In a challenging economy, deciding when to invest in growth–or to stabilize so to avoid losses–is a complicated choice. Stripped of politics (a high bar), the calculations basically have to do with understanding what the return on investment might be. Sometimes projecting ROI is difficult. The ‘window’ for any ROI can be short, intermediate, or long. Having some sense of when a return is likely helps determine if an investment makes sense or not.
Paul Krugman, the Nobel Prize-winning economist, (among others) has argued eloquently in a number of posts and columns that strategic investment in a staggering or weak economy makes all kinds of sense (one example on ‘Self-defeating Austerity’ here). What I like about his arguments is that there is a powerful corollary to what we have happening in chiropractic.
For chiropractic, these times can certainly be viewed as a down economy. Demand is down; supply is up; competing products are abundant. Consumer needs are certainly greater than ever before, but our profession, viewed as a maker of widgets, can’t get the right product to market in the hands of the right people at the right time. Many are incurring hundreds of thousands of dollars in student loan debt, only to get out into the cold cruel world and find that they are ill-prepared or have ill-prepared for the realities of running a business.
“But I only want to serve humanity!” We hear the plaintive cries of those who have fallen by the wayside. Cynicism is up; confidence is down. What’s wrong?
Fundamentally, it’s my view that our leadership has largely failed the profession. It has failed to effectively anticipate, track, and respond to trends; mobilize around opportunities; address professional fragmentation; or align graduates of chiropractic schools (our ‘educational products’) with marketplace needs and interests.
Other than that, they’re doing a great job.
In fairness, those in place as professional leadership have come there out of a professional culture dramatically weakened by healthcare economics over the last twenty-five years. Prior to the advent of managed care, chiropractors commonly established themselves successfully in practice, and a notable contingent was able to afford the luxury of giving back to the profession in the midst of their careers, mentoring and fostering the interests of those coming up behind them. Managed care changed all that, and a generation of DC leadership had to do the work of two generations. Exhausted, they have aged out or retired from the scene, having done yeoman work for more years than they could have anticipated, or even desired. The leadership in place today for much of the profession looks pretty lost, from where I stand, unable to effectively mobilize a critical mass of the profession around any degree of consensus on identity, goals, outcomes, or even agreement on threats. So, in balance, those in leadership have had to figure a lot out on their own. And in chiropractic, we’re not very good at knowing what we don’t know.
In times of duress, it’s tempting to contract. Retrench. Cut your losses, lick your wounds. And some or all of those may be appropriate or even necessary on given issues. But largely, we appear to be in a professional contraction that masks itself as an opportunity.
There are clear signs that many are seeking to change chiropractic scope laws around the country so that some degree of drug prescription is possible by doctors of chiropractic. This may appear to be a way of broadening business revenues or meeting patients’ needs as a one-stop shop. But I would argue that it is, in fact, a professional contraction away from a core value: our very identity as a drug-free and surgery-free profession. What we believe we’re adding will, I predict, result in confusion, weakness in market interest, and a diffusion of our value over other, more-established professions we’ll then have to compete with and explain why we are better. In my view we won’t be able to effectively make that argument. We’re contracting away from who we are to save what we want to do. For a case study, look up osteopathy. Net gain or net loss? You be the judge.
Strategic investment requires a sense of what strategic goals are appropriate. For discussion’s sake, I’ll offer a few as a way to figuratively draw out the shape of an effective, vibrant, stable and viable profession. In the words of many who’ve come before us and issued patients’ reports of findings, ‘there’s nothing wrong with us that what’s right with us can’t correct.’
Strategic Goal #1: Align our contribution with marketplace needs. The health care marketplace needs a cost-effective, clinically-effective range of services and products that meet the needs of consumer-patients.
Example of a strategic investment: Foster a discussion to determine what services and products we can agree on, then establish that shared agreement as our professional core. Tolerate expansion and refinements of that core.
Strategic Goal #2: Develop a research agenda that meets marketplace needs. Chiropractic has nobly chased a mechanistically-based research agenda within the established, orthodox, medical model for a long time. Significant accomplishments have been achieved. Compelling outcomes have been documented. Many have done remarkable work. We’ve proven we can operate within a heavily medically-mediated funding and evaluation culture. But a reality is also that our mechanistic research outcomes have not resulted in material changes in how chiropractic is viewed by the supply side, and the demand side doesn’t understand the value of what’s been accomplished. Further, we’ll never catch up to what the marketplace wants in terms of mechanistic research, and those outcomes may be fundamentally misaligned with purchasers’ interests and needs.
Example of a strategic investment: Foster a discussion about broadening or realigning our profession’s research agenda to include market-facing outcomes. These are a variant of the clinical outcomes we think of in comparative research: the market-facing outcomes I speak of have to do with value-based purchasing, so that the purchasers of chiropractic services and products (employers and consumers, not insurers) can develop a better, clearer and more transparent understanding of what the value is for using chiropractic care and its vitalistic paradigm of disease prevention through optimal neurologic functioning.
Strategic Goal #3: Develop an integration strategy based on the distinction of our vitalistic paradigm and clinical contribution, rather than subjugating ourselves to a medically-driven decisionmaking process. The health care needs of this country alone cannot be met by the existing primary contact/point of entry/care medical resources. Arguably, they shouldn’t be, either, given the evidence of needless expense, redundant services, inappropriately prescribed and managed medications, and the hulking sham of evidence-based medicine. So there is a role to play for doctors of chiropractic (and others) who, because of the vitalistic paradigm of self-directed growth, development, health and healing can play a significant role in thought- and clinical-leadership.
Example of a strategic investment: Foster a discussion about what integrated care really means from the standpoint of the chiropractic profession, not the medical profession. In terms that align and resonate with our own perspective and clinical paradigm, set criteria out for integration that the profession can use as a set of guideposts for evaluating and promoting opportunities to more effectively address the needs of our various populations.
These are goals we should be able to agree on or revise; these are investments we should all feel that we are stakeholders in with the ability to make a meaningful contribution. No provider in chiropractic should imagine that they have no role in achieving these strategic goals, or participating in efforts around strategic investments. Where will these conversations begin? Who will take ownership in their development?
What do we think will happen if we fail?