Letter to the Editor: Supply and demand

David Wickes
October 06, 2015
Written by David Wickes
The September 2015 column by Dr. Anthony Lombardi, "Business is Life" is a poor attempt to address an important issue in chiropractic - the question of supply and demand for chiropractic care.
The article contains faulty assumptions, a lack of supportive references, misrepresentation of the purpose of accreditation, and an overeager attempt to apply the Pareto principle to the delivery of healthcare by chiropractors. I will only attempt to address some of the major flaws in this article.

1) There are numerous statements and assumptions made without appropriate supporting data and references. A statement that most chiropractors who leave the profession become graduate students, hospital technicians, insurance sale persons, or professional musicians is presented without substantiation, most likely because there is no published evidence to support this speculation. Similarly, stating that 20% of DCs don't invest in continuing education is made without supporting evidence.

2) A common misconception relating to the Pareto principle (i.e., the "80-20 rule") is that it applies to all business situations. The author does not support the general statement that in Ontario "80% of the revenue is generated by 20% of the DCs", but even if the general application of the Pareto principle was accepted at this level, it cannot be assumed to apply to all samples within the province. Application of the Pareto principle is most useful when data is carefully collected, the right questions are asked, detailed Pareto charts or diagrams are developed, and when contributing factors are clearly identified.

3) The author's solution to the perceived dilemma of oversaturation of DCs is to have the Council on Chiropractic Education (CCE) mandate that all colleges stop admitting students for a year. This is simply an untenable and illogical solution. The purpose of accreditation is to ensure the quality of the educational process, not to control the growth of the profession. The CCE, of course, is a USA entity that has no impact on Canadian education. Neither the CCE nor the Federation of Canadian Chiropractic and its associated CCEC is empowered to mandate limits on admissions of students to chiropractic educational programs in their respective countries. Attempts to do so would likely result in litigation and possible anti-trust actions. The Canadian Memorial Chiropractic College (CMCC), unlike many of the American DC programs, has a capped enrollment and declines enrollment to twice as many students as it accepts each year. Obviously there is a great demand in Canada for chiropractic training. If CMCC were to reduce its enrollment, this would simply drive up the number of students applying to the US schools and then returning to Canada after graduation. Furthermore, reducing the number of students accepted to many of the US schools would very likely result in severe economic consequences for those schools from which recovery might not be possible. A reduction of enrollment by 25% would not be accompanied by a proportionate reduction in expenses and because many of the US schools have tuition dependency in excess of 80%, these schools would be hurt badly. This simplistic "solution" also doesn't take into consideration union contracts, existing articulation agreements, undergraduate programs hosted by many institutions to prepare students for entry into the DC program, funding for research, etc.

I am not disputing the concept that currently there may be an oversupply of DCs in Ontario. A nice study by Mior and Laporte (J Manipulative Physiol Ther. 2008 Feb;31(2):104-14) concluded that there may indeed be an excess of DCs. Since that study, however, a report by Longo, et al (J Can Chiropr Assoc. 2011 Sep; 55(3): 193–203.), suggests that the OHIP delisting of chiropractic services in late 2004 had not had the severely adverse impact on chiropractic practice that was forecast and which was one of the factors considered in the Mior and Laporte paper. A recent US study (Davis, et al. JABFM 2015, July-August; 28(4):481-490) on the impact of chiropractic care on visits to primary care physicians for back and neck pain surprising revealed that in areas where there was the highest saturation of DCs, there was also the greatest percentage of patients with low back and/or neck pain seeking care from DCs rather than from their PCPs.

It is important that all factors be evaluated, not simply the number of graduates from DC colleges. Obviously the Pareto principle cannot explain why BC and Alberta have utilization rates reported to be close to 25%, much higher than is seen in Ontario. Perhaps some greater insight can be gained in exploring this issue by examining the Gallup Poll results as reported by Palmer this year and http://www.jmptonline.org/article/S0161-4754(15)00124-4/pdf.

I hope that the above information helps to correct for your readers some of the potential misconceptions introduced by the Business is Life article in the September 2015 edition.

David Wickes, DC., MA.
President, Canadian Memorial Chiropractic College

Read: Dr. Anthony Lombardi responds to Dr. Wickes' letter


+14 #1 Keith 2015-10-07 07:43
As a Ontario chiropractor for over 12 years, I fail to see how the market supports the annual increase in chiropractic graduates when the utilization in Ontario has remained stagnant and the attrition rate due to retirement, career change or death is low. The OCA should have enough internal stats to demonstrate this if they chose to present it. Instead, year after year, we are presented a rosy picture of the future of chiropractic in the Canadian health care system by CMCC and the OCA/CCA but the reality for the average chiropractor is much different. In addition, we still do not have a uniform chiropractic identity with various factions of subluxation based and rehab based chiros not to mention dubious new techniques and technologies sprouting forth every few years (ie. Spinal decompression, Proadjuster, etc).

Although Dr. Lombardi has not provided supporting evidence, we can still make some logical conclusions regarding the state of the profession.

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