Succeeding in the International World
INTERNATIONAL CHIROPRACTIC
By
Laura S. Dowling
DC
After graduating from Life University in 1997, I decided to locum and work from home in order to care for our two daughters while my husband completed medical school and his family practice residency in New Jersey. We had always planned to return to his home, the beautiful island of Bermuda, but there was much trepidation about whether I would be able to resume full-time practice and appropriately care for patients.
When the time came, the excitement of the new adventure was quickly replaced with the daunting actuality that it had been five years after graduation and starting a new practice in a completely new country had its challenges.
Much was unknown about practicing in an international arena, so a plan was needed. Thankfully, a course taken at Life University prior to graduation afforded me a rudimentary business model. The concepts were enough to take to the local small business administration for further retooling and a much-needed foundation. I had the opportunity to purchase an existing office and adapted the initial business model to suit the new practice.
Upon opening doors in 2002 at Bermuda Chiropractic Health Centre, I faced many obstacles and challenges unique to practicing internationally. Chiropractic was lawful but unregulated in Bermuda, and although the chief medical officer verified credentials such as NBCE qualifications and any overseas licenses, there was no legislatively defined scope of practice. Malpractice insurance was difficult to obtain and not required by law.
Access to diagnostic imaging such as X-ray and MRI technology, which were deemed standard in the U.S., was very limited. Diagnostic imaging, and to some extent chiropractic care itself, required a medical referral to have insurance reimbursement.
In Bermuda, 80 to 90% of people were insured because legislation required employers to provide some level of health insurance. The idea of introducing an out-of-pocket payment concept, at the time, seemed untenable, particularly with chiropractic in its fledgling state. Health insurance reimbursement was on a set feefor-service schedule but, on average, only covered 12 visits per annum, irrespective of outcomes or the services provided.
At the time, there were few chiropractors, and whether for good or bad, government regulators, healthcare insurers, the medical community, and, most importantly, patients were holding the actions of a few doctors as the standard for all chiropractic care. It became abundantly clear that whatever I did must significantly improve patient outcomes, be cost-effective, and could help shape the perception of chiropractic for an entire population.
A small handful of colleagues and I formed the Bermuda Chiropractic Association in an effort to form a cohesive voice for promoting and protecting the profession. While uncertainty remains regarding chiropractic’s role under Bermuda’s future health care model, BHP 2020, significant progress has been made to date. We’ve worked to develop legislative guidelines, a scope of practice, and improve public awareness. The progress has been slow and, at times, arduous.
Since 2002, the number of chiropractors has tripled; chiropractic no longer requires a medical referral for reimbursement; access to imaging has improved; all major insurers cover care; there is an improved payment schedule; we have direct portal of entry status; and most chiropractors enjoy a referral network with medical physicians and other providers. While there is still much work to be done in terms of improving professional standards and developing public awareness, significant strides have been made against what often seemed like a rising tide.
In addition to the overall professional logistics of international practice, there were also limitations involved in day-to-day management, such as the cost of importing products and services; generating a consistent stream of ancillary revenue; finding companies that will ship to and support your international practice; and keeping current with continuing education that will improve the standard of care and add value to each patient visit.
In modern medicine, where there are a myriad of techniques, tinctures, and tools, it was evident that I needed to clear through the noise and find what worked, how long it had been working, and if research supported the claims. By necessity, I developed a no-frills version of patient management that valued time-honored principles, such as taking the time to listen and gather a comprehensive subjective history, which included quality of life, activities of daily living, social and emotional barriers to health, and learning the patient’s goals for care. Often, patients are objectively improving, but if their reason for seeking care hasn’t been addressed, they may deem the care unsuccessful. Outcome-oriented care meant that each visit was capitalized.
The often-dismissed postural and gait analyses became an imperative adjunct to traditional orthopedic and neurological tests. I was grateful to find Foot Levelers, whose principles resonated with my biomechanical approach and met the criteria of being research-driven. I recognized that technology doesn’t replace good doctoring but enables it.
The Foot Levelers digital scanning technology offered an objective biomechanical evaluation and serves as an effective patient-education and report-of-findings tool. The graphics give a visual depiction showing how musculoskeletal disorders are the consequence of abnormal loading and postural faults, which begin at the knees and feet. We don’t get arthritis, osteoporosis, or back pain. These conditions develop over time due to biomechanical adaptations explained by Wolf’s law and its inverse, senescence. In time, a greater understanding of posture, biomechanics, and the consequences of modern lifestyles unfolded. It was noted how sedentary habits, smart technology use, and the resultant postural distortions, as seen in forward head posture (FHP) with upper-crossed syndromes (UCS) and lower-crossed syndromes affect populations in Bermuda and many other communities around the world.
The world has become a much smaller place, and while the logistics, culture, and local practice parameters may change—ranging from a therapeutic model to vitalistic principles—all populations can benefit from chiropractic care.
According to the Chiropractic Diplomatic Corps Global Professional Strategy for Chiropractic, “There are now chiropractors in 123 countries all over the world where most (74) have only one chiropractor for every 100,000 to 10 million or more people.” Here, the profession is in its infancy, where a handful of doctors have the responsibility of developing the profession in their country, as is happening in Bermuda.
As healthcare providers with a primary focus on the nervous and musculoskeletal systems, chiropractors are poised to catapult the growth seen in North America on an international scale. The 2017 Global Burden of Disease Study (GBD), as reported by the WHO, noted that musculoskeletal conditions are the leading contributor to disability worldwide, with low back pain being the single leading cause of disability globally. It was also noted that signs of degeneration begin early in life are present through the course of life, and that there are between one in three and one in five people (including children) globally who live with a musculoskeletal pain condition in all regions of the world.
What was extremely significant is that the GBD 2017 also found that musculoskeletal disorders (MSD) are linked to depression and place patients at an increased risk of developing other chronic health conditions. This finding confirms the need for the continued international expansion of chiropractic. Organizations like the World Federation of Chiropractic and the Chiropractic Diplomatic Corps offer extensive information and support for doctors wishing to practice internationally. Companies, such as Foot Levelers, provide comprehensive ongoing support, including continuing education, current research, low-tech rehab protocols, and the social media marketing tools needed in an international practice.
As chiropractic continues to gain recognition, it may well be that the growth seen in Bermuda is a reflection of a broader global movement toward nonpharmacological approaches to care. Timeless principles, modern technology, and supportive partnerships are key for succeeding in an international chiropractic office.
Dr. Laura S. Dowling has practiced in Bermuda since 2002. In 1997, she received her Doctorate in Chiropractic from Life University, graduating magna cum laude. She has written numerous healthcare articles and has been featured in several publications. She is certified by the Academy Council of Chiropractic Pediatrics (CACCP), is a certified structural management provider (CSM), a qualified researcher with the National Institutes of Health (NIH), and an internationally sought-after speaker on women's issues and chiropractic care. Dr. Dowling is a member of the International Chiropractic Pediatric Association and is vice president of the Bermuda Chiropractic Association.
https://www.chiropracticdiplomatic.com/legal-requirements-for-practicing-abroad/
