–Robert Louis Stevenson
As we write this article, we realize that life as chiropractors has been good for both of us and we are mindful and aware that we have been very fortunate. We also recognize that we are among an ever-shrinking minority, and that there are some very real problems afoot in our profession today.
We first met in 1988, when chiropractic was enjoying the effects of a hot economy in what has been dubbed the “Mercedes ’80s.” Fast-forward 25 years to the present day – we find ourselves on the heels of a global economic collapse with the Canadian health-care system buckling under the strain of poor planning and inefficiency. In all of this, the winds of change have not blown favourably for chiropractic. At this time, we would like to objectively evaluate chiropractic within the larger spectrum of emerging health-care needs. Our goal is to identify a path for chiropractic success today and, more importantly, within the future landscape of the emerging health delivery paradigm.
RESEARCH MODEL, À LA GLADWELL
In the spirit of objectivity and in our attempt to remain “relevant,” while conducting our own research we utilized a Malcolm Gladwell-type approach. We chose Gladwell, a journalist with Canadian roots and the best-selling author of the widely acclaimed and referenced books Tipping Point, Blink and Outliers, as a guiding model. Gladwell-type thinking involves uncovering and discussing unexpected truths, possibly redefining our collective mandate based on new discovery and informing those who seek to understand the same.
As we embrace this approach, we hope to uncover signals and clues to guide us in finding new direction for a profession that we estimate to be in serious peril. Our intent is to harvest sufficient data so as to formulate new strategies that support growth, while staying true to the “Big Idea,” put forth by B.J. Palmer in 1944, that forged our defining identity.
It is a fair and accurate observation that a growing number of chiropractors today do not enjoy a reasonable quality of life, do not achieve high professional satisfaction and do not enjoy financial stability. Although anecdotal evidence suggests that although we are generally well-liked by our patients, the profession continues to be poorly understood and not well trusted by the rest of the health-delivery community.
Research indicates that New Patient Visit Rates and Patient Usage (two accepted and objective economic indicators of predictive future market strength and business “success” in any sector) have been on the decline for a number of years.1 A comparison of annual earnings and work intensity of health and non-health professions in Canada, revealed that chiropractors had a decrease in median annual income (-30.9 per cent) between 1991 and 2001.2
Consumer adoption rate in any industry/business is an important and accepted measure of predicted future economic success. Measurable variables such as adoption rate, market share and penetration are used by loan managers to evaluate a business’ ability to service debt when calculating the feasibility and viability of any business. This same model can be applied to anticipated future success for a chiropractic clinic. One bank-indicator that quickly measures our profession is the change in chiropractors’ ability to borrow money on the merit of business potential alone. Due to the high number of failed and failing chiropractic businesses, chiropractors are now considered “Triple A” borrowers due in part to risk and history of loan default.
Up-to-date data is not readily available, but with the current recession and straw-pole surveys we have ourselves conducted, we are certain that both chiropractic utilization and related incomes have continued to decline in recent years. The British Columbia Chiropractic Association reports “the percentage of the adult population currently utilizing chiropractic care is at best, stagnant at around seven per cent.” When we looked at relative compensation for all “primary contact practitioners” over the past two-plus decades, we learned that an average wage for a DC in Canada has shrunk from a high of $97,000 take-home in the late 1990s to less than $50,000 in 2005.3 Not surprisingly, a study published in 2010 in the Journal of Osteopathy and Chiropractic, revealed a 20-25 per cent defection of chiropractors from the profession in some regions.
According to an article by John O. Marty entitled “Making Your Dream Come True,” the true impact of this trend towards shrinking income is felt most strikingly with new grads who start practice burdened with an average debt load in excess of $125,000. The high cost of a DC education and low average wage potential is troubling, and more so when one considers the growing number of new grads who are flooding the already shrinking marketplace. Furthermore, studies have concluded that the current flow of DCs into the marketplace is unsustainable.4,5 Even within research published a few years ago, Mior et al. found that percentage growth of the (patient population) market over the previous 10 years has actually constricted when coupled with the growing number of new grads entering the marketplace.
In short, the average DC is seeing fewer new patients and providing fewer treatments. As a result of this excess in manpower and decreasing patient-demand, the Whitehall study predicts, “there will be a slashing of fees with the price of an adjustment falling to levels that will fail to sustain a free-standing office.” Compound this with a stagnant or shrinking patient base. In addition to internal competition, chiropractors also face real and certain external threats from other competing service providers and products that promise similar therapeutic benefits.
OFFERING VALUE AND UTILITY
It’s not that chiropractic doesn’t work – we all know it does. We’ve seen positive results, with most patients satisfied, if not overjoyed with their care. In this competitive landscape, “value” becomes a driver and it can be measured along the entire cycle of care. A consumer’s “value quotient” of a product or service is dictated by the following criteria:
- quality versus price;
- perceived value = perceived benefits – perceived costs;
- interaction between supply and demand;
- value as compared to existing competition;
- personal experience;
- collective impression (opinions of peers, media, opinion makers).
Another wrinkle in this model is related to “utility,” which pertains to “usefulness” or “perceived usefulness” of a product or service to the consumer. Even with government subsidization, health care for musculoskeletal conditions, or “MSK”, is considered an “open market,” where the individual can choose from multiple treatment options. Consumer perceptions of a product’s or service’s relative utility is often the pivotal factor for those services or products in their quest to establish market relevance.
In the category of pain, for instance, the list of perceived market solutions includes a wide variety of options: NSAIDs, opiates, nerve blocks, surgery, physiotherapy, massage therapy, acupuncture, rest, chiropractic and the elixir of time. The “utility,” therefore, of each is measured by the individual health consumer’s experiences, and weighed on the basis of the option’s promise to: first and foremost, effectively reduce pain; second, restore function; and last, help patients resume normal activities of daily living. All of these are further overarched by cost and time considerations. Every patient consciously, or subconsciously, decides on a course of action based upon some or all of the above criteria, with pain being the first and overriding motivator.
Unfortunately, chiropractic’s relative advantage when compared to other interventions is marginal, according to some studies, at this time. Elemental to our position on the hierarchy of consumer options is attracting support and referral from MDs. Here, chiropractic has failed to demonstrate a real competitive advantage. A February 2011 Cochrane Systematic Review article entitled, “Spinal manipulative therapy (SMT) for chronic low-back pain,” revealed that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain.
If there is any consolation, chiropractic is not alone in this dilemma. In a major body of work resulting in the book entitled, Redefining Health Care (Harvard Business School Press), a team of leading and well-funded U.S. researchers – including the book’s authors Michael E. Porter and Elizabeth Olmsted Teisberg – conclude that the health care system is on a dangerous path, “with a toxic combination of high costs, uneven quality, frequent errors….” We propose that the disparate volume of evidence that exists among health-care professions in Canada leads to the same overwhelming conclusion – that the Canadian health system is tragically skewed in its approaches towards what constitutes health, that it is hopelessly unsustainable in its current form, and that the magnitude of the problem is staggering.
Society’s rampant and growing dependence on, and perception of, value with respect to pharmaceuticals is an important element that has, we believe, led to further market decay and patient attrition. In addition to this, consumers have adopted a potentially catastrophic acceptance of destructive values related to health and longevity – generally Western society equates being healthy to short-term disease control, not the absence of disease or long-term enhancement of health and vitality through constructive living habits.
Chiropractic, collectively, has done little to correct these potentially disastrous misconceptions of and about health and the preservation and maintenance of well-being – but this is where we must evolve. We have to step up to a new role as thoughtful and passionate leaders in the drive for change. We need to be stronger regarding our own “messaging,” to create a shift in the perception of what being healthy or getting healthy really means.
HOW CAN WE DO THIS?
Our belief is that for us just to survive, our leadership has to vigorously communicate the importance of efficient mobility as a primary element in the control of many of the diseases associated with aging, enhancement of health and quality of life. Establishing the chiropractor as the mobility specialist in health care is critical to all future growth. There are growing bodies of evidence and clinical experience to support this claim, especially when applied to many of the developmental conditions facing adult and aging populations. Since it is contended that evidenced-based health provision will ultimately be the only paradigm compensated by third-party providers within the next 10 years – and that payment for everything outside of what evidence deems to be “standardized care” will be considered elective and the responsibility of the consumer – it is paramount to position the basis of our utility on research that supports a broader more realistic paradigm and then to build additional evidence, and hence value, for the benefits that our methods can offer to patients through the creation of a healthy society.
It is clear, then, that the profession sits at a critical crossroads and faces fierce competition. In spite of rhetoric to the contrary, we are weak, which is blatantly evidenced by the facts presented. We suggest that as the number of practising chiropractors grows, our profession actually weakens. If chiropractic fails to identify and adapt to new market trends and opportunities, the profession will actually weaken. If research is not geared to provide new opportunities for practice growth, the profession actually weakens. Three strikes and you’re out!
Logic points to the importance of providing measurable and more consistent outcomes, aligning with evolving consumer values and delivering “utility” as the base platform from which to create a blueprint for future relevance and success. These have to be starting points as they are in step with where consumers and related economic realities are headed.
One hundred plus years of history provide rich field data that we believe contains the solutions necessary to steer the profession away from its current downward spiral. The keys to our future relevance and competitiveness will be found with you the field practitioner – with how you position yourself as a health-care option and with how you identify and present your value to your community. We believe that the strategies for success are all here. We know that chiropractic works and is intellectually a fit for the health-care needs of today and tomorrow. We also believe that without change, consensus with a progressive and tangible strategy, we risk redundancy. We believe that our leadership must step up to the challenge and continue with you, the chiropractor in your clinic, and your commitment to deliver relevant value and evidence-based utility to your patients.
In summary, three things must happen for chiropractic to survive: manpower and market needs must align; we have to expand market opportunity to maintain relevance; and research must be extended to include the field practitioner and be directed to aggressively support an expanded footprint for the profession.
- Mior, SA and Laporte, A. Economic and Resource Status of the Chiropractic Profession in Ontario, Canada: A Challenge or an Opportunity.
- Galarneau D. Health care professionals. Perspectives: Statistics Canada Catalogue no. 75-001 XIE. December 2003;14(12):14–27.
- Waalen JK, Mior SA. Practice patterns of male and female Ontario chiropractors in 2000-01. J Can Chiropr Assoc. 2005;49:21–31.
- Whitehall Management published an article in Dynamic Chiropractic entitled “The Sustainability of Chiropractic.”
- S. Mior and A Laporte conducted research published JMPT article, entitled “Economic and Resource Status of the Chiropractic Profession in Ontario Canada: A Challenge or an Opportunity?”
- Flexner’s Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, 1910.
Dr. Jody Anderson consults in the fitness industry with a focus on speaking and writing about health and wellness matters. He is also involved in change-behaviour, working with an evidence based set of practical tools geared towards improved quality of care, improved clinical outcomes and increase in health professionals’ job satisfaction, within the health-care field.
Dr. Pooley graduated from CMCC in 1978 and has been in practice in St. Thomas, Ont., where, 14 years ago, he created Canada’s first true comprehensive natural health care centre. He has served as president of both the OCA and the CCA. He was elected to the CCO in 2008 and sits on the CCO Quality Assurance Committee.