Practice Management

How to End a Roller Coaster Practice
Practice Management
Written by Paul S. Inselman, D.C.   
Thursday, 30 August 2012 00:57
he January 5, 2012 CNN Money article “Doctors are Going Broke” stated, “most doctors in private practice have experienced a 10 percent to 15 percent profit leak which can lead to significant losses in their bank account.” Since 2008, the majority of chiropractic practices are down an estimated 25% or more. Unfortunately, the news gets worse. Higher gas prices and more forecasted insurance cuts will continue to create headwinds for the profession.  Since the beginning of time, chiropractors have experienced the proverbial roller coaster practice. This article will provide you with information that will help put an end to the nauseating dips, turns, and uncertainties that a roller coaster practice provides. 
rollercoasterYou will only get one chance to make a great first impression and that begins with your consultation. Your consultation will literally make or break your practice. There are two reasons, in my opinion, to perform a consultation. (1) To adhere to the standards of care in case you are ever sued. All professions require that you perform the minimally acceptable standards of care. All first-line health providers are required to perform a proper OPQRST (Onset, Provocative/Palliative, Quality, Radiation, Site, and Timing) consultation and proper examination to arrive at a proper diagnosis and treatment plan. Failure to perform either the consultation or an examination will cause an almost guaranteed loss of your case. 
Non-performance of a proper consultation and examination also puts you in jeopardy that an insurance company not only will not have to pay you, but can also ask you to refund monies that they have already paid. (2) To determine why the patient is really there. Our patients will tell us that they are there for neck pain, back pain, or sciatica. Please be aware that they are really there because their neck pain, back pain, or sciatica is precluding them from doing something they want to do; or they are afraid that their neck pain, back pain, or sciatica will prevent them from doing something they want to do.
Here is a scary test for you to perform. Go into your clinic after reading this article and ask yourself why Mr. or Mrs. Patient is on your table. If you get answers like neck pain, shoulder pain, or tendonitis, guess what? You missed the boat in your consultation, as you will soon see.
It is very important, especially for those doctors practicing greater than five years, to remember to be “human” and to project empathy and sympathy with each and every patient. Why even make mention of that very basic fact? After you have been practicing for awhile, and you have seen thousands of patients and their problems, it is easy for you and me to take it for granted that this is “just another case”. What I want you to remember is that for the patient, the experience is painful, scary, and upsetting. It is also the most important thing in their life at that time. For us not to give them our full attention, complete with the human caring qualities that we would want to receive, is doing our patients a terrible disservice.
The mechanics to performing a proper consultation are as follows:
  1. Establish rapport
  2. Establish commonality
  3. Praise them for however they came to your office (walk-in, referral, advertisement)
  4. Start with OPQRST
  5. Categorize the disruption of activity of daily living (ADL)
  6. Ask them what would their life look like if _____ went away?
  7. Keep it human and conversational
  8. Do not make it sound or feel like an interrogation
  9. Be 100% present
  10. Do not allow staff to disturb you unless there is an emergency.
In step number 5 above I suggested that you categorize the disruption of ADL. In my experience, I have found that the majority of patients can be classified into the following categories:

realreasonschartOther doctors that I teach have found the above table to be very helpful in figuring out why a patient is “really” coming for help. Typically, the patient has a real problem of job loss, disability, medication, etc. Or, they have a fear that if their problem continues it will lead to a job loss, disability, medication problem, etc.
During the interview with the patient, ask questions about each category and determine if it applies, if it is a real problem, or if they are fearful of the problem. You should always resist the urge to guess why they are really there. You need to know with certainty why they are really coming to you.
A great way to practice and train yourself is to role play with friends and family members. Play the game “why am I really here”? The way the game is played is have your partner choose a problem. It can be neck pain, tendonitis, or whatever they choose. Remember, the pain is precluding the patient, or the patient is fearful that the problem will preclude them from doing an activity of daily living.  The object of the game is for you to determine the real reason why the patient is there. The answer will typically be in one of the categories above. Some examples of why the patient is really there that you should come up with are as follows:
  • The patient is here because she has a fear that her migraines will cause her to become addicted to pain meds like her mother.
  • The patient is getting adjusted so they can get back to exercise. Exercise is important to the patient because they suffer with depression. Exercise is the only thing that really keeps them from becoming depressed. The real reason that they are here is to give them the best opportunity to ward off depression.
  • The patient is getting adjusted because they are afraid that if they can’t take care of the house and kids that their spouse will divorce them.
If you are coming up with the patient is here for headaches, you have missed the boat. Go back and keep practicing.
Another good tip is to video and/or audio tape yourself performing practice consultations, as well as actual consultations. Evaluate for present time consciousness (PTC), quality of your questions, rapport skills, empathy and sympathy projection, and excitement. A great metric to use is: would you be happy if a doctor that you went to performed the same consultation in the same way? (Golden Rule)
Performing a complete consultation followed by a solid report of findings will go a long way to helping you ward off a roller coaster practice. It is important to remember that you and I treat patients, not conditions. If we offer treatments that are aimed at repairing disruptions of activities of daily living instead of symptoms, we will stand out head and shoulders above the crowd of other doctors that the patient has seen in the past. You will be the first doctor in the patient’s mind that actually listened and more importantly heard their real complaint. This will lead to more respect, more referrals, and a more solid and enjoyable practice.
Dr. Paul S. Inselman, President of Inselmancoaching, is an expert at teaching chiropractors how to build honest, ethical, integrity-based practices based on sound business principles. From 2008-2012 his clients’ practices grew an average rate of 145% while the general profession was down 28%. His 26 years of clinical experience coupled with 10 years of professional coaching has allowed him to help hundreds of chiropractors throughout the nation. He can be reached at 1-888-201-0567 or This e-mail address is being protected from spambots. You need JavaScript enabled to view it
What Does It Take to Succeed as an Entrepreneur?
Practice Management
Written by Tom Owen III   
Wednesday, 29 August 2012 23:40
aking the decision to open your own chiropractic practice can be both exciting and terrifying. First of all, congratulations on your decision to branch out from the comfort zone you have enjoyed while working for someone else's practice. Taking a leap into the unknown by becoming your own boss is risky, but that risk is an essential ingredient in your success as an entrepreneur. 
success9As chiropractors, we are more inclined towards the technical aspects of both our work and lives. Having a love for the technicalities of your work is great! This knowledge, as well as your passion for chiropractic philosophy, is what got you through chiropractic school in the first place. To succeed in running your own practice, however, you will need to harness your inner business person – and business involves both risk-taking and creativity.
If you haven't picked up a copy of Michael Gerber's book, The E-Myth, I would highly recommend that you do so. Here, Gerber teaches his readers to not fall victim to a common entrepreneurship myth (or, "E-Myth"). This myth tells us that if we know how to handle the technical side of our business, we have an understanding of the entire business. 
A chiropractic business is more than just the technical aspect of service. While it is true that the business would not exist without the service, we have to understand how to manage a business and maintain a customer base in order to succeed. In addition to handling the patients and problems that arise in the moment, we must look ahead and plan for the future.
Success tip #1: Know what you need
Your particular skill set is what makes your practice possible, but do you have what it takes to turn your skills into a successful business? You may find it necessary to hire help for administrative duties, reception, and billing. The key here is to keep any overhead expense at a minimum. Try to hire employees who are capable of handling multiple tasks, or find software programs that can reduce and simplify administrative or billing work.
Success tip #2: Manage your staff
Until now, you have only worn one hat – as the chiropractor. When operating your own practice, however, you must also put on the "boss" hat. Though your staff may be trained in skills beyond your particular areas of expertise, it is important that you hire knowledgeable, experienced employees with whom you can work closely and trust. Ask questions and be involved with the business side of your business. It is imperative for the success of your entrepreneurship that you have a solid grasp on what is going on with your accounting books, appointments, etc. at all times. You must also work closely with your staff to ensure good morale and customer service practices. Your administrative staff will likely be the first staff members that your clients will encounter, and first impressions are everything.
Success tip #3: Market yourself
In order to succeed, you must make yourself known! Develop a mission statement that clearly conveys to your potential clients what it is that you can do for them. Reach out to the public through social media (Facebook, Twitter), radio advertisements, mailers... even go door to door. It's important that you get creative when trying to establish a solid client base. Host an open house, develop special promotions – whatever it takes to get people walking in through your doors.

Success tip #4: Maintain your clients

Never become comfortable with the status quo.

Once the people are making appointments, the ball is in your court. This is your time to shine with your technical expertise and ability to help others. Make customer service a priority in order to retain your clients. Again, it is key here that your entire staff is on board with keeping clients happy. From answering phones to answering questions, you and your employees should all represent your practice with eloquence, authority, and knowledge. You will find that the majority of your new business will come from reviews and referrals, so it is essential to your entrepreneurship that you maintain 100% customer satisfaction.
Success tip #5: Educate and expand
Besides recommending you to other prospective clients, happy patients can aid in the growth of your entrepreneurship in other ways. Though you may be taking care of one problem for a client, they may not realize how many other ways you can improve their health and quality of life. It is your job to educate your patrons on the various services and educational products that you can offer to them. This is a mutually beneficial tool that will both increase your revenue and your customer satisfaction.
Remember that of utmost importance in your journey into chiropractic entrepreneurship is your constant passion for your work and your business. Never become comfortable with the status-quo.To keep your practice vibrant and successful, you must always work to improve and grow your business.
Anatomy of a Practice Consultant Buyer Beware: How to Choose the Right One
Practice Management
Written by Mark Studin, D.C., F.A.S.B.E.(C), D.A.A.P.M., D.A.A.P.L.M.   
Wednesday, 29 August 2012 23:05
Disclosure: I am a practice consultant and, after 31 years in the industry, I have been on both sides of the fence. I see and speak to many new consultants in the industry and some are excellent, yet I see many leading doctors down a "slippery slope." Beyond the emotional choice, too many doctors do not have enough tools to make an informed choice. This document is dedicated to giving doctors additional tools to guide and protect themselves.    
 am trusting, eager, believe in my "gut," and hungry to take my practice to the next level. Therefore, I will seek counsel from  many who are smarter than I and I am willing to pay for their knowledge. That was my mantra for many years and I paid handsomely for answers from consultants whom I trusted to bring me to the "promised land" of practice. At one point, I paid 7 years in a row and many, many $1000s to be guided. 
risk8My disillusionment and subsequent enlightenment came when I was assigned a consultant who constantly called me for advice on issues he had difficulties with. It was at that time I realized it was time to find a formula to make better decisions. This was a learning experience that I ignored 10 years later and, again, I spent countless $1000s  based upon blind faith that brought me close to total financial ruin because the scheme created did not stand the test of time and I willingly became their guinea pig. They made money and I ended up writing checks to lawyers and carriers.
Most consultants in our profession have either stumbled upon or developed formulas in their private practices and feel they can profit from the profession by putting together a similar program in a "canned" package where the message remains constant. That in itself is not a bad thing...for today. The one constant is that everything changes, and, in today's healthcare marketplace, those changes are occurring more rapidly than ever. Therefore, consultants need to be able to change and alter their messages to keep up with those changes. In cash practices, states are passing legislation and updating regulations on how you can bill. 
Workers' compensation practices face even bigger challenges as the rules are changing so rapidly that even the carriers can't keep up with the changes. Many states have adopted evidenced-based outcomes as criteria for care. Others are strictly using ICD as criteria and yet others have a formula that is completely arbitrary. Then there are court rulings regarding labor issues that also have to be dealt with.
Personal injury is even more intricate. Doctors have to deal with internal insurance company rules, which are arbitrary, but have to be dealt with nonetheless. There are the state regulations and laws which do not change rapidly (except in Florida) and then there are court rulings which literally change on a daily basis, redefining how we need to conduct ourselves in our triage and paperwork. After all of those issues, lawyers representing the patients have issues that must be dealt with on a constant basis. 
Managed care is usually more straightforward, yet highly secretive at the same time. The rules are clearly laid out, but they hide their fee structure formula behind a metric based upon their actuarial tables and will not divulge them. It usually requires a court order or subpoena to obtain them. On top of that, they have so many ways not to pay you, a fact you often only discover following the completion of a voluminous amount of paperwork. If you are lucky enough to get paid, you get a fee so low that if every patient was a managed care patient you'd close your doors in financial ruin. 
If you  have a consultant for any of the above financial classes, how well versed are they in the process they are consulting you for? I didn't ask if they are good at getting you business because it is relatively EASY to get business and make money. The real issue is: Do you get to keep the money that you make?
A few years ago, one consultant created a scheme for cash practices and then exposed all of his clients to lawsuits for acting as insurance companies without the proper licenses.

Another consultant's advice resulted in almost every client being sued by the carriers for improper corporate structures, costing some doctors millions in legal defense, and in the end many lost their practices. Another consultant strongly recommended the use of certain documentation to overcome the carriers' objections in payment. One doctor he consulted with did get paid, but 5 years later the doctor was sued by the carriers, retrospectively costing the doctor close to a million dollars. He lost his practice. The consultant, who was not a doctor, walked away to spend the doctor's hard earned money, never to be heard from during the lawsuit or any time thereafter.
How do you choose the best consultant for your practice? 
Here are strong suggestions:
1. What are the qualifications of the consultant?
This is the most important issue; more so than the subject matter of the consulting program. Your consultant will eventually drive your practice. The only verifiable, valid vetting process is through the consultant's curriculum vitae if he/she is a professional or a résumé for a non-professional. A professional CV is preferable for 2 reasons. First, you want someone who has been where you are and understands the issues from the inside out vs. a spectator who is commenting on a game he/she has no "skin" in. Second, a professional CV is a legal document that cannot be falsified, as that is a felony in most states and can be the cause for loss of license. 
2. What is the experience of the consultant?

One doctor he consulted with did get paid, but 5 years later the doctor was sued by the carriers, retrospectively costing the doctor close to a million dollars.

Is your potential consultant experienced in the specific field he/she is consulting for and for how long has he/she been one? Too many consultants are only experienced in their personal offices or ancillary fields and that is problematic. Many consultants have figured out a "scheme" to get more patients or extract money from carriers and/or patients without knowing whether or not 5 to 10 years downstream that scheme will stand the test of time and not trigger a lawsuit later in practice or retrospective audits as many schemes do. Remember, your consultant is not responsible for your actions. You have the sole responsibility and, in the end, you alone will be writing that big check for a lawyer to defend you or a refund to the carriers if the consultant is wrong.
3. Is the subject matter being taught in line with your practice goals?
Simply put, are the teaching materials offered sufficient for you to make the changes you need to positively affect your practice?
4. Has the method stood the test of time and done so in your state?
How long has this method been employed and by how many? Is it important that the consulting method be deemed successful in my state? Some programs are universal and not state-specific while others have been altered state-by-state. Time is critical to determine the success of a program, and although some "start-ups" will thrive over time, do you want to be the "guinea pig?" In some cases, the answer is yes, but be very discerning. Remember the adage of "a fool and his money.."
5. Scour the credentials of the consultants and all that work for them.
It always goes back to credentials and not just those of the primary consultant, but everyone in a consulting capacity within their organization. Be alert for telltale signs, such as improper grammar in a signature line. Does he/she sign his/her name Dr. Joe Smith DC?  You can't have a "Dr." in front and a "DC" at the end. Does he/she consult on workers’ compensation despite having run a cash practice for an entire career? Does he/she consult on personal injury with vast experience in "on the job injuries?" Credentials do not lie. You also might end up with an employee of the main consultant working with you. What are his/her credentials?
6.  Schemes

Does the consultant build an entire program around a scheme designed to confuse the carriers or alter usual and customary practice standards for you to make money? Unless the program is based upon accepted clinical and practice standards, which include documentation standards, you leave yourself exposed to huge issues downstream. Creating a scheme of "smoke and mirrors" is big in the "get rich quick" programs, and in the end they rarely stand the test of time, instead resulting in a necessity for lawyers to defend you. 
If a program is centered around "busting" something vs. learning how to succeed at a higher level of clinical and business excellence, look at other professions and realize they do not have any of these programs, confirming this is just another "get rich quick scheme." 
7.  Testimonials

Testimonials drive business. However, be careful as any business owner can get his/her friends to write testimonials. The key is how many testimonials are offered and is there diversity in the messages? Getting an individual referral to talk to is important, but, again, you will be handed the "cream of the crop" for that person's business. Certifying success in this instance is more a function of sheer volume from a diverse geographical location. 
Budgeting & Planning: Budgeting Includes Short and Long Term Plans
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Practice Management
Written by Eric Kaplan, D.C., F.I.A.M.A.   
Sunday, 22 July 2012 21:57
Look Beyond Next Year!

e are very excited when we get more new patients. To get new patients, marketing is important, but financial management can be the key to successful marketing. Once you get a new patient, the key is to get them to accept care, which is the importance of a Report of Findings. Remember, no person calls you or your office without a need. The exposure you are getting for your office, for chiropractic, is exciting and the cost is minimal considering the exposure. Once an ad or a commercial is placed, hopefully your phone will ring. The key is for your staff to try to do less phone talking and instead get new patients into the office. My experience has shown me no person can close a patient better than the doctor. The amount of new patients that stay for care is where you can determine the cost effective nature of your marketing. 

spendsaveA good budget encompasses all the financial details of running your practice. Good budgeting goes further and projects how those details will help achieve your and your practice’s larger, long-term goals. The dual purposes of operational and strategic planning lie at the core of your success.

Look Further Ahead

Yes, in order to grow your practice your budget will need to grow. But in today’s marketplace there is no better place to invest your money than in your office. Chiropractic practice budgeting is more than a series of annual targets. The effective planning process considers strategic issues for the coming five or even ten years. This is business goal setting. Where do you want your practice to be in five years? What is your plan?

Before your accountant, manager or administrator can “run the numbers,” you must provide them with your plans, your goals for the coming years. If your budgeting and planning efforts don’t project beyond the coming year, schedule such planning sessions. Otherwise, it’s like building a bridge from one riverbank with no knowledge or concern of what’s lurking on the opposite shore. That’s exploring, not planning.

Strategic questions such as “What do we want to be doing in five years?” produce natural operational questions such as “What will we do next year to put us, or keep us, on that path?” This strategic planning step involves questions about internal (physician goals) and external (competition and other market forces) factors such as:

  • Do you want to make the practice larger?
  • If so, how? Should you add physicians? Should you increase your geographic market, perhaps with an additional office? Should the practice introduce new services you’ve referred out in the past?
  • What competitive threats exist or are likely to develop? How can you react to them or eliminate them?

Budget Mechanics

Next, begin the traditional budget mechanics. Have your manager start using the budget framework to attach numbers to agreed upon ideas and goals. We’ll look at the following different budget components in greater detail in the coming months:

1. Revenue budget. Looking at past data and projecting forward, how much revenue does the practice except from insurance payments? And what about managed care plans, prepaid HMO contracts, patient co-pays and self-pays, receivables on the books and the prospective sale of any assets? Well-researched revenue budgeting explores all likely income sources.

2. Expense budget. The health care services you render cost money to provide. You must meet fixed, variable and “semi-fixed” expenses to keep your doors open and the revenue coming in.

3. Capital budget. Small and mid-size practices (even many larger ones) rarely develop capital budgets. Nor should they. But for larger practices, capital budgeting can be an important part of the overall process and an alternative to borrowing.

4. Profit plan. This integrates the revenue and expense budgets to show net income for the practice. Some groups even start the budgeting process by deciding what take-home pay their doctors should receive and then work back up the line to project the revenue needed to produce that profit.

5. Cash budget. The cash budget details the anticipated cash flowing through the practice. Net charges and actual revenue don’t march in step. Prepaid contracts, workers’ compensation and outside referrals can create a significant short-term difference between what you’re due and what you actually receive. And cash outflows like malpractice premiums and meeting travel may vary significantly from month to month. The cash budget helps keep you on top of your practice’s monthly cash needs.

6. Balance sheet. The balance sheet puts all the revenue and expense data together and projects the practice’s assets and liabilities—essentially a snapshot of the practice’s financial health—at the end of the budget year.

7. Review, revise. After you put the collected information into an initial draft, the crucial review process begins. Are the numbers accurate to the best of your forecasting ability? Are the forecasted results good enough to support the practice and meet the needs of the physician owner(s)? If you project these numbers into the future, will the practice likely stay on track toward achieving its long-term goals? Was anything inadvertently left out?

Project some problems

Consider the financial implications of falling a little short, or a lot short. That raises the issue of whether a budget should represent your best projection of what will likely happen, a “stretch” goal to strive for, or a near worst-case scenario that will still meet the needs of the physician owner(s). We’ll focus on that issue next month when we examine the planning process.

Regardless of the approach you choose, instruct your manager to run some good, bad and middle-of-the-road scenarios so you know what to expect if the unexpected happens. But, if you carefully gather your information, project reasonably and don’t get blindsided by external changes, budgeting shouldn’t provide too many surprises. And that’s the point of the entire process.

Dr. Eric S. Kaplan, a former President COO of a NASAQ traded public company, which included Nutrisystem, Currently he is CEO of Concierge Coaches, Inc.,, a comprehensive coaching firm with a successful, documented history of assisting doctors create profitable practices nationwide, providing over 30 New Patient marketing Programs. Teaching doctors nationally how to develop a successful business in the health care industry of today. Dr. Kaplan is the best selling author of Dying to be Young, and Lifestyle of the Fit and Famous and Co-developer and President of Discforce and Palm Beach Massage Centers,, the next Generation Chiropractic Practices, massage and Spinal decompression For more information on coaching or spinal decompression, call 1-561-626-3004.


Working with the Medical Community Without Losing Our Identity
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Practice Management
Written by William Owens Jr., DC, DAAMLP, CPC   
Saturday, 02 June 2012 00:31

uilding a working relationship with the medical community is a wonderful way to reach patients and create a referral network that will continue for the life of your practice.  If done properly, chiropractic can stand as a separate and distinct treatment option.  Many doctors erroneously think that you have to “change” chiropractic for us to be accepted into the medical community.  In my personal experience nothing could be further from the truth, but there are steps to be taken for the process of building the relationship properly.  Understanding the barriers is the best way to start. 

communityandidentity2The first major barrier to building medical relationships is your ability, as ridiculous as it may seem, to convey your diagnostic skills to the MD.  The first family practice resident that I had in my office for the chiropractic elective at the State University of New York at Buffalo School of Medicine and Biomedical Sciences actually said, “I am surprised at the level of detail in your initial examination.”  Medical providers do not receive any exposure to chiropractic practice; therefore the default reasoning is chiropractic care is sub-par.  While we know this to be untrue, it is the reality nonetheless.   I have said it before and I’ll keep saying it, the medical community does not care at all about your technique.  They refer based on trust and clinical reputation.  They need to be able to trust that you will be able to take care of their patients. Can you and your office handle complex cases and manage patients in a collaborative environment? Does the medical community in your area know?
The next barrier to building medical relationships is continuing to display your clinical skills through reporting.   Reporting is a critical part of building a relationship with health care providers.  Without it you are a NON-PLAYER, pure and simple.  Your report is critical and many chiropractors have trouble understanding what to write and when to do a report.   It is important that you touch the report only once, therefore your initial note should be in a format that can be used for insurance reimbursement, compliance, reporting to the MD and, if necessary, reporting to the lawyer.   The initial report and each re-evaluation should get sent via fax.  To keep this streamlined my office staff will take the report that is printed from my EMR and fax it to each of the providers or professionals that are CC’d at the bottom.  For example, the original would go into the patient’s chart, a copy would be sent to the primary care physician, the medical specialist, the insurance carrier (this is sent with the billing automatically) and the lawyer.  We didn’t spend any money on stamps, the reports get there immediately and we have a delivery confirmation so we can prove they were received.  That is extremely efficient and I should point out that I do not do a separate progress note and a letter to the MD, the progress note IS the report. Touch it once and be done with it.  

I have said it before and I’ll keep saying it, the medical community does not care at all about your technique.

Lastly, all this can be done without compromising who we are and what we do.  Our single biggest problem and the reason we only treat 8% of the population is we don’t effectively report what we do.  When we don’t communicate effectively, all that we are left with are other providers’ assumptions on what chiropractors are thinking and doing.  We rely on the patient going back to the MD and telling them what is wrong with them, and you know how accurate that can be!  The language in our reports is critical to building relationships; we are not “becoming” them any more than they are “becoming” us.  There is a place for discussion of chiropractic principles, vertebral subluxation and who we are as a profession.  Please understand that none of those things can be discussed until the medical community that you want to work with trusts you as a doctor and clinician.  That is how we win.
Dr. Owens has established the nation’s first chiropractic elective in a Family Residency Program with the SUNY at Buffalo School of Medicine and Biomedical Sciences.  He has developed and credentials chiropractors to teach courses approved for CME credit to the medical community.   He can be reached at 716-228-3847.

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