Chiropractique

Kinesiology Tape?

2012-02-14T19:25:00.000-08:00

Recently, I was interviewed on a local television show here in Boise called Healthy Idaho. Though nerve wracking, it was fun to explain the therapeutic process I use with most patients.

To start my 4th month in practice this way was a real treat! My goal was not to just explain how kinesiology tape works but also to show how I use manual medicine in combination with kinesiology tape. This all happened in about 4 minutes.

The goal of using kinesiology tape is really icing on the cake with most therapies. Theoretically, kinesiology tape provides a gentle tug on the skin and lower fascial layers, which allows agitation to occur and mechanical lifting of the superficial tissues. Hence, greater blood flow to the local area and an increased rate of healing. An additional theory is that the tape stimulates surface receptors of the peripheral nervous system, providing greater proprioception. Proprioception is a term used to describe the body's way it monitors and adapts to the physical demands of an ever-changing environment. For example, if a rock pokes you in the foot or you step onto an uneven surface, you can and do adapt to the situation without even looking at the object by gaining feedback from joint and surface receptors of your peripheral nervous system.

Another quality of kinesiology tape is pain reduction. Pain and soft touch receptors use different pathways in the spinal cord which transmit their information to the brain. Applying a gentle tug on the skin with elastic kinesiology tape, tells the brain that there is more than just pain receptors being activated. The brain interprets the information as an either-or situation and with greater soft-touch receptors being activated than pain receptors, pain reduces as a result.

Kinesiology tape is quite versatile. We can use it to reduce swelling by cutting the tape a certain way. We can provide stability to an unstable area by stimulating proprioceptors around a joint. And we can create a fascial pull to the skin by stretching the tape and anchoring it around a painful area.

Is kinesiology tape the only thing that needs to be done to fix musculoskeletal problems? Absolutely not! I use it as icing on the cake in conjunction to adjusting joints, stretching tight muscles, stimulating tissues to heal with the cold laser and teaching proper firing sequences of muscles (ie., sword/seatbelt patterns, D1-D2 patterns for the lower extremites etc.).

Throwing kinesiology tape on an undiagnosed problem is no different than chucking pain pills at it and hoping it will go away. Diagnosing a condition is key to using such a therapy because there are many, many reasons for musculoskeletal pain or pain in general. Sometimes kinesiology tape is contraindicated as a therapy and can make a condition worse due to the lack of appropriate intervention.

Take home message: Get evaluated before using it.

I hope this information helps folks understand the role of kinesiology tape and the importance of being evaluated by a professional prior to using it.

All for now,

Dr. Spangler
Trailhead Chiropractic

What is Our Role?

2012-01-28T18:17:00.000-08:00

Wrapping up my third month in practice recently was a real treat! The clinic is growing weekly with new referrals from previous patients and marketing efforts aimed at getting the word out are finally coming to fruition. It is amazing what happens when you focus on solving problems versus selling a protocol.

I recently gave a talk at Boise Cascade, a timber and paper company, to help explain my approach to patient care and to give insight into when traditional chiropractic adjusting is appropriate and how it can be used to inappropriately create dependency for the adjustment.

Many folks in the crowd were long time users of traditional chiropractic. There was some eyebrows raised when I told them there is more to chiropractic than simply adjusting the spine for every condition.

It was evident that there has been a lot of DC's in Boise pushing subluxation theory on patients. The claim of better nerve flow for optimum health has been the hallmark for many successful clinics in town. From my perspective of wellness obtained through fitness, I have some reservations in building a practice this way because it falsely represents the reality of what's going on when a person gets adjusted.

I continued by explaining that most conditions require a fair amount of myofascial release and rehabilitation of dormant motor programs instead of simply adjusting the area over and over. I explained how our dominant movement patterns throughout the day set us up for dysfunction because of adaptation of soft tissues. I then explained the force-couple relationship involved with overactive muscle groups and the risk of demanding excessive loads through "rare" activities, such as: skiing and snow boarding with such dysfunction. It was wordy but they were deeply interested.

The intention of explaining things logically to this crowd was purely educational and objective. I told them I don't adjust every condition and the assessment approach I use helps depict what tissues are causing the restricted motion. I explained how traditional chiropractic adjusting creates movement to the deeper musculoskeletal structures such as: the ligaments, joint capsules and surrounding stabilizer muscles. I then helped explain how some conditions are myofascial and using traditional adjusting on these problems will not completely solve the issue. I told them, this is where dependency on traditional manipulation is established. I ended with explaining how it is no different than PT's using exercises as the only tool to fix problems or MD's focusing on medication only. We must be versatile.

If our role is to be technicians that merely provide adjustments to patients, I feel we are doing a great disservice to the community. If we focus on getting patients better, our clinics grow because that is what they want - results.

All for now,

Dr. Spangler
Trailhead Chiropractic

Justifying the Adjustment

2011-12-17T23:23:00.001-08:00

As I finished my second month in practice last week, I began thinking about a topic worth writing about that may stir the pot a bit and provide insight into what it's like trying to build my reputation on results.

In school, we are thoroughly taught how to adjust every joint in the body. They teach us that adjusting is the best method to use in practice and they raked us over the coals heavily to conform. The dogmatic approach they used, builds a complex, as if we have to adjust people no matter what and that is what patients are seeking when they come into our practices. I am here to say, this is a mindset of the past. People want results, not adjustments.

What has been eye-opening is how many people fear getting adjusted. Most say it is because they remember seeing some bad guy getting his neck snapped in the movies. They tense up and protect the area from any harm. So even if an adjustment is given, the soft tissues absorb a ton of the force and the joints do not get a therapeutic manipulation.

If you step back and forget about their fears and actually assess the physical issue, the specific tissues in need of manual therapy display themselves. Is it a capsular end feel or a spongy end feel? Are there sore origins and insertions of muscle groups? What's the history? Could there be fascial adhesions?

Now if you go and adjust them without assessing things thoroughly or explaining things logically, there is a lack of trust built and a negative viewpoint of chiropractic is planted in the patient's head. You don't have to adjust people just because you are a chiropractor. If they need it, that's another story. I personally look at chiropractic adjustments as an aggressive/last resort therapy that should only be used if absolutely necessary. If other less aggressive therapy fails to give relief or restore motion, then I reassess and adjust the patient. People seem to really respect this approach and they trust it because they feel I am taking their condition seriously and do what is necessary.

It comes back to why are we doing what we do. Are we trying to get people to come back over and over for meaningless therapy that doesn't affect specific tissues? Or are we trying to help people get over their specific condition with tissue specific therapy? The ethical answer is the latter. You can do just as well and even better if you are honest about what the patient really needs versus approaching patient care with dogmatic/engrained thoughts.

Too often, chiropractors adopt the mold of businessmen/women first and doctors second. Trust is key with running/building a practice and if you depict specifically what issue the person is dealing with and apply your therapy directed at specific tissues in need, business will flourish.

If you use one tool for every job you'll fix 10% of the issues and screw up or mildly help the other 90%.

Food for thought,

Dr. Spangler
Trailhead Chiropractic

Fate?

2011-11-30T21:00:00.001-08:00

To be clearly honest, I'd have to chant a prayer and explain current events according to religious antics that are indescribably indescribable to most people.

Yes, things have turned around in the blink of an eye. Folks are seeing the idea I have created and taking action based on intuition. Today alone, I logged 4 new patients out of the blue. Was it fate or was it marketing? I don't know. Being that I don't market, it may be the former. I do know that being in business has it's ups and downs and at times, it feels as if things may not work out.

Feelings such as these are not positive and they lack productivity. Yesterday, I had a long conversation with myself and basically proclaimed freedom from any harm that this clinic could do to me if it fails. I transitioned my thoughts, efforts and energy toward positive development. If there is a "Secret" out there, I do think I have found it!

We all go through life with fears and limiters that prevent us from taking full action on our innermost desires to succeed. We stamp out ideas swiftly due to a fear of rejection or the fear of failure. If those fears go away, all that is left is either failure itself or a solid foundation for growth. As a true optimist, I choose the latter.

For the first time since day one, I am looking forward to going into the clinic tomorrow morning!

Don't squash your dreams.

All for now,

Dr. Spangler
Trailhead Chiropractic

Dysfunctional Movement

2011-11-19T08:45:00.001-08:00

After finishing my first workshop on injury prevention at the clinic this week, I thought a blogpost on dysfunctional movement would be a good idea.

In October I attended the SFMA or the Selective Functional Movement Assessment seminar. This course was awesome, by the way! It helps practitioners with a baseline movement assessment that can be used in re-evaluations to see if the issue has cleared up.

I was quite impressed by the way the assessment could be broken down into figuring out which muscle groups and structures were inhibiting movement and causing imbalances/asymmetrical movement. It was also interesting how the assessment had the ability to define the dysfunction as a mobility or stability issue. After the assessment is complete, you have a nice package of information that can be used as a baseline to show improvements post-therapy.

Trying to explain this to folks who haven't had anatomy or biomechanics training last Thursday, was extremely difficult. The task of switching from medical terminology to understandable language and back, over and over, was very challenging. I could barely see straight after the workshop.

My hope at the clinic is to help explain dysfunction as a performance hindering and potential risk for injury issue for athletes and non-athletes and offer services and classes aimed at clearing up the problem.

Diving deeper into the goods of functional movement is the FMS protocol. The FMS protocol is the non-medical SFMA screen. Professional teams around the country use this approach to find dysfunctional movement in their athletes during the pre-season and if pain is causing the dysfunction, they evaluate with the SFMA screen and apply therapy/rehab.

The FMS or Functional Movement Screen, detects faulty biomechanics which lead athletes and non-athletes toward a greater risk for injury and poor performance. Here is a testimonial of the FMS screen that I found explanatory and helpful:

“We now use this program with every player as a pretest and evaluation tool before we even begin to train them. This individualizes our training as we can now focus more on improving weaknesses, imbalances and asymmetries in an effort to improve functional movement patterns. Not only that, it's an integral part of our program; rehabilitating injuries, decisions on return to play, and it's a test before training camp that tells us:

1) has the player improved?
2) do we feel good about putting him on the field?”

John Torine, Head Strength Coach for the Indianapolis Colts

If these assessments work on professional athletes that rely on staying injury free, I believe any athlete, endurance or power, can be assessed using these screens to help improve performance and prevent injury.

I have found a few road blocks in my attempt to explain this approach to the public. One issue is that it is conceptually challenging to wrap your head around dysfunctional movement. Without going through an actual assessment or seeing it performed on someone, dysfunctional movement sounds like a weird disease.

The way I see it is like this: the muscles of the body all have specific duties; some are prime movers, some are helpers or synergists and some are stabilizers. If we move in a particular way or do the same activities everyday, we develop dominant motor programs that make the the particular way we move each day, easier and more efficient. It is all about adaptation. Now, if those particular daily movements are sitting and riding a bicycle, you can see how going for a run with these dominant motor programs could leave you at risk for injury. Add in the body's ability to physically mold itself into postures from doing the same activities day after day, you can then see how our biomechanics can be altered.

Take a the cyclist from the example above who has a desk job. More than likely, this person will have very tight hip flexors due to being in the seated position on the bike daily and sitting at work daily. Looking at the time spent in hip extension each day and you can see that this person likely walks to the car to go home, walks in the grocery store and walks around the house a little, everyday. How much time is being spent sitting versus standing? I'd say it is 80% or more of sitting.

This prolonged sitting creates a movement pattern that is very efficient for the activity of sitting and not so much for the pattern of standing and walking.

Now, with this in mind, think about what happens when a muscle group becomes dominant over it's antagonist muscle group. The opposite muscle group, the antagonist, becomes inhibited or dormant.

The cyclist above likely has tight hip flexors from being in the flexed-hip position at work and in cycling. If the hip flexors are dominant, the opposite muscle groups that becomes inhibited are the glutes or hip extenders and the abdominals.

What does this do to the biomechanics? In the standing position, the person will have an anterior pelvic tilt which causes the belt line to be angled toward the feet and the lumbars or lower back will be hyperlordotic or excessively curved. This change puts tension on the hip stabilizers, the IT bands, the knees, the ankles and even the cervical, thoracic and lumbar regions of the spine.

Now go running with these issues and you are at risk for injury and degeneration of joint surfaces due to faulty dysfunctional biomechanics.

Clearing these biomechanics up with manual therapy and rehab strengthening for inhibited muscles, prevents injuries and helps the body function as it is supposed to with clean, powerful movement.

I hope this all sheds light on the power of movement assessment.

All for now,

Dr. Spangler
Trailhead Chiropractic

Snow Day's and Tryptophan

2011-11-19T01:50:00.001-08:00

As the blood saturates the cells with tryptophan after a delicious Thanksgiving gorge, the eerie silence in my new clinic is starting to bug me.

These startup days can be confusing. One day you'll be busy as ever and the next, there is absolutely nothing going on. If two or three days go by with no patients, it is hard to see the bigger picture. This is why you need advisers when opening a practice. They keep you from making stupid decisions that waste your resources when a few days pass that do not grow the practice.

The natural tendency is to try to buy your way into establishing a practice. This doesn't work. I know because I just wasted a lot of money advertising in the Boise Weekly. I had hoped to get the word out to the masses, that my clinic was trustworthy, modern and legitimate. Obviously, this effort didn't blossom into new patients or inquiries. You live and learn.

During times of silence I think it is important to focus on the basics. For me, it is important to keep consistent with physical activity. My sports provide me with solid connections into sports medicine patients and they help me stop worrying about growing a new practice. It's a win win situation.

For now, I will be using the silent times to focus on email marketing and making new connections in medicine. Interestingly, I met an MD the other day who told me that 80% of the patients who seek his care have severe back pain. That seems ridiculously high, but he said so and I trust that he is correct. Making connections like these are critical in establishing a medical practice.

I developed a new Winter Injury Prevention and Performance Program designed to reduce tight musculature and improve performance via activation of dormant muscle tissue. The intention is to provide a cost-effective way to help endurance athletes avoid injury and perform better. Hopefully this will take off and pave the way to the clinic's success!

Here's to good intentions and motivation!

All for now,

Dr. Spangler
Trailhead Chiropractic

The First Month

2011-11-11T20:05:00.001-08:00

I finished my first month of private practice today!

Nobody told me about the obstacles of launching a new clinic back in school. It is almost like they keep it hidden because of how incredibly hard the process actually is. Regardless, the first month is done and the 6 month lead up to opening for the first month of practice is now history.

The details involved with sculpting a practice into launch form is intense. If these details are not covered, your message will be misconstrued, saying you don't care about the details, so why should I trust you with my problem? Nobody wants that.

During the last, say, two years of school, I sat in the back of the class developing the concept of my now 1 month old clinic. All the details were designed and redesigned numerous times. Colors were selected for the website, then trashed and reselected. Themes were taken on and then canned for better ideas. On and on it goes. This process brought me to the business plan which encompassed an ideology that was based in ethics. Something that is lost in many other clinics due to a lack of a business model and a lack of an personal identity. You can have any ideology but it comes down to delivery.

What is it you want to portray to the public? Nobody that I know wants to be that guy selling chiropractic at the annual fairgrounds. Who wants to be a salesman or a gimmick? I don't. That has been a real challenge working with advertisers because they all seem to go after the 'discount' to get people in your door. They don't understand that we are doctors first and a business second. Those who get this concept backwards, end up pushing discounts to the public and always struggle with their identity.

I've decided if I advertise with anyone, they have to make the effort to get to know my business whole-heartedly and they must have an angle that portrays me as the person I see myself as. Otherwise, I am selling myself short and allowing public skepticism to continue running it's course. Also, if an advertiser doesn't understand me or my ideology, how is it they can develop my brand in their publication and portray me as I see myself? They can't and that is the point.

For instance, I met a nice group from the magazine, Healthy Idaho, today. They were working the angle of using my knowledge to gain interest in local business wellness initiatives. It was respectful and they took the extra time to tour my clinic and gain a real grasp of what I see for the future of the clinic. Now, these are the types of people I want to work with. Not people who are rushed to make a sale to their advertising agency or those who try to up-sale me.

It's all about passion and the weeds are being pulled.

All for now,

Dr. Spangler
Trailhead Chiropractic

Quack

2011-11-08T20:40:00.000-08:00

As I venture into my fourth week of private practice, I have noticed a trend. This trend is one that is worth a blog post, clearly.

Could this trend be one of mistrust, fear and anxiety toward chiropractic? Why would there be such resistance to an ethical approach to care? Lets explore...

I've noticed since being in practice, a lack of trust with chiropractic. Of course, you could throw me under the bus with being "new" to practice or whatever, but you cannot discount entering a fire fight with a knife.

The fact is, we are seen as non-expert, unprofessional, quacks whenever we open our mouths. When we advise manual therapy or rehab to be done 'onsite' in our clinics, we are viewed as the devilish chiropractor that is only in it for the money. Obviously, this upsets me because new patients have lumped me into this category without any effort to earn such a response.

If the profession could take some needed notes from a newby doctor, I'd say, quit thinking with such short projections and change your mindset to a 5-year or 10-year plan that solidly plants you into your community. When I say plant, I am hoping you know what that means. In my mind, it means to be trusted and viewed with integrity versus being viewed as a money driven quack.

When I decided to stay with chiropractic, I told myself I would not let the discrimination bother me, but as the weeks tick by and the offensive, demoralizing things happen, I tend to sway toward the pissy-end of the spectrum.

What can be done? Don't be a quack is the only thought that comes to my mind. Believe that the mission of providing conservative orthopedic care is worth it's shortcomings and adherence to the ideology of health via fitness is actually plausible.

I look at the handful of patients that have pushed away and those that have committed to my approach and I see two different sets of people. One has the goal of achieving a pain free life through the use of my care and adoption of home-based therapy and the other wants a quick fix. I can't judge the quick fix folks though because they have been conditioned to look at health care this way over the matter of decades.

We aren't all quacks, is my statement. There is a large group of chiropractors that I pride myself to be in the presence of, professionally. We see eye-to-eye and we approach patient's with objective minds and clear goals that sway from the mainstream allocation of pharmacy for symptom reduction.

The nice thing is, we are not stuck using a set methodology that consists of Norco, Naproxen and Flexeril for any ache or pain. At our clinic, we utilize a unique/ethical approach.

All for now,

Dr. Spangler
Trailhead Chiropractic

Staying True

2011-11-01T21:51:00.000-07:00

As the weeks tick by in private practice, my ideology is tested daily. If you have read the previous blog posts, you know the ideology of chiropractic I have tried to portray over the years. When you go into business these ideals are tested and retested daily.

Everyone wants to make a buck. It is all about 'my' rent and 'my' car and 'my' student loans. Who cares about the patient and what 'they' really need, right?

Of course, this is not how my clinic operates. We do not create dependency on passive treatments. We use passive treatments to restore function to dyfunctional regions of the body. Once function has been restored with manual therapy, we utilize this new functioning system to create stability and strength to the area. The lack of stability and strength is largely the reason why the region became dysfunctional in the first place.

The biggest problem with my profession is that we are forced into a small business mindset and this creates mindless technicians. Yes, I could easily have patients come back over and over for passive care to simply alleviate their pain for a short timeframe. However, I am against this because this would push me into the category of chiropractors that disgusts me and the public. Dare to be different!

How can you make a small business tick without repeat customers? My answer: focus on quality care and wait for referrals. This takes patience and consistency with care.

If you believe our role in health care is to extinguish fires, then you fall into the technician category. If you feel it is important to diagnose, treat and prevent issues from occurring later on, I'd say you are a modern chiropractic physician and you deserve the recognition from the public and your peers in medicine.

What if the patient gets better and a large void develops in my schedule? If you truly care about getting people better, they will not only pay more for the quality services but they will also refer their friends and family because they trust you. In the long run, you have built an ethical practice which follows the Hippocratic Oath and this creates a foundation for our profession to be fairly judged from.

Be thorough and be patient.

All for now,

Dr. Spangler
Trailhead Chiropractic

A New Life

2011-10-24T22:14:00.000-07:00

Every student studying medicine or a related health field knows what it is like to want the end result more than the process of obtaining the end result. You are forced to your wits end with tests and deadlines and can never find a chance to calm the fire. We sit there and wish it would just hurry up already so life can continue in a much more leisurely fashion.

Well, that time has come for me. Although, I can't say it has been less stressful than school. It's a different kind of stress, one that is more "real". Yes, things are quite real these days.

All through school I planned every detail of my clinic down to the colors, the theme and the equipment. I went on a hunch that people value quality health care services and no matter what, they'd see my genuine effort and decide my clinic was a good fit for them. Fortunately, this has happened, to some extent. We aren't bursting at the seams with too much to do, but there are a few that have trusted me and my staff with their needs. As we do good work, the word will spread and we will obtain more clients looking for trustworthy chiropractic and rehab.

We have been successful and great results have transpired from our efforts. Each time I work with a patient at the clinic, I have a sense of gratitude for how hard it was to get to this point. We can only share stories of these things and there are others with larger stories than mine.

My first patient at the clinic was a great one! A family stressed over their child's inability to compete in their sport due to thoracic pain and a dream lost due to a lack of a treatment plan. I evaluate the patient and find the issue to be restricted joint movement in the CT junction and upper ribs. I adjust the patient and do some pin and stretch on the muscles and have my LMT massage the tight muscles. The patient feels better immediately and the next day performs a personal best in a competition! Now, we are looking at the State competition!

This is definitely a success story and one to use as motivation to continue onward with this new practice. I know more stories will come through this sweet chiropractic clinic as we grow, some will be more challenging and provide less immediate success, but we intend on doing our best.

All for now,

Dr. Spangler
Trailhead Chiropractic

Selective Functional Movement Assessment - SFMA

2011-10-09T16:02:00.000-07:00

We just wrapped up our seminar with the SFMA program today. Getting to Indiana was a bit intense with thunderstorms viewed from 30,000 feet and long layovers. Despite all this hardship... I made it.

The program began with an overview of what the SFMA approach is from a theoretical and practical explanation and slowly we moved to hands-on movement assessment using the "big 7" global movements designed to target dysfunctional movement patterns pre and post intervention.

After finishing chiropractic school, I left feeling like all the dots weren't connected in the assessment of movement. I felt like I had mastered adjusting skills, orthopedic, neurologic and primary care physical exams, but there was a huge gap between these skills and exams and how to assess the issue if it wasn't one outlined by the above exams or if irresponsive to an adjustment. The question became, how do we assess whether our manipulations and physiotherapies are doing anything at all besides decreasing pain? Just because pain is gone, that doesn't mean dysfunction is gone. Assuming an issue is better after pain is gone, is a poor assessment protocol. We must consider the kinetic chain. In the PT world, this is the concept of regional interdependence.

Regional interdependence is a concept that suggests a painful problem in one area can be caused by a dysfunctional area nearby. For example, knee pain can be caused by immobile hips and elbow pain can be caused by cervical joint restrictions. Focusing entirely on the painful area is not a longterm strategy to the patients issue. If we approach patient care using the pain model, we become the people who put out fires versus fix the problem. I became a chiropractor because I felt the medical approach to musculoskeletal care was aimed at symptom reduction versus actually fixing the problem. I definitely learned to do just that, but ever since DC school began adhering to evidence-based practice, we have slowly become symptomatologists with a lack of ability to intervene appropriately.

Besides palpation, what is our objective marker for improved biomechanics? ADL improvement is not objective, it is subjective and inaccurate. Retesting orthopedic tests is our only objective indicator of successful treatment and we know how limited these tests are with biomechanical joint dysfunction diagnoses because they revolve around a painful response. We need a system to guide us with our adjustments besides simply palpating and orthopedic tests. We also need a system to check our work pre and post intervention to show that our work was effective. This will create trust with our patients because they can see exactly how our manipulations improved their biomechanics. This is a very important concept.

What if a patient didn't need an adjustment but actually needed to reactivate a lost motor program? Do you have time to test every muscle? Can you test multiple muscles in a global movement and know what to look for? Probably not. Say you learn to spot dysfunctional global movement, you reactivate the inhibitied musculature and the movement improves significantly and the patient's symptoms reduce without ever adjusting the person? What if you could differentiate between a stability issue and a mobility issue? That would greatly affect clinical results and the two issues require totally different interventions. See how there are gaps in our education? To make you feel better, PT's are taught to exercise the issue until it goes away and their manual therapy skills are acquired in seminars, which leaves them with gaps in their education, causing a misunderstanding on how to intervene.

Chiropractic school focused intently on overall health from a primary care perspective with a musculoskeletal focus. However, there was a serious lack in movement assessment pre and post treatment besides asking, "how do you feel now?". They sort of left it all up to us to decide how to treat the patient and taught us a limited toolbox revolving around vague therapeutic exercises and adjusting the body for ALL issues, even if an adjustment was not needed. This is the underlying reason why I pursued the SFMA seminar series. I wanted a way to assess movement, differentiate between treatment options (ie, manipulation or therapeutic exercise or both) and to have the ability to re-evaluate the area treated using a standardized set of cardinal movements. SFMA was the solution.

I am looking forward to sharing this knowledge back home and applying this all into clinical practice.

All for now,

Dr. Spangler
Trailhead Chiropractic

The Big Transition

2011-10-05T00:28:00.000-07:00

I promised to update the blog as I venture into private practice, so, here we are again.

This blog has become quite popular. Last check of the monthly stats showed 2,500 hits per month! I had no idea there was such an interest in chiropractic. Thanks for reading!

The transition to private practice has been slow and arduous, to say the least. My patience has been tested again and again, just like the final term at UWS. I guess all that sitting around wishing and waiting really paid off! The time these days isn't spent sitting around though. I am waiting though.

There was a back order on all the doors to my clinic which delayed opening by 3 weeks. The clinic is done but lacks doors. You can peer right in from the hallway because my front door is not attached. It is kind of funny but when reality sits in, I realize how much money and productivity has been lost due to this backorder. Nothing can be done except wait a little longer. I have postponed all the major deliveries of big equipment and my apartment continues to stockpile crap, making it quite cramped. Oh well.

Money aside, I am happy the clinic isn't done yet. I have been scrambling to get on all the big insurance provider networks in hopes of getting paid later on down the road. Massage therapists have been interviewed and hired and the fitness pro/rehab provider is all ready to go. All we need is patients and clients. Much of my time has been spent planning the grand opening party scheduled for October 20th. There is plenty to do.

In addition to all this, I have many little marketing ideas going on with local businesses. My intention is to sell the clinic's services softly by offering clients and patients a glimpse into our world at the clinic. I don't intend to overstep my sales by pushing my awesome ideology on them, but I do intend to show them what we can do for them. This takes quite a bit of training for the staff to adhere to and practice the strategy. Regardless, we have to prove ourselves to the community and head into the proverbial battle and we must have a plan and follow it.

It excites me to think I can finally put the training to use and start helping people. So many folks can be helped by simply providing guidance through the challenging first few weeks of a fitness plan or helping them regain function of a dysfunctional area of their body. This might sound funny, but pain and disability affects not only the person afflicted with the issue but those around them. It renders them useless and quite bothersome to their friends and family. Restoring function and obtaining freedom from pain and dysfunction and perhaps obtaining a new level of fitness, sets people up for success in all realms of life. People know this. Insurance companies know this.

Our clinic will be quite different than the competition and it will push an ethical ideology. Many of the insurances are moving toward quality improvement these days. This means, no more long term passive care programs. They want to see active care throughout the patient's program. Rehab will be the future of chiropractic and the lines between physical therapists and chiropractors will soon be invisible. The old ways of the past will vanish and the modern practice will be forced to conform or be left in the dust. We can differ from PT's by thinking about overall health versus simply recovering injuries and dysfunctional joints.

I see this as an opportunity. We have a chance to be the clinic in town that is cutting edge and pushing forward the most recent evidence in chiropractic and rehab. Combine this with high quality fitness training and you are practicing true preventive medicine through active care. I think about what I would want in a clinic if I was looking for one and my hope is to provide exactly that.

We open our doors in a week and a half!

Cheers,

Dr. Spangler
Trailhead Chiropractic

Dr. Spangler but Awaiting Licensure

2011-09-14T23:45:00.000-07:00

It's official, I am now Dr. Spangler. My degree is officially in the mail and all of my requirements are complete as of today. In a couple weeks, my license will be approved and I can begin practicing in Idaho. It is a weird feeling to think back to all that had to take place in order to venture down this path. I am glad it is over though and I am excited to move on. New challenges are on the docket for this new Boise chiropractic clinic.

My first challenge has appeared with the clinic. A veteran chiropractor has approached me with the intention of sharing my clinic space with me. I have contemplated sharing space but it just doesn't ever fit with my ideology. It was a very humbling experience being that he was my mentor during my undergraduate studies here in Boise. It was an honor to be approached by him. The issue that makes this challenging is a lack of space in my clinic.

Originally, I planned on having 3 treatment rooms, a rehab room, a reception area and an office for me. You'd think I could just make one of the treatment rooms an office for this DC and have him use one of the treatment rooms. I have thought about this, a lot, but where do I put my massage therapist and where will I put acute patients when they need electric stimulation to calm their spasmed muscles? Complicated.

If I rent out two rooms, I am left with one and that will not work. I am tempted to build out the space next to my current clinic and provide this DC with room to accommodate his needs. This, however, would put financial stress on me if and when he leaves.

I don't like saying no. This a fault of mine, which needs work. We all are faced with situations like this where a plan has been in place for years and an attempt to change that plan pops up. Honesty is key when it comes to these things and we must stay true to our values and ideologies when deciding what to do. If we sway from the end goal to accommodate, we can lose focus of what we intended to do in the first place.

It is exciting to move forward with all this. The clinic has been delayed due to a backorder on doors, so we'll be launching in mid-October now instead of the first of October. I am kind of glad for this because I need time to put together my marketing plan and deal with the current challenges.

All for now,

Dr. Spangler
Trailhead Chiropractic

Home at last!

2011-09-07T18:16:00.000-07:00

I arrived in Boise last night after wrapping up things at school and saying the final goodbyes. It was much easier than I thought it would be to say goodbye and hit the road one last time.

We sit wishing for the moment when the torture will stop with all the tests and requirements and then the day comes when it is time to move on. The final days are weird because there is absolutely nothing to do and all you do is wonder what it will be like when the plane takes off and the hugs commence. I can say that it is quite bitter-sweet. People wish you well and say they'll keep in touch and stop in Boise but the fact is, we are all going in opposite directions. We all have different goals and places we want to be. I chose Boise and nobody else did.

It will be quite surprising if I ever see most of my class again. Maybe a few here and there but for the most part, when we said goodbye, that was it. We all have to move on eventually and start our new chapters.

For me, I have been waiting to exit for sometime now. It is good but I know there is a mountain of work awaiting that will demand every ounce of my energy. The difference is that no tests remain, no cruel demoralizing situations await and I am the only one holding me back! It feels great!

I wish you all the best and hope that the experiences we've had together provide a nice foundation for ethical balance in practice.

All for now

Final few weeks...

2011-08-25T21:39:00.000-07:00

We 12th quarter students are finishing our last couple weeks of clinic and we are checking out of the school/clinic's system the first and second week of September.

This has been a long journey that has tested every ounce of patience in us and has taken us all to our breaking points several times. To think only 2 weeks remain between the school world and the real world is a bit overwhelming to think about.

In a sense, when you get to this point, you tend to recollect the good and bad times you have experienced, pretty much daily. You wonder if the hard times experienced actually happened over the past few years and then reality hits. I am done!

Too often we let others define what it is we have accomplished versus looking at the path taken and the obstacles overcome. We downgrade the effort and act as if it didn't really happen. When in fact, we suffered immensely; mentally, physically and emotionally for nearly 4 straight years to obtain our degree. This sacrifice has taken us to the doctorate level in our education and we should always remember how incredible this feat actually was.

Many of my friends are packing up and moving home. Some are living in their cars because the cost of renting is too high in order to plan for no money coming in later this fall. Others, like myself, are crashing on couches at friends houses or sleeping on futon mattresses to save a little cash. We want to go home. Enough struggling, enough hardship.

When it comes down to percentages, not many people pursue higher education simply because it sucks. It is uncomfortable and demoralizing. Not many people sign up for things like this and it makes complete sense why - in a practical/present-tense sort of way. I sometimes wonder what life would be like if I stayed as an auto body technician. What would it be like today, 15 years later?

The fact is, deciding to become a doctor of any caliber comes with a huge responsibility. We all know what this responsibility consists of. The stress that comes with this decision is huge, not only with actually obtaining the degree and licensure but living a new lifestyle that comes with a new social standard.

When I think back to the days of straightening truck frames on the hydraulic frame machine and sanding fenders, my life was pretty low key and simple. Focus on the job, do my best and get paid for doing good work. It was simple, concise and an honest life. Who knew things would elevate to this current level, where each decision has consequences when working with patients and each decision in our personal lives must be weighed.

We all make decisions in life. It comes down to being good at what we do and providing services rooted in ethics and honesty. Success comes when we keep it as simple as this.

All for now

Liebenson and Ethics

2011-08-05T23:35:00.000-07:00

I have applied to join my first professional society, ISCRS. This acronym stands for, International Society of Clinical Rehabilitation Specialists.

You can find the ISCRS website here: http://www.clinicalrehabspecialists.com/

I came upon this society when I was researching rehabilitation seminars on Craig Liebenson, DC's website. If you haven't heard of this guy, you should check out his work. He has authored a number of books on rehabilitation and manual medicine.

Usually, I shy away from DC's that publish books because many have an agenda and that agenda is typically an anti-medical, pro-subluxation theory agenda. On the contrary, Dr. Liebenson has helped to integrate evidence-based chiropractic into the medical world via his consistent publishing of journal articles and books. I respect his work and I am proud to join a multidiscipline society that advocates this ideology.

With that, I am awaiting approval by the board of directors and when approved, I will gain access to the site which will give me access to JBMT (Journal of Bodywork and Movement Therapy) and JMT (Journal of Manual Therapy). The site also has numerous articles and fact sheets for common musculoskeletal conditions we treat daily.

If we approach chiropractic in a musculoskeletal manner versus a business manner, we will be more successful and much more respected in society. When people think of the word chiropractic, most think about low back pain. Many even think we are musculoskeletal specialists, which is what we are. When it comes to practice, there is a line we must not cross and that line is one of ethical choice. Defining ourselves becomes tricky due to the hazy definition of alternative medicine and the type of business model each DC adheres to.

My hunch is that many DC's practicing alternative medicine are good at what they do and they should keep doing it. While others adhere to a marketing theory that puts butts on benches in their exam rooms through public deception. The ethical approach to alternative medicine that I witness and practice a little at the CIC, is to aid the patient in what ails them musculoskeletally, while educating them on the benefits of self-care and nutritional therapies. It isn't about going against medicine or deception, it is about giving options that are less risky and less invasive that create therapeutic outcomes similar to pharmaceutical invervention. Knowing when to NOT intervene conservatively and advocate pharmacy instead, is a complex paradigm. Thankfully, a large portion of our education is on the understanding of physiology and nutrition.

Chiropractic is a mixed bag. However, when practiced ethically (for the good of the patient vs. our pocket books), it is a wonderful profession.

All for now

12th Quarter Sentence

2011-08-02T16:32:00.000-07:00

There is a lot of sitting going on this quarter for all the CIC 12th quarter interns. You might be wondering why we are not involved in patient care to some extent. Of course, I have a great answer that stems beyond the surface.

Many people in the medical field judge the chiropractic education based on it's historic lack of residency programs for it's fresh graduates. These naysayers, believe the medical education is far superior to chiropractic medicine. Ideologically, of course I disagree, however, based on my current level of clinical activity, there is some truth to the medical argument.

Our time at the CIC these days is spent playing the game UNO and chatting about how useless we feel as interns. Occasionally, we are involved with patient care, but for the most part, we sit around and wait for the minutes to tick by.

A few of us chose to stay and there were some, including myself, who wanted out back in June. Things didn't work out, so I am now bored and feeling a bit useless. To end an educational experience like this is a bit challenging to accept.

I know if I were to have ventured down the Osteopathic path with my friend Andy Slater back in fourth quarter, I'd be beginning my 1st year NOW. That was too much of a sacrifice for me, but he will definitely reap the benefits of public acceptance and a stellar education beyond the 4 years of doctorate education.

To fill the gap in the education, I am spending time observing doctors in Portland and Boise. This has helped to some extent. I am also building my clinic in Boise which has taken quite a bit of time. All in all, it is relaxing compared to what it was like only a few months prior.

As far as the education system in chiropractic goes; something needs to change. The school's preceptor program should be revamped to allow a smooth transition from school to a clinic. Someone not only needs to keep in touch with these DC's but there needs to be some effort made to get more opportunities and perhaps, link up with a hospital or two that is willing to offer chiropractic care. Create rotations through these clinics and restructure the system to where we work with orthopedists, dermatologists, gynecologists, pediatricians etc. You can't just throw books at us and make no effort to connect us into the medical system. That would take effort on behalf of our school, so that is probably not going to happen and that is why we have virtually NO opportunities once we finish our clinic requirements. There shouldn't only be business opportunities for us. This fact is probably the most annoying thing I have encountered since finishing things up in May.

DC's that offer preceptorships largely want to expand their clinic system or add an associate doctor. This makes it difficult when you are looking to expand your knowledge base. In the field of physical therapy, 1,000's of post-doctorate programs are available to allow for specialization. It is quite unfortunate to have absolutely NO opportunities accept opening your own practice or becoming an associate at some clinic.

If you are not proactive in 12th quarter, you will not have any opportunities at all. I guess it's time to get busy.

All for now

Stalled...

2011-07-27T19:01:00.000-07:00

The clinic is right on track to open in October, however, with the chiropractic licensure laws the progress has been stalled a little bit.

The sign I am going with is really nice. The cost is not nice though, but you get what you pay for. This sign cannot be installed until I obtain full licensure in Idaho. The reason for this, is that, it could falsely lead someone to believe I am in practice when I am not. It is unfortunate because I now will lose 3 months of advertising that could have benefited my business later this fall when I open.

To get around this, I am continuing my personal facebook page but stopping my clinic facebook page and my website for the clinic until October. I will update the clinic's progress on my personal page, so no licensure laws are broken. It would not be good to start out with a legal issue before opening the clinic.

I personally see no harm in having a website or facebook page as long as it is very clear what the intention of the websites are. If there is any reason people could misconstrue the message, an issue could pop up with the board and things could get complicated.

On another note, I have ordered the chiropractic table for the clinic. The brand I decided to go with is Hill Laboratory. They look to me like the best table on the market, but we all have opinions.

That said, I am also debating cutting out quite a bit of rehab equipment from my budget and retaining those funds for operating costs for the first few months. My hope is to bring in nice equipment later when the clientele is established. This tactic will preserve the money I have for the unfortunate reality of really slow growth. We all want our clinics to blossom overnight, but I realize this is a bad economy and I am a soon to be new doctor.

All for now

Graduation

2011-07-09T00:58:00.000-07:00

Our class graduated last month. It was a bittersweet end to a long, arduous program. Even though we have participated in the ceremony that publicly portrays us and celebrates us as doctors, most of us are three months away from the official stamp from the school.

Does this mean we should begin using the prefix Dr. in front of our names or do we have to wait until the school approves everything this fall. My hunch is the latter, but it is sure tempting to start the transition. Regardless, the celebrations are over and we are now venturing into a new world of professional practice.

The ceremony itself was awesome. Many speakers from the community and board of trustees gave words of wisdom and shared intimate stories that may or may not have had an effect on the graduates. I was impressed by most of their advice and stories. These ceremonies have such a long history dating back to as early as the 14th century! The costumes worn are symbolic and the colors represent our place in health care. To go through such a ceremony is an experience most do not get to do in their life. Our hard work and patience paid off with entrance into a elite level of academia and health care. We are doctors and we should do our best to uphold the standards placed upon us.

With that said, the next months ahead will have their own challenges. Opening a clinic is one that I am personally grappling with these days. Many products are being purchased and every little detail is being thought about with precision. Designers are involved and they ask the craziest questions! I never knew it would be so demanding and exhausting.

As time progresses, clinics will open, patients will get better and money will be earned. My intent is to stay ethical in the process and offer services beyond chiropractic medicine so the pressure is not incredibly high to keep the clinic viable and growing. It is my hope that this approach will provide a blueprint for other doctors to follow in the future. As I have said before, I believe marketing groups that push DC's to sell subluxation theory are unethical and they prey on the fresh grads who are worried about paying the bills. Investing into fitness equipment opens up a huge source of revenue that is ethically based. It is something to consider before socking 20k into a marketing program.

Invest into services that legitimately improve a persons health beyond reducing biomechanical faults. You will retain your patients longer and gain respect in the community. Our role is critical but without adherence to an active lifestyle, the adjustments and manipulations will provide temporary relief. We all know this is true, so it is our duty to be truthful and honest with our treatment plans and provide services which fill the gap in each patient's health.

All for now

Exciting times...

2011-06-24T23:01:00.000-07:00

Boards have been passed, classes have been conquered but one last hurdle remains, OSCE 2. We have yet to get our OSCE 2 scores from the higher ups. This anticipation is no different than waiting for grades to be posted for any other exam. However, the OSCE 2 test has more power than the others.

We must pass this exam in order to go onto preceptorships. Supposedly, this exam proves we have met the bar that UWS has set for clinical practice, which exceeds most schools in the US. It is a high bar to meet, mainly because they make the testing situation so stressful. New documents to learn how to fill out with speed and accuracy, weird testing environments and a time crunch cloud normal judgement are just a few chaotic things we had to manage that day. Oh and being burned out from 11 terms of intense academics didn't help at all.

Failing the OSCE 2 is no big deal. You simply pay a hundred bucks and retake it, hopefully to pass it the second try. Failing the OSCE does prevent you from going to the State you wish to practice in though. That is not fun. I hope to move in July, so here's to positive thoughts!

On another note, I have finalized the floor plan to my clinic and I am currently working out all the details with carpet selection, paint color and decor. There are so many things to think about with all this that it can become overwhelming. When I get overwhelmed, I tend to start worrying about where my patients will come from this fall. That is a very real fear. My hope is to get to Boise next month and begin integrating into the community and establishing a reputation for myself. Thankfully, I have a large family in the area and many friends from living there for over 20 years.

These connections do not guarantee a patient base. Each individual will have to decide whether or not to use my services and choose to refer the clinic to others or not. For the time being, it is a free market in health care. We all can choose which clinic is best for us.

I will have to provide the best care I can and earn the community's trust and respect. It will take time. My guess is I will see about 15 to 20 total visits in October and around 30 in November. Being that we will offer massage and fitness, these services will help cover the overhead and hopefully we will be out of the red by November. You never know, that is why I have budgeted 3 months of expense as well as strategically placed purchases for fitness equipment as the patient base/clientele is formed. No need to buy everything up front if the same job can be done without it. For instance, there is no need to buy a bunch of chiropractic tables when I only need one in the beginning. That is a savings of 4k right there!

There are other things I can do to increase the draw to my clinic. Facebook is a great way to stay connected with your patients. It is a great place to share advice and offer deals from the clinic. The challenge is learning what to say in order to keep people excited about the happenings at the clinic.

My hope is to create a word-of-mouth marketing system. So many DC's in Boise focus entirely on adjusting their patients and offer no soft tissue therapy, fitness training or even rehab exercises. They want their patient's to keep coming back, so they create dependency with getting adjusted. Many people I have spoken to have shared these exact words with me in the past week. I can see having patients come in for maintenance care once their issues have subsided, but the care will be a balance of adjusting and soft tissue work during each and every visit. This is how Dr. Roberts taught us and I do believe it is the best approach.

In the first three months, I will be functioning as a chiropractor, a physiotherapist and a personal trainer/coach. Once the chiropractic care gets busier, I will hire a personal trainer/CA to take over the fitness and physiotherapy role. A massage therapist will be hired in September and hopefully, this person will be an established LMT.

These days are exciting and a little scary, but we only live once and why not take the leap now while the motivation is high.

All for now.

No Crystal Ball

2011-06-09T21:53:00.000-07:00

I never thought this day would come. All the requirements to finish at school are nearly complete. The end is near.

A week remains in my education at Western States and then I will begin a new chapter in Boise Idaho under Dr. Tiegs, a Western States grad who has been in practice for 15 years. Hopefully, he will be approved by the administration. If he is not, I will find a different person to work with during the summer. It is hard to put my ambitions on the back burner right now. There is no encouragement from our professors besides Dr. Sepulveda, a veteran doctor working at our school only to help us become successful. I do believe there are others who want the best for us, but their egos cloud these thoughts from ever becoming a reality when we are around them. Sad for them, their egos cannot control everything.

This Monday, I signed a lease on a space in Boise. The building is built but the individual spaces are not. The spaces are currently dirt floors and exposed pipes. I entered an agreement that risks everything. If my clinic fails, I will lose a lot. This is what it takes to become successful though. Cleverly placed moves during a long drawn out game. It is fun. Without this pursuit, I would easily become bored and complacent with it all. There is only so much evidence-based practice you can take until you can't swallow another ounce of "concealed allocation, blinding of participants and p-values." I need to witness my dream become physical reality. In two weeks, they begin building!

On another note, I am going to continue writing in this blog through the summer months to share the experiences I have at Dr. Tiegs office. That is, if he is approved by our administration. Unfortunately, there is no crystal ball that tells us anything in life. And the crystal ball appears quite dismal for preceptorships this year. We have to roll with the punches and be okay with whatever happens though. The challenging thing about this is that our future is in the hands of a select few. They determine which path we take from here. Their intentions are to find doctors in the field that uphold a standard that is not met by the many in the chiropractic profession. Unfortunately, many doctors are denied the privilege of having a Western States intern under their guidance. I think this is a good thing (which may upset some of my friends). We are trained as primary care doctors and our school holds the profession to a higher standard with this selection process.

Our schools ideology is one that I hope to emulate in practice. The knowledge I have obtained is far greater than I had ever imagined. I hoped to get a solid musculoskeletal knowledge base, which I have and after a few years, I now have a vast pool of knowledge in many, many pathologies seen in primary care. I have even studied minor surgery, despite how it makes me want to puke. I feel as if I am ready to see any patient and safely make a diagnosis and refer to a specialist if needed. This is powerful. We have been taught to keep the patient's interest's first at our school and I do believe this is why we will be accepted by the public more readily and recruited more frequently by medical professionals. It is this knowledge that will help us build our practices and become long standing, positive members in our communities.

A select few of our class will pursue money making opportunities in chiropractic. They will buy into a set methodology even though no scientific evidence exists in the paradigm besides a positive cash flow. My advice for these select few is to stay true to the reasons you initially pursued the doctorate at Western States versus the other options. You picked UWS for it's evidence-based approach to chiropractic. You also despise the other lackluster methodologies that plague our highly competent profession. You probably feel as if the school does everything they can to make your life as hard as possible. Maybe this stress will push you to rebel against the school's philosophy. I urge you to recognize that adapting to this stress is a trait that will make you far superior to your counterparts in the field. You know, quite intimately, the standards you have had to meet in order to get through this curriculum. I bet you feel overwhelmed because of it and have lost many hours of sleep because of it too. Don't discount all that you have achieved.

When you are in the trenches of a doctorate program you tend to internalize a lot of crap. You focus on details that are only observed by fly's on the wall and you tend to judge all that is thrown at you to a degree that would seem pathologic to anyone short of a doctorate degree. You have risen to a level of intellect that sets you far apart from most of society. Don't screw it up.

Provide ethical care my friends.

All for now

Clinic Plans

2011-04-19T21:00:00.000-07:00

At this juncture, many students are trying to figure out what they are going to do once they graduate. We are heading into our final set of board exams in May, which contain the practical portion of the tests. These exams are the final ones we have to pass in order to officially get our license to practice in September. In the midst of all this, we also have our final set of OSCE's that may or may not fall on finals week. There is lots to think about and a bunch of work left to be done before the doctorate is in hand and lots to figure out before launching the clinic this fall.

Clinic plans have always been on my mind. I have drawn numerous different layouts and have researched products and financial estimates. It is consuming and can take up an afternoon in the blink of an eye. My big hold up these days is what to name the clinic. I took a poll to see what my facebook friends thought about a few ideas and most who replied felt that naming the clinic after a neighborhood was better than naming it after myself or some sort of ideology that I have strong feelings for. This to me is important information to think about. People want to feel as if the place they are going to trust with their health care is part of the place they live in. Neighborhoods, many times, have strong ideologies that they adhere to. The ideals draw people of similar mindsets to the area because they feel as if the neighborhood justifies their identity.

The trick is naming the clinic strategically so that it grows in the coming years versus the alternative. One drawback to naming something after the neighborhood or region it is in, is that it isn't unique and potentially does not stand out. This is a fear of mine because if it doesn't draw attention to itself, then I will be sitting idle with no patients to work with. We don't want that.

Branding is a big deal from what I have read. You want a symbol that people correlate to your business name. The symbol must encompass not only your clinic's mission but also it must speak to the population you want to work with, such as the neighborhood you named your clinic after. Now, if the neighborhood has the highest population of endurance athletes in the city, then it might be wise to find a symbol that they can relate with or at least gets their attention and perhaps draws them into your clinic. From what I have read, it is all about getting the people into the clinic so they can feel comfortable with what it is you are trying to sell. In my clinic, we will be selling snake oil and life long treatment plans... Just kidding..

I can now see why many of my friends are going to start out as associate doctors before they venture out on their own. There is less risk with this idea and it is just as respectable as opening your own clinic.

All for now

Visits

2011-04-10T20:34:00.000-07:00

Our education and profession is heavily burdened with having to balance the margin with the mission. Due to our lack of full integration with medicine, we are put into a peculiar situation to make our numbers in order to keep the clinic operating and our time at school productive. We students, some more than others, must find a way to get patients into our clinics in order to finish clinical requirements while we watch the school take absolutely no responsibility or action to help us achieve these goals. This follows many into practice once they graduate - when the numbers needed become money earned.

It all begins by putting a quantitative amount of visits on the interns in chiropractic school. The motivation isn't to learn all we can about each case, it is to get as many visits completed as quickly as possible so we are not stuck in the system for a long period of time. This motivation sets up the mindset of a stereotypical chiropractor looking to milk each patient as long as they can. The ethical boundary is stretched due to this unfair pressure placed on every student and doctor in the field.

I can't speak for everyone, but I do know that it has taken a long time for me to generate visits at both the CIC and WBC. It wouldn't be fair to say this is equal to those at the CHC or GIC clinics. However, it hasn't been handed to me. It has taken a fair bit of work and quite a bit of frustration.

When a patient is getting better and my attending physician makes an effort to end patient care, I tend to go against her efforts to kick the patient out. She largely tries to end patient care when the patient is only a few days past the subacute phase of an injury. This leaves me scrambling to figure out where I am going to get a new patient. On average, I see 5-6 patients a week and primarily on returning patients. I do not see very many new patients and can add up on one hand how many I have seen at the CIC.

In the journal, Chiropractic and Osteopathy, an interesting article was written in 2008 in regards to reform of the chiropractic profession. Many researchers and outspoken DC's in the field have recognized this by making efforts to push the profession in a "spinal specialist" model of care. Despite what people think, this is largely what we do as a profession. We provide non-surgical, non-pharmaceutical spinal care.

In the the C & O article - How can chiropractic become a respected mainstream profession? The example of podiatry, by Donald Murphy et al, they outlined how podiatry filled a gap that medicine was failing in and became a respected, integrated university-level profession. Much of the respect was built upon requiring entrance exams and higher education requirements to matriculate into podiatry school. Once these standards were set in place and uniform in the profession, large universities allowed integration of this profession. Chiropractic hasn't done this yet. You will not find chiropractic medicine offered as a professional program at your state college.

Chiropractic has been reluctant to enforce the "Publish or Perish" rule that most colleges and universities require of their professors. Instead, the colleges hire professors who want to teach and researchers who want to research. Not saying the professors aren't top notch. The lack of research, however, is a huge detriment to the profession as a whole and partly the reason for lack of integration because it attracts people who want a cushy job with no research requirements.

When podiatry adopted the MCAT requirement, they saw an increase in student interest. This could be the same for our profession. Like chiropractic, podiatry has an evil twin - foot reflexology. In the article, the author suggests bagging the subluxation theory and focus intently on being non-surgical spine specialists. Of course there could be offshoots of specialities in sports medicine, women's health, pediatrics etc. Largely, this is what is happening with our profession but there are two professions operating as one. One is evidence-based and one is a belief system.

The unfortunate thing is that we are stuck in the rigor of this program until our visits are completed and we cannot do anything about it unless we jump ship into an accepted program of study, such as podiatry, physical therapy or medicine.

How can we market without focusing intently on building a practice on a handful of patients? Focus on medical practitioners that do not know how to treat back pain. Primary care doctors suck at back pain. We just read an awesome article in our evidence-based practice class that showed a significant improvement in disability with acute low back patients under chiropractic care. The article revealed medical management of LBP is a cluster of randomness that operates on whatever the doctor feels is the right choice, while chiropractors in the study followed a specific protocol. Disability markers stayed the same for 24 weeks with medical management of back pain and 78% of patients were still on narcotics at week 16 of the study. Chiropractic care consisted of 4 weeks with visits between 2 and 3 per week focusing on spinal manipulation and active care.

You can find the above articles here:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2538524/
http://www.dynamicchiropractic.ca/mpacms/dc_ca/article.php?id=53496

All for now

11th Quarter

2011-04-07T01:33:00.000-07:00

A fresh term has been started this week. One for the books, in fact. In a little over two months, a large group of our original cohort will be venturing into their final term at Western States. It is a little bitter sweet to be at this level in the program. Often times, I find myself reflecting back to all the hurdles that were once standing before us that seemed impossible to conquer. With only a few months left, I see the remainder of school as a small hurdle at best.

Another big deal that is happening right now is that all the interns at the CIC are from my original class! We are running the clinic. Six 11th quarter interns are currently treating as primary interns, which means they are finishing their required 215 outpatient visits. This seems like a small number but it takes quite a bit of work to accomplish. The trick is getting a rhythm with patient care and getting in-sync with the patients by communicating solidly with them. They feel cared for and you deliver focused care.

Six 10th quarter interns arrived to the CIC this Monday ready to go. It was quite the change from our previous environment, but thinking back, it took a little while for the previous group to get used to each other too. There is a window of time that it takes for interns to bond and feel comfortable around each other. There is a period of time that it takes to learn how to work with each other with efficiency. Unfortunately, everyone has goals that sometimes get in the way of efficiency. However, trust must be earned by the patients and the attending doctor before goals can be obtained. Everyone has to know their roles in the clinic or else it is chaotic and way more stressful than it should be. It is wise to be respectful to everyone.

The weird thing is that you cannot rush the process. Even now that I have a little cohort of patients that I treat, I still have to keep each of them at the forefront of my thoughts when I am around them. Just because I have been treating them for 3-4 months, doesn't mean I can be lackluster or too relaxed with them. That being said, there is always time to joke around a little with them so they know you are human. I showed a human quality to all of my patients today, which consisted of severe pain. Who can't relate to that?

Today was a very challenging day, probably the most challenging day since I began working at the CIC 5 months ago. My back has been causing me issues lately from doing too many long runs while I was on vacation. All week I have had fits of back spasms in my lumbosacral region. It was my SI joint earlier this week and after being adjusted, it felt 100%. Today the pain started creeping up again and became a full on spasm with certain movements. I had to grin and bear it today while working with patients and I found myself pushing through the pain. You don't realize how physical chiropractic is until you are hurt. Most of the patients noticed and thank goodness I had a secondary in the room with me to help out. Unfortunately, I screwed up by not telling my first patient that I was in pain. I think this person thought I was acting funny but didn't want to say anything. Hopefully we'll continue onward in a few weeks. If not, oh well.

Hopefully the meeting will be made tomorrow morning. It is now 1:30 in the morning and the meeting starts at 7:30.

All for now

Part II and III Boards

2011-03-23T09:50:00.000-07:00

Now that the drama of part II and III boards have passed, life can go back to normal... until May. Part IV is coming right up in May and this section is an expensive/difficult practical exam that must be passed the first time. The good thing is that part II and III are done for now.

It was interesting how relaxed I felt taking these exams. Only a few moments of anxiety were felt as each exam was taken. This anxiety was primarily due to not knowing the answer to the question and having to guess. Nobody likes guessing, but this was not that frequent, so that is good. One section of part II had a lot of guessing, which was Principles of Chiropractic. This section was quite useless and completely theoretical, although interesting to some extent.

The nice thing about going through these tests was it sort of defined what chiropractic really is. My take on it is this: it is a profession that largely consists of musculoskeletal specialists sprinkled with a few romantics who feel that they must justify their work with a complex neurological explanation that is really hard to prove. The principles section painted this picture for me because the other sections were largely based in differential diagnoses in both general health/disease and neuromusculoskeletal.

Some of the theories are interesting if you read them with an open mind. Like the over-stimulated sympathetic nervous system. I find that very interesting. Apparently, the thoracic vertebra house the sympathetic chain neurons and from this theory, joint restrictions can cause a heightened sympathetic tone of the muscles, which means a constant fight-or-flight state. Another big theory that we do not study at Western States was the cord compression theory. This theory suggests that with cord compression from the "subluxation", depending on the area being compressed, specific symptoms will follow. My impression of this theory from reading about it on the exam was that it is minor-myelopathy. We've learned many times if you compress spinal cord structures you get myelopathic symptoms such as, spastic paralysis, heightened deep tendon reflexes, loss of bowel and bladder function and an uncoordinated gait. Say you reduce the load, so to speak, but still have compression on an area of the cord. Could this cause low grade deficits? From a logical point of view, I would tend to agree that this could happen. Hence, the reason we use the McKenzie exercises to help reduce pressure on the cord/spinal roots if symptoms are present.

That being said, since many of these major cord compression issues develop over a long period of time, could prophylactic chiropractic care be used to prevent these issues? If so, at what frequency should patients get adjusted? Every month, 3 months, 6 months, a year? And when should treatment start? At the onset of symptoms or in an asymptomatic status? Unfortunately, there is no research that I know of, that has helped define this dosage of care. Prevention via chiropractic remains a very controversial subject in health care.

If we approach our preventive argument through logical thought processes and suggest that adding mobility to an immobile spine could reduce the occurrence of myelopathic, orthopedic and radiculopathic problems, then yes, I could see people buying into the idea. However, if we say that the subluxation is the cause of all disease and therefore, we should eradicate it via regular chiropractic adjustments, expect rejection and continued distrust by the public.

It was pretty clear from taking the boards, that our profession has adopted more of a medical model than once thought.

All for now

Success!

2011-03-17T17:56:00.000-07:00

All the worry of sending a patient home worse yesterday, was for nothing. The person came back today feeling 80% better! This was a surprise to me because I literally helped the person to their car with the aid of a walker. I knew from what I felt pre and post therapy, the problem had gotten better. The pain was just heightened which is a bit confusing. There was more segmental movement after I adjusted the patient in the lumbars and thoracics. It was a weird reaction, for sure.

Today, I used the reflex gun or Activator gun, to adjust the patient and relax hypertonic soft tissues. I used Yeoman's test to check to see if I gained any ground as I proceeded with my approach. I also put the patient on pelvic blocks to facilitate flexion in the SI joint on the left. With the aid of the reflex gun, I adjusted the sacral base and worked on getting each lumbar segment to move again. The person was very locked up!

A few passes with the reflex gun and a couple stretches to the piriformis allowed me to perform a Yeoman's on each side without any pain at all! I was super excited about that.

We ended with K-taping in an H-pattern again with spray Biofreeze and Arnica gel. I held my breath as the patient helicoptered off the table and stood up straight. He said he was mildly tight but had no pain at all.

Things aren't always as they seem.

All for now

A Challenging Case

2011-03-17T01:07:00.000-07:00

A patient unexpectedly showed up to the CIC today with an antalgic posture, one hand holding the left lumbosacral region and in very obvious pain.

The history revealed a lifting injury suffered 3 days prior. At the time of the interview, the symptoms had reached a peak in the 3 day duration and nothing made it better or worse. The physical exam was positive with a left unilateral Kemp's, negative resisted muscle tests and a normal neurological exam. Active straight leg raise was positive on the left with severe pain/spasm in the left sacroiliac joint. Yeoman's was positive bilaterally with left causing greater pain than the right. Farfan's was positive on the left, especially in the lumbosacral region. Nachlas, Ely's and left Hibb's were negative. Right Hibb's induced a left SI joint spasm.

Muscular palpation exhibited severely spasmed QL's, tight gluteus medius muscles and spasmed thoracolumbar paraspinals. Rising from a chair was very painful as well. The left ilium had a flexion restriction which was confirmed with provocation in both flexion and extension as well as leg length. Where extension of the SI joint reproduced the patients symptoms and flexion relieved the symptoms on the left and the left leg was about 1/4 of an inch longer.

Dr. Roberts confirmed the diagnosis of a left-sided sacroiliac sprain with associated myospasm, myalgia and related joint dysfunction. Quite the issue.

She advised we start on the flexion-distraction table. Immediately during the first minute of care, the patient spasms worsened when the table pulled into flexion. The pain was primarily in the left SI joint. I put the table back to neutral and reassessed. I decided to stop trying to fix it and go get the inferential current modality to hopefully fatigue the muscles into relaxation.

Ten minutes go by and we venture into a drop maneuver to free up the SI joint. First drop, the patient spasms and releases nicely after holding flexion pressure in the left SI joint for about 20 seconds. Second drop, no spasm. The patient is feeling a bit better, reporting no pain in the prone position, where before during the physical exam, prone was not comfortable at all.

I have the patient helicopter to a standing position and BAM another spasm happens. The patient slowly sits down and I reassure that it is okay and that the muscles are just a bit confused as to what is normal. A minute goes by and the spasm dies down. Thank goodness! The patient tries to stand again and BAM, spasms up again. I am thinking, what the hell, the person was fine on the table and reported relief from the work I just did. Dr. Roberts enters the room...

I get her up to speed as to what the patient is feeling. She says that the muscles are confused as to what to think right now and this is to be expected during the acute phase of an injury. She then says we should put the patient back on inferential current at the 80/120 level to help retrain the brain as to what it feels.

We cart the patient to another room and hook up the device. Fourteen minutes later and the machine beeps, I detach the cables and clean off the patients back hoping that this pain killing modality did the trick. I K-tape the lower back in an H-pattern with a horizontal band at 50% tension across the injury site and two vertical strips on each QL. I tell the patient to slowly get up using the helicopter move.

The back spasms again! I am thinking, oh man, I wish I could prescribe medicine right about now. We slowly rise again and with the aid of a walker, yes, a walker, I assisted the patient to their car. I ran back into the clinic, snagged an ice pack and advised further treatment tomorrow. Yikes!

Tonight, I reviewed the treatment protocol for such a case and in recollect, icing down the back during the last IFC modality would have been better versus using a luke warm heat pack to weigh down the electrodes. This would have reduced the inflammation and perhaps allowed greater mobility in the standing/walking position. All other therapies were correct and Dr. Roberts felt confident that we did the right thing. That doesn't help the fact that this patient left feeling a bit worse, despite the greater segmental movement we facilitated and reduced palpable tissue tone in the prone position.

Acute cases suck. I had one earlier this quarter where a patient strained/sprained their upper back/lower neck. The first treatment is always a make or break situation. It is a delicate balance between applying too much and not enough therapy. I struggle to know the right recipe for such cases because for the most part, we are largely working on asymptomatic patients or chronic conditions that need adjusting and soft tissue work and my experience with acute conditions consists of about 6 hands-on cases. Thank goodness there is a Dr. Roberts nearby.

Tomorrow, if the patient returns and if I can get to sleep here soon, we will reassess the situation and decide the best course of action. I will probably advise pulsed ultrasound at a very low level, mobilization versus manipulation with a flexion emphasis and utilize post-isometric relaxation stretches to trick the tight muscles into relaxing.

Hopefully, we will have a favorable outcome that has some subjective loss of pain involved versus objective changes only.

All for now

Availability

2011-03-13T23:53:00.000-07:00

My biggest fear was achieved at the CIC last weekend. A patient of mine that I had been treating for several months called in for an appointment and scheduled with a different intern. I took this pretty hard initially but as I recalled what had transpired during the past two weeks, I figured out why.

Sadie (my lovely lady) and I have been trying to figure out where to live once I finish my requirements in the clinic this spring. She accepted a job in Boise Idaho as the News Director for the local/regional NPR station. This was sort of an unexpected scenario because she had been working at Colorado Public Radio as the Senior Producer for Colorado Matters, a daily local NPR talk show. When the offer came up for her, we bounced several scenarios around with both Colorado and Idaho in mind. In the end, we chose Idaho for the lifestyle and career change for Sadie. And it has always been our home.

That said, a few weeks ago, I traveled to Idaho to check out some space for a possible chiropractic clinic and looked at a few apartments. During that weekend, my patient was planning to come in but hadn't called to set up the appointment. The weekend before this weekend in Idaho, I had a very serious conversation with the patient and advised weekly visits. In the midst of a busy week, I forgot about it and ended up taking off the weekend to go to Idaho not knowing the patient was going to show up expecting me. Not good.

The patient scheduled with a different intern and I lost the patient due to my lack of communication in regards to my travel schedule. Of course, the new intern rocked the visit and impressed the patient so much that this past weekend, the patient scheduled with the new intern again. I was shocked and a bit frustrated about it all. I decided to be a secondary on the visit with the hope of regaining some connection with the patient, but it was really awkward. I hadn't figured out what went wrong quite yet and I was helping this new intern perform therapies that I had been doing for several months. The whole time I was thinking I must have made the patient too sore or something from the last treatment.

Once I got some rest and started backtracking, I figured it all out. I broke the trust I had built with this patient by simply not communicating well enough. It was a big deal for this patient to commit to coming in weekly and I was expected to be at the clinic to provide weekly services. I screwed up.

Long story short, I intend on having a direct conversation with the patient this week to potentially re-connect and get the plan I wrote previously in place. If I cannot patch things up, I will have to find a different intern to take over the case because the current one is nearly finished with his visits.

It pays to be available.

All for now

Boards Part II and III and Offensive Jargon

2011-03-09T21:50:00.000-08:00

It seems as if boards are here again. Last time this happened was about a year ago and the weeks prior to the exams, I was freaking out about them. They are ominous and scary due to their career delaying potential. During the exams, it feels like time flies by in the beginning and slows way down in the end. At least this was my experience last time.

Our exams, parts II and III, are supposedly easier than part I. I think that is because they are clinically based questions and all we have been doing is studying clinical science since the beginning of last summer. Personally, I feel pretty prepared and calm with it all. I haven't studied as much as I did for part I. This is partly due to having no motivation to study and having no quality time to pour into the books. I imagine this weekend will be busy with finals coming up next week as well.

My hope is to enter with confidence and a calm mental outlook so that I can critically think for many hours of examination. If I remember correctly, the nerves were pretty fired up during the last exams and I do believe that took it's toll on my scores. Thank goodness it wasn't too big of a toll. Things do happen like that, so if something happens where I have to retake a board exam or two, I wont be too wrecked over the news.

In regards to my last post on Gonstead, I removed it a few days ago because I felt it wasn't fair. I didn't stay through the doctor's lecture in order to give a very good synopsis of what was taught. I judged them unfairly and should have stayed longer to be fair.

That being said, I still believe technique systems are the plague of our profession and they are lacking in ethical character. They convince people that their health status is solely due to the subluxation and that is not right. We are musculoskeletal doctors and their moves are cool and that is it. We should use them to our advantage but stay clear of the dogmatic principles they preach to their followers and vulnerable patients.

If you believe in some awesome connection to the universe and think that your work helps connect them to this powerful entity, keep it to yourself. Don't tell your patients that this is what you are doing because they, at large, have their own religious backgrounds and beliefs. It is not only a recipe for a weird/awkward conversation that turns into a sales-pitch, but it makes people think that all DC's are like this and that is not true.

Interestingly, I do find some of the theories on placebo very fascinating. The power of suggestion is so incredibly strong that significant changes can occur simply by changing someone's thought process. Take psychotherapy for example. A patient with a mental health condition goes to therapy for treatment of anxiety and within a few sessions, he or she is back to normal. No drugs given, only education and suggestion. They changed themselves so, could this be a placebo? How about when we are trying to get a person to relax in order to apply a precise adjustment. If we tell the person to relax and place a hand on their back in a gentle manner, they relax and BAM, we adjust them. They changed their tissue tone and allowed a physiological change to occur. Is this a placebo?

My point is that we are largely customer service representatives with our patients. We are here to make them feel better and obtain therapeutic results eventually. We can use objective markers all day and lose our patients because they don't feel as if they are treated any better than a lab rat. I find the evidence-based approach a bit annoying sometimes due to this ignorance. Patient satisfaction effects clinical results and compliance to a treatment plan is critical. Without compliance, what kind of objective outcome can be measured? Notta.

Lastly, in my blog post "Nearing the end", I referred to the entering class of 10th quarter students at the CIC as newbies. I used this term loosely and offended a few people. I usually do not care if I offend anyone on this blog because it is my blog and if you are offended, at least I got your attention and you took a fricken stance on something. Anyway, my use of the word newby was quite innocent. Newby means, a new person to a situation. Have the fabulous 5 ever worked at the CIC? No they have not, so they are technically newbies to the CIC. Are they competent? Hell yepper! Do they have skill? F'n A!

Was I called a newby by the 11th and 12th quarter students when I arrived at the CIC? Yes I was. And I am very proud to have gone through the hazing. Good luck fresh, innocent, new CIC interns...

All for now

Nearing the End!

2011-03-02T22:50:00.000-08:00

As I finish the 10th term of this 12-term program, I am seeing 12th termer's in their last days at the clinic. It excites me and boggles my mind as to how much I still have to complete in the next 4 months. The fact that they made it, makes me even more motivated to finish this program up.

My friends and collegiate buddies at the CIC are about done with his tortuous time spent at Western States. They haven't lost all hope and motivation, which is motivating to me. I find that their attitudes revolve around accomplishment and intense exhaustion while waiting for the final days to end. Similar to senior year of high school, they too are taking as much time off as they can and they find ways to occupy time that has nothing to do with clinical proactivity or school work. If they are called to duty, they spring from their seats and rush off to help deliver quality chiropractic care to patients in need. They live the good life. One that does not consist of long hours of study and stress. I do wish I was in their shoes, but I know in about 4 months, I will be.

These students who are entering their final days at Western States are incredibly skilled. It amazes me how good they are. They enter any treatment scenario calm and ready to deliver conservative therapies to people who wish to avoid needles and drugs. It is as if they have accepted who they are as practitioners. I find their presence a real confidence booster and realize that I too am skilled just like they are, just less aware.

In April, a small cohort of students are entering the CIC as newby interns. They will be scrambling to get visits and freaking out with the pressure Dr. Roberts provides. It should be entertaining and a bit daunting at the same time. Our current seating arrangement will be altered to allow newcomers to do their paperwork, while we continue writing and delivering patient care. The days ahead will be challenging because each of our patients and our secondary entitlements will be at stake due to five Western States interns.

In the end, we will all graduate. Many have walked before us and being at the CIC provides a huge patient-base to tap. With no effort at all, interns who have gone through our clinic have finished consistently on time. Most have finished by 11th quarter or shortly thereafter. These newbies will be where I was in November of 2010, freaking out as to which room to be in, what computer to use and how to establish a patient-base. It will be hilarious!

Until then, I will be doing my best to finish my paperwork and free up a seat at a computer. Knowing how many visits I am getting currently, I don't think a fight will be had for such meager blessings.

All for now

Field Doctors

2011-02-22T16:59:00.000-08:00

I took a trip to Boise this past weekend. With President's Day off school and the clinic, it felt like a great time to drive down to Boise and visit with my family and a few field doctors.

It was interesting to sit and chat with my potential preceptor friend because he has been in practice for 19 years and he has a particular way in which he practices. I was happy to see how busy he was. He told me he sees about 120 patients a week. This is about 30 a day since he works only 4 days a week.

I met this doctor in 2008 by becoming one of his first patients in his new clinic. He had just moved to Boise that year after spending 16 years in Seattle practicing. I was excited to learn he was a graduate of Western States, because this was the school I had my eyes on. Through his first 6 months of opening, he became busy quite rapidly. In fact, he was over 100 visits a week after his 2nd month! The guy knows how to get patients to adhere to his plans and he is one of the best adjusters I have been adjusted by.

As we chatted, I learned that he only adjusts people and does his best to stay away from physical therapy modalities and rehab. He told me that he loves adjusting people and he thinks that is the chiropractors role as a health care practitioner. He isn't against other approaches, but he feels this is how we should practice. I disagree with this approach because it corners you into relying on one set of tools and one source of income. I heard a lot of talk about keeping patients in the system as long as possible and I witnessed one of his associates tell a patient that the reason she was crabby was because she was "subluxated". Not cool.

The associate complained because his numbers had dropped from 100 to 50 in the last month. In my opinion, it is because he is trying to convince people that the subluxation is the root of all their problems. If he focused on health versus a sales pitch, I bet he'd get busier. Weirdly, he has been practicing in Boise for 9 years and his numbers are slipping. You'd think the numbers would climb and maintain after a while once you build your reputation.

The doctor that is going to be my preceptor is a bit different than his associate. He still adheres to the theory of the subluxation but he is a very personable guy. Even though I know I have feelings against this style of practice, I still think I can learn a lot from him just based on his communication skills and of course, he is very good at chiropractic adjustments.

It was a good visit overall. I still believe if we focus entirely on adjusting, we are missing the boat to many avenues of opportunity. Adjusting is important but there are many, many other areas that are just as important, of which, could be sources of revenue for us and easily delivered ethically.

All for now

Differential Diagnosis

2011-02-15T23:52:00.000-08:00

A patient on Monday was inquiring about whether an MRI was needed for an upper extremity issue and I was put on the spot with no Dr. Roberts in sight. It was an interesting situation to be in because the patient had been suffering from chronic pain for awhile and was searching for an answer as to why.

Thankfully, the question was raised after I finished doing some soft tissue work because I was able to show the patient the change in range of motion and reduced pain. I was pretty confident in what was going on and felt as if an MRI was not needed. If the therapy was not successful and there was a lack of work related movements tied to the injury, then perhaps, imaging could have been a good idea, but the therapy was successful and there was also a history of repetitive trauma to the extremity.

After writing the last blogpost about massage versus chiropractic, I began wondering why folks choose massage over chiropractic and vice versa. One thought was that under the massage therapists care, a person can passively receive treatments without worry. It is a really beautiful way of applying soft tissue therapy because the patient feels as if they are taking care of themselves proactively and accepts a treatment. The patient can relax and the skilled person can relieve aching muscles and calm the mind's negative injury mechanisms. Blood flow can be restored and new tissue is built a few days later that is in better working order than before. Our chiropractic work is no different for some. However, there is a negative association with DC care because we diagnose and adhere to rigid treatment plans. It becomes a problem focused approach. I think this is why many DC's move toward the wellness end of the spectrum versus the medical end of the spectrum.

As chiropractors, we do the same thing as MT's, just quicker. Granted, at times, massage is the best choice for care because the fast approach is either not tolerable or it just doesn't work. A friend of mine shared a story recently that suggested our health care system for musculoskeletal problems is flawed. I can't share the story in it's entirety, but I can say that I agree. We are being taught to rule in or rule out pathology in order to decide if chiropractic care is the best approach for the patient's problem. Our MD and DO counterparts are taught the same exact thing in school and guess what, they screw it up too sometimes. My friend's story outlined the main problem with seeking care as a money-focused issue. Meaning, there is such a demand to make money that good quality health care is lost in the process. Dozens of practitioners later and thousands of dollars lost, the patient ends up at a massage therapist's office and gets better. We chiropractors are perfectly set up to NOT miss musculoskeletal problems like this.

Here we are slaving away at learning how to formulate a differential diagnosis list for every patient, learn orthopedic and neurologic exams and screen for visceral/organic disease and we can't figure out a musculoskeletal problem? This is called a huge waste of time for everyone and etches a deep wound on our profession as well as the big brains in medicine.

I tend to wonder if patients get caught in the mix of things because assumptions are made by doctors based on what pays the bills. Or if the doctor doing the diagnosing, practices with a limited toolbox, such as using high-velocity adjusting only for all problems.

The hardest part of being a chiropractor is knowing when NOT to adjust a patient. We are taught to use high-velocity thrusts from day one in our program as our number one tool, so going against this engrained truth is challenging. Recognizing the problem that responds well to adjusting is not easy and takes many, many years to learn and the same can be said about the problem that doesn't respond well to adjusting.

Our differentials consist of many different diseases and conditions that can be identified with proper orthopedic exams, neurologic exams and palpation. Even our joint restrictions can be found with this approach. The misses that happen, such as my friends, are really due to poor quality in assessment. I know we will all miss things in our careers, but we are paying a ton of money to not miss things and we will pay with our reputations if we do. On a side note, this is why I will be referring for all radiographic imaging versus investing into an in-office set up this year.

The going joke is that all chiropractors are poorly trained and are mostly concerned with draining your insurance versus actually taking care of your problem. I want to stop this generalization. The crappy thing is that we all need to eat and pay the mortgage. So, who can you trust for your health needs? Do you trust the highly educated doctors or do you trust the more passive approaches to care? I hope the answer is the highly educated doctors because they are trained to rule in or out serious disease. The issue is, how do we minimize the misses, particularly when the problem, such as my friends, was a perfect case for conservative musculoskeletal care.

Always be present (as Dr. Roberts says).

All for now

Massage Therapy vs Chiropractic

2011-02-13T08:00:00.000-08:00

Last week was interesting. A patient of mine decided to pursue massage therapy for the musculoskeletal problem that was causing pain and decided chiropractic was not a good choice for the condition. Being that we live in a free country, we can choose how to manage our health problems anyway we see fit. Our profession of chiropractic is misunderstood by the public.

Unlike massage therapy, chiropractic is open to interpretation by the public. Massage therapists have done a great job defining themselves in the public as a profession that relaxes muscles and calms the mind. Therapeutic massage helps many people overcome pain and regain function. Their work is understood for the most part by the public and it is trusted. Even though we do the same exact thing as MT's, some do not equate DC's in this manner.

Chiropractic is misunderstood. Many people feel as though the only thing we can do is fix lower back problems. This misunderstanding forces practitioners to sell chiropractic to people. Hence, the reason people adhere to questionable marketing tactics. That being said, massage therapists fill in the gaps of our profession and having an MT in our office would be a very smart idea.

Going back to the case I spoke of earlier. This person does not understand chiropractic and when I tried to explain what we could do to help, it was like a door was slammed in my face. Rejection! The patient chose massage therapy because there was a misunderstanding as to what chiropractors actually do. It was a very frustrating moment. Had the person known that we relax soft tissues, free restricted joints and guide patients through rehab, as well as address nutritional factors, I believe more good would be done. Will this patient feel better after the massage? Definitely. Will the problem be resolved completely? I don't think so.

In the long run, the person will get some relief from the problem. As far as rehabilitation goes, the patient will not get the care needed to rebalance the muscles and the potential for re-injury is there.

We are in a peculiar situation as fresh doctors in a society that does not understand our work. I propose we take control of the situation by taking the effort to be the go-to doctors for musculoskeletal care. We have to own what we do so that it is not taken from us. Not only are we competing against MT's, but we have DO's and PT's, even MD's to think about. These professions are just as good as our own and for the most part, more understood by the public.

If chiropractic was thought of as the place to go to for all musculoskeletal problems, we would be elevated in society to a new level of professionalism and trust. I do believe the ACA is doing a great job helping the profession succeed, but it would be nice to see the colleges and practitioners do something to educate the public.

All for now

Gimmick or Not?

2011-02-10T21:32:00.000-08:00

Talking with a fellow student at the CIC today, I realized there is a lot of gimmicks (a trick or device intended to attract attention, publicity, or business) in chiropractic. It's as if these practitioners cannot make it as honest health providers and must adhere to questionable tactics to obtain business. You'd think the Hippocratic Oath would deter them away from such practices, but there is a huge market for "snake oil" out there.

I think what is going on is that when new graduates get out into the "real world" and they realize there is a lot of negativity out there against our lovely profession, they get smacked down too many times and turn to the dark side of theoretical dogma. Adhering to such a concept is one of ethical charisma. Meaning, if we decide to follow the model of adjusting a person to free pinned up energy and sell this concept, we are deceiving the public. As doctors, we cannot take advantage of patients through selling ideas like this because they are trusting us with their health. Health is the only thing we really own in life. We can't take advantage of people this way.

Some would say I am not being fair to the subluxation-based doctors when I say they practice mainly to take advantage of patients. Maybe they are right. I know a few straight doctors that really like helping patients and they follow the theoretical ideologies of the Palmer's. They are good people too. I question their legitimacy and wonder how they get paid by insurance when insurance is largely based on empirical research. Being that insurance is modeled on an injury/pathology model, how does a theorist get paid time and time again from them? I know how. It's called deceiving the insurance companies on a particular condition to drain their piggy banks. This is called fraud. Being that chiropractic is largely preventative, our diagnoses have to be tweaked many times to get reimbursed. So, does this mean we evidence-based practitioners are similar to theorists? No. Well, maybe a little.

The weird thing is that no matter what side of the fence you sit on, we are all chiropractors. Seeing some of the weird crap that does exist in our chiropractic world, I will say this, buyer beware. Not all DC's are alike. For instance, I watched a video of this veteran DC who "specializes" in cranial-sacral therapy. He literally, lays a person prone, takes a contact on the sacral base and toggles the base with a feather-light touch to adjust the upper cervicals. What?? Seriously? Apparently, it has to do with the mechanical pump of our cerebral spinal fluid. Theoretically, this means our sacrum and our upper cervicals move in-sync with respiration and if a toggle move resets this pump when we are "out", then health will be restored. I'd like to see a study designed that tests this theory. That is a dream that will likely never happen.

I will end with this, gimmicks exist everywhere. Drug companies want to sell drugs and they sell A LOT of them. Our doctors tell us that we NEED a particular drug to fix whatever ails us. It is big business. Looking at how healthy our society is, I think their approach is not working well at all. Is there a need for pharmaceuticals? Sure. I strongly believe health care needs to be service based versus prescription based. If you are overweight, you get X amount of dollars for personal training each year. If you have type-2 diabetes, you get X amount of dollars for a trainer and Y amount for a nutritionist each year. Versus two bottles of pills to take each month.

When you look at the harm that theorist-type practitioners cause in relation to MD's and DO's historical over-prescribing practices, you can see these theorists are harmless. I hate to say it but they are.

I am reading the book, The DO's by Norman Gevitz, which is a historical book on the development of the Osteopathic profession. It's a great read! According to the book, DO's fought hard to establish themselves as legitimate doctors in the early 1900's. Public perception was horrid toward their work but the government, at that time, saw the benefit and demanded standards for education. The profession became more musculoskeletal and less alternative as it grew and from their adherence to standardization, they became the second most powerful health profession in America. In the early years, Andrew Still, the founder, was quite upset at the standard medical practices of the time and instead, pursued magnetic healing and eventually manual medicine. Manual medicine paid off and they made a name for themselves.

I am going to read a historical book on Chiropractic too, but this book, The DO's, is helpful to understand where our profession is at currently. When comparing DC's and DO's, the interesting thing is that osteopaths adhered to standardized methods early on. They conformed the profession to satisfy the publics need for competency and the governments need for social hierarchy and public safety. When looking at DC's, I see an adherence to principles versus conformation. Yes, we now follow more evidence-based approaches to care, but we have not conformed as the DO's did. This all comes with a price. The DC profession puts it's value for drugless treatments higher than public perception, which is why I chose chiropractic over osteopathic. However, this allows questionable treatments to arise because standardization is not uniform in America for DC schools. If DC's had formed more standardized practices early on versus in the late 1900's, we'd be way further ahead than where we are. The reality is that we have had 100+ years to unite and become standardized, but we shy against such behavior so that our ideals for health remain the most important aspect of our profession.

I just hope we can practice ethically by finding services that will honestly improve a persons health and well being. If all we do is adjust people and tell patients our adjustments do things that we really don't know if they do, we are crossing the ethical boundary. Instead, hire a personal trainer, offer massage and push forward physical rehabilitation. Get people to take control of their health and empower them with the tools of prevention. Adjusting a person is only one small aspect of their health.

All for now

A Crazy Chiropractess

2011-02-07T22:36:00.000-08:00

Today in our adjusting technique lab we met a very eclectic veteran female chiropractor. I was not sure what to think of her at first with how she spoke to our class in that tone, but I decided to give her the benefit of the doubt and see what would come out of all the talking.

In chiropractic medicine, there is a lot of practitioners out there that practice unorthodox techniques that most of the profession do not support. Our college is one that adheres to the scientific approach to chiropractic medicine by it's commitment to evidence-based practice. Evidence-based practice is primarily associated with skills in research. These skills allow the most up-to-date treatments to be administered for certain conditions. There are many research tools available if a practitioner wants to learn how to use these tools to obtain information about a patient's particular condition or the treatment of the condition.

Some chiropractors adhere to their own research methods. Like our little friend today, they think if they chew little chunks off of dogmatically based technique systems and form their own technique, they are putting the scientific method to use. If you have a bag of worms and you reach into the bag and grab a handful and put them into a new bag, what does the new bag consist of? WORMS!

I watched this lady profess her love for chiropractic and listened to her tell a classroom of 4th year doctorate students to find a new profession if they didn't "believe" in chiropractic in the way she does. She told us she loves chiropractic and sees herself equivalent to MD's. Talk about an ego. Some say that the one who speaks first is the subject of their own debate. Meaning, if you have to tell people you don't have an ego and that you think you are equivalent to MD's, then perhaps you do have an ego and you don't think you are equivalent to MD's. There would be no argument if you did not make the argument.

Do I think we can diagnose a lot of stuff? Yes. Do I think we are equivalently trained as MD's? No. They get much more exposure to diseases we only read about in text books. Do MD's understand biomechanics like we do? Not many. Most PCP's handle the stuff we cure with adjusting by handing out pain killers and muscle relaxants. These words, I write, are true...

Our guest speaker today suggested that we follow a set method in evaluating our patients. These techniques are so incredibly cookie cutter that they force people to think the only problem they have is a joint restriction. I find it so frustrating to think there are practitioners out there that believe this evaluation process is legitimate. It's as if they dance around the problem with a big song and dance, neglect any other reason for the condition and diagnose everything as joint restriction (or subluxation). Really, no other conditions cause pain? Retarded thoughts plague them.

I have seen too many of these jokesters since I have been in this college. Synopsis: Lets impress the youngsters as to how incredible I am because I failed to study orthopedic tests in college. I have to dance around like an invalid and take the attention off of my lack of understanding of current orthopedic approaches to musculoskeletal care and put the blame on spinal joint restrictions as the etiology of all pain and pathology. Give me a break!

The alternative nature of chiropractic is dead. Get over it.

All for now

Patient's patience

2011-02-05T23:35:00.000-08:00

Now that the month of January is complete, we've gotten our feet officially wet at the CIC and the Burnside Clinic with patient care. Some of the interns at the CIC are rocking it mysteriously and some are getting visits slowly and wondering what they are doing wrong. I am somewhere in the middle. Overall, the first month of patient care has gone very well and I have learned a lot.

Patient care is tricky. It is a real balance between entertainment and being a professional. You have to be on your game the entire time or the patient begins thinking you are not giving them their moneys worth. Customer satisfaction is quite important when treating each patient, because happy patients follow treatment plans more closely. If they follow treatment plans, they continue as active patients. It is really a win-win scenario for both the patient and the intern.

Lately, I have seen a real slow in the number of visits I am obtaining weekly. It is so significant that I have begun putting time into analyzing why this is happening. I have been going through my patient files to remember how the interaction went between the patient and myself with hopes of finding a reason for this slump. The largest factor that I have found is that I have been treating patients and failing to speak to them about their treatment plan and the steps I have outlined for them to follow. It has been this way for the past few weeks and of course, my visits have fallen. Eventually, I will have to get over this hump by taking time every visit to show the patient where they are at in their plan. This does work when I remember to do it. Sometimes I get so into treating the condition that I forget about the plan and the patient doesn't come in for 4 weeks.

It is interesting to work with the public like this. The experiences teach you a lot about yourself and how people think. It is challenging being a student in an environment like this. We try very hard to look like doctors but we are constantly challenged by the attending physician in front of patients. This makes us look like amateurs and the patient judges us in that manner. How do you bounce back after such instances occur? Keeping the chin up and a smile on ones face helps.

One patient told me the other day that they come to the CIC because they feel as if they are getting the most up-to-date chiropractic care available. It was an interesting exchange of thoughts. I kept my thoughts mostly to myself in that regard and reaffirmed the patient's comment with a smile and a nod of the knoggen.

Chiropractic is such an art and is formed from many years of hands-on treatment. When a patient comes into the clinic in pain, this pain they are experiencing is their reality and a story is wrapped up into the injury. It's part of their life and the event becomes a part of their life story. I find that very fascinating when interviewing patients. Many times they define certain events in their lives by the injuries they have suffered or surgeries they have had. Coming into the clinic is another big deal for them which marks yet another story in their life. This is why we must be entertainers to some extent. Their story must be very important to us when we work with them and we must find ways to get them to take action in order to get better as well as offer drugless, natural and effective treatments. Hence, my new commitment to sharing my treatment plans with my patients each visit.

Dr. Roberts gives little speeches every Saturday and Thursday morning at the clinic and I find them inspiring every once and a while. Someday's I cannot stand the demeaning tone in her voice but others, I start the day inspired. I guess we all have our bad days. The speech this weekend was about how neurosurgery is failing back pain sufferers. The evidence is in that suggests this invasive, popular approach to back pain relief is a poor choice. I find this very interesting because the solution which is stated in the current Back Letter (a publication), was to focus treatment on less invasive "alternative" treatments.

She extended this information into why some patients have more pain than others. Why some patients who have severe degeneration in their spine and joints have no pain at all and why some with the same level of degeneration have severe debilitating pain is a complex phenomenon. She spoke of the work of a popular researcher who looked into this phenomenon and apparently he found correlations to the diet as well as the level of one's exercise to one's propensity to become excessively inflamed or heightened pain sufferers. I find this so very cool! This concept is definitely known to most health professionals but the system is not set up to fix the patient's real problem.

The real problem is their lifestyle. It is keeping them at a constantly inflamed state and any insult or injury, whether mild or severe, causes excessive reactions that result in a large pain response. Inflammatory precursors are well-studied and anti-inflammatory precursors are well-studied as well. NSAIDs work off this anti-inflammatory biochemical pathway and so do many fruits, vegetables and unsaturated fatty acids. If a person can infiltrate their system with anti-inflammatory precursors while eliminating inflammatory ones (saturated fats, sugars etc.), they will theoretical experience less pain in life and perhaps less disease.

All for now

Burnside Clinic Part 2

2011-01-24T19:38:00.000-08:00

My second shift at the Burnside clinic was an interesting one, to say the least. I told myself to go in with a relaxed mind and confidence, so the shift would feel less chaotic. Wishful thinking is all that was!

The patient I had during my first shift returned reporting that the work we did resolved the issue entirely for one day, then the pain and tightness returned the following. We track outcome markers for bodily function versus pain and all the markers were better for this patient, so I felt we were on the right track. I reminded the patient the problem is chronic and one treatment will not fix twenty years of pain. To have reduced the symptoms completely for a day is in my mind, a good outcome. I took blood pressure again to see if there was in fact, track marks and there were none. Only a slight discoloration of the skin. I left the issue alone and didn't press further. We rescheduled for a week and hopefully the results are still positive. This patient is the only patient I have had where all of my adjustments have not popped anything. No cavitations at all! But, we are on the right track, so popping or not, we should continue the care.

Second patient arrived late and of course, was a new one. Dr. Yancy took over and began the history without me in the room and without writing down anything at all. I hadn't a clue where to take it once she left, so I just started into the physical exam. I was shocked by the findings that presented themselves that day. Positive bilateral Babinski, sensory loss to the hands in a glove-like manner, hyperreflexia to all deep tendon reflexes, jump sign elicited when upper thoracic and upper extremities were palpated with light pressure, hypertonia of the upper thoracic musculature and a positive Soto-Hall with right arm heightened paresthesia. Yikes! I palpated the cervical spine and with light lateral flexion and rotation, right arm symptoms increased. It was then I decided to stop. I didn't feel comfortable with the patient because I felt we needed thoracic, cervical and brain imaging to be safe in our work. I loosened up the thoracic muscles a little and did some light work using Farfan's maneuver in the lumbars and lower ribs which made the patient feel better and more loose. We will continue care on Friday this week and the patient will be getting blood work and imaging (hopefully) Tuesday. To be continued.

Third patient showed up late too. I rushed through the history, but being I had control over the interview, I was able to get all that was needed quickly. We began the physical and nothing bad popped up, so I treated the patient by adjusting the cervicals, thoracics and lumbars with traditional adjusting. The patient responded favorably and I counseled the patient on proper posture and gave specific exercises to complete. It was a good visit overall.

Having two new patients like this is a bit daunting. It leaves no time during the day to get paperwork done. We rush to complete our notes so that we can leave on time and get the weekend started knowing that another day of stress is looming if we do not find time to finish things up. I will have to go in on Tuesday morning tomorrow to finish my CTP's on 3 patients in order to stay on top of things. This means, my personal time is affected and no break will be had this week away from the clinic.

I can't complain though. There are worse situations out there and the work isn't physically demanding at all, just mentally challenging and time consuming.

All for now

The Influence of the Past

2011-01-18T11:48:00.000-08:00

Most of our class, myself included, chose the University of Western States as a school to obtain our Doctorate of Chiropractic based on it's supposed evidence-based approach. We knew going in that the influence of the past was still present in our profession. Slowly, evidence was being produced in research in support of conservative orthopedics, which in turn, has helped the profession become more accepted by the public.

Conservative orthopedics is modern chiropractic care. The old ways suggest a different reason altogether for getting adjusted. This old way is based on flawed theories suggesting neurological interference, meaning, a pinched nerve leading to disease. I have written about this before in attempt to show that this theory is ridiculous and a modern version is more appropriate and justified. The pinched nerve idea does happen, but it causes radiculopathy type symptoms into an extremity. Numbness, tingling and weakness are a few symptoms based on this entrapment or compression of nerve tissue. This happens all the time and is a real problem.

Even though there is a heavy influence in the scientific literature showing the modern version of chiropractic medicine's legitimacy, there is still a lot of old school doctors out there that believe in this theory of subluxation-based disease.

In class yesterday, the instructor gave us a summary of a bunch of techniques in chiropractic that have become popular among non-medical chiropractic doctors. Applied kinesiology and toftness were discussed by the professor and from the tone of the conversation, she believed there was legitimacy in the use of these technique systems and almost suggested their use. She told us about her approach to finding the "subluxation". It consisted of scanning the area with her hands superficially and when she gets a stomach ache, she "knows" there is an issue there. That isn't quackery, is it? The technique systems out there, use this subjective approach and they are frowned upon by a large majority of DC's and of course, medical doctors. The toftness device was banned by the Oregon Chiropractic Board due to the inability to prove it's diagnostic objectivity. This is why chiropractic will struggle forever.

It was really weird how she approached the conversation. She acted like my dad used to when he'd let us get away with things my mom would not when I was a kid. She told us, this conversation never happened, then proceeded to spew her belief's all over us like a preacher from the pulpit. I was offended by her. I kept thinking, we've been working so hard to get protocols memorized and the committee that has worked so diligently to help chiropractic grow into a mainstream/supported profession was being kicked in the proverbial undercarriage by this "believer". Her rebellious approach was somewhat supported by the class by them giggling at her unorthodox comments of going secretly against the University's commitment to integrative chiropractic care. As a side note, integrative chiropractic utilizes objective qualities from a biomechanical/medical perspective that make sense in all medical disciplines. I threw the packet of techniques into the trash on my way out the door. Her copyright violation also struck a cord with me.

I don't know if I was alone with all this when we were being subjected to her beliefs, but I do know there are reasons people don't go to the chiropractor and this "established" veteran chiropractor is one of them.

Some may think I am not open to other ideas. Some may think I am a bit too serious with all this. You may have good reason to believe this, but in my opinion, the only reason to not use scientific/objective approaches to patient care is for the doctor's benefit only. Whether that be emotional, financial or just some need to rebel from the medical standards in place, those reasons do nothing for patient care. In the end, the public becomes confused by all these technique systems and the profession becomes less legitimate and strong.

I will never buy into a technique system no matter how challenging it gets in practice or in school.

All for now

Scope of Care

2011-01-16T21:47:00.000-08:00

There has been some remarks to my previous post about the Burnside Clinic that I felt were not the vibe I'd like to present to nearly 1,000 readers per month. I removed them and have decided to write a bit about why. I would like to clear the air with the past blog post to make it known my intentions for the course of action I had in mind for my patient with a suspected drug issue.

At the Burnside Clinic, we see all types of people who cannot afford any medical care due to their present circumstances. We must make immediate decisions for the people we see that have a multitude of issues going on at the same time. There are some, not all, who are on drugs and alcohol who need help just as bad as those who come in that are not on drugs and alcohol. The problem is how to deal with these folks. Do we educate them on the harm they are doing to themselves by using drugs and alcohol or do we ignore it and fix their musculoskeletal problem and wish them luck? It's a tough call. As chiropractors and according to the laws that exist for first contact providers, we have to intervene or we are at risk of doing injustice. As for my patient, I will recheck blood pressure and I have already spoken to Dr. Yancy about having her there when I take the reading so that she can be involved in the process. I should have added this to my last blog post, which may have been more clear. Sorry. I sometimes portray these interactions with patients as one-on-one, when in fact, there is typically a licensed provider in the room.

Some students feel they are not prepared to deal with circumstances like this and it makes them uncomfortable when they have to actually deal with all this. I totally get it. In our education at Western States, we are informed on the negative consequences of excessive alcohol and drug abuse. What we are not fully prepared to do is refer in a necessary manner. I feel totally out of my league when it comes to this but I trust my attending physician will help me take the appropriate action. As far as the comments that were left that I deleted, I never once said I was going to treat the individual with the drug problem for the drug problem. I will only treat them for their low back pain and upper thoracic pain. Will I manage the drug issue? Absolutely. Will I help the person get off drugs? Hell no! I know what can happen when a person tries to quit cold turkey. Their system can go into all kinds of medical uncertainty.

My point of the last post was to talk about how difficult it really is to manage these individuals. Not to suggest chiropractic was a treatment for these individuals. In our clinical internship, we learn the ropes of patient management. When a problem is beyond the scope of chiropractic we quickly refer to the appropriate specialists who can manage the problem more readily. We don't learn this in school. We learn this in the internship under the guidance of experienced chiropractic physicians. I am glad Dr. Yancy is there to step in and provide guidance with the process of dealing with challenging cases.

I hope this clears up what it was I was trying to portray from the past blog post.

Burnside Clinic

2011-01-15T19:28:00.000-08:00

My shift at the community outreach clinic on Burnside in downtown Portland started Friday. Three other colleagues and myself made it on time to the clinic and began the first shift with a gut full of butterflies. Just getting to the clinic is a lot of extra work. Parking at the Lloyd center, getting on the Max and finding our way to the clinic was quite exhausting.

Dr. Yancy, the attending physician at the Burnside clinic, sat with us explaining the charting they use at the clinic and how it differs in comparison to the other clinics. The first difference I noticed was that the clinic is heavily based in outcome measures that differ from the ones we have used so far. They are very big on endurance tests, disability questionnaires and the use of the patient specific functional scale. Depending on the level of disability, subjective function and physical endurance as well as biomechanical function, we decide how long the person should come in for treatment. It's a great way to track patient progress but it adds a significant amount of paperwork.

The interesting thing about working with the less fortunate folks of society, is how incredibly thankful and generous many of them are. To give them relief from pain and increase their physical function, is a truly gratifying experience. I can't say that I am comfortable doing such work because I have always felt so bad for these people when I see them on the streets. Their lives are so simple but very complex at the same time. I am not the person to give their complex lives the best justice, but I can say, from working with my first patient, not everything is exactly black and white.

Many of these people are living lives that revolve around finding free food and a dry place to sleep each night. Intuition suggests most are addicted to drugs and alcohol, leaving them mentally fogged up and able to live in disregard to conditions of living on the street. I cannot relate to these people at this level and I think that is why I get uncomfortable working with them. We are all human and I believe strongly that we all deserve to live good lives, but when choices made force a person to live on the street in the elements, I tend to get on a soap box. Backing up a bit and realizing that there are thousands of different reasons people end up in these situations, makes the situation look a bit more complex than simply making poor choices in life.

If many of these people quit drinking and doing drugs, they would be able to find a way out of the street life. We are so overburdened in our society with quick fixes for pleasure. Drugs and alcohol provide a level of pleasure that masks the pain these and many socially established people incur each day. Whether it be for musculoskeletal pain, emotional pain or a debilitating disease or a conglomerate of conditions, people self-medicate to make themselves feel better. I think there are a lot of people who don't see a way out of their situation so they stay intoxicated or high all the time. The Burnside Clinic is a place where we get to put to use all the disorders we have studied up to this point. Dr. Yancy made a point to tell us that we will see things that we've only seen in textbooks up to this point.

I would be a lier if I said this all is no big deal. How do you help a person help themselves when they are this low in life? And how do you do it respectfully and authoritatively? Is this even our job? Unfortunately, I have no answers. The thing I can say is that doctors are like parents to the society. They take an oath to look out for the betterment of society and it is their job to hold people accountable for their actions and hopefully guide them to making good decisions.

Unfortunately, my first patient at the clinic turned out to be a suspected heroin addict. It wasn't until I took the person's blood pressure that I saw track marks in the cubital fossa. I then figured this individual had been telling lies to me the whole time. Regardless, the person needed help, I helped out the best I could at that moment and made sure an additional appointment was made before I sent this person back into the wild.

I am trying to figure out how to approach this issue. My plan is to take blood pressure again, and just make a comment on the track marks and suggest that doing intravenous drugs puts you at risk for a multitude of conditions. One of which is osteomyelitis, a bone infection. There are other more important reasons to not do intravenous drugs that I will touch on and hopefully, the seed will be planted for better choices. Ultimately, it is the patients decision to continue using or not. All I know, is that I cannot personally take on the burden of society's poor decisions. To error is human and that's that.

All for now

Focus Pocus

2011-01-11T21:11:00.000-08:00

Intention was written on one of my ACMAS's last week. For those who are confused as to what an ACMAS is, it is an evaluation of your patient encounter. I have talked about these evaluations previously. The only word I have seen on an ACMAS since I left the campus clinic, is intention.

Dr. Roberts is a peculiar little lady. She has been in practice for nearly 30 years or more and she has a knack for chiropractic (go figure). Her ability to find a movement restriction by looking at the body is remarkable! I still have no idea how she does this and to tell you the truth, it stresses me out! My respect for her has grown throughout the last few months at the CIC. Primarily because she has saved my sorry ass many times with patient care. Not to make myself look bad (I hate that), but she really does step up for her flock when she is needed.

For instance, I have a patient at the CIC who doesn't like to be adjusted even though there is every sign present suggesting otherwise. Every time I go to adjust a restricted joint, the patient tenses up because there is fear of getting hurt. I assure the adjustment will be therapeutic and not injurious but still I get blocked by tense muscles. Instead of plowing through the tightness, I decided to just try to relax the person by focusing on stretching and massage. This seemed to worked well and I got the neck and upper back muscles to calm down. I went back to the neck to see if I could get the segments moving I was interested in and I was blocked again! Not good.

I marched down the hall to Dr. Roberts and told her the patient was blocking my impulses and the segment causing the patient pain was in need of a good adjustment. She set up on the patient, adjusted the segment in a translational type movement and the patient was given instant relief! I was amazed. She told me that patients who block rotatory adjustments respond well to translational movements because they can't really block them. Interesting.

She told me to have intention. I took this badly, of course because I felt as if I have been trying hard to give adequate patient care since I have been there. The remark wasn't about adequate patient care, it was about centering myself mentally prior to and during patient care. Those who have worked with patients in this manner know very well that if your mind is elsewhere, the visit goes south quick. I personally have an issue with this because I tend to get super exhausted from thinking so hard. The simple remark to have intention was exactly what I needed to become a better student doctor.

I feel very fortunate to be given the opportunity to work with Dr. Roberts. I know she can be harsh at times and sort of push us around, but I truly think she does it for our benefit and for the benefit of her large/loyal patient base. If I were in her shoes, I don't think I would change much. There is always some small details in need of tweaking, but for the most part, I think she does a great job.

Intention is a weird concept. We have to use it during exam preparation and patient care, but in totally different ways. The most challenging thing I have had to accomplish thus far is this concept. Each day, it gets easier, particularly if I know what's heading my way. Shooting from the hip and going in live has never been my strong suit, but it is Dr. Roberts' greatest attribute.

All for now

Busy Clinic

2011-01-05T20:34:00.000-08:00

Today I logged three patient visits back to back. I have only done this once before in the CHC about 2 months ago.

The first visit was sprung on me due to a 12th term intern. She has been done with her patient visits for a week now and I was next in line to work with her patients. I did the assessment, she asked the patient questions about the current status of the problem we were to treat and just like that, I was treating my new patient. Fortunately, I got a few good adjustments on this new patient and the problem cleared up immediately, which was a severe headache.

The next visit today was a patient with lower back pain and shoulder girdle/thoracic pain. In conjunction to this pain, the patient was also seeing a PT for a shoulder problem. I treated the lower back problem and the upper back/neck problem by adjusting the spine and deep tissue work. The adjustments went well, the patient felt immediate relief and obtained greater motion overall. The issue was a locked up pelvis and upper back. Once these segments began moving, the pain level reduced significantly to almost no pain at all! Directly after the adjustment, I spoke with a massage therapist who was treating the patient after me and gave directions as to which muscles to focus on. Apparently, the patient left pain free. I will see this person again on Friday.

The final patient of the day was a challenging one. One that I have been struggling to figure out how to adjust due to the physical condition of the patients body. The issue was largely due to severely weak abdominal muscles which has been causing excessive absorption of mechanical forces into the lower back musculature. We utilized the flexion-distraction table which is motorized and allows tissues to be pinned and stretched. Great relief was obtained using this table but unfortunately only around 25% reduction in pain was elicited with this approach. Overall, a 75% reduction in pain was achieved after two visits. The slow response is likely due to the poor health of the tissues we are working with. I think I will be using electrotherapy to wear out the muscles next time I see the patient which will allow me to adjust the lumbar spine more effectively.

We chatted about proper lifting and bending habits that must be implemented in order for the problem to subside. Hip hinging and abdominal bracing is key for this patient to regain control over a highly dysfunctional abdominal system. I will treat this patient for the 3rd time either Friday or Saturday if the symptoms go up or do not reduce. Next week I will see this patient two times and then reduce the frequency to 1 time per week for maintenance care and wellness implementation for dietary counsel and fitness improvement.

After all was said and done, Dr. Roberts sat next to me and told me I need to up my game with my patient care. She advised that I give more to the patient as far as services go because they can easily go to a field doctor for their care. She wants me and everyone else to go the extra mile. Sort of pamper the patients a little and offer an expansive approach to treatment. Make them feel as if we are giving them a lot for their money and more than likely, if they get results and feel pampered, they will continue care.

Lessons are being learned and the stress is reducing each day I spend at the clinic.

All for now

Nerve Interference?

2011-01-04T22:30:00.000-08:00

During our new pediatrics class on Monday, we watched a video about chiropractic pediatrics. The DC in the video spoke of nerve interference and how our adjustments alleviate it. I couldn't help but start wondering what that really meant.

When I adjust someone at the clinic the last thing I think about is nerve interference. The term is a bit confusing because it lacks a good definition to begin with. Are we talking about the garden hose analogy or proprioception or etc, etc. It becomes a confusing thought process.

In an attempt to discuss nerve interference, I thought I would just ramble on about it for a little while and see what words hit the keyboard.

An interesting bodily response that we all know well is pain. Pain alerts us to noxious stimuli that may harm or is harming our delicate tissues. Nerves pop out of the spinal cord and innervate all tissues of the body at a microscopic level. We've all seen those cool drawings showing where the nerves exit the spinal column and all their major branches. Those drawings represent a macroscopic view of the major nerves in the body. Like the cardiovascular system, nerves come in all sizes.

Interestingly, pain can mimic visceral disease but in reality it is a muscle issue and not a visceral issue. In a previous post, I spoke of an elderly patient that suffered a lower back injury and immediately became constipated. No history of constipation until the day after the injury. What is that about? After a treatment, the constipation goes away. Very cool stuff but how does this make sense? Somatovisceral reflex is a term used for that issue. Meaning, an insult to the soma (musculoskeletal system) inflicts an inhibitory visceral response via a neurological reflex. Maybe instead of a reflex, it is an inability to focus on two major things at once and due to the shared neurology in the region, the inhibition to the viscera comes from a draw of physiological attention to a more important matter - an injury.

The vitalists would call this neurological force the innate and the injury is a subluxation. Correct the subluxation and the innate intelligence is restored. To be clear, a subluxation is not a pinched nerve. If you have a pinched nerve, you are going to have symptoms such as, bowel and bladder problems, radiculopathy into an arm or a leg, loss of strength, decreased deep tendon reflexes etc, etc. Subluxation theory largely revolves around pinched nerves and decreased nerve flow to the body. This theory doesn't make sense in a macroscopic way. A better explanation of nerve interference should be developed so that our patients understand what chiropractic adjustments do.

My interpretation up to this point is that joint restrictions scramble neurological feedback from mechanoreceptors located in joint capsules and muscles. Altered movement sends forces that usually naturally disperse throughout the musculoskeletal system into ligaments, tendons and muscles, creating an inflammatory state. Joints that usually slip upon each other remain stuck in place and the tissues surrounding them adapt to this state and further restrict segmental motion. Feedback from the altered biomechanics and inflammation sends a pain response which makes the person aware of the condition. If the problem progresses, the patient may guard the area, further recruiting larger and larger muscles. Eventually, a full blown orthopedic problem grows out of a small joint restriction. The entire kinetic chain can be affected and problems can begin occurring elsewhere.

A case was presented to us in lab today about a patient that had a sacroiliac joint restriction. The altered pelvic movement lead to spinal pain between the shoulder blades. Once the patients SI joint was adjusted, the shoulder blade pain resolved. Thinking back to the somatovisceral reflex theory, think about how this could have affected the viscera. Interesting stuff.

For now, this explanation will have to do. Knowing adjustments help regain neuromuscular control helps explain how nerve interference could be interpreted. Add in the cardiovascular effects of ischemia in tissues which have absorbed unnatural amounts of force and adjustments get a bit more complex. Sprinkle in the neurological control of blood vessels and the hormonal changes during a pain response and things get even more interesting. Then look at the dietary influences on inflammation and you'll see some folks are more prone to extreme inflammatory responses to joint restrictions. Add in immunity and the demand these insults place on our system-wide defenses and adjustments become even more justified. The list goes on and on. We mustn't compartmentalize the systems of the body.

All for now

The Final Year

2011-01-01T21:31:00.000-08:00

We begin our final year of chiropractic school on Monday the 3rd. I cannot believe I am at this point in my academic career! It is exciting and a bit daunting to know each day that is logged is one closer to the final.

This year will be challenging. We must complete our clinic requirements and finish our academic training. The academic side of things will be a bit less than the usual, thank goodness. While in the clinic, we will log 25 hours per week and complete as many visits as possible to get the required numbers tallied sooner rather than later.

I have heard the stress of the next quarter revolves around staying alert. Much of the time spent at the clinic is quite slow at first until your patient base grows. This leads to groggy heads. My hope is that the graduating interns transition things smoothly so that we are all set. In a way, I hope things start slow and pick up gradually so no scrambling occurs the week we get back.

Another change next quarter is a new shift at the West Burnside Clinic. Treating patients who are homeless will be very interesting and quite satisfying on many levels. I have heard many stories, good and bad, from the last class to work at the WBC.

The term will begin and end quickly just like the past 9 and before we know it, a big group of us will be walking across that stage June 18th!

All for now

Blend it

2010-12-30T09:11:00.000-08:00

As time draws closer to the end of my education here in rainy Portland Oregon, I am thinking more and more about how to structure a clinic that will draw patients in with musculoskeletal problems and clients who are interested in bettering their health.

My personal interests are in wellness as well as manual medicine for musculoskeletal problems, so a clinic design that speaks both values and services is necessary to be as clear as possible to potential customers. The public largely sees Doctors of Chiropractic as back doctors. This, as we know, is a very narrow view of our beloved profession and skill-sets, for that matter. How do we get people to recognize our skills which branch far beyond adjusting the back bones? In my opinion, we will pigeon hole ourselves if we throw our last name and chiropractic behind it as the name of our business. Spangler Chiropractic doesn't speak the message I want to be heard.

I know many of my fellow DC peeps will probably do the exact opposite of what I am chatting about in this blog and will likely buy into a technique system that gives them a way to market themselves. My hope is that instead of marketing ourselves as followers of some cult, we'll look at what people need as a whole to gain health and reduce musculoskeletal disease.

The idea of my future clinic blends chiropractic medicine, physical therapy/rehab, fitness training and massage therapy. Four unique disciplines that blend nicely into an ethical, legitimate clinic design. It isn't fair of me to say we all need to do this but it is fair to say that if we buy into a marketing/technique system that suggests adjusting the back is the only thing a person needs to get healthy, we are doing a disservice to the public. I know I have preached many times about this idea of blending services and I hope at least one person who reads this blog will see the light.

How much square footage would be needed to open a business like this? I think you can get by with 1500 sqft. This is based on working for a fitness franchise in the past and how they structured their space as well as working for a few chiropractors in the past 6 years. If you have 1 personal trainer/assistant, 1 massage therapist/assistant, a front desk person and yourself, you can create a referral system within your clinic. The personal trainer can do rehab for you, the massage therapist can do soft tissue work and the front desk person can handle patient/client scheduling and customer service.

To get such a program going it will take capital to buy chiropractic, fitness and massage equipment. As far as exam rooms, you could use 2 chiropractic treatment rooms, 1 massage room, a 12x10 fitness bay that could function as a physical therapy area and use the remaining space to build an office for yourself and a cardiovascular deck. The expense comes from cardiovascular equipment. Most treadmills are about $3,000-$4,000 dollars and recumbent bikes and elliptical machines are about the same. However, if you offer personal training services and massage services for a cash fee, you can profit enough to cover the expense. I believe paying a trainer $15-$20 for a session is fair. You charge the client $50 or more for a session and you've made $30-$35 for a 45 minute training session. The same can be done with massage therapy.

On top of that service, which by the way, is ethical, you have the entire chiropractic medicine world to play with too. Insurance pays for chiropractic and physical therapy services which is quite profitable if done correctly and ethically. In the grand scheme of things, you can offer full service rehab and fitness in a health optimizing, ethical manner. When you compare this model with a technique system that forces you to practice unethically by selling subluxation theory to vulnerable patients, I think the former versus the latter will allow you to sleep at night. If you believe otherwise, I think a good counseling session would help.

Coming from a personal training background and entering the field of chiropractic medicine has opened my eyes to the possibilities which lie before each of us. We each have the opportunity to be different than allopathic doctors, in that, we can get people healthy without drugs or surgery and be their coach with all their fitness needs. It really comes down to defining oneself based on a set of values and objective standards that the public understands. Selling a theory that is controversial in order to build a business is wrong.

Now that we are clear on that subject, I will get off my soap box. I would love to see chiropractic become a college at any university and perhaps connect it with psychology departments, kinesiology departments, health science colleges etcetera. The only way I know to do this is to set an example of how chiropractic can be practiced ethically and work diligently to change the public's perspective.

We are all going to be subjected to brutal criticism when we are in practice. I have experienced this many times since being in school. We cannot take this harsh reality to heart because it will create a negative life that we live everyday. All we can do is know that what we do is ethical and our intentions are purely for the betterment of the public. Their criticisms are largely based in ignorance and the hierarchy of self-fulfillment via mediocre discriminating viewpoints. If you fall into the category that these critics hate, then you deserve every bit of their heckling and abuse.

All for now

Sacroiliac joint

2010-12-22T22:40:00.000-08:00

Every once and a while my back gets all screwed up from some minuscule movement that should not cause harm. Yesterday was one such day and this "injury" forced me to go see a chiropractor here in Denver.

From my knowledge of back pain, I knew my sacrum was stuck in flexion and not gliding between the ilium bones. How did my sacrum get stuck in flexion? One reason is I sit ALOT! For the past few years, I have been in school sitting for most of the hours I am awake. When you have poor posture with sitting, this leads to a decrease in lordosis and a flexed sacrum (sort of like a dog with it's tail between it's legs). If there are other forces involved in this scenario, such as, tight piriformis muscles, which I have, then the sacrum is pulled strongly anteriorly from the attachment of the piriformis. If the piriformis is taut and poor posture is the norm with hyperflexion, a severely restricted SI joint is very likely. Hence, my reason for seeking care today.

The minuscule movement that set all this off was as simple as picking up a trash bag while holding a heavy door open with my foot. A slight twinge of pain occurred and immediately I noticed a difference in my gait. It was almost as if I was waddling around. The pain didn't really get that bad until later that day and the next morning. This heightened pain left my back quite spasmed. Extension hurt like hell and flexion at end range was a little sore. The forces that accumulate from a stuck joint like the SI joint, absorb into the surrounding tissues. Muscles become hypertonic and as wastes accumulate in the overactive tissues, pain increases and circulation reduces. Why did this happen?

My thoughts are that the day before, I did a relatively long run. I am a bit dehydrated from being at altitude and swilling coffee and a little bit of Denver's finest micro brews (less tissue pliability). Coming off a long quarter of sitting and running and skiing with poor posture, this lead to very tight piriformis muscles. Being that I do not stretch nearly enough, my SI joint was prone to injury yesterday from the relatively minor movement.

I searched out the chiropractors in town and found a handful that seemed good. One I found appealing was Primary Care and Chiropractic. Yes, that is the name of the practice. The couple that owns the clinic went to Texas Chiropractic College and seemed quite successful. I checked them out pretty thoroughly online and searched for any negative comments left by prior patients. Nothing looked bad and their clinic was pretty sweet. I filled out the medical forms and was questioned by a CA for my chief complaint history. I did my active ranges of motion for her and reported pain in my SI joint with extension and left rotation. It was weird being a patient. I caught myself answering questions similar to many patients I have worked with, where they give a long winded answer to something as simple as saying, "yes, I did take ibuprofen for the pain" or "no it doesn't hurt when I do this". Realizing these folks are very busy and not students made me answer more concisely. It was like looking in a mirror.

The doctor came in, asked me some questions about radiculopathy and past history of this issue and he did four orthopedic tests; Nachlas, Hibb's, Ely's and Yeoman's. All confirming SI joint involvement. He did not do, SI compression or distraction, sacral thrust or thigh thrust. He also did not do active straight leg raise. Regardless, he figured it out pretty quick.

He sent me to this motorized machine first. It rolled on my back muscles rhythmically and reduced a lot of my muscle splinting. This lasted about 10 minutes. Then the CA took me to a treatment room and hooked me up to the inferential current machine. She hooked up my upper back and my SI region and pumped it up to contraction then below. I believe the doctor wanted to reduce nerve accommodation and confuse my brain as to what it felt peripherally. They also put four ice packs on me. I thought that was counterproductive being that they were trying to induce movement versus control inflammation. It was a little off from what we do in the clinic. For a patient like me, I would use IFC and moist heat, then adjust them.

I got off the table feeling worse then I came in. I was much more sore and my back was stiff as hell. My muscles were guarding every movement. I kept thinking, once he adjusts me the pain and stiffness will reduce and my joints will begin moving correctly, therefore reduce spasm. The doctor came in and told me to lay on my back. I figured he was going to adjust my thoracics into extension because I told him this was an area of ongoing pain (thank you school posture). He planted his hand behind my back, placed his abdomen on my crossed arms and pulled me into flexion and did not drop over his contact. My back EXPLODED! He did this down to the thoracolumbar junction. I then went to side posture and he adjusted a few lumbars into right rotation. Flipped over to the other side and he adjusted my pelvis. INSTANT RELIEF!

I stood up, moved into extension and flexion and rotation and no movement reproduced my pain. As my wife as my witness, I have improved 98% since the treatment. I have some sore muscles around the SI joint and my piriformis muscles are still tight, but my joints are moving normally and I do not have any muscle spasm.

This whole incident got me thinking about our role as chiropractors and how incredibly powerful our treatments are. There are so many people out there that suffer from all sorts of musculoskeletal pain and avoid chiropractors. This is a big issue. Faulty biomechanics can have a significant effect on all aspects of life. For instance, we had some friends in from Portland last night and first thing this morning we were planning on going downtown for breakfast. I was in so much pain from spasm that I was quite withdrawn from the conversations. It was depressing and debilitating. Imagine having such pain from a similar problem chronically and you avoid things you love to do to avoid pain. These issues are quite common.

I now have homework to do to prevent this problem from happening again. Largely this homework is to stretch more. Secondly, I need to regain strength in my gluteus medius muscles and medial arch stabilizers of the foot. I think I can do that.

All for now

Lessons of the CIC

2010-12-20T00:01:00.000-08:00

The CIC is a whole different animal of patient care. When people are paying for services the service being provided must be worth the money or else the patient will not follow the treatment regimen. This new level of care pushes new interns to up their game.

Dr. Roberts is quite good at what she does at the CIC. Her dexterity is amazing. She can find restricted motion insanely fast and has the patient adjusted before you can blink an eye. The interesting thing about her skills is that she expects us to be at her level. The funny thing is that I felt pretty confident going to the CIC in October this year and I have been humbled many, many times by her. I do believe her intentions are to help us become better at what we do and to also provide excellent care to her patients she has worked with for nearly 30 years. However, this can be intimidating at times.

The interesting thing about going through the clinic phase program last year and correlating it to the process of interviewing a new patient at the CIC is that the training didn't help. Dr. Roberts does things quite different which can leave you flustered and looking foolish if you don't expect it. For example, we were trained to write our own history and utilize the written information to not only keep us on track with the interview but to also weed out further information. In the CIC, you do not write a word during the history. You are expected to keep track of your whereabouts by simply remembering. And when you have two people asking questions, it is very challenging to know what has been asked. The end result is we look dumb and the patient loses respect for us. The physical exam and treatment is where I personally make up for my losses. Hopefully, this new skill will be learned soon!

Ending the term with 3 new patients and a handful of primary visits was plenty. If there was any more added to the list, I believe I would have imploded!

As far as patient care and new treatments go, I feel as if I picked up quite a few useful things. One useful tool in particular was the use of a drop table for fascia restrictions. I am still quite surprised this even works! For example, a patient with back pain had a prior LCL injury and was scheduled for surgery next year and the limping induced back and neck pain. When working on the patient, I could not do the normal rotatory adjustments on the lower back due to the knee being in a splint. So we utilized the drop table. Initially, we intended to move the joints with several adjustments to the pelvis and spine and then Dr. Roberts moved onto the fascia. Essentially, we found fascial tightness, pushed it into a "relieving" vector and impulsed through with the aid of a drop table. Re-palpate the fascia and it changes instantly to a more pliable tissue. Very interesting stuff.

Another important lesson learned is cost control and results. Nobody wants to pay $75 per visit for chiropractic care. Some may if an end with care is provided up front, but most would not. In order to keep costs affordable and patient care high, there are services that are provided that are not charged. All the therapy is documented and legal but the patient is only charged a fraction of what it really costs for the elaborate treatment. At the CHC we were taught to document everything we do so the front desk can keep things tallied, but no costs were associated with any treatment because they were all students. Being that students get free care at the CHC, all the route slips were carefully filled out. Not so at the CIC. To retain patients in the real world means keeping costs down for cash paying patients. It sucks but it is true. And without results, we have no patients so that means we absorb the costs!

What does this mean? This means we must be really, really skilled with adjusting and soft tissue therapies that do not cost us much money. Using a modality will cost money, using heat will cost, ice and K-tape also cost money. This is why Dr. Roberts forces us to become excellent manual therapists.

I am very happy to be at the CIC! Even though it can be stressful and humiliating at times, I do believe my skills have improved and my tolerance for conflict has improved. This all leads to greater confidence in the end and eventually less reliance on a veteran chiropractic expert.

All for now

Somato-Visceral Reflex

2010-12-16T20:19:00.000-08:00

What is the somato-visceral reflex? Who knows. From our studies in chiropractic school, this reflex is largely theoretical and controversial. Controversy breeds creativity, as they say, but this theory has caused a lot of grief to the evidence-based chiropractors in the US, mainly due to a select few who "believe" more than they observe.

Somato-visceral reflexes are theorized as inhibition to the viscera due to a somatic (musculoskeletal) problem. Nerve roots are shared throughout the spine and information passes through the nerves and spinal cord largely uninterrupted each day. However, there are nerves that share communication networks that consist of both parasympathetic (resting and digesting) and sympathetic (fight or flight) fibers. It is thought that these networks can effect each other if they become disturbed within the system or if disease plagues the viscera (organs) or the musculoskeletal system.

This idea is very interesting and the subject of current rigorous academic investigation. Controversy exists among providers because this theory has not been proven and providers use it to sell their care.

Our professor, Dr. Sepulveda, tried to push some of these ideas forward in our last lecture of the term yesterday and my initial response was to be upset at him for taking such a radical stance. After some thought, I sorted through these intuitions and decided he wasn't completely wrong to open our eyes to such connections to our work.

Keep in mind, this DC sees a ton of patients every week. I don't know exact figures but he is very competent in his work and he has a vast amount of experience with chiropractic and it's effect on different health conditions.

My own personal experience with the somato-visceral reflex is this: an elderly patient presented with lower back pain incurred 4 days prior from playing golf. Since the onset of the back pain, the patient experienced a 4-day long bout of constipation. No changes to the diet occurred that would explain the constipation and there was absolutely no prior history of constipation. The patient is honest and provides a long list of medications, all of which do not have constipation as a side-effect and they have each been taken for over 10 years.

Did the lower back problem cause the constipation? If so, we are talking about real-world proof of the somato-visceral reflex theory.

It is interesting to see such issues arise due to musculoskeletal problems. I think about other visceral problems that refer pain to musculoskeletal locations and the shared neurological connections, and wonder which created the overall problem.

The rabbit hole continues with low-grade musculoskeletal inflammation and movement restrictions. It doesn't take a professor to see that there is correlation between systemic allostatic stressors and overall health. Discounting musculoskeletal problems as major players in overall health is not only ignorant but foolish.

Health is a biopsychosocial entity and competent doctors of all academic stripes, must abide by this common knowledge in order to serve their patients ethically. Delusional behaviors that are performed to discredit an entire profession, hurt the public and society as a whole.

I hope, through sharing these first-hand experiences on a consistent basis, public perception of modern chiropractic medicine will change and societal limiters will vanish, allowing the conservative nature of chiropractic to impact the lives of more than 7 or 8% of our nation (the current national usage of chiropractic care).

All for now

Filling in...

2010-12-11T14:50:00.000-08:00

Today I filled in for the regular intern on the schedule who was at his graduation ceremony. To know graduation looms for me someday, makes me very excited! I cannot wait to one day open the clinic I have been working on for nearly 6 years! Seeing these interns clock in for their very last time was quite inspiring to see.

A patient presented with neck, thoracic and lumbar stiffness. There was a history of a long bout of heavy coughing, which had caused a few new complaints in the lower anterior ribs as well as the left iliopsoas region. Initially, I suspected a hernia in the left lower abdominal region and perhaps a minor fracture in the right lower ribs. After evaluating the patient, I found no evidence of a hernia and the ribs were not fractured. There was a little tightness in the muscles around the ribs and thoracic spine, but nothing severe enough to suspect anything other than joint dysfunction.

I palpated the patients cervical spine and found segmental restrictions in the C2-C4 region with some lower cervical muscle hypertonicity. I adjusted the restricted segments and performed CRAC stretching (contract-relax-antagonist-contract) to the neck rotators. The cervical spine range of motion became symmetrical and within normal limits post treatment and the patient reported no stiffness or discomfort.

Dr. Roberts adjusted the thoracic spine before I could palpate it, so I did not get a chance to see how affected these segments were from the excessive coughing. She found a lumbar restriction that was causing the patient pain at about L3-L4. She had me palpate it and I found a very obvious restriction. I had the patient lie with the right shoulder down, I pulled the right arm down to add some right lateral flexion, found the segment, added some counter-rotation and the spine adjusted. I didn't have to add a lot of force. The patient sat up and told us the back symptoms and neck symptoms were gone. Next, I had the patient lie face up so that I could stretch the left iliopsoas/rectus femoris muscle. Apparently, coughing caused pain in the groin, so I used coughing to test whether my treatment worked. I used PIR (post-isometric relaxation) stretching on this muscle and checked in with the patient frequently to make sure it wasn't too deep of a stretch. The patient sat up, coughed and said there was no rib or groin pain.

This case is a great example of how the musculoskeletal system is effected by a bad chest cold. Coughing utilizes accessory muscles of inspiration to expel mucous from the lungs and bronchials and if severe enough, the iliopsoas muscle can be recruited abnormally. Interestingly, the lumbar restriction was on the same side of iliopsoas hypertonicity at the level of its origin on the spine. If a large muscle such as the iliopsoas can be affected by coughing, think about the smaller muscles around the spine and how the diaphragm affects the abdomen and rib cage. A chest cold is complicated! Over time, excessive coughing can lead to increased stress on the musculoskeletal system and faulty movement patterns begin. This leads to joint dysfunction and pain during normal daily activities. If the joint issues remain present, they can become more and more painful and eventually become quite debilitating, hence the reason this patient came in for treatment!

Chiropractic care is helping this patient heal from the severe chest cold. Correcting restrictions in movement will take stress off of this patient's body, shifting the focus to the lungs in order to heal. There was no need for anti-inflammatory medications or muscle relaxants for this case, however, if this patient did present to a medical clinic, there would be no doubt pharmaceuticals would be used to treat this patient. A dose of muscle relaxants would be given for the rib, back and groin pain and rest would be prescribed. In turn, the liver would be taxed by the drugs and further stress would be added to an already stressed system.

As you can see, we essentially "cured" this patient's ailment by using manual medicine. Not to suggest manual therapy is a good treatment for a chest cold, but it is theoretically plausible to suggest reducing musculoskeletal stress may reduce the allostatic stress load on the entire system. In that realm, getting adjusted preventatively makes good sense.

Thanks for reading

Rib dysfunction

2010-12-11T14:31:00.000-08:00

A patient came in a few weeks prior with crippling lower back pain which began 4 months prior and progressed to the point of antalgia. The muscles in the left thoracolumbar junction were very tight in a spasm and the pain was intense. I took the patient's vitals and did a heart and lung exam to rule out other causes of this pain. The patient had markedly reduced range of motion in all directions but primarily right lateral flexion.

I had the patient lie face down so that I could palpate the ribs, thorax and lumbar spine. The most tender spot was right at the thoracolumbar junction on the left and it seemed to be the paraspinal muscles that were fired up. The ribs in that area were restricted in movement and breathing hurt the patient. The thoracic and lumbar spine had segmental restrictions as well. Kemp's test was positive bilaterally and all neurological tests suggested no deficits. The history was free of red flags.

We transferred rooms and begin treatment. I decided to put some heat on the patient's back for 10 mins to loosen up the tissues that were in spasm. This helped. The muscles became a little more pliable and less spastic. I then had the patient lie face up and I set up a rib adjustment a little higher that needed work and one a little lower, then I went to the lowest restricted rib and it was not going to move! Dr. Roberts tried to adjust it as well and it stayed spastic and "stuck". I then adjusted the thoracolumbar region in hopes that the costovertebral joints would move, but the pain persisted. It was then I decided the problem was just too acute to fully resolve that day, so I stripped the muscles in the area, applied some KinesioTape and sent the patient out the door with instructions on how to use ice for inflammation.

The patient came in two days later. There was quite a lot of improvement in pain and the range of motion was much better. The ribs in that area were still quite restricted. I decided to do a Farfan-type maneuver (patient lies face down, doctor grabs the side of the pelvis and pulls up to the ceiling while pushing into the rib cage down to the floor) first thing to see if that torquing action would free up those costovertebral joints. I had the patient take a breath in and blow it all out while I added pressure to the lower rib cage. My hope was to get the lower trunk moving a little bit more each time the patient took a breath. After about 5 passes through, there was a little audible "pop" around rib 8 or 9. The patient sat up and said the symptoms had improved to almost normal!!

I finished by adjusting the upper thoracic spine and cervical spine because there was some movement restrictions in a few segments and I adjusted the thoracolumbar junction. The TL junction was a bit painful for the patient but I eased into each side slowly and as it loosened up, I gave it a little bump. A few audible pops occurred with those adjustments as well.

The patient stood up, flexed to the floor, extended back, bent side to side and rotated each direction and no movement caused any pain. We resolved the issue that day and told the patient it would be wise to get adjusted once every 4 to 6 weeks to prevent this problem from occurring since this occurs every 4 months.

This case is a great example of conservative treatment for lower rib and thoracic joint dysfunction. It is a common problem patients present with in the chiropractic clinic.

All for now

Wrist Wrath - Part 2

2010-12-05T00:14:00.000-08:00

I thought I would write an update on the wrist pain patient. Two weeks have passed since I saw this patient originally. One treatment was applied and home-based pain-free active range of motion was prescribed as well as self-massage to the extensor muscle.

I am pleased to report the patient is pain free and functioning near 100% after a total of about 4 months of living with this issue. The patient is able to play the guitar at 100% function and work at 98% function. Overall, the subjective end of things is incredibly positive for a good prognosis. The most amazing thing is that one adjustment set the wrist on a path to heal rapidly. Awesome stuff!

I palpated the previously taut extensor muscle in his forearm and it was definitely still tight and a little tender. However, there was no swelling in the carpals like last time and each carpal was moving with joint play. I compared sides and the side of the injury had less joint motion, so I went through the carpals like last time adjusting them in multiple directions. No popping or cracking occurred like last time. My hunch is there is still some Substance P left over in the joint capsules and soft tissues in the wrist due to the chronicity of the problem. This will take time to filter out and over time, the brain will re-wire what it is like to have a pain free wrist again.

I used the Cold Laser on the carpals and the abductor pollicus muscle as well as the common extensor tendon of the forearm. I stripped out the extensor carpi radialis and the abductor pollicus muscle as well. We went over stretches to do and I showed the patient strengthening exercises to do to balance the flexors and extensors. If money was not a factor, I would likely see this patient twice next week to break up the extensor muscle and apply more modalities such as ultrasound. Being that money is an issue, home-based therapy will have to suffice.

Overall, I am happy with the results this patient was able to obtain in such a short period of time, particularly the chronic nature of it all and the dramatic improvement. It prides me to share these stories and all the positive attributes of outpatient care.

All for now

Wrist wrath

2010-12-02T02:01:00.000-08:00

Chiropractors are viewed by the public mostly as back doctors. We have made unparalleled strides in conservative care for back pain sufferers and with this success comes a general view of what chiropractic care is all about. Many do not know that we work on the limbs too. In fact, some people are completely shocked to learn we can adjust any joint in the body. This to me is a good thing because it defines us as a profession and many patients will be educated by these adjustments.

A patient with wrist pain presented to the clinic the other day who was suffering badly from a repetitive work injury. No neurological findings were present and cervical spine orthopedics were all normal. Upon palpation, mild swelling was present amongst the carpals and tenderness was also present. The extensor carpi radialis longus was painful as well. Active range of motion was limited to 20-30 percent of normal in flexion and extension. Subjective function was quite low with the patient's ability to work and play the guitar. Joint play of the scaphoid, lunate and capitate was nearly absent and caused significant pain.

We took the findings to the doctor, explained the treatment plan and we were given the green light to treat. I decided to adjust the lunate first, followed by the capitate and lastly, the scaphoid. Each adjustment caused significant pain to the patient. I felt awful for causing such pain but I knew those joints had to be broken free. My approach to dealing with inflicting such pain was to tell the patient this was going to hurt and to grit those teeth!

The patient felt immediate relief from the adjustments. The range of motion improved significantly as well. One treatment fixed this problem. I will likely adjust the wrist one last time and strip out the extensor muscle and the problem should be 100% resolved!

I had the patient do pain free active range of motion, ice the wrist for pain relief and self massage to the extensor muscle. At the clinic, we used the cold laser modality on the carpals as well as the common extensor tendon to speed healing.

It has been 13 days since I saw this patient last and based on a brief telephone call today, the patient is 95% better.

This is a great example of our ability to work on any of the joints in the body. The phenomenon of joint restrictions plagues so many lives in so many ways. It was really cool to see someone return to normal with such speed after one adjustment.

This patient's alternatives were; anti-inflammatory medications, cortisone injections and at worst, surgery.

I hope someday alternative medicine is redefined as the use of invasive therapies versus the use of noninvasive therapies like chiropractic care and nutrition.

All for now

Knee Pain

2010-11-24T22:11:00.000-08:00

I spoke of this case on my Facebook page recently. A friend of mine cornered a colleague and I about his knee pain that began for no known reason the day before. He spoke of the pain being in the back of his knee and it created a crepitus-like grinding noise when he walked. Walking made the pain worse and he said the foot on the same side was beginning to feel as if it was tingling and weird. He denied feeling fatigued, feverish or sick and he appeared healthy and coherent.

We began by looking at the knee from behind. Checked for swelling or any obvious abnormality. Nothing too bad was observed, so I palpated the knee for tenderness. He had pain from the lateral epicondyle of the femur to the medial condyle of the tibia, which outlined the popliteus muscle. I checked his pulse in his popliteal fossa and his posterior tibial artery and the dorsal pedal artery on this foot and they all felt very strong and normal. No neurological deficits were observed.

I decided to do some pin and stretch techniques on his popliteus. This caused a lot of pain and didn't quite address the real issue. I then thought back to a patient my old mentor Dr. Tweedt had who was suffering from the same issue as my friend. Dr. Tweedt adjusted the tibia anteriorly and the kid stood up pain free. The symptoms looked similar to my friends so I had him lie on his back and I debated which adjustment to do on the tibia with a fellow doctorate student (Megan). She recommended I do one where you put your forearm in the popliteal fossa, flex the hip and knee fully then thrust through the vector. I set it up, thrusted through and a weird cavitation-like noise happened. My friend stood up, walked around and said he was 50% better!

I got a text message later that night saying he was near 100% better. He said he still had some pain but not debilitating pain like the days prior. I texted him this morning and he said it was much better but still had some pain behind the knee.

Another treatment and some soft tissue work should fix this ailment. His alternatives? Medications to reduce muscle spasm, steroid injections to reduce inflammation and at worst, surgery. I wonder how many folks get those alternative treatments and I wonder if they are still suffering from their problems.

I feel like this is a great example of the power our education at UWS. We should be proud to be orthopedic specialists because we prevent surgery and restore proper biomechanical function without the use of invasive alternatives. We are being taught to correct pain producing problems that wreak havoc on many people.

I have been witnessing the power of non-invasive musculoskeltal care on a number of patients at the CIC. I have also been applying therapies personally and seeing how quickly people respond to care. It prides me to know that there is so much good out there in the profession I chose against many others of equal value.

Go us!

Columbia Integrated Care

2010-11-20T20:27:00.000-08:00

The transition has occurred to the outpatient setting at Columbia Integrated Care. In the last two weeks at the CIC, I have had the opportunity to be a secondary intern on over a dozen different cases. These experiences have afforded me the opportunity to meet many of the patients who utilize chiropractic care, as well as, see a variety of different approaches to patient care. I have been very impressed!

The CIC differs in many ways compared to the Campus Health Clinic. One way that it differs is the level of care. Dr. Roberts is very involved in all her patient's care at the CIC. She makes sure all the work we do is done at the level of practicing field doctors. No one really knows what this is like until you experience it. At the CHC, it feels like a real setting but the patients are not paying for services. At the CIC, every service is purchased, so this means all the interns must provide excellent, well-documented care. All the outcome markers must be tracked each visit for changes because those changes determine 3rd party payment reimbursements. The main difference at the CIC, is the fact that everything matters and there is no room for mistakes.

Today, I had my first outpatient. I worked up two problems starting with the history and then moving to the physical examination to rule out disease. Upon completion of the PE, I presented the findings to Dr. Roberts, she asked my 12th quarter intern if he agreed with the results and the treatment plan and she gave me the go ahead to treat. This was my first experience treating a patient who was effected so extremely by a problem. The results of my treatment after I applied it were instantaneous. The patient reported immediate relief and the active range of motion improved significantly.

What were this patient's other options? Steroid injections, anti-inflammatory medications and surgery. The issue was musculoskeletal and biomechanically oriented. I corrected the joint dysfunction, worked some soft tissues using pin-and-stretch techniques and reciprocal inhibition to deactivate a tight muscle. The end result is not here though. In the coming weeks, I will know whether or not the manual therapy I delivered was adequate in resolving this issue. Of course, a few visits are needed to make a therapeutic change that returns the tissues/joints to normal. I also realize there is more negating factors going against resolving the issue like; repetitive movements, compliance with exercises and compliance with care at the CIC.

The paradigm of the healing arts is so complicated, particularly when you are looking to reverse the effects daily life has on the body without drugs or surgery. It then becomes a matter of behavior change and trust in the care the patient is receiving. If the therapy is appropriate and the motivation is there to make change happen, results will follow.

All for now

The scientist, the chiropractor and the insurance man

2010-11-09T21:18:00.000-08:00

Tonight was interesting. All the talk about being chastised and discriminated toward in regard to medicine and health came true this evening.

I thought the classes preparing us for such instances were sort of ridiculous when it comes to real life. I was wrong. The societal norm is to discriminate against chiropractors, even if the person is one who follows an ethical approach to patient care. It happens among medical practitioners and it happens among those who work to supply more medicine to the masses.

What is it that got me all pissy? I was having a meaningful conversation with an acquaintance over a pint of fresh hop beer about Maxwell's scientific advances in electromagnetism ( Guass's Law s/t Newton's inverse square law of gravity), when an insurance man from Kaiser Permanente sat down with a co-worker and joined the conversation. Granted, the innocent conversation sort of branched out into medicine including him into the conversation, but nevertheless, his comments and stupidity added a sense of complete ignorance with the current medical norm in our society.

The acquaintance I was initially talking with was a retired engineer who was studying old-school mathematics. I told him I was a chiropractic student at UWS and he was delighted to be speaking with me. We chatted about electromagnetism and it's role in MRI studies and why it wasn't being studied beyond diagnostics in realms of treatment modalities. It was a great conversation. He was open to learning more about the mechanically-oriented chiropractic world of medicine. I shared things I have learned while studying it all and he was completely receptive and respectful of what was shared. The conversation quickly turned to his ankle injury he suffered 10 months prior that was inhibiting him from sailing, golfing and running - three things he loves to do. He equated the problem to "getting old", but I assured him that he would be able to run, sail and golf pain-free again if he utilized chiropractic care with me at the CIC.

I highly doubt he will accompany me a the CIC due to a Kaiser Permanente employee's involvement in the conversation.

An obese fellow walked in with his co-worker and loitered next to me and my new friend. He seemed to know my new friend and I included him into the conversation. He quickly asserted himself as a Kaiser Permenente employee and persisted to try and recruit my friend as an employee, who just joined me with his lovely wife person, who is trying to get into DO school. I was offended by the KP employee's ignorance and stupidity with how he socially behaved amongst us. He ignored the true meaning of the conversation and decided to make a monetary ploy to recruit my friend. The more I hung out with his ignorant ass, the more I learned how stupid he was.

He blurted out that chiropractors are 30% MD's. He complained that the DC he worked with as a patient wanted him to come in every month because it was a good way to prevent his musculoskeletal condition. Being a medical professional (a man with a BS in economics... whatever!), he chose to discriminate against such advice and continued living his sedentary lifestyle, now being an anti-chiropractic advocate at KP. Granted, he probably consumes 5-10 prescription medications from living such a gluttonous lifestyle, but he knows health (yeah right!). Not to be harsh on those who do live this way. There are some who finally get it and seek professional help to learn how to be as healthy as they can. This is honorable and in a way, our role as their DC is their ticket to success.

The 80/20 rule exists in our society, meaning, eighty-percent believe in Western medical thought for their ailments. Twenty percent avoid the risks involved with medical intervention by living a proactive lifestyle. Now, whether that involves chiropractic or not is another story.

Many people seek chiropractic for pain reduction. They suffer from musculoskeletal pain and they want a cure. Medical management of these problems consists of pain medications and muscle relaxants or surgery. Manual medicine (musculoskeletal manipulation) is a bit of a problem for primary care practitioners, in that, they mismanage it with drug therapy and ignore the biomechanical association of pain. Here lies the modern medical phenomenon that plagues the lives of many PCP's, chiropractors included.

Do we allow such ignorance to continue by simply avoiding conflictive conversations that guide the modern view of wellness? Or do we stand up for what we believe and educate the ignorant morons who believe their mediocre views of health care are correct? My stance is to educate the morons, of which, I proudly expressed tonight!

It is up to us to either be cowards or stand up for what we believe. Getting the UWS education gave me the education to defend the science-based approach of chiropractic tonight.

If you are a DC student, do you let society dictate what they believe is right and what is wrong? Use your education to determine if maintenance care is right for each case. Prevention is a thought process used by 20% of the masses or less. Do not justify your stance based off of 80% of those who do not utilize preventative action for health gains. The inability to take action for personal health gains is an ignorant lifestyle and a risky one at best.

All for now

An Interesting Situation

2010-10-29T11:26:00.000-07:00

I finished up the first tier of patient care at the Campus Health Center yesterday. To be considered for an outside clinic position, you must pass the second tier of patient care at the CHC, but with a shortage of interns in the outside clinics, there are a handful of 9th term students being considered for outside clinic placement early.

To finish the first tier you need 50 patient visits on UWS students, 15 ACMAS's (this is where a clinician watches you treat your patient), a handful of academic credits and you need to pass a quality assessment (this is where a quality assurance person comes in and watches everything you do during a patient visit). I ended up with 61 visits to pass this first tier. The reason for this is I could not get my ACMAS's. In the CHC, the attending physicians are so swamped with things to do that they cannot come in to observe everyone treat their patients. So, I had to annoy my clinician right up to my very last visit this week to get checked off. In the end, I will likely get some sort of credit for the extra 11 visits but who knows what for.

Now that I am done with the first tier, I am a bit worried about the next phase. From my understanding, we must find our own patients. If we are off-sited, we will be responsible for building a practice. Granted, we need these skills for real life but we are also balancing academic work too. The system is flawed in my opinion. I look at OHSU, the medical school in Portland, on how they have a huge presence in the community as being the number one source to go to for the best medical care in Oregon. When you look at it from afar though, they are a school educating young doctors who have never done elaborate procedures on patients. They are rookies just like us. Do they have to find their own patients? No because the school is pulling a huge number of patients from the community due to their ability to pay top dollar for the best physicians.

UWS is quite different. We are supposed to be the number one evidence-based school in the States but the staff cannot get patients into the clinics. So their solution is to force the students to get their own patients and to make it even more cheery, they hold you back if you can't get your patient visits. How are you supposed to make plans for a preceptorship in the community you want to set up shop if you may not graduate in the time you hope to? This is the reality we face.

Could UWS be different? Absolutely. My impression of it all is that there is no creative energy in the approach to market the school as a the best place to obtain treatment for musculoskeletal and conservative/preventative health care. There is absolutely nothing being done. The massage school on campus is doing a better job of marketing their program's services than the chiropractic school is. This is what boggles my mind. We pay over $100,000 each for our education at UWS and we are constantly beaten down by the professors and the clinic requirements. It is a bit masochistic and quite unfair.

On a positive note, if there is one, moving forward is satisfying. There is a level of pride that comes with venturing forward in a program like this. My satisfaction comes from seeing results with the patients I work with. In the long run, there will always be a business side of any health program and it should not be all about the business of things that tend to deter ones path. Patient care should be the number one priority and when looking back, I think my decision to go to UWS was a good one despite the ongoing hurdles.

All for now

No Walk in the Park.

2010-10-24T22:28:00.000-07:00

Learning that you have met the bar with what the top evidence-based chiropractic school has termed sufficient for practice is both humbling and exhausting. I am not alone when I say that it was luck that brought the results these past two weeks.

Exhaustion does weird things to your mental abilities when the pressure is high. When your mind is telling you to rest and the school says differently, a battle begins. The winner is determined by your ability to overcome the exhaustion. It is these tests that determine if you are ready for practice because it does not matter if you are having a bad day that day. You have to find the mental strength within to prove you are competent that day or you don't move forward. The other scenario is that you pass the OSCE's but miss a few questions or stations in the process. You will then have to schedule time to prove you know your stuff at a later date while continuing to move forward. Either scenario is taxing because the workload in the clinic and the other classes is also significantly high.

In the next 10 months, we will be taken through the rigors of preparation for chiropractic practice. To the outsider looking in, this may seem simple or miniscule compared to our medical counterparts but I assure you, this is no walk in the park. Every waking moment is spent thinking about the next step that needs to be taken. Our lives consist of pessimistic feedback and constant ridicule of everything we do and say. We live under a microscope and are forced to subscribe to the model our school follows and if we screw up, we pay for it with our time and energy.

In the end, we will be competent practitioners. We will be able to recognize disease patterns and diagnose diseases typically only MD's spot. The public doesn't know this though. It seems that the only ones that do know this are the DC's who graduate from UWS or an equivalent school. That is okay though. We work hard and we will educate our patients and the public as to what we can and cannot do when the time comes.

For now, I and my peers must prep for a few exams coming up next week.

All for now

First Tier Nearly Done

2010-10-16T15:53:00.000-07:00

Next week I will be finishing my first tier of patient care at UWS. This means I may go offsite to a community clinic beginning in 2 weeks. The long hours at the campus clinic have finally started to feel as if they paid off.

Thinking back to the first day at the clinic, I remember how anxious I was to start this new role at school. The worry of getting patient visits was present in all of our minds and the fear of screwing up was also there. A few weeks into the system, things calmed down and all the newness began to fade away. Some patient visits were more challenging than others and the confidence in chiropractic grew as results started trickling in.

In previous classes we heard about the negativity the public has for chiropractic medicine, particularly the pseudoscience practitioners and the stereotype of accepting our new role as DC's wasn't easy. It was then we ascended the ladder one more step toward becoming doctors.

Some of us performed the dreaded female gyn lab and others the proctology lab. The pressure to overcome any feelings of escape left us once we began the procedures and once finished with the examination a realization struck home with a big statement in regards to the massive hurdle it truly was. If we can do this type of exam professionally, what can't be done?

I am excited to get into a community clinic and begin the next phase in an outpatient setting.

All for now

Objective Standardized Clinical Examination

2010-10-15T07:01:00.000-07:00

We took our first OSCE yesterday and it was pretty challenging. It consisted of a large amount of questions which you must answer strictly from memory. No multiple choice questions, all fill-in the blank! This format is quite different from what we are used to at UWS. Up to this point we have been taking Scantron tests and preparing for them is not as taxing.

The nice thing about Scantron exams is that you can usually pick out the right answer through a process of elimination. If you have looked through the required material, you will know the answer when you see it or at least rule others out. The OSCE was very challenging because we must follow our professor's lead with what he considers pertinent to memorize. Being there is so much information to memorize, there is really no way you can get it all in your brain prior to the exam. This means it comes down to critical thinking during the exam versus doing a massive knowledge purge and forgetting it a day later.

I am anxious to know how I did because this is the only thing that remains in my way to get sent to an offsite clinic in two weeks. If I don't pass, then I remain at the Campus Health Center until the end of the term when I retake the exam in week 8 or 9. There is another exam held today which is a skills competency exam. I am not as worried about this exam because we have been practicing these skills since we started the program and I trust I can figure out what it is they want from me.

Here's to doing it live!

Why Chiropractique?

2010-09-24T10:24:00.000-07:00

Looking at the new blog site statistics Blogger has recently added to the blog, I noticed there are a lot more people reading my blog than initially thought. The blog is getting around 300 visits per month! Since there are many people reading, I thought I would explain why the blog is called Chiropractique.

When I first named the blog Chiropractique, I was very upset with the profession I had chosen to enter. All the negativity associated with being a chiropractor was taking a toll and I thought about what I could do to educate the public on the specifics of this negativity. In the world of chiropractic there are several techniques. There are more pseudo-science based techniques than science-based and this fact pushed me to name the blog Chiropractique. Meaning, science-based chiropractic as a technique in itself.

My biggest qualm still to this day is how science-minded chiropractor students quit thinking when they graduate and buy into a pseudo-science methodology. Their fears of not being able to pay school loans back, make a good living or keep the business running, force them to go looking for a way that eases their fear of failure. Technique system owners know this and they pray on these young chiropractor's vulnerabilities. We are sold things based on our belief systems and the overall state of our psyche at the time of purchase. The technique pushers know this and they feed on it.

It is my hope that those on the fence will choose a better route. Meaning, instead of thinking you have to push crap-medicine on people, put together fitness, nutritional and massage therapy programs aimed at actually improving health. It can be done and it can be very profitable if done right.

Those who buy into pseudo-science techniques are rebellious and attention seekers. Anything they can do to go against the norm makes them feel satisfied with their life. Selling these services takes a believer because there is no other reason to sell them beyond personal benefit to the seller. The seller sells it to their patient claiming good results are sure to come when in fact, there is no legitimate research supporting these claims. Mechanically-based chiropractic care has research supporting it in numerous journals which are peer-reviewed and this method is the foundation for chiropractic colleges around the world.

Science-based chiropractic is becoming the norm in the profession. Insurance reimbursement demands objective markers for continued funding of patient care and the system is based on science-based research. Objectivity is lacking in pseudo-scientific techniques and eventually (I hope) they will be put out of business. Although, being that we live in a free-market, I don't see them losing their foothold anytime soon.

What are we science-minded, objective practitioners to do? Erase all the clinical knowledge we have obtained and replace it with one technique that has lots of anecdotal data? I hope the answer is no. Chiropractique or science-based chiropractic is a legitimate technique.

Defining Chiropractic Care in a Science-Based, Ethical Manner

2010-09-21T10:01:00.000-07:00

New definitions for acute, chronic/recurrent and wellness chiropractic care were outlined a few days ago by the ACA and the Council on Chiropractic Guidelines and Practice Parameters. The consensus looked like this:

Care of acute conditions - Medically necessary care of acute conditions is care that is reasonable and necessary for the diagnosis and treatment of a patient with a health concern and for which there is a therapeutic care plan and a goal of functional improvement and/or pain relief. The result of the care is expected to be an improvement, arrest, or retardation of the patient's condition. Initially, the care may be more frequent, but as levels of improvement are reached, a decrease in the frequency of care is to be expected. A patient may experience exacerbations of an acute injury/illness being treated that may clinically require an increased frequency of care for short periods of time. A patient may also experience a recurrence of the injury/illness after a quiescence of 30 days that may require a reinstitution of care.
Care of chronic/recurrent conditions - Medically necessary care of recurrent/chronic conditions is care that is provided when the injury/illness is not expected to completely resolve after a treatment regimen but where continued care can reasonably be expected to result in documentable improvement for the patient. When functional status has remained stable under care and further improvement is not expected or withdrawal of care results in documentable deterioration, additional care may be necessary for the goals of supporting the patient's highest achievable level of function, minimizing or controlling pain, stabilizing injured or weakened areas, improving activities of daily living, reducing reliance on medications, minimizing exacerbation frequency or duration, minimizing further disability, or keeping the patient employed and/or active. Chronic/recurrent care may be inappropriate when it interferes with other appropriate primary care or when its benefits are outweighed by its risks, for example, psychological dependence on the physician or treatment, illness behavior, or secondary gain.
Care for wellness - Achieving wellness requires active patient participation. Wellness is a process of achieving the best health possible, given one's genetic makeup, by pursuing an optimal level of function. “Optimizing levels of function” may include a combination of health care strategies such as chiropractic adjustments, manipulative therapy, manual therapies, exercise, diet/nutrition counseling, and lifestyle coaching.

These definitions are exactly what practitioners need in my opinion. It seems there is a lack of unity among our colleagues as to what it is we do. Some are musculoskeletal doctors and follow the evidence-based orthopedic and neurological exams taught in school. Others throw all they learn in school out the door and buy into some ridiculous way of diagnosing and treating patients. That is what I don't get with some of the people in our profession. We go to school for thousands of hours studying evidence-based physical exams and diagnostic criteria and when they get done, they chuck it all and go running for pseudo-scientific marketing gimmicks. It doesn't make sense.

There are folks out there that are working hard to end chiropractic because of the handful of practitioners who buy into BS versus science to treat their patients. They put their needs first before the patients by convincing the person that subluxations are the root of all disease. These people should be weeded out by sanctions and some kind of punishment for fraud.

Interestingly, I was on a plane the other day and was writing this blog entry and the lady next to me asked if I was a student. I told her I was and she asked what I am studying and I told her chiropractic. Her body language shifted to a very negative, stand-offish persona and our conversation stopped. I can assure you my breath was just fine with a fresh stick of gum so that was not the offender.

If this lady knew our training included only medical orthopedic tests and neurological tests to diagnose REAL problems which ALL orhopedic doctors use, she'd probably have no problem with me. Since she thinks chiropractors lack authority and our education is untrustworthy, she'll go on to believe we are all quacks. This issue is real and will be quite difficult to navigate when trying to get new patients in the door to our practices. I believe this is why DC's buy into these dubious practice methods because they are easy to implement and require no logical thought at all. The motto of, "convince them they have subluxation syndrome and need regular care 3 or more days a week forever", takes the pressure off of diagnosing anything because they all have subluxations and these subluxations are causing ALL disease.

No need to diagnose a disease when the diagnosis is a simple subluxation. Get it?

On the flip-side, the orthopedic tests and neurological tests we use to diagnose musculoskeletal issues are quite expansive and do a great job forming a differential diagnosis list. We can order imaging for certain cases which can be helpful at ruling in or out a suspected issue. If the case is one that would benefit from chiropractic care, then a treatment plan is built and office visits are scheduled.

Now when you look at wellness care, this may look a lot like subluxation theory. I assure you, it is not. Wellness care is used to prevent an old problem or new problems from occurring through regular care. Aging is horrible on joints and regular chiropractic care can keep things moving optimally. Some of the less science-based practitioners would say wellness care is doing the same as subluxation care. They are incorrect because wellness does not put so much emphasis on chiropractic adjustments. Wellness care utilizes fitness training, massage therapy and proper nutrition to improve health. No convincing beyond stubborn lifestyle vices are needed with wellness care. On the other hand, subluxation theory suggests that with a subluxation free spine, the nervous system will operate optimally and the person can literally eat out of a garbage can and still be healthy. Sounds a bit quack-like eh?

To end, I will say that the ACA and the CCGPP did a great job putting together a defining model we can integrate into our practices.

Thanks for reading

Medical Scrutiny and Justification

2010-09-05T23:47:00.000-07:00

I just spent an hour of my time reading a blog called Science-Based Medicine. It was an interesting read, particularly the negative scrutiny of chiropractic. There are various contributors to this blog who all reside as medical doctors. The pessimistic nature of the blog made me realize how incredibly happy I am to have stayed in the chiropractic profession.

There are many MD's who support chiropractic and refer patients to them for services and there are others who hate DC's and do their best to defame the profession. My impression of those who write such negative crap is they have nothing better to do besides sit around thinking negative thoughts. The interesting thing is that most of the bad that I read was all about the vertebral subluxation theory. By now, we all know that this theory has not been proven and with our education at University of Western States, we also know that health is a complicated biopsychosocial phenomenon. The allopathic way is designed based on the western diet and the western culture of overindulgence and sedentary ways. Drugs designed to ramp up some system or hault another are thrown at lazy, overindulgent people with the expectation they will magically become healthy.

Look at the epidemic of obesity. It continues to climb regardless of the effort the AMA has made to slow it's progression. When I read the negative propaganda about chiropractic, it gives me more motivation to continue forward. It is really easy to judge something from the outside. My suggestion is for the critics to spend some time at our school in the classroom and clinic systems. Document our outcome measures and subjective markers. Patients do get better with manual medicine and nutritional therapeutics and the results are longer lasting than drug regimens alone.

My hope is while in practice we students branch out of our chiropractic worlds and educate these naysaying ignorant fools. It is annoying to read the garbage, particularly when the patients I am now treating are thriving under my care. My colleagues at school have similar stories and I witness their success every time I am in the clinic with them as a secondary intern. We fix the underlying problems, reduce pain and restore function without drugs or surgery. I'd be jealous too if my toolbox masked results.

When you look at our curriculum at UWS, there are protocols in place that we use with patient care that are peer-reviewed by clinicians and professors on campus. A consensus is derived and we students implement it with patient care. We have a protocol for dyslipidemia, obesity, dermatitis, hypertension, osteoporosis and many others. The emphasis isn't on which drug to implement in patients suffering from dyslipidemia but how to categorize the patient into a level of risk and severity for management. Is pharmaceutical intervention a possibility for some individuals, definitely. Do we automatically refer out for such therapy, not usually. We advise natural methods of treatment that have been shown to work in research and practice. How is this quackery?

We use the same orthopedic, neurologic and primary care physical exams as any MD or DO. Our exams are actually much more holistic than most. We are trained to rule out red flag diseases which may mask a mechanically oriented problem. We refer severe conditions out just like primary care MD's and DO's do. Many times we refer to specialists versus general practitioners. We are trained to draw blood, send for lab analyses and interpret the results upon their return. We can take our own X-rays (unlike MD's and DO's) and we are trained extensively in bone pathology (anomalies, fractures, metabolic disease & cancer etc.) and clinical pathology.

The last thing I will share is about my continued interactions with simulated patients. We use simulators that work at Oregon Health and Science University, the medical school in Portland Oregon and each week we get a new simulator to take a history and do a physical exam on. In 3 of my interactions with these simulators, I have been told that we student chiropractors are consistently much further along in our diagnostic abilities and patient communication skills than the students at OHSU who are at our equivalent level of education. This to me is such a compliment not only personally but professionally. It makes me proud to know the exhaustive work at school and in the clinic is paying off.

Despite what the critics say, we are competent practitioners and our approach to healthcare is better than theirs.

All for now

8th Quarter

2010-08-26T00:11:00.000-07:00

We are officially into our 8th term at University of Western States. The transition from student to intern is brutal. It seems as if no matter how good of student you are, at times, the transition makes you wish you chose a different path in life.

The fact is, we are being forced on many levels to be doctors. Despite public perception of what a doctor is supposed to be, our school, our profession for that matter, makes us become doctors in every facet. We live the lives of uncertainty and hope our past schooling has prepared us to give answers that are competent and trustworthy. Some knowledge has been mastered but gaps form when patients ask us questions and the answers are lost in brain matter tucked away at the top shelf of some random closet. When we go digging for the answer, the information becomes present and accessible if needed. It's as if we have to be forced to make connections with the material we've learned in real life situations before we can be truly competent and confident with the information. Weird.

The quarter was very exciting at first. Lots of time being spent in the clinic, new patients to get to know and a new system to master. Now that we've had a few months to adjust, there is a new attempt being made to take the next step to outpatient care. The first tier gets your feet wet and the second increases your responsibility. Not only do you need to be confident in your diagnostic skills and treatment skills, but you have to be able to portray this to the public in a professional manner. Sure, the students we treat are the public but they are students who have more of a grasp on what we other students are going through. There is a silent compassion that exists amongst each and everyone of us. That is deep!

In time, we will proceed to more and more responsibility and with that new found responsibility comes lots of work! Reports due quickly after patient visits, outcome markers tracked diligently, new patient referrals from current patients - on and on it goes.

The web is growing for each and every one of us.

All for now

Clinic Ideology

2010-08-01T10:02:00.000-07:00

As we enter our 5th week of patient care we are getting more efficient in the clinic. Our SOAP notes are improving, our palpation skills are getting quicker and our communication skills are improving with our patients. The daunting task of going to school and treating patients is enormous. It becomes a sink or swim mentality and when you look back at all the swimming that has been done, it is a confidence booster.

The challenge is to keep your ideology present during every patient visit. Meaning, what do you want to achieve with the patients you treat as a whole. It is hard to keep this mindset when you are trying to meet the patients immediate needs of both pain reduction and improved function. The task requires a solid grasp on why we are marching through this doctorate program to begin with. To this point, I have been meeting my patients immediate needs but I haven't been able to apply my ideological values to my care. This is mainly because I am just now getting used to the flow of the clinic.

It is interesting to look at things critically and find ways to add tidbits of information to the patient visit and still get the job done. My ideology stems from physical fitness and nutrition which in my mind are most important to achieve health. Are the patients I oversee participating in consistent physical fitness and are they eating well? Those two things are huge to me because they effect all aspects of health. This is the time to develop our own approach to patient care. Remembering that there are rules to follow but add our own personal spice to the mixture.

For the next 5 weeks I am going to try hard to keep my values for health present at every patient visit and push forward a wellness model. I will be doing this in practice next year, so it is time to start focusing more energy into this department. Now that we've had a few weeks to adapt to the rigor of this new world inside the clinic, it is time to make some changes. This will be a challenge because we are already lacking time during every visit. It can be done and should be done. Some of us have similar ideologies of wellness and some of us view the role of chiropractic quite differently. For instance, some believe the role of a DC is to relieve pain and release the patient from care once they are out of pain. Some believe care should extend beyond pain and be applied prophylactically and some take it one step beyond that to fitness, in which, could extend patient care well into the future. It all comes down to your vision of the role of a DC.

All for now

Pinning Ceremony

2010-07-24T07:33:00.000-07:00

The 8th quarter pinning ceremony is now behind us. Dr. Lamm, the clinic director, opened with a speech explaining how many before us have been given this right of passage and now it is our time to take the leap into patient care.

A speech from a field doctor sort of summed it up by explaining what we are feeling right now is normal. There is a lot of pressure to perform and a new system to learn at the clinic. She explained that in time, we will see health conditions in practice that we never thought we'd ever see. My feeling is that people who have gone to Western States will be better able to detect and deal with bad problems that we think live in textbooks right now. The other speeches felt more or less like pep-talks. Words like, "It's going to get harder, but it should" and "You know what to do but you are just a little awkward about it" were spoken and reaffirmed by telling us it will get easier and develop into an unconscious competence in time.

There is only one way to get to the other side and that is to head straight into the depths with determination. When they spoke of the increase in intensity, it is so true. For instance, in class you study a lot to memorize patterns for conditions and you regurgitate it onto a scantron form during an exam. The information is logged in the brain but when it comes to actually extrapolating it in a competent, efficient manner, the knowledge flow sort of jams up like trying to squeeze a golf ball through a straw. Over time we will be used to this process and we will know exactly what to do in an efficient manner. I guess this is the point of slowly working us into the system this quarter.

Time to add more knowledge to the noggin and prepare for Monday morning's exam.

All for now

No Show's

2010-07-20T14:49:00.000-07:00

I got my first dose of preparing for a patient visit with a couple hours of work and nobody showed up. It is frustrating to have this happen after so much work has been done but the fact is, students are busy and they cannot be expected to remember everything. My solution is to call the day before to remind them of their appointment.

When I was working as a personal trainer a few years ago, I had no shows all the time. It is just a part of patient care. Things come up unexpectedly, schedules get crossed, the list goes on and on. In the meantime, I was able to finish a write up on a patient and submit it to my attending clinician for review. No time was lost.

So far, this has been quite the adaptation process. I am sure it will get even better the further I head into it.

All for now

Eyes, Ears, Nose and Throat Simulator

2010-07-19T19:34:00.000-07:00

We have gotten hot and heavy into the primary care aspect of our education with our first simulator presenting with a visceral problem. My patient presented with a head ache and was recovering from the flu she had supposedly experienced about two weeks prior. She didn't feel like a real patient though, mainly because of her lack of physical findings. When you have to ask what it is your are supposed to document, the situation becomes a bit weird. If you don't ask, you don't get your finding - I learned this the hard way. And they correct you if you don't do a procedure correctly, which is good to a certain extent.

The reality is that most people don't go to chiropractors for eye, ear, nose and throat conditions. It is quite rare in fact. The reason we are taught these skills is to recognize what I like to a call, the bad ugly's and treat the patient with conservative methods that do not involve drugs, which are, at times, equal if not better than medicinal approaches. A good example is doing an opthalmoscopic exam on a patient with a head ache. Why would you look in a person's eyes if they just have a head ache? It could be many issues that are not eye or even head related, like a vascular problem or diabetes or hypertension. The list goes on and on. Another reason we are being taught primary care skills is so we can intervene early on. For instance, if we find that there are vascular changes from an opthlamoscopic exam associated with diabetes in a patient who comes in for neck pain, we could order some labs to make the diagnosis and treat the migraines conservatively in conjunction. If we couldn't recognize or if we were not allowed to use such diagnostic tools, we'd miss the boat entirely and the patient would likely progress into a worse state due to lack of treatment. Most people want to see their chiropractor without a referral and some would prefer their chiropractor to manage the in's and out's of their overall wellness. There is nothing wrong with this.

There is a lot of research showing that most back pain patients go to the doctor and their problem is biomechanical in origin, while a small percentage of folks with back pain have a "bad ugly" lurking in them. The issue is that the medical management of back pain or musculoskeletal pain revolves around treating the symptoms of pain through the use of anti-inflammatory's and muscle relaxants. Our approach is to find restrictions in segmental movement, rule out bad ugly's and avoid the use of pharmacology. If we were to prescribe meds to all back pain patients just like our medical counterparts, our patients would most likely injure themselves again, and again, and again because their problem is a biomechanical one, not a lack of pharmacology in their blood. Make sense? We are best at treating biomechanical problems and able to diagnose and manage the bad ugly's if they are present. Neither situation is easy to manage. The funny thing is, biomechanic problems are at times more complex than the bad ugly's like tumors or infections.

I have a clinical nutrition exam to start getting prepared for and a little wifey who is coming to my pinning ceremony this Friday, which means I need to get all this stuff tackled early!

All for now and thanks for reading!

First Patient in the Clinic

2010-07-12T00:37:00.000-07:00

My first "real" patient visit occurred last Friday in the Campus Health Clinic. This was quite the milestone. I can't share the details of the encounter due to HIPPA but I can chat a little about the intensity of the experience and how incredibly daunting it can be.

The main issue was learning the paperwork. We have had minimal exposure to re-evaluations, SOAP notes and chiropractic treatment plans up to this point and when there is a hiccup in your memory of it all, it can throw a wrench in the works. I stumbled a bit on taking a proper SOAP, particularly the assessment part. Mainly because I had nothing to really gauge my patients progress on besides illegible notes from the past intern. Next time, I can document things better being that I am now writing the progress down and I can read it!

There is no time for second guessing when you are with a patient and for the most part, you have to think on your feet and be quite present mentally. The balance of patient satisfaction is held quite delicately in these first few visits and their trust in your ability to help them is based on a very small window of time. In a nutshell, it has to work out the first go around because they will not come back for further treatment if it doesn't. In the long run, the patient loses out and quits coming to the clinic completely in these situations. The intern loses confidence and it doesn't turn out nice. This is why it is very important to really know the person's status prior to seeing them initially and to go in with a game plan so things run smoothly. The patient must come first and they have to know you truly do mean this. If I had it my way, I would end all the requirements to get through the clinic and base it on merit. The way we have to go about obtaining visits is controversial. I figure if I have to spend a little more time here to get things done honestly, so be it.

Another hiccup in the mix was my understanding of where chairs were in the room. I knocked into one I was sitting on because I forgot it was there. It slammed into the adjusting table. Embarrassing! I then moved it aside and of course it was placed right by the door so when the attending arrived, the chair was knocked across the room in a loud bang. This doesn't help things a bit. Know thy surroundings.

This is so much fun. Transitioning into this role is hard but so worth it. I keep thinking how close I really am to the end product. It is a journey, that is for sure.

All for now

8th term on the horizon

2010-06-20T23:59:00.000-07:00

Apparently we can now move on to 8th quarter. After the butt kicking week of finals, we are now two weeks away from being "real" interns.

This new reality is going to sink its teeth into our brains once we meet and schedule our first patients. The pressure will be much higher next term with the increase in responsibility in the clinic as well as the higher workload in clinic phase 2. In ten weeks, it will be over and we'll be celebrating another victory. The crazy thing is those who are in eighth quarter now will be receiving a doctorate in 5 quarters!

I never thought we'd get to this point. In a way, it has been tough to know what it is going to be like because there is so much fluff out there. By fluff, I mean BS. Many say that splitting the 8th and 9th terms is much smarter than going straight through. They might be right but up to this point, I have gotten through and I think it is possible to adapt. Ask me in a few weeks and my answer may change.

In preparation for this big change at school, I ventured into the clinic on Friday after finals to review my new patient files. My attempt to understand their issues was short lived because I was exhausted from the weeks beat down. In the end, I logged nearly 3 hours reviewing their files and chatting with a few upper quarter students. I do plan to go back next week to make another attempt to meet the lead intern and discuss each patient's file with them. According to the senior interns, those who put forth the extra effort up front, end up staying on schedule and satisfying their requirements for entering higher tiers of patient care faster. My hope is to fully understand each case I have inherited and establish contact with each patient by the end of the break. The trick will be to learn how to schedule patient visits. Lots to learn!

In the near future, I will not be able to discuss any particular case on the blog due to HIPPA privacy issues. However, I can discuss the other inner workings of the clinic. Things like, the amount of work needed to get done by the end of 8th quarter, the competency exams heading our way and perhaps the massive amount of paperwork associated with being a student doctor.

The excitement of it all is balanced with a little anxiety. I think we should be a little nervous because we are now in charge of a handful of people's health. If we are not a little on edge, we will make mistakes and we will lose our patients to someone else. It is a fact that we must keep in mind. Many students don't use the clinic for their health care because they had a bad experience. I think those issues can be avoided if enough effort is made to become familiar with the patients problems and the intention to treat is purely for the benefit of the patient and not just for student credit. Nobody likes feeling used.

One thing is for sure, it will not be a boring quarter. For now, it is time to enjoy some time off, furnish a new apartment and begin relaxing.

Wrap up and big changes

2010-06-09T22:36:00.000-07:00

Seventh quarter is wrapping up and there are some enormous changes occurring both personally and professionally at school. Next quarter is eighth quarter! I never thought I'd say that, but we have arrived and now it is game time!

The intensity is supposed to get higher next term with tons of work in our clinic phase labs and the new stress of managing a handful of patients. It is interesting how your perspective changes the further you get in the curriculum. My first impression of my intern in 1st quarter has changed to one that respects what he was going through when I met him. I didn't understand the pressure he was under and I judged him too severely. The changes that will occur in July for about 45 of us, are immense. We will likely be judged just as severe and it will be tough to deal with it and move on. Our awareness of the patients we are inheriting must be the number one priority from here on out. It is our job to be their advocates in school as well as their health. If we treat them with sincerity and respect, they will do the same for us.

We'll be given the typical Western States workload along with adapting to the clinic and learning to treat patients as well as retain them. I don't think students, who will be our patients, understand the system if they haven't given it a try and tried hard to get to know it. My hunch is that the system does work if the students are educated by the interns and the new interns are educated/mentored by the senior interns they replace. It all comes down to being respectful to each other and being open to learning from one another.

If there was one thing I could change during that first quarter at Western States, it would be to give my intern a shot and use him as an education source. Comparing where I am now to where I was in first quarter, is insane to think about. The skills I have obtained (not that they are perfect) are way further than I ever thought they'd be. Even since the last quarter (6th quarter), I have changed leaps and bounds. Going from being afraid of palpating the neck to adjusting it and seeing therapeutic benefit from it, is huge. It is hard to explain the situation we are going through right now unless you've been there before or are walking through the trenches.

We are, in a way, between worlds. One foot is still stuck or hesitating to leave life as we have known it our whole life and the other is edging closer to becoming a doctor.

Not many people get to feel these things and we should be proud and confident in who we are becoming.

All for now.

Patient Simulator

2010-05-30T23:31:00.000-07:00

Last Thursday I had a patient simulator to do a physical exam on. The whole experience was strangely realistic and I left thinking more good things than bad.

Our patient was a 41 year old lady who complained of chronic neck pain. The other student intern interviewed her and we both wrote the pertinent information down on our history form. We transitioned to the physical exam smoothly by having her put on a gown and some jogging shorts. The other student started with the first section of the exam which consisted of taking her vitals (blood pressure, pulse, respiration rate and temperature), height and weight and several seated exams. The physical exam is separated into sections based on patient positioning. One section is seated with doctor in front, another is seated with doctor behind and others are supine, prone, side posture and seated straddling the exam table. This helps keep you on track with the flow of the exam and prevents missing any tests. Having a flow like this also prevents you from having the patient move from lying on their back to their belly several times. Memorizing an exam such as this takes many days and can leave you wanting to pull your hair out.

We ended the exam and received good feedback from our patient. She was a professional simulator but had a knack for knowing what a patient wants in their doctor. Her impression of us was that we were trusting and competent. In the midst of it all, you notice all the tiny details that go wrong, what you didn't say that you should have said and how your skills were still in their growing stages. But in actuality, your patient sees a confident, competent person who they trust. I left feeling good with my growth up to this point and gained insight into the small things that still need work.

Apparently, we are going to have around 20 simulator interactions by the time we graduate. Each time we will gain more insight into our development and the next experience will be even better.

All for now

Clinic Experience

2010-05-22T12:16:00.000-07:00

Yesterday, I shadowed a couple interns at the campus health center. My first patient observation was an interesting one. Her condition was pretty obvious right off the bat and it became more complex the further the visit moved forward. She had an interesting autoimmune condition which caused significant pain every time anything touched her. Although, I couldn't help but notice that when she touched things, she didn't yelp in pain. It was only when the intern palpated structures when the pain became present and extreme. Is this a trust issue, where anyone who touches her inflicts pain because she has been physically or emotionally hurt in the past?

The interns moved forward to help relieve her pain by stretching her iliotibial bands, her piriformis muscles and glutes. She gasped for air every time the intern palpated a landmark as if she was being assaulted. It was a little tough to watch because the lady was clearly hurting at an intense level, at least it seemed like that. I could tell the intern had to use a high level of patience and reassurance to get the desired results.

I started wondering whether or not she was in actual pain because it was almost over-acted in a way. She presented with jump signs on multiple areas along her hips and legs but I left not feeling convinced that she was truly hurting. I want to believe she was in pain but there was something that made me think she might be suffering from psychogenic trust issues.

Regardless of whether she was truly hurting or not, the experience made me realize I will be in those intern's shoes in the matter of months. I will have to muster up the skills to manage a patient of this complexity. To look at where I am now and where I need to be, it is a huge leap. We are sort of in the middle of a proverbial lake and the distance to go back to the shore where we started is getting larger and larger. The only way to proceed is to get to the other side.

Here we go...

Goodbye Master's Degree

2010-05-16T11:22:00.000-07:00

I decided to quit the sports medicine program on Friday. The stress from this quarter started creeping up on me and I sort of cracked. On a whim, I decided to get out of the program.

My intention for doing this is more complicated than merely being stressed. All along I have been up in the air as to whether this is for me or not. The courses are focused on contact sports (i.e., soccer, football, lacrosse etc.) and my personal interests are in endurance sports like, cycling, running, mountain biking and nordic skiing. I couldn't see how the information in the program would correlate to the sports I am interested in. And devoting my weekends to the program seemed like a huge sacrifice based on my lack of interest. So, I quit the program.

I can't begin to explain how much relief I feel from ending the program. I can now focus on the DC curriculum and actually have time to study on the weekend versus merely glancing at the notes prior to a test. My hope is that by focusing solely on the DC curriculum, I will get more out of it and become a more proficient and competent chiropractor. Some people can handle all the stress because they are 100% on board with pursuing the masters in sports medicine. If the program is along your interests then the stress is really not stress at all.

It is tough to know what really motivates you in life. Once you find that carrot to chase, the work becomes fun and easy to handle. My hope is to continue full time in the DC program through the summer and be treating the public by 9th quarter. I think this is possible if that is all I focus on.

All for now

To Split or Not to Split

2010-05-14T16:21:00.000-07:00

At UWS there is a program that allows students to "split" their 8th and 9th quarters into three terms versus two. Many are doing this to unload their schedules a bit so that they can digest the material a bit better and unload the mind a bit. Some higher-up students suggest splitting the material up so that you don't go bonkers from the stress and other's say that by now we are geared pretty well to push forward. It is a tough decision because splitting requires more fees and more time at UWS.

One good thing is the extra time available to study and to hang out not studying. The credit load would be about 25 versus 45. This is a huge decrease in time at school and pretty attractive. I sometimes wonder if the stress of midterms has anything to do with contemplating splitting. It has been a tough week since we have had a few exams to deal with and a few more still looming. Extending out the program will be a commitment and a definite increase in UWS imprisonment. I also wonder if I did split the terms up whether I would actually use the time studying or if I would procrastinate even more.

It is such a huge amount of information you must overcome when you are full time and if you had a little more time to prepare, it might feel normal. Not normal in undergraduate terms, normal in graduate terms. Normal in undergraduate terms is 12 credits. One aspect I think is important is training yourself to overcome hurdles and adapt to stress. In actuality, will we be that stressed at the office when we get done? I don't intend on being freaked out while in practice. I do want to start practicing sooner rather than later though and the only thing I'd rather do right now versus go to school is ride my bike and drink beer, so maybe I should stay full time...

The registrar advised that I let them know before the end of the quarter if I intend on taking the split. I need to see how I feel after midterms before deciding to venture forth.

All for now

National Boards

2010-05-06T18:32:00.000-07:00

National board scores were delayed due to analysis of the results and today they were posted. It was quite the relief to see they were all within passing limits. The anticipation was killing me because the day they were supposed to be ready to view was last Friday and that day was on my calendar as "special".

Now that the hurdle has been jumped, I can now focus on transitioning into the meat of the clinical sciences. Our expectations are climbing and the midterms for this quarter are getting closer. Dr. LeFebrve posted an email telling us that the reading demand will be increased significantly and the expectation/learning curve will steepen for the last 5 weeks of the quarter. He demands excellence and we must comply or else!

It is exciting to get to this point in the program. Next quarter is supposed to be the toughest of them due to being buried in paper work. I sort of feel like this quarter has been the hardest up to this point mainly because the expectations have risen and we are tested weekly in clin-phase. The internship has also been demanding, in that, we are learning to actually adjust each other for therapeutic gain. This takes confidence not only in your adjusting skills but also your palpation and assessment skills. It is a huge leap next quarter when we begin treating students under a licensed DC.

I feel ready and willing to continue pursuing this program. Time to celebrate the minor victory and buckle down for a quick trip to Denver Colorado to scope out post-school plans then mid-terms begin next week.

All for now.

The Clinic

2010-04-30T19:41:00.000-07:00

I had an interesting experience at the student health clinic today. For seventh quarter, we have to observe 4 patient visits and write a brief synopsis about what we observed. My two patient observations were interesting clinically but the conversation during my second visit sparked some strategic planning for the future.

The patient of my second observation today was a 10th term student. He sat and chatted with me about what it was like going from 7th quarter to 10th. My impression of him was that he was legit in what he was sharing with me and completely honest in how to deal with it all. To better outline what it is I am talking about, first I must talk about what the expectations are for us to graduate on time.

We are required to get over 250 visits between now and when we graduate next fall. This falls on our shoulders, in that, we have to find patients and retain them. On top of regular classes and busy work given by professors, we have to drum up our own business. This is daunting.

My new acquaintance from the clinic today told me there are few who graduate on time because they can't get the required visits. Yikes!

So, what will it take to get there and stay on track? Many are taking what is called the split. This is where they split 8th and 9th terms into 3 terms versus 2. The advantage is you'll have more time to get visits and retain patients. You'll have more time overall to get the requirements fulfilled as well. Others are taking the summer off. This might be the wisest choice because the class size this fall will be smaller for 8th quarter students.

In a traditional medical school, your patient visits are guaranteed. I believe this is why medical schools are so difficult to get into. The competition is fierce during the clinic phase due to limited off-campus clinic space at our school. These positions are selected randomly supposedly. My hunch is that it is very political and based on the students academic prowess during their time at Western States.

I guess the best thing to do is to strategize versus stress out. The only way through this is to head straight in and figure things out.

All for now

Physical Exam Flows

2010-04-22T12:12:00.000-07:00

Week three is about done and 2 parts of the general physical exam are done and out of the way. This means we have memorized and regurgitated a large number of exams. It is similar to taking a test every single week but with an emphasis on skill development. The instructors watch you during a section of the exam being performed that day and critique you on your ability to perform them. This is quite nerve racking for most of us which results in profuse amounts of unintentional sweating and huge butterfly's. The weird thing is that we all more or less have the exams down but when you are watched, the pressure goes up and the brain stops working! Luckily, you can retry later if you don't pass the section of the exam flow.

This new way of studying and preparing for skill testing is quite difficult. There is another element that we are aiming to conquer and that is doctor-patient relationship building. This means building enough trust with a person you don't know that well to do a whole bunch of up-close and personal tests. Any nerves in regards to this element fire up if you are not okay with the scenario.

This quarter is interesting on so many levels and exciting! We are getting there, one step at a time.

All for now

Permit to treat patients

2010-04-16T12:12:00.000-07:00

Our first internship is now underway and we are beginning to treat classmates weekly. This new responsibility is quite the bonus for those of us who have been waiting patiently to apply our skills. It is interesting to transition into this realm because over the past 2 years, we have been learning adjustments but not with a focus on finding musculoskeletal restrictions. Our internship is based on finding restrictions in movement in our classmates and correcting them with the adjustments we have learned thus far. This takes a lot of dexterity and trust in your palpation skills.

Before adjusting anything, you have to take a SOAP note. This requires asking the patient of their current or ongoing complaints which is written in the subjective area, followed by evaluation of the person's area of complaint with palpation, motion analysis and measurements. The information obtained from the evaluation is written in the objective portion of the document. Prior to manipulative treatment you must find out if the patient's problems are worsening, getting better or staying the same.

When ready, you approach your clinician with a route slip and get it approved. Once approved, you are essentially a doctor for the rest of the class and you are left alone to treat your patient. It is pretty exciting to be at this level in the program.

All for now

Sports Medicine Master's Program

2010-04-11T21:25:00.001-07:00

I am now 16 hours closer to obtaining a master's degree in sports medicine. On a whim, I decided to hunker down and pursue this degree path after many hours of contemplation. These decisions take time, for sure. This weekend was very top notch and reassuring that the decision was well worth it.

Our first course was Emergency Management in Sports Medicine. We saw gnarly pictures of lacerations, eyeball punctures and fractures which emphasized certain points in critical sports decision making. Our instructor was great. He had many years of sports medicine experience in chiropractic and lots of firsthand experiences that drove home the points thoroughly. I felt he had charisma and passion for sports medicine. In a way, he laid the groundwork for a great program.

At first, I thought the program might be a bit lackluster in it's inception and progression but they proved otherwise with the talent provided. I left today feeling inspired for once and it felt great.

I think you have to be inspired to be in a program like this. If you don't have anything to aim for, it can become overwhelming and quite repressive. The time commitment is so incredibly huge that if you don't feel inspired being there, you'll fizzle out pretty quick.

For the next 4 weekends, my time is booked with classroom study and hands on skill building with the sports medicine program. On top of the DC curriculum, this will be a bit intense but I do think my motivation will be higher to attack the work more vigorously in the weeks to come.

The students that entered this first class seem to be very motivated and focused people. Many are from our 7th quarter class. There is a representation from 6th quarter up to 12th and a couple DC's. The group is pretty diverse too which is nice.

Next week is approaching in a few hours so this post needs to end.

All for now

Clinic Phase

2010-04-05T20:27:00.000-07:00

Monday is done and only 10 weeks, 4 days left of this 7th quarter. Man is it ever flying by!

It was interesting how intense today became after meeting Dr. LeFebvre. The silence was deafening across the room. My impression of him was that he demands excellence from his students and he will not let anyone skate by. I think this is why everyone was on edge today. Perhaps it was the fear of possible failure may exist in all of our futures. No one is safe!

It really isn't that bad. I think we'll adapt after a few weeks and get a rhythm with it all. We'll come to realize that we have some skills already and that this next phase is just adding more tools to our proverbial toolbox. It wont be easy though.

I have already started on the busy work from our Patient Practice Management class - finishing the alcoholic patient portion of it. It had me thinking about my own whereabouts with my nectar indulgence. When I read that a person who drinks 20 beers a day may need pharmacological help to abstain from alcohol safely, I breathed a sigh of relief and finished my 1 IPA.

This quarter will be full of challenging times and possibly some mild crash and burns while under the UWS microscope.

My hope is we all attack this section with pure endurance and will.

All my best

Return to the Grind

2010-04-03T10:21:00.001-07:00

The spring break is ending with only 2 days left of "freedom". Next week is the beginning of our 7th quarter transition into the clinic which will be completely applicable to practicing chiropractic. I am excited to begin but wishing for another week to spend playing in the spring snow and sleeping in.

Some of the students who took a quarter off last summer are now in 6th quarter. This is a great change from sitting endless hours in the classroom to hands-on skill building. For those who skip class a lot, this is a big change because you have to be in the labs to learn the skills. It can be exhausting. However, the skills are awesome and build upon the basic understanding of anatomy.

Seventh quarter will be challenging in new ways. We are learning more specialized anatomy, more specialized adjustments and more clinical application. The instructors are more intense and will call us out one at a time. Nerves will be firing at a heightened level as we adapt to the stress being poured all over us.

My hope is that the stress doesn't get overwhelming and that my board scores were sufficient enough to leave behind.

All for now

Part One Boards

2010-03-22T10:19:00.000-07:00

It is official, we are done with part one boards! This is great news and worth 2 weeks of relaxation. Even though they are done, they aren't officially official until the end of April. We will find out what our scores are in each subject and whether they are sufficient enough to pass.

My hope is that I passed them all and no retakes will be necessary. There were two sections I struggled to get through, microbiology and spinal anatomy. You'd think I would have spinal anatomy down being that is what chiropractors focus mostly on, but the reality is, the test was primarily on neuroanatomy.

I felt comfortable with the spinal anatomy questions but when the test turned to structures in the brain and specific nuclei I started drawing blanks. I did my best to answer the questions but knew that I was really just giving a best guess.

There were a few questions like this in all the subjects and I think that is their point. You cannot be prepared to answer every question. They test mastery of the information you've been given and your strengths and weaknesses shine equally. I feel proud to have given it my best shot. In retrospect, if I were to approach this differently I would have been more consistent with my study habits leading into this weekend. Trying to balance final exams and boards was a task larger than anything I have ever experienced in life.

I am so glad we are done with this hurdle. I know there will be plenty more to come and equally taxing. For now, I am kicking my feet up and chilling out for a few days.

All my best

2010-03-19T04:25:00.000-07:00

Finals wrapped up yesterday with a hard exam in neuromuscular diagnosis and two afternoon lab exams. I am excited to be done with 6th quarter!

The two lab exam were back to back. This caused a little anxiety because we had to switch subjects quickly and be on our game. There was no room for making big mistakes and the pressure was on. My first lab exam was in neuromusculoskeltal diagnosis. The stations were not only a "show how" of many orthopedic tests but we were required to interpret what a positive or negative test meant. This was no easy task and ended with most students being peppered with questions for about 40 minutes each!

I made it through, a bit battered but ready for more. I wandered over to the muscle testing lab exam hoping we would have a little time to practice prior to going in. There wasn't much time for that. Thankfully, we had been working on the muscle tests the last few weeks and fine tuning our skills. Although, I had some hiccups in my skills during the exam.

The exam consisted of a professor assigning a muscle test then watching you perform it. It also consisted of "showing" via palpation. This meant moving other muscles out of the way to get at the actual muscle belly he assigned. I screwed this up on a few but learned a ton from it. Thankfully, he was in good spirits due to my ability to muscle test the muscle correctly and he only took a few of my points.

The muscle testing lab was really helpful for me because I now know how to test most of the muscles of the body. This consists of knowing where they originate and insert as well as which nerve supplies the muscle. Understanding things to this level helps with the neurological component of chiropractic a bit. The idea is that if degeneration of a vertebra gets too bad, it will grow osteophytes and end up compressing the nerve in its exiting canal and inhibiting the tissues function down stream. Regular chiropractic care can put a halt on this process and assure proper motion continues in our numerous joints.

I am happy to be done with 6th quarter and a bit pressed for time to get my head around boards. In time, I will be typing a blog entry about the process of the boards and how I and everyone else totally aced them!

All for now

Round Three

2010-03-17T18:56:00.000-07:00

Okay, we are half way through the mess. The physical diagnosis course wasn't too bad and very straight forward. As expected though, the biomechanics exam was a nightmare and probably the hardest anatomy exam I have ever taken. What a shock to the psyche. No need to give up now but being I have a mid-B in the class, I can only afford half the answers to be wrongly answered. I don't think I bombed it that bad but you never know when a test is given that is so incredibly picky and confusing. It is what it is.

I am looking forward to being done tomorrow and the day and a half break that follows before boards seems like a long break right now. My hope is to get some needed rest and get some solid board review down.

All for now

Round two...

2010-03-16T20:03:00.001-07:00

Two days in and half way done! The anxiety has settled and I am feeling focused. I think we make things worse than they really are when the stakes are high. There is a lot to lose so we tend to take things more serious and even become anxious. I know I am not alone when I say that this anxiety can have an effect on performance.

This morning consisted of a final exam which was unlike any exam we've had. It consisted of deciphering a page of type-written information and placing it into history, physical exam and patient management paperwork. We will be mastering this paperwork by the time we get done with school because it is used daily in the clinic. However, the first time you are pushed to use the forms can be a bit daunting. I spent 75 minutes transferring the data from our 1 page document of information to the forms. It was harder than I thought it would be.

Later we had an extremity adjusting final. This consisted of 8 adjustments involving the shoulder, elbow, wrist, clavicle, hip, knee, ankle and foot. Many reading this will probably be flabbergasted to learn we chiropractors adjust these joints. This is a good thing because it is highly applicable to the field of minor orthopedics and prevention and it should be known that chiropractors are top notch musculoskeletal specialists and not just spinal specialists.

We finished the day with our lecture final in cervical adjusting. This consisted of 50 multiple choice/true-false questions. I thought the test was fair and very straight forward. Our biomechanics final which is tomorrow afternoon, will be a whole different story. Dr. Carnes is known for his tricky questioning that seems picky and inapplicable when looking at things from afar. The details are good to know but he likes to find things students overlook and with a long history of teaching at Western States, he has stockpiled an arsenal of mind draining weaponry.

At noon tomorrow we have a physical diagnosis final which will be over the neurological exam, dizziness, vertigo, imbalance and nystagmus. As a side note, when I was Dr. Tweedt's assistant in Boise before DC school, we had a patient with peripheral nystagmus. Her eyes would rapidly twitch when her head was rotated to the left. Now that I have had some classwork in this area, I understand what was going on and how I might approach her problem. The Epley's maneuver could have been used to move particulates in her left posterior semi-circular canal into the saccule and utricle of the inner ear. This is all theoretical but the procedure has been documented as quite successful for folks with dizziness and associated nystagmus like Dr. Tweedt's patient. I feel proud to know how to approach a problem like this and how to determine the difference between central and peripheral nystagmus.

I need to study some biomechanics and get to bed early tonight. We have an exam tomorrow at noon and one at 4 pm and that is it. Plenty of time remains to prepare for them but one will be tricky.

All for now

Round One

2010-03-15T14:59:00.000-07:00

Round one of finals week is over. No sleep to speak of last night really made it nice to try and think early this morning and on into the afternoon. The first exam was our lecture final in clinical laboratory which consisted of 96 questions of blood analyses and pathologies associated with heightened chemicals. This consisted of 75% new material and 25% old material. I knew about the 75% but hadn't a clue about the old material. I have been "busy" during some of the lectures and missed one where he talked to the class about this 25%. I knew the answers to the majority of the old questions, so no issues came up. There were a few I scratched my head during a long fixated stare at the wall due to 2 hours of sleep. Fun stuff!

The second exam was a venipuncture and urinalysis. I had a great partner with huge veins. Before I stuck the needle in his arm, I thought, this is going to be easy. I sadly stuck through his vein and got NO blood! This has happened twice this term out of 11 punctures! I continued as if I was getting blood and changed out the vials so he could see I could do the procedure. He scolded me for uncovering the needle too early, even though I handled it with care. No points were deducted for that. My partner, however, successfully drew 2 full vials from me and all was good. We proceeded to the urinalysis section where a vial of piss sat ready to be dipsticked. This part was easy because you simply dip a pH-like stick into the yellow, dab it, then watch for the multiple absorbent markers to change colors, indicating the presence of a chemical. You record what seems to match in color to the chart and hope it's right. Quite subjective but useful in detecting wildly high abnormal urine metabolites.

We then practiced adjusting the neck for about an hour and decided it was time to go into the lab and see if we could get in early. Within a 15 minutes we were on our way to being tested on over 300 adjustments for the neck, the thorax, lumbars and pelvis. All were randomly selected by our instructor and we hadn't a clue which would be on the exam. I did really well on all the adjustments, only screwing up on one which I believe was scored by a cocky new DC. Regardless, I made it to the 3rd station of four adjustments with enough points to end early. I decided to go ahead and do the remaining two ending with 59 points. A passing score is 48.

I am glad it is over and now I can get some rest. It is weird how stress changes your routine. Any medical student, no matter the discipline, deals with the overwhelming nature of the program's demands. Some quit because it is too hard for them and others continue no matter how hard it gets. It's all about endurance.

14 exams remain. Five of which are board exams this weekend. Three are scheduled for tomorrow.

All for now

Nerves

2010-03-15T02:02:00.000-07:00

Here we go again. Finals start tomorrow morning approximately 6 hours from now and I am still awake. For some odd reason my mind wouldn't shut off tonight even though I pumped myself full of melatonin and relaxed for several hours. I think this week will be tough and I question whether I have done enough to be prepared for the intense week of exams.

Last week I was able to get most of the adjustments down for the cervicals and extremities, so a review before the exam will suffice. The neuromuscular diagnosis course will be challenging in lab. Tying together concepts is very hard particularly when neurological and orthopedic tests converge. Keeping it straight will be the first step, verbalizing it the second and performing it, the third.

It is weird to go through a program as intense as this one. At times, I am completely relaxed and calm and the next, my nerves begin to fire and keep me up late. The triggers are hard to detect in regards to controlling such visceral reactions. I have pinpointed some of them and mostly they consist of fears of failure and a lack of adequate preparation to feel comfortable being tested. When I am ready, I tend to sleep well and nothing worries me. Those days are long gone and for the next 7 days I will fight to keep things balanced.

On another note, I think my board preparation is on par. I studied all weekend as planned a few weeks back. I tried really hard to get ahead with our regular classes last week so that this weekend could be devoted to board preparation. In retrospect, I think forming a plan such as this was very important but there is always a little thought on my shoulder that wonders if my preparation will match the demand of the board exams. Sometimes, as my friend Andy says, you just have to do it live.

Rolling with the punches is tough when you have a lot invested into something. You want to do well and succeed. It really comes down to looking back to what you've accomplished to this present day. Nothing compares to the anxiety I felt in anatomy lab. The finals, boards and practicals will be a walk in the park compared to the gruesome nature of those long 30 weeks in that lab. I wonder what the new students are going through, whether they too are trying to keep it together and adapt.

Dr. Gillette, our neurophysiology teacher told us one time that the human brain needs 6 hours of sleep prior to a big exam. I better get to bed so my glial cells have time to restore their glycogen.

All my best

Sports Clinic Plans

2010-03-07T22:15:00.001-08:00

The weekend was full of time spent studying for the basic science boards as well as the musculoskeletal classwork we've been handed so delicately. It is a bit daunting to think we still have nearly 40 hours of new information left that hasn't been handed down yet. These next few weeks are going to be tough.

Many of my friends are freaking out about balancing finals and boards. Eighteen exams in 7 days is a lot to balance. Particularly when most are skill proficiency exams. I guess this is why they call this the medical school of chiropractic.

In a way I am excited to attack this next week with a full focused effort. Sort of like the final push during a race when you feel like crap but know if you recommit to the effort you'll end up placing. School is no different. If we shut off the fear of failure and turn on the drive to succeed we will smoke through the next two weeks efficiently. It is all about being confident and knowing you have put in the time not only recently but cumulatively.

On another note, I am looking forward to taking the next steps in launching the sports clinic in Boise. From what I have seen with my market research, there isn't a program like the one I am planning in Boise or Idaho. This is pretty exciting. I am setting up some meetings for the break to visit with a few folks that will be major players in the next few years during the clinic's growth phase. My calculations suggest we will have our expenses covered in 2 months. This means I will need money to cover the initial cost of equipment and overhead for 2-4 months. Most likely, I will try for 6 months of revenue just incase we grow slower than anticipated.

This all seems like a dream. I remember when I moved back to Boise in 2005 to pursue chiropractic. Having 2 full years left on my bachelors to complete back then felt like an eternity. I remember I couldn't take general chemistry because BSU required a math prerequisite of precalculus. Testing in at a high school level in math was a huge blow to the psyche back then. Now, I am 18 months away from opening the clinic I envisioned back then! The time spent in the books these last 6 years is really going to pay off. All of these tests and obstacles are miniscule in the long run. Yes, we do need to be proficient doctors and exquisite diagnosticians but not at the expense of our happiness and health. This has been the struggle during the past 18 months at Western States.

With that, I will close by saying this to my fellow DC colleagues, don't let the intensity derail you next week. You've made it this far and that is quite remarkable! Don't forget what you have sacrificed to get to this point in your career.

All my best

Business Plans

2010-02-27T09:31:00.000-08:00

The realization that school will end someday is creating motivation to sculpt a business plan these days. I purchased a book written by a former successful (ethical) chiropractor called, The Business of Chiropractic. The book has turned out to be quite useful for such an endeavor, being that he practiced ethically and has great advice on how the business of chiropractic medicine works.

The time spent working on a business plan doesn't amount to much these days but planning things is always on my mind. It gives me great joy to think about the type of equipment I plan to purchase and how it is I will approach the community for their business.

From what I have read, targeting a specific customer is quite important when it comes to building a business. In any business you must have a clear definition of the customer you are targeting or you run the risk of not getting any business at all. You'd think defining your patient base would be easy, which it is. However, communicating what it is you are offering to them and why it is they need you is a very complicated thing to do. I am a customer to some companies and I am trying to learn why it is I devote my spending habits to these businesses. What do they offer that keeps me coming back beyond the product they provide? Is it the experience? Probably a bit of both.

There are teams that do this planning for you if you are financially set prior to launching such a business. Us poor folk, have to get creative and do the work ourselves. In my mind, it is really fun to design a dream clinic. I've thought about having a large office with a great view and a training area that is fully equipped with training equipment and a private shower/bathroom. I envision having a small studio size physical therapy area, large enough to accommodate a treadmill, recumbent bike, an elliptical machine and strength equipment. It will be spacious enough to allow a few assistants and personal trainers to work with patients/clients simultaneously. The difficult part will be separating the clinic area from the therapy area and designing it so people aren't running into each other.

It is a bit daunting to get all this planned out and also become a chiropractor. With boards approaching too it feels like I don't have time to do anything else but school and business planning. I know it will eventually come together and I will be sitting in my beautiful clinic busy as hell and financially secure. 18 months from now, this all will happen. Now to decide when to launch the fitness and massage side of things.

There are good incentives to launch the fitness and massage side of things first prior to opening the clinic. It allows a clientele to form prior to opening the medical side of things and gets the business familiar in the public's mind. If the expenses are covered when I walk in, I will essentially be much better off. That's a tough decision and a huge commitment while in school. We'll see.

All for now

Biomechanics of the Lower Extremity

2010-02-25T02:04:00.000-08:00

As I lay here in bed thinking about the intricacies of lower extremity biomechanics and not sleeping, I have started formulating a three-dimensional model in my mind in regards the movement patterns. Similar to organic chemistry where you must construct a molecule in your mind and move it around, biomechanics is really just a macro-version of organic chemistry models. Some people really excel at this, where others, like me, have to work at it.

I find the biomechanics course we are in to be quite fascinating. Linking movement from distal to proximal is incredibly complicated. For instance, we learned the normal movement of the foot during the gait cycle a few weeks ago and now we've ventured into abnormal foot, knee and hip biomechanics. If, for instance, the femoral head grows too anteriorly, it will cause an internal rotation of the distal femur near the knee and a compensatory external rotation of the tibia and even excessive pronation of the foot. If the femoral head grows too posteriorly, it can cause genu varum at the knee which is essentially "bull-leggedness". Genu varus of the knee could lead to rear foot varus and potentially over supination or pronation depending on how the foot compensates.

Now if you take these abnormal biomechanics a step further and talk about functional issues versus congenital, it gets even more interesting. Functionally, you can have an anteverted femur or a valgus knee or even a excessively pronated foot which can be corrected. Congenital issues can be corrected with posting up short legs or correcting for a malformed foot bone. The trick in learning this stuff is to know when the issue is functional or not. I am not there yet with my understanding of it all but I know I will be there soon.

What I find most interesting is how the muscles are involved in faulty movement patterns. Connecting the structure and function of muscles is very hard to do. There are so many muscular actions and details to human movement beyond bones gliding on one another that it can get overwhelming. For instance, when we were studying the foot, there was something mentioned about the lower leg muscles forming a sling which supports the arch. The tendon of the fibularis longus wraps behind the lateral malleolus and attaches to the plantar surface of the foot just proximal to the first ray (big toe). And the tibialis anterior muscle attaches to the dorsum of the foot, practically on the other side of the attachment for the fibularis longus. This apparently forms a harness or sling that dynamically supports the foot during movement. If one muscle involved in this harness becomes weak or too strong, it can cause a functional abnormality and become a pain producer. And if the issue persists for years where the person copes with the pain, osteophytes can grow producing bone spurs and arthritis.

It is fun to start wrapping the mind around these concepts in a clinical way. For the past year and a half we've learned what "normal" is through taking tons of basic science classes and now we are getting a good dose of "abnormal". Combine this with the orthopedic and neurological tests we are learning and eventually we'll be able to diagnose the problem and fix it. The knowledge we are gaining is so versatile and applicable to everyday life. We all get pain from physical activity or the lack of it. Sometimes the pain dissipates over time and the problem fades away but other times the issue becomes more chronic and abnormal movement patterns become "normal" to the brain. We, as modern chiropractors, are suited not only to fix the problem but to re-educate the kinetic chain to work as it should.

When thinking about the future, I will be doing a lot of physical therapy in my office. At least, this is my thought right now. My reasoning is that if you look at the amount of time people spend sitting, it is much greater than the time spent working out or countering the effects of sitting. My hope is to have a therapy focus that continues care into physical fitness services. Hire some trainers and essentially feed them clients through extending their care in the office. I see this as a win-win situation for both the patient's health and my bottom line.

It isn't unethical in my mind to advocate healthy living beyond adjusting everyone in hopes the natural forces take over and bring good health. Unfortunately, there are some who believe bone's out of place impinge nerve flow and if they are "freed" up then health will follow. This is stupid and should be disenfranchised in the profession. Health is a biopsychosocial phenomenon and is much more complicated than a bone out of place pinching a nerve. This could turn into a tangent so I am going to end by wishing good luck to those who must struggle through another difficult test tomorrow.

All for now

Keeping a Level Head

2010-02-21T00:22:00.000-08:00

In four weeks my class and I will be taking the first set of national boards. All of the information we are supposed to have soaked up during the last 2 years has to be ready for recall in subjects like pathology, microbiology, biochemistry, neuroanatomy, neurophysiology, general physiology and general anatomy. Much of this information is being built upon this quarter and will be easily put to use during the exams. The difficult part is going to be reviewing the details of each area and balancing the current course load at school.

I go through freak out fits in regards to this massive balancing act, as does the majority of my class. Some are poised and nothing bugs them or at least that is what we see. I think most everyone is trying to figure out how they are going to jump through this hoop and keep things in check. I for one have some major anxiety which goes away when I go on a run at threshold pace or drink beer. Unfortunately, beer makes the anxiety worse the next day so I have reluctantly been holding back with an occasional indulgence.

Next quarter we are in 7th quarter. This means we enter the clinic phase of the education and we are officially junior interns! The time passes so quick at school and each week seems like a blink of an eye. The information piles up so high, so quick that when you start digging through it to get it embedded in your brain the effort becomes a 2-3 hour event. Exhaustion sets in and motivation declines leaving it to be done another day. Unfortunately, every day that is missed reviewing, puts you that much further behind. All you can do is try your best.

On another note, the school has launched a masters degree program in exercise science which starts next quarter. The students entering this program will basically be taking 3-5 extra credits per term and mostly at night. In my mind, adding more work onto an already insanely busy program is a recipe for disaster. Personally speaking, I am already struggling to master the current information and at times feel I cannot get it down well enough to be competent. When I think of volunteering for more classwork, I feel as if the only response would be to gag. I guess if someone wants to go for it then I am supportive.

I was strongly considering going into the masters program but my gut says it isn't really what I want. After talking with the program director, I know it is not for me. The program is set up so that you get clinic hours working with high school and college athletes during competition. Essentially, you are trained to be a doctor on the sidelines of sports like basketball, football, baseball and soccer. It makes sense to design a program like this because the students are guaranteed to work with injured athletes and prepare them for competition. However, there isn't much emphasis on endurance sports like marathon running, cycling, mountain biking, nordic skiing and triathlons. When I asked the director if we'd be able to work with endurance athletes he pretty much said no. He told me, injuries are injuries and the only difference between endurance athletes and speed athletes is that they use different energy systems. Interesting. I completely disagree, on many levels.

Instead of doing the masters degree, I have decided to get sports medicine training from different sources that emphasize on endurance athletes. The National Academy of Sports Medicine is a great resource for this type of training. In fact, they have a few masters degrees in the subject of performance enhancement that can be done primarily online. Another program out of Arizona from an Osteopathic medical school has a similar program to NASM's which can be done online as well. Granted, you wouldn't be able to get hands on training like the Western States masters. When I think about how I am going to market myself in the outpatient clinic in the near future, I see myself setting up shop at running events, nordic skiing events, cycling events and triathlons. Under the supervision of a DC, of course. So, essentially, I will most likely get the training I want without the hassle of taking more classes.

The rigor and demand for excellence in our current program makes me think my training at Western States is top notch. It has it's issues but I don't think the bad outweighs the good. We are slowly becoming musculoskeletal and preventive health experts. I trust the program and believe I will eventually become a competent doctor.

All for now

Neuroanatomy

2010-01-23T12:07:00.000-08:00

We are applying the principles of neuroanatomy these days in our neuromusculoskeletal courses. This involves grasping the foundations of all the different tract types that convey information from the environment to the central nervous system and back via the spinal cord. The details can be a bit daunting but applying it via physical exams on each other, lodges the information deep in our brains nicely in multiple ways.

We are in our infancy of understanding how to weed out an upper motor neuron lesion from a lower motor neuron lesion. There are many screening exams that we are learning and ones we haven't learned. In conjunction to these neuro-exams, we are learning muscle tests that will help determine how to properly diagnose the problem and approach the patient's treatment. The orthopedic exams will help us figure out whether the problem is at the nerve root, the joint capsule or soft tissues. Everything I am learning is legit stuff. Our school is not teaching any fluff associated with questionable diagnoses or treatments. The information we are learning is the same information medical doctors, osteopaths and physical therapists learn.

Many professionals see chiropractic as an equivalent degree as an MD or DO. For instance, I went to the Osteopathic Physicians and Surgeons of Oregon pre-med group last Tuesday with my friend and I was treated respectfully as a colleague. I felt compelled to thank the lead doctor for his professionalism and courtesy in regards to the interactions that took place during the meeting through writing him a nice email. He responded with similar professional courtesy and invited me to attend the other scheduled meetings this year.

I felt proud to represent chiropractic in this manner and in return for this effort, I opened a door to many future possibilities. My hope is that by reaching out into the community like this I will start to redefine the profession as conservative orthopedics and wellness based health care. My hunch is that there isn't many people in the profession who make the effort to do this. Instead, they sit around and focus only on their own world. Granted, we are in school and time is limited for this kind of work. However, we live in a city that houses education opportunities for practically every health discipline, which is quite rare.

Tonight there is a meet and greet function put on by all of the health care schools that will allow students and faculty to network. I find this so critical in redefining the profession of chiropractic. I and everyone else are working way too hard to be disrespected as care provider. It really is our responsibility to get out there and share what we are learning with them and the public. If I felt what we are learning is unworthy of sharing, I would have quit DC school a long time ago. It seems like our school doesn't provide nearly enough opportunity to collaborate with other disciplines. There is nothing to hide and there is no reason for us to be defensive about our entitlement. Until we change the approach to proactivity and move away from being defensive, we'll always be seen as lesser providers. And this is not my definition of professional pride.

All for now.

Joint Restrictions

2010-01-20T13:56:00.000-08:00

I had an interesting thing happen today. I woke up with a right sacroiliac joint restriction which was causing severe pain after every step I took. My suspicion is that the huge amount of sitting I did yesterday altered how my sacrum glided between my ilium bones. It felt like the bone was caught and each time I went to bend forward (put on socks, pick up my shoes etc.) my muscles would spasm, forcing me to protect the area with a distinct limp. My entire biomechanics changed, something many people have experienced shoveling snow, moving a box etc.

From my experience at DC school, I knew the area involved was the SI joint and I also knew if I forced that area to move through an adjustment or exercise it would likely loosen up and begin moving again, stopping the painful cycle. Not all issues with the SI joint are this simple but fortunately, mine was. I took the gamble of making it worse by going on a jog. My hope was it would begin moving again and decrease my symptoms. During the mechanics of running, the pelvis moves rhythmically with the legs as well as the spine via the sacrum. Sitting all day yesterday most likely shortened some muscles and ligaments and lengthened some others to a point where the right SI joint became wedged incorrectly ever-so-slightly. When I got up today the joint was "stuck" and not gliding, therefore the surrounding soft tissues were pushed and pulled in abnormal ways, absorbing energy from vectors unnatural to them. This led me to protect the area with a noticeable limp or antalgic gait.

During the run I started with a slight limp but slowly found a nice rhythm. My pain slowly subsided and on the way home my pain stopped. Essentially, my SI joint was not moving correctly or at all. From that perspective, I think many of the restrictions chiropractors fix with their adjustments basically mimic the effects of exercise. Being that many people don't exercise, these restrictions could develop fully into arthritis or some kind of bone spur, causing severe neurological deficits. As I continue into this curriculum, I notice more and more applicability and usefulness of chiropractic. It can be used for the overworked athlete and the sedentary couch surfer to avoid the consequences of chronic joint restrictions.

It's exciting to continue forward in this curriculum.

New Students

2010-01-18T10:07:00.000-08:00

I have noticed many new faces on campus these past few months. New students enter in the fall and winter term every year and with that comes many new stressed souls. During the first week of this term, a new student fainted in gross anatomy lab. The fire department and paramedics came and wheeled the young man out of the lab and into an ambulance. This event brought back memories of my friend Andy who had a similar experience in the first term, minus the ambulance ride. The intensity of starting a new program like this is beyond simply moving for a new job or relocating for a change of scenery. Add in removing the skin of a dead person and you have a recipe for an ambulance ride.

It is weird to look around at all the new faces on campus and recall the old memories and feelings I had when I entered the program. Not knowing anyone and trying to settle in was challenging to say the least. I often wonder if they know what they are getting themselves into and what led them to choose chiropractic as a career move.

The first year is, in my opinion, the hardest. You are inundated with a huge pile of notes and no coping skills. The material isn't that applicable to practicing chiropractic and the schedule drains your energy. I am glad I stayed until I finished the basic sciences because now we are in the chiropractic coursework which is motivating me to study hard and become a DC. I see the reasoning for the first year or so of class time. It prepares you for the tremendous demand they put on you later on throughout the curriculum. I don't know if I could keep up today if I didn't endure the first 5 quarters. My endurance and coping skill has improved.

To tie it all together, as we are currently, is motivating. I know that all the coursework being taken this term is applicable to practicing chiropractic. For instance, in neuroanatomy we learned the pain pathways for the limbs and the sensory pathways in order to pass exams etc. Now, we are applying this knowledge (relearning it) in order to do neurological exams on each other. Using the information obtained earlier in neuroanatomy is now allowing us to understand what it means to test sharp versus dull sensation, vibration or soft touch. We are checking for abnormalities - interruptions in the flow of information from environment to the CNS. In conjunction to this, we are diving into how chiropractic can restore the pathways or maintain them and when it is not useful.

I am enjoying our muscle testing course too. In gross anatomy, we had to memorize the bones, muscles, innervations and other structures to merely pass exams. Now, we are integrating movement into the picture and mastering anatomy through comparing antagonists to agonists. The extremity adjusting class also forces us to recall the bones and soft tissue structures in the foot, ankle, knee, elbow, shoulder, wrist and hands. We are learning anatomy on an new scale, one that guides us to understand movement and abnormal movement. I love it! This is why I chose to come to WSCC in the beginning. I wish some of this information was provided at the start of the program beyond simply sitting through lectures and cramming for exams. Regardless, I am here and I am enjoying the process on all levels.

All for now.

Stab me, touch me, adjust me, prod me....

2010-01-08T13:53:00.000-08:00

The first week of the 6th quarter is coming to a close while I sit here in our radiographic technique course relearning basic radiographic physics. The week was quite intense with all the labs and having to overcome some fears/anxieties I have harbored (and many others have too) for years.

One fear was injecting someone, stabbing someone with a needle and of course, being stabbed by a shaky-handed person. Stab lab started the first day of the term. As we sat getting the run down about what to do and not to do, I began getting nervous. I couldn't imagine what it would be like sticking a needle into someones vein and sucking blood out of them into a vial. Would I screw up the needle placement and cause an injury?

When I was readying myself to stab my partner, a person from a group behind mine about fainted and walked swiftly to the sink and started dry-heaving. He didn't eat prior to the lab and essentially got nauseated by the experience. My partner had a similar issue but controlled it by getting some water and prepping himself mentally before going forward. I think the first time you do anything like this that pushes you to combat your fears is an epic experience and sometimes adverse reactions occur. I am happy to say, the only problem I had was shaky hands and my partner's "stab-hole" or injection site, began bleeding after I filled my second vial.

In addition to the fear of being stabbed and stabbing others, we are getting up close and personal with each other this quarter. We are in cervical adjusting, a muscle testing lab, an NMS lab, a PDx lab as well as an extremity adjusting lab. All of these labs require a fair amount of hands-on the body time. Being a person that doesn't necessarily like being touched by strangers, this has been somewhat challenging for me to adapt to. But, luckily I am adaptable to a certain extent.

The challenges that lie ahead are going to be massive. We are being pushed to master the anatomical sciences this quarter on multiple different levels. I feel like I have gotten a good start but there is an enormous hurdle to jump in my way. Not only are we heading down the road to the intern days beginning next quarter, we are heading toward our first round of boards. This year will consist of conquering fears and becoming competent in the clinical sciences, a feat larger than most we've overcome in our lives.

All for now

Transitioning into Clinical Science

2009-12-28T11:56:00.001-08:00

I spoke with a friend of mine who just graduated from WSCC this month about the transition from basic sciences to clinical science yesterday and felt compelled to write a blog post about the conversation.

I found the conversation a bit depressing but quite informational as to how to tackle the transition. He told me the information to prepare for the OSCE's as well as the later, more difficult boards is hard to come by even though you go through all the classwork. Supposedly the organization of the coursework and information to make the transition could be better and the basic sciences is above and beyond the clinical sciences in many ways.

One way the clinical sciences is lacking is clarity. Meaning, we are expected to retain all the information learned in pathology and gross anatomy as well as physiology and PDx as if we are walking medical dictionary's. The notes get more confusing and less organized that what they currently are, supposedly. Apparently the expectation as far as performance increases significantly from here on out and the days of logging time in the classroom are over. Its time to become proficient chiropractors and I guess that transition is insanely hard at WSCC.

The professors get harsher and more demanding too. Pathology was a walk in the park compared to what will be expected from us in the very near future.

My friend advised that I buy the orthopedic physical assessment book that is displayed in the bookstore as well as a "learning radiology" book that he found useful. I plan on doing just that so the information has some order to it and is readily available if I need to reference it.

I think any clinical education comes with the hard transition from classroom stasis to application. Extrapolating the vast amount information lodged in our craniums is going to ridiculously hard. We will have to follow the "rules" as to what WSCC expects from us as to how to come to a diagnosis based on a very strict, set criteria. We'll need to show proficiency in how to perform physical exams, our bedside manner with patients, our knowledge of disease, the treatment of disease and of course the prevention of it. All of the information we've learned in neuroanatomy, neurophysiology, gross anatomy, even physiology will be connected in the next year so we are competent interns beginning in 2011 (for some of us).

This transition seems quite daunting to me. I have been very good at preparing for exams that consist of multiple choice and true/false questions but not short answer/essay questions. The answer is more or less always there so retaining the information has been merely based on word recognition and minimal at best. I looked at the clinical proficiency exam we must take at the end of next year, in December and the difference between it and the tests we've had thus far is that every single question is essay style or short answer. And it consists of MANY questions. I find this stressful and hope I can get through the rigor of such an experience. Currently, I would fail it miserably and can only imagine how stressful the experience will be during those weeks.

For now I will do some preparation for part one boards and do my best to really master the next quarter's material early on. I think the only way to really get proficient is to start early and use other's experiences, like my friend's, to guide the way. No matter what, this next year will dominate our time and make us grumpy at times. There is no way around it. There will be some who continue to wait until the last minute to study, I will likely be included in this population to some extent and we'll experience stress unlike we have to this point.

There is one week left until it starts. I am going to enjoy this time off because I know once we start it's going to get crazy.

The Halfway Point

2009-12-21T22:43:00.000-08:00

By mid-quarter in February I will be officially halfway through chiropractic school. It is exciting and daunting to know I have so much more time to spend at WSCC before I graduate. The hard exams, the brutal schedules and lack of sleep that will be endured does not seem fun. In the long run I know this path is the right one.

Ending the basic sciences in any medical program is a huge breakthrough. No more genetics, biochemistry, or any other class that doesn't apply to clinical practice. Now it is time to transition to the clinic and march forward toward the reason we came here.

This quarter started a bit rocky with our pathology teacher being publicly scorned in front of our class and with me catching swine flu (I think, anyway). It ended similarly with everyone pissed at the pathology instructor but thankfully, I was flu free. The class was taught a lesson as a whole this quarter due to a select few who have treated the instructors and their classmates unprofessionally since the beginning of school. Unfortunately, the students not involved with their antics were punished too. Our pathology instructor did the punishing by slowly ramping up the intensity in the class. He gave pop quizzes over an enormous amount of material and in the end he gave us a final exam consisting of diagnosing conditions versus testing us on what he went over in the class. In a way he did test us over the material but it was written to intimidate us and confuse us rather than test our knowledge of the individual pathologies.

He got under my skin pretty bad because I felt I was prepared to be tested over his notes. After 50+ case studies to diagnose, I was shaken for the rest of the exam. I ended up getting a 71% on it. After he curved the exams I got 71 out of 78 correct. I suppose that is fair being that the majority I missed were the case studies. I will look at my exam when I get back and talk with him about why he did this to us. My hunch is that he has never been treated so disrespectfully by graduate students. In my mind, those who have been unprofessional needed to be shown this path shouldn't be taken for granted. We should be respectful to each other and our instructors. If something is not fair discuss it diplomatically rather than disrespectfully.

On that note, I am happy things went the way they did. Initially, I was upset and wanted revenge but after thinking it through, I think what happened needed to happen. After the exam people were crying and carrying on about how unfair it was. In a way, I am glad we were pushed to this limit. It seems to me that there are a lot of people who need to be taken down a notch at our school. To be humbled is a good thing every once and while. I think the visceral reaction to the exam was because we work so very hard for our grades and when there is a possibility of having to retake a class like pathology, it makes you wonder if this path could get any harder.

Now that we are halfway, I am hoping the lessons learned (or not learned) from the first half of the program make the school less unbearable to go to. Socially I can see our class bonding more and relying on each other to get through. We'll be forced to change and adapt in new ways that may make us all double think why we chose such a rigorous career. In the end, we'll be there with a new set of tools to help a lot of people and walk across that stage to receive a doctorate degree.

I hope everyone has a nice break.

Weeks and Weeks of Exams...

2009-12-04T15:41:00.000-08:00

We have been inundated with exams the past 4 to 5 weeks having 2 to 3 per week. The last exam was finished today in microbiology of which I surprised myself with. I committed the material to memory without going to one single lecture!

Granted it took some effort but not as much effort as it takes to drag myself into school at the crack of dawn. I think approaching school this way will be beneficial for my psyche and based off my attitude when being diligent in planting my butt in a lecture hall, I think I prefer the former idea.

The exams are done which matters most. A sigh of relief can be had until the 14th which is when finals are, until then I intend on getting ahead this weekend and next week, reviewing early rather than the night before the final.

There isn't much more to share right now being I am so exhausted. After finals I will update with a nice synopsis of the quarter and venture forward into the next phase, the start of our clinical education.

All for now

Meeting with the President

2009-11-22T23:02:00.000-08:00

I wrapped up the week with a 40 minute meeting with Dr. Brimhall, the president of WSCC. The meeting was concise but covered a lot of ground. My intention was to talk to him about the perception of chiropractic in the public's eye. Why does the public not understand what it is we are about? Beyond back pain, most do not understand chiropractic at all. They don't realize we are trained to diagnose ALL health problems and legally responsible to do so. Most don't understand the academic degree is at the doctorate level. And a high percentage clearly don't know we can order an onslaught of blood tests to track metabolism and nutritional insufficiencies.

We can defend ourselves by saying our education mimics that of an MD's. But this comes across as a ploy to keep up with them. There is no reason to defend ourselves. The fact is, we are going to be given a scope of practice when we graduate and for the most part, adjusting people is a minor element. I get excited when I think about this. When I was working as a personal trainer/coach in Flagstaff I always felt blood tests were needed to get clearer understanding of each particular client. If I knew the persons nutritional makeup, I could give supplemental/dietary advice customized to their needs. As a personal trainer, I couldn't do this due to my lack of skills as well as licensure.

As a chiropractor, I am legally authorized and professionally trained to order blood tests and evaluate them. My scope will allow me to advise nutritional supplements as well as counseling for dietary/lifestyle modification. It's a win, win for me and a benefit to those who I intend on helping at that level. This takes me back to the meeting today with Dr. Brimhall.

I asked him if it matters whether or not the public knows we are trained at this level. He said no, it doesn't matter. He told me I should only be worried about educating my patients as they roll through my door. My expertise and ethical approach to health will allow me to work with my patients at this level. Being that most people don't know chiropractors can perform most of what they are trained to do, each time a person questions our work we must approach it as an opportunity to show them what we're about. For the most part, he's pretty positive about chiropractic and where it stands in the health care market.

I know by writing about these things many people will learn more about chiropractic and might give it a shot. Or at least realize that most of the chatter on the street is questionable and diluted. Those who know me and trust me will realize what I write in this blog is real and true. I convey the information I receive at school to hopefully portray chiropractic as a medically-based/safe approach to health - a way to achieve wellness. In my mind, chiropractic is a way for some people to find wellness. For others, it is a non-surgical approach to reducing musculoskeletal pain. I intend to practice both approaches in 2011 and beyond.

Next quarter I am roughly half way through the program. In the summer, I will be starting as a junior intern in the clinic. The stories will be pouring in on my end and I hope they are taken objectively without bias obtained through street chatter. As an outsider looking in, I was once a HUGE skeptic of chiropractic but as I have ventured through the curriculum, my outlook has changed and I trust my new skills and intelligence with human health. Modern chiropractic is evidence-based (scientifically approached) which should be trusted. I never thought I would say these things but my impression is that I can trust the education I have been given. Being a person who initially wanted to go into medicine, putting these words down is a big deal in my world.

Think about dentistry. These doctors spend a ton of time learning how to work in a person's mouth without hurting them. They drill into teeth, cut out lesions, remove diseased teeth all without doing harm. Their training prepares them to avoid harm and to improve health. It is no different with chiropractic. We practically live on campus learning how to manipulate every single joint of the human body, safely. And we learn how to interpret lab results which define the internal chemistry of our patients. We spend the time practicing at school so that we are competent and safe at administering our treatments in the real world. Just like dentists or medical doctors, we are professionals and masters of health.

Thanks for reading

First Neck Adjustment

2009-11-20T02:18:00.000-08:00

This week was challenging with the pathology exam on Wednesday and our principles of chiropractic exam Thursday. It is amazing the amount of work it takes to get ready for big exams. You don't realize it while you're in it but once it is over the body gives out and seeks a pillow. Today, there was a nice surprise waiting for me in adjustive skills that made it seem all worth it.

Our instructor announced that we'd be doing cervical palpating at the beginning of the class to learn more on how to set up a neck adjustment and if we found a restriction they would allow us to give it a little bump to free it up. It is a little nerve racking being the recipient of someone's first neck adjustment and it is even more nerve racking being the person giving your first neck adjustment.

I was the patient first. My partner palpated my neck to see how it felt and checked my motion in lateral flexion and rotation as well as extension. He found a right rotation restriction and a left rotation restriction lower down. The instructor checked to see if he was right and told him he could adjust it if he wanted to and if I was okay with it. I okayed it, he set it up at end range and gave it a little bump. It popped and I had an instant increase in range of motion. He didn't do the left rotation, only the right. So, my next partner addressed this one and it felt great. Both were confident and light-handed which means they had finesse versus being aggressive.

They told us to switch doctors and patients. Now it was my turn. I instantly got a little bit nervous being this was going to be my first neck adjustment. We've palpated each other's necks before but we haven't been allowed to find restrictions and release them. I found one on my partner and had the teacher come over to make sure I was right, she okayed it and I set it back up into end-range. I gave it a bump and nothing happened. I tried again, nothing. I set his head back down and talked with the teacher and the student, set it up again with a little help from both and tried it again. This time was successful! A little audible pop sprang loose and the student said it was good.

He said I slowly increased my force until it was high enough and seemed pleased. I moved onto my next patient who was the guy who adjusted my neck first and found a few restrictions in his neck too. I had a teacher double check and I set it up but this time I went to tension a few times too many because I wasn't confident with it. This caused some tension in his anterior neck muscles to develop because he felt he needed to help me (this happens when you don't trust the person who's behind the wheel, so to speak). I rested his head a minute, picked it up, took him back to tension and gave a bump and an audible pop happened. Two neck adjustments in one day! Pretty cool stuff.

The coolest part was that I could see an immediate increase in range of motion in both patients. It is pretty crazy how social adjusting people actually is. You have to gain their trust or it doesn't work. Fear is a big part of why people stay far away from chiropractic. They fear getting hurt which is completely valid. It looks like you can get hurt during an adjustment and you can if it isn't done right. So far, I have been getting adjusted almost every week by students and no injuries have occurred. This to me speaks pretty loudly because if there is any risk of injury it is way higher in a student adjusting lab. That being said, having been worked on continuously each week for the past year, there has been no problems whatsoever with any part of my back. If anything, this is the best my back has felt in years!

I realize there are quite a few people who read this blog that don't go to WSCC and will never go to chiropractic school. But they have an interest in what it is like to be a DC student. I want people to know that the chiropractic adjustment is safe and the validation for this should be what I have written above. In the real world the DC must rule out serious disease processes that can mimic mechanically oriented back pain or musculoskeletal pain. This is the reason for such depth in the sciences. Too often I get asked why we chiropractors have to study such complex science and my answer is this - the human element is complex beyond what we can ever imagine. There is a "typical" model of what a normal human consists of but when you add genetic variability and environmental influences into the mix, it gets complicated. If we didn't study basic science we couldn't really operate in the real world.

We hear the stories of people wandering in off the street with back pain and after taking a history and performing a physical exam the back pain is really some kind of visceral issue. It takes a trained eye to catch the bad stuff. Many people think we could become chiropractors in about a year. Graduate and just be on our way to crack backs. It is so much more complicated then that and I hope what I have written today will begin to shed some light onto why it is we go through such a vigorous amount of training.

I am enjoying this education more and more these days and I am very glad I didn't quit. I can't wait to get into the clinic with everyone and earn that doctorate!

All for now