On 'Care Plans'

Prescriptive care plans are not something I am a proponent of, at all, I have to say.

I had a call from someone who wanted to ask me some questions yesterday. After answering her very reasonable queries, she went on to describe her experience at another chiropractic clinic, where she had been told that she needed to come in three times a week for the first few weeks and then twice a week for some more weeks and then once a week, for a while more.
The best way to arrange this, the chiro said, was to pay $2000 up front for the suggested course of care because that gets a discounted rate for each visit, which the sales spiel also suggested would make a real difference with what she had going on.
She was committed to trying this out because she was totally over being in pain all the time.
The appointments she booked were at 4pm as that was when she could get there after work, and the following week (with no obvious changes to her presenting complaint) the chiro she was seeing there decided that they didn’t want to work those shifts any more. She couldn’t make it during the day to see them, and so she was shuffled onto another chiropractor at the same clinic, with a gap in her prescribed care plan because they needed to rearrange schedules. Not ideal, she thought, but she agreed.
Then, the next week, the new chiropractor had a sick child, which happens, and needed to cancel some more appointments. This patient was understanding of the circumstances, you can’t help if your kids get sick, but she got a bit concerned because she’d been told that she needed to come that often to see the improvements she wanted, and seeing things weren’t changing much and she was already ‘falling behind’ on the care plan, when further visits were cancelled later that week, she rang them and asked: What does this mean with what I’ve been told about my problems? Is it still going to help? Am I going to have to keep coming longer now? Will it cost more?
Oh, it won’t really matter, it will still help, she was told, just carry on.
As you might expect, that made her wonder if she should have believed any of what she’d been sold!
Which is why she rang me.

She first of all asked if I used the little clicky gun thing, and I said yes, I do use an activator for some things I do, but mostly I use a drop segment table and it’s a bit different to the typical ‘whack’em crack’em’ approach people sometimes think is what all chiropractors do.
She asked if I worked on things other than the spine, and I said yes, I adjust shoulders and elbows and wrists and hands and knees and ankles and feet, and that I also did a bunch of soft tissue work and used stretches and exercises as well.
She asked how often I usually wanted to see people, and that’s always a question that gets me a little uncomfortable because more often than not, it’s one of those ‘how long is a piece of string’ questions.
I said that usually, I find getting a couple of sessions in about a week apart is quite a good kick start to things, and sometimes it might be weekly from there for a while. Sometimes we can drop to every couple of weeks quite quickly. Very occasionally I will try to get someone a couple of appointments in the first week, but they’ve got to be pretty broken for that to be necessary. If there’s a good improvement in three or four sessions some people are happy to carry on managing things themselves from there, but to be perfectly honest, I do end up seeing a lot of people long term, because life is complicated and bodies are complicated and people often find what I do to be very helpful so they start telling me about more and more things that are going on for them, once they learn that I’m not solely focused on the spine. As amazing as working with the spine is, man, it does not fix everything.

Oh, she said. That sounds quite good. And this is the point at which she proceeded to explain what her experience had been, and unfortunately, it is a story I hear occasionally. Not usually with the chiro cancelling visits that much, but most certainly the excessive treatment plan was very familiar.
I apologised, saying that I really didn’t like sharing a profession with people who were into the sales and marketing side of it as much as some chiros are, adding that I don’t try and hang onto patients, because quite honestly if there is someone I can think of that’s going to get you where you want to be quicker, I don’t want to get frustrated and I don’t want you to get frustrated, so I’m going to suggest seeing whoever is more appropriate. If people want to keep seeing me while they concurrently work on other things with other good practitioners I refer to, great. If they want to go and try something else and then come back, great. If they want to try something else and not come back, I’m ok with that too- this isn’t about me, it’s about the patient in front of me and what’s best for them.

She said she was going to ring the clinic and ask for her money back, as she had only had a few visits and really wasn’t happy with much about the experience. I encouraged that, and she said that she would be back in touch to make an appointment.
Sure, whenever you are ready, I replied.

I spend zero money on marketing. I don’t run facebook ads, I maintain a google listing and a website which both cost money, but I spend nothing on boosting my google ranking or keywords and the rest of that stuff. That hopefully doesn’t sound like I’m bragging, it’s just that I don’t need to like most chiros will, and I mention it to be up front about how I do things.
My work speaks for itself, many of the new patients I see are word of mouth referrals, and really that’s been my thinking for a long time: If you’re good at what you do, and people know you do good work, you should be busy.

Unfortunately, it’s impossible to tell from the brief videos and other chiro website content that makes it sound pretty amazing and all, what you’re getting into.
These care plans are most often part of what is termed a ‘high throughput’ practice model, where the younger chiros working for a practice are required to go out and do public screenings and market themselves and the clinic to the general public and get potential patients in through the door. Then, in the new patient appointment, they literally run through a scripted spiel, which was concocted by a marketing company that the practice has probably subscribed to for a long time, that they know will result in people essentially being scared into a care plan because of what might happen in years to come if they don’t do something right now. More often than not that first appointment will include xrays that the chiro then makes concerned noises about when viewing them together with the patient, to support what they’ve been taught to say to people about why they need chiropractic in their life.

Some of the worst, blurriest, pointless xrays I’ve seen have been taken by chiros. Which they have told patients they need to have, so that the chiro knows it’s “safe” to adjust them and that the xrays will help with them being able to adjust the right areas, or to see the correct direction of thrust, or whatever. Of course they’re very happy to charge people for taking these xrays, or say it’s a “complementary” part of some fairly expensive all-inclusive initial exam that’s necessary before care can start. Sometimes things are split into two or more visits, with the assessment and a report of findings on separate visits, and then an adjustment at the report of finding visit, or even the next one.

There are very occasionally times when I have not adjusted someone in their first appointment, but there’s usually some pretty messed up stuff going on for that to be the case.
I don’t think it is at all necessary to have xrays to be able to help people. If you know what you’re doing. And, funnily enough, most people see me and feel miles better without ever needing them.
If we do a few sessions and things don’t seem to be progressing as expected for someone, I do use xrays and other imaging to assess further. I choose to refer out for those, to Pacific Radiology, because their radiographers spend all day taking xrays, and their radiologists spend all day viewing well taken images to write very professional reports about what they pick up. Or most commonly, what they don’t pick up, because imaging is most useful to rule out bigger issues that are unlikely but worth checking for.

It really feels a bit weird to write about this, but I just so thoroughly disagree with that sales-y marketing-y approach, and I have finally had one too many of those conversations to say nothing.
If reading this saves one person from being talked into something like I’ve described, then it was worth the time writing all this out.
The reason it’s called a ‘high throughput model’ is because those chiros sign people up and sell them long, intensive, expensive care plans, and then people realise it isn’t working, and they want out. The visits are quite short. You’re in and out. Often by the time people realise it’s not for them and the rewards aren’t there for the time and effort they’re putting into getting across town three times a week for a 10 minute session, it’s quite a few weeks in and quite a few visits.
When asking for a refund, of course the way the contract works, is that the chiro wants to sell you the visits you’ve already had at the full price now, because you can’t have the discounted rate unless you do all the prescribed visits, and you end up getting next to nothing back.
Sometimes you owe them more.
There’s a lot of effort that goes into getting new people and more new people, because people are dropping off the other end pretty quick. And not because things are all amazing and life is better. Because not much changes.

I do encourage people to book appointments ahead, which is simply a function of being as busy as I am- if I tried to just rebook people whenever they come in for a visit, it won’t be the next week or the following where there’s availability. That was possible in the first couple of years I was in practice, but as it stands now, if it’s a month or more between appointments, yeah, getting progress can be hard. There are plenty of people who do book monthly or six weekly or two monthly or longer even sometimes, as regular maintenance. That’s a different scenario to working on a complaint that’s a daily issue, or a new injury.
I have no interest in a hard sell. If people want to cancel appointments no problem, if it’s just not for them, I take no offence. If we decide good progress has happened and it’s time to reduce the frequency then that isn’t an issue, as there are always people on my wait list who will happily take any space that comes up. Sometimes I suggest more frequent sessions, but booking is always the patient’s decision. I want good patient outcomes, but I don’t need to be busier than I am. Being booked so many weeks ahead is actually a little bit stressful if I’m honest, although there are obviously worse problems to have in life!