Is it me or should we be telling chiropractors to set their standards of care at 40 PVA

February 24, 2012

Just to clarify a few things for all the skeptics visiting the site to see this posting. I am a qualified chiropractor and as I have put it up I can say  its not what I would call typical chiropractic. It American sales techniques which have infiltrated chiropractic in Europe in  recent years. Yes a minority of chiropractors do use these techniques in the UK and since this started I and many chiropractors have  spoken out against the practice and if we make the public aware, it will stop. For Skeptics to suggest this is how all chiropractors practice is untrue, but skeptics often ignore truth for a good Tweet.

In my opinion getting chiropractors to think like this is what has caused most damage to the profession in recent years. Where traditionally chiropractors focused on being great adjusters now its the numbers. According to Bob Hofman  in this video average chiropractors only see their patients 19 times a year, the elite at the Masters circle manage to see them 40 times. Perhaps thats how a good prostitute in Amsterdams red light district operates. Fucking the patient each week is better for everyone, they feel better and  she makes more money.


it starts in the colleges where you are set a target of 40 new patients and 400 treatments. Surely the best chiropractor is the one with the best technique, who can deliver an adjustment that will hold for longer than a week and empowers patients to take control of their health with exercise and nutrition and visits the chiropractor when the need to be adjusted rather than when a practice needs to maintain the “Masters” average.

If you are not a very good adjuster dont worry you can still make it happen, people will agree to almost anything when they are in pain. Get them to sign up for their Visit Average in advance, like the Gyms do. Gyms dont want members to exercise because they have signed up to many for the Gym to cope. The want them to join  pay the membership and use the bar and restaurant. I was the only General Council Member who wanted to restrict the use of prepayment schemes??

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74 Responses to Is it me or should we be telling chiropractors to set their standards of care at 40 PVA

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  3. Sandra J on October 5, 2013 at 5:30 pm

    The American sales techniques has not only infiltrated chiropractic care in Europe but also Australia. Does it matter if your Chiropractor advise treatment 3 times a week or once a month? It definitely does to you pocket, but do you really need 3 treatment a week? Not according to my chiro.

    For those who is thinking about going to the chiropractor, get as much info as you can before you visit your local chiropractor. Only when you are informed that you may be able to ask the correct questions.

  4. Guest on April 27, 2012 at 12:34 pm

    I think we are all agreed the marketing is abhorrent and agreed that different folk practice equally ethically but in different ways.
    I would suggest that perhaps sometime Liam do check a loved one or even your CA/receptionist every two weeks and see if although without sign or symptom is does in fact have a subluxation or restriction?
    As for the new patients – if it took years to get like that it might be worth suggesting it will take more than a snap pop and crackle in your office to correct it (;

  5. Stefaan A.L.P. Vossen on April 27, 2012 at 11:58 am

    I wasn’t trying to get you Liam, just explaining that it’s easily done and easy to give out the wrong impression. You and I agree about quite a few things especially on what we should aspire to give our patients but I urge anyone to keep an open mind as it will eventually oblige everyone in the profession to be open-book about their treatment protocols and outcome measures, whereas pointing fingers tends to create ghettos and gangs and they are much harder to reform/make do the right thing. I think this type of marketing is abhorrent.

  6. Liam Mulvany on April 27, 2012 at 11:47 am

    Right I have 3 new patients in a row should I try to sign em up for 3 or 4 dozen visits??

  7. Liam Mulvany on April 27, 2012 at 11:46 am

    OK u got me on that one, and I was taking the moral high ground there. Do you feel this type of marketing is good for the patient or chiropractic?

  8. Stefaan A.L.P. Vossen on April 27, 2012 at 11:36 am

     Your comment:”The so called chiropractors running this youtube crap have deleted my first comment so I’ve posted another.”Not sure why my last comment was deleted, so I’ll say it again, and if you delete it again, ill put it on again. This is disgusting, why don’t you try evaluating your patients progress at each visit rather than deciding on how much money you can make. Can you really tell me you can assess a patient and decide they need 40 visits???? Ok you had better give me some lottery numbers then. Try putting the patients needs first rather than how much you can get from them.”Sounds like you are questioning, but again I might be wrong here…S

  9. Stefaan A.L.P. Vossen on April 27, 2012 at 11:34 am

    Problem free in whose opinion?

  10. Liam Mulvany on April 27, 2012 at 11:31 am

    Oh Stefaan, I have never questioned treatment protocols only had mine questioned. Should I get a patient back every 2 weeks when I know they can return in 6 months and have no problems? At no point have I said anybody is wrong. I am not looking down but I say again, “but if you try and tell me what I do can’t be or is impossible I will tell you you are wrong” and that means 6 monthly check ups for the majority of my patients and they stay problem free. Perceived or not.


  11. Liam Mulvany on April 27, 2012 at 11:16 am

    So can somebody be problem free over 6 months or not? Or do you beleive there will definately be restrictions by 6 months?

  12. Stefaan A.L.P. Vossen on April 27, 2012 at 9:48 am

    You showing me your perceptions through pelvic check procedures (as it would be if I showed you mine) are still opinion, not fact. Whether an adjustment is supplied by a therapist or a robot is irrelevant to the measurability of the outcome and I do consider a person taking a stance looking down (and maybe you didn’t mean to come across as such but you came across that way to me on this particular topic) as trying to establishing a “higher moral ground”. I don’t agree with seeing patients lots, because like you I don’t perceive the need for it, and quite frankly haven’t got time to, but that does not deny that I am willing to examine and appreciate the relevance of those treatment protocols if there were any without me getting uppety about my perceptions and assumptions. Fact is that I care about one thing only and that is : am I giving the best patient care possible? and if these protocols exist I want to know what their value is (if any) to the patient and as I have stated before: until we have a real way of evaluating the value to the patient of differing protocols it is just one perception versus another and there is no moral high ground whatsoever whether in clinic for 5 year or 30 years…

  13. Stefaan A.L.P. Vossen on April 27, 2012 at 9:39 am

    I think that your perception of contradiction here largely underestimates the body’s coping abilities… I believe the human body can tolerate disability, restriction, subluxations for very long periods of time, the ‘problem’ to the patient is when they start taking their toll and translate into symptoms, the problem to the clinician is ascertaining their presence, the stability of their absence, the least amount of care required to anticipate them and the trust to be allowed to provide that service.

  14. Liam Mulvany on April 27, 2012 at 9:16 am

    They can be either problem free “without getting adjusted and remain outwardly problem free and in good health ”

    or they can’t ” I don’t believe that after 6 months someone is restriction free never”

  15. Liam Mulvany on April 27, 2012 at 9:14 am

    Its not an opinion, I  will show you how I check for pelvic alignment anytime. But if you use that argument so is almost any adjustment or manipulation that isn’t done by a robot.
    I have never tried to establish a higher ground in this debate. From the start I have said its my opinion, I may be wrong and maybe I’m just left with the peolple my technique helps the most, but if you try and tell me what I do can’t be or is impossible I will tell you you are wrong. Just because you don’t see it doesn’t mean it can’t happen. If you are still working on the assumption based on what somebody told you at college then you have learnt nothing. I constantly altered the way I worked for about 6 years trying to understand what happened and why after somebody came to see me, what I’m actually talking about is from 20 odd years of experience not what a lecturer told me when I was young.

  16. Stefaan A.L.P. Vossen on April 26, 2012 at 6:14 pm

    I don’t see the contradiction?

  17. Stefaan A.L.P. Vossen on April 26, 2012 at 6:03 pm

    OK, I get that. BUT “as a correction is needed to maintain skeletal symmetry”… is it? Just opinion isn’t it? Assumption even from what we think we have seen in practice. To make matters worse, the assumption is based on the fact someone told us so when we were young and impressionable… There is no solidity to anyone’s statements in this debate in my opinion, just an attempt to establish a moral high-ground on a few assumptive statements, just as bad as the likes of canardnoir in fact.
    Just one last thing. I did a review of someone’s practice the other day and the joke was that the data told an entirely different story to what the practitioner thought was going on… 

  18. Liam Mulvany on April 26, 2012 at 5:56 pm

    Missed this bit

     ”it’s quite likely that you are undereducated as to the possible detrimental effects of a subluxation”

    Don’t worry guest I’m not offended by it, it just concerns me that unfortunately all you do is offer ammunition to those that wish to shoot us down.

  19. Liam Mulvany on April 26, 2012 at 5:20 pm

    Hi Guest, I also think this statement

    “As to the question directed to Stefan and I – of course it’s likely that folk can run around without getting adjusted and remain outwardly problem free and in good health but the chances of them being subluxation free is nil.”

    Contradicts this statement

    “In regard to the question directed to Stefan I don’t believe that after 6 months someone is restriction free never mind subluxation free.”

  20. Liam Mulvany on April 26, 2012 at 5:17 pm

    Hi Guest, I had to look that up. It,s not a slur, just that in the US, I beleive, 95% of patients have their treatment paid for by their insurance company,(I may be wrong) so basically it doesn’t really matter how many times you visit it’s included in your monthly payment, whereas in the UK 95% of treatment is paid for by the individual. Out of their own pocket. I think there is a realistic chance that is would be far easier to get a patient with health cover to visit far more regularly than somebody that has to pay for it.

  21. Stefaan A.L.P. Vossen on April 26, 2012 at 4:21 pm

    You’ve burst my bubble ;)

  22. Liam Mulvany on April 26, 2012 at 4:04 pm

    To calculate this number, multiply your average collected office visit fee by your patient visit average (PVA).
    For example: If your average collected office fee is $50 and your PVA is 12, your current base patient value is $600. Add in the value of other services, such as x-rays, to get a total current average patient value: $600 + $80 = $680.
    Finally, multiply the current average patient value by the number of patients you currently have (in this example, 20) with the insurance company to see their total value: $680 x 20 = $13,600.


  23. Liam Mulvany on April 26, 2012 at 4:00 pm

    Hi Stefaan, don’t worry water off a quacks back :-)
    Ok I beleive in maintenance care, not wellness. You cannot aspire to no visits as a correction is needed to maintain skeletal symmetry. I am a chiropractor remember so understand the importance of adjustments. I beleive that you can gradually lengthen the period between visits to 6 months, thats all. By 6 months there will be some deterioration in position, but not enough for symptoms to start to show. I have found that the vast majority of people I see are able to go 6 months between visits and be symptom free, longer maybe, but at the risk of allowing that deterioration to cause problems. It’s not set in stone, things change, but my goal with everybody is 6 months. I did go through a spell about 10 years ago of trying yearly check ups but many people arrived back early having problems, so went back to 6 months. I haven’t just picked 6 months out of the air I have found that over 20 years of working in a certain way that that is a realistic time limit for a lot of people. Not all obviously.

  24. Stefaan A.L.P. Vossen on April 26, 2012 at 3:31 pm

    PVA I assumed to be the number of visits divided by number of new patients, NOT number of times a patient is seen per year

  25. Stefaan A.L.P. Vossen on April 26, 2012 at 3:29 pm

    Just to clarify: I am not one to listen to people’s aspirations, but rather what they actually do. I made the mistake to understand what you said to be about your actual actions. That is my fault. Aspirations are about how people fancy themselves. Liam, tell me what you actually do, that way we can have a real debate rather than bounce on each others’ dreams

  26. Stefaan A.L.P. Vossen on April 26, 2012 at 3:27 pm

    Liam, I don’t get it. If you didn’t mean it as a measure of your practise, then why only aspire towards 6 months and not 1 visit for a life-time? Or in fact no need for visits at all?  If we’re going to aspire…let’s aspire properly! I am sorry but that is a ridiculous commentary in my opinion

  27. Guest on April 26, 2012 at 3:05 pm

    Chaps the space is getting very narrow so I hope you don’t mind me using the wider space of a new comment?

    Richard two points I said not drinking enough water – many folk in fact a lot of folk walk around in a mildly dehydrated condition. A subluxated C4 would affect diaphragmatic activity – do we argue now which is more important air or water – no because it would be foolish and beginning to get off topic and so lump my practice in with that that it is not. You really believe I am exaggerating the effects of a subluxation? Perhaps not.
    “Many people live perfectly healthy lives without ever seeing a chiropractpor.” How much healthier and connected could they have been?
    “I have seen far more patients from ‘twice a year chiros’ and osteos than I have from ’40 a year chiros’. But that MAY be because those have been dissuaded from ever seeing anyone…”
    Stefan I would go further and say DEFINITELY
    I don’t think we are that far apart Liam. If I check a person and they don’t need adjusted I generally get them to call back within a week. If they go two checks without needing an adjustment fortnightly then I advise them to continue the steps they have taken to better their health and yes I advise a three week gap.
    Now without intentionally being confrontational and with the utmost respect if you disagree that walking around with a subluxation for four weeks could be more detrimental to health than not drinking enough water during the same period it’s quite likely that you are undereducated as to the possible detrimental effects of a subluxation
    Why repeat UK or US a second time when it’s pejorative?
    As to the question directed to Stefan and I – of course it’s likely that folk can run around without getting adjusted and remain outwardly problem free and in good health but the chances of them being subluxation free is nil.
    In regard to the question directed to Stefan I don’t believe that after 6 months someone is restriction free never mind subluxation free. I agree with your placement within the market place given how you see your role and their need but do you really think you offer nothing else?

  28. Liam Mulvany on April 26, 2012 at 3:00 pm

    Great to hear it, I don’t have every patient on 6 months but Im aiming for it. Its a goal. But it is dictated by the patient recovery, lifestyle etc,

  29. Stefaan A.L.P. Vossen on April 26, 2012 at 2:51 pm

    No, I have plenty patients on 4 to 6 months. just not all of them as you do

  30. Liam Mulvany on April 26, 2012 at 2:51 pm

    Hi Stefaan, ehy is this getting narrower? I have said my ultimate goal is a visit every 6 months, but of course we have gone from weekly to 2 weeks to a month etc, with constant monitoring. If at any point problems re emerge then the treatment plan is altered to suit. I do not say to patients “you must not come back for 6 months or else” And I do not say you must come back every month or else. I re assess every time and advise accordingly. If somebody has just been involved in an accident of course you wouldnt leave it. I’m not saying EVERYBODY can go 6 months and be problem free but that is MY goal and it happens with the MAJORITY of people I see. I’ve seen 4 people this morn for 6 months check up. None where in pain or had any symptoms. 

  31. Richard on April 26, 2012 at 2:15 pm

     ”I believe walking around with a subluxation for four weeks could be more detrimental to health than not drinking enough water during the same period” 
    The problem for chiropractic is you and many others believe that.  think about it, the human species has evolved over millions of years without chiropractic. Many people live perfectly healthy lives without ever seeing a chiropractpor. You could not survive much more than ten days without water. Say   a person has a subluxation causing nerve interference at C4.  The C4 nerve receives collateral input from the spinal nerve at C3 and C2 so the impact of interference at C4 would not be huge over a four week period, compared with being dehydradeted which would cause severe health problems. Dont you think saying things like that to people with a little physiological knowledge might be damaging to chiropractic because you are exaggerating the effects of  a subluxation on wellbeing. Dont get me wrong, its important but not as important as you would have us believe.

  32. Stefaan A.L.P. Vossen on April 26, 2012 at 2:07 pm

    Liam, I would really love to agree with you, and although I oddly seem to place my work somewhere between you and Guest (in terms of frequency of check ups: and yes, it will extend over time, but it will vary between athletes and post-surgical times and it will vary between levels of activity of the patients involved) I can’t agree that there is uniformity in the looking after of such widely varied population groups (the likelihood of you being wrong (conscious or subconsciously) about it being possible (to have  similar results with patients with such widely varied presentations and histories despite using the same after-care protocol) is in my view far greater than the likelihood of being right. But that does base itself on logic and intuition. Both open to fallacy, I accept that. The other thing to bear in mind is that I see a lot of people who were on “twice a year” schedules but weren’t getting good enough results to their liking and came to me on referral. Point is we are all capable of delusion, even the person who thinks they have the moral high ground…in fact I have seen far more patients from ‘twice a year chiros’ and osteos than I have from ’40 a year chiros’. But that MAY be because those have been dissuaded from ever seeing anyone…

  33. Liam Mulvany on April 26, 2012 at 1:07 pm

    Just one more question for you and Stefaan. Do you think it,s impossible for a patient to only need treatment every 6 months to remain problem free and in good health? If so is that because you are unable to provide it?  and because you don’t see it it can’t happen? I’m not being funny just curious.

  34. Liam Mulvany on April 26, 2012 at 12:24 pm

    Hi stefaan, By OK I meant within limits, no pain, no restrictions. What else do most patients come to see us for? What more can you realistically offer? What else can you prove to be beneficial for the patients health except their perceived lack of pain? When a patient first sees you I bet they want you to help them with their pain Right? Some then sell them the importance of regular visites to maintain health, right? I only sell them the treatment necessary to prevent their pain from returning, which is their only reason for seeing you in the first place.

  35. Liam Mulvany on April 26, 2012 at 12:12 pm

    Hi Guest, I think we are at the complete opposite ends of the chiropractic spectrum, but thats fine. If somebody comes to see you and you check them and they don’t need an adjustment do you then advise them to leave it longer? What has been the longest period and you felt they didn’t need adjusting?Again uk or us?
     ”I believe walking around with a subluxation for four weeks could be more detrimental to health than not drinking enough water during the same period.” I don’t agree.

  36. Guest on April 26, 2012 at 10:39 am

    Liam no stress – its obvious that we practice differently indeed and have differing perspectives on what patients want most probably based on our own care schedules – a comfortable deterioration is not what I would wish for me or mine so I suppose I carry the same standard into practice as per Stefan’s post.
    How does one know they need an adjustment – if I am pain free and symptom free yet a check determines I need an adjustment I most likely need an adjustment. If I am checked and I don’t need an adjustment – then I don’t. How would a patient know if I don’t?
    This is how I care for my patients along with advice as stated because personally I believe walking around with a subluxation for four weeks could be more detrimental to health than not drinking enough water during the same period.
    I would like to see lots of people lots of times and make a difference to a wider circle. You are wrong that we have a role in ‘maintaining well being’ we have a role in creating a better higher more robust level of health (salutogenesis) through chiropractic care.
    I think what is key to this debate is money – I do not charge patients to check them if they do not require an adjustment.

  37. Stefaan A.L.P. Vossen on April 26, 2012 at 10:25 am

    Richard, I think the first sentence is key: “need” Defining need is the hardest thing to do and to find the balance between the patient’s needs (as I think the clinician’s needs are superfluous). Having worked and working with national, international, premiership, Olympic, Paralympic, world champion etc athletes I would indeed say that it is ‘impossible’ to meet their ‘needs’ with 2 annual visits. Bearing in mind the earlier comment about the clinician’s needs being superfluous and irrelevant to any discussion about clinical ethos, I think that Liam’s comment about ‘OK’ symmetry highlights the crux of the matter: maybe my patients come to me with a ‘greater need’… and ‘OK’ won’t do. Or maybe I ‘sell them’ the usefulness of a greater  need’, but either way; Liam’s patients are happy, my patients are happy, your patients are happy…The problem and source of confusion may be that we are all “chiropractically trained” but ‘selling solutions for different needs’ whilst using similar tools.
    Human beings are very good at projecting their own needs and wants onto others and maybe this very humanity of being a clinician is the source of the discrepancies we are discussing here.
    I don’t know if 40 visits per year provides a better solution for a greater need but I would love to find out… again, the only way we will find that out is if we can compare notes of results across the different treatment protocols. I think

  38. Richard on April 25, 2012 at 10:55 pm

    If someone needs an adjustment correct it. Do we try and see lots of people or the same people  lots of times. Do we need to check someone every two weeks, rather than say every six weeks. Would walking around with a subluxation for four weeks be more detrimental to someones health than not exercising and eating properly. Chiropractors have a role in maintaining people well being, thats all we have, a role and by exaggerated the importance of that role we damage our credibility to all except those who want to bleed people getting them to pay thousands up front. I know when I need an adjustment so do my clients, they are the consumers.  

  39. Liam Mulvany on April 25, 2012 at 8:23 pm

    This deterioration you talk about is fine in moderation, my patients seem happy with it. They are pain free, engage in all their sports and hobbies, don’t feel they have to come back all the time and of course most importantly they recommend all their friends and family. Feel guilty? about what? I have no problem in making a living from it, I have done that for over 20 years and yes it’s great to make a good living, make people feel better and be told how wonderful you are several times a day, I know it’s not a crime, we offer a great deal and change peoples lives, though it is immoral if you adjust somebody on a regular basis for your needs, not the patients. And thats what this whole blog is about. PVA patient visits per annum, nowhere does it talk about the patients recovery just PVA PVA “get em back”. The more times the better. Thats our problem.
    Again I’m not forcing anything just giving my opinion and I have made that clear from the start. Don’t get so stressed about it. 
    PS are you from the UK or USA?

  40. Guest on April 25, 2012 at 7:26 pm

    Let me start out by stating I do not agree with sticking it to the ‘patient’ to get a 40 PVA, nor do I agree with massive forward payments or prostitute my profession, but neither do I feel comfortable selling it short nor providing a comfortable deterioration when I doubt very much this is what any ‘patient’ wants – even yours.
    If you assess objectively a patient’s condition every fortnight and find they need an adjustment – they most probably need an adjustment. If they don’t – don’t adjust them. However knowing they need an adjustment – most folk would then in all likelihood want and like an adjustment.
    The problem then I find with alot of chiropractors decrying those providing a regular adjustment is they feel somewhat guilty about earning from this situation of need and they need to force that feeling outward when in fact most when it is reasoned out would not feel it a crime or immoral to earn a living whilst making a difference to people’s lives.

    It is not a crime nor is it immoral to adjust someone on a regular basis be it weekly fortnightly or monthly on the basis of their needs and be paid for it.

  41. Liam Mulvany on April 25, 2012 at 6:34 pm

    Hi guest. I don’t feel i’m treating a symptom or condition, I’m merely removing any mechanical “restrictions” that may be preventing the patient from recovering. You are right I am allowing comfortable deterioration, but hopefully never to the point where an inflammatory response becomes present. If you never extend the periods between visits how can you possibly determine how long is ok between visits? If you stick to a set period of time and never push the limits how can you realistically monitor the true benefit of your treatment? You say gravity, mass etc is the basic cause and I agree but I view the main cause of problems as what that gravity or mass does to the skeletal symmetry of the patient. Symmetry equates to strength asymmetry cause stress point, therefore I do nothing but try to return a patients skeletal system back to a symmetrical position, then correct at ever lengthening periods. I find most people will maintain “OK” symmetry for 6 month eventually.I don’t view any portion of chiropractic as harmful, but unfortunately some chiropractic “selling” techniques and 40 PVA IMO are negative for the patient and chiropractic in the |UK. 
    I understand that regular visits make the patient feel better, I know that I could get patients back every 2 weeks and I’d find something to do and they would feel better, but that brings us back to the prostitute in Richards original post.
    This is only my opinion, I’m not right and nobody is wrong, its just how I work.

  42. Guest on April 25, 2012 at 4:01 pm

    This is a very interestingly thing to say and it is obvious you feel you are ‘treating’ a condition or symptom. Perhaps with your care plan you are affording the ‘patient’ a ‘comfortable deterioration’ rather than addressing the causes? The most basic causes of which are gravity, mass, movement and aging which would infer never addressing but rather managing.
    Also such a sentiment would signal some consideration within it that chiropractic adjustments are not good for the ‘patient’ and should be limited. Can you tell me which part of the adjustment you feel introduces something negative into the ‘patient?’
    How do you assess the need for an adjustment – do you have or use an objective system to do so?
    Any pro sportsman or woman I have ever adjusted enjoyed the freedom of a wider limit to their performance and as a pro continued to push them so requiring more regular care than every six months.

  43. Liam mulvany on April 24, 2012 at 7:26 pm

    Impossible? How can that be when I have seen it happen. I dont for 1 second presume what I do is the be all and end all and I’m quite aware of my limitations. I understand extremely well how and why the technique I use works and I’m also aware that sometimes a different approach is needed for the best end result. All I can do is look back at what I have done, seen, experienced and been told and use that as a template. Maybe it is placebo and my expectations are then mirrored by the patient outcomes? Or maybe in my experience if I get somebody back for treatment every month it’s not in their best interest as they are not in pain, suffer any restrictions and I basically have nothing to do.

  44. Stefaan A.L.P. Vossen on April 24, 2012 at 6:12 pm

    Although I have as much evidence as you do to support any such statement, logic dictates that your comment as I understand it is impossible ie someone with multi-level djd, ddd and/or rod and screw fixations requires as much/little looking after than someone with a normal spine?

  45. Stefaan A.L.P. Vossen on April 24, 2012 at 5:56 pm

    The only way we could ever know whether that is true is by comparing patient self-reported stats between treatment/management protocols

  46. Liam Mulvany on April 24, 2012 at 1:52 pm

    PS, I work with every group, acute, chronic, sports, pro and casual and it seems to work for every type. Your welcome to come visit any time :-)

  47. Liam Mulvany on April 24, 2012 at 12:48 pm

    Hi Stefaan, didn’t realise it was a reply to me. The end goal with everybody i see is to end up at 6 monthly maintenance visits, wether they have had the problem for 60 years or are a pro sportsman,  thats my goal, based on my experience. I expect to see their structural stability improve and remain within their limits for longer periods. If you need to see your chiropractor less than evry 2 months then IMO thats just ongoing treatment not maintenance. If that person needs adjusting on a very regular basis then the “source” of the problem is not being dealt with, it’s no better than taking an anti inflammatory IMO. Again maybe all I’m left with is patients that respond and fall into my “treatment plan”.

  48. Liam Mulvany on April 24, 2012 at 11:34 am

    I can’t quite beleive the MCA has thought of adding a “clinic for sale” with their latest newsletter, especially as the clinic is described like this, “With an average of 150 practice visits/week in 24 adjusting hours and a Patient Visit Average (PVA) of 42 over 2011, this policy pays dividends.”
    42 visits a year average????  Bad practice IMO.

  49. Richard Lanigan on March 3, 2012 at 1:06 am

     Check this out a good program on how to improve a business, its a garage
    but the principle is the same and no need to pay a chiropractor in a
    shiny suit £500 a month

    The bottom line is if you provide excellent service and the customer knows this and tells their friend you will have success in practice and no need for all the glitter

  50. Richard Lanigan on March 3, 2012 at 1:02 am

    Check this out a good program on how to improve a business, its a garage but the principle is the same and no need to pay a chiropractor in a shiny suit £500 a month

    The bottom line is if you provide excellent service and the customer knows this and tells their friend you will have success.

  51. Richard Lanigan on March 3, 2012 at 12:55 am

    I thought this was a very good program on how to improve a business. Its about a garage, but the principles are the same and no need to pay a chiropractor in a shiny suit £500 a month, the information is out there, if you can think outside the box. Success will come from providing excellent service to the customer and make sure they tell their friends, its as simple as that.

  52. Liam on March 2, 2012 at 12:40 pm

    Hello F Mac, no it definately does not mean he is bad. Of course treatment sessions close together are needed in the early stages, but for the majority of the people I see, I aim for maintanance visits of once or twice a year, its what I expect. Your treatment is keeping you active and off pain meds which is great but I also beleive patients should not become dependant on chiropractic care. Have you tried any other form of treatment? If you have and what you are getting is the only way to stay mobile then you have found the only course of treatment for you. If you havent tried any other treatment then something else may have the same effect but require less visits. This thread is aimed more at the chiropractor who tells you you need to come every 2 weeks for the rest of the year before they even know if they can help.

  53. richardlanigan on March 1, 2012 at 10:12 pm

     Normally,I have my spine cheched every 4 weeks, at the moment because I have health problems I go every two weeks. If I lived by the beach ran and swim every day eat lots of fish and beries, I might not even need a chiropractor. The point is everybodies situation is different and they respond differently.

    No one knows how each individual is going to respond, so to use a cookbook script and aplying it to all patients is what I object to.  Its not about the number of times you visit a chiropractor,  its about whether those numbers are for your benefit or the chiropractors. You are happy with you care and make  a great advocates for chiropractic.

  54. F Mac on March 1, 2012 at 8:23 pm

    Hi Liam
    If I went to the chiro one or twice a year then I would be back on the daily codeine pain killers and still not exercising. I prefer to go every 2 to 3 weeks (depending on chronic my back is) and be off the pain mess and able to walk my dog 3 times a day.

    Does that make my chiro bad that he works with me in this way?? It seems like that is what you a saying.

    Fiona – a patient not. Chiro

  55. Stefaan A.L.P. Vossen on March 1, 2012 at 8:12 pm

    Dont agree, not because you’re in my opinion wrong but because you have to sub-specify the group of patients this statement would be true for. I work in chronic and sports and I would love to see how you would achieve that level of stability in those two groups.

  56. Stefaan A.L.P. Vossen on March 1, 2012 at 5:57 pm

    HI CDC,
    I hear you loud and clear, but the nuance I would put into this commentary is that there is nothing absolute about anything (the number of treatment visits, the way to package treatment costs) until you have defined your target group enough. Some people will hate that which another person loves and unless you know who you have in front of you and what kind of thing that kind of person likes. This is why I think the key-word is “choice”.
    I don’t like open-plan practice but some people do. And unless I am going to descend into fascism I think that it is their right to like it and it is mine not to.
    The biggest problem lies in the way we present choice. Take the consent process for example: I always explain that a clot might dislodge with cervical manipulation causing a stroke and that I might fracture through an osteoblastic spine. Everyone understands that there are risks and despite whatever old Edzard is saying, they are not expecting things to be “risk-free” whether by virtue of being CAM or being practiced in a clinic where crystals dangle from the window (again you are allowed to like that stuff, I don’t) everyone understands that something that potentially carries benefit inherently potentially carries risk. Point is that these stark notions don’t get rejected in my consent process but is that because there is an informed consent going on or because I wear a tie and my office looks like I know what I am doing.
    The “choice” in my experience lies with the old adage of “voting with the feet”. Others have seen patients of mine because I wasn’t their cuppa flavour and vice-versa. I have always refrained from saying bad things about others because sometimes I will get it wrong and will have done already no-doubt but some names just keep cropping up with the same complaints, and you know what? they’re not doing that well right now…
    This is what I love about this recession: we simply cannot afford to mess people around or have a messy street cred and like many businesses and industries: it is in recessions that reputations are made and businesses are liquidated.
    But please forgive that tangent, because what I really want to say is that there are ways of finding the right patient for the right process if only we were willing to open our books for all to see and assess…

  57. Richard on March 1, 2012 at 5:28 pm

     This one is so bad I am not sure its genuine, anyway learn from ace chiropractic salesman  Joey Speers he looks about 18 and lives down in the cellar so i suspect he could be a skeptic!

  58. Liam on March 1, 2012 at 12:13 pm

    We understand the need for chiro treatment and if you explain the benefits of it then many patients will return for maintanence care, the problem lies, I feel, in the sales techniques used to “sign patients up” for this many visits. If we look at why patients first visit a chiro, when they are in pain, its easy for the skeptics and money minded chiros to use the bait and switch analogy. You should not, in my opinion, be selling 40 PVA to a patient in pain, especially if you cannot guarantee to deal with the pain in the first place. Lets say you have dealt with the patients problem, which is basically why they came to see you in the first place, and then talked about “so many” visits over the next year, surely that would be a better way of doing it, BUT of course far fewer would be likely to sign up for so many visits.

  59. CDC on February 29, 2012 at 9:01 pm

    Hi Richard!
    Just e-mail me. A hint … I got wood legs when I tried to score goals on you in football.

    Maybe I am blind, but I do not think there are that many colleagues around that rob their patients or act unethical. I think there are a lot of rumors, misunderstanding, lack of knowledge and pride. 

    I give patients options of discount if they want to pay all or some of the visits in chunks. It shows commitment, reduces stress at front desk, makes it easier for my accountant. They only pay for what they use, so if they paid 50 visits up front and only came to 5 and wanted to end care I refund the cost of the remaining 45 and they will keep their discount. No pressure, no questions, no talk. It happens, but it is rare that they want to end care. I guess 2-5 patients per year want to end care, some years nobody. 

  60. Richard on February 29, 2012 at 5:32 pm

    Hi CDC,
    I thought you were American, I will e-mail you and you can tell me who you are? I think everbody should have their spine checked every month, they sit at computers etc, I have made this graph which shows the increase in back problems since the mid 80s from Gordon Wadells book “The back Pain Revolution” the increase in problems almost mirrors computer purchases. So I do offer the same care to patients as I do my family, some take it up some dont. In these times less than ever.

    Now everybody knows if they go to the gym regularly their health will improve, they dont keep it up. The gyms figured it was best to charge them in advance when they were in the mood for exercise. Like wise people will sign for a lot of chiropractic treatment when they are in pain. If one persons uses these practices unethically it reflects on the entire profession. If chiropractors focused on what we do well rather than our differences the public would understand chiropractic better and I believe would go as they do to dentists. WE are out own worst enemies.

    I did not like that Chuck Gibson, he asked me to leave the seminar because I asked him why you had to make this commitment for twelve months. I asked if the programme was as good as he said why would anybody leave?

  61. CDC on February 29, 2012 at 12:09 pm

    Hi Richard and Stefaan!
    First of all I hope things are good with you Rich and that you are recovering.

    I am aware of that we will not solve this issue here, but here are my thoughts. I am one of “those” who would give a ROF and let the patient know up front that it might be 40-50 visits first year. I do not know if you remember Rich, we were in the same class :-) but in Problem Solving and in Patient Management at AECC we did give treatment plans to our patients. 3 times a week for so long and twice a week for so long and then maintenance, BUT ALWAYS with continues re-assessments!!

    When I started practicing first year after AECC the DC I worked for told me I could not do that because the MDs hate that! So I stopped and started telling people 4-6 times or 10 times and we will see how it goes… I never felt comfortable. I almost always had frustrating discussions with the patients later on. By coincidence I got to go to Gibson and he told us to do what we were taught at AECC. He had some other ideas as well but it is up to you which procedures and ideas YOU want to implement in your practice. Everything is not for everybody at the same time.

    I think it is fair to ask the patient why they are seeking my help and what they want and what they hope to get out of coming to me. If someone with acute LBP wants pain relief I would not give a recommendation of 40 visits. However if they had problems on and off for 20 years and the exams, their lifestyle and my experience told me this will most likely take quit some time I would tell them up front, how many visits I would GUESS it takes, what frequency we should TRY and when to do re-assessment etc. And if they had a lifestyle that would effect their “spinal health” they smoke, do not exercise, sedentary lifestyle, bad food habits, always stressed, not proper sleep etc I would discuss the 3 dimensions of stress to them and how they could avoid or reduce risk to re-create the subluxations in the future. And by the way, I am crystal clear to each and every “patient” that I do not treat a symptom or cure a disease. 

    If you and your family Richard get checked twice a month, why would you not give the same advice to your patients? Money? Time? Not right for them? If you do give that advice to your patients then you might as well say 26 times a year for the rest of your life…? I believe that if I have a pretty good idea of how much and how long I think it will take then I tell them before we start adjusting. I believe that is honest.

    Another thing that has amazed me during all these years is that it is often a lot of bashing towards DCs that gives treatments plans of 20-50 visits, but almost never people get asked why did you only treat this patient 5 times. I think undertreatment is much more common (and  much worse)  than overtreatment. Overtreatment is not giving 30 visits, but adjusting a joint that is already moving natural or too much.  We either give our patient something good with the adjustment (reducing subluxations or hypomobility whatever you call it) or we do not. Why should you stop treating a patient just because the pain is gone if the mobility in the joint is still reduced? If you do not give a crap about the mobility but just let the patients pain guide you as a reason for treatment – is that not unscientific and unprofessional? If you stop treating a joint just because it is not painful then you cheat the patient of their health. A joint that is not moving properly starts to degenerate so by not treating the patient you allow the degeneration to progress. Where is the riot about this? Where is the chase for the people not doing their job?!!

    I just came out of a re-assessment with a 85 year old lady. She never had chiropractic before coming to me. Past 5 months she has gotten +30 visits and she tells me she moves completely different, with a smooth secure flow, she got back her will/lust to live (joie de vivre) and she got back her power to initiative. Furthermore she tells me that I “need to come out and give lectures about chiropractic to all senior citizens groups/homes as people do not know this kind of service is available. A lot of people are left with the MDs short answer; there is nothing to do – learn to live with it. There is an alternative to sit and get old and stiff!”

    The alternative is not 5 visits and if you know it is more than 5 visits, why not just tell them in advance?

  62. richardlanigan on February 28, 2012 at 11:57 pm

    Hi Stefaan,
    I have never been to a masters circle and I am sure they would say its about establishing a relationship with a patient. However the practice building seminar I attended soon after graduating was by a guy called Chuck Gibson he was talking about a “million dollar practice” by having high annual PVA,s, and generating them by x raying every patient and you know the rest.

    Now of course chiropractors need business and marketing training, I watched Alex Polizzi “The Fixer” on BBC earlier this evening, the principles of good business practice and marketing are the same, so why would one go to a chiropractor for sales and marketing expertise and then to find much of the advice is scripted into a cook book resipies for a successful practice. Bob Hofman speaks of some guy called Larry who always talked about “two to four dozen visits in the report of findings”. 

    We provide a service and its up to patients to decide the kind of chiropractic care they want. I cant imaging a situation where I would set in front of someone and tell them the needed to come in 24 times never mind 48. There are patients I have seen  every moth for years, for them its like going to the gym, if they decided not to come  in I would never chase a patient  up  unless it was in the acute phase and I would never use a script or instruct a member of staff to speak to a patient using one.

    I am sure everybody who goes on these course will say its helped them, the question is do these practices help the chiropractic profession when it only needs one person to use them unethically to create a problem for everyone. The fact this clip has generated such interest in the skeptic world, suggests they dont look good.

  63. Stefaan A.L.P. Vossen on February 28, 2012 at 8:38 pm

    I don’t know how that works….
    This pva stuff. Does this refer to the number of visits “you can sucker out of a patient” or does it refer to the nature of the relationship you have with patients?
    What I mean is that I have a pva of  40 ish but this includes many patients I have been looking after for nearly a decade and who I see once every three or four months.
    My goal is to have a pva of 116… 3000 patients, seen once every 3 months… with 2 new patients per week, working 90 hours a week. Is that wrong?
    I guess I am just being anal here but ‘pva’ doesn’t mean anything if you don’t offset it against the frequency of check ups and the total number of active patients and as far as I could make out of this clip they arent really commenting about that. I think it is easy to argue that these “shiny suit people” are out to deceive but I think it is too easy to do that and do so with the risk of throwing the baby out with the proverbial bathwater.
    I also think it is potentially slightly condenscending to those clinicians who are chosing to attend these seminars, circles and clubs… surely they are doing so for some reason? And that reason may be a sense of loss of direction and structure (or philosophy as some will call it) but that doesn’t make me feel like I should judge. These people give direction, ideas and goals to people who need these and although I don’t agree with some of them I don’t feel it is right to assume that the people attending the seminars just lap the statements up at face value. Let’s give some credit to intelligence, even if prejudice dicates we shouldn’t.
    I don’t like the feel of those events personally but I understand it could be for some people.
    Hope it makes sense

  64. richardlanigan on February 26, 2012 at 10:57 pm

     Hi Liz
    I remember in the 80s I opened one of the first Aerobic centres in Europe and went to US to learn. No prices in reception which i thought was weird, then they took you into a room with on of the “sales team” it was nauseating  and they all worked like this, Its the American way. In Sweat Shop we werer so busy all classes booked up for three weeks, however the  big money is in pre payment memberships, I never went there, so we did not make the big money, but I sleep well at night.

    Young kids come out of college, taught by people who were not sucessful themselves in practice . These kids have bills to pay and along comes another chiropractor who probably does not practice, in a thousand dollar suit and colourfull tie telling kids about the millon dollar practice, based not on seening lots of people but seeing the people they have in the practice lots of times.

     It happens in Dentistry, Gyms, Law, Banks and many professions putting people under pressure to purchase things they dont need.  Can someone explain why they are so impressed with people talking about the joy of a succesfull practice when they dont practice themselves and just want you to sign up to their scheme. I love what I do and I love talking about it and I rarely charge money. I have an interesting story about that which I will share next weekend.

  65. Liz Ditz on February 26, 2012 at 8:25 pm

    Hi Richard, I am one of the skeptics who retweeted this.  I live in the USA and this sort of marketing is very common.

  66. richardlanigan on February 24, 2012 at 8:45 pm

      Do the “ends” justified the means. The ends being getting people to have their spines checked regularly. My family and I get checked about every two weeks, thats my choice, I think all patients should have their spine checked at least once a month, but its their choice, and not subject to the colours of a SEMG scan or the chiropractors bank balance. If a chiropractor gave me a year long treatment plan based on having me return 40 times, I would laugh in his face and so would most chiropractors and yet many offer this bullshit to patients daily.

     Its not acceptable to me to set a target for practice growth based on an average number of visits a patient can be convinced to come in, and the convincing is done  when many patients are in pain. This contradicts the whole theory of the “vertebral subluxation” and each individuals innate healing ability and its time subluxation chiropractors stood up and were counted. Some people need one adjustment others need 20, but we cant tell in advance. Some athtlets need to lift a lot of weights others do little. 

    If  chiropractors cant convince patients in a honest way of the benefits of regular care, then they should find another career, and let the rest of us get on with providing quality chiropractic care . There was a guy in Sligo in Ireland did a spinal screening on weekend signed up people for around £20,000 and fucked off on Monday, with no regard for the people he had ripped off or the chiropractors left behind. 

     We are approaching a junction, some will go left and buy shiny suits and colourful ties and get into sales. Others will turn right and become pseudo medical doctors, they rest will follow the leader wherever that will go. When I am finished chemo I have decided where I am going and anyone will be welcome to follow.

  67. Liam on February 24, 2012 at 4:52 pm

    LOL my how a lot of chiros seem to act in the same way. I have tried to post again on that youtube website and guess what I’ve been blocked by the owners, you never know they may even try to sue me! If anybody else feels like copying and pasting my last comment to the video feel free.

  68. Liam on February 24, 2012 at 4:48 pm

    I can’t stop thinking about this. How does 40 PVA make you a good chiropractor (he salutes them) when the average is 19PVA. If I had to get a plumber out to fix my boiler every month but somebody could look at it a couple of times and sort it, how can the former be regarded as the better plumber?? 40 PVA might mean that you arer a good salesman, it might mean you are good at marketing but if definately does not mean you are a good chiropractor. Infact you are probably the worst kind of chiropractor as you cannot rely on your own skills, you cannot rely on your patients improving so you have to try to lock them in to as many visits as you prossible can, some up to 60 PVA FFS.

  69. Liam on February 24, 2012 at 4:06 pm

    The so called chiropractors running this youtube crap have deleted my first comment so I’ve posted another.

    “Not sure why my last comment was deleted, so I’ll say it again, and if you delete it again, ill put it on again. This is disgusting, why don’t you try evaluating your patients progress at each visit rather than deciding on how much money you can make. Can you really tell me you can assess a patient and decide they need 40 visits???? Ok you had better give me some lottery numbers then. Try putting the patients needs first rather than how much you can get from them.”

  70. Liam on February 24, 2012 at 2:33 pm

    I’ve posted on the youtube site, disgusting. AT REPORT OF FINDINGS TALKS ABOUT 2 TO 4 DOZEN !! VISITS. And they wonder why chiros in the USA, or chiros that use such dubious tactics over here, are not trusted.

  71. Liam on February 24, 2012 at 1:58 pm

    Once or twice a year should be plenty for most people, more than that try something else.

  72. Maryellen on February 24, 2012 at 1:36 pm

    think that we should do what we do best, stand on the shoulders of the
    giants that came before us, use our best clinical evidence and research
    experience (where it exists) to grow healthy people from the people who
    come in to see us> for some that is a
    crisis period before maintaining their health through adjustments and
    new healthy behaviours, for others, its digging them out of a trench
    that 40 people could sit in, the coaxing little by little to take on
    things (like eating fresh whole food, managing stress, exercise, sleep)
    to take back their health. Chiropractors have always seen people as
    INDIVIDUALS. I do think that more regular care keeps people healthy.
    Actually i dont just think it , i live it. But i dont go in for the one
    size fits all type of thing at all!!!

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