Chiropractic Training at VA Medical Facilities

Since the introduction of chiropractic services to the Veterans Health Administration (VA) in 2004, there have been a number of developments at the national and local levels. One development of much success and pride is the academic affiliations for training chiropractic students.

Part of the VA's mission is to promote excellence in the education of future health care professionals. This educational effort is led by the Office of Academic Affiliations, which oversees the training of health care professionals who will serve the needs of the VA and the nation. In 2008, more than 30,000 medical residents, over 20,000 medical students, and in excess of 50,000 other health professionals received some or all of their clinical training at VA facilities. This is accomplished through partnerships with more than 1,300 academic institutions including schools of medicine, dentistry, optometry, podiatry and nursing, among many others.

As many readers may know, chiropractic colleges are now among this group as well. As of April 2009, 17 VA facilities have established academic affiliations with 11 chiropractic colleges (see table) and several others are in development. These affiliations are not required by the law that established chiropractic services in the VA; rather, they arose from the successful work of individual VA doctors of chiropractic, the willingness and support of the given VA facilities, and the cooperation of the affiliated chiropractic colleges.

The first such affiliation was realized in 2004, with several others initiated each year thereafter. To date, more than 500 chiropractic students have participated in VA training rotations. Under the direction of the supervising DC, chiropractic students function much like they do in a chiropractic college clinic setting, taking patient histories, performing examinations and providing treatment.

These training opportunities - called clerkships in medical education - mark a significant step in the evolution of chiropractic education. Our students are exposed to a broad patient population, hospital policies and procedures, and integrated case management strategies. A number of chiropractic colleges had developed such opportunities with other medical facilities prior to the VA program. However, at present the VA is the largest integrated health care system in which chiropractic trainees can acquire clinical skills along-side other medical professionals.

To provide a glimpse into the perceptions of those who have gone through one program, three recent graduates of the University of Bridgeport College of Chiropractic (UBCC) have agreed to share their insights in the following interview format. All three completed a VA clerkship at the VA Connecticut Healthcare System under my supervision.

Gregory Mara, DC, is a 2006 UBCC graduate practicing in Carver and Cohasset, Mass. His practices are in the physical therapy department of a medical center and a health club, respectively, and about 90 percent of his patients are from medical referrals. Andrea Buccino, DC, is a 2007 UBCC graduate practicing in Essex County, N.J. She has practiced in conjunction with a medical neurologist, and sees a varied patient population including occupational injuries and general orthopedic conditions. Norman Eng, DC, is a 2007 UBCC graduate practicing in Atlanta, Ga. His practice approach includes myofascial and manipulative techniques, with a focus on functional rehabilitation of patients with diverse musculoskeletal conditions.

Do you feel your clinical training at the VA has helped you in practice, and if so, how?

Dr. Mara: Absolutely. The integrated setting at the VA provided a unique understanding of traditional allopathic care pathways for spine pain and provided a background for integrating chiropractic care into the local medical and hospital communities.

Dr. Buccino: Yes. I developed the opportunity to work with a neurologist early in practice and began seeing some complicated chronic pain cases. I felt prepared for this due to my clinical experience at the VA with many patients who had failed previous therapies, injections and even surgeries. I was able to discuss the application of chiropractic treatment to complicated cases in a hospital setting, and apply that to the private practice arena.

Dr. Eng: I agree; my VA training has allowed me to identify and manage complex cases in my practice. During my first year in practice I saw a patient with severe degenerative lumbar spondylosis with appreciable weakness and atrophy in her right leg who required a neurosurgical consult. My training at the VA has not only helped me identify such severe cases, but also has taught me appropriate case management.

How was the VA experience different from your clinical training at the college clinic?

Dr. Eng: The experience at the VA allowed me to evaluate and treat real-world patients with conditions that seldom come through the doors at chiropractic college clinics. This truly challenged my academic and clinical skills, exposing me to various conditions and complicated cases. In addition, the VA allowed me to work in an integrated environment with MDs of various disciplines.

Dr. Buccino: That is an important point. It is a valuable opportunity to co-manage cases with many providers - neurologists, orthopedic surgeons, pain management physicians, PTs, OTs, psychologists - as you discuss and deal with a wide range of co-morbidities. It really prepares you for whatever is out there.

Dr. Mara: The VA provides the opportunity to experience a diverse patient population with multiple co-morbid health factors. Also, we must collaborate in care with the medical providers and communicate with them. In the VA, the consult note for every pa-tient is transmitted to the primary care physician or other referring doctor. Most interns at chiropractic college clinics do not have the chance to collaborate or communicate with medical doctors.

Is there a particular patient who stands out in your memory?

Dr. Mara: One patient who comes to mind is a veteran stricken with ALS. It was my first experience with a "sick" patient. The patient's deterioration was rapid, from cane, to walker to wheelchair; however he still managed to attend his treatment visits and he appreciated the significant relief from the mechanical joint pain he was suffering from due to his relatively immobile lifestyle. This experience allowed me to understand that there is a time and place for palliative care, and will forever remind me of the value in providing education and compassion.

Dr. Eng: One particular patient I remember still to this day is the most complex case that I have encountered. He had severe cervical and lumbar degenerative spondylosis with radicular symptoms and sought out conservative care. HVLA spinal manipulation was essentially contraindicated in his case due to a number of reasons. However, we were able to employ a more suitable treatment, which consequently led to improvements in his condition.

Dr. Buccino: I remember a particular patient who is a double amputee. He had severe neck and upper back pain due to relying on upper back muscles to compensate for his lower extremity deficit. Our approach to treating this patient was challenging, not only physically, but also because we had to take a sensitive train of thought while interacting with [him]. I can remember every aspect of my dealings with this patient, and it is something that I will take with me as I continue in practice.

Do you feel there is value for current and future DC students to train at VA or other medical facilities?

Dr. Buccino: I recommend this to all students since there is no doubt the educational experience will help you in practice during your professional career. At the VA, chances are you will be likely to diagnose and manage any rare or complicated case you may have learned about in school. You will feel prepared for practice because there is nothing that can surprise you after having worked there.

Dr. Eng: Yes, there is great value for students to train at medical facilities. Such environments help harvest a student's skills and mold them for situations that may come through their door in the future. Most patients I encounter have co-morbidities. Being able to appropriately identify, manage and treat the most difficult cases makes the more common conditions easier to handle.

Dr. Mara: The VA experience is the closest educational experience to a medical internship that chiropractic currently offers. This is often the only opportunity a chiropractic intern may have to interact with the medical community and contribute to an integrated care plan. I would like to see our profession develop more of these student opportunities and possibly postgraduate training as well. Opportunities such as these can help us to gain the skills and the cultural authority required to best serve our patients.

The experiences of these new DCs - and of those who have trained at other medical facilities - have likely prepared them more thoroughly than most DCs who trained 10 or more years ago could have imagined. Certainly the current number of these clerkships is limited, so only a portion of our students can capitalize on these opportunities at present. However, as proposed by multiple speakers at the March 2009 ACC-RAC conference, the chiropractic educational community appears to have strong interest in furthering interdisciplinary, collaborative training opportunities for students and residents. As the VA chiropractic program continues to develop, it is positioned to contribute substantially in this regard, helping to educate chiropractors who will best serve VA patients and the nation at large.

This is the second in a series of articles by Dr. Lisi on chiropractic in the VA. "Giving Our Veterans the Care They Deserve" appeared in the Jan. 29 issue.