10 Ways to Know Who’s Good and Who’s Not.

 

Every profession has those who are good, those who are not, and then everybody in-between. I’m sure you can likely think of how this is true in your own profession.  For outsiders, it can be hard to know what to look for and what to stay away from. I’ve made a list of 10 things, the first three of which you would like to see in your chiropractor, or any doctor for that matter, and the following seven are things that should raise a red flag.

The purpose of this article is to give outsiders an inside perspective, to give the health care consumer knowledge to make a better choice. The chiropractic profession sees about 10% of the population, and this number has apparently stayed pretty stagnant for a very long time.  However, according to a consumer report in the mid-2000’s, about 25% of the population has been to a chiropractor at some point.  This does not speak well for the profession’s overall success in treating patients in a way that they find valuable and successful.

 

Expect More

I’m often amazed by the stories people tell me about the doctors they go to.  People tell me all the time how they continue to go to a doctor that they really like and think is really great, yet they go on to tell me about the pain and dysfunction that they continue to have. I know the barrier to going someplace new can be a lot, especially when you are comfortable.  I think the biggest thing is that it’s hard to know what you don’t know. And how are you going to know what to look for or what to expect if no one ever informs you?

 

Two Things I Want the Reader to Learn and Understand

First, I want you to understand that the chiropractic profession is really two professions trying to co-exist under one roof. One faction is science-based, and the other faction is philosophically and metaphysically based.  The differences between the two are nearly as great as the differences between podiatry and foot reflexology.

If we compare and contrast podiatry and foot reflexology, while the two professions have always been distinct, there is commonality in that each focuses its treatment efforts on the foot; however, this is where any resemblance between the two professions ends. Podiatric medicine is a science-based profession dedicated to the diagnosis and treatment of foot disorders. Foot reflexology is a metaphysically-based group, consisting of non-physicians who believe that many physical disorders arise from the foot. Podiatrists have rejected foot reflexology as an unproven and unscientific practice and do not consider it part of mainstream podiatric practice. Thus, it would be quite unreasonable to think that podiatry and foot reflexology could ever exist under one professional roof.(1)

Second, I want you to understand how to decipher the responsible, educated, and ethical from the unresponsible, uneducated,and unethical.

 

THE GOOD 

 

1. A good chiropractor uses scientific language that the rest of the healthcare field is using.

A good chiropractor will talk about principles of physiology and biomechanics that make sense and don’t seem highly specific to this doctor or some kind of philosophical approach that this particular doctor has adopted. They will say the same kinds of things and use similar language you might expect to hear from a medical doctor, surgeon, or physical therapist.  Your doctor should respect science and the scientific and peer-review process. It’s not to say that science/research have all the answers, but it has many, and some doctors are missing that boat. Subsequently, so are their patients.  Your doctor should keep themselves current on topics in their field. For a chiropractor, those topics can include manual therapy, exercise, biomechanics, physiology, pain, neurology, and other topics in human and health sciences.

To me, this first point is your best overall indicator in deciphering what kind of chiropractor someone is and knowing which of the two camps they occupy. This point will tell you a lot about how much your chiropractor has actually familiarized themselves with research in their field.

This is what we expect from those we consider DOCTORS: someone who respects principles of science such as predictability, reproducibility, objective measures, accountability, and explainable and feasible mechanisms of action. There are many products and services that claim to help people with their health, disease, or pain.  Are they all doctors? Of course not. Do they help some people sometimes? Absolutely.

 

2. A good chiropractor, or any good doctor of physical medicine, uses the following similar template:

1. Rule out Red Flags of serious pathology such as Fracture, Tumor, Infection, etc.

A competent history and physical exam is 99% effective in ruling out red flags of serious pathology. This can take a significant amount of time depending on your condition. For me, it typically takes 30-60 minutes.  Imaging is typically more for confirmation or to rule out suspicions of serious pathology.  For more on this, or if you think you need imaging, please read this:Structure vs. Function – Do You Really Need Those X-Rays?

2. Attempt to identify the pain generator, and treat accordingly.

Think – muscle, joint, disc, nerve, etc. – Often it’s a combination. Sometimes a condition is too acute, and it’s difficult to tell, but most of the time, it’s not that hard to get a pretty good idea.

3. Attempt to identify and eliminate the perpetuating factors.

Think – “What has gone wrong with this person, or what are they doing that caused the issue to happen, and what is continuing to drive it?”  The doctor should look at things like how a person moves, posture, working position, daily tasks, diet, stress, state-of-mind, lack of muscular stability, lack of strength or mobility, etc.

 

3. Caring, Compassionate, a Good Listener

“Nobody cares how much you know until they know how much you care” – I don’t know who said it, but I agree.

Perhaps for some conditions, bedside manner isn’t a big concern; you just want the best doctor possible. For chiropractors though, it is important. We touch people and need to spend time with patients educating them on how to avoid reinjury. Trust and rapport between doctor and patient can be very helpful when dealing with the psychosocial elements associated with chronic pain in particular.

THE BAD

 

1. High Volume

If your doctor sees 10-20 patients per hour or more, the chances that you are getting responsible, quality care is very small. Since it would be hard to know what the doctor’s schedule looked like, just do the math. Less than 5 minutes with you? If you don’t really consider chiropractors to be doctors anyway, but rather excessively trained back crackers, and you just want a “pop,” then you might be fine with this.  If you take your body and physical pain and injuries seriously, then you want a physical medicine doctor who takes the time to come up with tissue and movement specific diagnostics and tailors treatment accordingly. You just can’t get this from a high-volume practitioner.

These kinds of practices tend to want you to believe that an adjustment is of almost a metaphysical, spiritual, or magical power. Some of these practitioners will even tell you that your “Power Is On” after the adjustment. Was it off? Where did it go?

 

2. Taking x-rays on all or most patients

Many chiropractors in the past, and even currently, were trained to take x-rays on nearly every patient and are now either not staying current on evidence or don’t care.  Some chiropractors will say that certain indicators on x-ray such as vertebral positioning or curvatures give them insight about your health or lack of health.  The problem is that this has never been demonstrated to be the case; it is based on a theory and a pretty flimsy one at that.  There is very little to no predictive value when assessing x-rays for markers of health and disease outside of overt pathology.  And just because someone takes x-rays and their treatment was helpful does not mean that the x-rays had anything to do with it. Research tells us that although patients are more satisfied when x-rays are taken, they have greater severity of pain, longer duration, reduced functioning, and poorer health status than those who did not have them taken.(2)  This likely has to do with patient perception that the doctor is more thorough when taking an x-ray, so we need to do a better job educating patients that a competent and thorough exam not only rule out serious pathology with over 99% accuracy but also give us much more useful and important information.(3,4)

 

3. Being a guru on a specific technique or building their practice around one technique.

There are no magic techniques or magic cures.  There is no secret technique.  There are people who are more coordinated, have better dexterity, touch, and sensitivity, but the techniques themselves are never magical.  Sure, some techniques are better than others or may work better in certain situations, but it is only because they follow biomechanical and physiological properties, not due to some magic or secret in the technique. If someone thinks they are using a “special” technique, it is a dead give-away that they actually have no idea how it works. Of course, they’ll tell you differently, but it will be all philosophy.  What I mean is if you go to a chiropractor or to their website and it strongly seems that they have based their practice around essentially one technique, it is not a good sign.  Common examples of this are Gonstead, Upper Cervical Specific or Atlas based, and Activator.  There are plenty of others, but those are the most common.

There is very little clinical decision making happening in this kind of practice and very little customization to an individual’s needs.  These practices are similar to infomercials where you might consider trying them if you’ve tried everything else first and don’t have much to lose or your friend told you it worked for them.

 

4. Telling you that you have a subluxation.

This is not really a diagnosis. It’s actually a category of multiple things that can be wrong.  Chiropractors who use this terminology tend to not differentiate the categories even though it is important to do so as it changes treatment significantly.  A good analogy for this is shoulder impingement syndrome which is a very common diagnosis with several possible causes. Knowing you have it doesn’t do you any good.  You need to know the type that you have and what your specific contributing factors are.  The same goes for a subluxation. For more on shoulder pain and impingement check out Part 1 and Part 2 on the topic.

 

5. Long-Term, Up-Front Contracts

If a doctor wants you to sign a long-term contract or prepay hundreds or even thousands of dollars up front, this is a big red flag. Not only is this not how responsible and ethical chiropractors practice, but very few businesses function this way.  Are they trying to be your cell phone or cable company? You should always be in control of your treatment.  If you don’t like it or decide you don’t want it, you should be able to stop, and your doctor should not be so insecure in the quality of their service to try and lock you in.

 

6. Wellness Care

If your doctor talks to you about wellness care and how your spine needs to be adjusted regularly, it’s another bad sign.

What do we even consider WELLNESS? Wellness is mostly an active endeavor that you must live out on your own. It isn’t a passive procedure that someone can instill upon you. As a chiropractor myself, I am financially biased to encourage repeat visits but ethically obligated to be honest that there are many things that far surpass spinal manipulation when it comes to wellness. What wellness is a chiropractor providing you by adjusting your spine? It really depends on you. Does it help you feel more relaxed, decrease your stress, or decrease your aches and pains? That could be wellness.

There are also people that we can call “chiropractic responders”. For whatever reason, these kinds of people seem to have almost miraculous results by being adjusted.  This can include relief from allergies, acid reflux, Parkinson’s, ADHD, asthma, multiple sclerosis, and tons of other conditions. There are some theories for why this happens, some much more feasible than others, but we don’t really know. Considering these people are the exception and not the rule, a credible scientific profession cannot be built on these cases. There are many alternative health options that also have lots of successful anecdotal cases with little explanation. Many chiropractors, whether on purpose or inadvertently, promote their practice this way which takes them out of the legitimate health science profession and places them in the category of fringe alternative health options. This is an example of what I mean when I say that that the profession is really two professions in one.

If you want wellness: Eat right, exercise, move right, and be or get emotionally healthy. That’s wellness, not getting adjusted once a month for the rest of your life.  If you have an injury or pain, go to a doctor that can help you get over the pain and teach you what caused it and how to avoid it from happening again. If chiropractic wellness care is working for you, don’t stop doing it.  Some people are “chiropractic responders,” and some people DO feel significantly better when they get adjusted on a regular basis.   But that’s not for me to decide for you or to manipulate you into. That’s for you to decide.

 

7. Chiropractic Chains

This issue is dependent on what you are looking for. If you just want a quick pop or a crack, and you want to walk-in when you want, then some chiropractic chains are possibly a good option for you. But don’t go with expectations beyond that, and please don’t judge the profession from these chains.  These chains are built around reproducible and financially sustainable business principles not on quality of care or doctor expertise. These chains often offer very low cost, as in $20 or sometimes free, initial consults, exams, and sometimes x-rays. You get what you pay for. People don’t typically give things of value away for free or almost free.  What you may not realize is that typically, you are not actually getting a thorough exam; it’s often the bare minimum to cover the doctor’s liability. What you also may not realize is that this is a tactic to get you in the door to upsell you on what will often be a lengthy and expensive care plan.  Assessing, diagnosing, learning new conditions, and staying current on research takes a lot of time and effort, and it is the foundation for determining how to proceed with quality treatment. If you’ve got a real issue, you don’t want a cheap exam. 

Starting your own practice from scratch is a scary thing, like starting any business. Most Chiropractors have very little business background and get virtually no business education in school. This franchise “market” has found that there is an opportunity to offer a sense of security for chiropractors who need the extra confidence that someone has their back or is holding their hand. What many realize later is that they could have done it on their own and that the franchise or practice management company was not actually worth it. Often it is too late, and the doctor is too bought in.  So now you’ve got all the expenses of starting a business, plus all the additional expenses from the franchise, which makes for a lot of overhead expense.  In the end, this kind of debt can really bury a person and trap them.

One other thing that these franchises do that I am most shocked by is essentially trying to educate or re-educate its members on how to care for patients.  In order to incorporate the assembly line style of operating a franchise, they give you scripting/lines to tell patients, how to give a report of findings, what treatment plans should look like, and sometimes cookie-cutter rehab that is focused on profitability.  This is not care out of a science journal, textbook, or school; this is care out of a business manual.  Is this a patient-centered model?

I’m all for capitalism, making a good living, and allowing the market to decide what it wants. But I also believe in an educated market that knows its options and understands what it is paying for.  I believe in transparency and owning the business model you practice. Let people know who you are and what you are about, and let them decide if that’s what they want. Marketing should not be about deception.

 

Remember, I’m not saying that this is a list of absolutes and that there are NO exceptions. I’m just trying to give you an insider’s perspective and inform the healthcare consumer. At the end of the day, it’s just advice…

 

Most chiropractors actually fall into kind of a gray zone where they utilize some from the good category and some from the bad category. The majority of the profession is very well-intentioned and really do want to help people.  The majority of the profession is essentially as confused as you are at this point (if you’ve read this far) about what exactly the chiropractic profession is and what it’s about. That seems crazy, right? But I can’t emphasize enough how true this is.  So they function in a sort of middle ground of desiring to be somewhat of a legitimate specialist but mimicking the marketing strategies and falling into the ruts created by those before them.

 

 

Sources

1) Murphy D, Schneider M, Seaman D, Perle S, Nelson C.  How can chiropractic become a respected mainstream profession? The example of podiatry. Chiropractic & Osteopathy 2008, 16:10

2) Kendrick D, Fielding K, Bentler E, Kerslake R, Miller P, Pringle M. Radiography of the lumbar spine in primary care patients with low back pain: Randomized controlled trial. BMJ 2001;322:400-405

3) Deyo RA. Low back pain – A primary care challenge. Spine 1996;21:2826-2832

4) McGuirk B, King W, Govind J, Lowry J, Bogduk N. Safety, efficacy and cost-effectiveness of evidence based guidelines for the management of acute low back pain in primary care. Spine 2001;26:2615-2622.