A recent string of posts on the list serve of the MCA (Minnesota Chiropractic Association) painfully highlighted aspects of how powerless the chiropractic profession is today. For me it also offered insights as to why our profession is drifting, fragmenting to the point of disintegration, and seemingly bent on self-immolation. For a profession capable of doing so much good, of providing such a necessary service, we seem to be in a tailspin. What is wrong? Why is it so wrong? And what, if anything, can be done about it?
The thread started with one doctor raising the question of whether or not their peers thought the colleges were turning out too many DCs for the marketplace. A few reactions were posted; opinions ranged over whether there was an oversupply or not. Counterpoint expressed was that our marketplace penetration was so limited that we should regard that as the problem, not the number of DCs in the marketplace. I posted some thoughts on the issues. After the thread had run its course, I was left with several strong impressions. The first was that it was a little surprising that for an organization with a membership of many hundreds of DCs only a dozen or so had weighed in on the issue. While that number is in line with social media metrics (normally only 1-2% of a social community actively post on bulletin boards), I was still struck that so few opinions were expressed. Perhaps those expressed captured the feelings and sentiments of everyone reading the list serve, and the rest just thought it unnecessary to add their views. But I have my doubts whether that was the real reason.
The second impression was, I thought, perhaps evidence of our worst malaise. I had a gut sense that more people didn’t weigh in on this because they feel there is no solution, and that they feel so helpless and hopeless that they didn’t think it was worth speaking up…or that it was simply too painful. Or perhaps they feel there is no problem, because they are doing well. While there are many, many success stories out there of people who are or have been immensely successful in practice, the truth is also that there is an extraordinary amount of pain being felt by those who are not enjoying that same success.
Conflicted profession, conflicted outcomes
It must be pointed out that there is some real progress being made in some areas where the benefits of chiropractic are becoming more widely understood. Whether those areas of progress will benefit the profession as a whole is yet to be seen. The inclusion of chiropractic more widely in federal health efforts is wonderful; what will that lead to for new doctors graduating from our colleges? The promotion of chiropractic in UnitedHealth’s physical medicine clinic concepts may be great for professional visibility; what effect will this have on non-participating DCs? It seems that a broader, more collective effort is required.
Where are the leaders?
From where I sit and from what I hear from a number of people around the country, a good proportion of the profession is under extreme duress, and I think part of that is a lack of visible, inclusive leadership. There do not seem to be many leaders openly tackling the disengagement and despair that seems to be out there. The lack of clear leadership in these matters means that if we were to issue a role call for leaders with pragmatic, inclusive solutions, we’d be left with the metaphorical sound of crickets chirping. There is no ‘there there.’ I have come to believe that generally most chiropractors feel they are really just on their own, and that no one really has their backs. Professional associations have lost their ability to aggregate field doctors into a heterogeneous culture united by common values; they have become, by and large, (necessary) lobbying operations, and their business models must compete for attention in a very crowded field. It’s not certain they will be able to survive in their current forms: the contracting membership of the ACA and ICA illustrate what must be inferred to be waning vitality and a striking lack of engagement by the profession with its national leadership.
Is the business model of chiropractic schools hurting the profession?
The business model of our chiropractic colleges and universities is based on graduating a steady stream of students. As non-profits, their revenues are heavily tuition-dependent. This may or may not be a problem, depending on what’s happening in the marketplace. With most schools facing declining enrollment and because little had been done to examine the pool of potential chiropractic students, two of the larger professional vendors (Standard Proces and Footlevelers) recently used their influence and pushed schools into an uneasy peace and collaboration so that the pool of applicants could be more closely examined. Sheathing their weapons for a time, schools collaborated on looking at how they might better understand who the potential students were they have been competing for. Spoiler alert: the pool is shrinking. A lot of money has been spent over the years as schools sought to climb over each other for the hearts and minds (and wallets) of a group that is getting smaller.
Under the pressures imposed by these vendors, schools agreed to hew to the greater good of the profession’s interest to a certain extent and collaborate on recruitment messaging (see the Foundation for Chiropractic Progress) but diversify their institutional identity-based messages in the recruiting marketplace. This tactic superficially offers a diversity of options for students in how the profession expresses itself, but in my view also may cause further self-inflicted harm. One person’s diversity of brand is another person’s cultural fragmentation, and I fear these efforts are likely to further codify the fragmentation of vision and identity that is already taking place. What does it say about us that a potential student is faced with messages as broadly different as the expression of chiropractic at Northwestern, National, Western States, Sherman, or Life? In a healthy marketplace, this range of choices should signal professional vitality. Does that hold true for chiropractic?
At this point, I think not, because what’s missing in these messages–and across the spectrum of practicing clinicians–is what we share. It’s clear what separates us. Taken together, this direction and these efforts alone cannot heal the profession. They are taking place in a vacuum of leadership. Our profession does not enjoy the benefit of a unifying leader or group that has a single vision that can rally everyone. We have, instead, competing visions that seem to be based on very different conceptions of chiropractic–differences that may be important marketing tools for schools, but may be further weakening the profession.
A number will protest, I’m sure, that there are in fact inclusive leaders out there, but that their messages simply aren’t being heard/listened to/received. I fear the reality is more that we don’t have professional leaders, but rather tribal leaders, leaders who have honest, heartfelt, and important messages for doctors of chiropractic, but who are functioning more in a hall of echo chambers where their messages play well to a segment of the profession while alienating others. “Inclusion” is based on tribal characteristics, and doesn’t look welcoming to those outside the tribe. For some, this is an appealing tactic, as in a polarized culture the idea of winners and losers seems to be an end that justifies these means.
For others it’s a painful strategy, and because our own internecine battles are taking place at a time when the marketplace is terribly confused about chiropractic, every ounce of effort we put into reinforcing our tribe acts to fragment our profession (and promotes winners and losers). I don’t think we appreciate the negative impact this has in the health care consumer and payer marketplace: increasing confusion, disinterest, and choices that include professions other than chiropractic. The reality is, the other ‘tribes’ are strong, and aren’t going away any time soon. We may think we’re promoting winners and losers by self-congratulatory back slapping and the ‘attaboys’ that come with clever putdowns, but the collateral damage is that we’re encouraging and contributing to a cultural stalemate. If true, the entire profession loses.
What can be done?
I don’t pretend to have a clear sense of what a comprehensive and effective solution might be, but I can think of elements of an overall strategy that might help. Framed in terms of the problems I see, here’s one person’s take on three things I think we need to do (and three things I think we should avoid) that may be needed to ensure chiropractic is around for another century–as a success story:
1. We must agree on a common premise of the chiropractic paradigm. We’ve tacked so many things on the core chiropractic paradigm of optimal neurologic function that a lot of our customers (public, employers, insurers, researchers) may have lost sight of what chiropractic actually is. Across the spectrum of clinical philosophies–from exclusively subluxation-based to those with the beliefs that chiropractic and medicine are compatible, there are common elements that can be defined as chiropractic. That core must be clearly defined and subscribed to by all involved. This would clear the way to understand what is not chiropractic–but that is available for DCs to practice in addition to chiropractic. Without this common definition and efforts to get everyone ‘on message,’ the public will remain confused. That confusion will kill chiropractic, because other professions have got their messaging in order.
2. We must strengthen our professional culture. It can be argued that in our early history we needed to be very independent so it was harder for political medicine to hurt us. That fierce independence has become characteristic of our professional culture, and has also permitted a number of our profession to adopt clinical and business tactics that are misleading, ineffective, unethical, and worse. Based on agreement on the common premise of the chiropractic paradigm, we must be willing to call out those who are hurting the profession and the public.
3. We must align schools’ educational ‘products’ with marketplace needs. Schools depend on alumni for recruiting and philanthropy, but often don’t do a good job of weaving their alumni into their culture. Alumni experiences–successes and failures–are an effective feedback loop, and they should be more dynamically part of schools’ work and planning. It’s time the profession demanded greater accountability from educational institutions for the degree to which their graduates are effectively prepared for the current and anticipated marketplace realities. Schools’ business models aren’t based on seeking change. They should be based on a much more dynamic and nuanced view of the health care consumer/patient marketplace.
What shouldn’t be done?
There are converse aspects of these three strategic elements, too, and I think it’s important to identify them as the ‘rails’ we should operate within.
1a. We must stop vilifying those who disagree with us. The antipathy in print, social media, and other communication channels aimed at those with whom we disagree on elements of philosophy, political beliefs, clinical practices, and other aspects of personal and business livelihood is often virulent, denigrating and painfully personal. Arguing against this trend at a time when civility has been set aside in most aspects of our society may seem like a lost battle, but until we understand how much this weakens the profession, we’ll keep inflicting a death by a thousand cuts. The ‘frat boy’ pack mentality that makes it so appealing to be divisive, offensive and juvenile has to be called for what it is. We need to grow up and stop tolerating or rewarding it. Being civil isn’t being weak.
2a. We must stop viewing those who practice differently from us as not being of us. Chiropractic is a profession that can be wonderfully inclusive, and that inclusivity can be built and and based on agreement on common elements and what I’ll call ‘layers of clinical practice additions.’ If and when we find accord on what chiropractic is, even if individuals choose to do things in addition to chiropractic, we can strengthen our culture by acknowledging what we share in common and identify what we do not, even if we choose to practice in a different manner. We will never be a homogenous culture. We can–and should–be a heterogeneous culture with a common set of values and definitions. That heterogeneity can be the basis for a healthy professional culture…if we’re willing to be healthy citizens of that culture.
3a. We must stop thinking we have the luxury of being unengaged with chiropractic schools. We may often have profound differences with the direction schools take, but if we succumb to the sense that our views don’t matter, we contribute to the weakening of the profession by our silence. One only has to look at the power of social media in cereal marketing, of all places, to see what effects can be brought about with intention and collective action. What might a parallel effort lead to in encouraging schools to value their alumni in more ways?
So now what?
Doing anything about the problems facing the chiropractic profession will require a clear vision and collective action. What might lead to this?
A small number of people I’ve been talking to are interested in getting together locally to begin discussions that might lead to a draft set of proposals which should then be more widely discussed and debated. If anyone out there is potentially interested in being part of this effort, please send me a message.