Presenting Chiropractic to Medical Students This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: J Manipulative Physiol Ther 2000 (May); 23 (4): 290–290 ~ FULL TEXT
Daniel Redwood, DC
Private practice of chiropractic
1645 Laskin Rd, Ste 103,
Virginia Beach, VA 23451For the past 3 years I have lectured to 4th-year students at Medical College of Virginia as part of an elective course on complementary and alternative medicine (CAM). Because most US medical schools now offer at least one course in CAM 1 , 3 and because chiropractic is generally considered an important part of this growing field, opportunities for chiropractors to lecture at medical schools are likely to increase in the coming years.
From the Full-Text Article:
INTRODUCTION
For the past 3 years I have lectured to 4th-year students at Medical College of Virginia as part of an elective course on complementary and alternative medicine (CAM). Because most US medical schools now offer at least one course in CAM [1, 2] and because chiropractic is generally considered an important part of this growing field, opportunities for chiropractors to lecture at medical schools are likely to increase in the coming years. The purpose of this article is to initiate a discussion about what constitutes appropriate content for such medical school lectures. As a result, chiropractors currently offering such lectures may be able to improve their presentations; furthermore, chiropractors to whom such speaking opportunities are offered in the future will not have to prepare notes without background assistance. Please see the Appendix for an outline of my presentation; what follows are my observations about the students, a rationale for my choice of topics, and commentary about my experiences.
About The Students
Preparing an effective lecture requires an understanding of the audience to tailor the content to its specific needs.
With rare exceptions, the students in CAM classes are friendly and open-minded. Defensiveness on the part of the chiropractic presenter is counterproductive. Even students who have mixed or negative opinions about chiropractic sincerely want to hear the case for chiropractic.
Most medical students, including those taking CAM courses, are unfamiliar with chiropractic. Few have been treated by chiropractors, and even those who have sought chiropractic care professionally are unlikely to have more than a minimal understanding of contemporary chiropractic. None of the 4th-year medical students I addressed reported hearing any mention of chiropractic (positive or negative) in class during their entire medical education.
Medical students are steeped in the language and concepts of biomedicine. Chiropractic presenters must explain chiropractic in language the students can understand. Chiropractic terms with which they are likely to be unfamiliar should be clearly defined when first mentioned.
Areas of Emphasis
When I was first formulating this talk for presentation to medical students at the Medical College of Virginia and postdoctoral fellows at the National Institutes of Health in 1996, I thought it advisable to emphasize chiropractic’s intellectual and theoretic foundations (including a detailed discussion of somatovisceral, viscerosomatic, and somatosomatic reflexes). I therefore focused less on the nuts-and-bolts description of a typical first visit to the chiropractor. Based on the written comments (which were quite positive overall) of the Medical College of Virginia students after the initial lecture, I altered that emphasis for future classes. Essentially, students wanted a more brief description of theory and neurology and more focus on the practical aspects of what chiropractors do, why we do it, and what kinds of patients they should refer to chiropractors.
Research
The students expressed appreciation for the strong emphasis I placed on research. They noted that this contrasted sharply with the absence of research documentation from some of the other CAM practitioners who had lectured to the class. I recommend brief, focused presentations of the best available studies on musculoskeletal [3] and visceral disorders. [4]
In many respects, research is the most persuasive approach for lecturing to a group of medical students. Such lectures should include, at a minimum, a strong presentation of the seminal studies in the chiropractic field (eg, Meade et al, [5, 6] Kirkaldy-Willis and Cassidy, [7] Boline et al, [9] and Nelson et al [10]) along with summaries of relevant guidelines and meta-analyses (eg, Bigos et al, [11] Manga, [12] Anderson et al, [13] Shekelle et al [14]).
These studies can be covered briefly but should not be omitted. I have also found it helpful to mention the 1998 Croft et al [15] British Medical Journal study on the persistence of low-back pain (LBP) in which the authors demonstrate the shaky basis of the common assumption that most LBP resolves quickly without professional intervention and conclude that most acute LBP is an expression of chronic LBP.
Because of the widespread publicity surrounding the publication of three 1998 articles on chiropractic [16–18] in the New England Journal of Medicine and the Journal of the American Medical Association, it is crucial that chiropractors lecturing to medical students be intimately familiar with these articles and are able to contextualize them. Specifically, without a clear explanation of the methodologic controversies inherent in the construction of the placebo, sham, and/or “active control” arms of the Balon et al [16] and Bove and Nilsson [17] studies, the negative conclusions in the abstracts of these articles will continue to go unchallenged, with a resultant erroneous impression that chiropractic treatment was not helpful for patients with headache and asthma in these studies. Previous articles [19, 20] have addressed these issues.
From the Cherkin et al [18] study on LBP, which compared spinal manipulative therapy (SMT) with Mackenzie physical therapy and to providing an educational booklet, 3 points are important to note.
When dozens of controlled trials are performed for any intervention, rarely do they all yield positive results. The key issue is whether most yield positive results. In the case of SMT, most do, forming the basis for the positive conclusions reached by several researchers. [11, 12]
Treatments cannot be identical from one patient to the next or from one doctor to the next, particularly with nonpharmaceutical interventions such as SMT, physical therapy, acupuncture, and massage therapy. This variability is inherent in the nature of the therapies and accounts in part for the variable findings in controlled trials.
The results of the cost-benefit analysis from the Cherkin et al [18] study did not factor in time lost from work, a parameter on which the chiropractic group fared substantially better than the Mackenzie or booklet groups. Rather than basing conclusions on the overall cost to the patient and employer, the Cherkin et al [18] study calculated only the cost to the health maintenance organization where the study was performed. (The medical students, acutely concerned about some values inculcated in health maintenance organization practice, grasped this point immediately.)
Case Studies, Small Trials, and Anecdotes
Including a few thought-provoking case studies or smallscale trials from the literature that deal with nonmusculoskeletal pain problems in the research portion of the presentation is also recommended for lecturers at medical schools. Among the examples I have used in my talks at the Medical College of Virginia and National Institutes of Health are the Browning [21] case study on flexion-distraction adjustments for a case of long-term pelvic pain without lowback pain and the Pikalov and Kharin [22] study on duodenal ulcers. My purpose in presenting these examples is to illustrate the potential breadth of the effects of chiropractic, while also demonstrating our ability to distinguish among the proven, the probable, the suggestive, and the speculative. Mentioning such studies is both helpful and appropriate when they are presented as food for thought and as tantalizing spurs for further research.
Moreover, I advise chiropractors who speak to medical students to underscore certain points by briefly citing cases from their own practices. Examples I have used include
a woman with cauda equina syndrome whom I immediately referred to a neurosurgeon for emergency surgery
a physician with neck pain and brachial paresthesia that resolved with chiropractic care
a man who with persistent nausea for 1 year who was unresponsive to a wide range of conventional and alternative therapies was cleared permanently with 1 upper cervical adjustment after he was referred to me by his medical physician
Using such cases offers the chiropractic lecturer an opportunity to demonstrate (in both content and tone) the nature of chiropractic practice and the caring approach chiropractors bring to their work. The presence or absence of this caring nature is a significant part of what the students are looking for when a chiropractic lecturer appears before them. Upper-level medical students often struggle with the conflict between the requirement to see patients quickly and their desire to understand these patients deeply. No profession has truly solved this problem. However, as Kaptchuk and Eisenberg [23] have noted, a key contribution of the chiropractic profession to the healing arts is the connection and compassion we bring to our work. Although as chiropractors we are aware of how we may fall short in this regard, the fact that we are perceived in this way by outside observers should encourage us to share with the students our approaches, our emotions, and our struggles. This is an unexpected opportunity for developing interprofessional cooperation.
Safety Issues
The matter of safety should be addressed forthrightly in medical school lectures. Although today’s medical students are far less likely than their predecessors to hear negative reports about chiropractors from their professors, at some point each has probably read a newspaper or journal article on stroke after spinal manipulation. In my medical school lectures, I draw heavily on the works of Dabbs [23] and Dabbs and Lauretti, [24, 25] whose approach cites the best available statistics on cerebrovascular accidents and death after cervical spinal manipulation and then compares and contrasts these with safety statistics for another common treatment (nonsteroidal anti-inflammatory drugs) that many people with neck pain or headaches use instead of SMT. Statistically, SMT fares quite well in this comparison. Most importantly, this approach moves the discussion toward a practical representation of the real-world choices made by patients and doctors and away from a misleading comparison between chiropractic and a hypothetical therapy without side effects.
Chiropractic Demonstration
The demonstration of hands-on palpation methods and adjusting set-ups is probably the medical students’ favorite portion of the class. They have expressed great interest in the hands-on nature of our work and disappointment at my unwillingness to demonstrate an actual adjustment. I have explained that it is inappropriate to do so without a prior work-up with history and examination. In response, they have suggested arranging a history and physical examination on a student volunteer before the class session, thereby removing this impediment. Thus far, I have refrained from accepting this offer. I am interested in feedback from readers about whether there are circumstances in which demonstrating an adjustment would be appropriate.
Adapting This Format for a Shorter Presentation
Not all speaking opportunities will involve sessions as long as the 3 hours I have at the Medical College of Virginia. For shorter presentations, I would still suggest covering all the primary topics listed in my outline, condensing each of them as required. In particular, I recommend keeping the strong emphasis on research, on the ways we evaluate and treat our patients, and on the kinds of cases that medical physicians should consider referring to chiropractors
CONCLUSION
Until recently, there were no presentations by chiropractors at medical schools. The end of the official medical boycott of chiropractic as a result of the Wilk versus American Medical Association26 case and the growth of the CAM movement have combined to create a more collegial relation between the chiropractic and medical professions. Chiropractors invited to lecture to medical students bear the responsibility of representing the profession and can help to advance interprofessional cooperation, in some cases forging new forms for such cooperation. To rise to this challenge with competence and artistry, thorough planning of such presentations is essential. Exchange of information among chiropractors currently lecturing at medical schools may enhance the quality of present and future medical school lectures by chiropractors.
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