In January of 1997, Kaiser insurance (through managed care) had begun offering chiropractic and acupuncture as an option in various plans. The need to have a better understanding of these healing arts became more necessary partly because of this new option and partly because patients were asking more and more about alternatives to traditional medical practice. I met with assistant residency program assistant directors Dr. Denise Flaherty and Dr. Leslie Brickner, who explained the inception of this unprecedented program. The ACGME (Accreditation Council of Graduate Medical Education) guidelines do not implicitly state that alternative medicine be a part of the curriculum, yet there are some questions asked on the board exams which relate to alternative care. In response to this, along with requests from the residents themselves, this new program was proposed by the residency program director to the assistant directors and put to a vote. The proposal was passed by a 5-4 margin, and Dr. Flaherty designed and implemented the program.
Kaiser has an in-house behavioral medicine clinic that provides "mind/body approaches to wellness." The clinic utilizes yoga, T'ai Chi, meditation, visualization/imagery and biofeedback in the treatment of illness and the promotion of health and well-being. Chronic pain patients are referred to the clinic to help deal with the physical and psychological symptoms of pain. As this clinic is a part of the hospital, it was a simple arrangement to have the residents do a rotation there. Oakland acupuncturist Katie Mink was asked to be a part of this ambulatory program, and I gladly accepted Kaiser's request to host a rotation in my Oakland office as a representative of chiropractic medicine.
I was thrilled with the prospect of finally getting an opportunity to let medical doctors know exactly what we do as a profession. It was quite an honor to be asked to be a part of this educational process. I also felt a great degree of responsibility to my profession to do an exemplary job. With this in mind, I put together a comprehensive syllabus outlining what the residents could expect in my office, along with a detailed description of the different types of problems and injuries treated in a typical chiropractic office. Also included was an explanation of the complete examination, special diagnostic testing, treatment and referral protocols. As we chiropractors know, most medical doctors have very little knowledge of what we do in our offices. I wanted to be as specific as possible.
Internship/residency programs are the next step for a medical school graduate. This is a three-year, on-site, in-hospital training program. For the first year, students are considered interns and thereafter, second- and third-year residents. When I inquired about the amount of education medical students get regarding musculoskeletal conditions, I was not surprised to learn that their exposure is minimal. They have an eight-week anatomy course the first year--that includes the entire body! Generally they don't have a class that discusses musculoskeletal conditions. Some programs have rotations that include a couple of days with an orthopedist, but not much more than that. After graduation, interns choose a residency program in the area they want to specialize in. The group involved in the alternative care rotation are internal medicine specialists. In their second year of residency they participate in a one-month musculoskeletal block. This includes time spent in orthopedic medicine, occupational medicine, podiatric medicine and sports injury urgent care. Suffice it to say, they are hungry for more knowledge in musculoskeletal injuries by the time they get to my office.
The first resident arrived in my office in August 1997. I explained to her that she would basically be following me around as I worked on my patients. She would primarily observe, but occasionally I would have her feel hypertonic muscles and altered joint motion. I would explain as much as I could about what I was doing without imposing on the quality of care the patient was entitled to receive. The vast majority of my patients were very cooperative and amenable to having the residents observe their treatment. The patients seemed as eager as I was to educate medical doctors about the benefits of chiropractic, and they often shared stories about their "Kaiser experiences." This first resident seemed interested initially, even somewhat enthusiastic, yet always a bit measured and distant. I was disappointed when she only came two of the four weeks that she was supposed to attend. At the end of her rotation I called the assistant director to find out what the response had been. As it turned out, this particular resident had her mind made up in advance that she was not interested in alternative medicine. She was just as non-responsive in the other alternative care rotations.
In the beginning of any new program, there are always a few bugs to be worked out. WHen the next resident came, I had him fill out a questionnaire detailing his expectations, what he hoped to learn, and any questions he had. I gave him chiropractic educational material and I reviewed the syllabus with him. At the end of the four weeks I had him critique the rotation. This resident's reaction was the complete opposite of the first. He was interested in learning as much as possible about what we do. His main concern was understanding what cases were appropriate for referral to a chiropractor. He was very thankful for the opportunity to come to my office, and he came back to my office later for an examination and treatment (I offer this as a part of the rotation).
I had an interesting experience the day one of the assistant directors, Dr. Brickner, came in to observe my work. The first patient I had that afternoon was a middle-aged woman suffering from persistent, nonresponsive thoracolumbar pain. Prior to the visit I had sent her for x-rays and the radiologist had noticed calcification in and around her kidney. I referred the woman to her medical doctor, who referred her to a nephrologist: she had kidney stones in her right kidney (her other kidney had been removed). It was a perfect case for Dr. Brickner to see how various medical professions can work together in the diagnosis and treatment of a patient's condition.
Presently there are five residents that have gone through the chiropractic rotation. I routinely have the new residents fill out an initial questionnaire so I can focus on their main concerns in the time they spend with me. The following is a list of common questions and concerns given by the residents thus far:
- When is it appropriate to refer a patient to chiropractic?
- How does chiropractic differ from physical therapy?
- Are there different types of chiropractors?
- How does the Kaiser insurance coverage work with chiropractic? What are the costs?
- What should the patient expect?
- At what point do chiropractors refer their patients?
- How can they reassure their own patients about the myths of chiropractic, and how can chiropractic be used with their area of medicine to better serve their patients?
And here are some suggestions for future residents:
- Observe different types of treatment.
- Observe the process involved in arriving at a diagnosis.
- Observe the kinds of tests and maneuvers that are utilized in the diagnostic process.
- Get a feel for the type of patients who see a chiropractor, and their expectations.
At the end of each rotation the residents fill out a critique of each specialty that they have visited. I spoke with Dr. Brickner last week; she reported that the majority of responses from the residents have been positive. On the rating scale used, the chiropractic rotation has been rated as "great" (the highest rating). The residents indicated that this program has been very helpful and informative. The residency directors at Kaiser Oakland plan to continue the alternative care rotations with the next class of third-year residents.
I hope to continue participating in Kaiser's innovative educational opportunity. We can only hope that other medical teaching facilities will soon follow suit. This is certainly a step toward breaking down the interprofessional barriers that have for so many years cheated patients out of their right to know about alternative healing options. There is an appropriate place for each medical field in our continual search for wellness. As health care professionals we are all responsible for providing the best possible care for our patients (whether it is in your office or someone else's) regardless of the specialty. I applaud Kaiser Oakland for implementing this innovative program and paving the way for better understanding and harmony between medical professions.
Abby Irwin, DC, DACBSP
In Line Chiropractic
2100 Lakeshore Ave, Suite E
Oakland, CA 94606
Tel: (510) 893-1577
Fax: (510) 893-8907
Editor's Note: Dr. Abby Irwin is a graduate of Life Chiropractic College West and has been practicing chiropractic in Oakland, CA since 1987. She specializes in sports chiropractic, having completed her CCSP and DACBSP with Los Angeles Chiropractic College. Dr. Irwin has been team physician for numerous local and national sporting events, including the 1996 Summer Olympics in Atlanta as a team physician for Panama; Women's pro beach volleyball; the World Corporate Games; and the national rugby, powerlifting and volleyball championships. She has also been the team physician for the national champion women's rugby team at the University of California at Berkeley since 1993.