Integrating Chiropractic Education in a South African Hospital

Chiropractic preclinical education is characterized by three years (four years in South Africa) of increasingly relevant clinically-related education and training. Student progress from the first year to the year of clinical experience in most countries is referred to as the internship. All of this forms part of the student's undergraduate studies.

In the medical sense, an intern is usually defined as "a recent graduate or an advanced student receiving supervised training in a hospital and acting as an assistant physician or surgeon." With appropriate modifications, the definition can be applied to the education of a chiropractor, with particular reference to the "advanced student." However, the major difference between the medical and chiropractic programs in this respect is that the medical intern has a full-time year of additional clinical experience over and above the clinical experience gained. In most instances, chiropractic graduates spend no more than half of the final year gaining clinical experience. A move to change this approach in chiropractic was made by the Swiss many years ago.

In the medical model in South Africa, students are taken in to the program straight from high school. The program is for six years. After graduation the student completes one year of hospital internship and is then eligible for independent practice. Included in the medical undergraduate program are subjects such as physics, chemistry and biology, which in the North American system are part of the preprofessional program. Chiropractic in South Africa, in this respect, adopts a similar approach to medical internship. As the medical students progresses from the fourth to the sixth year, they become more involved in the management of patients, always, of course, under supervision. On completion of the six year they graduate, but are then required to complete one further year of clinical experience in provincial hospitals and clinics before being allowed to register to practice independently or to specialize. This additional year in medicine is, of course, called the internship. I am sure this practice applies in principle the world over in medical education.

In most parts of the world, the chiropractic model is slightly different, but I suspect that it is different for practical reasons. Some of these reasons may include the fact that chiropractic colleges by and large does not have the vast reservoir of patients and other resources that are traditionally found in state or provincially-funded hospitals and clinics. And because the number of patients seen at any one chiropractic teaching clinic could vary greatly, it has been necessary to set a minimum quota of new and follow-up patients that need to be seen by students. This has been one of the tasks of bodies such as the CCE or its equivalent in different countries: to reasonably ensure that senior students have received sufficient clinical experience to not be a danger to the public on entering independent practice.

One may well ask on what basis it was felt that 25 new patients and 250 followup visits constituted a sufficient clinical experience in this regard. Perhaps that question could be pursued at one of WFC's educational conferences. Even 35 new patients and 350 followup visits (or whatever numbers are used by any one college) do not keep the senior student busy all the time in the clinic: an unfortunate but understandable lost opportunity.

Do the variety and severity of conditions seen by chiropractic students in their one year of clinical experience reasonably compare with what they can expect to encounter in private practice? Are they adequately prepared to function as primary contact practitioners? Furthermore, Do chiropractic students on completion of their four or five-year programs feel sufficiently self-confident to go into private practice?

As a participant observer, it is my opinion that the answer to all of the above questions is "No."

However, in public hospitals and clinics, at least in South Africa, there are always sufficient patients to keep the medical interns busy most of the time, and hence the question of minimum quotas becomes unnecessary. It would be reasonable to assume, and our experience in Kimberley supports this, that provincial hospitals and clinics would also furnish chiropractic interns with an abundance of patients. Furthermore, a hospital or public clinic is also a source of patients with a greater variety of pathologies and psychosocial circumstances than what is found in a chiropractic teaching clinic. Therefore, sessions in a hospital setting could significantly expand the future chiropractors' clinical preparedness.

A further advantage of such an additional year of clinical experience is that although supervision of such interns is necessary, it is not the closely supervised and drawn-out exercise that is educationally necessary during the students' first year of clinical experience.

The statutory council in South Africa, which determines minimum educational requirements for registration as a chiropractor, asserts that one year of clinical experience for someone who wishes to function as a primary contact practitioner is insufficient in terms of the public interest. Furthermore, they feel that the internship, i.e., the second year of clinical experience, should, with the appropriate structuring, better prepare the intern for the "real world" of private practice.

And finally, this additional year is an ideal opportunity to increase the profession's service to the local underprivileged community. The statutory council in South Africa therefore requires that there will be two years of clinical experience before registration. The first year will be the same as that to be found at all other chiropractic colleges, while the second year, the internship, is started once the student has completed the academic and clinical requirements of the final year.

Although the South African statutory council made the decision for a second year of internship shortly after the start of our program 10 years ago, it did not then, nor does it now, have hospital or public clinic resources at its disposal in which the interns could gain additional clinical experience. Because of this, Technikon Natal makes available the resources of its Day Clinic to the interns each morning of the week, whilst the afternoons and evenings in the clinic are reserved for the final year students.

As an incentive for the senior interns to build a practice, and in line with the principle of paying medical interns for the services they render, the Technikon implemented a commission-paying basis for the senior interns for the patients they treat. Therefore, for the first 25 new patients and 150 followup visits, the interns receive 25% of the income they generate, and thereafter they receive 50%. Unfortunately, because chiropractic is still not part of the total health care service of the country, the government does not pay our interns a salary. Once chiropractic interns earn a salary, paying commissions will fall away.

South Africa is largely a developing country with pockets of developed communities. Its needs and opportunities as they relate to chiropractic may well differ significantly from those in other countries.

With this in mind, when the chiropractic program at Technikon Natal was invited in June 1996 by the Department of Health of the Northern Cape Province in South Africa to assist in the offering of health services in that area, it was seen by us as an ideal opportunity to:

• expand the experience of the interns;
• expose people to the benefits of chiropractic;
• change the attitudes of medical and supplementary
staff toward chiropractic; and
• have a positive public relations benefit.

Following negotiations with the government of the Northern Cape Province, it was agreed to start the program in January 1997. A 10-seater plane of the Red Cross Society of South Africa, the same type of plane used by the famous flying doctors of Australia, was used to fly five senior interns and a clinician (along with portable adjusting tables) on a visit to the Kimberley Hospital one and three quarters hours flight away.

The hospital fed and accommodated us during the stay in Kimberley. Five curtained-off cubicles in an otherwise open ward were made available to us. Three nurses were allocated to the clinic. They prepared the patients for the interns, ensured supplies were maintained, and organized lab tests, x-rays and referrals for patients.

It was only a matter of a few days before medical and physiotherapy staff were visiting the clinic to see who these chiropractors were who were writing such professional referral notes. One medical practitioner even stayed for treatment. Interns saw patients from 8 a.m. until about 6 p.m. Afterward, two interns would in rotation spend until about midnight assisting and observing in the emergency ward.

A summary of the patients seen reveals some interesting data. Females constituted 79% of the patients (a mean of 53.3 years of age and an age range of 2-91 years); 83% were of mixed and black African racial groups, these being historically the most underprivileged groups in South Africa. Pensioners and the unemployed constituted 42.4%. Clinically, 19.4% had problems of the lumbar spine; 14.4% of the cervical spine; 13.9% of the sacroiliac joint, and 12.5% of the thoracic spine. Extremity disorders constituted 29.8% of complaints with knee disorders constituting 11.3% and organic disorders 8.6%.

Obviously, the type of clinical experience was skewed by the high percentage of pensioners and the unemployed. But in a country where the unemployment figure lies between 30% and 40%, our service meets a very definite need of the community and slots in well with the government's policy of health for all.

As a result of the visits over the first year of the program, a full-time post for a chiropractor at this government hospital was established in January 1998. The chiropractor that holds this post is busy working on her second masters degree, this one in pediatrics through RMIT; as a result, the hospital gives her access to the pediatric ward. She also has access to two local schools for physically and mentally handicapped children for the administration of chiropractic care.

The positive attitude of the hospital superintendent and his staff, as well as of the provincial health department has resulted in an expansion of the services of the interns for 1999. Other than what I have already mentioned before, these include:

• ward rounds in orthopaedics;
• assistance in the orthopaedic outpatient department;
• observation of orthopaedic surgery;
• day trips to outlying towns for patient education in terms of
health promotion and disease prevention; and
• chiropractic care for physically and mentally handicapped children.

Who then benefits from this exercise? Firstly, the interns:

• through an exposure to patients with a wider variety of pathologies and psychosocial situations than could have been expected from an ordinary chiropractic teaching clinic;

• through additional experience by assisting in the casualty and orthopaedic outpatient wards;

• through an improved awareness of the sociology of the hospital;

• through a greater preparation for the "real world" of private practice by having to work under pressure, in that lines of unscheduled patients had to be cared for;

• by learning to use the "blank page" approach to case taking; and finally

• by gaining confidence in working in a medical environment and with medical personnel.

Secondly, the community benefits:

• it is the most underprivileged group in that area that is cared for;

• there isn't a single chiropractor in private practice in the entire province, let along in the town of Kimberley;

• this need for chiropractic care, particularly amongst the historically underprivileged communities of South Africa, is reaffirmed by two epidemiological studies done by past students of ours, one of which was presented at the 1999 World Chiropractic Congress, and also by the high numbers of patients coming to the chiropractic clinic at the Kimberley Hospital.

Thirdly, the national and provincial governments benefit, as this service helps meet a desperate need for health services in the country.

Fourthly, the chiropractic profession benefits, in that this sort of exercise is of the best public relations that one can get.

Technikon Natal also benefits through the increased status of the institution and, more importantly, from the feedback of the clinicians and interns.

What of the future? As a result of this experience in Kimberley, negotiations with the Department of Health of another province in South Africa (KwaZulu-Natal) is well under way. KwaZulu-Natal is the province in which Technikon Natal is located. This current venture is therefore vital for the further development of our program and the expansion of the profession in the country. Once our credentials are accepted in serving the community, we will make overtures for the education of our undergraduate students to include hospital experience. Should we be successful in this regard, we'll have an opportunity for true community-based education to be incorporated into our program, rather than just a community-oriented program.

Although we believe hospital experience will add tremendously to the growth of our interns, the main thrust of our educational program remains a balance of the invaluable features of both the wellness and disease paradigms. We believe that this approach will ultimately see chiropractic gaining full recognition and incorporation into all aspects of health care in South Africa.

We had an opportunity and we took it. To what extent out experience can be made of use elsewhere, each country must decide for itself. All that we can say is that everyone concerned has benefited from the experience and chiropractic's status has been enhanced.

Chiropractic has sacrificed none of its traditional paradigms. On the contrary, this experience has given chiropractic the opportunity to express them more volubly and in practical terms that are beneficial to the community. If you can manage a similar experience in your country, we can highly recommend it.