Editor's note: Dr. Chester Wilk's article, "The Dichotomists within Chiropractic" in the September 1, 1991 issue provoked Dr. Gerard Clum to respond with "The Propagation of Destructive Myths," in the October 11, 1991 issue.
Dear Editor:
My article dealing with the tragedy of dichotomy of chiropractic leadership provoked a response from Dr. Gerard Clum. In his reply he supports two national associations because, in his words, it creates "competition" while unity would be anti-competitive and create a monopoly and thereby hinder open debate, growth, and development of chiropractic. He said that big is worse because it suggests "one point of view" and resultant failure. He cites the Soviet government's breakup as an example. He supports "two credible organizations as the best guarantee" to insure a better professional future.
This is the most ludicrous, bizarre, and dangerous rationalization for dichotomy that I have ever heard. Both ACA and ICA are trade organizations. Yet, you will not be able to find one trade organization or union in the entire world, which subscribes to this position. They will all agree that only one strong trade organization representing whatever group there is, is always much better than multiple intraprofessional organizations. This is simple common sense. Unless the ICA knows something special that no other trade organization in the entire world knows or supports, then the folly of the reasoning of dichotomy is self-evident.
Dr. Clum's statement that "big is bad" contradicts all rational and logical thinking. First of all big is a relative term -- big compared to what? Chiropractic is actually small in numbers when compared to many of the other organizations and groups, and to purposefully make it smaller makes no sense at all. We need to be as big as possible, both in numbers and in spirit and attitude. The divisive and self-destructive attitudes within chiropractic diminishes all of these elements.
To compare chiropractic unity with totalitarian government such as the Soviet Union is absurd. The ACA is a democratically run organization. There is no status quo here, but rather some very spirited and highly competitive democratic meetings representing both conservative and liberal views under one roof. This is competition and democracy in action at its best. Diversification of opinions is healthy and should be encouraged but under a unified banner -- not running away and splitting into multiple groups. If Dr. Clum wishes to use countries as an example, might I suggest he look at Lebanon, Angola, and Ethiopia which are marred by multiple governments (our dichotomy) and he will witness distrust, civil war, bloodshed, and gravely unstable governments. Would you put your savings account in their banks? This is the sad effects of dichotomy placed into proper perspective.
Dr. Clum assumes that there is so little merit to the ICA point of view that debating it in a larger forum could never result in the ICA views being adopted by the majority. He seems to take the position that allowing different viewpoints to be debated separately in different forums, with different "leaderships," with extremely costly duplication of facilities, with an ultimate clash of final viewpoints not previously cross-fertilized with brain storming that normally results from open debate in the same forum, with the confusion fostered in the profession, and, consequently, in the general public, somehow benefits the chiropractic profession. He appears happy with -- and even welcomes -- the opportunity to allow the opposition (AMA, insurance companies, etc.) to "divide and conquer" chiropractic.
According to Dr. Clum's thinking, the profession would be better off with 40,000 individual organizations because then no one would be bound by a majority vote and each individual could reap havoc according to each person's individual agenda. He fails to accept the importance of a profession arguing out the differences among themselves and then presenting a united front to a sometimes hostile and anti-competitive world in which we live.
Rather than a common forum in which the best of ideas are adopted after debate, Dr. Clum appears to argue, in effect, that the United States is better off with 50 foreign policies, 50 different currencies, 50 different languages, and 50 different presidents. This way he will guarantee the leadership perks and the title president to ever splinter group in the profession. He prefers the Central American experience over that of the United States. He ignores the costs and waste of multiple headquarters, staffs, officers, employees, expense vouchers for duplicative travel, separate lobbying, and consultant and communication costs, separate publications, and the enormous damage to the profession of splinter group spokespersons confusing the public with a variety of conflicting ideas.
Dr. Clum's statement that the merger issue was defeated twice by ICA is intellectually dishonest. In reality, a clear majority of the ICA voted for merger in both elections -- this is fact. By the quirk of Delaware corporation law requiring two-thirds majority, the minority was able to thwart the will of 60 percent of the ICA members. Even then the minority was not satisfied because it had a new organization started in the wing ready to be introduced if a two-thirds majority vote had been successful. This is not democracy in action; this is a thoroughly self-destructive element in chiropractic and must be candidly recognized and exposed for what it is.
According to Dr. Clum's logic, George McGovern, Hubert Humphrey, Michael Dukakis, Walter Mondale, and all the other losing candidates over the last 200 years should have been president of the United States. If not, they should have been able to at least form their own countries so that they can be president of something.
If you read Dr. Clum's entire essay you will not see one constructive suggestion, and without a constructive agenda he offers nothing but words. While he talks about "my personal political goals" he does not identify them. If it is like the goal of George Washington or Abraham Lincoln to have a united nation, then I can proudly wear that label as it applies to our profession. On the other hand, if it is Dr. Clum's goal to encourage professional anarchy, then his personal political goal should be seriously questioned.
We know that the ICA is not asleep. We also know, however, that it is wasting precious assets, denying the larger segment of the profession the benefit of its members' debate in an open chiropractic forum and fostering public confusion about chiropractic. I am encouraged and confident that the great majority of the profession is perceptive and wise enough to recognize the foolishness and self-destructiveness of dichotomy and will rally behind our largest democratically-run organization. It is the only logical option.
The ACA, through democratic elections, has acquired some strong and aggressive leadership which is acutely attuned to the needs and wants of their constituency -- both liberal and conservative alike. This is only as it should be. I sense a new drive and a new commitment in this leadership, the likes of which I have never witnessed in my 35 years in chiropractic. If you are not an ACA member, I urge you to send a resounding message to the dichotomists by joining today. If you are a member, please send a membership application form to someone who you know is not a member. The ACA Journal carries these application forms.
As governmental power shifts from state to federal governments, we must unify. It won't guarantee that our problems will disappear as Dr. Clum so grossly misquotes me, but at least makes our effort a bit easier in these very challenging and perilous times. We need all the help we can get.
Chester Wilk, D.C.
Chicago, Illinois
There's More to Straights than Adjusting
Dear Editor:
Once again I read another of RHT's long-winded expositions on the sad state of affairs of chiropractic and health delivery in the United States. Once again the subject of Washington's (state) restrictive law has been brought up. I cannot restrain myself any longer and consequently submit this humble (with a small "h") rebuttal.
After a lot of work and soul searching, all three of Washington state's chiropractic associations have merged into one organization. Evidently some practitioners were wanting to do more than adjust and quote B.J., if three associations had existed originally. I, for one, am pleased there is one organization to represent the profession in our state capital and would hardly consider merger a step backward.
Next, Washington licenses naturopathy as a separate portal-of-entry provider. I have a referral relationship with local NDs, as well as with physical therapists in the area, and a medical office down the street. We have chiropractic consultants who perform consultation exams for labor and industry patients. There are several alternative medical clinics in the area staffed by forward-thinking MDs and associates. Hardly a lack of choices for the patient.
However, my biggest objection to Doctor T's editorial was the implication that straight chiropractors only adjust. Good grief, man, I read chiropractic journals, naturopathic publications, nutritional reports and commentaries, and take 25 hours of continuing education per year, minimum. No, I don't do homeopathy, but I am familiar with that as an alternative method. I don't do acupuncture, but I lunch often with an acupuncturist and we share ideas and understandings. Frankly, I enjoy doing chiropractic. I enjoy learning about other methods that can help the patient. I probably will never be a super doctor like RHT, but I respect the expertise of experts. I don't consider an upper cervical practitioner anything less than an expert, particularly if that is his primary method. And, by the way, just because our state law disallows extremity adjusting (last time I checked), it certainly allows examination of the appendages (get my drift). More than once I have found fractures on extremity films and made the appropriate referral. So please, quit making us straight chiropractors out to be nincompoops and recognize that we are just as caring and conscientious as you are and would do the same for our patients as we would for our own family.
Michael T. Ashley, D.C.
Bothell, Washington
The Canadian System, Another View
Dear Editor:
I graduated from Canadian Memorial Chiropractic College in 1983. I spent four years in Toronto and got a chance to see the celebrated "Canadian system" up close, and I must comment on the recent brouhaha regarding same. The U.S. General Accounting Office (GAO) sponsored a recent study on the Canadian system and although their findings were extremely positive, it is clear the GAO study merely looked at statistics, figures, and philosophy, and by no means took an up-close look at the situation. As patients were processed through the clinic when I graduated, the daily visit charge at the time was $7.20 (Canadian). This, of course, did not include x-rays or lab work, but it did include any and all therapies. The maximum annual coverage for a patient at that time for chiropractic services was $150. and that did include x-ray ($40 maximum for any and all views) and lab procedures. The basic Ontario Health and Insurance Plan (OHIP) charges these days for a chiropractic visit, regardless of any and all therapies a practitioner wants to use, is $9.60 (Canadian) with an annual maximum benefit of $220. In the Manitoba Insurance Plan the reimbursement for chiropractic services is $5 (Canadian). There simply is no incentive to invest in the therapeutic modalities that patients need when there will be no reimbursement for it. There is little incentive to invest in large, modern facilities for the same reason.
In speaking with the many friends I have in Canada about their system, I find it fascinating that without exception every chiropractor I know would move to the United States in a minute if they had the chance. A practitioner cannot get ahead in a centralized-socialist system such as exists in Canada. Medical doctors in Quebec (and very soon Ontario) currently have an annual salary cap. When the doctor reaches an annual gross income of $150,000, he must either hand over to the government any excess income or take a forced vacation. In Ontario, if a medical doctor accepts any cash payment from the patient in the form of a surcharge, he is liable for severe penalties in the form of a $10,000 fine and/or one year in jail, or both, per incident. There is a proposal currently being discussed that would put a salary cap on chiropractors as well. Most chiropractors do surcharge their patients between $5-$10. Another current proposal is to make it a federal offense for chiropractors to surcharge patients. In Ontario and Quebec there is a proposal for a so-called "user fee" such that if the patient wants to use his OHIP card, then the doctor will surcharge that patient $5 and hand it over to the federal government. The doctors are being considered as de facto tax collectors. Why? Because the system is broke. The provincial government dictates what fees a doctor can charge, but the government can't afford to pay the doctors.
The GAO study indicates that the federal government issues a 40 percent reimbursement to each province to help pay for health care. It seems the federal government stopped that practice two years ago. Rate setting and all other administrative decisions are handled on a provincial basis now. Currently, the federal government has asked all the medical schools to limit enrollment because the system cannot pay for all the new doctors graduating unless there is a drastic pay cut for practicing doctors. Each province heavily taxes all consumers for health care whether they need it or not. All employers are compelled by law to pay additional "Employee Health Tax" for all employees to help subsidize the public coffers. In a recent court case in Quebec, an obstetrician was penalized for delivering 251 babies during the fiscal year. The "cap" on delivering babies is 250. He was professionally requested to take a vacation and admonished for not referring the pregnant woman elsewhere. The overall standard of care in the Canadian system is lower than that in the United States. Most of the very best specialists have left the country. During the Desert Storm conflict, the Canadian hospital ship was deemed inadequate for the needs of the troops and was not sent simply because the government is so broke it cannot afford to pay for important and needed upgrades.
Although there is a certain sense of simplicity and, therefore, organizations with a one-party payer system (in this case the government) and perhaps less confusion regarding benefits and administrative overhead, the simple fact of the matter is the Canadian insurance system is an oppressive, socialist, monolithic plan specifically geared to stifle a doctor's incentive, limit his ability to make a living, and thwart any sense of entrepreneurship. The Canadian system is not the talismanic system the GAO makes it out to be, and much closer attention to the details of the average day in the life of a practitioner should be investigated and included in the final report.
John J. Haberstroh, D.C., D.A.B.C.N.
Brighton, Maryland
Fair Reimbursement for Fair Service
Dear Editor:
It is with great interest I have read the pro and con articles relating to percentage contracts by some practice consultants.
As a practice consultant (chiropractic/dental/medical), I submit there is no place for a percentage fee. There are far too many variables that will affect the bottom line of any practice. Yet, when consultants are discussed, it is usually how they can help make the practice grow. Growth of the practice is a relevant term.
Indeed, new patients are paramount to the success of any practice. All too often physicians want to know, "How can I better spend my advertising dollars," when the real question should be, "How can I train my office staff to make the patient want to return to the practice?" Surprisingly there are few offices that have established policies and procedures for handling such things as telephone protocol, collections (internal and external), insurance reimbursement, internal marketing, financial policies, operations, and personnel administration.
It is important for graduates and physicians opening a new practice after a group association, to get valuable assistance from business-minded consultants, not advertising specialists or percentage seekers. Most physicians will readily admit business management is not where they want to focus their attention.
Unfortunately, the "office manager" is usually the person that is given a title by reason of longevity or popularity, with little or no regard to that person's ability to lead, teach, or make sound business decisions. Send them off to a couple of seminars and all will be fine. Seminars are not cost effective. All employees usually do not attend and when they return to the office they are so busy catching up on the work they didn't do while at the seminar, they haven't time to tell other employees what they learned. Ask an employee two weeks after a weekend seminar, "What are the four most important aspects of the seminar," and all but the most exceptional employees will not be able to tell you.
Training done on site is more cost effective, better absorbed by all employees, and subject matter can be addressed to the specifics of your practice. Local (within your region) consultants can help your practice best, because they know the area and people, rather than zip codes and market-share studies.
When efficiency and productivity are met head on in a methodical fashion, your practice will grow and prosper. The physician can then put his "consultant percentage" into a tax-sheltered program that will provide for the future. Consultants should charge a reasonable hourly fee and remain a part of your "payroll" as long as they are productive, ethical, and prove to have the expertise to help build your practice, just as any other valuable employee.
Steve Glidden
Practice Consultant
Cleveland, Tennessee
Rethinking Prescription Rights
Dear Editor:
Although I have no desire to become a drug-prescribing chiropractor, I welcomed the recent effort to provide chiropractors with the educational requirements for prescribing. I welcomed this change because it embodied an excellent strategy to use in our ongoing conflict with organized medicine.
After years of dramatic chiropractic progress on the scientific and legal fronts, the medical-industrial complex (the MDs, the drug companies, and the hospitals) has hatched a new and thus far very successful plan for the containment and eradication of chiropractic. It is their under-the-table assistance to the insurance industry in the elimination of chiropractic coverage. It has been very effective, as witnessed by the workers' compensation disasters in Oregon and other states.
In all forms of war, "divide and conquer" has always been the easiest way to win. The medical-industrial complex has used this principle on us (with our cooperation) for years. Now, for the first time, we have a chance to use this principle on them.
What keeps the medical associations, the drug companies, and the hospitals working together is money -- there's a lot of money to be made by locking chiropractors out of health care delivery.
However, if we take this same desire for more money, and use it to pry the medical-hospital-pharmaceutical partnership apart, our ongoing fight with the AMA will be a lot easier. We can do this if we get prescription rights. The drug companies will see us as a financial opportunity instead of a financial threat, and they will quit working against us. Without the power of drug company money working against us, the medical-industrial complex will be like an under-watered house plant with a severe case of wilt.
Chiropractors are afraid of getting prescription rights because they see what happened to the DOs. But we must remember that first the podiatrists, then the optometrists, and now the psychologists, have grabbed the opportunity of diluting the opposition by going for limited prescription rights. It doesn't seem to have cost them their philosophy or their soul.
There is good reason to believe that the chiropractic profession should rethink this issue. In our upcoming battles with the AMA and the insurance companies, whether we have the drug companies against us or neutral to us could easily make the difference between winning and losing.
H. Gordon Ainsleigh, D.C.
Meadow Vista, California