Chiropractor practice management justifications for business degree program in chiropractic curricul

Chiropractor Practice Management: Justifications for

Business Degree Program in Chiropractic Curriculum

by Richmond S. Adebiaye, & Charlene Conner

ABOUT THE AUTOHR(S)

Dr. Richmond S. Adebiaye is a Professor of Computer

Information Systems, Information Security expert,

Academic Administrator and Researcher. He has over

twelve (13) years’ experience teaching various Computer &

Information Systems, Network Management and Security

courses. He also consults in the field of Database Design,

Management and Security, Digital Forensics, Penetration,

Vulnerability Testing, CyberSecurity, Application Security

Analysis and Development. He is presently the Program

Director of Computer & Information Systems at Parker University, Dallas,

Texas USA. He was the former Program Chair, CS/IT, Denver Campuses for

Colorado Technical University and former Program Director at the University

of Maryland University College. Dr. Adebiaye earned his Doctorate in

Information Systems and Communications from the prestigious Robert Morris

University, Moon Township, PA, and his Master of Science in Information

Security from Lewis University, Romeoville, IL. He is a Certified Information

Systems Security Professional and Certified Information Security Manager. He

also holds few Cisco certifications which include CCIE. Dr. Adebiaye is the

author of four (4) best-selling textbooks – (1) Object-Oriented Methods, (2)

Information and Network Security Management: Strategic Concept

Application, (3) Network Systems and Security (Principles and Practices and (4)

Network Systems Management which could be found on www.amazon.com. His

main expertise and research interests involve Designing, Building, Managing

Enterprise Network and Information Security and Forensics programs.

Dr. Charlene Conner serves as Dean, College of

Business and Technology at Parker University. Research

interests include human resources, organization behavior

with emphasis in team dynamics, generational influences

within the workplace, as well as organizational

development and change. Prior to entering Academia, she

served in both US government and corporate entities.

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Chiropractor Practice Management: Justifications for Business Degree Program

in Chiropractic Curriculum

Volume 02, Issue03, Jul – Sep’ 2015 2

AB S TR A CT

chiropractor is considered a Professional as well as a

Businessperson. The history of chiropractic profession has

been shaped with myriad of specific claims within healthcare

environment which led to desire to ‘fit into the perceived exigencies

and requirements of the health care system’. However, the strategy to

organize ethics within a profession exemplifies the need to be

compliant with professional requirements and to exhibit integrity

within the context of that profession. This study investigates the

relationship between successful chiropractic practice and attainment

of a Master of Business Administration (MBA) degree. A survey was

completed by 150 practicing chiropractors in four (4) states of Texas,

Tennessee, Oklahoma, and New York combined using an online

survey instrument. Questions about additional earned degree in

Business, its impact on financial and physical growth of business

practices and establishments were quantified in order to rank the

individual chiropractors as highly successful, having strains on

practice (moderately successful), and no growth (least successful).

Each of the independent variable responses from the research

questions was analyzed for each success group of Chiropractors to

determine whether the success level was related to any of the

independent variables. Correlation analysis, coefficient of

determination, and chi-square tests of independence were performed

on the independent variables and on the demographic variables of

age of respondent, location of business, cost of practice, attainment of

an earned MBA degree, implication of the earned degree to progress

of the practice and length of time in practice. Significant statistical

findings were obtained and significant statistical correlation was

found between the success variables and most of the independent

variables. Relationships between attainment of an MBA using

certain demographic factors and success level were also significant.

The research provided answers to questions regarding attainment of

an additional MBA degree and success aspect of a chiropractic

business practice.

KEY W O R D

Practice Management, MBA Program, Chiropractor, Chiropractic

practice

A

Richmond S. Adebiaye, et al.,

3 © 2015, IJASRD, All Rights Reserved

I. INTRODUCTION

Chiropractic is the most identifiable Complementary and Alternative Medicine

(CAM) primary contact profession in the United States [1]. Primary contact care provider

represents all healthcare professions that can “examine, diagnose, and provide care directly to

a patient, without a referral from another health care provider” with essential role of meeting

the health care demands of the society [2]. Chiropractors have several years of “professional

medical training, resulting in a Doctor of Chiropractic (DC) degree. They study the structure

and function of the spine and how it effects health and disease” [3]. In one research study, the

functions were more definite with notation that “Chiropractors may incorporate along with

spinal adjustments, massage, an exercise program, nutritional supplements, acupuncture,

homeopathy and biofeedback to name a few alternative medical treatments”[4]. Other

researchers also explored the professional and business combination of these functions.

According to one researcher [5], economic determinism comes with comfort

tendencies of self-actualization with decisions to be independent and have a successful

practice. However, while researchers deny the possibility of businessmen having ethical

obligations, probably due to competition of the market-place, the culmination of social and

the inter-professional interests, with the need to be relevant in professional establishment,

changed this trajectory [6]. It is now evident that successful professional could also be

responsible businessman through the combinations of both professionalism, knowledge and

attainment of additional higher business degree and institutional ethics with the desire for

economic and financial independence. The Chiropractic professionals require significantly

greater business acumen and practice management skills, earned through formal and standard

education, albeit Master of Business Administration (MBA) degree to be financially

successful and compete in the healthcare Industry [7].

This important role of a Chiropractor which utilizes natural healing through a “core

competency of spinal manipulative therapy (SMT), as well as other adjunctive therapies and

strategies”, is perhaps the greatest complimentary assets to the allied Healthcare industry.

Chiropractors manipulate the spine with their hands to realign the vertebrae and relieve the

pressure on the nerves. In so doing, have successfully healed symptoms associated with pains

and general body health. To support these important roles, a group of researchers [8]

established that several factors influencing the practitioner/patient relationship can include

educational factors such as business, marketing, public health, healthy lifestyles, and

collaborating with other health care professionals (Pg. 56). Other researchers [9][10][11]

surmised that the chiropractic profession has traditionally used preventative and active health

care strategies and patient-centered care in the delivery of services (Pg. 11) with verifiable

results and successes. The conclusion showed that, in order to be successful as a chiropractor,

the ultimate aim should be to allow lifelong “health process entrenched in the practice” with

additional astute knowledge of business skills which involve “educating the public through

marketing and patient communications regarding the available options that the profession can

offer” [12].

http://www.ijasrd.org/




Figure 1: Diagram showing Chiropractic noted area of prevention of spinal

subluxations [11]

As noted in the above diagram, “Chiropractors may incorporate along with spinal

adjustments, massage, an exercise program, nutritional supplements, acupuncture,

homeopathy and biofeedback to name a few alternative medical treatments” [13].

Additionally, the uniqueness of a chiropractic practice was justified by professional standards

exhibited by the practitioners. As one researcher [14] puts it, “Rather than continue to

emulate medicine, as chiropractic had done in the second period of history, chiropractic

instead pursued an entrepreneurial orientation, such as the reemergence of charismatic

leaders, new work arrangements and diverse educational curriculums that catered to

perceived opportunities in the contemporary health care market (courses in acupuncture,

homeopathy)[15]”. The researcher concluded that “What was old, was new again, and came

to be used as a resource in the trying, competitive times of the 1990s until present twenty-first

century. However, to have a successful Chiropractic practice that would include a change

from the “current health care paradigm to one that emphasizes prevention, lifelong wellness,

and the empowerment of patients” could only be attained through earning a business degree

albeit an MBA program [16]. This would very well be ascertained to be well within the scope

of the chiropractic profession. The existing gap, between needed business skills and existing

skills suggests that current training and education programs are not enough [17]. An earned

additional higher degree in Business will provide adequate knowledge and skills necessary

for integration into business, ideology and practice of the profession.

II. RELATED WORK

The Chiropractic profession is the largest Complementary and Alternative Medicine

(CAM) profession in the world and one of the largest licensed health care professions in the

United States (Bureau of Labor Statistics, U.S. Department of Labor, 2014) [18].

Chiropractic, an occupation could very well be described as devoted to ”restoring health by

analyzing, treating and maintaining alignment of the spinal vertebrae, is a case in which these



market elements have always been more prominent, legitimate and explicit” [19].

Chiropractic is of increasing interest because the profession has attempted to integrate

business ideals along with pursuing more professional ethical health care standards. One

researcher [20] provided insights into the timeline which showed how Chiropractic initially

pursued an “entrepreneurial orientation in period one (1895 - 1961) and repudiated anything

professional or medical [21]. The researcher found that with the culmination of social and

inter-professional pressures, chiropractic reversed its trajectory, and pursued a

professionalization process in the second period of history (1961 - 1992) (pg.37). But, as

quickly as professionalism was attained, the health care environment and chiropractic's role

within it was altered leading eventually to the re-emergence of entrepreneurialism (1992 -

present) [22]”. Each period of history involved ongoing attention to being an alternative or

allied health care provider.

III. SIGNIFICANCE OF THE STUDY

According to [23][24], the growth of complementary and alternative medicine

(CAM) utilization rates have resulted in an expansion of the chiropractic profession,

experiencing usage rates in the population for 2008 of 5.2% (Pg.89). Sometimes regarded as

a “fringe or vague science, chiropractic care has recently gained more legitimacy and greater

acceptance among medical physicians and insurance providers. Though, some doubt remains,

demographic trends and the healthcare reform bill will revitalize the industry in the next five

years” [25]. Researchers also discovered that the chiropractic profession fits into the

definition of CAM with core expertise within musculoskeletal (MSK) conditions [26]. Other

researchers like [27][28] also supported this view and indicated that “chiropractic usage rates

were 5.9% for persons 18-64 years old, 5.4% for patients over 65 with Medicare, and 3.1%

for persons 18-64 with only public insurance”. Another researcher [29] also correlated

different statistics and evaluated that eighty two percent (82%) of practicing chiropractors

recognize the need for business education, with 16% indicating that they possess these skills

(pg.77). The general business problem identified by the researchers [30][31][32][33] is that

current chiropractic training is not preparing chiropractors enough to compete in the 21st

century health care and managed care market due to lack of additional business degree or

curriculum which fits or incorporates comprehensive business courses. Researchers like [34]

[35][36][37] observed that some chiropractors are “experiencing a difficult time starting and

successfully maintaining a practice due to lack of this specific skill. It is also very important

to note that Chiropractors are also entrepreneurs, who take risks, organize and operate

businesses and achieve a level of profitability for the long term. Other researchers like

[38][39] summed up activities that are important for a business professional like a

chiropractor to include “the assumption of risk from uncertainty, supplying and managing

financial capital, being innovative, being a decision maker, organizing, coordinating and

allocating”[40]. These researchers concluded that the ultimate specific business problem is

that “some chiropractors do not know the relationship between needed business knowledge,

training and their current knowledge level”, hence the need for additional business degree

(pg. 71).





IV. CLINICAL SCIENCE HOURS CURRICULUM OUTLOOK COMPARISON

According to reference shown on [41] by American Journal of Clinical Chiropractic,

it became obvious that there is a level of confusion by the public and even the chiropractic

patients in appreciating the level of training and education of a Doctor of Chiropractic.

Research has shown that a Doctor of Chiropractic has more hours of training in Anatomy and

Pathology, and even more hours of training in Physiology and Biochemistry than their Doctor

of Medicine counterparts and a higher number in overall Clinical Science hours [42]

Invariably, a Chiropractor, equally, has several years of “pre-requisite undergraduate

courses which are required prior to the application process of the potential student pursuing a

Doctorate in Chiropractic”, similar to their Medical Doctor (M.D.) counterparts. In an article

published recently in a journal, ‘My-Health Magazine’ indicated that in the United States,

“approximately 20% of adults have tried chiropractic care. It is the largest alternative medical

profession in the U.S. and the third largest doctored profession - after medical doctors and

dentists” [43]. This indicates that satisfaction rates are usually higher for chiropractic

alternative medicine compared to traditional care by an M.D.

The table below shows a typical curriculum content and hours from accredited four-year

programs in Chiropractic and Medicine [40.]

Subject Chiropractic

Hours

Medicine

Hours

1. Anatomy 570 368

2. Biochemistry 150 120

3. Microbiology 120 120

4. Public Health 70 289

5. Physiology 305 142

6. Pathology 205 162

7. Total Basic Science 1,420 1,200

8. Total Clinical Science*

*Total Clinical Science hrs. Includes:

Chiropractic Science

Clerkships

3,406

1,975

1,405

3,467

0

3,467

9. Total contact Hours

(Basic + Clinical yrs.)

4,826 4,667

Table 1: Comparison of Clinical Science Hours training between a Doctor of Medicine and Doctor of Chiropractic

[18]

Other researchers[45][46][47] believe that “practice management and consulting

endeavors have become more prevalent in chiropractic due to changes in the larger context of

the system of professions; the restructuring of health care around a platform of multi-

corporate hospital chains, the heyday of reasonable and customary insurance reimbursement

and its retraction into cost-conscious managed care organizations, as well as the interest by

medical physicians, physical therapists and veterinarians in performing

manipulation/adjustments”. With attainment of an MBA degree, a versatile and more

enterprising Chiropractor could maximize enough area in which to carve an exclusive



jurisdictional niche and increase the need to defend and capitalize on available unclaimed

work, all the while concerning itself with economic survival and prosperity [48]. In another

prominent research article titled “Success in Chiropractic Practice” by [49][50][51] supported

the justifications on facts, that Chiropractic practitioners successful business practice would

be dependent on business skills and attainment of business programs skills.

V. METHODOLOGICAL SURVEY DATA ANALYSIS

5.1 Statistical Data Outlook:

In order to classify as successful in chiropractic business practice, a Chiropractor must

have been in practice at least three (3) or more years. Assumptions were based on students’

loans repayment, if any, and stability of entrepreneurship within the study period. Other

factors included verified evidence of financial growth, measured by increased sales and

positive cash flow analysis presentation [52]. This includes evidence of continuing practice

growth, measured by “increased patient base, increased employee base, physical expansion”

or a combination [53]. The surveys included demographic questions asked each respondent

to describe his/her age, sex, years in practice, and whether currently in practice. Education

relating to attainment of MBA degree contained questions designed to elicit information

about the degree of success in practice and attainment of an MBA degree in addition to a

Doctor of Chiropractic degree. The classifications were numerically valued for either success

with a value or non-successful with different value. In approximation of either assigning a

numeric coded value equivalent to each answer in each question; or weighted according to its

perceived importance by the researcher to successful practice. Responses to the five questions

were totaled and used to rank the respondents on a continuum of success. Using evaluation

indicative for all success factors were divided into three groups of approximately equal size,

according to level of success (low, moderate, and high) [54].

5.2 Statistical Data Results:

This research utilized a survey to describe higher education degree and social support

determinants of successful chiropractic practice and proposed that an educational degree

which included attainment of business qualification factors such as an earned MBA degree

through prior business training and experience would be “shown to contribute to success in

practice”[55]. Data from the mailed survey were analyzed using “descriptive statistics,

correlation analysis, coefficient of determination, and X2 test of independence”. Findings are

discussed in more detail as they relate to the variables used. This resultant analysis showed

relationship between demographic factors and success results. The statistical analysis

revealed no significant statistical relationship between gender and practice success, but a

higher than moderate significance was shown between attainment of an additional higher

business degree and success. Significantly, “aligned with an MBA degree are those in their

early 30s and 40s, evidencing a higher success rate than those in their 50’s and 60’s. This

same disparity in success levels was also seen in comparing years in practice, most likely for

the same reasons [56]. However, the result failed to show if this success could be matched

with specific demographic factors at a later point.





5.3 Findings:

Although 164 chiropractors were randomly invited to participate in this research

study, only 152 of them participated. There was no explanation provided by 12 chiropractors

regarding their non-participation. The distribution of participants who actually participated in

the research with respect to their gender is shown in the Figure 2. On average, they were

38.25 years old (sd=4.14), ranging from the age of 30 to 47. As noted in the Figure 3, most of

the participants were residents of Texas (28.94%), followed by residents of Oklahoma

(26.97%), Tennessee (24.34%) and New York (19.73%).

Figure 2. Distribution of participants with Figure 3. Distribution of participants with

respect to their gender respect to their gender

VI. RESULTS

6.1 Hypothesis (H1): There is a difference between chiropractors with and without MBA in

yearly profit earnings as estimate of their business successes.

As shown in Table

2, more participants were

compared regarding their

yearly profit (from

business) than with respect

to their estimation of

business success. This

occurred as a consequence

of the fact that 16 chiropractors included in the sample started working in a period of 6

months or less before the start of this research, so their estimate would be biased due to the

fact they are still new on the market. In order to test if the chiropractors with an MBA

diploma fare differently from ones without the diploma in terms of average profit per year

and estimated success of business, data was collected as ranks, as two Mann-Whitney U tests

were conducted. According to the results of the first test (U=1295.50, z=-2.907, p<0.01),

there is a significant difference between chiropractors who possess and those who do not

possess an MBA diploma in terms of their average salary per year. The chiropractors with an

MBA diploma (M=2.32) earned significantly more than those without a diploma (M=1.86)

per year. The results of the other Man-Whitney U test (U=933.00 z=-3.073, p<0.01) indicated

Table 2. Descriptive statistics of average profit per year and estimated

success of business with respect to possession of a MBA diploma

N M sd

Average profit per year MBA 31 2.32 0.83

no-MBA 121 1.86 0.77

Estimated success of business MBA 27 3.78 1.12

no-MBA 109 3.14 0.96



that the two groups of chiropractors fare significantly different in terms of estimated business

success, as well. Chiropractors with an MBA diploma (M=3.78) estimated their business was

more successful than those without MBA Diploma (M=3.14).

6.2 Hypothesis (H2): there is a difference between Male and Female chiropractors in yearly

profit and estimate of their business successes.

Another pair of Man-

Whitney U tests were used in

order to test if the gender of the

chiropractor affects their average

profit per year or estimate of the

success of their business.

According to the results of the

tests, gender of the chiropractor

is not related to differences in

their average profit per year (U=2588.50, z=-1.20, p>0.05) nor their estimate of success

(U=2287.00, z=-0.114, p>0.05).

Figure 4. Distribution of chiropractors with respect to estimate of their success in business

As shown in Figure 4 and Table 4, the

distribution of estimated success of the

chiropractors without a diploma was

symmetric (z=-0.09, p>0.05), while the

distribution of chiropractors with a diploma

was negatively skewed (z=2.10, p<0.05),

which is an additional justification that the

chiropractors with a diploma considered their

business to be more successful. It should be

noted that participants who stated they are

Table 3. Descriptive statistics of average profit per year and

estimated success of business with respect to gender of a

chiropractor

N M sd

Average profit per year male 74 2.04 0.85

female 78 1.87 0.75

Estimated success of business male 68 3.24 1.08

female 68 3.29 0.96

Table 4. Distribution of the participants with respect

to their estimate of business success and possession

of a MBA diploma

MBA no-MBA

much below average 2 4

below average 0 23

average 8 44

above average 9 30

much above average 8 8





new on the market were not included in this analysis.

6.3 Hypothesis (H3): Average yearly profit and estimate of success are related to age or

gender of the chiropractor

In order to test if the

average profit per year and

estimated success of business are

related to the age of the

chiropractor, with respect to the

ordinal scale on which data was

collected, Kendall tau-b

coefficients of correlation were

calculated, and their results are

shown in the Table 4. The most noticeable result is the strong positive relationship between

average profit per year and estimated success of the business (τ=0.717, p<0.01). However,

the age of chiropractor was weakly negatively related to average yearly profit (τ=-0.254,

p<0.01), but not related to his/her estimate of the success of his business (τ=-0.145, p>0.05).

This means that younger chiropractors usually earn more, while they on average equally

estimate their business success. This result could have appeared not only due to age

difference, but also due to possession and non-possession of a MBA diploma. To check if the

chiropractors with and those without the diploma differ in terms of age, a t-test was applied.

The results (t=-5.077, df=150, p<0.001) showed that the chiropractors with a MBA diploma

(M=35.13) are on average significantly younger than those without the diploma (M=39.05).

Therefore, it is not completely clear if the age is related to average yearly profit, or it is just

the effect of the earned MBA diploma.

6.4 Hypotheses (H4): Descriptive and Inferential statistics on those who had a MBA

regarding their attitudes, and attitudes of those without MBA diploma.

Further analysis was conducted on those chiropractors who had a MBA diploma

(N=31) in order to describe their attitudes towards usefulness of the diploma. Twenty-one of

them (or 67.7%; 95% CI [0.5031, 0.8517]) expressed that their MBA diploma had a

significant influence on the success of their business. However, twelve of them (or 38.7%;

95% CI [0.2055, 0.5687]) stated they had faced major obstacles in business regardless of

their diploma. Generally, obstacles were easier to overcome with an earned diploma and

knowledge gained in the process of getting it, stated twenty of chiropractors (or 64.5%; 95%

CI [0.4668, 0.8236]), while only six of them (or 19.4%; 95% CI [0.0462, 0.3409]) expressed

they would have performed better as both professional and business owner without the MBA

diploma. Twenty-three subjects (or 74.2%; 95% CI [0.5788, 0.9051]) answered they would

recommend their colleagues to earn a MBA diploma. As shown in the Figure 5, of those who

did not have a MBA diploma (N=121), 57 (or 47.1%; 95% CI [0.3809, 0.5613]) thought that

an earned MBA would have contributed immensely to their success in business, yet only 26

(or 45.6%; 95% CI [0.3228, 0.5895]) of them expressed their intention to earn the diploma in

Table 5. Results of Kendall tau-b correlations

estimated

business

success

age

average profit per year 0.717** -0.254**

estimated business success -0.145

* p<0.05

** p<0.01



the future. These 26 participants were not different from the remaining 31 in terms of age (t=-

0.812, df=55, p>0.05), average yearly profit (U=381.50, z=-0.381, p>0.05) or estimated

success of business (U=296.50, z=-0.509, p>0.05).

VII. LIMITATIONS , RELIABILITY , BIAS AND FURTHER RESEARCH

Further research is indicated, by this research, in various areas. Research into

Chiropractor’s practice may still lead to greater insight into the entrepreneurial success nature

in the growing healthcare system. Several limitations are prominently observed during this

research study and more in-depth study may lead to a more specific understanding of

Chiropractic practice’s successful integration into the healthcare systems. For example, the

element (attainment of an MBA degree) used to quantify this study could also be subjected to

further scrutiny, in order to ascertain the validity in measuring successful practice. It might be

possible to combine several other factors. For instance, variables such as increase in sales or

time to attain a positive cash flow may be a significant factor to consider and which was not a

focus in this study. According to [57] in a research concluded that “Focusing on time to attain

a positive cash flow, for example, might be useful in looking at the initial success of a

practice, before it becomes established and while it is growing”[58]. The researcher further

concluded that “despite the difficulty of obtaining a valid measure of ‘success’, which should

include new chiropractors, those in practice for less than 5 years”. The researcher indicated

that ‘If self-efficacy is related to initial success, the relationship of the self- efficacy factors of

modeling and mastery might show a more significant statistical relationship to success within

the first years of practice’[59]. Another limitation has to do with the Chiropractor’s

availability to patients. This was also not a construct in current research. Time availability for

a Chiropractor may also be an influencing but limiting factor for success, which was not

specifically measured in this research. The time availability for Chiropractors could be

linked to number of patients a chiropractor may be willing to treat, even if all things being

equal and all constructs were significantly higher. The notion construed that, if Chiropractors

have an ascertain position as entrepreneurs, then would inevitably have freedom of time in

which the determinant of freedom of time use will be dependent on the Chiropractor’s

willingness to succeed. The fact is that a Chiropractor selects who, and when, to be available

to patients and at what cost could represent a valid construct in generating new research.





VIII. CONCLUSION

The business acumen present in managing a Chiropractic practice within a cycle

involve a lot of continuous practice building strategies albeit contained contradictory

pressures for chiropractor [60]. Pushed by the need to “survive in the face of competition and

exclusion, chiropractors turned to practice management” [61]. In fact, one researcher [62]

confirms that, with this guidance has “led chiropractors to pursue two conflicting strategies

that resulted in financial survival but could not bring them a resolution to continual

competition and exclusion” (Pg. 97). In fact, the analysis showed that the very pursuit of this

entrepreneurialism jeopardized ability to gain acceptance, legitimacy, trust and recognition by

Chiropractic practitioners. And so, this process created new “social psychological dilemmas

not only for the profession at large, but also within each individual chiropractor” [63]. The

theme here is “Financial survival” in the face of stiff competition in a highly competitive

healthcare system. The resultant analysis showed that since the theme of a practitioner was to

provide more care, more services as well as generate increased revenue, [64] complete

integration of business programs or joint business degree earned would provide the necessary

skills, business acumen, knowledge and expertise to generate more revenues and high patient

volume which may lead to improved success rates. In one issue of a chiropractic journal

named, ‘Topics in Clinical Chiropractic’, one of the contributors, [65] expressed concern that

"chiropractors lack skills in practice management, capital development, and marketing to

compete in a more competitive marketplace" [66][67]. This supports this research

justifications since market completion provokes innovative ways to be competitive and

remain in business.

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