A Patient's Point of View

I was struck by the hat she wore throughout the seminar while sitting in the second row on Saturday during my presentation at the New Zealand Chiropractic College Lyceum. She wore a different one on Sunday. We don’t see women wearing hats these days so I was intrigued who this chiropractor was. Naturally, I was surprised when she approached me after the seminar and invited me to join her and her husband for dinner at their home. Even more surprisingly, I accepted!

Later, in the car during the 20 minute drive to her cozy suburban home, I revealed that I don’t normally receive such invitations and on those rare occasions when I do, I normally turn them down. She practically squealed with delight and went on to explain how on a recent visit to the United States that she and her husband had been impressed by the hospitality of the Americans they had encountered. “I just want to return the favor," she concluded.

I’ve just returned from my tour of New Zealand and Australia. Wow! Ostensibly it began with a several presentations at the annual Lyceum hosted by the New Zealand College of Chiropractic. From there, I facilitated three small group presentations in Brisbane, Melbourne and Adelaide. Limited to 12 chiropractors, our one day together was preceded by 40 days of homework assignments. Our day of “accountability” served as a means to get participants to become present to who they are showing up as with their patients.



Spending day with these courageous chiropractors, willing to look at what they previously had been unwilling to look at was an incredible privilege. Instead of me standing in front of the room yakking all day, accompanied by a thoughtful PowerPoint presentation, I got to ask questions and facilitate an intimate conversation among a group of chiropractors who had tested themselves and monitored their internal environment.

Last night Marilyn and I were taken to dinner by a close business associate at a restaurant that I drive by practically every day on my way to the office, but had never been.

It was spectactular.

But what struck me throughout our delightful dinner was the couple at the adjacent table. From time to time I couldn’t help but notice that they were eavesdropping in on our conversation!

For about six hours each year the CIA headquarters in Virginia is opened to the families of employees. This is an opportunity for those unable to share their daily activities with their family to “show off” the hallways they walk, the security measures they must take each day and even the cafeteria they eat in.

After opening remarks by General Hayden, we toured the “spy” museum and explored the countless exhibits along the labyrinth of corridors used by the various intelligence groups headquartered at this facility. We were able to try on some body armor used by the folks in Iraq (40 lbs.) and inspect other tools used for intelligence gathering and analysis.

On our recent trip to Washington, DC they seemed to be everywhere. In fact, I’d ridden tour buses in London, Barcelona and elsewhere. You don't have to worry about parking and you get a great overview of a city so you can get your bearings. Better yet, you can get on and off whenever you want. Some people choose to stay on for the entire circuit. Others get off with a moment's notice or at the slightest whim.

Kind of like chiropractic care.

Generals are often accused of “fighting the last war” and this is true also for chiropractors. The strategies and tactics used when most patients had generous health insurance are no longer working. Conditions have changed. And if you don’t (or haven’t) changed along with them, you’ll become a casualty.

There were only a couple of strategies back then. Most, a variation on the “extract-as-much-money-from-the-patient’s-insurance-policy-as-possible” theme. Even chiropractors with the highest motives found themselves avoiding the term “subluxation” in their insurance narratives, adding physical therapy or other services that were reimbursed by the patient’s carrier. Most chiropractors “followed the money” and now years later find themselves in a strange land. Some are understandably panicking like a child suddenly feeling lost at the shopping mall. But finding mommy won’t be easy. Because there is no mommy.

After my speaking gig at the UCA Autumn Conference in Birmingham, England this evening, I decided to leave the hotel for dinner at one of the dozens of restaurants surrounding the hotel.

After approaching the third restaurant and getting turned down, either due to an extraordinary long wait (I could see empty tables) or the lack of a reservation (half the restaurant was empty) it dawned on me. I’m not a desirable dinner patron!

He was an older gentleman with a full head of strikingly white hair. The twinkle in his eyes revealed a deep understanding and wisdom. His energy and vitality disguised his 72 years. That he was still practicing was even more affirming. I had the good fortune of sitting next to Dr. Stephen Owens at a pre-convention dinner meeting Friday evening.

I had been invited to deliver a talk the following morning entitled “The Post Insurance Practice.” The dinner invite was promoted as an intimate conversation with yours truly, offering suggestions on how the association could support their membership in making the transition from a reimbursement dependent practice, to cash. But after a couple of opening remarks, I think I was the one who benefited the most.

Used to be chiropractors were a wild breed. Radical. Unpredictable. They would espouse opinions that ran counter to the mainstream. These highly-certain healers often stood alone, hidden from view, but thriving on the periphery. They held the inborn healing ability of patients in the highest esteem. With their integrity to the principles of chiropractic and the results that applying the principles could produce, chiropractic was able to survive against powerful cultural forces, professional bias and for some, without licensure laws.

It’s hard to find too many purebred chiropractors anymore. Many have passed on, retired or have been defanged, domesticated and turned into docile therapists. Just how do you remove the rogue features in the genetic code of a chiropractor? Here’s how:

Many chiropractors have treated third party reimbursement like winning the lottery. And like the lottery, countless people who suddenly came into millions, lost it all.

Tales of the average Joe Sixpack losing his or her winnings after two or three years are common, it’s practically a cliché. Similarly, chiropractors who got the taste of generous reimbursement adjusted their lifestyles upwards, thinking it would last forever as the new “normal.”

But it wasn’t normal. And it’s not lasting.

As I spend more time and energy discussing the importance of patient financial education and the need to begin transitioning to a cash practice, there’s an important distinction that’s showing up. If you’re inclined to think that having a cash practice is about a new financial policy and telephone scripting to handle the “Are you on my list?” question, think again. Having a cash practice is about attracting cash paying patients.

In a magazine I was reading to pass the time before I could use my computer on the airplane after take-off, I ran across this ad for the Bellagio hotel in Las Vegas. It was the two-word headline that caught my eye: Superiority Complex.

Claiming to be superior is so un-PC these days. And while claims of superiority to other chiropractors or other methods is often specifically restricted by your state’s chiropractic licensing statutes, I don’t think that’s the source of the mousey, demure and inferiority complex that is so common among chiropractors. Some suggest it’s the result of rampant low self-esteem. I agree. However, we might part company about how to escape from this perceptual imprisonment.

On my most recent speaking gig, I and another speaker were invited to dinner by one of the attendees. As the dinner unfolded, I could tell I was dining with two chiropractors who take more of a short-term “catch and release” approach to patient care designed to ameliorate only the patient’s most obvious symptoms.

Eventually I asked how often both of them got adjusted.

It’s Election Day in the United States and it’s the usual showdown between conservatives and liberals. Some would assert that the difference between the two parties is a matter of great importance. Others, who are more cynical, see the choice as merely two shades of beige and the lesser of two evils.

I recently heard the terms liberal and conservative applied to the two major worldviews in chiropractic (mechanists and vitalists). As the terms were used, I surmised that conservative chiropractors are apparently those who limit their practice to the treatment of neuromuscular-skeletal complaints. And liberal chiropractors are those who think chiropractic can help virtually any health problem. This schism is what happens when politicians are in politics for power and chiropractors are in practice for prestige. Both overlook two factors far greater than the petty name-calling and the “I’m-right-and-you’re-wrong” division that handicaps this profession.

Because of their Denver hub, I’ve been flying United Airlines for years, racking up over a million miles with them. Because of my loyalty, I’m practically guaranteed a seat in their Economy Plus section. This is an area of Coach in which the pitch between seats is 5” greater than Economy, allowing you to cross your legs and use a laptop without the passenger in front of you reclining their seat into your chest. So I was taken by the gate agent auctioning off seats in Economy Plus for $41 prior to boarding the plane this morning.

"So Bill, I couldn’t help but notice that you’ve spoken in Orlando the last three consecutive weekends for the Masters Circle, Breakthrough Coaching and Ward Success Systems. So, which group was the best?

”

I couldn’t tell if he was fishing for some affirmation that he had chosen the “best” coaching program or looking for distinctions that made each audience different or asking me to rate the merits of the three organizations.

Our wonderful grandfather clock received service today. After 10 years of faithful service it needed some oil and attention. Mechanical (and non-mechanical) devices need an occasional tune-up. The symptoms? During the Westminster chimes, some of the notes were slurring. Not a serious problem, but one that portends future problems if ignored. So Tom showed up to do his voodoo. Towards the completion of his work, he called me downstairs to listen to his work. It sounded great.

“So tell me, what do you do?” he asked after demonstrating his handiwork.

In the popular book series, Rich Dad Poor Dad, author Robert T. Kiyosaki makes the distinction between assets and liabilities. Rich people invest in assets. Poor people spend their money on liabilities.

That came to mind as I was considering the wisdom of a chiropractor friend having a ball because he recognized the lifetime value of a patient. Turns out he “gets” the idea that his inactive patient files are assets. The names of people who know him, his personality, his results and his office location are a valuable asset. While other practices shuttle their inactive files first to the basement, then to the storage unit and then to the silver recycler, Steven understands that many of his inactives are merely waiting for an invitation to return!

I was speaking with a colleague this morning who, I suspect, is getting ready to change jobs. The reason I know that is because she complained about how she was being treated by her current employer.

After she ranted about working such long hours and being, not so much mistreated but unappreciated for two or three minutes, I stopped her.

“You’ve created this, you know,” I said.

(Long pause.)

“Yeah but,” and she continued her list of injustices and frustrations.

I expect she didn’t expect me to “fix” her situation, but needed a set of ears so she could speak what was true for her. Sometimes, it’s not until we utter the words that describe our circumstances and hear ourselves say what we feel, that we can finally accept what is; the first step to taking action.

The end of third-party reimbursement is around the corner. It was a great run. There is little evidence that the erosion you’ve seen in the last couple of years will slow, much less reverse. If you don’t adapt, you’ll jeopardize your practice and your livelihood.

Welcome to the future.

This is the first of several posts exploring patient financial education and the transition into a self-pay practice. Will you make the turn? Can your practice thrive in this brave new world? Ask yourself these vital questions:

One of the bright lights in chiropractic was extinguished over the weekend. Will Tickel, DC was one of my early inspirations. Perhaps our shared background in advertising and love of the English language brought us together. We would often exchange articles, thot pieces, as Will would say, in the hopes the other would either confirm our allegations and insights or provide clarity or direction for their improvement.

Inspired by his book, Down Right! Up Right! Chiropractic Inside-Out published in 1987, I asked Will to write the Introduction to my first book, A Patient’s Point of View. More recently, on the back cover of his second book One Liners, describes Dr. Tickel as the “Will Rogers of chiropractic.” That’s it! His folksy, unassuming personality showed up in his writing that while cerebral, was approachable and filled with “thot-full” examples and earthy frankness.

A philosopher. A chiropractor. A friend. I’m going to miss Will. Chiropractic is going to miss Will. I miss him already.

It’s been a combination of pride and cringing embarrassment. What could produce such an emotional mixture? Posting each of the chapters from A Patient’s Point of View and My Report of Findings to this website over the last couple of days. (The drop-down menu under “Books” above.)

Originally published in 1992 and 1993 it was difficult to avoid the temptation to do a little editing here, deleting a few paragraphs there, and generally freshening things up. After all, many of my ideas have matured since then. But I decided to post them as is.

The earlier post about a new practitioner asking about advertising for pain relief versus advertising for wellness prompted several public and private posts. Seems this issue may deserve further exploration.

How the public sees chiropractic will not be what visionary chiropractors say or claim chiropractic is. Perception is reality. If the public thinks chiropractors are “bad back doctors for pain relief only” then that’s what chiropractors are.

“Oh no, you’ve got us all wrong! We’re wellness doctors.”

You got through December. Now most patients’ deductibles have reset and you’re waiting for March or April to get back into the new patient groove.

Sounds like you may have a seasonal practice.

Are subluxations seasonal? Are physical, emotional and physical stresses seasonal? If they are, then if anything they actually increase at the exact time most offices slow down over the holidays. If you find yourself a migrant worker in the business of health care, this would be a good time to make some changes.

Your practice has dwindled. New patients are practically nonexistent. You have a lot of free time on your hands. But you’re not making enough money to have a viable business. You probably graduated toward the top of your class, but the clinical honors and hopeful optimism you enjoyed back then have long been sucked out of you. It’s crunch time.

Now that you’ve been humbled (or about to be), you have the possibility of becoming a tool that God can work through. Now that you’ve surrendered your dogmatism and egocentric view of the world, you can become a true servant. Now that you’re not so full of yourself, you’re empty enough to be useful.

California is in the midst of grappling with escalating health care costs. Early rumblings suggest that the California legislature is coming precipitously close to taking a path that is unsustainable and will serve to make the problem worse.

Here’s my radical proposal. And I use the word radical in its truest meaning: getting to the root cause.

Before there can be an intelligent conversation about health care costs and its increasing burden on California taxpayers, you must define your terms to effectively frame the debate. If the chiropractic profession’s contribution were merely to bring clarity to the language, this alone would be a Herculean accomplishment and advance its interests!

Seems that chiropractors with the greatest number of “tools” on their belt (nutrition, emotional work, rehab, orthotics, etc.) can go through a stage in which they seem to shun patients who enter the practice lacking the interest in pursuing these “extracurricular” resources.

Forgetting that the patient’s objective is symptom-relief (not wellness) and the patient’s focus is on results (not optimized health), it’s tempting to blame or judge patients for their shortsightedness and limited vision of what you can now do to help them.

Which causes your numbers drop.

Not exactly the affirmation you were expecting after having traipsed off to the weekend seminars, spent the money, bought the equipment or changed your examination procedures!

If your brochure rack is a dust collector or merely a neglected wall decoration, it’s time to put it to work and grow your practice!

Waiting for patients to take your brochures is the first mistake. Drug manufacturers shamelessly promote their wares by interrupting your patient’s favorite TV program, yet you’re somehow afraid to hand a brochure to a delighted patient to give to someone else?

Sure, some of your brochures will be discarded in the back seat, thrown away or somehow “wasted.” Constrained by predicting whether a brochure will reach its intended target or not keeps your message safely intact, but limited to the interior of your practice.

Even more significant is the mistaken notion that handing a patient a brochure is somehow self-serving; that it will benefit you more than the patient’s spouse or friend. This is a clear sign that you’ve made practice about you, rather than serving the needs of patients. (This belief is probably tainting other aspects of your patient relationships as well.)

Yesterday I had the pleasure to speaking to Dr. Mark Doerrfeld’s class at Palmer College in Davenport. The evening before, I spent an hour or so with the Masters Circle Club. Having never attended chiropractic college as a student, being on the campus of any chiropractic college is always a thrill for me. Spending time with students genuinely interested, who ask great questions, is among my favorite speaking gigs.

Besides the fact that students appear incredibly young (a sure sign that I must be getting old), I was struck by the fact that many chiropractic college students seem to have lost touch with the original dream that prompted them to begin the journey of becoming a chiropractor. Locked deeply into their left brain, most students have their heads down, intent on learning the neurology and anatomy and getting good grades. And while getting high marks may be a source of pride, good grades have little relationship on one’s ability to successfully practice chiropractic. (Often, just the opposite.) A fact lost on most students.

Thursday I completed a new, one-day program in New Jersey called the Cash Patient. I generally find East Coast seminar audiences generous and attentive, and the program in Saddle Brook was no exception. During this program, I tried to make the point that a cash practice is an effect, not a cause; a symptom of making the practice relevant and meaningful to patients willing to pay for their own care. Proclaiming that yours is a cash practice is often done out of frustration and is more about eliminating insurance hassles for you, rather than making the practice attractive to those who value their health enough to pay you, and if they have a policy, file the claims and wait to get reimbursed.

Naturally, if you don’t see the chiropractic care as something valuable enough that a sufficient number of patients would reach into their own pocket or purse to pay you, then you have a more serious problem than the arbitrary claims cutting that makes it impossible to predict your cash flow.

Is an adjustment commodity? That is, is an adjustment delivered by Doctor A the same as an adjustment delivered by Doctor B? You and I know that even if the same technique is employed, they can be two very different adjustments. It’s easy to forget this distinction because of the spell cast by third party reimbursement. Carriers have chosen to look past this difference (even though cash-paying patients don’t). To carriers, the full body diversified adjustment, the one-bone adjustment and the energy focused tonal adjustment are all the same. To a carrier, an adjustment is an adjustment is an adjustment. A commodity. It’s easier that way. This has created a huge problem for chiropractors coming out of the third party trance: “How much should I charge?”

As the influence of third parties wanes, more and more chiropractors are placed in the position of having to do what other small businesses have always had to do: set the price for their goods or services. What is an adjustment worth?

As I was editing the previous entry about clutter, it occurred to me that most chiropractors probably don’t have a formal new patient lead generating system. Instead, most take a passive approach—like a spider, who spins its web and waits. This may produce the occasional meal for the spider, but it’s hardly a strategy for a thriving business. You could probably benefit from a formal lead generation system.

Many chiropractors fail to realize they are first a small business, with the need to attract and keep customers like any other small business. Getting on the “list” was supposed to solve this problem. In exchange for a lower fee, you were supposed to get a steady stream of appreciative new patients. Since that hasn’t worked out liked you had hoped, you need a lead generation system.

If you’re a bit disoriented because things that used to work don’t, you’re feeling a bit like Rip Van Winkle, waking up after a 20-year sleep. And while chiropractic principles haven’t changed, patients and the environment you practice in has. You’re dealing with a handful of issues that must be dealt with correctly or you’ll become the equivalent of the buggy whip manufacturer of 100 years ago: obsolete and irrelevant.

Here are some of the most significant issues that have changed and some action steps to deal with them. Your ability to recognize and adapt to them is essential if you have any hope of thriving in the years ahead:

The argument continues whether humans are responsible for climate changes, or that we’re simply experiencing a cyclical “slipping and checking” due to changes in the output of the sun or some other natural phenomenon entirely out of our control. As I see people choose sides (or simply ignore the conflict), I can’t help but see the similarities with chiropractic. (Naturally, I see virtually everything as a chiropractic metaphor!)

I see several connections.

1. Beliefs control the whole show. In the same way advocates who believe in global warming find it difficult to convince those who don’t, convincing those who fear germs or are afraid to have their neck adjusted is similarly difficult. Once you realize you can’t change someone else’s mind (only they can do that), you see that belief changing is an inside job. Like healing. You can create favorable conditions, but ultimately it’s out of your control.

After speaking at the Masters Circle Super Conference last October, Dr. Dennis Perman interviewed me for MasterTalk, their monthly motivation and information CD. (You should subscribe or get to one of their seminars.)

I was still high from speaking in front of 2,800 people and auctioning my necktie for Oklahaven Children’s Chiropractic Center.

I remember leaving the interview feeling that it had only lasted five minutes (it was almost 17 minutes) and that maybe I’d been a bit too frank with some of the answers to his questions. So, it was with some intrepidation that five months later I listened to it while exercising on the treadmill yesterday. Click here to listen and you be the judge. By the way, here are links to some of the resources I mentioned during the interview that you may find helpful:

Patient Education or Patient Teaching?
Million Dollar Questions
Socratic Sign in Sheets
Perfect Patients Website Service

If you don’t have at least a few patients choosing not to begin chiropractic care at the conclusion of your consultation, you’re probably not casting your net wide enough. If your new patient lead generation system (do you have one?) produce prospects who all begin care, you may be playing it too safe. Without a rejection or two on a regular basis, it means people in your community are prequalifying themselves before showing up. This probably means your new patient numbers are down, and the ones showing up are largely those with neuromuscular-skeletal complaints. If you want a wellness practice; if you want to see more visceral complaints; if you want to see more miracles—you’ll want to create a larger opening to your practice.

One of the common themes of my most recent speaking gigs is the idea that many chiropractors get into trouble by caring too much. It’s the occupational hazard of being a professional caregiver.

Caring too much produces a variety of practice pathologies, among them, taking patient behaviors personally, thinking their headache is your problem, resenting patients for poorly prioritizing their health and ultimately burnout, in which patients become the “problem” of practice. So, my advice has always been, “Care, but don’t care too much.”

Last night, just as I was about to drift off to asleep, I was struck by the thought of caring as a continuum, with three general types of caring.