A Survey of Chiropractic Academic Affiliations Within the Department of Veterans Affairs Health Care System

Abstract

Purpose:

With the recent implementation of chiropractic into the Department of Veterans Affairs (VA) Health Care System, chiropractic institutions nationwide now share common educational ground with many of the nation's medical schools and other educational institutions. Chiropractic students may undergo clinical training within VA medical facilities that have affiliation agreements with chiropractic institutions. The purpose of this study was to gain a greater understanding of the current state of chiropractic academic affiliations within the VA.

Methods:

Survey method was utilized to obtain information about the program design and operation of VA chiropractic academic affiliations.

Results:

Chiropractic academic affiliations have been established within four VA medical facilities in association with three chiropractic colleges. There was considerable variation in staffing and internship duration among the locations.

Conclusion:

The four existing chiropractic academic affiliations were dissimilar in terms of their design and operation with different strengths and program characteristics identified. Additional study is indicated to determine the impact that program variation has on the clinical care and educational functions of VA chiropractic academic affiliations.

Introduction

Under Section 204 of Public Law 107–135: Department of Veterans Affairs (VA) Health Care Programs Enhancement Act of 2001, the Secretary of Veterans Affairs was required to establish a program to provide chiropractic care and services to veterans through VA medical centers and clinics.¹ The legislative integration of chiropractic within this federal health care system provided the authorization necessary for VA medical facilities to enter into academic affiliation agreements with chiropractic institutions. Since 1946, the VA has worked in partnership with the country's medical and associated health professional schools, creating the most comprehensive academic health system partnership in history.² According to the VA Office of Academic Affiliations, “The VA conducts an education and training program for health professions students and residents to enhance the quality of care provided to veteran patients within the Veterans Health Administration health care system.’′² Chiropractic institutions nationwide may now share common educational ground with 107 of the nation's 126 medical schools and over 1,200 other educational institutions.² Chiropractic students now have the opportunity to join the 76,000 medical and associated health students, residents, and fellows who receive some or all of their clinical training within VA medical facilities each year.²

An affiliation agreement is a standard legal document that defines the relationship between the VA and an educational institution in terms of patient care, education, and research.³ An affiliation agreement must be in place to allow for the clinical education of trainees from that educational institution at a VA or non-VA medical facility.³ The affiliation agreement requires that the affiliated educational institution accepts primary responsibility for the integrated educational programs conducted at the VA, while full responsibility for patient care and related functions is retained by the VA.³ With VA doctors of chiropractic providing chiropractic care at 28 VA medical facilities nationally, chiropractic clinical education within VA medical facilities has become consistent with the educational mission of the VA.

The Council on Chiropractic Education (CCE) was first recognized by the United States Department of Education in 1974 and serves as the sole accrediting agency for chiropractic education.⁴ According to the CCE, “The purpose of chiropractic professional education is to provide the student with a core of knowledge in the basic and clinical sciences and related health subjects sufficient to perform the professional obligations of a doctor of chiropractic” (p. 15).⁵ Within United States chiropractic college curricula, there is an average of 4,820 classroom and clinical hours, 30% of which are basic science training and 70% are clinical sciences and internship.⁶ An average of 1,405 hours are devoted to clinical internship within training clinics maintained by all of the chiropractic colleges. According to the CCE, students of the doctor of chiropractic program must meet certain quantitative clinical requirements as part of the core clinical training program.⁵ The CCE allows for clinical training to occur outside of chiropractic college training clinics as long as the curricular offerings at the distant sites are “equivalent in terms of their content, duration, and intensity to non-distant sites” (p. 25).⁵ This has allowed chiropractic institutions to develop various remote internships to be completed during the clinical internship phase of the chiropractic student's education. Chiropractic internships at VA medical facilities are examples of distant site clinical educational opportunities that have recently been made available for student interns from affiliated chiropractic institutions.

The first chiropractic academic affiliation within the VA began in September of 2004 at the VA of Western New York Health Care System (VAWNYHS). Three additional programs have been started since that time and others are in various stages of development. Of the current 28 VA chiropractic clinics, only four have established an academic affiliation with chiropractic institutions. The design of the chiropractic internship program in the VAWNYHS has been previously reported within The Journal of Chiropractic Education.⁷ The chiropractic academic affiliations at the Rochester VA Community Based Outpatient Clinic (CBOC), VA of Connecticut at West Haven and Newington campuses, and the VA of St. Louis Jefferson Barracks Division have not been compared to the program at the VAWNYHS or to one another. These programs have developed in relative isolation with similarities and differences that had not been explored. The intent of this study was to gain a greater understanding of the current state of chiropractic academic affiliations within the VA.

Methods

The proposal for this study was reviewed and approved by the local VA Institutional Review Board. Survey method was utilized to obtain information about academic affiliations between the VA and chiropractic institutions. The questionnaire was a nonstandardized instrument developed for the purpose of this study that was sent out electronically to each participant for completion and electronic return. The questionnaire was accompanied by a cover letter that disclosed the anticipated effort, potential risks and benefits, and the voluntary nature of participation or nonparticipation in the study. VA doctors of chiropractic who supervise academically affiliated clinics from the Rochester VA CBOC, the VA of Connecticut, and the VA of St. Louis were asked to complete the brief questionnaire with demographic information and questions regarding their academic affiliations and internship programs. The author provided information pertaining to the academic affiliation at the VAWNYHS. Data collected were summarized within the text or entered into tables for presentation.

Results

Chiropractic academic affiliation characteristics including the selected VA medical facilities, affiliated chiropractic institutions, program start dates, staffing of doctors of chiropractic, care line placement, and physical plant are presented in Table 1. Details regarding internship rotations, including participant selection, internship design, total internship hours, total interns to date, and suggested ideal duration of chiropractic internships are described in Table 2. Chiropractic student interns, under the supervision of VA doctors of chiropractic, took part in elements of patient evaluation and management. Such tasks included history taking, conducting patient examinations, and providing chiropractic care, ranging from chiropractic manipulative therapy to soft tissue therapy and the application of various therapeutic modalities. In each of the chiropractic academic affiliations, chiropractic student interns utilized the Computerized Patient Record System (CPRS) with varying levels of involvement in the documentation of patient encounters.

Table 1.

Characteristics of Chiropractic Academic Affiliations

VA medical facility	Affiliated chiropractic institution	Internship program start date	VA Doctors of Chiropractic	VA care line placement	Physical plant: No. of treatment rooms
VA of Western New York Healthcare System (VAWNYHS)	New York Chiropractic College (NYCC)	09/2004	1 full-time VA employee; NYCC adjunct faculty	Medical VA care line	2
Rochester VA Community-Based Outpatient Clinic (CBOC)	New York Chiropractic College (NYCC)	03/2005	1 part-time VA consultant; NYCC Faculty	Medical VA care line	3–4
VA of Connecticut at West Haven & Newington Campuses	University of Bridgeport College of Chiropractic (UBCC)	06/2005 (Clinic opened 10/2004)	1 full-time VA employee; UBCC Faculty	Diagnostics & therapeutics care line	2 treatment rooms per location
VA of St. Louis Jefferson Barracks Division	Logan College of Chiropractic	10/2005	4 without-compensation consultants; Logan College faculty	Medical VA care line	2

Table 2.

VA Chiropractic Internship Program Details

VA medical facility	Participant selection	Internship design	Total internship Hours per student	Total interns to date	Suggested ideal duration of internship
VA of Western New York Healthcare System (VAWNYHS)	Competitive application	10 wk; 35 h/wk; 2 interns at a time	350 h	24	8–10 wk
Rochester VA Community-Based Outpatient	Competitive application/ interview	15 wk; 16 h/wk; 1 “mentor student”	240 h	3	Duration not specified; suggests “core curriculum” for all VA chiropractic trainees
Clinic (CBOC)	Open to all interested students	5 wk; 8 h/wk; 4 interns at a time	40 h	40
VA of Connecticut at West Haven & Newington Campuses	Competitive application/ interview	10 wk; 30 h/wk; 1 intern at a time	300 h	5	10–12 wk
VA of St. Louis Jefferson Barracks Division	Competitive application	8 wk; 8–24 h/wk; 4–5 interns at a time	Varies: 64–192 h	11	16 wk

Collaborative exchanges and interdisciplinary training experiences have developed within some of the chiropractic academic affiliations. At the VAWNYHS, student interns have had the opportunity to rotate through the orthopedic department and observe surgical procedures. At the VA of Connecticut, student interns have taken part in grand rounds or other hospital presentations.

Within all VA chiropractic academic affiliations, the presence of student interns was reported to be associated with enhanced productivity of the chiropractic clinic. At the VA of Connecticut, student involvement seemed to make the clinic more productive overall, following “an initial learning curve of a few weeks” that effectively offsets the contribution of the student interns during that time. At the VAWNYHS, student rotations overlap by 2 weeks, allowing for the more seasoned interns to provide orientation to the incoming interns, which expedites the learning process and places exiting interns in a leadership role. Within the VA of St. Louis, the doctor of chiropractic considered the work of two to three interns to be equivalent to “the work of one experienced DC.” Student involvement at the Rochester VA CBOC was described as making the clinic, “much more productive.”

Evaluations of student competencies were reportedly carried out in a manner consistent with the policies and procedures of the affiliated chiropractic institutions. Evaluations have been completed in paper format or electronic media (eg, personal digital assistants, online) and relayed back to the affiliated chiropractic institution. Chiropractic as a discipline has been included within the VA Office of Academic Affiliation's learners' perceptions survey for those who had clinical training within a VA Medical Center on or after July 1, 2005. Students at the VAWNYHS and the VA of Connecticut have completed the survey to evaluate their clinical training experience within the VA Medical Center. In terms of student evaluation of the internship from the standpoint of the supervising VA doctor of chiropractic and the affiliated chiropractic institution, all programs employed either a formal exit interview or survey format to gather student feedback.

Discussion

The Advisory Committee on Chiropractic Care Implementation, in its report to the Secretary of Veterans Affairs in May of 2005, recommended that additional academic affiliations should be encouraged by the VA to provide chiropractic students with training opportunities and career path exposure within the VA.⁸ The VA response to that recommendation was as follows:

VA welcomes the opportunity to enhance multidisciplinary training opportunities as well as provide students of chiropractic with learning experiences in an integrated health care setting. Sufficient clinical workload to support the training activities and adequate infrastructure to accommodate students are necessary for academic affiliations. Local facilities are authorized to enter into approved affiliation agreements with accredited chiropractic educational institutions as appropriate to the setting.⁸

Chiropractic institutions and VA doctors of chiropractic can access current VA standards for academic affiliations and affiliation agreement templates by visiting the VA Web site at http://www.va.gov/oaa/agreements.asp.⁹

Of the four existing chiropractic academic affiliations, two sites were not originally identified as VA medical facilities in which chiropractic clinics would be implemented. Chiropractic teaching programs at the Rochester VA CBOC and the VA of St. Louis represent the 27th and 28th locations nationally to provide chiropractic services within VA medical facilities. These two chiropractic academic affiliations have contributed to an expansion of VA-based chiropractic services in advance of government mandates or systemwide data analysis of chiropractic practice within the VA.

The staffing of VA doctors of chiropractic within chiropractic academic affiliations varied from site to site. At the VAWNYHS, the Rochester VA CBOC, and the VA of Connecticut, there was a single VA doctor of chiropractic in the capacity of either a full-time employee or part-time consultant. The program at the VA of St. Louis was unique in that there were four doctors of chiropractic available at different times to staff the chiropractic clinic as without-compensation appointees with faculty positions through Logan College of Chiropractic. The VA of St. Louis chiropractic clinic did not depend on a single provider and was therefore not affected by the annual or sick leave of any single VA doctor of chiropractic. Although the other three programs may have offered the continuity of care associated with a single health care provider, these clinics would have effectively been closed during any leave time for the involved VA doctors of chiropractic. Within the academic affiliations at locations initially identified by the VA to provide on-site chiropractic services, the VA doctors of chiropractic were full-time employees. This was in contrast to the added locations at the Rochester VA CBOC and the VA of St. Louis, where the VA doctors of chiropractic were a part-time consultant and without-compensation appointees, respectively. Variations in the staffing of VA chiropractic academic affiliations appeared to be, at least in part, dependent on the available resources of the involved chiropractic institutions and VA medical facilities and whether or not the medical facilities were sites mandated by the VA to implement chiropractic clinics.

Differences in internship design were striking, with rotations for competitive applicants ranging from 8 to 15 weeks in duration and consisting of between 64 and 350 total hours of internship experience. Chiropractic student interns were selected for individual training experiences, working in pairs, or training in groups of four to five interns, depending on the training program. The program design at the Rochester VA CBOC was unique in that it provided for an extended learning experience for a limited number of student interns as well as relatively brief exposure to clinic operation for a multitude of student interns (Table 2). Also unique to the Rochester VA CBOC was an experiential learning model with a detailed curriculum including reading assignments, peer-led instruction, service components, and reflection topics for both discussion and journal reading.

Doctors of chiropractic at each of the VA chiropractic academic affiliations reported that the involvement of student interns with patient care enhanced clinic productivity. A review of the number of patient encounters, termed unduplicated clinic stops, could be used to compare productivity of VA chiropractic academic affiliations with nonteaching sites operating at similar capacities. Although student interns were reported to have access to CPRS, the role of student documentation within the health record varied. The impact of these variations in VA chiropractic clinic design and operation on both educational and patient care functions is unknown and provides a basis for additional educational and clinical research.

This descriptive study utilized nonprobability sampling of the four existing VA chiropractic academic affiliations. Because of the limited sample size, broader generalizations cannot be made from the abstracted data. The findings of this study represent the earliest stages of development for chiropractic academic affiliations within this established federal health care system. The use of a nonvalidated survey instrument designed for the purpose of this study was a recognized limitation. Questions regarding research involvement within chiropractic academic affiliations were overlooked during the design of this study and could have been incorporated within the survey instrument.

While the scope of this study was limited to clinical training experiences for chiropractic student interns, the next logical step is the development of postdoctoral residency programs within the VA health care system. A VA chiropractic residency would provide recent graduates with continued professional development under the supervision of attending doctors of chiropractic in hospital-based chiropractic practices utilizing an innovative computerized patient record-keeping system while working with a unique patient population. It is the contention of this author that chiropractic institutions with academic affiliation agreements should take a collaborative approach to the design of a structured residency program to serve as a platform for the training of doctors of chiropractic with advanced qualifications for assuming future roles in the potentially expanding landscape of chiropractic within the VA health care system.

Conclusion

The four existing chiropractic academic affiliations were largely dissimilar in terms of their design and operation with different strengths and program characteristics identified. Variation was the rule rather than the exception, with each program serving as a model only within its own unique setting. The design and operation of additional chiropractic academic affiliations that develop will likely be influenced by a number of factors, including the availability of financial and physical resources of the involved institutions. Chiropractic institutions and VA doctors of chiropractic are encouraged to investigate the potential to establish additional academic affiliations to contribute to both the health care of our nation's veterans and the clinical education of chiropractic student interns. Further study could investigate the possible effect of program variation on the clinical and education outcomes of VA chiropractic academic affiliations so that chiropractic institutions could be aligned with affiliated VA medical facilities in a way that maximizes quality patient care and provides optimal learning experiences for future doctors of chiropractic.