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:

S	Speaking the local language. Chiropractic needs to be communicated – to be understood.
T	Travel before deciding. Making a personal connection with the local people is critical.
U	Understand the culture. The less difficulty you will have acclimating to the area.
V	Visualize your clinic. See patients in waiting room, on the adjusting tables, etc.
W	Who, what, when where and why – all apply here as they have never applied before.
X	“X” marks the spot. Location could possibly be even more critical than you would ever think.
Y	Yes, you have financial means and the approval of family or spouse.
Z	The “Z” factor. Some call it “drive” some call it “motivation” – but if it’s not there, beware.

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.

– Ideas for an updated model of structuring chiropractic missions.

Chiropractic Ecotourism may well be defined as travel related activities that combine a vacation to a foreign country with a humanitarian activity. These missions are value driven experiences that bring great personal gratification for the participating Doctors of Chiropractic.

Short-term humanitarian missions are increasing in both the number of countries served and in the frequency of events in each country. There are two main groups of participants: secular and non-secular. Although motivation may vary from group to group, the common thread is purely humanitarian.

People living ordinary lives with only the occasional extra-ordinary experiences that bring fulfillment and satisfaction are finding themselves attracted to experiences that have the potential to “transform” their lives. Transformational experiences sought by the religious participants help them reach a closer experience and relationship with God through service to the needy. Transformational experiences sought by non-secular individuals help nurture their humanitarian tendencies and possibly also are opportunities to get closer to God.

Short-term humanitarian missions offer both physical and emotional experiences that provoke serious introspection in re-evaluating one’s “purpose in life” or one’s sense of placement in their community. For chiropractors, as in other healthcare and service oriented disciplines, the desired outcome of donating one’s time and money to participate in these missions is also to renew their dedication to the “reasons why they became a chiropractor in the first place.” In all cases we see successful outcomes.

Since we have seen more of these missions in the latter part of the 20th Century it is safe to assume that primary mission goals are being achieved. The question today is: “Do these goals serve the greater good?” What are some of the primary mission objectives?

1. To reach more prospective religious converts through healthcare services.
2. To renew a practitioner’s motivation in their profession by donating their services to the needy.
3. To acquire an appreciation for how good life really is at home after experiencing first hand the world’s poverty.
4. To increase awareness of the benefits of chiropractic care.
5. To participate in the healing of people without financial gain. (Humanitarian service)
6. To get away for a vacation that has greater personal satisfaction.
7. To visit new places and become exposed to different cultures.

As you can see, existing short-term missions are successful in achieving these personal objectives, but the questions of lasting benefit to the people served and the chiropractic profession as a whole also needs to be raised. Do short-term missions really help the intended target population? How can these missions be designed to produce a greater benefit to the establishment of the profession; which ultimately translates into more and better care for the patients?

It is always heartwarming to hear the reports from mission doctors about their renewal in the simple, beauty of chiropractic and, in particular, about some of the spectacular and miraculous results received by some of the individuals following their first chiropractic adjustment, especially the children. As doctors we have learned to personally appreciate the value of lifetime chiropractic care so it must be heartbreaking for the participating doctors to leave a population without care once the mission is over.

Short-term missions are just that… of short duration. What can be done to raise the outcome of missions to create more regular access to care? In answering these questions, several inspired DCs have attempted to create a network of some sort where a number of doctors could rotate into a permanent clinic location. They are finding this goal very difficult to accomplish and have to settle for scattered return trips with often, small groups, and admittedly, a hard task that is financially and emotionally depleting.

Reaching across borders, oceans, great distances and cultural differences presents many challenges. It takes resources and reserves of money, people, time and opportunities. We will likely continue to see an increase in foreign missions. How can these dedicated DCs meet the demands of today’s mission needs? Networking and sharing experiences and resources is a good place to start. Adopting an updated mission structure is the next step to take, one that addresses the deficiencies of older models and also takes partial responsibility to be a stakeholder in the establishment of the profession of chiropractic in the target countries.

Today’s researchers and businessmen and women have learned the value of “outcome based” designs for their work. If we really want to bring chiropractic to other countries it will require designing a mission structure that places patients’ needs first, the professional needs second and personal needs third. Since we’ve already established that personal needs are being met, let’s look at the other two areas.

Patients’ needs are pretty simple: They want access to a doctor when they need one. A doctor who is affordable and who is willing to become a part of their community. It’s really no different than what patients expect of their doctors where chiropractic is established.

The profession needs six things from short-term chiropractic missions:

1. Attract qualified doctors who may become permanent additions to the country’s roster. Let the DCs know that they are welcome to come back and become a part of the pioneer effort in that country.
2. Attract prospective students to the profession from the attention and PR produced by the event. Schedule regular “special student sessions” at local universities or have people return after the day’s clinic hours for a student talk.
3. Local DCs need to be included in the planning stages and their clinic advertised to the patients who are treated by the mission team. (So patients will have a place to continue care.)
4. Respect the authority of the local DCs and tap into their contacts but mostly use the “dignitary” status of the mission to further the cause of establishing the profession in a more formal or official capacity.
5. Only bring licensed doctors to treat people and be fully documented at all times. The only exception is when a DC schools structures a clinic environment within the mission group and even then, only senior interns who qualify and receive school clinic credits.
6. Make the mission a series of highly publicized events in each location. High profile events reach more people and have the best results across the board.

Humanitarian missions have left many of the existing practicing DCs with mixed feelings. If we are to extend the concept of outcome oriented activities, there could be special consideration made for the doctors who are pioneering chiropractic in the developing countries targeted by mission groups.

Chiropractic is only regulated or officially recognized in about 30 countries. These are largely “northern countries” with an advanced industrialized economy. In the other 65 countries, where chiropractic is not legislated, there is nothing to stop anyone from misrepresenting themselves as chiropractors. This is why mission participants need to be documented.

Understandably, pioneer DCs may not feel entirely comfortable with receiving too much attention since they actually live with the fear or the risk of sanctions by the local government should a chiropractic group create undesirable results. Always include the leadership of the existing DCs in any activities where chiropractic services are being delivered to the local population. They may have no interest in participating in the mission or it’s planning; being tied up with their own practice and families. Or, just the opposite, they can be a valuable ally and a primary contact. Either way, they are entitled to be notified and invited.

The New Chiropractic Pioneers – Part 1

By Michel Tetrault, DC – Chiropractic Diplomatic Corps

*** A series of articles designed for chiropractic students and others interested in foreign practice.***

As we observed the turn of this century, we find around 15,000 students enrolled in chiropractic schools and 69,000 Chiropractors in practice worldwide. The USA has 13,000 of the students while there are only 400 students enrolled in the 6 recognized schools located in non-English speaking countries. 85% of the DCs are in the USA and only 5,000 DCs are located outside of the United States and Canada. There are more DCs in practice in the state of Indiana than in all of Asia, Africa and Latin America combined.

This is the first of a multi-part article on “Practicing Abroad.” It is our desire to inform you, as students, of the opportunities and responsibilities of a foreign practice. Undoubtedly, it is hoped that these brief articles will either stimulate in you an interest in practicing outside of the USA and Canada, or strengthen your resolve, if you already plan on practicing abroad. There are many opportunities in chiropractic during the next century to be found outside the USA. Under the current global economic standards, the world can support upwards of 350,000 chiropractors and we have met only 20% of that total.

The Chiropractic Diplomatic Corps, a humanitarian, non-government, international organization, has set up an Internet based “Foreign Service Registry.” Some 500 DCs and students (10%) have registered their desire to practice abroad in 65 different countries. The majority expressing interest in Europe (43%) with the balance requesting Asia (27%), Latin America (28%) and the last 2% looking at Africa and the Middle East. Fifty percent of the registrants have been in practice less than three years or are still in school. Thirty percent have been in practice 4 to 10 years and the remaining twenty- percent in practice over 10 years.

Imagine being a DC in the early 1900’s? That same opportunity to pioneer chiropractic is just a plane ride away, offering you the chance to be a leader and to nurture the growth and development of chiropractic. See yourself respected as a drugless healer and treated according to the degree of education and social position you could earn as a valuable player in the future of chiropractic. If you don’t think these are tangible goals in your hometown, think again, think differently or think abroad.

Your thinking decides your success in life. If you go back to hometown USA and accept the status quo or practice where everybody else wants to be, you will create one type of reality for yourself. On the other hand, when you step “out side this box”, when you go where very few have gone and little is familiar to you, this foreign environment breeds creative and adaptive traits, evoking your noblest efforts. You are literally forced to think differently and, in so doing, create a different future for yourself. Up to the challenge? Three challenging areas come immediately to mind: language, time and finances.

The first major subject to consider is language. Chiropractic needs to be communicated to people in their own language so you should determine if you have the aptitude to learn another language; and one language in particular. Some of you already speak this “particular” language because of family heritage, previous travels or personal interest. The next two major challenges are time and money. That is: “When will be the best time for you to move abroad (or back home) and when will your finances support the move and the new practice?” Speaking to the “back home” crowd, statistics sadly report that only 30% of the foreign students who were provided full chiropractic scholarships returned home to set up practice after graduation. Until there are schools that teach chiropractic in every major language and in every region on earth, American Schools will need to see a greater percentage of their graduates establishing a foreign practice. If you are a foreign student or here on an international scholarship, please recommit yourself to your people and bring them chiropractic the way only you can. Are you willing to let foreigners decide how chiropractic is to be developed in your country (in your absence)? Besides, America is not the land of golden opportunities it once was. The opportunities for chiropractic are beginning to see a rising potential in less serviced countries.

The next upcoming sections will discuss the needs for humanitarian services and thoughts on future planning which include you and your family semi-retiring in your favorite country, for those who wish to wait before practicing abroad. Later, detailed steps involved in setting up a foreign practice will be outlined. If you wish more information, you are invited to further check this Chiropractic Diplomatic Corps’ web site. The current global statistics on the state of chiropractic are available there, along with links, articles and much, much more.

 

The New Chiropractic Pioneers – Part 2

This article focuses on available humanitarian programs and other things you can do in the future about bringing chiropractic to under served countries. It is completely understandable that you wish to practice in your home state or other location in the USA or Canada. Many doctors have a successful experience in practice for 15 to 25 years, then find inside themselves the desire to “reach-out to do more” for their personal fulfillment and are now looking to start over in a foreign country. Many of you reading this article right now will be in exactly such a position, years down the road. Here are a few suggestions to keep that spirit of “service” alive in you over the years:

Mission programs.

There have been many, many chiropractic mission programs where several DCs fly into a country and provide humanitarian care to the indigenous people. Some are exclusively comprised of chiropractors and others are medical missions, which have added a DC or two to their team. Life University’s “LAW: Life Around the World” and Palmer College’s “CAP: Chiropractic Abroad Program” have on-going, short-term missions that involve students AND graduate doctors. This trend will increase in the years-to-come; so, you can always plug into these schools for the experience. Coping with State Law issues, insurance issues, competition issues, IRS and other business-related issues, etc. can turn off a “turned-on” Chiropractor. The personal gratification reported by those who have participated in humanitarian missions is beyond words and will keep that giving side of you alive, as you maintain a regular Western practice.

The Christian Chiropractic Association has been very active for many years with their ongoing missions in Poland, Ukraine, Nigeria, Mexico, Bolivia, Columbia, Costa Rica, Jamaica, Hungary, Haiti, El Slavador, Ecuador, and the Dominican Republic. Also, there are also several privately organized expeditions that go to such places as El Salvador, Panama, Peru, India, Nepal and the Philippines. So, there will always be opportunities for you to participate with a variety of organized humanitarian efforts. This is an excellent way for you to visit and experience the cultures and consider where you may wish to return and establish a permanent practice down the road. It is recommended that you keep on file the Internet resources of the Chiropractic Diplomatic Corps’ web site address so you can inquire into the listing of Chiropractic Missions.

Humanitarian help begins in your neighborhood.

Another way to serve the needy, without the costs associated with travel, is to look in your own community. There are several ways to provide humanitarian care in your practice by dedicating one or two slower mornings per week as “community care”, “free clinic”, “children’s clinic” days on a “sliding scale” or “low fee” basis. You can consider donating several hours weekly at a homeless shelter, battered women’s shelter or Migrant Worker Center in your community. As you get involved with local service clubs and your local Chamber of Commerce, you will develop the contacts that will expose you to the needs within your community.

Travel and learn another language.

Not everyone is interested or motivated to have a foreign practice purely for humanitarian reasons and that’s perfectly fine. Taking a break from the practice by vacationing and traveling abroad is a fun and fulfilling experience. You will get more out of your travels by also learning the language, getting you close enough to the locals to enjoy their culture in greater depth. It comes as no great surprise that you will probably find yourself attracted to a particular country and culture. Eventually you may desire to bring chiropractic to one of the countries you visit when you find yourself ready for a foreign practice.

Chiropractic is a wonderful profession, full of diversity and personal gratification. The bottom line: “We need more DCs in foreign practices and we will coach anyone who is willing to go forward with this endeavor.” Those who feel they have the personal integrity and commitment to bring chiropractic to the under served will find inspiration in the next sections. The next article discusses criteria useful in making a proper country selection.

 

The New Chiropractic Pioneers – Part 3

It may come as a shock to our young or new people to the profession that chiropractic is only established in a handful of countries (USA, Canada and Australia and a few in Northern Europe). Although there are one or more DCs in some 90 countries, only 30 have laws that recognize chiropractic as a legitimate profession. Yet 65 countries have only one DC for every 100,000 to 2,000,000 people. There are 160 countries without DCs of which 120 are too poor, too small or too dangerous to try and establish practices.

Needless to say, making the right choice in selecting a country to open a practice is a serious matter. How do you select a country that is ideal for you?

Putting things in simple terms, the greater the familiarity and the genuine affinity between the doctor and the patient, the better the choice. Blood and heritage hold the strongest bonds between people. Familiarity includes language, physical similarities and common interests. Ask yourself this question: “What group of people do I hold dear to my heart?” Unless you have actually traveled to a country or have personal experience with that culture it is difficult to know if you can genuinely care about them.

Once you can honestly say to yourself that there is a love for the people of a particular culture or country you will have begun to narrow down your choices. The next question to ask yourself is: “Can I make a decent living in that country?” The demographics (population and economy) will indicate your potential for success if you are willing to work hard.

How do you determine these facts? Go to a local bookstore and buy a travel book on the country(ies) of interest. There is a wealth of information there to familiarize you with many facts. Another source is the CIA World Book on line. You can access this link on our website at  under the section called TOPICs (Topics On Practicing International Chiropractic). Be sure to use Internet Explorer as your browser and scan the TIP BOX that can be accessed on the menu page of 24 topics.

Next, take the opportunity to travel or even volunteer in a mission to your country of interest. This will either make or break your decision because it replaces fantasy with facts. It really is your “gut feeling” that will ultimately decide if all the facts are right for you.

Language is also an important factor min your decision-making. Here the question to ask yourself is: “Can I speak or learn to speak the local language?” In some countries like Norway, the Netherlands and Germany you are required to speak and write fluently in their language before being permitted to establish a permanent practice. Many countries are accustomed to having professionals who only speak English, but a doctor must rely on translators. Obviously, it is important for doctors to effectively communicate with their patients. This has always been especially true for the chiropractic practitioner. You will have to be the judge on how critical this issue plays in making your selection.

Let us look at these questions again:

1. What group of people do you hold dear to your heart?
2. Can you make a decent living in that country?
3. Can you speak or learn to speak the local language?

Once you can fully answer these questions to your satisfaction it will become easier to narrow down your choices. After all, you can only be in one place at a time. Why not make a solid decision and plant some deep roots; your future patients deserve that. So does the profession and so do you!

In the next article we will discuss the different opportunities available in foreign practices.

The New Chiropractic Pioneers – Part 4

As a chiropractic student you carry a full plate between classes, studies, clinic, work and what’s left for your personal life. Thoughts about the future are overshadowed by the demands on your time in the present. Besides, it’s kind of hard to envision what you have not yet experienced… being a doctor in practice.

Whatever motivated you to enter the chiropractic profession may or may not be enough to feed your passion. As a practicing DC of over 20 years I am thankful for the ever-consuming love for my patients that continues to sustain me; even stronger today because the dream of a practice has become a reality and a lifetime purpose. As you think about graduating there is a sense of anticipation and even some trepidation. The unknown, “will I make it?” is sometimes a little scary.

Fear if the unknown is easily conquered with knowledge and experience. If you do not have a close relationship with your field doctor, the DC back home who encouraged you, find a local DC whom is willing to be your mentor, or at least let you spend a little time in a real clinic and observe what it’s all about.  See yourself in that role and visualize your ideal practice… a day in the life of Dr. (you). It’s important to dream because it gives meaning to your work and raises your commitment to strive and do your best. So, do a little day dreaming.

OK, stop right here! Before we go any further. In that daydreaming, where are you placing that clinic… in your hometown or in another location? If you see yourself in a practice outside of the United States or Canada, the rest of this article will be of particular interest to you. (If not you’ll still get something out of it.)

The Chiropractic Diplomatic Corps is an organization that encourages doctors to establish foreign practices. We want you to seriously consider pioneering chiropractic in another country or to join the growing number of DCs in the countries of your heritage or interest. Not everyone can go straight from graduation to a foreign practice; so, we would like to help those who can to find their way.

There are two topics that we will cover here: 1. Seeking opportunities and 2. Making contacts.

If you already have a pretty good idea of which country you’re heading for, all you need is to know what opportunities are available. There are three types of opportunities:

1. Temporary or locum assignments that last 3-6 weeks or months.
2. Associate with an established practice for a few years.
3. Starting a practice from scratch (or purchasing an established one).

There are very few requests for a DC right out of school to come and take over a practice while the regular doctor takes a leave. There are a growing number of countries that require 1-2 years of internship before qualifying for licensure. We have heard of a few situations where a doctor places a new DC in an established satellite office. These are great opportunities to gain experience in exchange for a subsistence salary, but not enough money to meet student loan payments in US currency. The good locum positions generally go to a semi-retired DC and that makes a lot of sense from the resident doctor’s perspective.

An excellent choice is to seek and associateship for 2-5 years. You could be an additional DC in the clinic or the doctor in a satelite clinic. At the end of your term you may take over a clinic, buy another one or be able to start your own from scratch. As a new graduate you stand a better chance of getting hired if you are willing to stay for several years and if you apply in person. Yes, that means go to the country and meet the doctor in a personal interview. Actually, this becomes a two-sided interview and you get to see for yourself (not sight unseen) what you’re getting into and with whom.

If you have a personal relationship with a DC in practice in your country of interest you could discuss some arrangement that is mutually beneficial. If you have no contacts you need to make inquiries with the local DC representatives. Our website has this information on every country with an established National Association and can be found in the section called Global Statistics.

yuNew graduates who can financially start on their own have either been in business before and can rely on their past experience, or have a lot of support from family and friends to guide them in those first years. Starting your own clinic doesn’t mean “going it” alone. In closing, it is important to realize that the question of experience is not a casual topic since new doctors inevitably make more mistakes. When you are the only DC in the area… YOU are Chiropractic!

Students and doctors that are listed with our Foreign Service Registry are now able to receive a monthly bulletin on International Topics.

By Michel Tetrault, DC

– A brief editorialized review of the recent WHO publication “Legal Status of Traditional Medicine and Complementary/ Alternative Medicine.”

The World Health Organization (WHO) has released its 2001 “Worldwide Review” of 124 countries and their efforts at recognizing the value of healthcare services that fall outside the recognized and highly regulated Imperial or western medicine. In this work they elected to include the current status of the chiropractic profession in each country, wherever information was available.

A notable quote from the publication can be found on page 4, where it states: “The World Health Organization encourages and supports Member States to integrate traditional and complimentary/ alternative medicine into national health care systems and to ensure their rational use.”

We are thankful for the efforts of the WHO to objectively report the representation of chiropractic in the world today in its publication. Although there may be sound arguments against including chiropractic in these other classifications, nevertheless, the WHO has elected to include the information it has received on chiropractic in its Traditional Medicine (TM) and Complementary/ Alternative Medicine (CAM) report. Chiropractic is unavailable in 160 countries and so when one looks at the lack of chiropractic presence in the majority of the world’s countries, it is understandable for the WHO to lump this emerging and growing profession at this time in history within its existing administrative capabilities. Credit is due to the major contributing organizations, in particular the World Federation of Chiropractors (WFC) and Life University for their persistent presence at the WHO over the past two decades.

The following table is a snapshot of the 189-page document outlining to what degree we find TM, CAM and Chiropractic integrated, included, tolerated or unrecognized by the respective countries in each of the 6 major regions of the globe. What does stand out is the sheer lack of exposure there really is for chiropractic in comparison to the other non-medical healthcare systems we find throughout the world and something to take serious note of.

(TM and CAM disciplines)                                         (Chiropractic Recognition)

REGION  (T#)	IG	IC	TO	UR		0	A	B	C
Africa  (44)	19	15	2	8		38	0	3	3
The Americas  (19)	9	5	3	2		12	0	3	4
E. Mediterranean  (12)	1	3	1	7		9	0	1	2
Europe  (21)	1	17	2	1		10	3	4	4
SE Asia  (9)	7	2	0	0		9	0	0	0
W. Pacific  (19)	5	14	0	0		13	1	2	3
Totals	42	56	8	18		91	4	13	16

TM & CAM:   IG = Integrated         IC = Inclusive              TO = Tolerated             UR = Unrecognized

Chiropractic:  0 = Nothing Official    A = Included in CAM      B = Partial Registration  C = Fully Protected

The majority of the non-western countries that comprise 2/3rds of the world’s population are poor and can little afford Imperial medicine and as such is where the poor see their traditional healers. In looking at the regions with the greatest utilization and acceptance of TM and CAM services such as SE Asia, W. Pacific and Africa, TM and CAM are strongly accepted by their governments and integrated in national healthcare policies. This is in direct contrast with the European and E. Mediterranean regions where laws continue to allow the monopolization of Imperial Medicine at the exclusion of all others.

One of the significant values of this report for the chiropractic profession is the specific information provided about the existing non-medical services available to the average citizen in their own country. Even though there is no duplication of chiropractic services by any other provider, we have to realize that in the absence of chiropractic services people have to go somewhere for care and when they do they frequent their TM and CAM providers. Having the knowledge of what services are already available certainly is important to know, as more and more chiropractors are willing to pioneer their profession abroad.

One difficulty faced by the pioneer chiropractors is the trend to lump chiropractic as just one more manual therapy and the challenge to educate the community about the difference offered by chiropractic care in contrast to local manual healers… i.e.: that DCs are college trained Primary Portal of Entry health care providers that utilize non-allopathic, non-drug methods of assisting their patients in regaining and maintaining their health.

The publication “Legal Status of Traditional Medicine and Complementary/ Alternative Medicine” may also serve as a useful reference text in the development of a country strategy by the chiropractic leadership. This can go a long way to understand where the prospective allies and opposition may exist in planning efforts to legitimize the chiropractic profession in a given country. There is sufficient information reported to better understand where new chiropractic patients have been accustomed to seek care and to direct further studies on these local health care providers.

An excellent example is the study of the Filipino hilots by John O’Malley, DC, PhC extending from 1992 to 1996. His thesis has meticulously detailed the folklore and techniques of these traditional healers who continue to serve their communities today. This study was distributed to the hand full of DCs now in practice in the Philippines, to aid in their understanding of the roles played by the hilots and to foster respect for them. This type of study needs to be repeated in all counties where there are traditional healers and the WHO report does an excellent job of indicating this presence.

Out of the 258 separate countries in the world, 191 have joined the United Nations and the World Health Organization. The fact that 124 countries, about half of all countries, were able to contribute to this report one can attest to the relative value of this document. In developing better ways to effectively nurture the development of chiropractic for the many pioneers that are out there it calls for the chiropractic leadership to maintain a “satelite” perspective. When there are chiropractors in 100 countries today, in comparison to just 20 or 30 just 30 years ago, it becomes important to understand the bigger picture. Thankfully, through continued involvement at the highest levels in global healthcare we are beginning to see the fruits of years of seemingly frustrating efforts.

As readers find themselves attracted to the issues in the globalization of chiropractic it is recommended to also become familiar with the “Global Strategy for Chiropractic” that has been developed by the Chiropractic Diplomatic Corps. You are invited to read this book only available online at www.ChiropracticDiplomatic.com in Adobe format. Copies of the book “Legal Status of Traditional Medicine and Complementary/ Alternative Medicine” is available from the World Health Organization, publication #WHO/EDM/TRM/2001.2.