In the 1970s and early 1980s, association memberships were at record levels. They were male-dominated - a reflection of the complexion of the profession at the time - and these "good ol' boyss clubs" provided the opportunity to tell war stories and circle the wagons to support each other in the battle to survive in the shadow cast by medicine. Tom Brokaw, in his book, The Greatest Generation, documented the characteristics of this generation, which experienced the Great Depression, Hitler, Pearl Harbor, the atomic bomb, the iron curtain, the Berlin Wall and the world convulsing in massive change. The "enemy" was clearly identifiable and commonly acknowledged. There was little ambiguity in knowing who the "bad guys" were.
In many ways, this is a generational issue. The Baby Boomers are replacing the leadership in our nation's Capitol and in chiropractic state associations. With this changing of the guard, the imposition of new values and attitudes is resulting in fragmentation. The "question-authority, if-it-feels-good-do-it, do-your-own-thing" generation chafes at the lock-step regimentation that is the basis of many organizations. Whether they are civic groups, volunteer organizations, churches, or chiropractic associations, all are seeing declining memberships.
Many Baby Boomers and "Gen-Xers" do not find relevancy in these groups; while the "what have you done for me lately?" perception could be turned around with improved communications, that's not the problem. If state associations are going to be more than relicensure seminar sponsors (hardly a unique position these days) or organizers of phone trees to hound legislators, they must acknowledge something most have been afraid to face.
We Have Met the Enemy
What is the purpose of a state association? Like a practice that has become bland and without a point of view by attempting to be all things to all people, most associations have lost their power base, hamstrung in an attempt to garner a consensus in a profession that is bifurcating before our eyes. Thus, the struggles that associations are facing are merely the corporate manifestations of the struggle playing out in the profession itself: Is chiropractic a separate profession, or is it destined to be integrated into the medical model?
States already dealing with this dilemma find themselves fragmented between two or three different organizations, reflecting the answer to this important question. In addition to reflecting the views of their memberships, they duplicate overhead expenses, thin the leadership ranks, and confuse legislators. Today, the enemy is no longer a zealous AMA Committee on Quackery, but those among our own ranks who want to see chiropractic take a different path than the one we see! Increasingly, the reason for an association's existence is to secure greater reimbursement from insurance companies, be recognized as "real" doctors, or battle their chiropractic brethren who are trying to medicalize chiropractic and dilute its "separate and distinct" DNA. Meanwhile, the majority of the profession sit on the sidelines, focusing only on keeping their practices solvent.
Ironically, both factions claim that if they prevail, practices will flourish - but the rank-and-file chiropractor isn't buying it. Oh, a threatened work comp law or PIP change can produce a temporary spurt of attention and loosened purse strings, but today's chiropractor, who takes licensure and even the right to practice for granted, finds getting new patients, paying the bills and "keeping the doors open" of greater concern.
Those who see the value of a unified chiropractic front and look for a return to the good old days will be disappointed, because the problem playing out in chiropractic organizations will be with us for years-unless the chiropractic colleges become more consistent in what they teach (unlikely); chiropractic encounters another Goliath that would rally the troops (unfortunately, more likely); or a third possibility described below.
The Breeding Ground for Disharmony
The diversity in the profession that is tearing state associations apart is being bred at the chiropractic college level, and while overall enrollment declines (Is chiropractic no longer an attractive career path?), those who graduate do so with unclear or conflicting identities, depending on which institution they attended.
This has produced an epidemic of what Dr. Larry Markson calls "prefixed chiropractors." Here are a few you may recognize: straight, principled, objective, wellness, pain relief, multidisciplinary; not to mention confused, ambivalent, and those who use the name of their adjusting techniques as a way to distinguish themselves. Ironically, back when state association memberships flourished, simply being a chiropractor was enough to satisfy the need to be different and unique!
David Meets Goliath
Unfortunately, it is more likely that the unification those in state leadership positions yearn for will occur when an enemy great enough to stir up every chiropractor shows up; something more threatening than caps on personal injury awards, HIPAA compliance, or even the capricious polices of Trigon and Blue Cross.
This begs the question: Has the state association model run it course? Is it an unnecessary vestigial artifact from a different era? Is there another model more appropriate for our time?
As union membership plummets to an all-time low, and most of us don't even know the names of our neighbors across the street, is there a more appropriate way to connect the profession and exert influence on our culture? Have "acceptance" and "validation" not only tamed the profession, but made state conventions merely social occasions to commiserate about declining incomes, irresponsible associates, and raise enough money to fund the salaries for the staff in the state Capitol? If so, most chiropractors would rather use their monthly dues to belong to a practice-building group or join a country club. By the looks of the attendance figures of many association meetings, apparently many have done just that.
A New Pride and Purpose
Yes, the political sausage-making still needs to be done at the statehouse. But if I were asked (I haven't been) by state association members to help them turn the corner and become a vital force for chiropractic in their states, I would offer the following suggestions:
Champion success. As you make the state association a more relevant and entrepreneurial effort, you look for problems, and solve them. The biggest problem, one that prevents PAC donations and building the war chest necessary to do big things, is that most practices are struggling to survive. The solution is to turn state associations into vehicles for making successful chiropractors. With this role abdicated by both associations and the chiropractic colleges, a battalion of practice coaches, consultants and management firms are thriving. Scratch the itch that field doctors have and you become a magnet for dues-paying members.
Nurture a virtual community. At a time when more and more patients are showing up in chiropractic offices, waving pages downloaded from Web sites, many state organizations lack even the most rudimentary Internet presence. As online communities grow (by being personal and relevant), many state associations appear more interested in raising money than consciousness. Where are the discussion boards, best practice tips, staff- training resources and support that can be delivered instantaneously and at virtually no cost? A few have the vision and have done this - and more. But most have their attentions elsewhere, yearning for the past while rearranging the deck chairs on the Titanic.
Pool resources. If state organizations adopted the mission of making and nurturing successful chiropractors (which is much more than fighting the latest legislation at the statehouse!), they wouldn't squander vital resources duplicating what the other 49 states have done. Sharing information about how to hold successful conventions, conducting effective public relations programs, and being relevant and accountable to the membership is essential. Instead, many state organizations waste valuable resources training a local public relations firm about chiropractic, or paying for duplicative studies about the public perception of chiropractic!
Become an advocate for chiropractic. It is said that a rising tide lifts all boats. Little else would engender loyalty, support and membership from chiropractors in the state than if their associations became a source for new patients. "We'd love to do that, but it takes money!" Correct. So, make it your mission to create happy, healthy and successful chiropractic practices. Paying membership dues is a luxury if you're worried about paying the rent. Apparently, the association's executive director hasn't taken a pay cut like most chiropractors have. Send patients to chiropractors and the whole equation changes.
Are course corrections difficult to make? Absolutely. Are they impossible? I don't think so. But we're running out of time. I'm reminded of shortly after the 1967 Six-Day War between Israel and Egypt, when General Moshe Dayan was asked why Israel had so successfully prevailed. "The Egyptian soldiers were fighting for an idea," he replied. "We were fighting for our lives."
While the leadership of every state organization would love to see their membership ranks swell and chiropractors working together to advance the profession, it's a lofty idea few chiropractors can afford when they are fighting for their lives.
William D. Esteb
Denver, Colorado
www.patientmedia.com
Bill Esteb is a chiropractic advocate and new-patient marketing specialist with more than three decades of experience in the profession. He is the co-founder of Perfect Patients (www.perfectpatients.com) and the author of 11 books that explore the doctor-patient relationship from the patient's point of view.