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CAMPUS NEWS

FOR IMMEDIATE RELEASE
07/23/01

Success in Chiropractic Practice: A Practitioner-Based Content Analysis

by Brian J. McAulay, D.C., Ph.D., Sherman College Executive Assistant to the President; Daniel Lemberger, D.C., ’98, private practice in Colorado; and Edward Owens, M.S., D.C., Sherman College Director of Research

Success in Chiropractic Practice: Outcomes and Competencies
Although there has been much recent emphasis in the popular chiropractic press regarding the ability of recent chiropractic college graduates to survive and succeed in an increasingly competitive and regulated health care environment, there has been little scholarly analysis of the components of success in practice. This study is a content analysis of what alumni of one chiropractic college consider to be important components of chiropractic practice success and the competencies necessary to contribute to achievement of these components.

In studies of organizational success, positive outcomes are usually considered to be financial (i.e. net revenue or profit) or stock price. Occasionally factors such as environmental impact or employee satisfaction are examined in this context. Similarly, success in professional practice, at least in scholarly treatments, has tended to focus on practice income (e.g. Gaynor 1989; Lee 1990; Newhouse 1973).

This study questions the assumption that financial performance is the sole outcome of success in professional practice. In the absence of literature to support what other indicators might be, we elected to use an open-ended survey with practicing professionals (chiropractors) to ascertain the nature of those factors. This necessitates the utilization of content analysis for cogent interpretation of data (e.g. Hybels 1995).

METHODS
We identified the target sample of respondents as 600 alumni of an American chiropractic college. They were randomly selected from a much larger population of graduates spanning the last twenty-five years. We supplied them with a survey and return envelope. In addition, we supplied surveys to chiropractic faculty at that same chiropractic college.

As is the case with all primary research data content analyses, survey design was critical to obtaining usable data. In particular, we were careful to avoid bias by providing examples which would lead respondents in particular directions. We did provide an example in an unrelated industry to provide for them an illustrative example. We asked respondents to provide what they felt were “characteristics of success in chiropractic practice”; we asked for six such indicators of each respondent. In addition, we asked what competencies (or attributes) were required to achieve each of these six indicators; we asked for two such competencies for each indicator.

Three practicing doctors of chiropractic completed the pre-test survey, resulting in minor modifications prior to distribution to the entire sample.

When the surveys were returned, research assistants typed responses into a spreadsheet. Three researchers working concurrently categorized each response. The research team collectively evaluated each response three separate times on three different occasions. Categories emerged as analysis continued. The researchers developed “sub-categories” where appropriate, to enhance understanding of the essential nature of the characteristics of the indicator or competency.

Researchers discussed each item as categorizations were made; any disagreements were resolved by discussion. No assignments were made without consensus of the research team. The excessive consumption of time required by this technique was felt to be worthwhile, given the higher reliability and validity resulting of the resultant data categorization.

RESULTS
We received a total of 114 usable surveys, for a response rate of 17%. This is low, but not surprisingly so considering the amount of thought and time required to complete the survey. The result was 942 “lines” of data to analyze, each line consisting of a practice characteristic and accompanying competency.

Problematic in data interpretation in this study is the confounding between characteristic of a successful practice (or identifier) and the competency thought necessary to achieve a success factor. For example, some respondents felt that clinical success was a characteristic of a successful practice, while others felt that clinical success would lead to high volume, which they considered to be the indicator of successful practice in this case. In this regard, the line between indicator (or characteristic) of a successful practice, and success competencies is difficult to distinguish.

The content analysis produced twelve primary categories of characteristics/competencies. Table 1 lists each, along with the number of times they were mentioned by survey respondents.

In addition, the researchers made sub-categories of the three most frequently cited categories. Analyses of each of these categories follows.

Table 1

Most respondents focused their attention on the personal characteristics of the chiropractor. Much as the entrepreneurial literature (e.g. Amit 1994) has emphasized how important an organization’s founder is to a fledgling company, this research supports the notion that in professional practice, at least in chiropractic practices, the chiropractor’s skills, talents and abilities are a major factor in success. Within this category, by far the highest factor mentioned were traits associated with the personality of the doctor - his/her charisma, personal health, positive attitude, enthusiasm, honesty, etc. This suggests that for professional practice, the fate of the practice is tightly tied to the abilities of the individual practitioner. In other words, in chiropractic practice, chiropractors are not simply interchangeable parts; rather they are inseparable from the practice itself.

In particular, respondents noted that interpersonal skills play a major role in determining practice success. These skills include the ability to create rapport, communication skills, listening skills, and “people skills”. Clearly, the one-on-one service aspect of chiropractic practice makes these skills paramount in building successful practices.

For a surprisingly large number of respondents, confidence/faith in chiropractic is an important component in practice success. This includes the notion of practitioner commitment to chiropractic philosophy, understanding the importance of providing chiropractic care, “staying on purpose”, and being “principled”.

Notions of knowledge and a service ethic came lower down in the list. Perhaps surprisingly the happiness of the chiropractor was not frequently mentioned as a prime characteristic of a successful practice. Table 2 provides incidence counts for all eight sub-categories developed in this study.

Table 2

Not surprisingly, respondents also reported that various aspects of business skills and knowledge are important to practice success. Marketing acumen was the single most cited essential attribute. This included the ability to evaluate practice location, advertising and skills in networking to mine potential referral sources. Next in frequency mentioned were skills in managing office staff, including recruiting, training, and motivating staff. Also reported were skills in actually running the office (smooth office procedures and paperwork to promote efficiency). Table 3 presents these data.

Table 3

The third major category of skill reported by respondents was the clinical skills area. We discovered that these skills broke down into three sub-categories (Table 4). Some respondents mentioned specifically the ability to correct subluxations and some emphasized the analytical side of the clinical experience (i.e. locating and analyzing the vertebral subluxation); many respondents felt that the ability to create results (presumably symptomatic results) was paramount in creating a successful practice. Table 4 lists these results.

Table 4

In addition to these three main categories, respondents reported, in smaller numbers, having a high practice volume, having high levels of patient satisfaction, and income as determinants of practice success. They reported patient education as an important causative activity in creating a successful practice.

DISCUSSION
This evaluates in a systematic, empirical way, what chiropractic practitioners consider to be the identifiers of success in practice. In other words, if researchers were to attempt to identify successful practices from unsuccessful ones, what variables should be examined? In addition, this study takes a first cut at determining what the essential competencies are in creating a successful practice. The source of this data is from practicing chiropractors, in practice from one to 25 years.

Results of this study will be helpful to chiropractic college administrators and chiropractic management consultants, as they provide programs to assist chiropractic students and practitioners to succeed in practice. This data will help them to pinpoint their programs to the evaluative measures which best measure success, and to tailor their educational outcomes to those competencies most likely to lead to their students/clients’ success in practice.

This study provides several interesting and useful findings. First, the success of a practice is tied directly to the skill, talents, capabilities and behaviors of the individual practitioner. These results have implications for the sale of chiropractic practices. The importance of personal characteristics on the success of the practice suggest that the sales prices of chiropractic practices apportioned to goodwill should not be particularly high. If the incoming chiropractor cannot duplicate the selling chiropractor’s individual characteristics, the likelihood is that the success of the practice after the sale is consummated is unlikely.

These results also point out how important for chiropractors to develop interpersonal skills in order to succeed in practice. We infer that colleges and management consultant services should provide training in skills such as active listening, communication, leadership, etc. These skills, normally taught in the business school milieu, should be added to chiropractic college curricula.

This is supported by the emphasis on business skills in the data. Clearly, it is not enough to be clinically sound to create practice success. Business skills are felt to be very important in developing a viable practice.

It was interesting that the data did not support the notion that income level is a definitive determinant of practice success. Certainly practice volume was felt by more to be significant. This suggests that there is a strong service component implicit in chiropractic practice. It is much more often felt that taking care of more people is a strong indicator of success than income generated by the practice.

Also worthy of note is that the practice is a local phenomenon. In other words, the emphasis is clearly on the patients who come to the practice. Commitment to the larger community was not frequently stated as an indicator or determinant of success, nor was service to the profession.

Finally, the fact that practitioners see faith and confidence in chiropractic as a key component of success suggests that development of this confidence should be an important part of the education of chiropractors. This supports the efforts of some colleges and practice managers in the past to focus attention on providing confidence-building presentations for their students. Some of these lectures take the form of “miracle stories” of practice, and may serve to provide confidence to the audience members.

Future research investigation should take several directions. First, these results need to be replicated to test the generalizability of the data from the sample tested. Second, work should continue on isolating the particular skills which practitioners feel are most important. Many respondents noted, for example, “marketing skills”, without delineating further. It would be helpful to note specifically what types of marketing skills are deemed most necessary.

Finally, the logical next step from this research is to survey practitioners on their self-assessment of the competencies and then correlate these results with outcome variables. For example, a survey ascertaining respondents’ marketing skills could be correlated with their practice volume levels. This would create valuable information on the cause and effect relationship between the competency and the outcome.

This study takes a first step in investigating the nature of practice success in chiropractic. Much more study needs to be done in order to allow researchers to begin understanding the nature of success in private chiropractic practice.
 

REFERENCES

Amit, R. (1994) Contrasting entrepreneurs with non-entrepreneurs: Attributes and attitudes, Academy of Management Annual Meeting, Dallas; Tx; August

Gaynor, M. (1989) Competition within the Firm: Theory Plus Some Evidence from Medical Group Practice, Rand Journal of Economics, 20, 59-76.

Hybels, R. C., (1995) On operationalizing the legitimation construct in organizational theory: A content analysis of press coverage of the U.S. Biotechnology field, 1971-1989, Academy of Management Annual Meeting, Vancouver, BC; August

Lee, R. H. (1990) Monitoring Physicians - A Bargaining Model of Medical Group Practice, Journal of Health Economics, 9, 463-481

Newhouse, J. P. (1973) The economics of group practice, Journal of Human Resources, 8, 37-56.
 


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