Ethics, Morality, finding a good Musculoskeletal health professional
During the author's career in the musculoskeletal therapy field, there have been occasions when it was impossible to see a specific new consumer/patient due to geographic location or other prior commitments. Equally, consumers have frequently asked who would be the best person for friends or relatives to see in other parts of the country or world. One might think that finding a good health professional is relatively simple, but sadly this is often not the case. The author has written this article to help consumers make better-informed decisions about their health choices. Furthermore, the author has seen an alarming rise in targeted marketing campaigns aimed specifically at primary care practitioners, their practices, and with an emphasis on rapidly increasing consumer/patient numbers. Many of these marketing schemes utilise extremely questionable moral and ethical practices, which are highly likely to breach professional codes of practice and ethics. It is equally concerning that some operators of these marketing schemes are using video testimonials from supposed Allied Health Professionals on how effective the systems are at booking lots of consumers using a simple script. Again, the clear focus is on money, not the consumer/patient. The critical overriding takeaway from this article is:-
The Musculoskeletal Profession
As with all professions, there are "good" and "bad" practitioners. The Musculoskeletal - MSK field is no different, and being "good" or "bad" is not necessarily an indication of success or failure. Some highly successful practices within the Musculoskeletal - MSK field operate dubious/unethical practices until they get caught.
There is a wide range of disciplines within the Musculoskeletal - MSK health field, with varying educational requirements, scope-of-practice and professional status. Some of the more commonly known practitioners/therapists within the MSK field include (purely in alphabetical order):- Chiropractors, Exercise Physiologists, Massage therapists, Musculoskeletal Medicine Doctors, Myotherapists, Orthopaedic Surgeons, Osteopaths, Physiotherapists, Podiatrists, Sports Therapists. There are also countless other less well-known practitioners, treatments and techniques, some with awe-inspiring and scientific-sounding names, usually encompassing words like Bio, Neuro, Physical or variants of Spine. Chiropractors or ex-Chiropractors have developed many of these techniques, and the similarities are often uncanny. Practitioners may use Chiropractic drop-tables, quote inspirational Chiropractic quotes and similarly apply techniques to diversified Chiropractic techniques. However, such procedures are unregulated, unlike the Chiropractic profession, and the training is considerably less. It is important to remember that anybody can set themselves up to work with consumers within the musculoskeletal therapy field and even invent a technique with little to no relevant training or education. Hence, the saying "buyer beware" is very apt, and consumers should do their due diligence. As for which practitioner or therapist is the best, there is no specific answer to that question, so consumers should not just fixate on just one profession to solve any problems. However, there are cases where a particular profession is required, such as when surgical intervention is needed. Fortunately, a conservative treatment approach works in most cases, and surgery is in the minority of situations.
Equally, several factors influence how each practitioner works. Practitioners can be affected by personal interests/experiences, the academic institution they trained at, the level of higher education they have, the specific profession they have chosen to train in and a wide range of other factors, including behaviours. Hence, just because two professionals trained at the same academic institution does not mean they will work (behave) in the same way. Typically, if a consumer/patient has a bad experience with one or two individuals from any given profession, that can lead to the consumer/patient effectively writing off the entire profession.
Musculoskeletal profession training and education
The base training and education for Allied Health professionals working within the MSK field is more in-depth than that of Myotherapists and other Soft-Tissue Therapists. However, the behaviours associated with how a practitioner then utilises knowledge within a consumer/patient context can significantly impact consumer/patient outcomes. Chiropractors, Physiotherapists and Osteopaths are required to complete degree and or Masters level qualifications. Other soft-tissue therapists may have to complete an IV Certificate, Diploma or Advanced Diploma in the case of Myotherapists. Based on the author's experience teaching, there can even be surprisingly different levels of knowledge between students from various training providers and yet at the same academic level of qualification. It may be surprising to hear, but the author is aware of cases where practitioners/therapists have been using techniques they are not qualified or trained to use. If somebody is unqualified, there is no way they will be covered by insurance and be breaching any professional registrations.
Equally, there are many patented and or trademarked therapy techniques out there. Just because something is patented or trademarked does not necessarily mean it is better. It is more a case of protecting intellectual property, which has financial value and providing training can prove extremely lucrative. Some such techniques require practitioners to complete the initial training and further yearly continuing professional development/education. By fulfilling the annual, bi-yearly or tri-yearly requirements, practitioners can utilise the trademarked technique name and appear on the relevant technique providers register. The issue of practitioner/therapist skill qualifications or currency is easily illustrated with a simple example:-
Active Release Technique (ART®) is a reasonably well-known soft-tissue therapy technique with a certified practitioner register. A simple local search for Brisbane and Active Release Technique (ART®) on a search engine highlights many practitioners. However, if one searches the ART® Certified Provider register on activerelease.com, far fewer ART® Certified Providers appear within the same geographical (Brisbane) area. Such a situation raises legal and ethical questions for those practitioners claiming ART® Certified Provider status. There may even be potential insurance issues for not maintaining the particular techniques certified provider status. Such a situation may be a genuine mistake or a sign of dubious practices. There is no harm in asking to see a practitioners qualifications and other relevant credentials, and consumers should carry out due diligence. That said, as is covered shortly, professional registrations and memberships have stipulations governing acceptable qualifications and other annually recurring criteria.
Although education level has relevance to finding a good professional, it takes no account of how one applies it. Equally, some practitioners only complete the bare minimum yearly continuing professional education and view it as a chore. For example, a massage therapist could have far more experience and undertaken vast amounts of additional relevant training when compared to another allied health professional. It is also important to remember there is a significant practical element to treating within the musculoskeletal field. One could be academically brilliant and yet have a terrible "consumer/patient bedside manner".
Regulation and Professional Associations
Allied Health Professionals operate with legally protected titles and are regulated, which offers an additional level of protection to members of the general public. Regulated professionals have to meet set yearly requirements to maintain their practising status, including yearly continuing professional education, code of conduct/practice, ethical considerations, insurance requirements etc. Regulated professionals can face disciplinary councils, have restrictions placed on their practice or be stuck-off in the most serious of cases.
It is straightforward for consumers to carry out due diligence and check the registration status of a practitioner or therapist by simply searching the relevant body's register. Regulated professions have searchable records, as do professional associations. Surprisingly, some therapists will tell people that they are regulated health professionals, such as a Chiropractor, Physiotherapist/Physical Therapist or Osteopath. Regulated health professionals will be on the relevant regulator's register, and it is illegal for a person who professes to be such if they are not on the register.
Myotherapists, soft-tissue therapists and other professionals working within the MSK field tend not to be regulated. That said, reputable professionals are likely to hold registrations with relevant professional bodies. Like regulated professions, professional associations operate similar yearly requirements for registrants and can discipline or deregister practitioners who fail to meet the annual requirements. As with regulatory bodies, membership of a professional association(s) offers some level of confidence and protection to members of the general public regarding individual practitioners. The author would advise that consumers seek out people who are registered with and or regulated. Both offer the consumer/patient some form of protection and recourse if needed. Forms of accountability are highly relevant in light of some of the marketing practices targeting health professions.
Recommendations and reviews
Although personal recommendations and even online reviews can be helpful when finding a good practitioner, there are things to consider. Consumers need to be comfortable with who they see and how that practitioner works with them. We are all different, and what works for a friend or relative may or may not work for us. Personally, the author would go with a personal recommendation from a friend or relative over online reviews. The author has treated thousands of people over the fifteen odd years he has been in practice, and very few people write online reviews. The simple reason for this is that it takes time to do this online, and it is far easier physically telling friends, relatives or posting something on social media.
The other more severe issue with online reviews is that there are many fake reviews out there. Some unscrupulous companies offering web marketing services have written counterfeit reviews for products and services. Such issues do not just relate to the large well known online retailers. The author has previously seen some very dubious reviews regarding professionals within the musculoskeletal field. Typically, the reviews were extremely short, very positive, with little detail, and unusual posting patterns. The chances of 30-40 consumers all writing short reviews on the same day or over a few days and then nothing for months is highly suspicious, especially when the pattern repeats.
Marketers have used video testimonials from paid actors and genuine customers for years due to the powerful, influential effect on people. Such practices often go hand in hand with before and after pictures as evidence, which are incredibly subjective. Similar video reviews exist within the Musculoskeletal health profession, either from alleged "happy consumers" or "allied health practitioners", as mentioned at the start of this article. As a health professional, encouraging and then posting testimonials of consumers raises substantial ethical and moral concerns. Again, who's interest is at the heart of getting a consumer/patient to record a video testimonial and then post it for the world to see?
"Award Winning"??? and Vanity Awards
Besides, reviews "Award Winning" may appear in descriptions of various musculoskeletal professional's websites or internet search results. Some awards may be genuine and professionally relevant, while others are not. The author has some experience with such awards after being contacted about winning one on multiple occasions.
The awards always had a common theme of a small and usually geographical location, category and sometimes class. Effectively, the narrowness of the criteria above made it clear one would win the award. Advertising legislation in most countries prevents a company from buying or selling awards due to the misleading nature of such behaviour. However, marketers have found a way around this. In essence, one has to pay to attend an overpriced and ticketed black-tie gala event to get the award. There are usually various paid options around publicity packages too. Receiving such an award would have been morally and ethically questionable and misleading to the general public. Hence, it is always worth checking why an award was given, by who and for what? If members of the public feel that a particular award is misleading, then one should report the matter to the relevant authorities.
Good and Bad practitioners/therapists
In essence, "Who's best interest does the practitioner have at heart, theirs or yours?" Bear in mind, codes of ethical practice for professionals holding registrations with regulators or professional associations have a consumer/patient-centred focus. If the author were going to see a musculoskeletal practitioner, he would expect to see a marked change in his symptoms within three treatments and provided he followed aftercare advice. If he had not seen improvement within a three treatment timeframe, he would find another practitioner.
Good practitioner behaviours
Good practitioners will have a consumer/patient-centred focus, putting the consumer/patient at the heart of everything they do, not their bank balance or ego. The consumer/patient-centred principle applies from the initial consultation processes and throughout any treatment plan if one is warranted. A good practitioner will take a detailed history and time to assess the likely cause of the consumers' symptoms and other health-related factors.
Empowering a consumer/patient involves providing a detailed explanation of what is going on (symptoms), why it is going on (injury mechanism), understanding what the consumer/patient is looking to get from treatment (goal), agreeing on a plan of action to achieve the consumer's/patient's goal. Empowering is a process enabling the consumer/patient to control their treatment/destiny via a combination of education, self-management strategies and professional support if needed.
Consumers need to understand that treatment is a collaborative approach, and a good practitioner will actively involve consumers in the treatment process. Consumers should be given some aftercare advice or homework during any treatment plan, and following any such advice is equally important to any treatment provided. Aftercare advice could include one or a combination of prescriptive exercise, habitual changes or self-treatment.
Bad practitioner behaviours
For this article, a bad practitioner is one whose actions do not have the consumers best interests at heart. Such therapists can often use a combination of unethical and immoral practices, all of which appear designed to disable (build consumer/patient reliance) rather than empower the consumer/patient. Consumers should be highly mindful of practitioners exhibiting any behaviours designed to disempower them and report them where applicable. If one encounters a variety of the following behaviours as a consumer/patient, one might be with a bad actor within the profession.
Marketers have utilised "Emotional Manipulation" to get consumers to part with their hard-earned cash for millennia, and such techniques have developed over time. Emotional manipulation is at the core of "bad practitioners" operations, and there are many tell-tale signs of such behaviours and practices. Although reviews and awards may be genuine, it is better to perform due diligence and investigate further. Marketers hope to use emotional manipulation to create a positive impression within the consumer's/patient's mind and bypass any other more detailed thought process. Such a process makes people invest the time in seeing the practitioner first, at which point other techniques may come into play. Once somebody has emotionally invested in a process, it is much harder to extricate themselves from that.
High-pressure sales tactics
During the authors time in practice, he has heard consumers describe some extremely unsettling high-pressure sales tactics they have encountered. Typically, such consumers had responded to a supposedly hugely discounted (70-80%) initial consultation rate advertisement. Such offers invariably involved various patented or trademark named scans and or x-rays and glossy reports of findings. Just because something is patented or trademarked does not mean it has any clinical relevance for treating a consumer/patient. However, glossy, colourful images can make a report look better by an unethical practitioner? That said, there are cases where medical imaging (MRI, X-ray, CT, Ultrasound) may be warranted.
Bundling "free" add-ons
Many of these sales techniques are frequently used on television shopping channels to make the shopper feel like they are getting lots of extra added value products for little or nothing. For example, a practitioner could offer lots of different scans or treatments, each with a supposed stated monetary value and slowly adding up to $290. Whether or not anybody has ever paid $290 for all of the "special" bundled add-ons is open to debate and hard for a potential consumer/patient to verify. Such offers are for a limited time only, and one can get all of the bundled assessment and or treatment for $99. Such an offer may even combine with "scarcity" and "exclusivity" to include some other supposed value item for the first 20 new consumers only. Many tried and tested high-pressure sales and marketing techniques work on human psychology and should have no place in ethical healthcare, yet disturbingly they are far too prevalent. Such a technique also involves another powerful method of emotional manipulation, "reciprocity". If we are given something for free, we usually feel indebted to the other person. All of the free add-ons within such offers play on manipulating that natural emotional response.
Statements "Hundreds of consumers successfully treated"
Equally, a marketer or health professional could make a statement, which they expect potential consumers/consumers to take at face value. Typical statements might include "hundreds or thousands of consumers successfully treated by a given treatment or technique". The simple question is "Where is the evidence?". Again, one should be mindful of reviews and ideally should try and find multiple sources to confirm claims, especially those in social media advertising. Sadly, social media is often a hive of misinformation, due to a lack of regulation.
Plausible similar injury story
Sometimes marketers will use a plausible story that potential consumers can personally relate. For example, a practitioner may have a tale of suffering from back pain or similar from early in life or due to injury and then found some treatment that changed their life. Such a story could be genuine, though if the practitioner in question uses other potentially "emotionally manipulative" techniques, one should be wary. Having a similar story to potential consumers creates a form of "common ground" or bound and reduces the perceived risks of finding a practitioner who can achieve the consumer's/patient's goals. Such a process occurs in the consumer's/patient's mind before they invest the time and effort of seeing the practitioner.
Negative Narrative or terminology
Clever use of negatively worded terminology and fear-mongering can further disable a consumer/patient and make them feel that they have no choice but to see the therapist. Creating fear within a population is a long and well-established way of exerting influence over individuals or groups. The process is often performed gradually over time. Such practices are more evident now than ever before, in part due to the advent of social media and the ability to rapidly disseminate information. The author has seen vitalistic or subluxation-based chiropractors using the term "spinal decay" in the health profession. Spinal decay does sound terrible, and the various posters and models of vertebrae in various states of "decay" do not help matters. However, "spinal decay" by definition is not a medical condition. The use of a negative narrative is not just restricted to the Chiropractic profession either. Hence, beware of the terminology used by a practitioner. Is the language in use helpful to you, the consumer/patient or not?
Large treatment blocks
Being asked to sign up to large treatment blocks and being offered a supposed discount for doing so is not in the consumer's/patient's best interest. Such behaviour is generally frowned upon by regulators but not banned. Consumers may feel under undue pressure to sign up when they attend their report findings meeting and is disempowering by nature. Consumers can effectively become financially and psychologically locked into a protracted treatment process and reliance on the practitioner. Practitioner's using large treatment blocks should provide consumers with details of how they can exit such plans and what costs they may incur for doing so.
The other more prominent issue with large treatment blocks is that they zero account for individual consumer/patient differences. How a consumer/patient responds to any given treatment can vary primarily due to individual consumer/patient differences and following aftercare advice. There are occasions where a consumer/patient may require a single treatment, though this is not hugely common. The author has never seen a consumer/patient who would have benefitted from a large treatment block to date.
Multiple treatments per week
Some practitioners operate multiple weekly appointments with consumer's/patient's typically two-three appointments a week for "X" number of weeks. Such treatment frequencies tend to occur with large treatment blocks. To date, the author has never needed to treat a consumer/patient more than twice in any given week, which is a rarity. Occasionally, consumers have had a setback or a different injury during a treatment plan, thus requiring additional treatment. Typically, the author has spaced consumer/patient visits between seven and eight days apart due to aftercare advice and tissue adaption (see article).
It is very disempowering to encourage consumers to sign up to large treatment blocks combined multiple (two-three) per week. Actually, such a regular frequency is effectively conditioning the consumer/patient, forming a routine and building reliance on the practitioner.
Free weekly wellbeing / consumer/patient information events
Fortunately or unfortunately, the author has never had the pleasure of attending one of these such events. The author cannot see any rational or clinical reasoning behind consumers attending such general and non-specific weekly wellbeing events. Such events appear to reinforce the consumer's/patient's decision to continue with "family wellness" treatment based on conversations with those who have attended such events. If valid, this is particularly concerning and unsavoury behaviour and equivalent to how a cult recruits, retains and grows its following. Much like the multiple regular weekly treatments, attending a weekly event with other consumers builds routine and helps condition somebody. The conditioning effect is even more potent because other consumers attend the same weekly event, which can add to any perceived legitimacy. Such events are very different to support groups, as support groups focus on the individuals attending them and not the financial interests of a practitioner/clinic.
Payment plans and credit agreements
A practitioner suggesting a payment plan or credit agreement should set alarm bells off in any consumer's/patient's head, especially when combined with block treatments and discounts. Such a plan, by its very nature, financially and psychologically ties a consumer/patient into prolonged treatment. Also, a consumer/patient has to make a conscious effort to cancel and extract themselves from such agreements. Much like a subscription, it takes a conscious effort for somebody to cancel one, and marketers know that.
Unnecessary chargeable products or procedures
Some practitioners charge additionally for consumables used during treatment, such as needles, tape etc. Such practices can incentivise unethical practitioners to provide treatments that produce the most financial gain rather than what is in the consumer's/patient's best interest. Equally, some practitioners sell supplements as part of their treatment plan. Personally, the author would rather see an expert, such as a higher education qualified professional (nutritionist or dietician), rather than somebody who may have studied a nutrition module. Charging for unnecessary imaging has historically been an issue too.
Inspirational Quotes (Good or Bad)?
Some musculoskeletal health professionals have excellent looking clinic setups, displaying inspirational quotes inside and outside the clinic. Inspirational quotes can undoubtedly empower the consumer/patient on the face of it. However, it is essential to look beyond the inspirational quotes and see what is happening within the clinic environment. It is always better to judge by actions rather than just words. The words may sound empowering, but is everything else designed to build reliance and disempower you, the consumer/patient?
There are many examples of such quotes, including "The greatest wealth is health" (Roman Poet Virgil). An unscrupulous practitioner could easily use such a quote, along with sales techniques, to justify a long and expensive treatment course. Logically, most people would agree that you cannot put a price on good health, which is the starting point for said unscrupulous practitioners. If one logically agrees to such a statement, it is much harder to psychologically question the potentially high cost of an excess treatment plan. Such a situation is especially true if the practitioner subsequently raises the consumer's/patient's point about agreeing that you cannot put a price on health.
The article was written by Terry Davis MChiro, BSc (Hons), Adv. Dip. Rem. Massag., Cert. WHS.
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About the Author
As of December 31st 2020, the author chose to leave the Chiropractic profession and pursue studies within the Physiotherapy field. He no longer works as a Chiropractor and works as a Myotherapist in Morningside, Brisbane. The author possesses an unusual background for somebody who trained as a Chiropractor (McTimoney). His education, training, and practical experience span over two decades and relate to both health's physical and mental aspects. He has also needed to push his own body and mind to the limits of physical and psychological endurance as part of his time serving in Britain's elite military forces. His education includes a bachelor of science degree in Business Management, with a specialisation in psychology and mental health in the workplace, an Integrated Masters in Chiropractic, MChiro and a multitude of soft-tissue therapy qualifications (see the about section for more details). His soft tissue qualifications range from certificate level right through to a BTEC Level 5 Advanced Diploma in Clinical Sports and Remedial Massage Therapy. Terry also has extensive experience in security, work, health and safety and holds relevant certifications. He has also taught as a senior course coach at Advanced Diploma level (Myotherapy / Musculoskeletal Therapy) in Australia, both theoretical and practical aspects including advanced Myofascial Release Techniques and has certification in training and assessment. Terry will have taught many of the first students to train as Myotherapists in Brisbane. Terry's combination of knowledge through education, training, elite military service, and personal injury history has paid dividends for the consumers he sees and has treated over the last 15 years. He has extensive experience treating chronic pain and work and sports-related musculoskeletal injuries. Terry is still very active and enjoys distance running, kayaking, mountain biking and endurance-type activities.