Abstract
Objective:
This report is an examination of the perceived need for business skills among chiropractors.
Methods:
An online survey was completed by 64 chiropractors. They assessed the need for business skills and current levels of business skills. Using this information, gaps in business skills are identified.
Results:
The need for business skills is broad, encompassing all major business functions. Existing business skills are well below needed levels.
Conclusion:
The chiropractic profession needs significantly greater business and practice management skills. The existing gap between needed business skills and existing skills suggests that current training and education programs are not providing adequate business skills training
Key Indexing Terms: Chiropractic, Education, Commerce, Practice Management
Introduction
Rapid changes in the health care industry have led to an increasing need for enhanced business skills and knowledge.1–8 The ongoing need for training and education in health care management,9 marketing10 and legal and regulatory management11 has been documented, as has the need for new approaches to health care graduate education.12 Complicating matters is the prospect that the management ap- proaches used by many healthcare organizations continue to lag behind those of other businesses in similar competitive industries.
These gaps, while also commonplace in other industries, are of great concern to the healthcare industry for several reasons. First, healthcare revenues in the United States are approximately $1.2 trillion making it the single largest industry in the United States. Secondly, the industry faces environmental challenges far greater than those of most other industries. Both technology and regulatory changes have an almost immediate impact on healthcare organizations, often requiring radical change. Continued consolidation among healthcare organizations has created a complex, rapidly changing competitive environment. Finally, healthcare man- agers must balance issues like quality of life with bottom line profits in a way that no other managers are required to do. Consequently, gaps in any area of management can be detrimental to success in the healthcare industry.
However, while the need for health care education and training in business skills has been well documented, the health care industry is too broad to allow easy generalizations. Health care encompasses fields like, but also hospitals, pharmaceutical companies, and other quite different fields. This article is designed to look specifically at business skills needs.
The increase in the public's use of complementary and alternative medicine has grown the chiropractic profession into the second largest primary health care profession in the United States.13 Given the growth of the profession, today's ever-changing workplace demands, rapidly emerging technologies, the multifaceted needs of patients, and increased competition in many markets, the need for practice management skills in is unmistakable. Indeed, a solid knowledge of business skills and strategy is needed by self-employed practitioners in order to prosper.
As the science and technology of grow more sophisticated, the business side of the Chiropractic profession has its own unique challenges. According to Shelly Field, “Factors affecting earnings include the reputation, experience, personality, geographic location and marketing skills of the chiropractor.” Regarding curriculum, Field states,14 “… while chiropractic colleges teach courses in skeletal manipulation and spinal adjustments, there is a broad range of other courses. The program consists of clinical experience as well as classroom laboratory work in basic sciences such as anatomy, physiology, chemistry, pathology, hygiene, sanitation, and public health.” Of note is the absence of any mention of marketing, business, or related skill training even though Field writes that marketing is a factor affecting earnings.
In its accreditation standards, the Council on Chiropractic Education (CCE) states that,15 “The student must demonstrate an ability to develop a knowledge of ethical practice development strategies including marketing, community demographics, and patient management techniques as well as understand the need to follow sound business practices including those involving leases, loans, purchasing, selection of consultants and advisors, financial man- agement, and personnel.” However, a review of the curricula of the schools accredited by the CCE revealed few required courses in business subjects.
For example the doctor of chiropractic curriculum of the Cleveland Chiropractic College requires one course in Economics or Business Management.16 The New York Chiropractic College requires a total of 4650 total contact hours for the DC degree. Of these 4,605 hours, 30 are devoted to “Ethics and the Law,” another 30 to “Business Practices,” and another 30 to “Getting into Practice.’′17 Finally, in the University of Bridgeport College of Chiropractic's DC curriculum of 5136 hours, 36 are devoted to Hospital Procedures, Insurance and Office Management. Another 36 are allocated to a course in Small Business management.18 The authors believe that even when required, the business courses, taken at the same time when difficult technical courses are being taken, are less likely to be absorbed and retained.
Currently available options for practicing Chiropractors seeking additional business education include: web-based learning, professional association conventions, manufacturer support, mentoring, books, “trial and error” and educational opportunities outside of those tailored to the profession.
Web-based marketing courses are available through Chiropractic Practice-Building Dashboard.19 “Chiropractic MBA training,” a variety of business courses tailored to the Chiropractor, is offered by ChiroToday.com.20 Professional associations include sessions on the business of at annual conventions. Some manufacturers offer ongoing business and practice management support for their customers. Many chiropractors, already accomplished in their own private practices, generously help their col- leagues with a variety of business issues. In addition, there are two books currently published on chiropractic practice management21, 22 and one is scheduled for publication in 2008.23 Several chiropractic practice management books have been published in the past but are no longer available and/or so dated as to be of questionable value.
Even with the help provided by the above opportunities, one of the most common means of business education for chiropractors remains that of “trial and error.” Opportunities outside the profession for additional practice management training are a valid and perhaps necessary alternative. Current options include individual college of business administration classes available through local universities or the Small Business Administration as well as business seminars on a variety of practice management issues.
We turn now to a broader review of the scope of business education.
The Scope of Business Education
Previous surveys have examined narrow business fields in a broader health care context, but for this survey, we wanted to look at the broad field of business skills in the narrow context of management. Our first task was to divide business education into fields. We began with a plan to examine undergraduate and master's business education programs at fifty major universities. Fortunately, an extensive survey was not necessary since all programs had consistent common elements.
The fields that were common to almost all pro- grams were accounting, finance, marketing, law and ethics, organizational behavior and human re- sources, operations and systems management, managerial decision making, and strategy (Table 1). Not all programs had courses with these specific names, but all programs had elements of these fields, often in multiple courses. This is not surprising since all of the programs surveyed were accredited by the Association to Advance Collegiate Schools of Business.
Table 1.
Fields of Business Education
| Accounting is the process of managing the recording, reporting, and analysis of financial transactions of a business. |
| Finance is the process of acquiring, investing, and managing resources such as offices and equipment. |
| Marketing requires defining target markets, selecting market positions, and managing product, pricing, communications, and channels decisions. |
| Legal and Ethical Issues include tort liability, contracts, labor law, agency and organizational law, and ethical decision making. |
| Organizational Behavior and Human Resources includes staffing issues such as hiring and firing, and management issues such as leadership and motivation. |
| Operations and Systems Management focuses on managing the processes that produce and distribute products and services. |
| Managerial Decision Making is the use of research design and statistical tools to improve decision making. |
| Strategic Management is the process by which an organization determines its long-run direction and sets goals and objectives. |
After determining the appropriate scope of business education, we decided to use that scope to identify tasks that could be easily communicated to managers. We could not assume that those managers had any knowledge of business or its language, so we developed tasks associated with each of the fields and used web-dictionary definitions to help simplify communications. For this reason, it is critically important that educators carefully review the exact wording of the tasks before making decisions based on responses to the tasks.
The following represent the eight tasks associated with the eight business fields identified earlier.
Research Questions
Based upon these nine areas, the research questions generated for this study consisted of the following inquiries:
1. Of these key tasks, which require the most knowledge to successfully perform the task?
2. Are there gaps between the levels of knowledge required to successfully perform the tasks and the current levels of knowledge existing within the healthcare industry?
Methods
This study was one in a series of studies designed to identify health care education and training needs. In similar studies, Kennett, Henson, Crow, and Hartman10 and Bruder, Crow, Hartman, Brockman, and Henson9 evaluated needs in marketing and strategic management. Henson, Williamson, and Jacques24 completed an identical study with audiologists.
The population of interest for this study is man- agers in the United States. We began by searching the web for email addresses and chiropractor names or practices. All survey invitation and responses were submitted and collected online. The e-mail and internet framework for the on-line survey was provided by Hosted Survey (www.hosted-survey.com).
An e-mail message, a cover letter in effect, was addressed to the members of the sample, asking them to participate in an anonymous survey provided on the internet. The e-mail message provided the web address where the recipient could link directly to the survey. Respondents were also provided an opportunity to opt out of any future surveys and were offered an opportunity to view the results of the survey.
The survey included sixteen questions on a five-point scale ranging from very low level to very high level. These sixteen questions captured the knowledge needed and the level of knowledge in each of the eight business fields. Organizational and personal demographic information was also collected. Before administration, the survey was pre-tested, first by representatives in the academic community and then by representatives of the management community.
Of the 508 e-mail messages sent on the original mailing, 411 were deliverable. Of the 411 delivered e-mail messages, 64 participants completed the survey - a response rate of 15.57%. This response rate was lower than other similar studies in the health care industry, which ranged from 20% to 30%. The different response rate may reflect the different approach to developing the sample frame or the increased incidence of unwanted emails.
Given the relatively low response rate, several preliminary tests were completed to help assess potential non-response bias. There were no significant differences in responses that could not be explained by chance between “early” or “late” re- spondents, by two digit zip code classification, or by the employment or ownership status of the respondent.
Despite these tests, the response rate was relatively low and there were only 64 respondents. That means that these results should be interpreted with caution and that further studies might be indicated. On the other hand, the differences that we will describe between needed levels of knowledge and existing levels of knowledge were substantial and while the exact differences might be somewhat over- or under-stated, the differences are apparently very real.
Results
Respondents were asked to evaluate each of the eight business tasks and rate them according to the level of knowledge required to successfully perform the task. Results in Table 2 show the percentages of respondents who considered the knowledge required to manage the task high or very high.
Table 2.
Needed Levels of Knowledge
| Task | High Level | Very High Level | Combined |
|---|---|---|---|
| Organizational Behavior and Human Resources | 47% | 42% | 89% |
| Strategic Management | 47% | 39% | 86% |
| Finance | 57% | 26% | 83% |
| Marketing | 33% | 49% | 82% |
| Law and Ethics | 39% | 42% | 81% |
| Accounting | 57% | 22% | 79% |
| Managerial Decision Making | 34% | 36% | 70% |
| Operations and Systems Management | 26% | 36% | 62% |
Organizational Behavior and Human Resources was the business task that chiropractors said they needed to know most about. Forty-two percent of the respondents said that a very high level of knowledge about organizational behavior is needed and an additional 47% said that a high level of knowledge was needed. Combined, 89% of the respondents said that either a high or very high level of knowledge about organizational behavior and human resources is needed by chiropractors.
Strategic Management was the next highest rated task in terms of knowledge needed, with 86% of respondents saying that the amount of knowledge needed about organizational behavior and human resources was high or very high. Marketing knowledge needed was also rated at over 80%. More quantitative categories such as operations and systems management were rated lower in terms of knowledge needed. On the other hand, 62% of the respondents felt that high or very high knowledge is needed.
Next we asked respondents to describe the existing levels of knowledge among chiropractors about the eight business tasks. Results are provided in Table 3. Standing in stark contrast to the broad need for high levels of knowledge about business, respondents reported very little existing knowledge about business tasks. In the category about which chiropractors said they knew most about, law and ethics, only 25% said chiropractors have a high level or very high level of knowledge. In the task about which they knew least, accounting, only 5% said chiropractors have a high or very high level of knowledge about the task.
Table 3.
Existing Levels of Knowledge
| Task | High Level | Very High Level | Combined |
|---|---|---|---|
| Law and Ethics | 18% | 7% | 25% |
| Organizational Behavior and Human Resources | 19% | 2% | 21% |
| Strategic Management | 16% | 2% | 18% |
| Marketing | 13% | 3% | 16% |
| Operations and Systems Management | 12% | 3% | 15% |
| Finance | 10% | 3% | 13% |
| Managerial Decision Making | 8% | 2% | 10% |
| Accounting | 3% | 2% | 5% |
Combining the two tables allows us to highlight gaps in knowledge (Table 4). We show here the needed levels of knowledge and existing levels of knowledge. The gap in knowledge is the difference between the percentages of respondents who described the level of required knowledge as high or very high and the percentage of respondents who described the current level of knowledge as high or very high. Please note that this is not a variable obtained from respondents since we did not directly ask about gaps in knowledge. We do think it is an interesting and informative way to summarize the data.
Table 4.
A Gap Analysis of Business Education Needs
| Task | Need | Existing | Gap |
|---|---|---|---|
| Accounting | 79% | 5% | 72% |
| Finance | 83% | 13% | 70% |
| Strategic Management | 86% | 18% | 68% |
| Organizational Behavior and Human Resources | 89% | 21% | 67% |
| Marketing | 82% | 16% | 66% |
| Managerial Decision Making | 70% | 10% | 60% |
| Law and Ethics | 81% | 25% | 56% |
| Operations and Systems Management | 62% | 15% | 47% |
Reading from the table, 79% of the respondents said that chiropractors need high or very high levels of knowledge about Accounting to effectively manage practices. Only 5% actually have high or very high knowledge about marketing. This is the largest gap among the business tasks, followed again by the gap in knowledge about Finance.
Discussion
Based on previous studies of health care man- agers, we expected gaps in knowledge, but we continue to be impressed by the very broad and deep deficits in business knowledge. Although the questions weren't directly comparable to questions asked in earlier health care industry surveys, there was still a very obvious greater need for business education among these respondents and large gap between business needs and current knowledge.
This may have been because this current survey was completed with respondents primarily involved in practice management. Some of the earlier surveys also included broader representation from the health care industry, including hospital executives and manufacturers of pharmaceuticals and medical devices. These respondents are likely to be much more directly involved with customers and other service providers.
Some additional insight can be gained from the ranking of the different business tasks in terms of performance. Respondents seemed to indicate a stronger need for accounting and finance, but they were also sensitive to the need to manage human relationships, including customer relationships.
The most obvious implication of this study is the need for dramatically expanded business training and education for chiropractors. The needs are too broad and too deep to be handled with short seminars or individual courses. Chiropractors appear to recognize very clearly that they need significant expansion of their business knowledge and skills. There are several alternatives that might address this issue. First could be a significant redesign of chiropractic programs to incorporate additional business training, perhaps from existing MBA or MHS programs. This will be difficult to accomplish since chiropractic programs are rightfully directed by chiropractors. Giving up courses to business programs or extending program lengths will be difficult politically, especially if the program directors do not recognize the need for business education.
A second alternative might be the establishment or expansion of internships with a focus on business issues instead of patient care. This model might work best in partnership arrangements as successful practices grow and expand. A third alternative is post-graduate training. There are many offerings available. A web-search for chiropractic practice management produced 237,000 hits, though all obviously weren't offers of programs. Unfortunately, few of these programs have the depth and breadth required for adequate business training. For example, most MBA and MHS programs require 18 to 24 months of full-time course work.
A final alternative is an industry-wide effort to develop and manage a business education program designed specifically for chiropractors. This effort could be led by a national or international association and developed at one or more of the universities that currently offer chiropractic programs. A graduate program in chiropractic practice management offered online and available to students and graduates seems the best solution to such a wide-spread need.
Conclusion
We conclude with the opinion that this is not an area that should be ignored. Though chiropractic is a very healthy field, we suspect that many practices are not being optimally managed. If they are not, both incomes and wealth creation are being impacted. This means that chiropractors have an opportunity to improve their financial results without impacting patient care.
Acknowledgements
No outside funding was required for this study. Western Carolina University provided administrative support and assistance.
Contributor Information
Steve W Henson, Western Carolina University.
Milton Pressley, University of New Orleans.
Scott Korfmann, Western Carolina University.
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