Evaluating primary practice: proposals for a modified model suited to chiropractic care.

Although chiropractic care is not yet considered to have achieved scientific validity, it enjoys widespread public acceptance. It is hypothesised that one of the barriers to chiropractic establishing scientific validity is the propensity of researchers to frame their randomized controlled clinical trials according to a biomedical rather than a biopsychosocial model. It is proposed that while chiropractic care should be required to establish a cause--effect relationship between spinal manipulation and clinical response, subjective patient--valued outcomes should also be monitored. For chiropractic care to be adequately assessed recognition needs to be given to the usefulness of qualitative measurements in health care. Interventions selected solely upon the basis of statistical significance run the risk of overlooking clinically meaningful outcomes.

Counteracting nutritional misinformation: a curricular proposal.

Health authorities are concerned about community exposure to nutritional misinformation. Adequate education of health professionals in nutritional matters has been proposed as an important strategy for counteracting such misinformation. This paper provides an example of how the undergraduate chiropractic curriculum may be used to facilitate the development of a framework which enables discrimination between nutritional sense and nonsense. It also discusses how student awareness of discrepancies between personal belief, nutritional science and clinical practice reality may be enhanced.

Drugs in chiropractic clinical practice: contemplating the variables which influence utility.

Philosophical commitment to a natural form of health care does not exempt practitioners who function in a drug-utilizing health care system from an appreciation of the potential use and abuse of pharmaceutical agents. The strategies used for evaluating drug therapy may provide a framework for ascertaining the clinical appropriateness of drugless forms of health care. This paper proposes that in view of the regular use of drugs by chiropractic patients, the prescription of nutritional supplements by chiropractors and the universal applicability of the management principles underlying the "drug model," chiropractic practitioners would benefit from familiarity with the theory and practice underlying the use of certain drugs.

Chiropractic and medical models of health care--a contemporary perspective.

Chiropractic and medical models of health care are perceived as philosophically incompatible by chiropractic practitioners and spokesmen for the medical profession. This alleged incompatibility is used to rationalize the resistance of the medical profession to the functional integration of chiropractic into the orthodox referral system. Structural integration of chiropractic into the orthodox health care system which is unaccompanied by functional integration fails to confer upon patients the benefits of that system. It is therefore in the interests of patient care that the alleged philosophical differences be examined and, if possible, resolved. Examination of the chiropractic and relevant medical models of health care in the contemporary context of the health disease continuum sheds new light on traditional philosophical conflicts.

The chiropractic doctor.

Chiropractors as autonomous consulting professionals, acting as a portal of entry into the health care system, have a scope of practice which is diagnostically unlimited but therapeutically restricted. Chiropractic therapy is confined to natural means of intervention. Included in the health care responsibilities of primary contact practitioners is the requirement that they serve as a health relevant information source for their patients and clients. Chiropractors are achieving disease intervention by participating in the health education of their patients. Modern chiropractic doctors are teaching clinicians. In line with chiropractic philosophy, their perspective is holistic. In order to minimise intrusion upon the practice of their clinical expertise, health education tools are recommended and used by busy practitioners with a health promotion conscience.

Nutritional intervention in chiropractic clinical practice: the chiropractic student's perspective.

A survey of chiropractic students reveals that they regard chiropractors as a knowledgeable source of information about nutrition. While the dissonance produced by the use of nutrients in clinical practice may be overcome by denying that this constitutes drug therapy, the controversies of appropriate use need to be addressed. The challenge faced by chiropractic undergraduate nutrition education involves identification of justifiable nutritional interventions, selection of effective doses and an awareness of the potential side effects. By resolving to match or better the medical profession as a source of nutritional health care, the future chiropractor has unwittingly embraced the cost-benefit paradigm of medical drug therapy.

Dietary intervention in the clinical prevention of ischemic heart disease.

While some scientific doubt lingers with regard to the validity of minimizing mortality rates attributable to ischemic heart disease via nutritional strategies targeted at coronary risk factors, popular consensus is committed to such intervention. Chiropractic respondents largely support the notion that nutritional intervention can indeed facilitate prevention of ischemic heart disease. The precise strategies whereby such disease prevention may be achieved have proven problematic; even respondents who conceptually supported particular intervention strategies demonstrated some hesitation in clinically implementing their beliefs.

Nutrition education of chiropractic students: a survey of colleges recognized by the Council on Chiropractic Education.

Concern has been expressed that the public is subject to nutritional misinformation. Examination of nutrition designated units in nine chiropractic colleges enjoying accreditation or candidate status according to the Council on Chiropractic Education suggests that these colleges are not a source of such misinformation.

Chiropractic's functional integration into conventional health care: some implications.

Australian chiropractors have achieved functional integration into a referral network within conventional health care. In order that benefits from this achievement be maximized, one issue that needs to be addressed includes the streamlining of interprofessional referrals. Most respondents indicated that their preferred interprofessional communication pattern within this network was either by telephone or written report. Delineation of chiropractic scope of practice and/or the services available within chiropractic clinics is suggested as a means of further refining the efficiency of interprofessional referrals. Another issue to be addressed is the implementation of a rational approach when chiropractic belief and traditional medical practice are in conflict. As complementary conventional health care practitioners, chiropractors are representatives of the orthodox health care system. This paper proposes a format whereby resolution of conflicts between ascribed and perceived roles may be attempted. Evolutionary progress rather than revolutionary disruption is possible within conventional health care.

Dietary control of mild essential hypertension.

Chiropractors share the responsibility of primary contact practitioners for hypertension case management. Once mild essential hypertension has been diagnosed, the patient may be placed on either a dietary or drug antihypertension regime. The effectiveness of various dietary interventions in the management of hypertensive patients is discussed, and recommendations for the nonpharmacological control of mild essential hypertension are made.

Reducing the personal risk of perceived disease: the chiropractic patients' self-care endeavor.

OBJECTIVE: It has been suggested that clinicians should be looking at new ways to enhance the self-care of their patients. Patient education is one strategy that primary providers may use. This study investigates the behavior of chiropractic patients to identify whether they are using widely published community health information messages to reduce their personally perceived risk of various diseases. METHODS: An exploratory study of chiropractic patients was undertaken to investigate the health-relevant behaviors of patients. Purposive sampling of 9 Australian chiropractic clinics was undertaken. Convenience sampling of patients attending these clinics resulted in the participation of 102 patients. All participants completed a questionnaire, and data were collected and collated into a series of case studies that described some behaviors of participants that might have influenced their risk of acquiring disease. The study was limited to diseases for which participants believed they were at risk. RESULTS: A substantial number of participants had undergone a screening procedure as recommended by health authorities. The 67 participants who believed they were at risk for one or more of the conditions listed were more likely to have complied. In addition, all participants made certain healthy lifestyle choices. However, implementation of those lifestyle choices that would reduce the personal risk of perceived diseases was sporadic. CONCLUSION: The behavior of participants in this study suggests that many chiropractic patients would benefit from additional personalized health information messages. The use of information brochures in chiropractic clinics may not alone lead to a lifestyle change.

Self-care: chiropractic student's perspective.

Chiropractors, like other primary contact practitioners, function at the consumer-health care system interface. It is at this level of health care that consumer trends are manifest. Consumers are currently expressing increased interest in self-care. This paper assesses the attitudes and beliefs of senior chiropractic students to self-care; particularly insofar as these are perceived to impact on chiropractic clinical care.

Clinical competence: the use of simulators/models in diagnosis of visceral conditions.

As primary contact practitioners, chiropractors must be competent to screen patients for the presence of visceral disease. Special "clinical" preparation is required to provide students with adequate diagnostic skills in this area in view of the "select" group of patients frequenting chiropractic clinics--the vast majority of chiropractic patients present with musculoskeletal disorders or pain syndromes. The use of sound simulators and life-form models in a problem-based teaching format ensures that students are equipped to cope with any primary contact clinical eventuality in this area. The use of these sound simulators and models in the assessment of clinical competence furthermore enables the implementation of improved standardization and clinical relevance in clinical assessment.

Science in chiropractic clinical practice: identifying a need.

The chiropractic profession has resolved to establish chiropractic clinical care upon a scientifically acceptable foundation. In order for such an ambition to be realized, the cooperation and participation of field practitioners is required. A survey of chiropractors practicing in Australia demonstrated that respondents largely failed to appreciate the power of various research designs to provide clinical practice information. This paper suggests the chasm between professional resolve and clinical practice is not being adequately bridged at the level of field practitioners.

The health information brochure: a useful tool for chiropractic practice?

BACKGROUND: It has been suggested that clinicians should be looking at new ways to enhance their patients' self-care. Patient education is one strategy that primary providers may use. OBJECTIVE: This study investigates the format in which patients would like to pursue their health education within the chiropractic clinic. METHODS: An exploratory study of chiropractic patients was undertaken to investigate patients' preferred health education formats, their commitment to pursuing health objectives, and their literacy level. Purposive sampling of 9 Australian chiropractic clinics was undertaken. Convenience sampling of patients attending these clinics resulted in 102 patients participating. Participants completed a questionnaire. A research assistant was available to clarify any questions. Data were collected and collated. A Likert scale was used to capture responses to questions ascertaining patient opinions. RESULTS: Patients considered health the most important of the life objectives listed; however, they preferred spending time with family to undertaking health- and fitness-promoting activity. More chiropractic patients opted for health information brochures than health promotion classes, personally supervised self-care programs, or practitioner-supervised self-care contracts. Patient literacy levels varied within and between clinics. CONCLUSIONS: Brochures may provide a definitive health information tool for chiropractors who limit their clinical role to primary contact and a helpful adjunct to patient education for chiropractors committed to a primary care role. However, care should be taken to select brochures consistent with the patients' literacy level. Tips for selecting and preparing suitable brochures are provided. The discrepancy between how greatly patients value health and how they prefer spending their time may have implications for successful behavior change. Brochures may not alone constitute adequate practitioner involvement.

Patient satisfaction. A case study of a South African teaching clinic.

UNLABELLED: Patient satisfaction is a pre-requisite to successful clinical practice. While an efficacious treatment is an important consideration, other variables are recognized to contribute to clinical satisfaction. This case study of a South African teaching clinic identifies and compares variables perceived as essential, important and unnecessary by chiropractic students and their patients. METHOD: A case study of the chiropractic student clinic at Technikon Natal was undertaken. A non-random sample of chiropractic patients and student clinicians were requested to respond to a questionnaire. Participants were requested to select 12 from a total of 27 closed questions and allocate 4 items to each of the three listed categories. RESULTS: Forty-three (43) patients and 17 student clinicians completed the questionnaire. Behaviours considered essential to chiropractic practice largely focused on listening carefully to the patient's description of their problem and explaining how the problem could be avoided in the future. Patients and student clinicians were also agreed about the relative importance of the duration of the clinical consultation, the necessity for patients to choose how they wish to be treated and the desirability of a narrow/broad focus on the patient's problem. CONCLUSIONS: The importance of providing an understandable and comprehensive clinical discussion about the patient's problem emerged in both this and a similar Australian Study. It is suggested that competence in communication skills be considered as an integral component of the undergraduate chiropractic curriculum.

Innovations in education: a case study of a novel teaching/learning format.

OBJECTIVE: To describe an innovative teaching/learning option that engages the student as an active learner without compromising the financial advantages of large group/classroom teaching. METHOD: A case study is used to demonstrate an innovative teaching/learning format. The content of the case study is based upon the identification of referral criteria at the patient-health care system interface. The learning experience consists of a quiz followed by class discussion. SAMPLE: A convenience sample of final-year chiropractic and osteopathy students at RMIT. DISCUSSION: The case study demonstrates how this format may be used to create an environment in which each student is personally confronted by the necessity to reach a decision about referring a patient on the basis of the information provided. Having engaged each student in the decision-making process, this format then provides an opportunity for self-assessment and the enunciation of general guidelines during class discussion. An additional demonstrable benefit of this teaching/learning strategy is the lecturer's enhanced awareness of the learning needs of the student group. CONCLUSION: The format proposed provides an additional option for teaching/learning that is acceptable to students and is consistent with the need to contain costs, maintain standards and conform to the requirements of a competency-based curriculum.

The chiropractic consultation: a stressful experience?

INTRODUCTION: Psychosocial stress has been linked to compromised health status. Prolonged exposure to minor problems has been found to have an equal or greater impact on health status than exposure to isolated major events. Stress is, however, determined by the reaction of the individual to a stimulus; stress responses can be managed, and ill health outcomes can be minimized. This paper explores the stress level associated with the chiropractic consultation. METHOD: A case study using closed questions. Purposive sampling of chiropractors by the researcher and convenience sampling of patients by participating chiropractors was undertaken. Chiropractors and patients completed closed questions on the level of stress they believed patients associated with the chiropractic consultation. RESULTS: A case study of 25 chiropractors and 137 patients found that although the chiropractic consultation was not regarded as stressful by most patients, some patients found adjustment stressful. Chiropractors assessment of perceived stress varied according to the patient. The trend was for practitioners to overestimate the stress felt by the patient. CONCLUSION: Chiropractors demonstrated the personalized nature of their care by the specificity of their responses to each patient. The importance of explaining the adjustment and the sensations that patients are likely to experience, particularly in new patients, is confirmed. The desirability of scrutinizing the patient for evidence of stress and of using diverse strategies for minimizing the stress response are discussed. Although the chiropractic consultation is not generally regarded as a stress-provoking experience, chiropractors should actively screen their patients for evidence of stress and take steps to enhance their patients' perceptions of the chiropractic consultation as a stress-free experience.

An interactive model of chiropractic practice: reconstructing clinical reality.

OBJECTIVE: This study proposes an interactionist model of chiropractic care, uses practice observation to ascertain whether this framework is compatible with clinical reality and explores a novel explanation of how chiropractic clinical communication may contribute to healing. DESIGN: A constructivist inquiry paradigm based upon purposive sampling, grounded theory, inductive analysis and contextual interpretation was used. The compatibility of chiropractic clinical reality with an evolving interactionist model was ascertained through reflection on contemporary literature and practice observation of 208 consultations undertaken by 34 chiropractors working in geographically dispersed areas of Australia. Sample selection used a maximum variation strategy. Triangulation of data collected was undertaken by mailing the clinical communication scenario constructed by the investigator to participating chiropractors for comment and by having 144 patients complete a questionnaire. RESULTS: Interaction observed in chiropractic practice is bidirectional, is both task- and relationship-oriented, and seems to be verbal and nonverbal in nature. Touch, whether diagnostic or therapeutic, emerged as an fundamental feature of chiropractic care. CONCLUSION: Verbal and nonverbal communication in chiropractic practice, when analyzed within a interactionist framework, can be construed to create an environment conducive to healing by establishing a shared clinical reality. The ability of the consultation to change perceptions and reduce anxiety is presented as a substantial factor contributing to the potency of the chiropractic care. The interactionist model proposed for chiropractic care was found to provide a useful framework for reconceptualizing chiropractic clinical practice. By providing an additional perspective of chiropractic practice, this model enhances discourse on the variables contributing to the success of chiropractic care.