As the Wisconsin Chiropractic Association moves forward with its Primary Spine Care Physician Initiative, the issues this brings into focus will be felt across the whole profession in the near future. In essence, the state’s association is proposing that doctors of chiropractic or students have the option to take an additional two years of training, receive an academic Master’s Degree, and operate with the ability to prescribe certain drugs under a revised state Scope of Practice law. What’s right and what’s wrong about this approach? And are these even the right questions to ask?
There are at least two perspectives to take on this issue: one is from the profession’s interests, and the other is from that of the marketplace. For the profession, it’s legitimate to ask what can and should be done to improve educational processes, competencies, and preparation for practicing chiropractic. With those considerations, it’s fair to consider broadening the range of services available to patients–fair, but not necessarily a good idea. And in an age where health care consumers want and need convenience, it’s hard to argue against the thought that more options for patients means that they won’t have to go somewhere else for something simple like a prescription to help with pain or inflammation.
These aren’t just any services, however: adding drugs to chiropractic practice means that the profession’s identity isn’t ‘drug- and surgery-free’ any more. For many in the profession, that may be an easy transition to make, but for a great many it’s not, and is viewed as fundamentally destructive to the profession’s distinction. After all, if chiropractors do this, what will set them aside from physical therapists, osteopaths and allopaths?
At the same time, increasing the education to more fully prepare doctors of chiropractic for effective, ethical, science-grounded and viable business-based practices is an increasingly important idea. The biggest trouble with this is that for most students the costs are going to be piled on to an already crushing student debt load, and it’s hard to imagine how that will be manageable. In the roundest of numbers, current chiropractic programs cost around $100,000, and most students end up with a great deal more debt than that. If two years of education are added, bringing the total (again, in the roundest of numbers) to $150,000–with two more years of living expenses on top of that–how will those loans be repaid? If we imagine that the education required to claim the title of “PSCP,” along with the cultural assimilation that comes from hospital-based training is going to position us effectively to be ‘the’ assessment and treatment option of choice, we’re kidding ourselves. Expecting the ‘system’–one that is historically hostile to pluralistic treatment of DCs–to embrace us into a favored position is <a href="http://en precio de la viagra.wikipedia.org/wiki/Magical_thinking” target=”_blank”>magical thinking.
So, if from the profession’s perspective it’s got some appeal–even if the concept is polarizing and challenging–what about the other view? What does the marketplace want? How would health care consumers react to DCs as primary spinal care physicians? There’s some positives here, but some very real negatives.
On the positive side, the word physician helps lower the barriers that confusion over titles creates. Many in our profession know this and already claim the title, although in a number of states (including Minnesota) it’s a protected title and against the law for DCs to use. For many consumers, that would make them perhaps a bit more comfortable, and for some the ability to not have to go get a prescription from a MD would be appealing. Whether medical boards will consent to sharing this title is an interesting question.
On the negative side is a significant issue: the profession’s brand. ‘Brand’ isn’t what we think of ourselves, it’s what others think of us. Brand management by companies is often an immense effort based on an ongoing, dynamic and reciprocal relationship with their customers. Many companies ask their customers constantly what they think of the company and its products and services, and often spend enormous sums of money to educate consumers. If that effort fails, they are forced to realign their products and services if consumers aren’t interested in changing their perceptions. Target didn’t decide to pull out of Canada solely because they didn’t do their homework on supply chain issues; Canadians, as it turned out, were somewhat hostile to the brand and loyal to local brands, even when local stores cost more. Wal-Mart doesn’t offer higher end goods to its shoppers; their shoppers have a fixed price-point range and sense of value in mind when they walk in the doors. Adding more expensive options would be a waste.
It may be hard to think this is relevant to chiropractic, but consumers have a perception of our profession, and changing that perception is no small task. We have to ask ourselves: will it make our brand more clear or more confusing if we become ‘MD lite?’ There’s no doubt that the public needs chiropractors and chiropractic in a more prominent position; we do a better job than anyone in helping the body’s capacities for self-healing and optimal function. But that’s a different question than whether we should co-opt aspects of a medical identity because it may confer cultural authority. We have a superior ‘product’ but an inferiority complex. We need to establish our cultural authority on distinction, not similarity.
We also should remember that the marketplace is undergoing profound disruption, and it won’t be long before health care consumers are be in a much different position than they are now. The marketplace in several short years is going to be characterized by much greater independence from managed network restrictions, much greater consumer interest in the value they get for the money coming out of their own pockets (outcomes over costs), and much more sophistication about the kinds of services consumer/patients seek for different problems and conditions. Whether those consumers will like the fact that a chiropractor’s office is different from a MD’s because it has a plastic spine is a question we can’t answer yet. Much of the sense of value that comes from being a PSCP is dependent on the system staying aggregated and vertically integrated, but there are many sources of evidence that health care in the future is going to be exactly the opposite.
There’s probably some middle ground here, a blended perspective that understands chiropractic education must be profoundly revised to change its content, delivery, preparation, and costs. But in addition it’s very hard to see how this profession will survive if we don’t define it as distinct from alternatives such as PT, medicine and others. If we think we can preach health and wellness and use that to make us distinct, we’re kidding ourselves: everyone is, and will be, doing that. If we think we can manipulate the spine and extremities and use that to make us distinct, that’ll be a tough argument to make with more-prominent and connected PTs and DPTs saying the same thing. And if we think that vertical integration into hospital and clinic systems is going to give us an advantage because of proximity, we’d better prepare ourselves for the same rates of compensation, not increases.
What we should do, instead, in my view is prepare ourselves for the marketplace of the future that is increasingly easy to define. We need to double down on internal efforts to strengthen the profession, understand better what our adjustments actually do, and strengthen the educational context for what should be a very distinct paradigm on health and wellness counseling based on optimal neurologic and physical function. That’s where the future holds the promise of stability and growth for chiropractic.