The Uncertain Future of Provider Education

One of the more significant problems for doctors of chiropractic coming into the health care marketplace is that it’s increasingly clear our education isn’t just too expensive, but it’s not effectively matched to what we need to be successful.  It’s not just chiropractic–every health provider education process is subject to the same pressures as higher education is across the country. Most predictions are that higher education as we know it is collapsing, because the ‘knowledge delivery model,’ the actual content of those knowledges and the dysfunctional economics of the institutional paradigm all point to a dramatic collapse of the system. What can be done to help the profession survive and thrive? Do we need band-aids, rebuilding, or something in the middle?

A quick online search of ‘higher education collapsing’ turns up some very serious predictions. Among them:

  • This Fortune article points to higher education as the ‘next big jobs collapse,’ arguing that the system is too expensive and isn’t really returning consistent value for the investment. Others disagree; judge for yourself.
  • <a href="https://www.insidehighered viagra 25 mg” target=”_blank”>This article argues that higher education employees should ‘Get Out While You Can,’ citing the increasingly definable trend that the costs of education do not reliably return a benefit.
  • And this article argues from the point of view of Mark Cuban, famous entrepreneur, that the subsidized amount of student loan debt will put many colleges out of business.

Others argue that college is still a good investment. Among them:

  • This article points out that the vast majority of people repay their student loans, and that there’s a correlation between those who end up with higher loan balances and future earnings potential.
  • This Forbes article argues that college isn’t an investment, it’s a way of increasing personal value–that the complex set of influences are transformative for people, and add many other types of value than discreet knowledges.
  • And this CNN report highlights findings from a study across a number of countries that there is still a significant lifetime return on the investment college educations require.

Whether or not college–or chiropractic education–is a good investment or not may not actually be the question we ought to be asking. With the understanding that the rapid development of technology means that new jobs are constantly created, this futurist cites 162 ‘jobs of the future’ that don’t exist right now. Many point to the reality that when people start college, a good portion of the jobs they’ll face when they graduate don’t even exist when they begin. So how can people be effectively prepared? And where does health care fit into all this? An array of trends frames up the landscape and will profoundly influence what people need to be trained to do. Among them:

  • Health care consumers are able to use the Internet to access information that formerly took providers years to accumulate–and is often more current than what doctors know. So do providers need to be trained to amass those knowledges?
  • Those with employer-sponsored health benefits increasingly don’t have insurance, but more accurately get access to discounted provider networks. So do providers need to be part of networks when they are already effectively in competition with their peers?
  • Online exchanges will shortly dominate the way people purchase health & illness plans. So how do we need to change how we present ourselves, and how do we help people access our services?
  • Decision support tools that give consumers ways to compare and contrast options will give people the ability to choose between very detailed differences that suit their needs. So how do we effectively communicate our value? And what exactly is our value?

The trends in compensation for health providers also factor into this set of stresses. Fee-for-service models have fostered the ‘volume-based’ approach to health care: provide more services, bill more fees, make more money. Managed care has sought to throttle the volume of services to control what’s being spent, but this approach hasn’t assured the best outcomes. So ‘value based purchasing’ is coming hard and fast: the concept that for a given fee, established health goals for a given population are set and providers are paid to achieve and maintain those goals. Profit comes from being effective, minimizing costs and maximizing outcomes.

For doctors of chiropractic, there’s a further significant stress: the fact that we’re paid pennies on the medical dollar for same or similar services. We can often argue that our costs are cheaper because we’re paid less, but that’s a potentially dangerous argument–essentially that we’re a discount option to medicine and PT, framed in their terms, not ours. And because we haven’t learned how to successfully argue and defend the position that our outcomes are better, we have painted ourselves into a figurative marketplace corner. We’re cheaper but underpaid.

Some also argue that a correction in the chiropractic workforce marketplace is in order, that there’s ‘too many chiropractors.’ US Bureau of Labor Statistics forecast that more DCs are going to be needed in the workforce, but that’s not very comforting to people who are struggling with entry level jobs that are based heavily on commission or salaries that can be only $30-$45,000 per year to start. With 7-9% market penetration, where are the increasing number of  patients going to come from to keep a bigger group of DCs in business?

Given all this, what should happen in chiropractic education is that a significant re-engineering process takes place. It’s hard to see how tinkering with the system is likely to offer anything more than short- or intermediate-term solutions. For a sustainable solution that’s more flexible and nimble in the face of a very uncertain and dynamic future, it’s likely that a short set of strategic considerations need to be used as a basis for establishing appropriate goals and derivative tactics.

1. Realign the product with the marketplace. This requires both an assessment of current needs and a clear-eyed predictive exercise in future needs. Any assessment of the future that doesn’t account for the trends visible in the exploding retail health care marketplace is likely to be inaccurate. What does the provider of this very different marketplace look like? Among the elements that are likely to be required and which can be used as a basis for defining tactics include:

  • Technology-focused skills that emphasize adjudication of knowledges and options are used throughout education, rather than retention of a personal, specialized knowledge ‘volume.’
  • Social skills that establish relational ‘containers’ as a kind of emotional structure for health, wellness and healing that optimize the inherent recuperative capacities of living organisms (call it placebo if you want, but more appropriately call it the ability to evoke optimal inherent capacities).
  • Clinical skills that are distinctive and unique. Overlapping skills with other providers doesn’t offer differentiation, and only serves to confuse prospective customers (patients).
  • Demonstrable wisdom in the application of various knowledges and options that require personalization of clinical solutions that account both for the available evidence as well as the specific lifestyle context of the individual.
  • Use of ‘integration’ as a way of defining the ecosystem of different clinical paradigms and their distinctive contribution–and to identify the dangerous signs of potential co-option and the absorption of one profession into another.

2. Reimagine instructional delivery systems. ‘Design thinking‘ is required: reverse-engineering processes that are benchmarked to marketplace realities. It’s an effort that has to start by slaying the sacred cows of historical norms of higher education delivery, staffing, economics, and alumni engagement. What might this new effort look like? Among the elements that are likely to be required and which can be used as a basis for defining tactics include:

  • Transferable skill analysis needs to be a requisite for efficient learning. More than any model of ‘learning styles,’ the effective assessment of transferable skills can help design the most efficient strategies for acquiring, expressing and refining the skills and knowledges health provider education will need to impart and develop.
  • Distributed learning should be used wherever possible. The legacy ‘butts in seats’ model of education can be an enormous benefit in creating community and co-learning, but the costs of this physical capacity often force crippling overhead on the host institution.
  • Learning cohort identities should be fostered to strengthen the educational experience and share responsibilities in a new social contract. Fostering ‘mini tribes’ within an educational cohort with the advantages of electronic learning, social media, scalable building block sizes can help create unique groups of learners and their achievements, offering further differentiation and segmentation alignment in the marketplace.
  • Reconceived learning cost and payment models are needed to give students options that align with their learning options. One size does not fit all.
  • Reimagined lifelong learning needs to create new relationship scaffolding between learners and information resources. What might it take for provider educational institutions to establish a contract with students for lifelong learning, with content options and guarantees of value and performance?

3. Refocus on business as a context for clinical service. Increasingly, ‘business’ skills aren’t about commerce but about economic relationships, and health care providers are universally inadequately trained to understand the importance of the economic relationships they both require and bring with them. Dropping a graduate into an ecosystem they don’t understand and aren’t prepared for doesn’t augur well for success. What might a different focus look like? Among the elements that are likely to be required and which can be used as a basis for defining tactics include:

  • Retail dynamics will assume greater influence over providers’ success and failure. In a health care marketplace increasingly defined by retail supply/demand dynamics, providers are simply not going to be able to escape dealing with these forces. It isn’t fair and it may not be right, but it is unavoidable.
  • Clinical service=customer service. Increasingly differentiated (if not sophisticated) health care consumers will cluster to those providers who clearly segment themselves along definable lines of price, service, and amenities. This doesn’t mean uncomfortable truths need to be left out of clinical relationships. But consumers are going to be more and more insistent on new shared-power and control models.
  • ‘Value add’ enhances success. Those providers who figure out how to add additional value over and above their clinical services and expertise are much more likely to thrive and succeed.

4. Reconceive chiropractic’s contribution to population health management (PHM). Disease management really hasn’t worked, and the US health care system is shifting its focus to a variety of ways of looking at population health, and providers are going to be increasingly forced to defend a clear and measurable contribution to PHM. What might this look like? Among the elements that are likely to be required and which can be used as a basis for defining tactics include:

  • Quantify the benefits of fostering health and contrast with those of controlling disease. At the heart of chiropractic’s clinical philosophy–no matter the range of beliefs or how it’s applied in practice–is the acknowledgement and respect for the self-directing growth, development, recuperative and homeokinetic capacities of life. What simple things can we train people to do to capture basic data on this in everyday practice? What efforts critical to their survival must chiropractic educators make to support this, acquire, centralize and evaluate the data?
  • Emphasize distinction, not sameness. Data on the cost-effectiveness of chiropractic has been around for years, and hasn’t yet resulted in profound systemic change. And it won’t. Putting a chiropractor in a white lab coat may make them emotionally safer to an allopath, but subtly–and inappropriately–conveys assurances of sameness. Sameness practically ensures a nonthreatening ‘therapeutic dose’ of chiropractors on ‘integrative’ health care teams established in the mainstream allopathic model. That will leave many DCs literally out in the marketplace cold.
  • Claim and own the bigger tent. While the term ‘vitalism’ has been an easy and provocative way to emphasize the fracture lines in chiropractic, the reality is that as a basis for asking appropriate questions about health and healing it’s absolutely relevant today, and only cheapened if we treat it as a sound bite and rallying cry. The truth is that the chiropractic approach to optimal function (neurologic, orthopedic, or through whatever lens you use) requires that we embrace a clinical paradigm that is inclusive of the mechanistic approach allopathic doctors use and aligned with the philosophic touchpoint of a variety of other professions, including naturopathic medicine, Traditional Oriental Medicine, massage, Ayurveda, and on and on. We have the bigger tent. Let’s use it.

Those in leadership of chiropractic training schools are faced with a set of stresses and pressures that they cannot possibly get in front of without taking dramatic steps to change what they’re doing and how and why they’re doing it. Let’s hope that an appropriate sense of urgency begins to be visibly understood, and the talents of those who’ve committed their professional lives and work to education can be appropriately used. The effort it takes to ensure marketplace relevance will require a degree of coordination among chiropractic leaders that’s been elusive. The hope here is that the will, energy, focus and accord can be found.


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1 Response to The Uncertain Future of Provider Education

  1. Bob Thatcher says:

    Right on Stephen.

    Fascinating read.

    I also read Jim Nelson’s read today.

    The mood is changing and we who have the proper vantage point can quickly read the tea leaves. Others will try to keep the old system going as long as they can. They are invested in the system of the old and will choke in the process.
    We need strong leadership. I am no sure where the college is at??

    Those kids running through the maze of chiropractic education are going to have reality put right between the eyes….as they graduate and look for “their spot”.

    I am mindful of my old friend Doren Nelson.. DC from ST Cloud; He and Reggie Schuler were the only DCs in St Cloud…many years ago. I was President at the time. Doren called me one day…all upset. “ cannot beleive it. There was a young doc that stopped by my office and asked my opinion about practice in St. Cloud…that he was thinking of opening up there. Doren had a fit! He told the young Doc..”.go elsewhere…that St. Cloud was loaded with DCs…that Reggie had the west end of St. Cloud and Doren had the central and east side”. I told him “to get his own town…there are lots of them”. He wanted to know if there was anything the MCA and I as the President could do to see that this kind of harrasment of the older docs would cease!!!”

    Amazing and true story!

    An interesting aside as we observe the marketplace today and look to the past…and contemplate the future.

    Good work!

    Bob T

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