The ABC’s… No! Make that the WXYZ’s of preparing for a foreign practice.

(… as formatted from The Canadian Chiropractor Magazine (CCA’s professional magazine) – you will have to type in the search box: “XYZs of foreign practice.”)

Advising chiropractors about the many issues that come to play when looking to start up a foreign practice reveals a mnemonic that seems to apply here (similar to the OPQRS that is learned in preparation for conducting a thorough patient consultation). Call it the STUV-WXYZs of starting a foreign practice and it looks something like this:

Speaking the local language is often the first concern of English speaking doctors when contemplating where to set up a foreign practice. Many DCs have to limit their choices to English-speaking countries when they do not see themselves being able to learn another language. Others on the other hand may already speak a second or third language because of their family’s cultural habits, travel or because of personal interests. Speaking a second language does in fact open up specific countries that would be considered more ideal simply because the language card is a trump card.

When patients understand the benefits of chiropractic they will refer others for care. In pioneer practices, where the average person on the street knows nothing about chiropractic, success is built on referrals and primarily referrals from patients. A satisfied patient may or may not refer but an informed and enthusiastic patient will. The doctor will have to be a good communicator.

There are countries where it is accepted that patients are seen by foreign speaking doctors through a translator; Saudi Arabia is a good example. Other countries like the Philippines, Singapore and some Latin American countries also will see a specialist doctor when a translator is available. The secret would be to train the staff very well in communicating the chiropractic story under these circumstances.

Traveling to the country being contemplated is highly recommended and as early as possible. Call it a reconnaissance expedition! It is amazing to hear frequently from doctors that say they want to practice in a place they have never been. Television travel shows are fascinating but certainly cannot substitute for the personal experience of spending time in a new place and meet the local people face-to-face. Even a brief visit can reveal much about a country and its people. What is of particular concern is whether a true feeling of empathy and genuine concern exists inside the prospective doctor’s spirit for the local population. It is either present, or not, and will weigh into the ultimate fate of the practice venture.

Then there is the obvious confrontation revealing whether the prospective doctor can actually feel comfortable with the living conditions of their country of interest. First hand evaluation of clinic and home accommodations answers many physical and financial questions that need to be addressed early.

Understanding a culture is more about you than it is about the people you wish to serve and live around, at least in the early years of practice. Everyone has a certain ability to confront adversity and to tolerate a given level of change. Living in another country and getting used to the culture and the different standard of life can wear out a person’s ability to adapt to daily challenges and ongoing irritations that accompany a drastically altered lifestyle. Unless one’s tolerance for change can keep up with the degree of unfamiliarity that leads to frequent frustrations, the bottom suddenly falls beneath your feet and the next thing you know you find yourself returning home to the familiar – defeated.

Understanding the ways things are done in any country is paramount for establishing a successful marketing plan. Yellow page ads and coupons in local publications are not very appropriate in Asia and Latin America. How do you market your practice in the French Riviera or a small Swiss village? This article cannot possibly provide much specific information in this area other than raising the awareness that using local publicists who understand the way things are done in their ‘milieu’ is a better direction to take.

Visualization is a well accepted concept by successful people in sports, business and personal management. It involves mental imaging of an action or event with specific focus and intention. Visualization also is an integral part of developing the “Z-factor” or enthusiasm needed to make the new clinic a successful venture. On the more practical side, this also allows you to make better decisions about the details of your clinic: its size, location, patient flow, procedures, etc. Make scale drawings of the clinic plans. Extensively review maps of the country and city or cities you will be seeing patients. Think about every detail from patient flow to which charts or pictures you want to bring along and place on the walls.

Practicing abroad is not like moving to another town or city in the USA or Canada. The thrill and excitement of the adventure can quickly turn into a nightmare when you are not adequately prepared or do not have the adequate reserves of energy and tolerance for change we talked about in the former section.

Who, what, when and why – all apply here as they have never applied before:

• Who do you know in the country? Someone who can help you build a framework of logistical and emotional support. This can be a prospective partner, employer, family or other relative, friend of the family or other contact where trust has been established and there is a sincere interest in seeing things happen for you.
• What information do you need to know to better prepare? What has to be resolved (financially, timing, language, etc.) before you can actually make the move?
• When do you plan on taking a reconnaissance trip, wrapping things up where you are and when are do you actually starting seeing patients in the foreign practice?
• Why have you decided to practice abroad? The risks of failure are higher if you are escaping or running away from something – or someone. Doing the right thing but for the wrong reason can easily backfire, simply because your degree of commitment may be lacking just when you need it most. If on the other hand, you have done your homework and feel strongly, almost overwhelmingly about your decision, it stands to reason your opportunity for success will create itself.

X marks the spot! The location of a chiropractic clinic has been an important success factor seen in industrialized countries where the substantial middle-class population has been able to support a large growing number of chiropractors. Where there is one DC for every 10,000 people or less (USA, Canada, Australia) the clinic location can usually be found in a retail center or a stand-alone building on a busy commercial street. Some DCs have forgone signage for space in a medical office building. In earlier days, it was not uncommon to see home-office set-ups for chiropractic clinics and often the best place in town was near the local hospital. Today, the pioneer practices in new countries face different challenges.

If a country’s economy and humanitarian laws favor a larger middle-class, the locations for a chiropractic clinic will likely follow the same experiences seen in English-speaking countries. In countries where the middle-class is practically non-existent, a two class society has really only one group of people who will be able to pay for chiropractic care in private practices, namely the well-to-do folks. Here it is a mistake to try and locate a clinic using standards and criteria that work in the USA!

The locations that worked during the pioneer days in America, such as near the hospital and/or in a home-office on a busy street, may also be suitable for today’s pioneer practices. In addition, it helps to study the habits of the local healthcare providers in the country and copy the location decisions made by local dentists and medical doctors in private practice.

When chiropractic is initially being introduced to a developing country, go where the prospective patients live and work. The wealthy that can well afford care expect first class facilities in a first class location such as in a street level office in a financial district, in a ritzy mall, in a stand-alone building within a large secure community, or rent an office just in front of the main entrance to the large secure communities. Once the DC population increases to where there is one DC for every 100,000 people, the newer practices will then be selecting the “second-best” locations still near wealthier communities, but smaller sized or in a central retail location that attracts people from these smaller secure communities.

Due to the great disparity between financial classes people who can afford to live in middle-class homes or in exclusive communities have demanded secure, segregated home developments. This does make it easier for the chiropractor to locate in a nice neighborhood and maintain a good quality of life, even though the rest of the population, often over 80%, lives in poverty-afflicted areas.

Side Note: Many DCs who understand these economic conditions and still chose to serve the poor, usually arrange a free clinic for a couple of days per month in a church or community building located in the poorer communities. By lowering the financial barrier this way, hundreds more people can be helped.

There is yet an alternative practice model being recommended by the Chiropractic Diplomatic Corps called the Dual Practice that may apply in situations falling between the two extreme options mentioned earlier. The Dual Practice consists of designing a combined “Private Clinic” and “Public Clinic” where all the patients can be seen in the office setting that meets their needs and expectations and all under one roof.

The Private Clinic has a first-class theme where patients have a nice waiting room and are seen by the doctor by appointment in an exquisitely decorated and equipped adjusting room and/or private office. These patients come in by appointment and pay the full office visit rate as they leave.

The Public Clinic, located under the same roof, has a separate waiting room and an open adjusting area set up for volume visits that is humbly decorated and basically equipped. Here patients sign in, pay a greatly discounted fee (1/5th) up front, take a seat and are seen on a first-come-first-seen basis. Clinics usually require that patients hear a mini-lecture before they are permitted to go into the adjusting area. An interesting approach that makes sense considering that the poor can only afford to return 2-3 times, even at these highly discounted rates. Referrals must be high to work.

In all situations calling for a clinic location decision, the doctor must have a clear perspective of the economic influences and have researched the habits of other private practitioners before committing to a location. As they say in Real Estate circles: “The three most important things to know about success are: location, location and location.”

Yes, there is enough money and emotional support to undertake the challenge of opening a chiropractic clinic abroad. When this declaration is spoken with confidence – its time to get serious!

The “Z” factor refers to the degree of drive and enthusiasm needed to maintain the energy and focus for a successful venture – an important element of building the endurance required in facing the simultaneous challenges that confront the doctor setting up a foreign practice. When people travel on vacation there comes a time during the trip when everyone runs out of gas. These are dangerous times. Constantly having to cope with daily challenges can at times be daunting under the most familiar circumstances. Adapting to daily lifestyles of a foreign culture can wear out even the most experienced traveler. Making a living in these conditions increases the exposure and the risks of being overcome. This is effectively countered by the doctor’s drive, reserves of energy and enthusiastic dedication.

Hopefully, this potpourri of information can be of use by prospective chiropractors with interests in establishing a foreign practice some day or even sometime this year. There is more support and infrastructure available today to assist DCs who can make the transition into a foreign practice than there was 10 or 20 years ago. Realistically, less than 5% of people have what it takes to fit into this ex-patriot category and who can take up the need for pioneer DCs throughout the world. This alphabet soup may have a cute title but this is a serious subject; one that can change the lives of millions of people now without access to regular chiropractic services; and a positive step in establishing the profession there.

– The economic conditions that support the development of chiropractic, simply explained.

Occasionally someone in the world experiences a brief moment of creative genius that propels an idea into a life-changing event. That moment happened on September 19th in 1895 when D.D. Palmer made the connection between spinal misalignments and a compromised nervous system. This revelation rapidly developed into the Philosophy, Art and Science of Chiropractic and a new profession was born.

The first fifty years saw this new profession remain almost exclusively in America. Eventually there were foreign graduates and the profession began to spread throughout the world. Interestingly enough, the rate and distribution pattern of this growth occurred primarily in Western Europe like Switzerland, France, Italy, Norway, Denmark or the UK and elsewhere in English speaking countries such as Canada, Australia, New Zealand, South Africa, Hong Kong, Singapore and the Caribbean Islands. What these countries do have in common is a large economic middle class.

There are other characteristics that can be used to explain the profession’s peculiar distribution pattern of growth. The majority of these countries were formerly colonies that did well in the post-colonial industrialization era. Still others also have a geographical advantage that favors strong International trade such as major seaports or highly skilled laborers. Further studies into modern day social profiles of countries will reveal still other identifying factors that have favored the growth of chiropractic in their country but, for the purposes of this article, we will stick to the most basic element, economics. In conducting this type of analysis we find economic profiling as the common element. The string that ties it all together is the size of a country’s middle class.

I was reading an article by a young female chiropractor that opened an office with another woman chiropractor in Costa Rica. One comment in particular stuck in my mind. She said: “At first, we were surprised by the type of patients we saw. Knowing that Costa Rica is a third-world country, we assumed we would be catering mainly to the poor people. But, while poverty exists in Costa Rica as it does in any nation, mainly we’ve attracted the middle-to-upper class population (1).” The doctor does go on to say that they frequently donate their services to the poor whenever they visit outlying villages.

This story actually narrates what is and has been occurring in all developing countries where there are primarily two dominant socio-economic classes and an ever slowly increasing small middle class. In these countries, chiropractic is an imported specialty that is only financially accessible to the middle and upper classes that can afford to pay beyond basic medical care.

There is another report about a chiropractor in the Philippines that admittedly understands this two-class reality. First he has located his clinic in the city’s most exclusive mall to attract the portion of the population that can afford his regular fee. Then, on every other Sunday at his church, he donates his afternoons to hold a free clinic for the poor. Until governments can afford to provide for a larger safety net it seems to be up to the individual doctors to step in where possible. High profile foreign missions are also a part of solving this equation when designed to include the local chiropractors.

In order to truly appreciate the effect of economics on providing a fertile ground for the growth of chiropractic it follows that a review of the economic factors in the United States could well explain much of what has occurred through out the world. Yes, the USA stands heads up above the rest of the world with the highest Gross Domestic Product per Capita (GDP/c) of around $34,000. This compares to the lower GDP/c in Canada ($23,000) and Australia ($22,000) or to the much lower GDP/c in China ($3,800) and India ($1,800). Unique countries like Switzerland ($27,000) and Singapore ($28,000) are in the upper GDP/c ranges because of their small size, highly skilled laborers and globalized societies.

Looking at the United States and referring to a study by Harvard University that outlines four economic sub-groups: the very wealthy (3%), the well off (10%), the average working person (60%) and the underemployed, unemployed or unsuitable for employment (27% – which includes the children), the benefits of a country that has over 70% of the people contributing to the tax base means that there is enough money for everyone to afford healthcare. The taxes support a broad variety of welfare and unique social programs that provide an extensive “safety net” for the entire population.

Our lesson of basic-economics-in-action is like this: the very wealthy invest their money into businesses that are managed by highly qualified and well paid, now well off people. These businesses provide jobs for the average working person in the community who can now afford the services of professionals who are able to charge a high fee and join the well off group. Everyone gets to pay a fair portion in taxes which takes care of the community needs for a high quality of life and leaves enough money left over to provide for the 27% dependant and otherwise less fortunate people.

If you live in America and need or want chiropractic care, you can get it through public and private insurance, workers’ compensation and other plans. For that matter, the same can be said about Canada, England, Australia, Sweden, etc.

However, the same cannot be said about India and China where there are two chiropractors for over one billion people. There is one chiropractor for every one million people in Egypt, Kenya, Argentina, Ecuador, Guatemala, Hungary, Romania, Russia, Turkey, Brazil, etc. If one considers the proportionate economic middle class population of these countries it becomes obvious why it has been difficult to see a rapid demand for chiropractic.

Now, there is another important factor to consider… language. As we enter this new century, only 3% of all the chiropractic students in the world are being taught in the 17% of the schools (#6) that are teaching in a language other than English. This is the one single factor, other than the size of the middle class, which has severely hindered the establishment of chiropractic in most other parts of the world. The truth is that until chiropractic is taught in or near that country the profession can almost never become truly established, or enough to reach even the poor in their midst.

Here again, the issue is economics! In third-world countries only the middle class families can afford to put their children through college. The very wealthy families however can afford to send their children abroad for college and that is how chiropractic finds its way into many developing countries today; in addition to the hundreds of scholarships provided through chiropractic colleges in the modern countries. The current challenge is to create the right dynamics that will favor the establishment of new schools in all regions and all major languages like Spanish, Arabic, Russian, Cantonese, Africans, Punjabi, Hindu, etc.

In reviewing the two primary factors that are necessary for chiropractic to have a healthy growth, namely a large middle class and access to affordable chiropractic education, we can better strategize for future growth efforts. Looking at the flip side of this equation we can also see where not to waste our energy and resources and try not to allocate the majority of our focus on the establishment of the profession in countries where the conditions continue to be unfavorable for chiropractic; to do this it may be necessary to create a sliding graph that represents the conditions of each country along this scale; to be able to say in 10 or 30 years that the overall benefit to the people of the world has been good. It’s a matter of priorities.

As the chiropractic leadership begins to absorb these concepts there will be better progress because it will result from clearer intention rather than the more random-type results that are observed. It has been said: “When things don’t change… things don’t change.” It’s not that any change is a good change; but simply, that good people can promote the right kinds of change when they are given access to good information and are courageous enough to act.

(1) A Costa Rican Chiropractic Adventure by Lara Long, DC – The Chiropractic Journal, March 2000.