This isn’t surprising since, behind the scenes, organized medicine continues to fight to restrict chiropractic to musculoskeletal “treatment” of chronic low-back pain in adults. While I’ve always opposed expanding the chiropractic scope of practice into medical areas, I’ve spent my career trying to make sure we have the legal right to provide care to ALL people, regardless of age or symptomology.

Since I view chiropractic as a holistic and neurologically based approach — one that allows the body to better address all health issues — I’m actually a “broad scope” proponent in the widest meaning of that term. Yes, I draw the line at any kind of medical procedures (i.e., drugs, surgery, differential full-body diagnosis, etc.) but I definitely don’t want chiropractic limited to the role of pain relief for back pain.

For those who feel we’re ready to join forces with the medical profession, I suggest a review of how the American Medical Association (AMA) and other elements of organized medicine continue to fight the expansion of all CAM approaches into what they see as their “turf.”

For instance, an article Amy Lynn Sorrel published in the Jan 25, 2010, issue of American Medical News noted with a touch of braggadocio that “in 2009, physicians fought a blitz of scope-of-practice expansions by other health professionals on legislative, legal and regulatory fronts. Organized medicine defeated attempts by naturopaths to seek licensure, prevented chiropractors from being able to perform invasive procedures and achieved further regulation of lay midwives. The efforts were among more than 300 scope-related bills the American Medical Association tracked last year.”

Sorrel added that “Physicians don’t expect the battles to let up, and with patient safety on the line, they are countering such efforts with some fresh tactics.”

Among their efforts will be to make it illegal for anyone but medical doctors to use the term “doctor,” establish state MD-dominated review panels to evaluate plans by non-medical health professionals to expand their practice, and mandate that non-medical doctors wear badges identifying their credentials. Let’s hope they aren’t suggesting badges with yellow stars.

Among the health professionals in the crosshairs for the AMA are nurses, podiatrists, naturopaths, optometrists, and — of course — chiropractors, all of whom appear to threaten the AMA.

A case in point was the Texas regulation that permitted DCs to perform manipulation under anesthesia and needle electromyography. Because of efforts by the AMA, the court overturned the Board’s decision and barred those procedures. The AMA and its allies also won a partial victory in Texas over whether the word “diagnose” could be used instead of “analyze, examine or evaluate” (which is permitted in the Texas Chiropractic Act). On Aug. 17, the court decided that DCs may “diagnose” — within limits. The final decision is up in the air and no one knows, at this time, exactly what it all means.

As I mentioned above, I disagree with some of the suggested scope expansions promoted by chiropractors, but it’s because they tend to make the profession more medically oriented rather than broaden their scope to include more people.

What I do know is that no matter what we see as chiropractic progress — whether it’s to become more ‘medical’ or, as I hope, to become less medical and address a full slate of neurological as well as musculoskeletal issues — we need to understand that organized medicine is NOT a friend of chiropractic or any other non-medical health approach.

As patients continue to join in the mass exodus away from allopathic medicine, the backlash against alternatives will continue and I strongly urge DCs to be careful when establishing “alliances” with medical professionals. Exceptions do exist and I know several MDs who are truly interested more in their patients’ well-being than they are in protecting their turf, but these ARE the exceptions, not the rule. Let’s move as far as possible away from the medical paradigm and allow them to stomp on their own grounds while we claim more fertile territories.

SOURCE: “Organized medicine pushes back on expansions of scope of practice” AMA News, Jan. 18. 2010.

"Laptop-itis" -- a growing problem

For years, chiropractors have been in the forefront of posture-related health care and have led the campaign to raise awareness of heavy backpacks that can distort the young student’s posture. Now, they’re seeing an increase in the number of young people with neck, shoulder, and back problems caused by hunching over a laptop computer.

“More and more patients, mostly young adults, are coming to chiropractic offices for upper back pain, and this is something doctors need to be aware of,” Terry A. Rondberg, DC, founder and CEO of the World Chiropractic Alliance noted recently. “The medical profession has dubbed it ‘laptop-itis,’ only half jokingly. They’ll be recommending pain pills and surgery for these kids. If chiropractors can help them first, with adjustments as well as education on posture, we may keep them from the surgeon’s knife.”

Because of the way the computers are designed, using a laptop almost inevitably leads to poor posture, noted Kevin Carneiro, DO, a doctor in the Department of Physical Medicine and Rehabilitation at the University of North Carolina at Chapel Hill School of Medicine, one of several medical institutions addressing the laptop issue.

The widespread use of laptops in schools (some colleges actually require students to purchase them) means an even greater problem in the future.

“Just as they did with backpacks, chiropractors can step up and become the number one resource for helping students avoid these postural problems, and care for those already showing symptoms,” Dr. Rondberg added.

Some tips to pass on to patients who use laptops:

• Position the laptop for the most neutral wrist posture you can achieve; avoid having to bend the hand or wrist at an unnatural angle.
• Position the laptop on a desk or work surface and tilt the screen so you can view it without having to bend your neck.
• Whenever possible, use a separate keyboard and mouse. There are small portable devices that can plug into a USB port.
• Get a lightweight laptop — and determine the “real” weight, with batteries, accessories, etc.
• Take short breaks every 20 minutes and do gentle stretching exercises such as shrugging your shoulders, bending your head from side to side, or other exercises recommended by your DC.
• Drink plenty of water to keep the discs in your back lubricated and healthy.
• Consider loading the StretchWare program on your computer; it will remind you when to stretch, and give you visual guidance on a variety of exercises.

SOURCES: The World Chiropractic Alliance; University of North Carolina at Chapel Hill School of Medicine

He rightfully reminds us that we work hard to gain our patients’ trust and can expect them to ask about a variety of health and wellness services and products. The temptation is always to give them the least expensive options, but this isn’t always the best course of action.

“When asked, you should recommend what’s best for the patient, no matter the cost,” Dr. Breitenmoser advises. “There’s nothing wrong with recommending certain products, as long as you believe in them and know the company is a trusted name.”

These products can range from nutritional supplements, weight loss products, topical over-the-counter analgesics, and natural foods to orthopedic supplies, mattresses, pillows, backpacks, sports equipment, home gym and exercise equipment, or even ergonomic chairs!

You could, of course, refer them to the local pharmacy for their vitamins or the nearest Wal-Mart for the rest, but it could be helpful to patients if you would recommend or even sell high-quality items to them from your office.

In addition to helping your patients, this is also an ethical and low-cost way to increase your own revenue. As Erich notes: “Back-end marketing is extremely important for long-term practice growth and for the overall success of a sales and marketing venture… Back-end marketing is a very inexpensive form of marketing because the largest expense relating to marketing (new patient acquisition) has already been incurred or absorbed.” (Erich lists four specific reasons why you need back-end strategies, so be sure to read his complete article.)

The addition of multiple streams of income has become all but essential in most private practices today, and I’m not talking only about chiropractors. According to an article on the medical site, Physicians’ Practice: “As reimbursements fall and costs continue to climb, private practitioners across the country are adding an impressive selection of new products and services to their line-up — a direct attempt to diversify and enhance revenue streams. Some sell pharmaceuticals and prosthetic devices. Others offer physical therapy and smoking cessation clinics, along with inhouse elective procedures such as vasectomies, Botox injections, and laser hair removal.”

Thank goodness we don’t have to resort to doing that! But if we don’t help our patients find the health and wellness products that will help complement chiropractic care, they may end up at their MD’s office asking advice. So, take the initiative and give some thought to which products or services your patients would benefit from and consider implementing back-end marketing programs to provide those items.

As Erich succinctly puts it: “To be successful in chiropractic marketing in the long run, you MUST become adept at back-end marketing in your office.”

The drug industry is already beginning its back-to-school vaccine push, and once more chiropractors and other wellness professionals will be leading the campaign against mandatory vaccinations. You can help by learning the facts about vaccines (a good place to start is the National Vaccine Information Center and sharing that information with patients as well as community members (they have a number of excellent downloadable flyers).

Become aware of the exemptions allowed in your state for school children and protest the forced vaccination of children against their parents’ wishes. Many states are inserting “philosophical exemptions” that permit children to skip vaccines if their families have strong but not religious opposition to the drugs.

It’s also the time of year drug companies pump up their advertising for cold and flu medicines (every season is cold season to them!). In response, distribute information on the studies done on chiropractic and immune function (see the WCA position paper and the lengthy list of references supporting the claim that chiropractic can boost immune strength). Place a big poster with this quote in your waiting room:

“People who receive regular chiropractic adjustments have immune system competency that is 200% greater than those who don’t.” — Dr. Ron Pero, New York Preventative Medicine Institute and Environmental Health at NYU.

Chiropractors need to start a campaign to remind parents that health comes from INSIDE the body — not inside a bottle of pills.

And, of course, there’s the problem of backpacks, which seem to grow each year. I’ve seen kids wearing backpacks that would bring a longshoreman to his knees. The strain they put on back muscles, and the damage they can do to posture definitely involves the chiropractic profession.

CJ Mertz, DC, president of Full Potential Leadership, warned about this problem years ago: “The weight of their packs and the one-sidedness has led to an epidemic of adolescent back problems. The time has come for chiropractic to take the leadership position and save these children from a lifetime of suffering.”

There are a number of excellent resources online for information about backpack safety (such as Backpack Safety America and Posture Pro) where you can download research data. You might want to consider stocking some good backpacks to sell to your patients for their kids. Not only will you increase your revenue, but you’ll be going the extra mile to help protect the children’s health.

And don’t forget to use your local newspaper to spread the word about your efforts. Sending in an article, letter to the editor or press release helps educate the public AND position your office as a true “back to school” health resource. (search Google news for press releases by other chiropractic offices to give you some hints on how and what to write).

The kids may be going back to school soon, but we have to get back to work if we’re to help them get through the months ahead!

This is an important question because chiropractic isn’t just about getting sick people well. It goes far beyond the traditional ideas of health and actually has a powerful impact on the personal total well-being: physical, mental and emotional — all the elements that go into “performance.”

Parker College President Fabrizio Mancini gave the near-perfect answer when he stated: “One of the things that appeals to me about our profession is that it deals with function, which is a very similar word to performance. The reason why so many high executives, celebrities, and sports people use chiropractic is because they recognize that they do perform better. For the last 20 years, I always get adjusted before I give a speech. I never know in advance what I’m going to say and I believe I perform better when I’m adjusted. I get adjusted once or twice a week because of my travel experience and physical activities.”

It’s easy to sell “performance” to athletes because, in the chiropractic context, we tend to associate the word with some kind of physical feat. There’s even some research to support the benefits of chiropractic for athletes, such as the study published last year in the Journal of Chiropractic Medicine. Researchers studied 43 golfers and those who received chiropractic care hit their balls farther. In another study, 50 athletes were tested and the group that received chiropractic adjustments showed significant improvement in all 11 tests used to measure athletic ability, including agility, balance, kinesthetic perception, power, and reaction time. A study in the Feb. 2006 issue of the Journal of Manipulative and Physiological Therapy showed a significant improvement in quadriceps muscle strength in subjects receiving chiropractic care (good news for those athletes needing to lift large objects like opposing players).

Okay, so none of these studies are going to win the Nobel prize in medicine, but they confirm what we’ve seen in chiropractic offices for more than a century — chiropractic is great for both professional and weekend athletes.

But, as Dr. Mancini pointed out, athletes aren’t the only ones who “perform.” Executives have to hit a homerun at board meetings; mothers need to make a slam dunk every time the kids call for help; taxi drivers have to have the quick reflexes and stamina of an Indy 500 driver; computer operators require the concentration of a gymnast (and knowing how they hunch over their computers, most of them probably pull more muscles than a linebacker). Even giving a speech, as Dr. Mancini notes, is a performance that can be enhanced by chiropractic.

We can’t put a sign on our door saying we help improve public speaking skills, but in our patient and public education information we can make sure we explain that chiropractic does far beyond what we normally think of as “therapy” or “medicine” (despite the titles of our research journals). Nobody needs to be sick or in pain or exhibit a list of symptoms to be relieved. Healthy, active people who want to perform better in all aspects of their lives can benefit from chiropractic. You just have to make sure they know it!

In the past, I would’ve joined them in a good moan, lamenting my own financial losses and piling my worries on top of theirs.

Not any longer. I’m more and more convinced that this type of poverty talk is self-perpetuating. Call it the power of concentrated thinking, the law of attraction or whatever you want, the more we focus on lack and scarcity, the more we experience them.

The opposite is true as well. When we choose to think about abundance and success, we draw that to us.

There are many explanations for why this happens, and it may be as simple as the fact that our words and thoughts program our subconscious, which (even though we may not be aware of it) determines our actions. If we’re convinced that times are tough and our business is declining, we’ll most likely make decisions or take actions consistent with that belief. We’ll sabotage our own efforts without even realizing it.

Scientists have determined that the subconscious mind is 30,000 times more powerful than the conscious mind. The conscious mind works at slow speed, processes information at a mere 40 bits per second. Operating at 40 million bits/sec., the subconscious is a rocket booster in comparison.

Motivational guru Tony Robbins says that “All personal changes must take place at the subconscious level.” I extend that to professional changes as well. If we want success and wealth, we have to drill it down to our subconscious level that we can reach those goals. We have to replace our negative self-talk with positive reprogramming.

Personally, I couldn’t just jump from “woe is me, the economy’s rotten” to “I’m a magnet for money” in one leap. I had to take it a small step at a time. When I looked at things realistically, I had to acknowledge that many practitioners are hurting financially right now. But there are also doctors whose practices and businesses are actually growing and becoming more prosperous every day. The fact they’re doing it proves it can be done. So, it was logical to think that I could do it, too. One step closer to positive thinking.

Also, while it’s true that many patients are putting off needed care because they, too, are infected by the rampant poverty consciousness, despite the “recession” these same people are spending more on things like consumer electronics (up 12% this year over last year), chocolate (Hershey Co. profits in the first three months of 2009 surged 20%), wine (U.S. sales of California wines up 2% in 2009), and even gifts for their pets (an 11% increase according to an Animalfair.com readership study).

Whether they spend their money on health care or rhinestone-studded doggie collars is a matter of priority, not limitation. And if they’re not making health and wellness a priority, we share in the blame because we’re not educating them as well as we could.

Two steps closer to positive thinking.

Once I convinced my conscious mind of these two facts, I had to work on getting them embedded in my subconscious. That took repetition and vigilance. I constantly caught myself replaying the old tapes about the “hard times” we were in. Each time, I mentally “erased” that thought and replaced it with one of abundance and prosperity.

As my subconscious mind gradually accepted the new “reality,” my actions began aligning with that reality and I made decisions based on optimism rather than fear. It’s still a work in progress, but I’m seeing the results already.

Ask yourself whether you’re deriving any benefit from talking about how you can’t afford things, aren’t doing well, and are having a tough time in this bad economy. If you’re not, what would it cost you to try a more positive outlook for a while?

'Country Doctor Ernest Ceriani Making House Call on Foot in Small Town.' Photo by W. Eugene Smith / Life Magazine Archives.

Up until the 1950s or so, many (if not most) medical doctors made house calls in addition to seeing patients in their offices. That was before they felt they needed $2 million in equipment before they could write a prescription for antibiotics. When medical went high-tech, the little black bag wasn’t sufficient, so house calls went out of fashion. According to a report in the Clinics of Geriatric Medicine, house calls accounted for 40% of physician encounters in 1930, 10% by 1950, and less than 1% in 1980.

The really interesting thing is, in recent years that figure’s been creeping back up and now hovers around 5%. Apparently, many MDs are seeing the wisdom of seeing their patients at home. Some even do it full time in order to rid themselves of their high-rent offices, expensive equipment, and costly staff. Others offer house calls in addition to office hours in order to provide services for elderly, bedridden or housebound patients, or even busy parents who can’t get to the doctor’s office.

Chiropractors appear to be even more willing to try this creative approach to patient care. One DC used his blog to explain to patients that that he was going to start making house calls. He totaled the time it takes for a patient to have a regular in-office appointment and, with the preparation, driving, and waiting, it came to about an hour just to see the doctor for 5-10 minutes. “There are tools that I will not be able to take with me,” he explained to patients, “but as a chiropractor and a massage therapist all I really need is my hands. I have my portable table …

so, if you need a chiropractor or massage therapist, but don’t like the hassle of driving to an office and waiting to be seen, give me a call. Or if you know someone who is housebound due to pain. I will also be working with hospitals to treat people in urgent care centers and emergency rooms. I hope to be able to bring chiropractic to those who want it more conveniently or who can’t get to me.

Others are trying a variation on house calls and setting up mobile offices, complete with tables, selected equipment, and other supplies. In New Jersey, for instance, Demetrios Kydonieus, DC, drives around the area in his “Wellness Wagon.” Daren Bethia, DC, offers services “to make receiving chiropractic care convenient to the sick and shut in, the busy small business owner, the stay at home mom who is busy with the kids, those with limited transportation or anybody who needs immediate treatment, but can’t make it to our office.” He offers both chiropractic and personal training sessions to people in and around Charlotte, NC.

Obviously, mobile offices and making house calls isn’t for everyone and it’s too early to tell if they’re successful alternatives to traditional offices. Still, these are definitely interesting ideas that we’ll be seeing more of in the future. I invite anybody who’s tried either of them to let me know of their experiences.

The next most important reason for the relatively low malpractice lawsuit rate is that people tend to have a more personal rapport with their non-medical health care professionals. These are the people who actually spend time talking with them, getting to know their health issues, and show a genuine interest in them and their families.

That rapport alone can help prevent problems like lawsuits and board complaints. Lawyers have long known that if patients like you, they’re less likely to sue you even if you mess up.

“Plaintiffs’ lawyers report that 70% of malpractice claims are brought because of physician-patient communication problems or as a result of the physician’s attitude,” said Paul S. Sanders, MD, and Debra L. McBride, RN, JD in an article for Minnesota Medicine.

Researchers publishing in the Archives of Internal Medicine reviewed 45 malpractice cases and found that, in 71% of them, plaintiffs had a bad relationship with their provider. More than a third (31.5%) said they felt “deserted” by their doctors, and nearly that many (29%) said they had trouble contacting the doctor directly.

The image of the friendly family wellness provider (the kindly neighborhood chiropractor, the sage old acupuncturist, the sweet and caring nutritional counselor) is fading. Today’s high-tech environment, competitive health care arena, and emphasis on keeping our “professional distance” have given our offices a harder edge, a less personal touch.

The result? More stress for you and your patients, more lawsuits and complaints – and less effective care.

The solution? Hone your personal skills (verbal AND nonverbal) just as rigorously as you update your clinical knowledge.

Here are some specific tips for improving your “tableside” manner:

• Give patients/clients your full, undivided attention.
• Be aware of your nonverbal communication.
• Apologize if you’re late for an appointment, or if there was any other problem associated with the visit.
• Train your office staff to pay attention to patients and show them respect.
• Learn to listen to patient/client complaints without reacting with anger or impatience.

Watch your non-verbal communication as well.

• Maintain good eye contact. Don’t be constantly looking elsewhere or reading from your chart or notes.
• Watch your facial expressions. Match your “face” to your feelings and don’t be afraid to smile when appropriate!
• Be alert to body language. When talking with a patient or client, don’t be checking your watch, tapping your fingers on the counter, or shifting your feet impatiently.

If people skills aren’t your strength, take a course such as one of the famed Dale Carnegie training programs (http://www.dalecarnegie.com/search_courses/select_subject.jsp?courseSubject=CIS) or one of the offerings from the American Management Association (http://www.amanet.org/training/seminars/communication-skills-training.aspx)

Many courses are available online. Just a few hours spent leaning the basics of interpersonal relations can work wonders for your practice!

For the past few years, the emphasis of most American businesses has been to become “green” (or at least look green). Environmental consciousness was seen as a vital characteristic in any business — including chiropractic practices.

Now, trend watchers say health consciousness is the new priority among consumers. The general public expects businesses to be involved in health in ways that go beyond the health of their employees, according to a survey conducted by Edelman, the world’s largest independent public relations firm.

“Health Engagement Barometer 2010″ found that nearly three-quarters (72%) of people trust companies that are obviously engaged in health and two-thirds (65%) either recommend or buy products from those companies.

Three out of four people polled said it’s as important to protect the public’s health as it is to protect the environment. More than two-thirds (69%) pointed to the role business could play in doing this, saying it should put as much effort into maintaining and improving personal and public health as it puts into the environment.

“Business has gone ‘green’ — now it’s time to go ‘health,’” said Nancy Turett, global president, Health, Edelman. “For a company to be prosperous and relevant in the future, it has to factor health into its business strategy, not only to fulfill its social contract with all stakeholders but to realize its full market potential.”

They aren’t talking only about health benefits, but about creating new products or services that maintain or improve health, educating customers about health topics, taking steps to address obesity, and basically being engaged in activities that help increase overall wellness.

Also, take note that they are NOT talking about “medical care.” The public is specifically focusing on health and wellness. In fact, when asked about what the biopharma and medical products industry should do, the majority of respondents said the key priority should be creating new products or services that maintain or improve health, not “new drugs” or so-called “miracle cures.”

This is really good news for chiropractors and all other wellness professionals. By maintaining our strong position as leaders of the wellness “revolution,” we already have a giant advantage over the medical and drug industries, which are becoming increasingly irrelevant to the public.

We can further our lead by continuing to offer the best possible chiropractic care AND by offering related services and products to patients, including everything from stress reduction training to nutritional supplementation. If we do, the medical and drug guys will turn green with envy!

And that’s not just my opinion. Look at this April 26 email message from attorney Keith Pendleton, JD.

“Last week, at the request of several ProviderLAW members in Texas, I took a look at a case that some of you may have heard about, but doesn’t seem like it has hit the national press yet. I have to tell you, as a chiropractic patient myself, what I discovered was something of a shock.”

“The Texas Medical Association – a founding member of an AMA-led nationwide consortium called the Scope of Practice Partnership (SOPP) – sued the Texas Board of Medical Examiners to remove the ability of chiropractors to diagnose. The TMA isn’t just suing the TBCE on any old grounds either. It is challenging the ability of chiropractors to diagnose based on State constitutional grounds.”

I don’t know about you, but when a lawyer says he’s “shocked” by something in the legal realm, that gets my attention. Here’s a brief overview/timeline of what’s going on:

1. In January 2006, the American Medical Association (AMA) announced an industry consortium known as the “Scope of Practice Partnership” (SOPP). The consortium was originally formed by the AMA, along with six national medical specialty societies and six state medical associations, including the Texas Medical Association (TMA). The stated purpose of the group, among other directives, was to “concentrate the resources of organized medicine to oppose scope of practice expansions by allied health professionals that threaten the health and safety of the public.”
2. In May 2006, the Texas Board of Chiropractic Examiners (TBCE) adopted rule 75.17 regarding the scope of practice for licensed doctors of chiropractic in Texas. The rule, formed in response to a legislative mandate made in the state’s Chiropractic Act, governed two particular procedures being performed by chiropractors in the State of Texas – Needle EMG and Manipulation Under Anesthesia (MUA).
3. In September 2006, TMA filed suit against the Texas Board of Chiropractic Examiners (TBCE). In its lawsuit, TMA challenged the chiropractic board’s rules for Needle EMG and MUA, saying that the rules violated the Texas constitution because they represented an infringement of the authority of the Texas Board of Medical Examiners. Further, the Medical Association challenged the right of chiropractic doctors to “diagnose,” arguing that only medical doctors have the right to diagnose patients.
4. In November 2009, a Texas trial court’s “summary judgment” ruled that TBCE’s rules regarding EMG and MUA are invalid. The Texas Chiropractic Association is appealing the ruling.
5. On August 16, 2010, the court is scheduled to hear arguments and testimony on the board’s rules regarding “diagnosis” with respect to Texas chiropractors’ scope of practice.

Clearly, this case is of monumental importance to Texas DCs. So, assuming you don’t practice in Texas, why is this a big deal? Let’s review: this lawsuit doesn’t just seek to prevent the expansion of the scope of practice of chiropractic in Texas. It’s an attempt to restrict what chiropractors have been doing in Texas for decades. And the battle is taking place on constitutional grounds in one of the nation’s largest states. Make no mistake: if successful, this lawsuit could have major ramifications for SOPP and DCs operating nationwide, not to mention their patients.

But don’t take my word for it. Let’s hear again from attorney Keith Pendleton.

“You may have the right in your State (currently) to diagnose….Then consider a few facts… Consider the fact that Texas chiropractors have been reimbursed for years by insurance to diagnose (e.g., state worker’s comp). Consider the fact that statutes like these are being challenged as unconstitutional. Consider the fact that they are being challenged by one of the founding members of a national consortium that is systematically challenging scope of practice nationwide and even publishes a chart of its current actions.”

Now, I’m not suggesting that anyone panic. This legal wrangling may take years to decide. But you need to be aware that the wheels are in motion, and that this is part of a bigger movement to concentrate power in the hands of those “real doctors” who already — along with the drug companies — have the lion’s share of power and influence over our health care system today. Think about it.