Have you witnessed a patient with a severe disc herniation who appears afraid to move - fearful the pain will find them? Have you ever seen a patient with renal colic who keeps moving, trying to escape from the pain? Have you seen a patient with a vertebral tumor who has unrelenting pain regardless of position? If you confidently answered yes to these questions, you have clinical experience.
I thought working in an inner city had given me above-average experience with atypical diagnoses. Many of my office patients have a history of inadequate regular medical care. They only came to see me because they were injured or developed pain they couldn't tolerate. The percentage of patients who had regular medical check-ups has been very low. This has given me the opportunity to be the first provider to uncover the diagnosis in many patients.
While I have had the opportunity to diagnose an occasional kidney stone, tumor or osteitis condensans ilii, I had never seen a patient with an abdominal aortic aneurism, temporal arteritis or other less common, but significant red-flag diagnoses, before I started working in the ER. Without prior clinical exposure to these other types of patients, I, like many others, had to rely on a combination of "book learning" and a high degree of suspicion.
Obviously, graduating chiropractors who are afforded the opportunity to spend time in a hospital emergency room will benefit greatly from the experience. Working with Dr. Thomas Ventimiglia of New York Chiropractic College, we have taken the first baby steps toward developing a chiropractic student internship program in the emergency department. To date, we have had three interns spend one month each following us in our offices and in the hospital.
New York Chiropractic College's externship program matches senior students with established chiropractors. Most seasoned chiropractors can remember having all of the answers upon graduation, only to realize how much there was to learn after entering private practice. The NYCC program allows the graduating student the opportunity to become familiar with the reality of chiropractic practice before being thrust out into the real world.
Starting a chiropractic internship at a hospital program is replete with red tape and road blocks. In our hospital, we were very lucky to have been able to utilize the volunteer services department as an easy means of entry into the hospital. Our college interns were screened by volunteer services and trained in universal precautions, patient transportation and basic hospital rules. They then were assigned to the emergency department (ED) under our supervision. While the interns were not permitted to engage in direct patient care; they were present to observe and ask questions. They were welcome in the ED because they were helping. As volunteers, they would bring blood to the lab and transport patients to radiology or up to the inpatient floors. During and between their travels, they enjoyed interactions with hospital staff.
The chiropractic interns had the opportunity to listen to the colorful war stories of the ER nurses. They saw the variety of players who make up the hospital team. While the brain surgeon is responsible for knowledge, judgment and holding the scalpel, there would be no surgery without the anesthesiologist, surgical nurse, supply clerk, housekeeper, orderly, administrator and so forth. Fame, title, salary and political influence may differ, but a variety of personnel are necessary for a hospital to function at an optimum level. All involved should feel important - because they are. Best of all, the interns witnessed how chiropractors fit in as valuable members of the team.
One of the most important teaching tools was lunch. Our interns had the opportunity to feast in the physicians' dining room. This informal setting gave them the opportunity to meet a variety of medical specialists. The lessons were sometimes subtle, but always enlightening. The interns were able to speak with medical physicians as individuals, colleagues and intelligent resources of endless medical information and philosophical insights.
The interns had the opportunity to tag along with members of the medical staff. They learned the importance of studying the night before. The medical physicians treated the interns with unexpected quizzes (e.g., "What is the hormone that controls sodium levels?"). Fortunately our interns were well-prepared and represented our profession admirably. (For those of us who have forgotten, aldosterone is the main sodium-retaining hormone in the kidneys.)
One of my chiropractic college anatomy professors advised that graduating chiropractors should not return to teach for at least five years. The professor spoke of graduates who had taken on teaching positions while lacking the insight that comes from experience. These neophyte instructors could only pass on information from the books they had read.
Teachers need to have experience above and beyond that of the typical practitioner. Professors have the ultimate responsibility to teach from experience. Wouldn't it be fantastic if all chiropractic professors had emergency department experience?
In the movie "The Wizard of Oz," the wizard awarded the scarecrow a diploma and proclaimed that the difference between the scholar and the common man is the diploma. We have all seen professionals fall back on their degree as the basis for an opinion or to justify the use of the title, "doctor." In reality, the doctoral degree cannot be earned once. It needs to be earned over and over during one's career through continuing education. The best education is, of course, experience.
A good drill sergeant is the one with battlefield experience. The war veteran is much more likely to teach from the heart and place appropriate emphasis on what will save lives and win battles. Our goal in the hospital is to gain recognition so we can contribute our healing skills to a greater number of people in new and more diverse settings. Students and teachers with ER experience can help us win some battles and eventually the war. Taking advantage of the volunteer services department is a good way to initiate internship programs without the difficulty of changing the hospital's bylaws or searching for ways to fund a new program.
Click here for previous articles by John Cerf, DC.