Chiropractor and Entrepreneur – Mentor, Dr. Tom Cate
This mentor has built one of the largest chiropractic practices in the US consistently ranking in the top one percent. He is also an entrepreneur who has started several successful businesses. Dr. Cate grew up in a blue-collar family that lived in a tough part of a large city. His success proves that what you can achieve depends on your own ability and ambition and not your background. In his article, Dr. Cate also discusses changes in government regulations, the way insurance companies now reimburse doctors for medical services and how both these changes are affecting patent care. This article covers many important topics and should be read by anyone interested in becoming a chiropractic doctor or entering any part of the medical field as well as everyone who wants to better understand the way new regulations are affecting the quality of patent care in the US.
I grew up in Pittsburg where my father worked in a mill for US Steel. We lived near downtown in a tough neighborhood. I was a good athlete and was able to go to college on a baseball scholarship where I took a premed program. My intent was to go into sports medicine. I was a good baseball player and was considering playing professionally for the Cincinnati Reds. But before I graduated, I was injured when I fell while I was running. Among other injuries, my hip came out of the socket. I went to a number of doctors for treatment with no results and my leg began to shrink. So I tried chiropractic treatment. The chiropractor fixed the problem I was having with my hip when traditional medical treatment did not. I was impressed and learned more about chiropractic medicine. What I found was that chiropractic medicine was more effective than traditional medicine when it comes to dealing with many kinds of muscular-skeletal problems, which was my own personal experience. So I decided to become a chiropractor rather than an MD. I finished my premed in two and a half years and then went to Chiropractic College for four years. You should know that getting a chiropractic degree requires 1,900 hours versus 1,560 for an MD, which means you will be in school longer.
When I graduated in 1984, I took and passed both my national and state boards. Both have several parts and you must pass all of them. Here is a short summary of what is involved in the most important four exams:
- Six basic science subjects – general anatomy, spinal anatomy, physiology, chemistry, pathology, and microbiology.
- Six clinical subjects – general diagnosis, neuromusculoskeletal diagnosis, diagnostic imaging, principles of chiropractic, chiropractic practice, and associated clinical sciences.
- Case history, physical examination, neuromusculoskeletal examination, diagnostic imaging examination, clinical laboratory and special studies, diagnosis or clinical impression, chiropractic techniques, supportive techniques and case management.
- X-ray interpretation and diagnosis, chiropractic technique, and case management skills.
After I got my licenses, I worked as an associate for two years before I went out and established my own practice. I have now been practicing chiropractic medicine for thirty years.
During that time I have also started several successful businesses including a MRI center and a large, outpatient rehabilitation center. The MRI center employs six people and the rehabilitation center fourteen including two MDs and registered physical therapists.
I have also made investments in commercial real estate, oil and gas and sit on the board of a local bank where I am a shareholder. I have always made money when I either invested in businesses where I understood that type of business well. But I have also invested based on the character and experience of the people involved. I found out early on that it is more important to invest in people and not things. I have always lost money when I didn’t follow this simple principal.
The Practice of Chiropractic Medicine
The first thing I do when I see a new patient is give them a through neurological and orthopedic evaluation. This can include x-rays and MRI’s. It is important that you take your time reading these as you diagnosis and treatment plan is based on your interpretation of these images. You want to make sure you do not miss anything. When you have done your evaluation you will know whether or not you can help a particular patient. Not everyone will benefit from chiropractic care. For example, people may come in too late with joint and disc problems for chiropractic care to be effective. When that happens, I often refer the patient to an orthopedic specialist. Likewise, I often get referrals from these same doctors who feel a patient does not need immediate surgery and can benefit from chiropractic care. It is important that you always be 100% honest with your patient about how effective chiropractic care can be in their particular case. I usually give them a percentage probability of whether or not I think a treatment plann that I design can be effective and then let the patient decide.
The programs I design for a patient treat spinal joints and extremities through manipulation and adjustment therapy. The purpose is to restore the proper alignment of a joint, which reduces nerve pressure and in turn pain. Misalignment is called a subluxation. A subluxation is when one or more of the bones of your vertebrae move out of position and create pressure on spinal nerves. This pressure or irritation on the nerves then causes those nerves to malfunction and interfere with the signals traveling over those nerves. Because your nervous system controls and coordinates all the functions of your body, if you interfere with the signals traveling over nerves, parts of your body will not get the proper nerve messages and your body will not be able to function well. Chiropractic care is also sometimes called biomecanical engineering because the therapy concentrates on curing whatever is affecting that nerve root by mechanical alignment. Because I physically manipulated a patient, I consider myself a hands on blue-collar doctor who is tired at the end of the day just like a physical laborer. So those of you considering chiropractic as a career should understand it requires some physical stamina.
One of the things I like most about being a chiropractic doctor is the results are often immediate so you know right away if your treatment program is going to be effective. This is in contrast to other forms of medicine where it can take a long time to know if the prescribed medicines or surgery are successful. As an example, the founder of YPNG came to me because of pain and stiffness in his neck. He had gone to an orthopedic surgeon who had told him the only thing he could do was a fusion of two of the vertebra, which my patient did not want to do because it would limit the range of motion of his neck. After I took some x-rays and did a physical exam, I told him I thought I could help. After the first treatment, his pain and stiffness was significantly reduced and went away entirely after three months of treatment. That was over twenty years ago and he has been able to function well without surgery and only occasional maintenance manipulations.
I have what many people consider a heavy workload as I typically see over 100 people per day. I can do this because once the examination and treatment program is established; a manipulation only takes a few minutes. As I said earlier, I do spend a lot of time with new patients doing exams and reviewing x-ray and MRI images. This is critical to get a good diagnosis. But it is not necessary to spend this kind of time when doing manipulations.
I also have my office well organized. I hire good people who deal with patient scheduling and billing so I can spend all my time with my patients doing diagnosis and treatments.
Changes taking Place in the Practice of Medicine
Every kind of doctor is now spending more and more time dealing with paperwork because of new government and insurance company regulations. Before the new laws, doctors only had to show that the treatment was a medical necessity and discuss why the patient needed that treatment or service. Now they want you to document everything in more detail. For example, here are some typical questions I now have to answer:
- Document range of motion
- State Short Term Treatment Goals
- State Long Term Treatment Goals
- State how the patient’s condition has modified their daily activities
- How much time did it take to do the therapy
- How much time did it take to do an examination
These questions really have nothing to do with patient care and in my opinion are more about the insurance companies wanting to control the disbursement of funds for the medical services rendered to the patient.
In addition, a lot of these questions have to be answered by the doctor picking a code that best matches your answer if you actually wrote out the treatment and diagnosis rather than actually recording the story of the patient’s medical treatment. The result of this is that the new electronic records that are supposed to be easily available to all doctors who might treat a patient show only a coded history and do not tell a story about the patient’s treatment and the doctor’s thought process to arrive at a diagnosis. As a result, while the doctor in an emergency room might have easy access to a patient’s records, the information is not as useful in helping the doctor diagnose and treat the patient.
The new paperwork requirement also changes the way doctors are able to interact with their patients. Many of us now spend more time with our back to our patients filing out the new forms on a computer or computer tablet when before we would spend most of our time interacting with patients. Some doctors have tried to address this by having a person who is basically a scribe following them around and dictating to them. Doctors I know who have tried this say they end up hoarse by the end of the day.
Another way some doctors are trying to get back to treating patients and not having to spend all this time filling out paperwork is by not accepting any insurance and going to an all cash practice. While a few individual practitioners have done this successfully, there was a new medical clinic formed recently that is all cash. This group included internists, a pediatrician, surgeons and a chiropractor. The cash cost for their services appear to be about a third of the billing rate charged when a doctor files with an insurance company for the same procedure. Here is why the cost the reductions are so significant. First, there are no bad debts. Everybody pays. Bad debts can represent ten to twenty percent of the billing for many practices. Next, there is no longer the necessity to hire a staff of people to do billing and insurance company filings or invest in the expensive computer systems. While the doctors do keep a medical history on each patient, it is a history that reflects what the doctor and not the insurance company thinks is in the best interest of the patient.
This emphasis on insurance company documentation rather than having the doctor spend time with patient is something that many doctors feel will lower the standard of patient care. Another unintended consequence is likely to be poorer diagnosis that will lead to maltreatment and that will lead to an increase in medical malpractice lawsuits. These suits have been decreasing over the past ten years and it will be easy to see if it reverses under these new insurance company practices.
Every doctor I know will tell you those medical malpractice lawsuits not only raises the cost of medicine in the US because of the cost of malpractice insurance; they cause doctors to take precautions to avoid these lawsuits. In many cases this means a lot of testing that otherwise would not be order by a doctor is ordered to protect the doctor against liability. This has been termed “defensive medicine”. Defensive medicine does nothing to improve the patient’s care and only increases medial costs for everyone. Legislatures in both the State and Federal government are beginning to address this issue. But it should have been addressed years ago.
Preparing to Become a Chiropractor
It is important in high school to take the normal college preparation courses because you will need to be able to be accepted to a college for premed. But that college does not have to be expensive. Many people go a year or two to a community college and then transfer to four-year college or university. I would advise anyone that it doesn’t pay to get an expensive degree for premed. You need to keep your undergraduate costs as low as you can because Chiropractic College is expensive. Right now I would expect that the four-year program costs around $180,000 for tuition, room and board. I am not aware of any grants or scholarship programs for chiropractic colleges. But these schools are in every state and student loans are generally easy to get because of the earning potential of a chiropractic doctor.
I would encourage anyone with an interest in a medical career to look at chiropractic medicine. It is an area of medicine where I have found a lot of satisfaction because of the help I have been able to give my patients who often come to me with severe pain. While I have a lot of energy and see a many more patients each day than most chiropractors, you can still make a good living seeing just thirty or so each day and create a good balance between your practice and your personal life. I am also deeply religious and feel that a strong faith helped me succeed by keeping me focused every day on the care of my patients. Because my patients understand I am dedicated to their care, I have been able to build a large, successful practice. So just like any other career in medicine, dedication to helping your patients should always be your primary motivation for entering the chiropractic profession.
US Bureau of Labor Statistics for Chiropractors
There were 28,850 people employed as chiropractors in the US in May 2013, the Bureau’s most recent survey.
There was a wide range of earnings in that survey. The mean wage was $78, 410 with the lowest 10% earning $30, 980 to the top 10% earning more than $141,440. These statistics are very skewed by region. For example, the mean salary in Ohio was $114,000 and also high for other Midwest states while the mean in Oklahoma and Texas was $59,000.
Dr. Cate’s practice is one of the most profitable in the US and generates a seven figure pretax income. Having the physical ability to work long hours and the management skills to efficiently organize a chiropractic office like Dr. Cate are both important if you want to reach the upper end of the income scale. But as Dr. Cate told YPNG, you must not look at patients as a billing opportunity. Your patients come to you because they are in pain and are seeking relief. If you work hard at designing treatment programs that are effective in helping them, you will build a large practice.
The Bureau expects the job outlook for chiropractors to be very good with the number of chiropractors increasing at the rate of 15% between the years 2012 and 2022 because chiropractic care is becoming more popular with the general public. In addition, more insurance companies are covering chiropractic services.