Developing a model curriculum for ethical practice building at Chiropractic Colleges: Part 1: qualitative analysis of opinions from an International Workshop

Introduction

An increasing number of veteran doctors and new graduates are engaging in – or are being coerced into considering engaging in – unethical practice activities that put their own pecuniary interests ahead of the best interests of their patients. A recent report by the Canadian Federation of Chiropractic Regulatory and Education Accredited Boards (CFCREAB) stated that the number of complaints against chiropractors with respect to allegations of professional misconduct (i.e poor record keeping, sexual misconduct, practicing outside the scope of chiropractic practice, substance abuse) has not risen in proportion to the growing number of new graduates in Canada overall, with one notable exception: a steady increase in allegations of Commercial Misconduct (insurance fraud, for example).¹ This is especially puzzling since a recent audit of jurisprudence and business management courses taught at chiropractic colleges in North America revealed that all colleges teach codes of conduct and ethical behavior in their core curriculum, although the exact nature of this content was not described.² This is consistent with the mandate of the chiropractic academic accrediting agency in Canada and the United States agency which both state with respect to “Professional Issues”:

“The student must demonstrate an ability to:

1. exhibit ethical attitudes regarding the provision of patient care services, fees, financial arrangements, billing practices and collection procedures;

2. identify and acknowledge an obligation to refrain from illegal and unethical patient care and practice management procedures”^3,4

Recommended Codes of Conduct and Ethical Behavior have also been promulgated by various chiropractic professional advocacy organizations towards practitioners. For example, the Canadian Chiropractic Association delineates 40 duties and obligations practitioners have with respect to their patients, their colleagues (including obligations to provide fair and equitable contracts to potential associates), issues of jurisprudence (advertising, avoiding conflicts of interest, professional fees, third-party assessments), the profession, the research community and society at large, with the preamble of this document asserting:

“These principles are intended to aid chiropractors individually and collectively in maintaining a high level of ethical conduct. They are not immutable laws, for the ethical practitioner needs no such laws, but standards by which a chiropractor may determine the propriety of conduct in relationships with patients, colleagues, members of other health care professions and with the public.”⁵

A similar Code of Ethics has been disseminated by the American Chiropractic Association (ACA)

“II. Doctors of chiropractic should maintain the highest standards of professional and personal conduct, and should comply with all governmental jurisdictional rules and regulations.

XIII. Doctors of chiropractic have an obligation to the profession to endeavor to assure that their behavior does not give the appearance of professional impropriety. Any actions which may benefit the practitioner to the detriment of the profession must be avoided so as to not erode the public trust.”⁶

These ethical codes, however, are tantamount to “motherhood” statements that carry no statutory authority and are thus unenforceable by a licensing body. However, many jurisdictions have word-smithed these ethical codes and woven them into their professional misconduct regulations, which are indeed enforceable. A breach of these regulations can lead to a referral to a Discipline Panel that can, in turn, impose penalties up to and including loss of licensure. In addition the U.S. Department of Health & Human Services (Office of the Inspector General or OIG) recently published an even more provocative document, a “Road Map” for healthcare providers to enable them to avoid Medicare and Medicaid fraud and abuse. The Road Map cited several examples of practitioners who violated various national laws and described the punishment for their transgressions; penalties including loss of licensure, jail terms and fines in the hundreds of thousands of dollars.⁷

How then, to explain the discordant findings that despite the fact students and practitioners are inundated with curricular content, guidelines and enforceable regulations specifying appropriate codes of conduct and ethical behavior, some chiropractors nevertheless engage in unethical practice activities upon graduation? In order to investigate this phenomenon, the lead author of this manuscript organized a Workshop at the 2011 Association of Chiropractic Colleges Research Agenda Conference (ACC-RAC).⁸ The ACC-RAC was selected as the most suitable venue to conduct this workshop since the vast majority of attendees are teaching faculty at accredited chiropractic colleges from around the world and, as such, it was posited they would be in a unique position to provide valuable perspectives on issues related to this topic including; whether or not unethical practice building practices are on the rise in their home jurisdictions; if they are, the type of unethical behaviors that occur; causes of unethical conduct and; viable solutions to the problem. Based on these assumptions, the lead author of this article developed the following workshop objective: “To identify challenges graduates will encounter that complicates their ability to develop a successful, ethical, patient-centered chiropractic practice; challenges that may lead them to succumb to unethical behavior and; develop strategies to overcome these challenges.” In Part I of this project, this article will provide a qualitative analysis of the consensus opinions with respect to these challenges as identified by participants of the workshop. Part II, which will be based on an upcoming workshop in 2012, will discuss the action steps that participants posit colleges can take in order to combat these challenges.

That said, the authors recognize that, from a pragmatic point of view, it will be impossible to eradicate fraudulent activity from the chiropractic professional – or any healthcare profession – altogether. There are members in every profession who believe the rules do not apply to them and are essentially ungovernable.

Operationalization of the Workshop

Thirty conference registrants attended the workshop. The workshop began with a brief introduction by each of the panelists who respectively provided an overview of (i) the objectives of the workshop and the concept of professional obligations, (ii) issues germane to cultural authority ethics and (iii) the importance of practicing with passion and purpose.

Each of these presentations touched upon the issue of “moral blind-spots.” Moral blind spots or moral short-sightedness occur when an otherwise moral person ignores a specific moral issue or the moral implications to a specified group or situation. Thus, rather than the comprehensive moral insensitivity of the depraved person, the moral blind spot is a focal insensitivity to an issue. The moral shortsighted are insensitive to the effects of a behavior on a specific group or in a specific situation. These types of problems in moral reasoning are fairly common and some might say that everyone has some moral blind spots or shortsightedness.

Immediately following the introduction, workshop attendees were randomly assembled into four working groups and charged with the following three tasks: (i) identify what they felt were the motivators behind unethical practice activities (ii) list different types of “moral blind-spots” that lead to chiropractors engaging in inappropriate conduct and (iii) provide preliminary solutions that chiropractic colleges could inculcate into their curricula to address these concerns. A representative from each group then provided the group’s consensus opinions. The discussion was then opened up to all attendees for further discussion. The collective opinions are summarized below.

Discussion

Workshop participants divided the forces behind unethical behavior into internal and external forces.

Internal Forces

The overall consensus opinion of the participants was that the internal forces driving unethical behavior exhibited by new graduates was their debt load, an amount typically in excess of $150,000. The requirement to serve this debt upon graduation, coupled with the necessity of earning sufficient funds to pay for basic living expenses, gives the impetus towards making decisions based on financial gain rather than clinical need. Many attendees noted that Millennial or the Echo generation children (children of the baby boomers) often have no patience to obtain economic success by what is colloquially termed “sweat equity” – the requirement to build a loyal patient base founded on a solid reputation over time. Other attendees, seasoned hands in chiropractic education, commented on the sense of entitlement many students now demonstrate and how this sense of entitlement spills over to practice activities. These students are unable to delay gratification and instead seek the illusion of wealth. These attitudes may be further strengthened by the poor role-modeling of highly paid and successful celebrities such as Martha Stewart or Bernie Madoff. This all results in a downward-spiral of unethical behavior whereby vulnerable graduates want it all; they want it now and they do not particularly care how they get it.

External Forces

At the same time, new graduates are exposed and vulnerable to external forces contributing to poor ethical practice. “Practice Management Programs” were specifically mentioned by the workshop participants, especially those programs that teach chiropractors to deliver pre-packaged messages to patients that appear to push patients towards unnecessary and an excessive number of visits. Lengthy schedules of care were cited as an apparent outgrowth of these programs. Excessive treatment independent of patient needs is a practice activity that hinders the development of the cultural authority of the profession and tarnished its image, at least according to some.⁹ The problem of pre-payment plans has prompted the ACA to develop a policy warning doctors and a series of questions a practitioner ought to answer in order to determine whether or not a prepayment plan is in the patient’s best interest.¹⁰ Although the ACA does not call these plans inherently unethical, many of the workshop attendees opined that they are.

It should be mentioned that none of the workshop participants argued against recommending patients adhere to either a supportive care (a form of care that, when withheld, results in a return of clinical symptoms) or maintenance care (a form of periodic care that is provided even in the absence of symptoms and has many theoretical benefits including optimizing a person’s health, identifying a new problem as it emerges, enhancing wellness and preventing reoccurrence of the chief complaint) since evidence exists in support of these care plans.^11–18 However, the decision to adhere to these ongoing care plans ought to rest with the patient, not the doctor, and the patient’s decision ought not be influenced by unethical tactics (fear-mongering, for example). Furthermore, since the patient ought to be the final arbiter what is in his or her best interest, should a patient decide to discontinue care once their chief complaint is resolved that decision must be respected. Such thinking is at the root of “patient-centered health care.”

Combating the Problem

Not surprising, given the fact that the majority of attendees were academic faculty at accredited chiropractic colleges, workshop participants asserted that the colleges were not taking a lead role in this area of professional development. It would appear that colleges may be abrogating their responsibility to students by not offering more ethical practice guidance. The vacuum left by their absence was being filled by practice management firms.

Business courses should include content that provides real-life examples of “bad behavior” exhibited by field doctors, as gathered from annual reports published by licensing bodies and it ought to include reviewing contract clauses that are not equitable to the new graduate. Workshop participants emphasized that students need mentors and role-models who inspire them to practice with pride and to strive for excellence. It was suggested this could be achieved by requiring students visit successful alumni from a roster of doctors who were pre-screened by each chiropractic college. This approach was preferred to simply requiring students visit any field practitioner since without some over-sight, a student may inadvertently visit an unethical, albeit financially successful, doctor and consider emulating his or her practice behaviors upon graduation.

For example, although a practitioner may be able to boast efficient office policies and procedures, commercial success and high satisfaction rates among his or her patient base, this may be achieved by improper behaviors. Such unethical tactics may include fear-mongering, overly-aggressive scheduling strategies, unsubstantiated guarantees of results, false and misleading advertising, conspiracies to defraud third-party payors and other unscrupulous tactics. One tactic that has been identified as a source of concern recently is the requirement of a patient to bring their family members to an “education seminar” prior to the commencement of patient care. Although an argument can be made that it is far easier for a patient to adhere to a schedule of care and to perform home-care exercises or to refrain from certain household chores (i.e. laundry, snow shoveling) if there is support from the entire family, some chiropractors make attendance to an educational seminar a requirement in order to receive treatment. This has prompted the chiropractic licensing boards in some provinces in Canada (Alberta and Saskatchewan for example) to expressly prohibit this form of practice activity.

Not only should colleges maintain a roster of pre- approved (or pre-vetted) practitioners that exemplify appropriate practice activities that students may shadow, but it was suggested that these practitioners be offered training to ensure their alignment with the educational learning objectives of that chiropractic program.

Workshop participants suggested business courses in the core curriculum offer practice management skills along with patient management skills. Such skills include; understanding the terms and conditions of a lease or agreement of purchase and sale; basic accounting skills; effective advertising; how to use demographic information to increase patient traffic; staff training; insurances that must be maintained; requirements to maintain licensure and so on. As importantly, students should be shown examples of associate agreements, especially those clauses that can lead to strife upon dissolution of the agreement. Such clauses include; termination; save-harmless; moral turpitude; requirement to maintain malpractice insurance; requirement to maintain licensure (professional registration); non-competition and distribution of records.

Some workshop participants expressed the need to educate students about the risks and benefits of purchasing a practice. Methods to calculate purchase price- including the attribution towards the “Goodwill” of the practice- need to be taught. Students should be cautioned to avoid purchasing a practice solely built on a “cult of personality,” since the practice’s success may hinge upon the patient’s preference towards the doctor selling the practice (the vendor). Students should also be forewarned that some vendors require the purchaser hire them for a period of time at an outrageous fee in order to ensure patient retention and mentoring.

Workshop participants suggested that colleges should devote time to “success” stories, not just “horror” stories. This may be achieved by organizing panel discussions involving successful alumni. Lastly, “evidence-based practice” should include elements of “ethical-based practice” activities throughout the college curriculum.

Future Action Steps

Workshop attendees were asked to complete a brief questionnaire. All attendees indicated that they found the workshop insightful and would be willing to attend a follow up workshop in 2012 if it was scheduled. With that in mind, a proposal was submitted to the program organizers of the 2012 ACC-RAC to schedule a second workshop on this topic that will focus on the action steps required to inculcate these solutions into college curricula. In addition, the importance of teaching “leadership skills” has also been offered as an important component of this educational model. This proposal was recently accepted and the second workshop on this topic is scheduled to take place during the 2012 ACC-RAC in Las Vegas, Nevada on March 17, 2012.

Summary

Overall, participants of the Ethical Practice Management workshop of the 2011 ACC-RAC expressed their satisfaction with it. This article described challenges chiropractors, especially new graduates, will encounter that may tempt them to conduct fraudulent activities. At the end of the day, it is hoped that workshops such as these will be used to develop a “Model Curriculum” for ethical practice activities taught throughout the profession.