Happy New Year! I hope everyone's holiday season was fulfilling. This year's commentary will focus on three topics.

Maintenance

Even with a host of positive studies on the benefits of spinal manipulation, our market share continues to remain static. Why? In my opinion, it is the very poor reputation we have with a significant percentage of the public and many healthcare professionals. This is a reputation we have earned for continuing care of asymptomatic patients under names such as maintenance, wellness, or prevention. Until anyone can prove endless lifetime care has any benefit to anything but the wallets of the marketing man selling it and the chiropractor performing it, we should cease immediately and concentrate on how we can release patients faster. I know of no other health profession where so much "continuing education" concentrates on how to treat a patient longer. Not only does this strike me as totally backwards but, in my opinion, it borders on blatant dishonesty. Why our schools, our state, and our national associations continue to give the people who preach this deceit a platform is beyond me. I wonder how long it is going to take our profession to realize that this nonsense of continuing care costs us millions of dollars a year in lost business?

Let's look at this problem from another angle. Is there anyone out there who doesn't feel the insurance companies are here to make as much money as possible? If maintenance care really reduced arthritis, heart disease, colds, or ANYTHING else, you are kidding yourselves if you think the insurance companies wouldn't do EVERYTHING in their power to get ALL their policyholders on maintenance programs. In fact, you would think there would be a surcharge if insurance companies didn't receive regular bills from chiropractors proving that their policyholders were receiving maintenance care.

Personal Injury

Out here in California, times are tough. Practices are down and managed care is growing. Group insurance will soon be history. The same crooks who ruined group insurance by teaching people who are well to continue care and people who are healthy to start care have now turned their attention to personal injury. I have been receiving ads from these people encouraging doctors to sign up for their personal injury courses. These ads promise success in building large personal injury practices which they say is the last lucrative frontier in chiropractic. These practice builders, consultants, motivators, leaders, coaches, managers, teachers, or whatever you call them, are now using personal injury to separate you from your hard-earned money with the hook of a huge practice and a large income. Folks, there is a simple, easy way for us to continue to treat personal injury cases and to protect and even expand our market share. That is, get patients well faster with higher satisfaction and lower cost than our competition. The insurance companies' money and power are growing. It's only a matter of time before legislation will enable them to dictate who treats automobile accident victims. You don't have to be a nuclear physicist to figure out that the business of treating soft tissue automobile injuries will go to the group that does it the most efficiently. The last thing our profession needs is courses on how to stretch a low-impact, five-visit automobile accident case into a $2500 medical-legal lawsuit.

Manipulation

The last few years have been the best in history concerning the science of manipulation. With an ever-increasing body of well-controlled studies demonstrating the benefits of manipulation, even our most vocal critics are admitting that patients with uncomplicated back pain should consider spinal manipulation as a treatment option. They quickly add that physical therapists and osteopaths also manipulate. They don't say that chiropractors perform over 90% of the manipulation.

What really worries me with the trend to spread the word about physical therapists' and osteopaths' ability to manipulate is that, in my opinion, most of these people simply cannot compete with a chiropractor. The issue is training and experience, and I do not believe someone who learned manipulation in one elective course or one or two weekend seminars, and performs it one to three times per week, can compete with a person who has had years of training and performs 30 to 100 or more manipulations per week. If a referring gatekeeper correctly identifies a patient who has a need for manipulation (another subject we desperately need to address), but refers them to an inexperienced manual practitioner, I feel the following risks occur:

1. There is an increased chance of manipulation failing because the provider lacks skill. This will then mislead everyone into thinking manipulation was the wrong treatment. Other therapies will be employed, diagnostic tests will be run, but the patient will still not get well. As we know, if a lesion requires manipulation, no modality, medication, exercise, or surgical procedure will solve the problem. Only the correct type of manipulation delivered in the correct way.

2. There is an increased chance of a patient receiving a sprain-strain or even more serious injury. It takes training to know when manipulation needs to be aggressive, gentle, local, general, or even not performed due to the patient's clinical picture, which changes constantly during recovery.

3. There is an increased chance of excessive treatment which can give the impression that the length of recovery is longer and the cost is greater than it should be. Most DCs will agree that as they continue to practice, their skills improve. For example, a case that required 10 treatments in my first year of practice I can now usually solve in 5 visits. I have no idea how many times I would have had to treat this "case" after only four days of technique class. Many times, this is how much training our competition has received. Until proven otherwise, I think it is safe to assume that there is a high probability that practitioners with minimal training will not deliver optimal therapeutic results.

CONCLUSION

Manipulation (like medicine) can be both harmful and addictive. A conservative practitioner truly interested in his or her patient's health will do everything they can to insure they don't have a practice full of people addicted to manipulation. As Dr. Craig Nelson says, there is nothing conservative about endless treatment. The hypocrisy of less drugs, less surgery, and more manipulation is a major reason our credibility as a profession continues to suffer. There are two simple steps clinicians can take to improve our reputation, expand our market share, and protect areas like personal injury. They are:

1. Get patients better with as few visits as possible. By getting patients well rapidly and releasing them quickly, we remove the major reason gatekeepers, insurance companies, and allied professionals seldom refer to chiropractors. This will also ensure that when manual medicine is indicated, DCs will get the business.

2. Change the focus of patient education from continuing chiropractic care to programs that teach patients how to stay out of our offices with proper nutrition, exercise, and lifestyle. I feel if our profession abandons maintenance programs and the dogma that accompanies them, some doctors will experience a short-term reduction in business. However, in the long run the result will be an increased market share and unimagined prosperity for all DCs.