By Donald R. Murphy, DC, Stephen M. Perle, DC, and William Defoyd, DC
THE PROVISION OF ANY TYPE OF HEALTH CARE involves trained individuals (e.g., doctors, therapists, etc.) evaluating and providing services for sick, injured or otherwise ailing patients. Generally, this work requires the ability on the part of the practitioner to recognize signs and symptoms and to use skilled diagnostic and treatment procedures. Because these professionals are involved in the intricate, complex and often vulnerable nature of human health, considerable knowledge and vast experience is required to ensure maximum safety and efficacy of their services. Much of the background information needed to produce high-quality health practitioners can be obtained via textbooks and classroom education. The basic sciences, principles of health care and such topics as pathology and epidemiology can appropriately be learned in this way.
However, when it comes to developing clinical skills, classroom and textbook learning are not, in and of themselves, adequate. For this reason, virtually all primary contact health professions have, as an integral part of their education, an extended period of supervised clinical training. This has been standard in the allopathic medical profession and the dental profession for decades and more recently has become standard in non-allopathic professions such as podiatry.1 In addition, the physical therapy (physiotherapy) profession has begun a strong push toward enhanced clinical training via postgraduate residency.2 This article will discuss the need for, and the benefits of, the development of a postgraduate clinical year in the training of chiropractic physicians.
Necessity of Postgraduate Clinical Training
The chiropractic profession worldwide has been attempting to increase its cultural authority and establish itself as an important health care profession that is widely seen as providing needed services to society. Essential in this process is establishing credibility. Currently in most jurisdictions, chiropractic training includes a brief clinical experience called, within the profession, an “internship,” which takes place prior to graduation and occurs primarily in isolated school outpatient clinics as opposed to interdisciplinary centers of excellence. For the profession to increase its credibility in the minds of members of society, it is necessary to substantially expand the clinical portion of chiropractic training. This can be accomplished by converting the current internship to a fourth-year clinical clerkship and instead creating a residency that occurs after graduation, lasting a minimum of one year.
In most jurisdictions around the world, chiropractors are primary contact providers. That means patients see chiropractors without referrals. As such, the public expects that chiropractic physicians are well-prepared to recognize and handle a variety of human ailments and clinical situations. In order to adequately fulfill this expectation, it is necessary for future doctors of chiropractic (DCs) to be exposed during their training to all of the clinical conditions DCs will likely see in practice, even ones that the chiropractor will not necessarily treat.
Benefits of Postgraduate Clinical Training
It is critical for the practicing chiropractic physician to have both expertise and confidence in his or her ability to respond to the demands placed on any primary contact health professional. This expertise and confidence, as well as demonstrated additional clinical proficiency, comes from having experienced, under the supervision and guidance of one or more seasoned clinical mentors, a wide variety of conditions and clinical situations. A postgraduate clinical year, conducted at an established center of excellence that would typically be affiliated with a teaching hospital, can provide this expertise and confidence.
Also important to the practicing DC is an ability to interact effectively with other members of the health care team. Spending a year in an interdisciplinary environment in which the chiropractic intern spends time with other physicians, therapists, nurses and ancillary personnel provides the chiropractor with an understanding of the activities and thought processes of others involved in patient care. In the emerging health care environment in which future DCs will be practicing, appropriate communication among providers will be expected. The postgraduate clinical year will prepare DCs for this future.
The benefit to the chiropractic profession of a postgraduate clinical year will be the respect and cultural authority that comes from being a well-trained, experienced practitioner. In addition, it will help expand the awareness among other health professionals of the expertise of DCs and the benefits of the care provided, which will serve to enhance interdisciplinary interaction and referrals.
The postgraduate clinical year will have a research and scholarship component. This will greatly contribute to the much-needed research efforts in the profession and further contribute to cultural authority by expanding the scientific and scholarly contribution of the profession to the scientific literature.
Most important, the postgraduate clinical year will benefit the patients who are served by the chiropractic profession by ensuring that licensed DCs have the training and experience to provide optimum diagnostic and therapeutic services.
Obstacles and How to Overcome
Ideally, the postgraduate clinical year should: 1) take place in established centers of excellence run by experienced chiropractic physicians who are among the top in their field and who have affiliation with a teaching hospital; while providing 2) opportunity for rotations in a variety of medical primary care and specialty departments; 3) a research infrastructure; and 4) a large enough patient flow to ensure a widely varied clinical experience.
Currently, there are too few facilities in North America and many other countries to accommodate all chiropractic students now enrolled in school or preparing to enter. Thus, it will probably be necessary to begin the process at those facilities at which a postgraduate internship can begin immediately with select interested and qualified students. In the authors’ combined experience, a large number of students would readily welcome the opportunity to engage in such a postgraduate internship/residency even before this becomes a standard part of chiropractic training.
The chiropractors who graduate from such a program will likely, in some cases, become future internship/residency sites and, in other cases, will become clinical faculty for those colleges that become involved in the postgraduate clinical year program.
One potential obstacle will be funding. The intern/resident will require being paid a salary consistent with other health care professions. This will not be a salary commensurate with a physician. Funding sources may have to be sought to cover this in part, but because the clinical year will be postgraduate (i.e., the individual will already have his or her DC degree), the facility hosting the internship/residency will be able to bill for the intern/resident’s services, which can be put toward his or her salary. This will also serve to incentivize centers of excellence to take part in the postgraduate clinical year program.
We believe that the postgraduate clinical year is overdue in the chiropractic profession. There will be challenges to instituting this process, particularly in making it a standard part of chiropractic education, but these challenges can be responded to and the benefits to the chiropractic profession and the patients it serves will be worth whatever effort is needed to make it happen.
1) Murphy DR, Schneider MJ, Seaman DR, Perle SM, Nelson CF. How can chiropractic become a respected mainstream profession? The example of podiatry. Chiropr Osteop. 2008;16:10.
2) Di Fabio RP. Clinical expertise and the DPT: a need for residency training. J Orthop Sports Phys Ther. 1999;29(2):80-2.
On behalf of the committee on residency programs of the West Hartford Group:
Donald R. Murphy, DC, DACAN, is clinical director, Rhode Island Spine Center; clinical assistant professor, Department of Community Health, Alpert Medical School of Brown University; and adjunct associate professor, Department of Research, New York Chiropractic College
Stephen M. Perle, DC, MS, is professor of clinical sciences, University of Bridgeport College of Chiropractic.
William Defoyd, DC, MA, DABCO, is associate medical advisor, Texas Department of Insurance-Division of Workers’ Compensation.