When training counts: The advantage of teamwork in today’s healthcare
Cole Hosenfeld
DC, DACBSP
In the winter of 2016, Tom, a 58-year-old male patient entered my clinic on a busy Friday afternoon without an appointment. He was an established patient that I have seen for various ailments but had not been seen for a couple of months in the clinic as he was not currently on a treatment care plan. He presented to the front desk complaining of moderate to severe right hip, groin, and leg pain with an accompanying feeling of nausea and malaise that began on his morning route as a postman. The front office team explained that my afternoon was quite overbooked as there had been a number of new injuries that had called in that further complicated an already busy afternoon. Tom pleaded that he didn't want to go to another doctor or the emergency room and asked if he could just have a few minutes.
One of my clinical assistants of 13 years, Jenny, who happened to be up front, heard this conversation and observed the genuine fear and concern in the patient's voice. Jenny, who is trained and certified as a chiropractic therapy assistant and X-ray technician, relayed to the patient that I was with a difficult case
and had otherscheduled patients waiting, butthatshe was able to begin gathering his health history, vitals, and subjective findings to assist me.
With Jenny's experience, she knew he needed to be cared for and would make it happen. Later she explained, "Doc, there was just something off with how he was talking and he was in obvious pain."
Jenny proceeded to take him to an examination room where she began the history and workup. She realized that time was an issue and wanted to provide me as much information as possible to streamline the process.
As I came out of another exam room to run across the hall for a few standard office visits, Jenny communicated the situation in detail. She relayed that Tom was on his morning mail route and began feeling a bit sick while also developing right hip, groin, and leg pain of insidious onset. He had experienced leg pain in the past and, from prior episodes, he felt his "sciatica was acting up."
Jenny reviewed Tom's current medical history and the medications he was taking, which included a recent diagnosis of high blood pressure and diabetes. He was on medications to help control these conditions. She took vitals to show his blood pressure of 166/98, pulse 92, respirations 14, and temperature of 103 degrees. Jenny explained that he was sweating profusely and speaking "all over the place." This information allowed me to move his case up and direct her and my other team members on howto route my current patients in order to not reduce the quality of their scheduled visit. Taking into account the critical history information and observations that Jenny collected for me without my prompting, I was able to expand upon the examination and history taking. Although I was unable to identify a musculoskeletal pain generator and was negative for myelopathic or radicular signs, I was able to observe his confused cognitive function. In the course of my exam, his wife was allowed into the room. From Jenny's initial description of Tom's ailment, I was hesitant to allow him to drive anywhere on his own, so I had his wife called to come to the clinic in an act of forethought. As I know his wife well, I asked her to let me finish my exam and I would relay what needed to be done.
At this point, I was able to hone in on a focused pain
generator at the anterior hip and groin with skin swelling and red streaking. It appeared he was developing a systemic infection with cellulitis being observed. I explained to the patient and wife my concern and diagnosis suspicion, which I was simultaneously writing down, and that I wanted them to immediately go to the emergency department and provide the attending doctor my note and my diagnosis suspicions.
They soon left. Once again, I came out of the room and Jenny and another clinical assistant met me to provide information on their handling of the scheduled patients. With an understated confidence, Jenny "fist bumped me" to signal the clinic was operating well and explained that she would follow up with the patient's wife at the end of the day to see how they were doing.
Since chiropractic's inception, the profession has overcome many challenges and, as with any struggles, new innovations and concepts have been born. Chiropractic college and post-graduate training has been broadened to encompass more people, ideas, training, and innovative treatments. Chiropractic post-doctoral specialties range from radiology, nutrition, orthopedics, neurology, and sports medicine to advanced training in adjustment techniques and
structural biomechanical correction approaches such as upper cervical specific and chiropractic biophysics.
With the diversification of our doctors' interests, our team of paraprofessionals have also been given an opportunity to raise their game with new skill sets. Paraprofessionals are those who work side by side with chiropractic physicians to assist in providing quality care to our patients. Complexity with thirdparty payers has increased and, as the insurers' and patients' demands for "more value for less" increases, the need to engage the patient with intelligence, focus, and compassion has never been more important.
There has been a trend for certification and licensure throughout the country of paraprofessionals to develop minimal guidelines for assistants who work in clinical settings with patients. The Federation of Chiropractic Licensing Boards has worked to develop these minimal guidelines nationally. The certification and/or licensure educates the chiropractic assistant at a higher level in anatomy/physiology, chiropractic techniques, physiotherapy procedures, and protocols, exercise rehabilitation, examination techniques, X-ray, areas of risk management along with education on various disorders and diseases commonly seen in the office. Distance learning models have been developed to be more cost effective and convenient.
In my home state of Tennessee, the state began licensing chiropractictherapy assistants in 2000 and created an education model in anticipation of this need. The certification requires a 50-hour distance learning course with focus on the area of clinical treatment and therapy through textbook, workbook, DVD education, testing, and 1,200 hours of onsite apprenticeship hours under the practicing chiropractor. In addition, the state provides a separate opportunity for licensure as an X-ray technician. This training may be completed over multiple weekends, also accompanied by testing and required hours of apprenticeship prior to state licensure. These methods of training have been well received by doctors and especially by assistants, who are able to have on-the-job experience through the learning process while being able to earn a living.
There was resistance early in the implementation process of these advanced training programs for assistants secondary to doctor/owner concerns of increased wage reimbursement to the profession's assistants because of this increased training. These were valid concerns in light of diminishing healthcare dollar returns among third-party payers. However, after 17 years in place, the improved care delivery paradigm and improved competence have left the state's majority of chiropractors optimistic.
Remember the interaction with Tom, the patient described above. He was diagnosed with MRSAyielding moderate to severe developing cellulitis, which kept him in the hospital for 6 days and ultimately required him to go through wound care and remain out of work for 3 months. When I see him in the office now, he tells me that he wears compression hosing while on the job but is able to walk.
After his recovery, Tom explained that if Jenny hadn't taken him to an exam room he would have likely "just tried to sleep it off." He relayed to me that he told the hospitalist the same thing, and the doctor explained that if he would have waited another day, he would have likely lost his leg, if not worse.
Although this is not a typical encounter chiropractors see, these patients do walk into our offices. Due to the advanced training we take ourteam through, our ability to case manage to meet the patients needs has increased. Besides the self-satisfaction of helping this family, the family has become quite the birddog for referring patients into our clinic and this trust is the ultimate compliment to our practice.
Evidence-based care is evolving and guidelines are developing. There are many services a patient has to choose from when it comes to musculoskeletal care, but often it is the chiropractor's persistence, and that of their assistants, in addressing the biopsychosocial aspect of pain and dysfunction that sets us apart.
The broadening of a profession is a natural progression of any healthcare discipline that seeks to refine and hold itself accountable to the growing and aging population. Continued training of our paraprofessionals with certification and licensure helpsto standardize a baseline competency, which solidifies the backbone of our clinics and that is our team.
There are many advantages that have come as a result of this educational trend. Doctors are noticing improved patient and staff retention through a teamwide focus of delivering high-quality, cost-effective healthcare that is accessible, competent, and valueadded. Take the leap, raise your bar, and encourage your assistants to seek continued training.
Cole Hosenfeld, DC, DACBSP practices in Knoxville, Tennessee. He is board certified in sports medicine and practices in an integrative provider setting with a team of paraprofessionals. He sits on Tennessee ,’v regulatory board and is co-author of the textbook Chiropractic Therapy Assistants, A Clinical Resource Guide. He can be reached by email: [email protected] Contact Phone: (615) 383-6231
