By James J. Lehman, DC
ACCORDING TO THE ROBERT WOOD JOHNSON FOUNDATION, research has long suggested that interprofessional collaboration improves coordination, communication and, ultimately, the quality and safety of patient care. It uses both the individual and collective skills and experience of team members, allowing them to function more effectively and deliver a higher level of services than each would working alone.1 The University of Bridgeport and the Community Health Center, Inc. of Middletown, Conn., have embarked on a journey to improve interprofessional collaboration within a community health center, which includes the integration of chiropractic services, education and research. (For more on the Community Health Center, Inc. of Middletown, Conn., see “Health Care Reform: Integration of Chiropractic for Chronic Pain Treatment into Community Health Centers,” Jan./Feb. 2016 ACA News, Page 14.) This article introduces the University of Bridgeport’s chiropractic resident training program and the opinions of its first three residents.
University of Bridgeport
The University of Bridgeport (UB) through the health sciences postgraduate education department and the College of Chiropractic launched a three-year chiropractic orthopedic residency on Oct. 1, 2013. The program emphasizes the provision of chiropractic medicine services within an excellent primary health care system, the Community Health Center, Inc. of Middletown, Conn. This health care system is a federally qualified health center and a patient-centered medical home, which is committed to caring for special populations and focused on improving health outcomes, as well as building healthy communities.
In order to provide chiropractic specialty training and postgraduate education to chiropractic graduates, the full-time, three-year chiropractic orthopedic resident training program was developed. This training program prepares chiropractic physicians to become specialists in the evaluation and management of neuromusculoskeletal conditions with a focus on chronic pain. This community health center- based advanced clinical training program enables the resident to apply to sit for the Academy of Chiropractic Orthopedists examinations. Successful completion of the two-part examination grants certification as a chiropractic specialist, which demonstrates an exceptional competence in chiropractic orthopedics. At this time, three chiropractic residents are pursuing a diplomate in chiropractic orthopedics. Upon attainment of the credentialing as a chiropractic specialist, the resident may enter a three-year neuromusculoskeletal medicine fellowship.
Jonathan Rosa, DC
The University of Bridgeport College of Chiropractic (UBCC) provided me a solid foundation in basic skills, but I wanted more. I desired additional clinical training with a mentor. I wanted to be well-equipped with all the tools and abilities necessary to gain clinical expertise in chiropractic orthopedics. Soon after graduation as a doctor of chiropractic, I was offered an opportunity to start the chiropractic orthopedic residency program with specialty in neuromusculoskeletal medicine. It is a three-year endeavor to develop and expand my knowledge in the chiropractic field.
The first year of the residency program consisted of being in class as a teacher’s assistant and shadowing a chiropractic faculty member with a diplomate in chiropractic orthopedics for one day a week; the other days I treated patients on my own. There is no doubt that the first year is the scariest; you are trying to put everything that you have learned in chiropractic school together and apply it to the best of your abilities.
The advantage I had of being a teacher’s assistant in classes like differential diagnosis, neurology and orthopedics was that I could continuously practice and refresh my memory on what, in my opinion, are the most important subjects and expertise of being a chiropractor other than manual skills. Teaching and helping chiropractic students allowed me to retain and focus on the importance of neurological and orthopedic testing by repetition. This repetition served me well and was useful in building my skills for the clinical part of my residency. I also had constant access to a clinical expert who could answer my questions and guide me through my critical thinking when treating patients. ‘What should I do if someone presents with a particular condition? What are the best ways of treating it?’
Shadowing Dr. Lehman gave me one-on-one time to observe and ask not only about how to treat, but how to diagnose different conditions and manage patients’ varied personalities. Most of my confidence and retention of information came from assisting in class and observing how the different aspects of diagnosing with history and examination are integrated into daily patient care. The residency has given me a great deal of experience in patient management and exposure to a large variety of medical conditions.
After gaining confidence and organizational skills, the second year helped to build on the foundation of my skills, from pain management using acupuncture, to broadening my knowledge of more complex cases that might present to a chiropractic physician. I completed acupuncture training, which functions as another tool that enables me to serve my patients experiencing pain. Through the residency, I was able to complete an online neuromusculoskeletal medicine program, which contains a series of diagnostic and communication drills. These drills are extremely useful; I may apply what I have learned the following day. I feel that my diagnostic skills have improved because of the additional hours of training, and I can target the problem much faster.
Now that I have completed two years of training and am currently working on my third and final year of the residency program, I realize that I have gained a great deal of valuable experience. It has not been an easy program to complete. I have exerted much effort and many hours and weekends to achieve what I have accomplished. There is no doubt that this postgraduate training has made me a better clinician. For my last year, I hope to continue learning and build on what I have completed, through different specialty rotations I plan to attend.
Mildred Oxilas, DC
When I was completing my clinical rotations at a Veterans Affairs hospital, I remember thinking to myself, “This is where I could be of most use.” It doesn’t mean there is an absence of potentially important roles for me to play had I decided to pursue a career in private practice, but I knew that I wanted more — I needed more.
As a second-year orthopedic resident, I have gained tremendous insight as to what it takes to truly practice in an evidence-based and patient-centered environment. One of the strengths of this program is that it allows me to add layers to my clinical thinking. My ability to achieve this has been a direct result of my daily interactions with mentors, advanced practitioners, specialists and primary care providers. Another advantage of the residency training program is the exposure to a plethora of complex cases, a feat I believe could only be achieved by serving within the Community Health Center, Inc. The populations we predominantly serve often have been diagnosed with multiple comorbidities and, as a result, are often taking a number of medications. Subsequently, I have observed that these same patients often express their contentment with being patients in a coordinated care organization that provides their patients with an array of options in achieving their overall health goals, including non-pharmacologic treatment, which we provide.
What I have observed during my first two years is a commitment to quality patient care and the desire for clinicians to expand their knowledge base. Many of us have been guilty of this in the past — thinking we are practicing in isolation — but I believe this might be the worst possible way of thinking. Health is not achieved within a vacuum. Working within an integrated health care organization has allowed me to play a part in efficient, coordinated care exchanges with my colleagues. Relationships among primary care providers and specialists, including chiropractic, develop organically; as a result, everyone is always looking for opportunities to learn from one another.
It is my opinion that pursuing advanced clinical practice through postgraduate studies helps to fill in the gaps that may have been difficult to bridge during my basic chiropractic education. Furthermore, pursuing board certification in orthopedics through this clinical training opportunity has provided me with the chance to hone my clinical decision-making skills through formal preceptorship. As a result, I am certain that upon receipt of advanced training status, I will be more than prepared to continue to function as part of the medical team in any coordinated care organization.
Ultimately, while the chiropractic orthopedic residency training program is in its infancy, it serves as an excellent prototype for steps that our profession should take to prepare chiropractic physicians of the future. One step is the development of more residency training opportunities for recent graduates who wish to gain advanced clinical acumen. Additionally, it will allow future practitioners to be at the vanguard of a significant paradigm change.
Hyun Suk Kim, DC
I share my experiences as a first-year resident in chiropractic orthopedics and neuromusculoskeletal medicine at the University of Bridgeport. After graduation from the chiropractic college, I knew that I had to continue educating myself. It was important for me to improve my skills and knowledge to be a better physician. While researching advanced clinical training programs, I learned of this new postgraduate program at University of Bridgeport.
This postgraduate residency program gave me the opportunity to enhance my knowledge with on-site seminars and online learning. It continues to amaze me how much I can still learn following graduation.
One of my favorite activities as resident is assisting in chiropractic student classes. It is a perfect opportunity to share my experience as a resident and connect with my future colleagues. I think that it is important to be affiliated with the school because you can motivate and cultivate students to become better physicians and be involved actively in our local community and nation.
The residency program also requires the residents to rotate through different health care facilities and programs, which makes the practical training exceptional. I had the opportunity to work at a community health center, and it has been a great experience. I am working in an integrated health care system where the patients have a team of different specialists who can take care of their needs. I learned to communicate effectively with other health care providers and co-manage the patients. We have learned a lot from each other. In my opinion, the biggest advantage from working in an integrated health clinic is the close connection that you can develop with other health care specialists to co-manage your patients. The good communication among the health care providers and the quick in-house referral system are keys to improving patient outcomes and satisfaction.
My clinical training has been extensive. At the community health center, I am exposed to patients with many different types of clinical conditions. I manage patients with common conditions, such as lower-back pain, and uncommon conditions, such as Sprengel deformity. Many suffer from chronic pain and present with several comorbidities. Managing these patients has improved my diagnostic skills, and it has helped me to understand the importance of chiropractic care in prevention and treatment of chronic pain.
Managing chronic pain patients most often involves making the right diagnosis. Neuromusculoskeletal conditions treated ineffectively with medications and the ordering of unnecessary imaging can delay the recovery and harm the patient. I face this reality every day with my clinical work. I believe I am changing that reality by communicating with, and educating, my co-workers about my education, training and clinical skills, which enables me to provide valuable chiropractic services for these patients.
I finally started to understand that there is a place for me in the integrated health care system, and I can be more efficient and successful when I work with other health care specialists to resolve my patients’ needs. This postgraduate program has been an eye-opener for me.
I believe that chiropractic resident training is an approach to improving interprofessional collaboration in health care, worthy of consideration by other chiropractic institutions.
1) Robert Wood Johnson Foundation. What Can Be Done to Encourage More Interprofessional Collaboration in Health Care? Health Policy Snapshot Series. Sept. 2011.
James J. Lehman, DC, MBA, FACO is director of the Health Sciences Postgraduate Education Department at University of Bridgeport.