The definition of a chiropractic -- at least the Greek one -- tells you all you need to know about the highly-educated medical professional. "Chiro" means “by hand,” and “practice” translates to practice. "Ironically, if you walk into a treatment room, you’ll see computers, and our EMR (electronic medical record) system, and all of the diagnosis and treatment codes are computerized now," Robert F. Leibmann, an Arizona-based chiropractor, told ValuePenguin. "But as it turns out, the actual application of the chiropractic, for me, had changed very little." We asked Dr. Leibmann about his field and his path into it.
How did you get into the field and why?
I started in a standard pre-med background at the State University of New York. I was working towards, and ultimately received, my bachelor’s degree in biochemistry. I had applied to several allopathic and osteopathic medical schools and was accepted. I had not decided a speciality yet but was leaning toward orthopedics.
Concurrent with that, I had had a pretty serious car accident, was in the hospital for several days, and had a lot of residual musculoskeletal problems that would not resolve with standard medical care. By chance, I went to a chiropractor with a friend of mine, who went to one on a semi-regular basis. I liked the explanation of how the profession worked, what he was going to do, and ultimately he abated my pain. So from that point forward, my career path was set out for me.
I’d hate to say divine intervention, but certainly the path I thought I was on, by chance or by design, forced me to take a left-hand turn, and it’s worked out perfectly.
Once your body healed, how did you set your mind on becoming a chiropractor?
What was fascinating was, other than the initial conversation with the chiropractor that I saw as a patient, it did take a little bit of research on my part while I was studying, finishing up my undergraduate degree. And as it turns out, I had mutual friends that were ultimately ahead of me on that path. Luckily for me, they had done a lot of the homework ahead of time. Fortuitously, I got together with them, and four of us ended up going to the same chiropractic college, in Georgia, together.
The course load there was probably twice as heavy as my undergraduate degree. However, when you have that much work to do in small periods of time, and you’re working with a group of individuals that all have the same objective, you tend to get more work done in less time.
What I learned, once I matriculated, was that most doctorate-level health care degrees are very similar in the first two years. The gross anatomy, the essential nervous system study, the dissection courses, cadaver dissection courses, et cetera, are very, very similar, whether you’re going to allopathic school, osteopathic school, or chiropractic medical school. Biochemistry is biochemistry, and organic chemistry is organic chemistry, no matter where you take it. After the first two years is when you really tend to branch out more into your specific specialty.
Did you gain clinical experience in your third and fourth years?
Yes, over time, much like the standard allopathic, i.e. "MD," path. The first two years are spent in the sciences. You being to segway into more and more internships and clinical time in your third and fourth years. The chiropractic path is very much the same.
The confirmation for me began almost immediately, because I was surrounded by people of like mind. Chiropractors are an interesting amalgamation of science-oriented, health care-oriented people that also have a somewhat holistic perspective of health in general, and musculoskeletal health. So when I began and found myself surrounded by people of like mind, the confirmation of my decision was almost immediate.
To your knowledge, how different is chiropractic education today?
My touchstone, with current chiropractic curriculum, is usually a product of interacting with the young doctors who either intern with my organization or ultimately become employed with our group. I think many things have remained the same. The basic philosophy of trying to help people with their health conditions and musculoskeletal conditions without necessarily resorting immediately to drugs and ultimately surgery has remained the same.
These days, the young doctors coming out of school have a much greater understanding and background in exercise physiology and biomechanics that help as an adjunct to the primary chiropractic care that we administer. That’s a great bit of progression within the profession and ultimately for the community.
Back to your path: After earning your doctoral degree, what came next?
At the time — and this was 25 years ago — chiropractors took parts one, two, and three of the national boards. That was essentially our version of what the medical doctors take, and they call their USMLEs, which are their board examinations. We had three parts as well. Back then, once you passed all three parts of the national boards, you would have to go take specific state board examinations. Every state had their own licensure board.
About ten years after I graduated, they introduced a part four of the national boards, which was a practical exam. Upon successful completion of that exam, you would receive licensure and reciprocity in most states, and that number keeps going up. Ironically, I took the part four examination after having been in practice ten years, simply as a practical matter. In case I wanted to move somewhere down the road, and partially retire, I wanted to have as many options as possible, from a licensure standpoint.
After gaining licensure, where did you gain your first professional experience?
I worked for a gentleman here in Scottsdale, Ariz., who was established, which is often the case with chiropractors. Your internship in school is an internship that teaches you how to be a chiropractor. At the time, our education was lacking in helping with your level of business acumen. Working for another chiropractor would help you, obviously, with your practice skills to see how a practice is run well and efficiently. So I did that for approximately 18 months.
The first thing I learned there was how to be efficient. When you’re a student, and you’re examining a patient, you can spend an hour, two hours with a patient, and do orthopedic tests and neurological tests, X-rays, analyses, and use all that information to arrive at a diagnosis and a differential diagnosis. A good practitioner, who has been in practice a while, has learned to hone those skills. For instance, a good history with a patient might get you 70% or 80% the way to your diagnosis. So listening to the patient, taking a good history -- and doing it in a way that isn’t redundant and repetitive -- helps with your time management. One of the business things — for lack of a better term — was how to deal with patients; how to make sure that they understand what the treatment recommendations are, and make sure there are staff in place to go over the finances and the costs of care, because you want to make sure there are no misunderstandings or discrepancies.
What was the next step toward opening your own practice?
I met a gentleman who had previously had a business partner, and they had a very nice practice set up in a retail center. The business partner had gotten a job as the staff chiropractor for the Arizona Cardinals -- at the time, I believe, they were still called the Phoenix Cardinals. Essentially, half of his practice was vacant. I met him through mutual friends, and I said, “I don’t want to be an employee. I think I can run my own shop, but I prefer not to take on the overhead of an entire practice right away. Can I come in and pay you rent?” We agreed on a handshake, and I started my own practice.
The gentleman who I came and worked with has since semi-retired. He is now the staff chiropractor for the Cancer Treatment Centers of America in Goodyear, Ariz. He has since left, and I took over the entire building. But it’s the same location And I have four more locations now. But at this point, I’m at the same desk I was back then.
What did you learn about opening up your own practice?
My experience starting my own practice was an eye-opener. For students reading this, it’s fun, it’s challenging, and it’s a lot of work. I would say that it is very much a function of shoe leather. Find a spot, open your practice, and then you have to be confident enough, and sure of yourself enough, to basically go out and run for mayor. Meet everyone in town, and let them know you’re there and you’re available to them as a practitioner that really wants to help people. Sitting in your office, playing minesweeper and waiting for the patients to come, will never work.
I have a lot of friends who are family practice doctors, and I get a lot of referrals from family practice and internal medicine, et cetera. And they are friends of mine, and we talk about these topics. When they started in practice, they were dialed into a close-knit and hospital-based community, where the cross-referral system -- that network -- is really already set up for them. Someone like a chiropractor or a dentist, or someone who’s coming on, isn’t dialed as much into that program, really needs to recognize that the "Field of Dreams" — you know, “If you build it, they will come” — in the real world, doesn’t work. One of the original chiropractors used to say, “The parade can go through town without a band, but nobody would know.” You have to go out and make a little noise.
Things are louder for you with five offices now -- what is a working day in your life like?
I practice several days a week, and as you might surmise, I have a lot of administrative and corporate work to do as well. I’ve surrounded myself with very good people, and delegated a lot of tasks to those people. But I still enjoy seeing patients; it is the most interesting and fulfilling part of my day. With five practices, despite having an HR department, et cetera, there are still fires that, for various reasons, I’m the only one who can put out. So I wear multiple hats. Back in the day it was simply: Come to work from 9 a.m. to 6 p.m., see 50 or 60 patients, and go home. Now it’s a pretty busy workload, seeing patients, and then… it’s spinning a lot of plates, metaphorically.
What’s your routine when a new patient walks into your office?
Once they’ve completed their initial paperwork — and hopefully the staff has encouraged them to do so online — the initial consultation: The patient will meet with the staff, their history will be reviewed and then always the doctor meets with the patient. Much of the information you’ll find about the patient that will lead you to the diagnosis is gleaned in the initial history. A lot of the examination is simply to reinforce that presumption of diagnosis. So they’ll see me first, or they’ll see the staff first, and then they’ll see me for the remaining history and complete examination thereafter, including orthopedic, neurological, X-ray, if necessary. If X-rays are taken, we always prefer to read them first before the patient is treated, for obvious reasons. And then the patient, once the information has been gleaned, we always do some type of treatment on the first day. It’s my perspective that a patient who comes in, in many cases obviously in pain, is looking for some modicum of relief that day. Academically, I’ve heard doctors say, “Well, the diagnostic portion of the interaction occurs on the first day, and have the patient come back for treatment.” I don’t ascribe to that philosophy. The patient’s there, the patient needs help, that’s our job. So they’ll be treated in some capacity that day. Then oftentimes, during their second visit, we will do what the chiropractic profession colloquially refers to as “the report of findings.” Meaning, X-rays will be reviewed, exam findings will be reviewed and discussions had about what, in our professional opinion, it will take to fix their problem.
Part of what we pride ourselves on is having a very co-management philosophy in the practice. In other words, I will tell patients, even preemptively sometimes, “We are going to do our examination, and if I feel you would do better, either being referred back to your PCP, or to a professional of some type…” An example: I had a patient in last week who had a tremendous amount of leg pain. It was my perspective that the pain was not coming from their back; it was coming from their feet. And ultimately, I referred out to a friend of mine who is a very good podiatrist, and the issue was resolved. With that said, most of the time when patients come here — the majority of them because they’ve either been referred by someone else or they’ve had other analysis and treatment — the majority of them we can help. All doctors of all disciplines should be very acutely aware of whether or not the patient is in the right place. I have a very good friend who is an orthopedic surgeon, and he refers patients to me. He says all the time, “The problem is, if all you have is a hammer, everything looks like a nail.” He always steps outside the box and says, “Look, I can’t look at this just from a surgeon’s perspective; I have to look at this, to the best of my ability, as a biomechanist, and say, would this patient be better off at Dr. Leibmann’s clinic?”
As an employer of chiropractors -- and as one yourself -- what do you think separates a very good "chiro" from an average one?
To me, that is the $64,000 question. If you are simply a family practice allopath, and you are smart enough to get through medical school and smart enough to finish your boards, you likely can be a very good medical physician. I have personally seen chiropractors who were incredibly smart, at the top of their class, but as a technician were not very proficient. And therein lies the rub: You have to have a certain sense of confidence and hand-eye coordination to do what we do. Conversely, I have seen some chiropractics who are not necessarily at the top of their class, but were fabulous technicians, and really helped a lot of people. And that is the difference, I think, between our type of profession, and other professions that don’t require that same physical ability.
How much of that is innate, and how much is trained?
I think that Michael Jordan was born Michael Jordan, and I think Larry Bird practiced free throws eight hours a day. I think that there are people who can be good at their job, and train and practice and take seminars and become very proficient, but without that extra training they will be sub-par. I’ve seen other people who were absolutely naturals. It’s a combination of the nature and the nurture.
That may fall under the misconceptions category -- how else has your profession been mischaracterized?
When I started and even now, I go out of my way to interact with medical and osteopathic physicians. I take them to lunch, I bring lunch to them, specifically for networking purposes. Having done so for as long as I have, I have recognized what specifically they — and I think, by extension, the general public — would be concerned about, as it relates to the chiropractic profession. Much of it is folklore and anecdote. I have been practicing, again, for 25 years, so there’s very little I haven’t heard. And I joke with some of those professionals when I meet them. They all ask me questions, for instance: "Once you start going to a chiropractor, don't you really have to keep going?" Or, "Isn’t it dangerous to adjust someone’s neck?" And, "Chiropractic school: Isn’t that an 18-month correspondence course?"
I always respond the same way: "What, did you come here in a time machine? That’s a 40-year-old perspective of a chiropractic." Chiropractors are very well educated, and very good at their lane of traffic. Again, when I talk to my orthopedic surgeon friend, he laughs all the time, and says, “I’m good at my lane of traffic. If you come in here and ask me about antibiotics for a sinus infection, I have no idea what to tell you. That’s not what I do anymore; I’m an orthopedist.” Chiropractors, if a patient is non-surgical, doesn’t need quote-unquote “medication." Plus, standard physical therapy, which is OK for many muscular-type symptoms and post-surgical symptoms, falls short in terms of mechanical back problems and mechanical back pain, in my opinion That lane of traffic is very important, and we are the best at treating those patients; especially given that neck and back pain are at the very top of the list of reasons why people in America miss work, statistically speaking.
What concerns you about the future of your field?
That chiropractors, to a certain extent, have let the medical model of musculoskeletal treatment dictate, to a certain extent, what we do. Oftentimes, it’s the fault of the insurance industry. When someone is treated for back pain at a medical physician’s office, sometimes they’ll come in for one treatment, two treatments, they’ll get a consultation exam, possibly medication, et cetera. Initially, when I would receive referrals from medical physicians, they would write a script to me — although not necessarily, because chiropractors are portal-of-entry providers — and they would say, “Treat this patient for two weeks.” And I would call them up and say, “I don’t understand this recommendation. That would be the equivalent of saying, ‘You’re out of shape, go get a personal trainer, let them train you for two weeks, and you’re done.’” Many of these conditions have to do with inactivity and disuse atrophy, et cetera, and take time to fix. A lot of times, the insurance industry analysts will dictate and dumb down some of the allotted amounts of time for patients to be seen, simply for the sake of saving money. Some chiropractors have capitulated because they want insurance acceptance, and I find that to be a curious perspective.
What advice do you offer to the next generation of chiropractors?
Dale Carnegie said that, “Sometimes opportunity is missed because it’s dressed in overalls and looks like work.” The truth of the matter is that to be successful at anything, you have to be able to roll up your sleeves and work hard. I think there was a time 20 years ago, before HMOs and PPOs and Obamacare, where reimbursement was better. A lot of people got into the profession because they saw a great opportunity to not only to help people, but to make a fantastic living. That living is still available, but it’s a little bit of work these days. And that is not a chiropractic-specific perspective. My gastroenterologist friend, who I golf with and I consistently beat, says that when he got out of school, he went to the hospital and took everyone’s call. He didn’t see his wife for the better part of a year. He worked his butt off to make a name for himself. So although, as I said earlier, he was dialed into that network of referral, he rolled up his sleeves and he worked hard. Any young chiropractor who wants to come out of school and see a lot of patients and help a lot of people and have fun doing it and make a very nice living, is going to have to go in with the understanding that sometimes you have to roll up your sleeves and work hard.
Robert F. Leibmann's Reading List:
- The Road Less Traveled, byM. Scott Peck -- "I just went back and re-read this. It’s not a new book, but a wonderful read about self-analysis. How that dovetails nicely into what we’re talking about here is, much of what Dr. Peck talks about is discipline and working on delayed gratification: doing the hard things now — which, unfortunately in our society, is less popular than it was in years gone by — and being responsible for what you do, and telling the truth. And I think that’s a wonderful book for a young chiropractor, because you will sit a patient down and you will tell them, “I need to see you for two visits,” or “I need to see you for 32 visits.” And if you’re telling the truth, and you are doing a very good job, and you’re working hard, and always tell those patients the truth — even if that truth is hard for them to hear, for any number of reasons — you will be successful."