We Get Letters & E-Mail

Will the Real AK Please Stand Up

Dear Editor:

The board of directors of the International College of Applied Kinesiology-USA (ICAK-USA) wish to comment on the remarks made by Dr. Andersen under the heading of "Clinical Nutrition" in your January 1, 1998 issue. We are in agreement with Dr. Andersen's comments about "members of our profession who have the amazing ability, just by pushing an arm or pulling a leg, to diagnose nutritional deficiency, as well as a wide variety of internal diseases, disorders, and dysfunctions."

Muscle testing as part of a functional examination was introduced to the chiropractic profession as applied kinesiology (AK) by George Goodheart, DC. We are strongly opposed to how some doctors and lay people have abused this discipline. Applied kinesiology is a complex system of examination that requires dedicated study and practice to master. It should only be practiced in conjunction with the doctor's background in diagnosis, whether one is a chiropractor, dentist, osteopath or medical doctor.

Applied kinesiology is a system of examination techniques that augments standard diagnosis. It is a unique system that provides additional information by using functional neurology principles to determine the best method to treat the patient.

There have been recent peer-reviewed articles that help to understand the role of muscle testing in a neurologic examination. Muscle testing results used in conjunction with standard diagnostic tests and examination help formulate a diagnosis and corresponding treatment plan. Because there is often the misconception that using muscle testing is synonymous with applied kinesiology, the ICAK-USA has adopted that a doctor must have completed the 100-hour basic training course and passed the final examination before being considered as practicing applied kinesiology. Perhaps Dr. Andersen's muscle testing comments refer to someone that does not practice in the manner advocated by the ICAK-USA.

Applied kinesiologists have a very high referral rate from their patients because of the results obtained by using feedback from the patient's body to add information to the standard examination. This helps determine the best method of treatment. It is not a cookbook method of determining what to impose as treatment. Applied kinesiologists find and successfully treat many functional problems not found by conventional testing methods. As research is completed and the system continues to develop, we are understanding better how the testing procedures correlate with neurologic dysfunction. Some of the neurologic correlation to conditions such as the ileocecal valve syndrome can be found in the AK literature. More information about AK and the recent peer-reviewed papers can be found by visiting our website. The ICAK-USA Board of Directors Shawnee Mission, Kansas icakusa-usa.net [url=http://www.icakusa.com]http://www.icakusa.com[/url]

Dear Editor:

The article by Kiki Herfert in the December 1, 1997 issue ("A Cash Practice? Get Your ROF under Control First") sparked my interest. She did an excellent job of describing how the limitations of managed care can make the report of findings (ROF) seem hardly worth the effort. She insists that a prosperous cash practice must include a clear and strong ROF in order to succeed, and I must agree. I wish she has pushed her ideas a little farther and commented on the fact that no matter what mix of patients we have these days, reimbursement for a "visit" is low.

The promise of a robust cash practice is a myth for the majority of practitioners. We all depend on a significant portion of our revenue from our cash patients, and we always have. But to imagine great prosperity from an all-cash practice would, of course, also require a high volume practice. There is a rational limit to what a patient is willing to pay for a single treatment. After all, what is an average "cash" office call nationally -- $30? Then, what might be an average range of payment for typical managed care contracts per visit -- $20 to $50? Consequently, does it really matter what type of patient we are seeing, when from a per visit basis, we are often averaging no more than $40 per visit? (This would include Medicare, some modest number of worker's compensation and personal injury patients, and would assume a total reimbursement including any modalities.)

Using this example of $40 per visit, with 100 patient visits a week, a 50-week practice would gross $200,000. With a 50% expense overhead, a practitioner would have a net profit of $100K before taxes. Move the volume to 135 patients a week, a number considered about average in some polls, and the net profit becomes $135K.

But now, change the figures any way you wish -- say, to a $30 per visit/100 patient per week scenario. With the same 50% overhead, net profit is now $75K; certainly still a respectable salary. With about one third given away in taxes, the doctor can expect to live on $50,000. With the spouse also working, owning a Honda Civic, and sending the kids to junior college, life can be OK.

These illustrations are offered only to make one point: the average chiropractor will make a good professional living and may not profit excessively from treating patients. Our income can be much the same as the medical doctor, 43% of which are now working for a salary, according to figures from the Health Trends newsletter. My practice is saturated with managed care and paperwork. A cash practice sounds good, if it would save me clerical time doing reports. But I am not skilled at presenting an aggressive ROF, even when "optimal" results for the patient may be my preference.

The more successful cash practices that I have studied seem to use the "case basis" approach. For an entire family, offering everyone all the chiropractic adjustments they can withstand for a lump sum per year reminds me of the service contracts we are regularly offered when buying a television or a toaster. I don't think many doctors of any kind do well with this approach. No matter what any chiropractic consultant might say to make us feel "special", there are only a few of us that can become charismatic enough to rival the best televangelists.

The amount the patient has to pay out-of-pocket is a crucial issue. Either as a co-pay or on a "cash on the barrel head" basis, anything over $15 per visit is sobering for the patient faced with a ROF of multiple treatments over a period of 60 to 120 days. The illusion of the lucrative "cash practice" is one of the cruelest myths circulating in our chiropractic community. Yet, there is evidence that an average DC can make an above average professional living. Keeping costs under control and consolidating and sharing administrative drudgery while joining the emerging practice "networks" may produce more net profit than the traditional approach of "more patients/more visits."

John Hanks, DC, MHS, DABCO
Denver, Colorado

Dear Editor:

We read with intense fascination the physiatry article by Dr. Vincent Davis, "A Review of the Chemosmotic Theory of ATP Synthesis Relative to Clinical Direct Current Application" (DC, February 23, 1998). So much to know; so little time. We applaud Dr. Davis' creativity and find his hypothetical presentation of the effect of microcurrent stimulation as both informative and timely. Who would have thought that the mitochondrial chemosmotic theory would have come into clinical practice so profoundly?

One thing is certain: every field doctor using microcurrents in physical therapy should be forewarned that, because of the very issue raised by Dr. Davis, it is absolutely essential that such therapy be used judiciously. In a recent clinical mishap, a local chiropractor drew far too many protons to the instrument's anode, which resulted in a nearly explosive accumulation of ATP in the associated muscles where this negative electrode had been placed. In this case, the chiropractor, treating himself, was found unconscious; a police investigation concluded that his biceps had become super-excited to the point that the good doctor had beaten himself senseless.

All this reminds us of the pioneering work of Dr. Nissl de Coulomb, who convincingly determined that migrating protons can lead to rather substantial swelling of the mitochondrial inter-membrane space. The resultant distortion can easily cause "puckered mitochondria syndrome" (PMS). PMS has been strongly linked to high metabolic outbursts which occasionally overwhelm the normal feedback "loop" that inhibits this phenomenon. In all cases, fooling around with migrating protons is fraught with danger and certainly not a pretty sight.

Mark Kaminski,
Professor, Division of Basic Sciences

Robert Boal,
Professor, Division of Basic Sciences

Peter Shull,
Associate Professor, Division of Clinical Sciences
Western States Chiropractic College Portland, Oregon

Dear Editor:

Many doctors of chiropractic have won recognition for athletic prowess, weightlifting records, soccer championships and other fabulous neuromuscular achievements. Yet, these accomplishments are small in comparison to the training of the world's most difficult muscle.

I speak of that muscle posterior to the lips, usually called the tongue.

At least 50% of our professional problems come from a gnarly, stupid and regressive insistence by chiropractic leaders, writers and teachers who use the negatively charged, confusing, non-descriptive and essentially inaccurate term of chiropractor, instead of the term doctor of chiropractic.

Chiropractic means, roughly, "done with the hands." That would also include playing the piano, being an auto mechanic, giving a massage, or typing a letter. You get the picture. "Chiropractor" is overly general and highly nonspecific! Is this not true?

Doctor of chiropractic means "teacher of chiropractic." This is what we are and do. We need to call ourselves by our proper name, doctor of chiropractic, and stop using a hand-me-down tag given us by a preacher who happened to know D.D. Palmer!

It simply won't do to make nonsensical statements like, "It was good enough for the old-timers, and it's good enough for me." Please! We need rational thought on the critical matter of defining ourselves. Jesus said, "Let the dead bury their dead." That is precisely what we need to do with the dead and dying term that causes every one of you constant problems with your image: "chiropractor."

You need to be reborn as what you are: doctors of chiropractic. Get in front of a mirror and practice saying it. Train your major muscle! Say it loud and say it proud. Insist on it. Correct others who try to define you in old, damaging terms, if you have the nerve. A doctor of chiropractic that's you.

Paul Tuthill, DC
Grand Rapids, Michigan

Dear Editor:

In the final analysis, the chiropractic profession may be forced to form the heretofore unmentionable unity -- a municipal alliance. To overcome the tyranny of managed care, it may actually be very advantageous to form municipal alliances where all chiropractors are included in a "you get us all, or you don't get any of us" advantage against MCOs. It has been unthinkable in the past, because we would have to become allies with our nearest competition and forced to get along with our real human being colleagues.

I submit this is an unfounded fear if we follow proven "management by consensus" rules. Such an alliance may just be the most powerful defense against a host of threats we are now facing. And it just may be very healthy, much to the dismay of all the forces that wish to see us divided and fearful of one another.

Such an alliance has numerous advantages. The first is already mentioned, as an MCO-buster on a municipal level. Insurers who are going to provide chiropractic care in a given city or country must contract with the respective alliance as a whole. Our leverage will be that we reduce and often eliminate the need for MRIs, NCVs, surgery, drugs, and prevent the excesses of the "specialist merry-go-round."

But with a national average for an upper limit, our fees should not be cut (each doctor still having separate and confidential fee structures). Nor should any other discriminatory treatment be tolerated at negotiation time. Any noncompliant carrier would then be left without chiropractic coverage in that country or city. We could then afford to publicly recommend the carriers with the best chiropractic coverage. Now, that is market power.

It could have far-reaching effects in other areas as well. Our national standards of frequency and duration of care could then be leveraged, then x-rays, therapeutics, and possibly some diagnostics, such as our own NCVs, etc.

An alliance could also mean big cash savings in Yellow Pages advertising. Each year, the Yellow Pages' advertisers exploit our selfish fears of our neighboring colleagues, when we could have a highly effective, full page ad with everyone listed on an equal basis. This would leave it up to us and our own quality of care to make the real points of difference. Other marketing projects by individual doctors, such as newspaper ads and lectures, would still have their place in a health, competitive atmosphere, but not all competition is healthy for the profession.

Such an alliance should probably not be a legal entity for liability purposes, and other legal ramifications must be explored, but if fees are not part of the agenda and are left as an independent, confidential matter, there should be no problems with the FTC.

A municipal alliance could mean more references from MDs and other specialists, if we work together to make our alliance a state-of- the-art organization. This means working together and putting up with one another's weaknesses. It also means that we may be helping each other to overcome those shortcomings and becoming better professionals ourselves in the process.

Could we handle that? I not only think we could, but it is probably the thing we need, whether we like it or not. If we aim just beyond tolerance and toward mutual improvement, along with unity in marketing, it could mean big increases in the number of patients and referrals for us all. Most of all, it would mean freedom and higher visibility.

Darian L. Smith, MS, DC
Kernersville, North Carolina

(Editor's note: Dr. Lacerinza sent this letter to television's "Judge Judy" in regard to an incident that occurred on her program.)

Judge Judy
PO Box 949
Los Angeles, CA 90078

Dear Judge Judy:

I would like to take this opportunity to paraphrase an old Sinatra classic -- "That's Life." "That's life, that's what the people say, you're riding high in April -- shot down in May, but I know I'm gonna change that tune, when I'm back on top, back on top in June." Let's analyze.

Riding high in April -- this would be when the chiropractic profession won a tumultuous victory, since New York governor George Pataki signed an insurance equality bill which was enacted into law on January 1, 1998. This was truly a victory for the health care consumer.

Shot down in May -- this would be when "Judge Judy," a nationally syndicated television program which airs on the CBS network in New York, vilified the chiropractic profession on national TV. This is how my horrified patient explained the show to me.

A divorced couple were in front of Judge Judy. The wife was petitioning the court to have her ex-husband pay for outstanding medical bills for their 10-year-old daughter, which included bills for chiropractic care. Upon hearing this, Judge Judy vented her spleen at the petitioner with the following pontification: "How dare you take a 10-year-old child to a chiropractor, you should take her to an orthopedist and if he said that it's OK (fat chance), then you could go to the chiropractor. I have never heard of bringing a child to a chiropractor for back pain; request denied for chiropractic care reimbursement."

Judge Judy! As a member of the judicial community, you have a responsibility to be fair, impartial and in possession of the facts. Your personal ideology or prejudice should not enter into the courtroom when you do. The fact is, a vast number of patients bring their children to the chiropractor for a variety of health conditions, including back pain. Your personal and unenlightened views concerning the chiropractic profession need to be brought up to date. May I be so bold as to suggest that you contact the American Chiropractic Association for up to date and accurate scientific information?

Back on top in June -- this is when the health care consumer can and will access the doctor of their choice and not be intimidated by people in authoritative positions who further their own personal agenda. I think ol' blue eyes said it best: "Some people get their kicks stomping on a dream, but I'm not gonna let it get me down, cause this big old world keeps spinning 'round."

If you thought that there was some perverse comic relief in your diatribe, think again. Nobody's laughing. There is nothing greater in life than in idea whose time has come. That's life!

Andrew S. Lacerenza, DC
Lindenhurst, New York