Chiropractic + Naturopathic Doctor

Features Collaboration Profession
Interdisciplinary Collaborative Practice, Part 2


April 30, 2010
By Maria DiDanieli

Topics

For the chiropractor who wishes to explore the possibility of working
within an interdisciplinary collaborative practice (ICP) option – or
the researcher who wants to study this growing movement within the
profession – there are many formidable mentors from which to choose.

In Part 1 of this article, some concepts of interdisciplinary collaboration in a health-care setting were discussed. The consideration that, in order for DCs to effectively participate in an interdisciplinary working environment where collaboration is called for, preparation and training for this must be provided by chiropractic colleges – either at the undergraduate level and/or within continuing education offerings – was raised.

icp1

For the chiropractor who wishes to explore the possibility of working within an interdisciplinary collaborative practice (ICP) option – or the researcher who wants to study this growing movement within the profession – there are many formidable mentors from which to choose.  The profession in Canada is well aware of who its heroes are in this domain and detailed descriptions of their accomplishments and insights can be found in a variety of sources.1,2,3,4,5  They have made inroads in hospitals, family health teams, within elite athletics, on associations and in many private practice situations across the country and beyond, bringing chiropractic to a wide variety of patient situations, for which it would not otherwise have been available, while raising awareness of the profession’s work and fostering a patient-centred culture requiring cooperation and mutual respect amongst practitioners.6,7

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The author does not wish to gloss over these achievements or the people behind them but rather, to consider their legacy in this realm.  Part 2 of this article will draw from the experiences of a new generation of DCs who are participating in collaborative work with practitioners from other disciplines – having received some insight from the pioneers who initiated this journey – to provide further insight, from the field, regarding this option. We will explore what they are discovering about this movement as practitioners and as members of their health-care environment, and what still needs to be done in order for chiropractors to harness collaborative roles effectively.

Chiropractors in a team setting
Dr. Filipe Tiburcio is a clinic director for one of the Physiomed Health Group clinics in Ontario.  Physiomed is a growing organization of franchised clinics that are associated with leading fitness centres, offering its patients a number of health-care options, such as chiropractic, massage therapy, physiotherapy and more. Each franchise applicant is well aware that he/she will be expected to grow an interdisciplinary team that will work seamlessly with the goal of each patient’s wellness in mind.  Dr. Tiburcio graduated from Canadian Memorial Chiropractic College (CMCC) in 2007 knowing, from the get-go, that he wanted to work in an interdisciplinary, collaborative group but realizes that actually doing so taught him much more than he had expected.

“As a chiropractor you have to determine what your philosophy is with respect to patient care,” says Tiburcio. “To have an interdisciplinary collaborative practice, you must truly believe that this is what is best for your patient.  Once you have decided this, then you are ready to build your clinic around this vision.”

He continues:  “A clinic with multiple health-care providers requires a sense of respect between all members.  No one provider should be considered of less importance than the other.  Clear goals and responsibilities should be outlined in order for each vertical to be successful and experience growth.  Constant analysis of all healthcare providers and patient files will allow for constructive feedback and will ensure that the clinic grows and matures as a whole.”

Dr. Tiburcio agrees that the time and education necessary to prepare for effective and sustainable interdisciplinary collaborative relationships are best harnessed before leaping into a collaborative setting.  The next two sections will discuss different ways to approach this learning curve – one is in a practice setting, the other within an educational environment.

Chiropractors as collaboration leaders
A private clinic that includes practitioners from various disciplines – especially where there are medical doctors and other medical personnel working alongside natural and/or manual practitioners – can be arranged in a number of fashions.  The clinic could be owned and run by the physician/surgeon and staffed by the other practitioners, it could be a collection of practitioners who are independent, often under one roof and with minimal interaction, or it could be owned and run by someone other than a medical doctor, and staffed by a variety of practitioners.  Collaboration, in these settings, can be informal, or very structured – the collaboration strategy might be a component of the initial vision for the clinic, or may develop according to the needs of the patients who form its client base and/or the development of the practitioners who serve those patients.

There can be an alternate approach for achieving a collaborative environment: whereas the intent for integrated collaboration would be present from the clinic’s inception, the actual execution of this goal is carried out as a process (see part 1 of this article) that is intended to foster effective, sustainable, truly patient-centred collaboration – i.e., the learning curve to respectful integration is considered from the beginning. 

Dr. Hussein Rattansi graduated from the National University of Health Sciences in 2003 and practises in a clinic that fronts onto Toronto’s University Avenue. The clinic, called “Emkiro Health Services” (website, www.emkiro.ca), is an interdisciplinary health-care facility that offers patients access to a variety of health-care options under one roof.  It houses chiropractors, a registered dietitian, registered massage therapists and family physicians, and hopes to include a physiotherapist and psychologist amongst its numbers in the near future. 

Because the clinic is relatively new, communication and collaboration amongst its practitioners is currently relatively informal. The vision is to eventually hold rounds where the clinic’s services will all be integrated into a structured case management communication strategy.  Collaboration in this setting, then, is being developed over time as each practitioner becomes acquainted with, and accustomed to, the work that is being carried out by other clinic members, noting their expertise and patient-centred goals.  Respect and understanding is growing and developing amongst these health-care workers, leading to a communication structure which they hope, in Dr. Rattansi’s words, will “provide the best care we can give.”

Emkiro is an interesting set-up because, here, the chiropractor and clinic owner, Dr. Rattansi, is the leader of a health-care team that includes physicians and other medical members whom he has hired along with practitioners of other disciplines.  The practitioners are all quite young, as well, and have been recruited, by Dr. Rattansi, via university and training school employment placement services, professional publications/newsletters/online portals, and even provincial health-care provider employment agencies. (For information on health practitioner recruitment, Dr. Rattansi can be contacted at drrattansi@emkiro.ca.)  

Dr. Rattansi established his clinic with the clear vision of hiring practitioners whose paradigm involves optimal patient-centred practice through respectful collaboration with members of the health-care team.  Then, by not rushing into a structured collaborative process, he is allowing himself and his team members – who may not have received formal preparation for such a relationship – time to learn about each other’s work so that interdisciplinary efforts in future will be genuinely team-oriented and patient-centred.

From the halls of learning
Part 1 of this article mentioned that preparation for successful interdisciplinary collaborative work must begin within health-care training institutions, including chiropractic schools.  At CMCC in Toronto, interdisciplinary collaboration is being given increasing attention that has manifested, to date, as presentations, panel discussions and workshops at many of the school’s educational events as well as through various student interest groups. 

Two CMCC students, in particular, Luciano Di Loreto and Jessica Wong, were pioneers amongst their peers in these efforts.  Now in their fourth year, both were instrumental in starting up the school’s Interprofessional Education Council and taking the group’s efforts to other health-care students including those at the University of Toronto Faculty of Medicine. As well, Di Loreto is currently the 2010-2011 National Health Science Students’ Association (NaHSSA) president, and one of the representatives for chiropractic within that association.  Through the time spent navigating the role and potential for collaborative efforts in tomorrow’s health-care environment, Wong and Di Loreto have gleaned much valuable information.

Both students believe that learning to work in a collaborative fashion with practitioners from other disciplines is a process, but one that should absolutely begin at the undergraduate training level.  They hope that this will come to pass, in time, but feel this is not what is happening at the moment, for chiropractic and other health-care students alike.

“Educational training in the respective fields is still a relatively silo-oriented process, and the issue of feasibility is often a barrier to incorporating more interdisciplinary collaborative training into the programs,” Wong says. “Among other things, this makes it more difficult for other health-care students to learn about chiropractic and understand how chiropractors can play an important role in the health-care team.”

Di Loreto adds, “In my opinion, interdisciplinary education and collaboration curricula should be incorporated in all health and service programs.  For this to occur, stakeholders must decide on a common vision for interdisciplinary education.”

Wong feels that the profession, and especially its students, should be leaders in proactively seeking opportunities for dialogue as this will do two things:  it will ensure that health-care professionals will be well aware of what chiropractic is and the benefits it offers to patients prior to entering practice and, in turn, this will facilitate a more seamless referral network and/or more patient-centred collaboration in health-care.

Furthermore, Wong feels that in order for a DC to successfully participate in any interdisciplinary collaborative effort, confidence in one’s role within that process, as a practitioner of a distinct specialty that is an integral part of the health-care system, is key.

“Chiropractors should feel comfortable learning about the different health-care professions – also, they should not take a defensive approach when in a collaborative situation, but should instead proactively assume the role of an educator when speaking to other health-care professionals, helping them to gain knowledge of what chiropractors do.”

Di Loreto adds to these insights:  “When you dialogue with various health professionals you gain knowledge about their profession.  This enables you to make appropriate decisions as to when and how health-care providers may be incorporated as a part of the plan of management.”

“Interdisciplinary dialogue, and the many extracurricular interdisciplinary educational sessions that I have participated in at the student level, have provided me with knowledge, tools, and resources necessary to collaborate and communicate with other health professionals,” concludes Di Loreto, “I have come to the realization that interdisciplinary care is inescapable.  Patients utilize care from various health providers and will continue to do so.”  

Closing thoughts
It is clear that the time has come for health-care specialties to foster an environment of communication – amongst one another and with patients – and respectful collaboration that addresses each patient’s needs and our society’s wellness in general. But just because it’s clear, does not mean it’s easy. Let’s face it – older paradigms can stand in everyone’s way, fracturing the “roundtable” into a group of soap boxes that all face away from one another. Often, the root of the problem is lack of communication and knowledge amongst the practitioners in each field, with respect to the scope and potential of each other’s disciplines, but also lacking, the author speculates, is direction regarding how to proceed with effective dialogue and collaboration. Both of these problems can be solved with education and/or community initiatives amongst chiropractors and other practitioners but the first dot in the learning curve must be drawn as early as possible. The understanding that is necessary amongst members of an interdisciplinary collaborative relationship, in order for it to be effective, sustainable and patient-centred, takes time and learning to achieve, as does a knowledge base of the required dynamics for this sort of team initiative.

However, collaboration also requires that each member must have confidence in his/her own distinct approach in order for the group to fully learn about its potential, and for patients to benefit from its proper inclusion into their treatment plans. Each time a DC enters into a patient-care effort with a practitioner of another discipline, two things are unquestionably at stake: first, and foremost, the patient’s well-being; and next, but still very important, the profession’s role, as a distinct specialization requiring specific training, in patient care. If  a DC is not trained and prepared to take on collaborative work effectively, both of these elements could be irretrievably sacrificed.•

References for Part 2:



1)    
Triano J. and Raley. B. Chiropractic in the
Interdisciplinary Team Practice in Best
Practices in Clinical Chiropractic.
Mootz. 1999. Aspen Publishers, Inc.,
R.D. and Vernon H.T. Eds. pp.165 –
172.

2)    
Back to the Future –
Evolution of chiropractic care and its acceptance as a viable alternative is
evident at hospitals and universities. Article featuring
Deborah Kopanski-Giles in The Toronto Star, Friday May 29, 2010.

3) Steiman I. From Multidisciplinary to Interdisciplinary – it’s all about patient
outcomes.  J. Can. Chiro. Assoc. December
2007, Vol. 51, No. 4, pp. 247-248.




4)  Baskerville N.B., Keenan
D. (DC).
How Chiropractors began working in a
Community Health Centre in Ottawa.
J.
Can. Chiro
. Assoc. March 2005, Vol. 49, No. 1. pp. 13-20.

5) 

Kopansky-Giles
D, Vernon H.T., Steiman
I., Tibbles A., Decina P. Goldin J., Kelly, M.
Collaborative Community-Based Teaching
Clinics at the Canadian
Memorial Chiropractic
College: Addressing the Needs of Local Poor Communities.  J. Man. Phys. Ther., October 2007, Vol. 30,
Issue 8,  pp. 558-565
.

6)

    Brunarski, D., et. al. Moving toward virtual interdisciplinary teams and a
multi-stakeholder approach in community-based return-to-work care. Work: A
Journal of Prevention, Assessment and Rehabilitation
, 2008, Vol. 30,
No. 3. pp. 329-336.

7)

 
DiDanieli,
M. A Journey Ignited. Canadian Chiropractor, April 2010, Vol. 15, No. 2, pages
8-11.  (Detailing the work of Drs. Greg Uchacz and Robert Armitage on
the interdisciplinary sports team in the 2010 Vancouver Winter Olympic Games
Host Medical Services Polyclinics. Both Dr. Uchacz and Armitage are dedicated
to interdisciplinary collaborative sports practice.)