V. Rick Wren, DC, uses open-bay adjusting for efficient patient flow

Find a DC who makes a habit of adjusting more than 100 patients in a 5-hour day, and you could be looking at someone with a padded cell in his immediate future—unless the doctor in question is V. Rick Wren, DC.

High volume and short hours have been a staple of practice at Wren’s (until recently) one-man Wren Chiropractic Center since the 1980s. Burnout candidate? Not the Sherman, Tex-based Wren.

The reasons for his upbeat state of mind despite what many might perceive as a withering load are many, starting with Wren’s decision to use open-bay adjusting.

“Earlier in my career I had four private adjusting rooms,” says Wren of his 2,300-square-foot, freestanding facility. “Then as now, I was seeing 100 patients a day, but it took me 8 hours. When I switched to open bay, I still saw 100 patients a day—the difference was I could see them in 5.”

The open-bay model of adjusting allows Wren to keep better tabs on the flow of activity in the office. That lets him plot his moves a step or two farther ahead, and in so doing gain a certain amount of helpful extra efficiency.

“When you’re in an enclosed room, you don’t see the buildup going on out in the waiting room,” he explains. “As a result, you end up lulled into thinking everything out front is under control when in fact you’ve got chaos out there. You can easily then make the mistake of thinking you’ve got an extra few minutes to spend with the patient, which only makes things more chaotic. Before you know it, you’re running way late and not seeing anywhere near as many patients as you otherwise might.”

Pictured from left are Glenna Wren, office supervisor; Jennifer Nelson, CA; V. Rick Wren, DC; Deanna Williams, CA; Todd Redfearn, DC; and Martha Graves, CA.

Another plus to the open-bay arrangement is it enables Wren to educate up to four patients at once. “When I address one patient’s question, the other three get to listen to my answer,” he says. “Overall, I spend a lot less time conveying information this way.”

Less tangible but clearly important is the psychological boost that open-bay adjusting promotes.

“Open bay gives you such a great sense of freedom—you don’t realize how much a closed-room office shortchanges you emotionally until after you’ve knocked out the walls,” he says. “You feel the freedom, and it energizes you. You switch to open bay, and it’s like unleashing a tiger.”

Rome wasn’t built in a day, and neither was Wren Chiropractic Center’s open-bay architecture.

“I planned it 6 months in advance, and had weekly meetings with the staff to discuss everything we would need to do to make it flow properly,” he says.

HIPAA Exclusion
A concern for practitioners who contemplate adopting the open-bay model is whether doing so will violate the letter and spirit of the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), which mandates rigorous protection of patient privacy. The answer, according to Wren, is no—so long as what’s known as an exclusions page is included with the HIPAA-disclosure documentation given to patients for their review and signature.

Wren says none of his patients have ever balked at signing the HIPAA-disclosure statement and its exclusions page.

Likewise, Wren says few patients ever object to open-bay adjusting (by his tally, less than 5% of those who come to his office prefer a private room). “If the doctor is comfortable with open bay, patients will be too,” he says.

Prior to converting to open bay in 1993, Wren took the precaution of getting his patients psyched up for the change. Says Wren, “Weeks before it happened, we started telling patients about open bay and strongly played up the benefits that they would receive from it—such as how it would help them learn more about chiropractic care because of the greater patient-doctor interaction that open bay makes possible.”

Some doctors hesitate to adopt open bay out of concern that patients—aware of the presence of total strangers within earshot—will feel uncomfortable speaking candidly to the doctor about intimate or indelicate details of their health. Wren thinks such concern is misplaced. Periodically throughout the year, he meets in private with each open-bay patient, giving him or her the opportunity to freely discuss any matter that he or she might have been reticent to bring up earlier. But more so, Wren keeps such tight tabs on the patients’ symptomatic status that deception on their part won’t work. “I know where they’re at and what kind of progress to expect; were a patient to not be honest with me, I’d see through it right away,” he says.

TIPS FOR SUCCESS It’s not all that difficult to transform a plodding solo practice into one that crackles with energy and sees more than 100 patients per day, promises V. Rick Wren, DC, of Wren Chiropractic Center in Sherman, Tex. He has distilled his formula for success into 21 tips. Here is a sampling: • Always ask for referrals. Wren says the number of new patients a chiropractor schedules is directly proportional to how often he asks for a referral. “Begin asking for referrals as soon as the new patient calls for a first appointment,” he says. “Have the receptionist or scheduler say something along the lines of, ‘Is this appointment for you or the entire family?’ When the new patient is being given a tour of the office, subtly encourage that person to refer by stating things like, ‘This is where we examine families and friends for subluxations.’ During the initial exam, discuss possible subluxations and possible symptoms, then inquire as to whether the patient knows anyone with these same symptoms. Send the new patient home with a video about chiropractic and recommend it be viewed with the entire family; when the patient returns for the second visit for the report of findings, propose to give him 7 days in which to get his immediate family scheduled and, if he does so, you will pay for each one to be examined, x-rayed, given a report of findings, and first adjusted.” • Incentivize your staff. Employees often subconsciously sabotage growth efforts by not putting their hearts into it. Wren understands why. “Most employees don’t want to be twice as busy for the same pay, so why would they want to double your practice for the same hourly wage?” he asks. Financial incentives change all that. “Having incentives keeps staff more focused and involved with your practice; then it becomes ‘our’ practice. Daily, weekly, and annual cash incentives paid for things like reaching a certain volume of new and continuing patients allows the staff to be emotionally attached to the ebb and flow of practice.” • Book your appointments in clusters. Chiropractors conventionally spread their appointments over too many hours of the day—a ticket to burnout and even boredom, Wren says. Clustering solves that problem. It also sets the stage for a strategic shortening of office hours without a reduction in the number of patients seen, he says. “Every time I have talked a chiropractor into cutting back their hours, their practice has always gone up,” he says. “Working fewer hours creates more synergy and energy with the practice. It also creates excitement within the team to gain more personal time.” • Keep an eye on the clock. A practice that can process an arriving patient, deliver care, and send him on his way in 20 minutes or less is a practice poised for growth, Wren says. “If it takes 30 minutes or longer to get the patient in and out the door, you’ve got a practice that’s in trouble,” he says.

Precision Adjuster
Wren also has been able to accommodate 100 patients per day and more by using the technique of precision adjusting.

“In precision adjusting, you concentrate on just two vertebrae—C1 and C2,” he says. “It gives far better results than when you adjust all 24 vertebrae. The reason is that 100% of the nerve fibers pass through the spine at C1 and C2, whereas lower down, at about belt level, it’s only about 30%.

“We graduate from chiropractic college thinking that an adjustment doesn’t compare in value to medical surgery, so to make the patient feel the visit to us has value, we feel as though we should make the effort to move every bone they have. But the reality is the less you adjust, the more miracles you will see—because the less you adjust, the more energy you can put into each adjustment.

“It used to be that I’d refer out three to five people for surgery every year. Since making precision adjusting part of my practice, I’ve been referring maybe one patient for surgery every 3 years.”

Wren didn’t always precision adjust. He adopted the technique in the mid-1990s after participating in a mission trip to Central America where it was used by team leader Jim Sigafoose, DC.

“There were 19 of us on that trip,” he recounts. “In 6 days, we adjusted 46,000 people. The doctors who adjusted only at C1 and C2 were the ones who saw miracles; the ones who adjusted all 24 vertebrae saw no miracles.”

Regardless of the type of adjusting one prefers, Wren contends it’s vital from the standpoint of practice success to be able to complete the task in no more than 3 minutes.

“Many chiropractors think it’s robbery to adjust a patient so quickly,” he says. “But, if you check to see how many minutes they spend adjusting their own spouses, you’ll find it’s about 2 or 3 minutes. That’s because they don’t have 15-minute conversations with their spouse while the spouse is on the adjusting table, like they do with other patients.”

Wren says he understands why chiropractors feel compelled to chat with their patients, but he insists it’s a mistake to be quite so gregarious. “When you pull up to the drive-through window at the fast-food stand, you expect to place your order, receive the food, and go; imagine what would happen if the kid at the window took your order and then spent 15 minutes talking to you about the weather, the [Dallas] Cowboys, or your golf game before giving you the food—even though the food was ready and you could have driven away 10 minutes earlier.”

That isn’t to suggest a chiropractic office ought to operate with the cold efficiency of an assembly line.

“If things are running smoothly in your office, you’ll have time to be personable and caring and still be able to see those 100 patients,” Wren says.

Investing in the Future
Many of the cases at Wren Chiropractic Center involve chronic conditions, but increasingly, wellness care is being provided—a trend that began more than 15 years ago. Treatment recommendations are never predicated upon what the patient’s insurance coverage allows.

“Insurance is only designed to deal with the treatment of pain, which is why insurance on average only allows 20 or so visits a year, when what the average patient needs is more like 80 to 100 visits during the first year,” Wren says. “We work with the patient’s insurance, but we make sure the patient understands what the out-of-pocket costs are going to be if they elect to come in on a long-term basis.”

And long-term is clearly the goal.

“Patients have to decide whether or not they want to invest in their future,” he says. “If I’m going to address their pain, which is all that the insurance company wants me to do, then the patient is only investing in today. But if the patient wants to work toward making changes to improve the spine and slow down spinal decay, then he is investing in the future.”

Wren finds that nearly all patients who are properly educated about future spinal decay will consent, up front, to be scheduled for 50 or more visits per year, even though their insurance at best will pay for fewer than half that number.

“Most of our patients are on one-year plans, and many of those include an out-of-pocket financing package,” he says.

Wren typically schedules each patient in a block of 26 visits, which can cover anywhere from a few weeks to a few months on the calendar. The 26th visit routinely includes a surface electromyograph. Also, Wren takes x-rays twice during the patient’s first year of care and once annually thereafter.

“The purpose of re-exams and the retaking of x-rays is to demonstrate how tough the three stresses are on the spine, not to brag how perfect the patient’s spine is,” he says.

One advantage of getting patients to commit to a year’s worth of visits ahead of time is it helps condition them to think of chiropractic care as a lifelong proposition.

“In most offices,” Wren says, ‘if you schedule week to week, the last scheduled appointment represents for the patient an end point, a time to possibly say, ‘OK, that’s enough; I don’t need to keep coming in.’ However, for patients to get good results, continuing to come in is precisely what they need to do.”

Willing to Share
Sharing with other chiropractors his secrets of success has been a longtime passion for Wren. So much, in fact, that he founded the Society of Chiropractic Masters—a weekly study group in which participants explore and exchange strategies for clinical and business success. Currently, Wren and about 20 other area chiropractors gather every Monday for spirited and insightful discussion.

Wren already has taken on an associate to help carry some of the load, which will make it all the easier for Wren to give his lectures.

“I really love seeing chiropractors become truly successful,” he says. “And I really believe it’s possible for them to do that without falling prey to burnout along the way.”

Rich Smith is a contributing writer for Chiropractic Products.