Editor's note: This interview appeared originally in its entirety in the January 2013 issue of Health Insights Today (www.cleveland.edu/hit), a publication of Cleveland Chiropractic College - Kansas City. It is reprinted with permission from the college. Part 1 of our reproduction appeared in the June 15 issue of DC.

To what extent do you think the role of chiropractors in the VA can serve as a model for greater chiropractic integration elsewhere in the American health care system? That's a very important question. It would appear that it could serve as a very valuable model because of the size of the VA and the characteristics of VA's administration and the ways things are coordinated. Chiropractors have only been in VA for a short time [since 2004]. Chiropractors have been in Department of Defense facilities since the early 1990s and at private health care facilities since earlier than that. But it seems that the VA program is the most centrally coordinated and perhaps the most thoroughly integrated. So, I think that the experiences in VA are very likely to be influential in introducing chiropractic services in other systems.

Could you tell us about the demographics of chiropractic patients in the VA system? Are these mostly older veterans with chronic conditions? Is that changing as tens of thousands of active-duty service members from the wars in Afghanistan and Iraq transition into veteran status? There are about 22 million living veterans in the United States and about 5.5 million receive care at the VA in any given year. We've had something like 1.5 million veterans from the Iraq and Afghanistan conflicts who have left service and become veterans, and a little more than half of those, about 830,000 or so, have actually used VA health services. So the number nationally is changing. We've got 5.5 million of our existing population and about 830,000 newcomers who are mostly from younger age groups. But at this point the overall population tends to be older patients, mostly from the Vietnam era. We do have a number of Korean War veterans and we see a few 90-year-olds from World War II. But most are Vietnam era, with a growing number from the post-Vietnam and now the current conflicts.

Is it true that the number-one health problem, at least for the veterans of the more recent wars, is musculoskeletal conditions? Of those approximately 830,000 Iraq and Afghanistan veterans, the most common diagnostic problems seen in these patients are diseases of the musculoskeletal system. Based on our most recent data, those conditions were present in about 57 percent of these veterans, with mental disorders a very close second, at present in about 53 percent. So, musculoskeletal injuries are highly prevalent in the current conflicts and they account for a large number of the patients we see in VA clinics.

To what extent does post-traumatic stress disorder influence the effectiveness of chiropractic care and other physically-based care? That's an excellent question. There is a common overlap of musculoskeletal pain conditions and post-traumatic stress disorder. In fact, we even consider a third “P” to describe the triad of pain, PTSD and polytrauma, which is a term that refers to injuries to multiple systems, typically from blast injuries. It's often very challenging to find the dividing line separating the symptoms of one condition from another. That requires a coordinated team effort among the VA providers in managing these various conditions that veterans may have. In short, it does make management of musculoskeletal conditions much more challenging.

This is an important point not only for chiropractors working within the VA, but also for readers who may be in private practice and may see patients who are veterans. It is important to be aware that these comorbid conditions may be present.

What was there in your background, if you know, that led to your selection to fill the position you now occupy in the VA? At first, VA announced an initial group of 24 clinics back in 2004 for the initial rollout of chiropractic clinics. I applied for and was selected for the position at the VA facility in West Haven, Connecticut. All of these positions and the ones that followed were very competitive. I learned after the fact that there were 125 applicants for the Connecticut position. The factors that were helpful in my case, in addition to clinical competencies, were my background in academics, research and publishing. Those attributes, and the fact that I followed an evidence-based approach to practice, were strongly resonant with what the VA was looking for.

Speaking of the academic world, the VA has long functioned as the nation's largest site for medical residencies. In what ways do chiropractic educational institutions currently have affiliate relationships with the VA? And is there expansion on the horizon into the area of residencies? At last count, we have 17 VA facilities that have established academic affiliations with 11 different chiropractic colleges. These academic affiliations have been for the training of chiropractic students, very much like medical or dental students do rotations through the VA. We have had that in place since 2004, and over the years more than 1,500 chiropractic students have completed clinical training at various VA facilities. My office has been working to establish a residency program for graduate training of chiropractors. This is still in development. We don't have a clear timeline, but we are committed to making it happen.

This would be a major step forward for the profession. Absolutely, and it would be congruent with VA's mission, which includes training providers to serve VA and the nation at large. We anticipate additional chiropractic positions continuing to open in VA and other health care systems; thus, it is important to train young providers who may be filling these positions. I believe we have the infrastructure to do this, and are working to develop the funding.

And the other professions that have VA residencies do have that funding? Exactly. The vast majority of residencies are funded so that the resident draws a stipend during his or her training. That's the model we're trying to put in place for chiropractors. I should add that one chiropractic college has funded its own residency for a pilot residency project – New York Chiropractic College, at the Canandaigua, New York, VA facility. We're viewing that as an excellent model to demonstrate our capacity for DC residency training in VA.

With a typical residency for the other health professions, how long does it last and what does it entail? We've put a lot of thought into this. We have considered our experiences with chiropractic student training, and the characteristics of residencies in optometry or dentistry. Those are two professions that do not require residencies for licensure; but provide residency training for optional advanced competencies. In most cases, these tend to be one-year programs. Other professions like medicine or podiatry have a required residency as a component of licensure, and the residency duration is based on the given requirements. Based on these and other factors we are aiming to develop a one-year program for chiropractors that would be a full-time residency, with requirements for rotations in various specialties to facilitate interdisciplinary training and interprofessional education.

It sounds like you and the other DCs in the VA are taking the long view and proceeding step by step. Is there anything you'd like to add that we haven't discussed yet? For most chiropractors, I think it may be important to consider one hidden benefit of a successful VA program. In VA our goal is to provide the best chiropractic care for the men and women who have served our country – that's why we're here. But an interesting side effect of this is that a large number of physicians who train in VA facilities are now engaging in their training at hospitals that house chiropractic clinics.

So, the presence of chiropractors as part of the integrated team is seen as a normal part of care delivery. Precisely. It becomes part of the mentored training under the supervision of their attending physicians. At my hospital and at dozens of others, the chiropractic clinic will often receive consults from residents in internal medicine, neurosurgery or other specialties, and these residents are sending consults in the typical course of their training. We know that physician behavior, and all provider behavior, is largely determined by their mentored training. It is very hard to change provider behavior once they are out in practice. For those chiropractors who view increased cooperation with and increased referrals from medical providers as a valuable result, the VA program can be a strong facilitator of that outcome.

Many DCs who are in private practice in a community, who may never practice in a VA hospital, may encounter a new primary care doctor in town who has become accustomed to referring to chiropractors as a result of his VA training. I think that is an important benefit to the chiropractic profession at large. That, along with the potential for advancing educational and research opportunities, makes the success of the VA chiropractic program extremely relevant to the advancement of the chiropractic profession.

Dr. Daniel Redwood, the interviewer, is a professor at Cleveland Chiropractic College – Kansas City. He is the editor-in-chief of Health Insights Today, associate editor of Topics in Integrative Healthcare, and serves on the editorial board of the Journal of the American Chiropractic Association. Visit Dr. Redwood's website and health-policy blog at www.redwoodhealthspeak.com.