The past decade has seen substantial growth in the number of opportunities for chiropractors to practice in medical facilities. These opportunities exist at facilities ranging from large academic medical centers to smaller regional hospitals to small outpatient clinics. Facilities may be nonprofit, for-profit or public. Government-funded (public) facilities can serve general patient populations or be limited to specific populations such as the military or veterans.
The means by which chiropractors practice at these facilities also varies greatly. Some DCs are full-time employees and members of the medical staff; others simply sublease space. Some provide patient care only; others are involved in education, research and/or hospital committees. Some are well-integrated with other colleagues and departments at their respective facilities; others practice in relative isolation. Some are assigned to specific services such as physical medicine and rehabilitation or the emergency department; others are implemented as stand-alone services or as part of "integrative medicine" departments.
The emergence and evolution of these arrangements has occurred in a decentralized manner and developments are ongoing. Thus, it is difficult to portray the overall picture of chiropractic practice in medical facilities. At present, it is likely there is more we do not know than we do know. Consideration of the "way to do it" - optimal integration models, most advantageous clinical structures, processes to achieve best effectiveness and efficiency - is largely limited to opinion and anecdotal experiences.
However, one thing does appears certain: Many DCs have a continued and growing interest in this aspect of chiropractic practice. Colleagues who practice at private, military or veterans hospitals are routinely contacted by rank-and-file DCs with questions that can be aggregated into two major themes: "What is it like?" and "How can I get involved?" The answer to the latter question is elusive and must be deferred; let's attempt to shed some light on the former question, at least with regard to one particular health care system - the Veterans Health Administration.
To provide a glimpse into the nuts and bolts of chiropractic clinical practice in the system, four DCs working within the VA agreed to share their insights: Christopher Pierson, DC, a 2002 graduate of Northwestern Health Sciences University who has been a staff member of the Sioux Falls, S.D., facility since 2004; Pamela Wakefield, DC, a 1990 graduate of Logan College of Chiropractic, who has provided services at the St. Louis, Mo., facility since 2006; Shawn Neff, DC, a 2003 graduate of Palmer College of Chiropractic, and since 2005 a staff member at the Martinsburg, W.V. facility; and Forrest Lee Moses III, DC, a 1993 graduate of Parker College of Chiropractic who has been on staff at the Dallas, Texas facility since 2004. [Not all doctors answer each question.]
How Is Practicing in the VA Different From Private Practice?
Dr. Pierson: There are so many notable differences that I can't mention more than a fraction of them. I have found collaboration with different disciplines to be much greater in the VA. Medical resources, such as diagnostic testing, are more readily available. The VA's electronic medical record allows easy access to the patient's health records.
Dr. Wakefield: Yes, we have remarkable access to patients' health histories, imaging, labs and other information. The electronic system also enables us to coordinate care easily with other providers. However, we also see a much more complicated patient population, both in terms of medical comorbidities and mental health conditions.
Dr. Moses: Treating patients is the private sector is very interesting; however, serving those who have served our country, placed their lives on the line, is an honor. Hearing the veterans' stories is a strong reminder of the importance of providing the very best care each and every day.
What Are Some of the Unique Opportunities and/or Challenges?
Dr. Neff: As mentioned, there is an important opportunity to care for patients who have served our country. There is a unique opportunity to work in a community of health care providers of the highest caliber as a part of the whole, instead of as an outsider. There is also the opportunity to be the first experience with chiropractic for thousands of patients, providers, and health care trainees.
One of the unique challenges is being the only chiropractor in a very big hospital. There are days when it can be a little lonely, but you find common interests with neurologists, orthopedists, physiatrists and occupational and physical therapists, and these colleagues speak the same language and care for the same patients.
Dr. Moses: The chance to work in a hospital setting and establish chiropractic as valuable component of veterans' health care has and continues to be a very rewarding opportunity and challenge. Many providers at my facility had not worked with a chiropractor prior to my introduction in 2004. Learning the hospital protocol and establishing policies needed to introduce chiropractic in this health care setting has taken time. Now, much of the learning curve is behind us and chiropractic treatment has become an integrated and appreciated part of patient treatment.
Dr. Wakefield:The level of collaboration and integration strikes me as the most unique opportunity. Here in St. Louis, I am part of the team creating a multidisciplinary pain rehabilitation center. I am working with various medical specialties, psychologists, physical therapists, pharmacists and others. That type of opportunity has not been common in our profession.
How Would You Characterize Your Communication/Interactions With Other Providers?
Dr. Pierson: Most of the time communication concerning specific patient issues can be done through the computerized patient record system. This is very nice because there is clear documentation of the decisions and course of action taken and [it] is efficient since no time is wasted trying to contact a provider who is busy in a clinic. My clinic is physically located in rehab medicine, so I have the most interaction with that team, which includes physical therapy, occupation therapy and physiatry. It also includes chronic pain, polytrauma, and spinal cord injury clinics. I also have a good deal of interaction with a very wide variety of providers due to collaboration on facility and network projects and committee work.
Dr. Wakefield: My co-providers in the pain clinic and I meet once a week to review consults, and we speak to each other directly or by e-mail whenever needed. I will often speak in person to other providers in my same building, and I will use the electronic medical record to send a note to providers who are in other locations.
Dr. Neff: I am in constant contact with all types of other providers; whether by phone, e-mail or the casual "hallway consult." Chiropractors in the VA are, in my experience, treated as peers and colleagues in the hospital, and are regarded as [not only as]a source of information in the care of the VA patients; we are often called on to advise other providers or their family members who may need chiropractic care.
What Are the Most Important Contributions Chiropractors Can Make to the VA?
Dr. Pierson: One contribution is the treatment we can provide for veterans of the recent operations in Iraq and Afghanistan. These patients commonly suffer musculoskeletal injuries from combat due to heavy gear and body armor, motor vehicle accidents, and of course blast injuries or polytrauma. We have the chance to make corrective changes early in their lives.
Dr. Wakefield: Educating other providers, mostly by example, about chiropractors and chiropractic. Most medical providers with whom I have spoken had no clear idea about what we do. They were neither supportive nor opposed - it was just not part of the paradigm. We are adding chiropractic care to their paradigm.
Dr. Neff: Most importantly we are improving the health of the veterans by providing chiropractic care as part of their health care system. Additionally, the chiropractors in the VA bring new ideas and viewpoints to patient-centered care, clinical research and education. These new perspectives help strengthen the VA by providing innovative approaches and strategies.
Has There Been a Particularly Rewarding Moment or Case That Stands Out?
Dr. Wakefield: After we moved the chiropractic clinic to the Spinal Cord Injury building, a 32-year-old paraplegic saw we were here and asked his provider if he could see us. His provider simply and genuinely asked me what, if anything, chiropractic could do for his patient. I explained the role that chiropractic treatment could serve in this case, and the patient was [referred] to me. He had some good results and continues to be seen in the chiropractic clinic. He has a wonderful positive attitude and is a favorite patient.
Dr. Neff: I had a veteran who was bent over at the waist and was unable to walk without a back brace and walker. At initial consultation he could not even lie on the table unless I positioned him to maintain a flexed posture. I expected that his chances of improvement were slim; however there were no contraindications to a trial of treatment and no other options were reasonable. Two days later, one of the other doctors in the hospital called and asked me, "What did you do to that patient?" At first I expected that there had been a negative result, until I was told that he was walking all over the hospital with no walker or back brace. I am happy to say that this young hero is still walking upright and is now a whitewater guide and an avid rollerblader.
Dr. Moses: My most rewarding moment was establishing the affiliation with Parker College and the VA, and having my first students take part in a hospital rotation. The students have been extremely dedicated, and the education they receive will greatly enhance their ability to serve veterans and other patients in the future.
Any Advice for DCs Interested in Working in This Environment?
Dr. Pierson: I would advise continued education to grow your expertise on whatever subject you have a passion for. I recommend honing examination skills and developing an even stronger understanding of neurology as I have found that helpful when handling complicated cases and giving advice to other members of the team.
Dr. Neff: I would recommend that any chiropractors interested in working in the VA or other hospital setting definitely develop their interdisciplinary skills. Work with the MDs, PTs, OTs, DOs, ODs, and DPMs with whom you already have patients in common. Send reports make appropriate referrals, and most of all communicate for the sake of improving the care of your patients.
Dr. Wakefield: Be content to take small steps in the integration of our profession into the medical system. Be thorough in patient care and in your own professional development. Remain as academically based as possible; it affords the opportunity to learn of and participate in the latest research. There are no shortcuts in patient care or in the integration process.
Dr. Anthony Lisi is an associate professor at the University of Bridgeport College of Chiropractic. Prior to being named national director of VHA chiropractic services, Dr. Lisi became the first staff chiropractor appointed to the VA Connecticut Health Care System (2004), where he is now chief of chiropractic services. He has published numerous scientific papers in areas such as chiropractic integration, interprofessional education, and low back pain.