Nancy J. Soliven, MA, MFCC, DC, NCTMB, MD offers her unique perspective as both a Doctor of Chiropractic and Doctor of Medicine in this exclusive interview with Chiropractic Economics. At an age when many choose to settle firmly in place, Dr. Soliven elected to become a Doctor of Medicine, graduating in 1997 from Saba University School of Medicine, Saba, Netherlands Antilles. She already enjoyed a lengthy career as an educator, counselor and Doctor of Chiropractic, graduating cum laude in 1985 from Palmer College of Chiropractic-West, in Sunnyvale, California. From 1985 to 1994 she studied post-graduate education in Craniosacral Therapy, Visceral Manipulation and Muscle Energy from the Upledger Institute in Palm Beach Gardens, Florida. She received her Master of Arts in Counseling Psychology from the University of San Francisco in 1979. Dr. Soliven also holds a Bachelor of Arts degree in Social Sciences, Biological Sciences and Education from Michigan State University in East Lansing, Michigan. She currently is in private practice in Polson, Montana, where she may be contacted by phone: 406-883-3433 or fax: 406-883-4403.
Editor’s Note: The endowed research project Dr. Soliven refers to in this interview is the first $1.75 million permanent chiropractic/biomechanical research center to be housed within a major tax supported state university, Florida State University in Tallahassee, Florida. For additional information on this project, please contact the Florida Chiropractic Association at 407-290-5883.
Dr. Soliven, what prompted you to attend medical school?
As chiropractors, part of our general lack of trust is we always talk about what “they” are doing, meaning the MDs. And “they” are not doing things the way we would do it. But MDs have the money behind them and the acceptance that we never quite had. I got tired of sitting in conferences and always listening to chiropractic doctors talking about how medical doctors do this and do that, and not knowing what they do.
I’ve always had the philosophy that you’re either part of the problem or part of the solution and I want to be part of the solution. When I had the opportunity, I went to Saba University School of Medicine.
Of how many MD/DC’s are you aware?
I was number eleven in the State of Florida when I checked about a year ago. I believe there are a few more now and it’s becoming more popular. It’s a good combination: I’m really glad I did it.
What is the primary difference between your medical and chiropractic education?
As a medical doctor there’s a different emphasis you really need to know tons of information. The first two years, there is a big push on what is what and how it works, what it does and what can go wrong. As chiropractors, we have the same basic education. The difference between is as chiropractors we are geared more toward the thinking process as opposed to the “instant recall” process. Consequently, I think there is far more demand on memorization in medical school. The focus in chiropractic school is never on competition, it is, “How are we going to get through this together?” In medical school, it’s “How can I get better grades than you?”-a real difference in philosophy.
What happens after basic sciences is an entirely different thing. In chiropractic school there is still a camaraderie. In medical school you have to pass “initiation.” Once you pass, you are accepted when you get into clinicals, but you still get competition between students at that level.
It’s medical “Trivial Pursuit” seven days a week, 24 hours a day. They’ll say, “Excuse me, doctor, would you please tell me what this is?” and the questions tend to be rather tricky. Once I graduated I felt that I’d had enough. I decided to take a year off and get myself back to center. The further I’m away from it, the less I’m inclined to go toward residency. I really don’t want to practice that kind of medicine.
What are the differences in compensation?
As an MD I know I would get paid a lot better than I do as a chiropractor and would not have the hassles with insurance. When I first came to Florida, I was literally told by the Medicare people that as an MD or DO you can bill pretty much anything you want clinically. As a chiropractor you are more limited in what can be billed. It’s this inequality that creates a lot of the problems we experience as chiropractors.
I knew once I completed residency, I would be able to come in and have a salary in the six figure areaat least $115,000 to $150,000. Not only that, you can take a contract from a hospital or from an agency or doctor’s office and be able to buy a house or a car or do whatever it is you needed to be covered. You know your student loans will be taken care of. We’re in very different positions with chiropractic than the MDs. We really don’t support our students or new practitioners very well.
What did you find unique by attending medical school on a small Caribbean island?
I enjoyed getting my medical education in a foreign country because they do things differently than in the United States. For instance, the US is one of the very few, if not the only country that fuses vertebra for lumbar surgeries or cervical surgeries. What it really does, as you well know, is makes a larger motor unit, which means the joints above and below wear out faster. If you create that, many times the patient needs a second surgery to reinforce the next level ten or fifteen years down the road.
We had a lot of visiting professors, so we saw a lot of differences in how other countries treat different illnesses. We also saw various medications that are banned from this country and/or have not yet passed FDA inspection. It was a good experience.
Do you see multi-disciplinary practices becoming more common?
I don’t think we’ve seen the beginning of multi-disciplinary practices. When we start looking at the alternatives available within each profession we need moreevery health care professional has a piece of a jigsaw puzzle. Finally, we’re beginning to each put our pieces down and make a whole picture.
There’s good in everything. The trick is to find what works and when it’s appropriate to use it. For example, years ago when we first started using MRIs, it was found that a lot of people had bulging discs. So they would operate on bulging discs in the lumbar or cervical spine. Over time we learned there were a lot of surgeries that just didn’t work and actually created more pain than they resolved. Now we’re learning to more appropriately treat the “bulging discs” most of us have, with less invasive procedures. If that doesn’t work, then we move into more invasive or radical treatments. Out of our failures, we’re beginning to come into a different perspective of what’s appropriate and what isn’t.
What do you envision as a result of the endowed research chair at Florida State University?
Number one, it’s a state university, which means that federal funds come into that state university and finally at long last we can never be legislated out of existence. Medicare and Medicaid are going to have to deal with us. And they will have to deal with us on a physician basis as opposed to an ancillary process. I would love to see the rest of the United States join the FCA and what it has done for chiropractic especially for individual doctors to make a contribution. The chiropractic chair through the LCERF is really going to change the face of chiropractic.
Where else do you see this going?
It may lead to a chiropractic school, much the same as Michigan State University has done. I am a graduate of Michigan State and they house an osteopathic college and a medical college at the same place. The original idea was to compare the two and see what the similarities and differences were. Now they do the same basic sciences and the students decide to specialize in osteopathy or medicine. It’s the same stuff. I would love to see us do the same basic two years with MDs.
I must say I believe I received somewhat of a better education at the chiropractic school. The difference is there was more emphasis placed on thinking at chiropractic school as opposed to just regurgitating information at the medical school. We had more anatomy in chiropractic, with one entire year versus one semester in medical school. We also had more classes in supportive therapies such as nutrition and use of massage, hydrotherapy, diathermy and ultrasound to name a few. The difference in understanding the biomechanics of the body is phenomenal.
There’s a lot of fear we have coming out of chiropractic school. I don’t know that we’ve ever really learned to trust that there will be patients or we will make it and we will be OK. I don’t think we ever really get the chance to relax and enjoy what we’re doing because we have this perceived threat that chiropractic is going to be taken away or the insurance companies are going to try to jerk us around. I have never found that to be the case in medical school. Once you get out of residency, you’re in and essentially taken care of for life.
What direction are you heading?
I have the papers to apply for hospital privileges as an allied health professional. This gives me the right to treat my patients in the hospital, take x-rays, do lab work, use the hospital’s facilities and also become part of the staff process. At the bimonthly meetings I can sit in and talk about policies and procedures that would benefit the people I work with. I don’t see myself making a great deal of changes, but it gives me an entrance to at least voice issues and concerns. We are also approved to preceptor naturopathic medical students from Bastyr University in Seattle, Washington and we’ve had three medical students, one chiropractic intern and one naturopathic intern.
I don’t think health professionals know much about other fields and know when it is appropriate to refer and appropriate to work with other disciplines. As chiropractors we’ve been trained in the biomechanics of the body as well as pathology. Medical people are trained in the pathologies of the body and the things that can go wrong disease-wise. Well, there’s a place for both and one discipline can help the other. That’s what I think we’re going to see more of. I see medical doctors trained to focus on disease. We are focused more on the person.
What else do you see coming?
We’re learning more about what each other is doing via the internet and other technologies. We’re broadening our scope to begin talking about not only the physical body, but the mental, spiritual and emotional bodies. Plus, the fact that there is a relationship among these and how we service the cause of the pain the person is experiencing. Emotional trauma can bring about physical pain and so can mental trauma. We know very little about how to deal with physical pain, let alone emotional, mental and spiritual.
Do you see groups of chiropractors in practice coming into the picture?
I think we’ll see a change in the whole structure and we’ll find it’s important to spend more time with patients. I spend an hour with patients the first visit and between a half hour and forty-five minutes on subsequent visits. I’ve never been able to go in and think that adjusting the spine alone is enough to change the muscle balancesis enough to change the ligament balancesto be effective to treat the person. The reason is bones don’t move themselves. Muscles and ligaments move bones. I work with muscles and ligaments, get those balanced and then adjust the patient knowing the adjustment will stay. Although I treat people longer at each session, I usually end up spending less time overall because patients don’t have to come back as often. We’re bringing about some significant changes and the only tools I ever use are my hands.
How did you set up your practice?
I started doing craniosacral work in 1985 after setting up private practice in San Jose, California. Financially, there wasn’t a lot that I got out of my first practice because I really didn’t know enough to set it up correctly. I went in full tilt. In retrospect, I would have started out a lot more simply, but I thought I had to have all the right equipment, the right way to do it and everything in place. Looking back now I would start very small and simple. For example, you can have a hospital or radiology clinic do your x-rays.
In my second practice, which is located in Montana, I started out in one room with a table, my hands and a telephone with an answering machine. My message was, “This is Dr. Soliven. I’m with a patient right now, please leave a message and I’ll get right back to you.” Between patients I would call the person and answer questions, schedule an appointment and so forth.
I kept it on a low key basis. My investment was the price of a table, a telephone system and my paperwork. It gave me time to work with the patients. Although it was a little inconvenient, virtually within a couple of months I was into a three room 1,500 square foot office for a reasonable price. It is $500 a month, and that includes all utilities except the phone.
I put in a fax machine and a second phone line. My office was decorated very sparselyposters and charts are always good to hang on the wall. I brought in some comfortable chairs from home and put puzzles and games on the table, which made it kind of homey and nice.
How did you grow the practice?
I taught a class in craniosacral therapy and had a couple people from the class approach me about working in the office, so we set up an intern program with five interns currently working. I took a lymph drainage class and started working with another person from the class who came in as an intern. We then started a research project with women and lymphatic drainage.
Now we have a research project going, five other people are doing private appointments and recently someone whose background is in kinesiology approached us to do sports therapy. He also does sports massage and analyzes athletes on video tape. We’re in an area where there are a lot of native Americans and many kids depend on scholarships. If we can help them improve, we’re offering a service to the community and it pays the bills as well.
How do you work out the expenses?
Basically, as a group we split the expenses for our receptionist, phone and the office. We also have staggered hours so we can all use the space, although we may have to move, but that isn’t here yet.
It’s fun being in a group practice with other professionals. We talk about treating patients and what we would do in this or that situation. I find it very rewarding. My overhead, with contributions from everybody, is running about $2,000 a month maximum. We all pay the same percentage of our income toward the expenses.
Do you advertise?
We’ve done some advertising and I’ve learned if I say something like “Nancy J. Soliven, DC/MD, chiropractic physician, is pleased to offer a research program on lymphatic drainage” or a “program for weight and inch loss,” I find people really respond. If we report what we’re doing as opposed to who we are, the advertising is more effective. I have people walking in all the time saying, “My wife wants to know about this program” or “Tell me about the classes you’re teaching.” This is good advertising, but it also is an excellent educational opportunity. For us the advertising is secondary to the educational opportunity as most of our referrals come from word-of-mouth.
Our mission statement is one of service. We work with people to improve their own sense of health care and give them tools to work with. For example, by teaching the women the self-drainage techniques or teaching them how to do some of the craniosacral work, it’s actually made them and their families more aware of their own health and how they can help each other.
Do you offer products?
We prefer to offer services and I don’t carry any products for that reason. I carry catalogs and am glad to set people up with vitamin companies or products such as physio balls. They’re welcome to get the same discount I do. If I’m selling a product, then I have a bias toward that product. I’d rather not be in that positionI’d rather just be a service and educational organization doing research, offering treatments and having ongoing programs towards improving people’s health. To me it involves education as well as treatment.
What are your practice’s goals?
My goal is to see twelve patients a day for half an hour each. I’m looking to bring in about $300 a day and that translates to $6,000 a month. Twelve patients a day is basically six hours. I usually end up seeing more than that and stay in the office between nine and ten hours a day. We donate a lot of work to the community for people who truly cannot afford it and we try to do a lot of service activities. I’ll never get rich on itthat’s not my intention.
My needs are very simple: to pay off my bills, take care of my kids, work with my son who wants to go to medical school and so forth. I don’t need a lot. There was a time when I thought I did, back in that “fear” place when I was being driven out of a sense of failure rather than knowing that somehow things work out. I found I needed a lot more material things in that place of fear. It’s almost as though I had to prove I could make it and these were the things that I needed to show it. I guess I’m not there anymore.
What do you see happening in health care now?
I think people are going to move away from HMOs and managed care because it’s not going to serve their needs. The HMOs are basically limited to looking at physical reasons for chronic pain. They utilize so many diagnoses by exclusion right now. For example, chronic fatigue, fibromyalgia, multiple sclerosis and lupus.
By diagnoses of exclusion, I mean if a person comes in with strep throat, you know what to do. Diagnoses of exclusion are more in the gray areas. For example, if it’s not this, if it’s not this or this or this, then it must be multiple sclerosis or fibromyalgia. I’m not implying this is all in people’s heads because I don’t believe it is, but we’re looking in the wrong places. We need to look at a far more integrated model of human beings than we’ve been doing.
As HMOs are put under more and more pressure to follow the standards of care that are being offered and put in place, and the lack of time physicians have with patients, the next five or ten years will be very interesting, to say the least.
As an MD and a DC, how do you feel MDs view you?
I haven’t had any problems with being a chiropractor. I see it as an educational process. In many of my rotations, I would be asked, “How would you treat this patient or evaluate this patient?” And I was very free to tell them what I would do. I never had any resistance from the people I worked with. However, there’s one MD in our community who makes a blanket statement, “I don’t refer to chiropractors.” This same physician belongs to a clinic that is rather prominent in our area and he doesn’t refer outside the clinic, either. So, I don’t consider that I am being singled out. Even if I were practicing medicine, he still wouldn’t refer because I wouldn’t join the clinic. I don’t see it as being a problem.
I have found a lot of openness, as well as many medical people who don’t understand what we do. We need to do a far better job of educating. The endowed research chair at Florida State will provide us the platform from which to speak and we can become a little more assured of our own space and our profession. There will be a sense of knowing that what we have cannot be taken away and I don’t think we’ve ever had that assurance before. It’s powerful when we can start negotiating as equals or as people who are not going to disappear or be legislated out of existence. I also think it’s powerful to say, “Yes, I am an MD and no I will not practice as an MD. I will practice as a chiropractic physician.”
We have one of the original alternative health forms and preventative medicine forms and look at a far more holistic point of view. I would rather deal with prevention than deal with the actual disease process. I think we’re at an advantage.
What are your parting thoughts?
Number one, we all need each other in the health professions. There are things that I cannot handle as a chiropractic physician and I don’t want to handle as a chiropractic physician. I need people I can refer to and I need people that trust me and my knowledge enough to refer to me. I need to know that I can spend time with people and that what we’re really doing is a service. I am not interested in treating fifty or a hundred people a dayI’m too person-oriented for that. I really want to be able to intervene in people’s lives to the point where it’s going to make a difference for them. In return I get that as well.
Specific start-up costs compared to today’s costs and income for Dr. Soliven’s Polson, Montana practice are:
|Table (Portable adjusting, pelvic drop piece)||$700|
|Furniture (Purchased from a used furniture shop)||$300|
|First visit (60 minutes)||$50|
|OV (30 minutes)||$25|
|Avg. revenue per day||$300|