Abstract
Objective
The purpose of this descriptive report is to describe the development of a preparticipation risk assessment screening process for incoming students prior to participation in practical labs.
Methods
A committee at the Palmer College of Chiropractic, Florida met to discuss a health history questionnaire, physical examination process, and course of action to have second-year students use their current knowledge to screen incoming students for possible clinical considerations of practice lab participation. The aim was to identify potential risk factors that may require application modification associated with performing and receiving adjustments and other hands-on lab activities within the curriculum. The preparticipation screening process, focused on general health and curriculum referenced chiropractic clinical considerations, and was created as an expansion of the existing informed consent procedures to screen incoming students prior to participating in palpation, technique, physical examination, and open adjusting labs in the chiropractic program. Any clinical considerations identified during the screening were referred to be fully evaluated by a third-year clinic intern and faculty-licensed chiropractor to maintain classroom safety standards for the students. Referred students were restricted from full classroom lab participation until recommendations from the clinic or outside licensed healthcare providers managing their concerns were received.
Results
The program was implemented in April 2022. Eight out of the 48 students evaluated in the first group and 12 of the 81 in the second group had possible clinical considerations to participation and were referred appropriately for a full evaluation. In the third group, 35 out of 146 students with suspected clinical considerations to participation were identified. Of the 55 students referred out, all students are now actively participating in classroom activities. Fifteen have been cleared to return to classroom participation with no restrictions and the remaining 40 students have been released for participation with patient-specific restrictions as directed by their managing health care providers.
Conclusion
The preparticipation screening process was implemented as all incoming students since the inception of the process have been screened, referred for evaluation when deemed appropriate, and cleared to participate in labs either with or without restrictions. This process has also demonstrated the possibility of identifying multiple clinical considerations for safe curricular participation while participating in doctor-patient simulated classroom activities. This process may be helpful for new students to recognize the patient history and examination procedures as an important aspect of a patient encounter prior to receiving treatment.
Key Indexing Terms: Students, Medical, Safety Management, Chiropractic, Informed Consent
Introduction
Students entering chiropractic colleges may have different backgrounds and experiences with chiropractic care. Students may enter chiropractic school without experience as a patient of a chiropractor or having received a spinal adjustment. Without their understanding of chiropractic care, there is a potential risk for students to be injured.
A study found that at chiropractic colleges in the United States, 53% of students reported that they sustained injuries during technique class,1 prompting the administration to proactively recommend further screening be implemented. The recommendation was to design and implement a process that would simultaneously mandate a health screening to identify possible clinical concerns to classroom activities of examined students while providing second year “examining” students with an educational opportunity for supervised clinical skill development. The literature search was performed looking for examples of screening instruments or tools used prior to utilizing students as subjects. We searched the most comprehensive health sciences and chiropractic databases (PubMed, Medline (Medline Industries Inc, Northfield, IL), CINAHL (EBSCO Industries Co, Ipswich, MA), ScienceDirect (Elsevier's Inc New York, NY) and the ICL) for information on “patient simulation,” “human simulation,” procedures, screening, risk, injury, mitigation, and students. Search parameters were English language dated in the last 10 years including human subjects. (see Supplemental file for Literature Search). The literature search resulted in no other current studies that mandated student screening during skill development.
A 4-year chiropractic degree program typically includes 2 academic years of classroom participation followed by further clinical education and internship. As part of the chiropractic curriculum at Palmer College of Chiropractic, students practice and demonstrate their newly acquired skills of practical classroom activities including palpation, adjusting, rehabilitation activities, and hands-on examination procedures on each other. These skills include but are not limited to psychomotor drills and short lever high velocity low amplitude adjustments. To train how to properly utilize these skills, students will assume the simulated roles of “doctor” and “patient” during clinical courses like palpation, technique, and physical examination labs. If these skills are performed incorrectly, injury may occur.1, 2, 3, 4, 5 The students throughout the curriculum serve in a simulated role as both the “patient” and the “doctor.” The purpose is to find potential health conditions that may affect a student's ability to participate in either the “doctor” or the “patient” role during these classroom interactions. Students are educated about these skills, knowledge, and assessments throughout the curriculum utilizing National Chiropractic Board of Examiners referenced texts as a guideline. Within these texts are where the curriculum referenced chiropractic clinic considerations are found.
There are proposed red flags and contraindications to chiropractic adjustment procedures.6 Screening helps to identify red flags, relative and absolute contraindications and any risk factors or clinical considerations, which are additional considerations that may need to be evaluated further before participation. These chiropractic clinical considerations may be risk factors when the student acts in the simulated role as either the patient or the doctor.6 A contraindication is considered to be a factor identified before a procedure is applied that would make application of the treatment inadvisable because of its potential to cause harm or delay appropriate treatment.3 Before someone elects to be a candidate for chiropractic care, they must be carefully screened for potential red flags that indicate the need for further immediate imaging, or referral to a specialist.6 Once identified, any concerns are classified as a clinical concern for the purposes of the screening.
The goal of a screening process in an educational environment helps to identify and request further evaluation of any areas of clinical concern that may place the student at risk for possible injury and ensure the evaluation of these concerns prior to participation in the practical classroom activities. Incoming students do not yet possess the knowledge to self-identify contraindications, red flags, or distinguish what pre-existing issues may require further clinical evaluation. During new student orientation, students are informed of their potential to become patients at the college's clinic and are educated on their informed consent as class participants. Students are also required to read and sign an informed consent prior to participating in any practical labs. The informed consent has served as the means to identify potential risks to the student in serving in the “patient” role prior to the start of each new course.
Before we adopted a screening procedure, the students were encouraged to visit the institution's health clinic for their health concerns. A new patient visit at the clinic includes a complete patient history, comprehensive physical examination, diagnosis, any necessary imaging, testing, or lab work, and a care plan developed and implemented by a 3rd year chiropractic intern under the direct supervision of a licensed chiropractor faculty member. This service is provided to the students free of charge and strictly on a voluntary basis.
New students are encouraged to make an appointment at the clinic if they have any preexisting conditions, current health complaints, or if they wish to receive maintenance care. However, due to the voluntary nature of this recommendation, it was hypothesized that some students with health issues did not seek evaluation or care prior to classroom participation. Therefore, the purpose of this study was to describe the development of a preparticipation risk assessment screening process for incoming students prior to participation in practical labs.
Methods
The following describes the implementation of a preparticipation process in one United States chiropractic program. The preparticipation process was presented by the Associate Dean of Academic Affairs and received approval by the academic management committee on February 7, 2022. This was a retrospective study utilizing secondary data analysis of pre-existing data. The Palmer Institutional Review Board exempted this study from review (N2022-9-28-CL).
A process was developed with the aim to ensure that all incoming students were screened to identify any clinical considerations to the student participating in a practical skill development in a laboratory setting. A committee was formed on February 11, 2022, to create the screening process. The purpose of developing this process was to screen the incoming and transfer students, using the curriculum referenced text, to mitigate any possible risk associated with classroom participation based on pre-existing or undiagnosed health conditions.3,6 The curriculum coordination would be targeted to benefit active learning for both the examining students prior to entering the clinic, as well as the examined students as they come into the program. This process provides examining students additional practice interaction encounters and integrates previously presented course learning objectives. It provides the examined student with a screening for their safety as well as the opportunity to see the progression of their education via the knowledge and skill of the examining student.
The screening process focused on general health utilizing curriculum referenced chiropractic clinical considerations and was created as an expansion of the existing informed consent procedures to screen incoming students prior to participating in practical classroom activities. In the applicable classes, including palpation, technique, physical examination and open adjusting labs, the participating students are not patients and are not receiving chiropractic care; rather they are acting in a simulated patient interaction for the purpose of honing their skill sets in a practical setting.
The committee was chaired by the Associate Dean of Academic Affairs and included 4 additional faculty members ranging from Instructor to Associate Professor from the Department of Clinical Sciences in Academic Affairs. As a focus group, the committee formulated a health history questionnaire that targets red flags, past medical, family, and social history and brief physical examination that includes vitals, posture, spinal range of motion, and an abbreviated functional test for pain during performance. The preparticipation examination form developed by Funk and Cantito was utilized as a resource in the development of the health history questionnaire and screening process.7 The course of action was then agreed upon by the subcommittee, if any red flags or curriculum referenced chiropractic clinical considerations are identified during the screening examination process the student will then be referred to the college clinic or other appropriate physician referral for an evaluation and determination if the student should participate in specific practical classroom activities and at what capacity participation is recommended. During the faculty department meeting on March 11, 2022, the affected faculty were introduced to the preparticipation examination screening process and were given the opportunity to discuss and ask questions. The program was initially implemented starting in the Spring 2022 term.
Procedure
Second year academic students were given an assignment by the lead instructor of a clinical sciences course to complete a health history questionnaire and abbreviated physical examination on an incoming chiropractic student. These 2 groups will be referred to as “evaluating student” and “incoming student” respectively. The process was explained to the evaluating students both verbally and via written electronic communication. The evaluating students were instructed to begin the encounter with a review of the written informed consent with the incoming student and have them sign it. The examining student then interviews the incoming student utilizing the health history questionnaire. Each interview was then reviewed by a licensed, supervising chiropractic faculty member. Lastly, the student was instructed to employ the abbreviated examination form and record the findings for vitals, posture, spinal range of motion, and simple functional testing for pain during performance. The entire encounter and process is supervised by a licensed chiropractor faculty member.
In the 2nd year of the curriculum, students have completed coursework related to clinical skills including history taking and physical examination. The evaluating students were asked to bring their sphygmomanometer, stethoscope, and thermometer as well as given electronic access to the informed consent, health history questionnaire, and physical examination form and instructed to bring a printed copy of each for their meeting with the incoming students. The evaluating students were divided by last name into groups across 3 days to meet with the incoming students after class in a supervised setting to perform the screening. The Associate Dean of Academic Affairs announced the screening process at orientation for the incoming students. The incoming students were divided into groups alphabetically, instructed on the date and location of their screening, and paired with an evaluating student. After administering the informed consent, health history questionnaire, and physical examination the evaluating student then reviewed the findings with a licensed chiropractor faculty member. The faculty member made the decision if the incoming student should be cleared to fully participate in practical classroom activities or referred to the college clinic or other healthcare professional for more thorough evaluation. If a referral was warranted, the referring chiropractic faculty filled out the student referral form identifying the area of concern, reason for referral, and the incoming students contact information.
Student referral forms were collected by the Associate Dean of Academic Affairs and sent to the Director of Clinics. The clinic scheduling department then contacted the referred incoming student to make an appointment. The Associate Dean of Academic Affairs notifies the academic faculty via email about the student's referral and specific restrictions from participating in class. The faculty members are asked not to allow the student to participate in adjusting classes until further recommendations from the clinic have been received. Once the clinic has evaluated the student, they will give clearance to participate when appropriate. The Associate Dean of Academic Affairs has kept track of the incoming students referred and their clearance status via a secured shared Microsoft Excel document that all technique and practical classroom faculty have access to view.
Results
The new screening process was initially implemented in April 2022 within the dates of April 6, 2022, and April 13, 2022, 49 incoming students were evaluated by 55 evaluating students. During this 1st cohort 8 out of the 49 students involved were found to have possible clinical concerns to participation in practical classroom activities and were therefore referred to the college clinic for further evaluation. These clinical concerns included 7 musculoskeletal complaints, 3 cardiovascular findings, and 1 neurologic finding. They were identified during the health history questionnaire, range of motion, vitals, and functional testing portions of the exam.
During the second implementation of the process, from July 13, 2022, to July 15, 2022, 81 incoming students participated in the screening and were evaluated by 58 evaluating students. After the health history questionnaire and examination 12 were found to have possible clinical concerns for participation in practical classroom activities and referred appropriately. The areas of concern identified during the second implementation were as follows: 10 musculoskeletal, 2 cardiovascular and 1 neurologic. These clinical concerns were identified during the health history questionnaire, vitals, postural, range of motion and functional test portions of the screening. The final cohort in this study was examined October 4, 2022, through October 6, 2022, and consisted of 146 incoming students. They were screened by 61 evaluating students. This cohort found 35 incoming students to have clinical concerns to participation warranting a referral for further evaluation. The following regions were identified as areas of concern: 13 lumbar spine, 13 upper extremities, 5 cardiovascular, 5 lower extremities, 5 thoracic spine/ribs, 2 cervical spine, 1 neurologic, and 1 circulatory. All 3 cohorts combined a total of 55 students referred to the college clinic of 275 students evaluated, see Supplemental File.
The results have been broken down by percentage of students per cohort with findings that warranted referrals, screening component that identified the clinical concern for appropriate referral, and anatomical regions of the findings indicating referral respectively in Fig 1, Fig 2, Fig 3 Of the 55 students referred to the clinic, all students are participating in classroom activities. Fifteen have been cleared to return to classroom participation with no restrictions and the remaining 40 students have been released for participation in practical classroom activities with patient specific restrictions as directed by their managing health care providers.
Fig 1.
Percentage of students referred by cohort.
Fig 2.
Student referral numbers by exam component.
Fig 3.
Student referral numbers by suspected area or system of contraindication identified.
Discussion
Our study found that 20% of the incoming students showed a need for a full evaluation prior to serving as subjects for their peers in practical lab settings. This is not to say that those students were unable to participate but rather that they should receive a thorough evaluation by a licensed physician and be cleared or given limitations on participation dependent on those findings. This study suggests that there is a need for incoming students to be screened prior to serving as simulated patients in an effort to offset possible negative outcomes. Some students by participating in the screening process were able to identify comorbidities of which they were previously unaware. One such student was referred to a medical doctor after the screening and subsequently given a diagnosis of Type 1 diabetes.
In chiropractic schools throughout the United States, students learn psychomotor skills in order to become chiropractors and often serve as subjects for classmates to develop and practice these skills.7 This includes but is not limited to history taking, physical examination, and a variety of treatment procedures. Prior to program completion, a student must first demonstrate clinical ability in a classroom setting. In many chiropractic schools this entails demonstrating said skills on fellow students. One of these skills being the high velocity low amplitude adjustment which utilizes a quick force through a short lever. The HVLA has known red flags and contraindications to treatment.6 In a retrospective study, 71% of chiropractic students self-reported at least 1 injury sustained during technique class.4 This is also compared to other studies where the prevalence of injury was found to be 53% or less.1,2,5 These previous studies found that females are more likely to be injured than males, but there were no correlation between age and likelihood of injury. Practicing chiropractors also have reported a high prevalence of work-related injuries with a study showing 40.1% of doctors reporting injury to the wrist, shoulders, and/or low back.8 Other studies have found incidences of preexisting low back, hand/wrist, and neck/shoulder pain at 50.4%, 40.1%, and 53.2%, respectively, by survey before attending chiropractic college2
There have been very few studies done on the prevention of injury for incoming chiropractic students.1,4,5 This classroom preparticipation screening process aims to expand procedures towards setting a standard for classroom safety for chiropractic students. This process should serve as a demonstration of the importance of due diligence when it comes to patient safety.
Students entering the chiropractic program without any screening or modification of classroom activities may be more susceptible to reinjuries or exacerbations of previous conditions. It is important that potential risk factors are identified early in the curriculum and the student involved informed of potential risk and complications to participation in class. Students may learn that they must make certain accommodations in order to prevent injury to themselves as well as patients.
The aim of our project was to identify risk factors early in the curriculum to reduce the risk of injury during technique class and other practical classes. Knowing about the possible risks prior to participation allows the faculty to make adaptations and instill preventative strategies for those specific students in mind. These preventative risk management strategies can then be carried over into clinical settings, enabling the student to identify potential risk factors and modify techniques and treatment procedures to decrease the likelihood of injury to a patient or a self-inflicted work-related injury in the future.
Students with possible clinical concerns can be identified and can confirm the need for a screening exam. Students can then be cleared for full participation and released from clinic care or released for participation with patient specific restrictions.
Limitations
The process described here is from 1 chiropractic college's implementation therefore may not necessarily be applicable to other chiropractic programs. There has been no data analysis done on the effectiveness of the process to prevent student injury to date. Further statistical evaluation of the data is needed to determine effectiveness. A future analysis needs to be performed to identify if the screening process was able to identify undiagnosed health conditions and if identification of clinical concerns that increased the likelihood of injury allowed for fewer injuries by modification of student specific participation. Student interviews and focus groups as well as continued evaluation of incoming cohorts of students could help to evaluate the processes effectiveness. The long-term benefits to the students are likely to be multifaceted and will require future research to understand the impact on the students’ outcomes and injury prevention. Prevention Quality Indicators could be used in the future to assess the effectiveness of the screening including appropriate follow-up care after referral. Patient Safety Indicators could also be used to detect potentially preventable adverse events and risk adjustments where appropriate. In this case, classroom simulations of care specifically focusing on potential complications and adverse events following simulated patient interactions during the curriculum were addressed.
Conclusion
We were able to successfully implement a preparticipation screening process in a chiropractic program. All incoming students since the inception of the process have been screened, referred for evaluation when deemed appropriate, and cleared to participate in practical classroom activities either with or without restrictions. This process has demonstrated 1 approach to identifying possible clinical concerns to participation in certain practical classroom activities in an educational setting. The screening described may be helpful for 2 unique student cohorts. The examining students have the opportunity to see the process of screening for clinical considerations including red flags, contraindications and vulnerabilities to injury, as taught in the curriculum, and the importance of doing so prior to treating patients. The examined students receive a screening for educational and possible safety benefits. This preparticipation screening process has now become an institution standard for all incoming students prior to participation in practical classroom activities.
Acknowledgments
Acknowledgments
We thank the following who assisted in this project: Steven R. Cuono, Sean T. Norkus, Marc Lucente, Dallas Durrance, and Jefferey P. Krabbe. We thank Edward Murphy at the Palmer College of Chiropractic Florida library for assistance with the Literature Search execution and interpretation.
Footnotes
Supplementary material associated with this article can be found in the online version at doi:10.1016/j.echu.2024.02.001.
Funding Sources and Conflicts of Interest
No funding sources or conflicts of interest were reported for this study.
Contributorship Information
Concept development (provided idea for the research): J.Q., M.C.L., B.C.
Design (planned the methods to generate the results): J.Q., M.C.L., B.C.
Supervision (oversight, organization and implementation): J.Q., M.C.L., B.C.
Data collection/processing (experiments, organization, or reporting data): J.Q., M.C.L., B.C.
Analysis/interpretation (analysis, evaluation, presentation of results): J.Q., M.C.L., B.C.
Literature search (performed the literature search): J.Q., M.C.L., B.C.
Writing (responsible for writing a substantive part of the manuscript): J.Q., M.C.L., B.C.
Critical review (revised manuscript for intellectual content): J.Q., M.C.L., B.C.
Practical Applications.
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A preparticipation screening procedure was successfully implemented.
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The project demonstrated the feasibility of identifying red flags and contraindications to student classroom activities.
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This procedure may be helpful for incoming students to see the process of screening for red flags and the importance of doing so before treating patients.
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Appendix. Supplementary materials
References
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