practitioner into an inauthentic salesman and reduces his or her practice to a high-pressure closing booth.

Dig deeper and this justification reveals several unattractive qualities:

1. It reveals a profound mistrust of patients. By attempting to manipulate patients to do the so-called “right thing” (says who?), it indicates that you believe, if given the opportunity, patients will make the wrong choice. What does “wrong” mean? Wrong for your statistical goal or income needs? Wrong because it will sabotage their health? Naturally, you think health is a top priority—you chose it as a career path. But each patient, imbued with the free will granted their Maker gets to decide for him or herself what priority to place on their health. Tampering with that free will, justified as being in the patient’s best interest is a slippery slope. “But Bill, you don’t understand, they consulted me because I know how to help them.” Of course. Make your recommendations without being attached to their choice. And then honor it without judgment or resentment! Hard, I know.

2.It reveals the incorrect belief that what patients do is a reflection of you. When your five-year old turns heads by throwing a tantrum in the grocery store, it’s a reflection on you. Or when your teenage daughter wants to date the “bad boy” delinquent, it’s probably a reflection on your parenting skills. But when an adult patient rejects (or overrides) your recommendations it isn’t a reflection of you or your doctoring skills. Imagining that if a patient rebuffs your suggestions that you’re somehow responsible for the potentially less-than-ideal outcome or that it will somehow tarnish your sterling reputation is so ludicrous as to border on fantasy! Patients can’t ruin your reputation. But you can. Many do.

3.It reveals that you think you’re actually in control. The only power you have over a patient is if, when and where to adjust their spine. Thinking that three-visits-a-week-for-the-first-four-weeks was handed down by D.D. himself, or that you have any say over whether patients heal or not, are signs of hubris of the highest order. In truth, your power and influence is modest at best. And it immediately plummets as patients start feeling better. Thinking you can make things happen on your schedule or that you can legitimately demand or impose certain behaviors on patients is a form of bluffing that needlessly squanders your limited cultural authority.

Patients in your practice complete you. If you rely on heavy-handed management techniques, you’ll tend to attract those who are all too happy to abdicate their personal responsibility and turn their health over to you manage. Careful! While that may boost your ego and give you a sense of importance, it’s emotionally draining, keeps your practice small and unsustainable.

Unlearning the memorized scripts or subjecting your procedures to the ministry/manipulation test isn’t easy. In fact, there may be many things you say and do that are so much a part of your practice culture you can’t see their long-term negative implications. You might want to ask some patients. Or people who used to see a chiropractor—but would never go back. I have.

Here are some suggestions:


  • Before you utter the words “office policy” to a patient, be completely certain your policy benefits patients and not just you.
  • When you think, “What more do I need to say to get this patient to do the right thing,” bite your tongue and trust the patient.
  • If you’re inclined to judge a patient for the choices they make, become mindful that in doing so you invite judgment from the patient.
  • Acknowledge how little power you actually have and wield your limited patient influence with extreme care.
  • Accept that the patient is the master and you are a servant, knowing that serving others is among the highest of all callings.


If referrals seem rare and even fewer former patients return, requesting instead that their X-rays be sent down the street, they may be telling you that what you’re doing is disrespectful, demeaning or at least off-putting. Or shall we just blame the economy? That might be more convenient.

Comments (4)

You are right about patients doing whatever they choose to do. The best you can hope for is to establish enough rapport with them that eventually they trust your genuine recommendations. I still think that you should educate all patients about the conciquences of their decisions, good or bad. That way they will be making an educated decision about what they choose. I also reserve the right to make recommendations about what I think that they should do, if they don't want to do what I recommend, fine; but I would feel horrible if I didn't tell them. After all, I am supposed to be the authority on chiropractic and if I don't recommend what to do chiropractically, who will?

Jon Bullock, D.C.:

Bill,
Where would we get this point of view if it wasn't for you? We're constantly being bombarded with practice management ads and concepts that almost make a new graduate feel that this is the only way to be successful. You seem to address everything that had been a source of my frustrating discomfort in practice, not just in this article, but in others as well. I'm truly grateful that I can read your articles and feel that there is a deep down honesty and that it's not just me "getting in the way of my own success" or that it's "all in my head." I appreciate that you can speak for this side of the profession and often time throw us a "reality check."

Doris Doheny, D.C.:

Dear Bill,
Thank you for addressing the same concerns I have regarding what the practice management groups have been teaching our profession. I have enjoyed practicing in a small town in Pennsylvania for the past 22 years.
I believe in judging clients individually, educating them and allowing each office visit to build trust in the process of healing through chiropractic. In my area, many younger chiropractors have succumbed to a high sales, high pressure contractual chiropractic care. It has caused the local residents and local medical professionals to develop a bad attitude toward chiropractic. Thank you for your work to bring common sense and respect back to the profession.

Tony Russo:

Bill,
After 15 years of "not always" humble service, falling flat on my face just when I thought I was on top of the world, regurgitating weekend seminar scripts that I knew I didn't believe in, I come to appreciate the gold you give up to us. And it's free! I can't believe it. I recently sold my practice to a recent graduate and I see myself of 15 years ago, in him. Bold, cocky, self-certain and indulged. I advise him on your advice, but it falls on deft ears. Why?
And now I had my own epiphany. Just as we cannot pass judgment on patients for not "following" our advice, so too we cannot pass judgment on our colleagues for not following our advice.
Thank you very much for helping me self-realize.

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From October 26, 2009 10:46 AM

This page contains a single entry from the blog posted on October 26, 2009 10:46 AM.

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