Backseat Driving
by William D. Esteb
It's a warm summer night. Perfect for a drive in the country with some friends. You're in the backseat. Suddenly you're traveling at a high rate of speed, probably faster than you should be going. The sense of being out of control might cause you to laugh. It's a nervous laugh, but it only begins to relieve your tension. Or you might react by tightening every muscle, physiologically attempting to regain control of a situation out of your control. Regardless of your response, you're out of control. Driving somewhere you don't want to go, at a speed faster than you feel comfortable going, is not a pleasant experience.
This is not unlike many practices. Who's in control at your office?
There are many possibilities or combinations: 1.) No one's in control; 2.) The patients are in control; 3.) The staff is in control; 4.) Insurance companies are in control; Or 5.) The doctor is in control. Which is it?
Control is what we think will finally create calm and fulfillment in our lives. Yet, full control is never possible because we are always a servant to someone or something else. Because of this inescapable fact, we must find a way to obtain joy from the process of serving others while maintaining a healthy balance somewhere between absolute control and total chaos.
Control is to direct and regulate the care a patient receives in the office. In a business setting like this, control does not mean to dominate or coerce. There's the temptation to succumb to this level; it's taught by many management firms who continue to perpetuate a style that worked 10 or 20 years ago and was based on the "do as I say" approach. This dictatorial approach, which often uses fear tactics, has lost its effectiveness except among the poorly educated and least loyal group of patients. Keeping patients (or staff members) in an agitated state of fear is resented, and while you may seem to get compliance, it comes through gritted teeth.
Without an alternative to the authoritarian style that many doctors find distasteful, all too many doctors are in the back seat of their practices. Besides the frustration and ineffectiveness of being a back seat driver, it causes too many doctors to look for ways to make their million dollars and get out of the profession. If chiropractic is to be the primary mainstream healing art, we need every effective chiropractic doctor committed to a lifetime of service. For some, this will mean rethinking the way the office works to make it a place where you and your staff would be interested in making a career. Interestingly, this revision will make your office a win/win proposition for you and your patients, maybe for the first time!
Depending upon your current state of affairs, you need an action plan to effect this transformation process. Here are some ideas:
1. No one in control. This is a leadership problem. This situation can be recognized by an emergency lifestyle, high staff turnover, low patient retention, and signs of burnout. The doctor has abdicated his or her primary responsibility of leading and directing patients and staff. Clearly, leadership and management skills are a blind spot for most doctors; it's borne out of a low self-image and the short-term strategy best described by a "being-all-things-to-all-people-I-hope-I-don't-offend-anyone" attitude. You must lose the fear that someone might not "like" you.
Action steps. Like many management challenges, this is a self-esteem question. Recognize that no one is going to "build" your practice except you. Recognize that everyone is hoping you'll take a stand and provide direction. Accept the responsibility of having and voicing your opinion! Sit down and list your beliefs; what do you stand for? What personal and chiropractic values will you not compromise under any circumstances? End the chameleon complex that sabotages self respect! Then live by your list with passion.
2. Patients in control. My consulting work in offices and meeting doctors at seminars indicates this is a frequent problem. And guess what? Patients are in control and will always be in control! And that's OK. The challenge is to create relationships in which the exchange of chiropractic services is fair and equitable. Until it is, frustration leads to resentment, which leads to anger, which again leads to burnout.
Action steps. Consider changing your office hours so you don't have to be open at both ends of the day, every day. Make sure your staff knows what constitutes an "emergency" so patients aren't taking advantage of your willingness to drop everything on their behalf. If you want to discourage the habit, have the courage to turn away walk-ins, even if you have an opening. Knowingly or unknowingly, you teach patients how to treat you and your office. It starts with the first visit. You are in control of this and other procedural considerations. Yes, there is a price attached to taking control of these issues, but it is surprisingly small if changes are phased in over a period of time and the entire staff is behind their implementation.
3. The staff in control. How many times have I heard a doctor say, "All I want to do is adjust!" Since most chiropractic colleges seem reluctant to teach even fundamental management skills, others have stepped in to fill the vacuum. Most of these are the "I-had-a-huge-practice-you-can-too" schools of management. This outdated approach presupposes similar personalities, values, and long term objectives-an identical match that is rare in a profession made up of "Lone Rangers." Often the doctor abdicates his or her responsibility to an office manager, and "management" becomes merely a spotty enforcement of a written or unwritten staff policy manual. Office management becomes a "black box." Filing a patient's insurance form is a total mystery. Staff accountability is impossible if the doctor doesn't fully understand all aspects of every job function.
Action steps. Get a procedural manual created or updated! Systematize your office procedures in the manual, explaining the what and the how and the why of every job function. Make sure every staff member understands and agrees with the long-term objectives of the office. Team members work for the common good of the team. Self-gain power trips, tantrums, or feet dragging should not be permitted by the staff-or the doctor. And if your office uses a computer, the doctor must not be held hostage by a staff member who refuses to cross-train others. Even the doctor should be able to sign on and process records in an emergency. What if your computer person got run over by a bus during the lunch hour?
4. Insurance companies in control. Many veteran doctors are quick to point out there that were many hugely successful practices before chiropractic was recognized by the insurance industry. There are financial, philosophical, and communication challenges that arise by fighting the natural tendency to openly embrace the sickness care outlook extolled by the insurance industry. Financial because, frankly it's easier to make money if you play by their rules. Philosophical, because when you simply treat the patient's symptomatic picture, you are actually practicing medicine, not chiropractic. And communication, because to combat this powerful force requires effective patient communications.
Action steps. Start weaning yourself off insurance cases. Pretty soon, insurance coverage that was seen in the 1980s is going to be gone anyway. When deductibles are regularly $500 or higher or HMOs take over, many offices are going to fail, especially newer doctors who emerged from school with large loans that were secured years ago in a different insurance climate. Create some flexible payment plans that can make Initial Intensive Care affordable. Start imagining the day when you won't be accepting insurance or have the overhead associated with it. Actually, it will be a pretty exciting time for chiropractic.
5. Doctor in control. This is what everyone wants. It requires vision, leadership, and courage. And it means being unpopular at times and making optimum care recommendations that can't always be afforded or followed in the real world. The world is hungry for leadership. Effective leadership tends to pull patients and staff to a loftier goal, a higher purpose, and a demand for stricter standards. It helps bring out everyone's best. It puts you in the front seat were you can read the road signs, move confidently through traffic, and take charge.
Action steps. Read some books, especially The E-Myth, Why Most Businesses Don't Work and What to Do About It by Michael Gerber. Get some neutral management advice from the many excellent resources of the American Management Association. Get a management coach. Have lunch with a patient who is in a managerial position and pick his or her brain. Develop a "board of directors" to provide ideas, guidance, and direction. Be willing to make mistakes.
Get out of the back seat! Just remember that sharing the chiropractic truth with the world is a process, not a destination. You'll never "get there." However, you will need a map and plenty of energy; why not pack a lunch?
Buy the book
A Patient's Point of View
Originally published in 1992
240 Pages
US $19.95
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