COMMUNICATION - WHAT YOU SAY AND HOW YOU
SAY IT
April 7, 2001
Louis Sportelli, D.C.
I am truly perplexed that the officers of FCLB have asked me to speak at this conference for the third year in a row. I am beginning to feel that something is either very very wrong and weird with this group…or something is very right. I will let the answer to that question up to you. When given this invitation I was told, "Don't be kind"…as if anyone in this audience would believe that they have to make sure they said that to me!
All joking aside, however, I am honored to speak to the licensing board members from across the country and to perhaps provide some provocative thoughts to challenge long-held positions often believed to be truths.
Donna Liewer read my recent paper entitled: Communicating Chiropractic With Integrity which appeared in the December 2000 issue of Topics in Clinical Chiropractic, and she asked if there were "communication issues" that involve boards of examiners, which might be addressed.
Communication can be defined as a PROCESS by which information is exchanged between individuals through a common system of symbols. Information that is gathered, but NOT exchanged, does not fit this description. Impediments to the exchange of information are therefore impediments to communication.
Let's talk about CIN-BAD.
FCLB touts the fact that access to this database allows for proper credentialing of DCs to protect the public. Now I will ask a very touchy and controversial question: If FCLB really wanted to enhance the exchange of proper credentialing information, why doesn't FCLB allow FREE access to CIN-BAD by the public? Somewhere there is a discussion of a $20 fee for a "doctor search," which may be characterized by many as a "nominal fee." A fee of any kind nonetheless is an impediment to communication. In this particular instance, a fee puts a price on access to the information. When faced with the prospect of spending money on health care, how many patients on limited budgets and limited coverage are really likely to jump at the chance to part with an extra $20 to access information about their doctor?
What does that say about giving lip service to protecting the public? "Hey, we have this data that can protect you-and we will gladly sell it to you for $20!" That's not "protecting the public"… it could be misconstrued as exploiting their need to know. The position is a bit illogical as well as misleading. If a licensee used the same tactic in their marketing or advertising, some boards across this country would say it was false, deceptive and misleading. If FCLB is going to communicate CIN-BAD efforts with integrity, perhaps the economic impediments to access should be deleted. I know that FCLB and its staff are sensitive to this issue and go above and beyond the call of duty to steer patients in the right direction to obtain information from their own state regulatory boards, but the fact remains the question of "free public access" to practitioner data is being hotly debated.
This is not a decision I am suggesting should be implemented without thoughtful deliberation, but merely to suggest that the discussion on this issue begin. Perhaps FCLB can take a lead role in making a decision that will create great consternation among the other boards of examiners whose disciplines perhaps enjoy a bit more public confidence. How will they react under fire?
Forget the patient for a moment. What about the need for a doctor who is about to hire an associate? He or she wants to obtain information to "check this doctor out." This kind of due diligence is taught in many of the NCMIC risk management programs, where the issue is discussed relative to how it may impact a malpractice defense. If one of the goals of FCLB is to keep licensees who have been disciplined from hiding that evidence from potential employers, why wouldn't FCLB consider making the information as accessible as possible to all doctors in the field…oh, did I say free?
It seems to me that the conduct of FCLB is inconsistent with its stated purpose and that is precisely what communicating with integrity requires. If FCLB cannot set the example of communicating with integrity, how can any board in this country dare to discipline individual doctors for failing to communicate with integrity with their own advertising materials?
While we are on the subject of licensees, I would ask rhetorically: Should FCLB not make some kind of effort to assist the doctors they license? Does FCLB really serve the public by eliminating licensees with problems, or does FCLB better serve the public by identifying and correcting problems before they manifest? This seems consistent with chiropractic philosophy… correct the problem by getting to the cause. Perhaps FCLB should be looking to create a "template" for all boards to use as a guideline for structuring and "mentoring" a program to "rehabilitate" troubled licensees.
Whether the licensee's problem is generated by illegal drugs, alcohol or boundary issues, levying fines, suspensions and revocations are ill-suited to facilitating the "rehabilitation" of a "problem doctor." Perhaps the focus needs to be placed more on finding ways to create a condition of "probationary" status for licensees. If the boards really want to protect the public, doesn't the kind of philosophy relative to rehabilitation make more sense than the punitive mindset that seems to have been embraced?
Has there been an FCLB ad hoc committee charged with the task of looking into the causes of recidivism? Do we really know why problem doctors continue to be problem doctors? Is it not the responsibility of FCLB and all the boards to help find the underlying causes that are repeated and repeated, or do we simply ignore the core cause and continue to find ways to punish and perhaps even "school" the doctors into a mindset of illegal or questionable behavior?
If boards are looking simply to "pad the numbers" and parade and shout about out how active they have been in "policing" their own, shouldn't there at least be more honesty in the way they go about it? To me there is something inherently distasteful about saying…"We're afraid that someone else less sympathetic to chiropractors will come in and regulate us if we don't make it look good." Doesn't that sound more like the ultimate goal is to protect "chiropractic" than it is to protect the public?
Why is this nuance so important? Because of the power and influence that communication exerts and the ultimate authority boards have over licensees. Are you setting yourselves up to appear as either SELF SERVING by protecting the profession or DISHONEST by pretending that you aren't. Not a great choice.
How much better it would be if FCLB could communicate that they are actually trying to do BOTH! Field doctors do not trust boards of examiners! The more the examining boards shout they are protecting the public, the more the boards portray themselves as being "AGAINST" the doctors. It becomes a self-fulfilling prophecy. Licensees don't trust the process because there is so much rhetoric about "cleaning up the few that cause all the problems."
The rehabilitation of the distressed doctor is really more in keeping with what the goals should be for licensing board. Assuring access of the public to ethical and competent doctors does not always mean the removal of those who do not measure up, but rather a corresponding responsibility of the boards in assisting them to measure up. Focusing on "probationary rehabilitation" of the doctor, boundary training, counseling, personality testing and profiling, drug screening and perhaps something really controversial…a testing mechanism to demonstrate precise skill in manipulation, or even perhaps an ethics test…might be a direction for the future spearheaded by FCLB and incorporated by all board across the nation.
Let's take an in-depth look at the specific issue of
determining competence in manipulation by the practitioner for a moment:
What does all this mean for the licensing boards?
Historically, jurisdictional control in health care follows a rather distinct
sequence.
The chiropractic profession can help to safeguard and insulate its claim of jurisdictional ownership of spinal manipulation by demonstrating clear dominance in skill/efficiency. The scientific evidence defining skilled adjustment/manipulation is now available in the marketplace. There have been several companies and products which can provide the training and demonstrate the expertise in manipulative skills. This information is readily available and has been published by John Triano, D.C., PhD and others.
If the boards of examiners and the national boards decide
to require the demonstration of this skill as part of a competency requirement
for licensing, it would provide several advantages.
This is a very significant area for future consideration by the examining and testing boards. Does it make sense to implement this testing procedure? I cannot answer that question, but certainly an ad hoc committee of DCs, researchers, legal advisors and others can help provide the framework to develop an answer and proactively meet the future challenge. Just look around the world and see the challenges faced by countries where there is no clear and convincing evidence to demonstrate what level of skill/competence/efficiency is needed to call oneself a chiropractor. Some countries will have great difficulty in keeping weekend classes of 12 hours from becoming the only criterion for calling oneself a doctor of chiropractic.
As for the requirement for ETHICS training and mandatory courses of study in this very difficult subject, this is again a tough question for the boards and FCLB. How can we measure ETHICS or determine the moral fabric of those who seek to be called a doctor of chiropractic. I don't have the answers, but we must continually strive to find the answers to the questions relative to our collective value system.
Finally, in the area of communication, let me finish with a real current example of a licensing board's rules and regulations and the challenges they create when ambiguity in language is allowed to become regulations.
Colorado has just passed a rule which includes the use of "cold" lasers in the treatment of various cosmetic and dermatological conditions. The regulation does not clarify a key issue such as the definition of "surgery" which is excluded in the practice act and if laser falls within that definition. Confusion within the field exists as we speak with DCs wondering if they can utilize this procedure or not, and what are the criteria, training requirements and qualifications that are needed in order to comply and meet the boards requirements. The regulations do not include clear definitions as they relate to permissibility for utilization of "hot" laser or as "cold" laser, etc., etc.
DCs, in an effort to increase income, want to do tattoo removal, hair removal, dermabrasion, cosmetic face-lifts, wrinkle removal, as well as a host of other procedures that will eventually be advertised by the laser manufacturers. The DC is without clear and unambiguous guidelines by the board.
Contrast the situation in Colorado with the recent clear and unambiguous directive issued by the Massachusetts Board of Regulations. The ruling was written to provide guidance for Massachusetts doctors on the subject of "runners" or payment to agents for providing patients. The language states:
"No licensed chiropractor shall offer to pay any remuneration, including any bribe or rebate directly or indirectly overtly or covertly in cash or in kind, for the purpose of inducing any person to purchase, lease, order or arrange for any product, faculty, service or item related directly or indirectly to chiropractic care, treatment or service. Furthermore the healthcare provider shall be punished by fine not to exceed ten thousand dollars ($10,000.00) or imprisonment for no more than 5 years or both, and may be held liable in a civil action."
There is no equivocation here. The message is clear, the public is protected and the provider has guidance. Kudos to Massachusetts. The only issue is the fact that the state association was responsible for getting this message out to the field and not the board of examiners.
With the wave of e-commerce, e-technology, and ultimately e-healthcare… will the licensing boards be proactive in communicating to those doctors in the field who look to the boards for guidance, or will they make rules and regulations that are unclear, or wait until the doctor has violated an unclear rule or regulation and then haul them before the boards in an adversarial administrative hearing? Why not provide that guidance in advance of any activity rather than simply remaining silent and let case law, board hearings and judicial appeals create chaos and confusion from jurisdiction to jurisdiction, defining the law which the boards should be responsible for?
The boards have functioned under a mentality that has virtually held them HOSTAGE. Many board have been afraid to "open the act" for fear of challenge by the opposition. So the antiquated, irrelevant, ambiguous, confusing, vague, and obsolete regulations and statutory language remains on the books.
Perhaps it is time in 2001 to take off the gloves of fear and replace them with a suit of armor prepared for the battle armed with information, support from the states practitioners and associations, as well as the knowledge that the activity is predicated on communicating what constitutes contemporary chiropractic and not some medieval procedure without substance or science.
Communication is the key to many challenges faced by the board and the entire profession today. Our communications must be proactive, clear, conveyed with integrity and a desire to provide solutions to problems and not develop problems without solutions. The boards can truly be a service to the public they serve and the profession they license, if your communications convey your vision.