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Six Scotomas

What are you seeing?Maybe the reason more and more chiropractors are not enjoying the fruits of a chiropractic practice is because they don’t have a chiropractic practice. They have a chiropractic medicine practice.

Not that they set out to water down the principles that attracted them to chiropractic in the first place. Instead, dozens of small nudges, expediencies and temptations along the way has brought them to a confusing place. As they see their practice volume erode they feel increasingly disoriented.

Instead of focusing on the real problem (a lack of clarity about their identity and purpose), they focus on convenient outside factors such as the economy, the weather, stingy insurance carriers and all the other usual suspects. As unseemly as this predicament is for the established chiropractor, it is even more pronounced for the newest batch of chiropractors who, because of the limited vision of their chiropractic college, emerge as over trained spinal therapists.

Unless they were fortunate enough to attend off-campus philosophy sessions and the good fortune of learning about (and reading) the green books, today’s graduate is confused about his or her place in the world. Being shielded from the musings of B.J. and Stevenson, misunderstandings emerge:

1. Vertebral subluxation is a bad thing. Naturally, this assumes that the chiropractor even acknowledges subluxation! Some have abandoned it in favor of “mechanical dysfunction” or some other mechanistic term that apparently sits well with the medical profession, which they tend to revere.

Thinking that subluxation is bad is like thinking that the increase in heart rate, blood pressure and cortisol levels linked to a fight or flight response is bad. Subluxation is merely a way our body creatively accommodates an overload of physical, chemical or emotional stress. Thankfully, instead of dying, we subluxate. So, in the short term, subluxation is a good thing. It keeps us alive. However, like any short-term survival strategy, should the stressor continue unabated or the body gets inappropriately “stuck” in this pattern, our overall health can suffer.

Being anti-subluxation is akin to being anti-adaptation. It’s probably an unhelpful way to think of a patient so afflicted.

2. Chiropractic adjustments treat conditions. Treating conditions, symptoms and even subluxations is the practice of medicine, for which chiropractors are not licensed. Granted, veering into the discipline of medicine has been encouraged due to the considerable monies available from insurance carriers for “treating” neuro-musculoskeletal conditions. Remove the metaphysics originally attached to the practice of chiropractic (“connect man the physical with man the spiritual”) in favor of treating neck and back pain syndromes, fortunes were made by many chiropractors in the “Mercedes Eighties.” Today, their mass of inactive patient files and gapping holes in the appointment book suggest that what was good for the ‘tor wasn’t necessarily good for the ‘tic.

Younger chiropractors who have only practiced within the context of third-party reimbursement, have suffered the most. Lacking proof that practice members value themselves and chiropractic enough to pay for their care, their practices are tortured affairs, constantly seeking new gizmos, codes and therapies that will garner the favor of the reimbursement genie. Walk the exhibit hall gauntlet at most chiropractic gatherings and you’ll see what I mean.

If chiropractors don’t treat conditions, symptoms or subluxations, what in the heck do chiropractors do!?! Simply put, chiropractors help revive a patient’s ability to self heal by reducing the distortions of nerve communications between the brain and the body, usually along the spine. That’s a far different intent then treating headaches. And rarely communicated appropriately to patients.

3. A chiropractor’s job is to fix spines. What’s with this obsession on spines and bones? No question you can detect areas where there may be neurological compromise by looking at the shadows cast by ionizing radiation. However, this convenient metric overlooks the neurological focus of chiropractic. And while there is a camp within chiropractic that suggests that an “ideal spine equals ideal health,” this objective falls apart when confronted by a patient with a gorgeous cervical curve, yet complaining of persistent headaches.

Worse, this “fixing” mentality infects many chiropractors with the notion that it’s their golden hands that are producing the symptomatic improvement patients want. But the fact is, if there’s going to be any fixing, the patient’s body is going to do it. Or not. All a chiropractor does is add energy at opportune times and places along the spine and the patient’s innate intelligence either uses it (or doesn’t) to abandon a no longer needed stress response. Granted, I don’t know how to do this incredible thing, but when a chiropractor takes credit for such changes (if and when they should occur) it borders on stealing.

Lasting changes occur with repeated visits after symptoms subside. Something that most patients who look to an insurance company are unlikely to stomach or even believe. Especially if their chiropractor thinks they’ve made lasting changes after the six visits doled out by insurance carriers.

4. If patients don’t respond as expected, it’s the chiropractor’s fault. It’s breathtaking how many chiropractors are inclined to become defensive when a patient doesn’t improve as quickly as pain-numbing medications or the imaginings of patients. If most patients improve, but a few don’t, it’s probably the patients, not you. Is the stress still present that produced the defense posture we call subluxation? Is the patient getting more exercise, restful sleep and water? Are they making lifestyle changes that serve to enhance the healing process? The list is endless. Assuming that you’re responsible, and worse, allowing the patient to believe that you are, (as if you control their recovery by the dosage rate of your adjustments), is a significant and preventable oversight.

Naturally, the reverse is true as well. Taking credit when a patient’s inborn ability to self-heal is revived is equally inappropriate. The challenge is to show up as a facilitator, collaborator and cheerleader. While this flies in the face of the adoration many patients are often quick to anoint you with, how you handle such cases either honors appropriate doctor/patient boundaries or compromises them.

5. Build it and they will come. This myth has destroyed the retirement nest eggs of far too many parents of chiropractic college graduates. Imagining that simply completing the build-out and erecting a back lit sign somewhere with adequate drive-by traffic is all that it takes to build a practice is naive and simply untrue. Oh, maybe in 1985 that would have worked. But not today.

Instead, countless graduates who lack any real-world business experience, squander thousands on their new office, thinking that it alone will be enough to sustain a practice and begin paying back their student loans. It isn’t. Especially, if you’re one with an analytical-introvert bent. If you have a habit of living in your head, even the most gorgeous practice environment will do little to attract and sustain a profitable practice.

My frequent presentations at chiropractic colleges have uncovered that most chiropractors-to-be plan on relying on two main strategies for launching their new practice: advertising and referrals from delighted patients. This idealism is so childlike, I’m often at a loss how to compassionately break the truth to them.

6. Failure to set clear boundaries. Most chiropractic patients have had medical doctor experiences prior to trying chiropractic. If not, television dramas fill in the rest, portraying medical doctors as heroic figures, saving lives and untangling the complexities of human pathologies. So, if you don’t set the chiropractic “rules of engagement” at the outset, patients abide by medical doctor professional boundaries.

Attending to this key responsibility, ideally at the initial consultation, parses out the responsibilities of both parties and establishes a clear understanding where your obligations end and theirs begin. Neglect this critical duty and you set yourself up for patient misunderstanding (“I should be feeling better by now”), blame (“My insurance company won’t cover any more visits”) and guilt when patients don’t follow your recommendations (“What should I have said or done differently?”).

During a telephone consultation last week, the chiropractor was lamenting about not being able to take vacations. Naturally, if you have a personality-based pain clinic (chiropractic medicine), vacations can be challenging. However, if you have the interest, ability and communication skills to inspire a sufficiently large tribe of cash-paying wellness patients who can schedule their nonsymptomatic visits around your frequent vacations, having a life beyond your practice isn’t a problem. That’s why you want to shy away from practicing chiropractic medicine in favor of a chiropractic practice. It’s not to win some philosophical purity award or achieve some dogmatic holier-than-thou sense of superiority!

Ultimately, this is a communication issue. First with yourself. Then with patients.

Comments (3)

Dr Clyde M Burke:

While I agree with a lot of what's in your newsletters, it must be said that most PR material, (including yours) in our profession still puts too much emphasis on "bones out of place" instead of neurology.

One of the best articles I've read to date describing the current state of Chiropractic and practice building.

brian lonsdale:

Once again, cut to the core of it all. I have trouble understanding how someone from without our profession can understand so much more than so many of us. The current buzz/controversies over who should be doing what to who in chiropractic would all fade into the background if the y were able to grasp the utter simplicity/complexity of the chiropractic premise. Thanks Bill!

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From November 12, 2011 3:05 PM

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