Keep it simple, silly: Our CMCC COVID externship experience

This is our experience from both the intern, and the supervising clinician, on CMCCs first broad-based externship program.

COVID-19 turned education on its head. Everyone struggled to some point, especially those finishing high school and missing out on many rights of passage, and those entering higher education. The thought of paying $5,000 for university tuition and sitting in your dorm watching glorified YouTube videos and being marked as if the status quo existed is tough. Beyond that, imagine going back to chiro school and spending $25,000 to do virtual consults and desperately hoping some people come in during the series of lockdowns experienced in the GTA. This has been a hard time for chiropractic interns.  

Any seasoned doc in the trenches will tell a student that getting as much hands-on experience as possible is the key to a solid start. You need to assess, educate, adjust, and do your rehab. Over, and over, and over again. Traditionally, interns required 350 subsequent visits in their clinic year to graduate, along with 30-40 new patient assessments and all of the learning objectives (LOs) that go along with it. During COVID, interns struggled, and CMCC moved away from a numbers-based internship, and guided 4th years through a competency-based protocol for graduation. They really had no choice, because holding back 150+ interns because of their “numbers” was simply not practical, nor ethical. The downside of this, is that CMCC was graduating academically capable DCs, but with a distinct disadvantage with regards to patient management, and technical skills. The CCEB boards are set to create end of education and licensing competency. This is already in place. Missing your “numbers” will come back to haunt grads who simply didn’t get the experience. Seeking out strong mentorship for the first two years of practice will be essential in launching their careers.

The college did indeed recognize this, and supported enterprising interns who sought out externships to complete their clinical education in community clinics around the country. Dr. M. Jacob Hayes was one such intern who sought out the support of Dr. Erik Klein, and Dr. Dan Comeau for his clinical education, which took place in New Brunswick. This is our story:

Jake ‘the intern’
Not having family or strong social connections in the GTA, I knew I was going to have a great deal of difficulty completing my requirements, which led me to seek out Dr. Klein and Dr. Comeau. Even though clinic started in June, I didn’t get into Sherbourne until August to see my first in-person patient. I reached out to Dr. Klein to see if he would be able to help and he was excited. 

I learned very quickly how differently things happen in community clinics vs. the teaching clinic. My clinicians really endeavoured to provide a mentorship that would help balance my educational competencies while gaining knowledge of “the real world.”  

As with the beginning of every internship, your first patient intake appointment lasts about four hours. History – talk to your clinician. Ask more questions that you missed – talk to your clinician. Do a physical examination – talk to your clinician. Go back in and complete another SIJ test – talk to your clinician. You then take about 25 minutes to write out an ROF (for the first time anyway) – talk to your clinician. You finally get to the treatment. But, this is necessary, as in the beginning we always miss little things in the history and physical examination. Now, how applicable are these little details that we miss? That is up for debate, but overall this process is supposed to be lengthy and awkward, because it is something we have never truly done before. Going through comps in 3rd year CE cannot replicate what you are about to experience in 4th year. In addition to this, the school internship does not necessarily prepare you for the real world. Especially with the COVID-19 pandemic, this only complicated things further. No class at CMCC can prepare you to send a ROF PDF over Zoom and then explain how the patient can download it, sign it, and send it back. Once I started my externship, I realized there was another layer to learn. How to be efficient in a 20-minute subsequent appointment. How to get everything done – history, physical, and treatment in a one-hour initial appointment, and realizing that these patients are paying real money for our services. I quickly learned from Dr. Klein how to identify and execute a focused treatment plan. Test, treat, re-test, give active care advice. How he was able to do this over a 20 minute period amazed me at first, but I quickly realized that Dr. Klein, with his experience, prioritizes certain aspects of each condition that he sees (These priorities can change depending on the patient, even if it they have a similar problem). Some patients in the short term truly only want pain relief, and some just want the ability to performed certain function. Dr. Klein does a good job at siphoning this out, and dictating the treatment towards the patient’s needs in an evidence based, and efficient manner. The test aspect is quick and to the point. I learned I don’t need to do every single shoulder impingement test to figure out if someone has a shoulder impingement. Apply pertinent tests depending on the suspected condition, and go from there.

Dr. Erik
It was an absolute pleasure having [the now Dr.] Jake in the clinic. There is a saying that in order to learn, you should first listen, then do, then teach, then inspire. I took this as an opportunity to learn, and develop myself both professionally and personally. I fondly recall my internship at CMCC with Drs Decina and deGraauw and I enjoyed having the opportunity to “pay it forward.” 

My teaching goal for Jake was to encourage the transition from academic assessment and treatment to real world assessment and treatment techniques while allowing Jake to make decisions on what he feels will work with his own ethos. My experience and my academic research has found that purely focusing on orthopaedic testing as a stand-alone assessment tool is largely ineffective, and frankly not evidence-based (Cox, deGraauw, Klein; JCCA 2016). Having said that, it does form the basis of an assessment protocol that allows the practitioner to grow further, but they have to choose to do so. I gave Jake all of my clinical pearls, my algorithms, and “tricks of the trade” while keeping in mind he still had board exams to complete and encouraging him to keep his brain open to all angles.  

Jake excelled on all levels, showing great competency, connecting with patients, and really gaining traction on what will be required of him once he completes his training.  He finished with 467 subsequent visits under his belt, which to me seems like it must be some kind of record!  

Jake ‘the intern’
I learned to always keep red flags, yellow flags etc., in mind. I also became more aware of applying the KISS principle: “keep it simple silly.”  What stuck with me was the following concept: Abnormal presentations of common conditions, are more common, than common presentations of abnormal conditions. This has brought me a long way with my clinical intuition, and not fearing the worst, but yet being prepared for it. The treatments I have learned to execute are an expression of what we find during the testing. Just because someone has PFPS, does not mean to do soft tissue passes over every muscle that influences the knee. Find the keys, and address them with whatever tool you see fit. Using every test and treatment modality available simply is not practical. In the end of the day, CMCC gives you a lot of tools, but not all of them are practical in a real world setting. For whatever reason, I know way too much about Myasthenia Gravis, and not enough about how to manage a torn hip labrum. Its all about taking these tools, appraising them, and figuring out which are practical in a real clinical setting. This will not only make you more efficient, but it will save the patient’s time and money down the long run. Results-driven solutions, in a patient centered, time orientated, and costly manner.

I saw so many things, from the normal, to the abnormal, including ectopic pregnancy, severe hypertensive headache and neck pain, and rare neurological disorders. What was more important, was seeing all of the different subtle presentations and trajectories that low back, hip, neck pain and all MSK presentations can take so that I can make the best decision for the patient AND be effective for them. People aren’t cyborgs, they are people and we need to treat the whole person.  

Dr. Klein
For me personally, I definitely grew as a doctor. It was a lovely opportunity to teach, AND be taught. We docs out in practice for 15-20 years still have a lot to learn, and this was the best opportunity for me to do so. CMCC provided a great deal of training and they were very supportive and responsive. From a practical stand-point, having an extra set of hands and eyes in the office allowed me to spread the work a little bit, freeing me up to take care of some business matters which made me a more efficient business owner, and to support my teams. So as a doc in the field, if you’re wondering if this is for you, and you enjoy the idea of paying it forward. I also encourage CMCC to make this a permanent option for their clinical educational program. This is the most patient-centred path forward.

Dr. Erik Klein is a chiropractor and CEO of Town Health Solutions, a network focused on the growth and development of clinical excellence and entrepreneurship for manual therapists. For more information, please visit www.townhealthsolutions.com/franchising.

DR. M. JACOB HAYES is a recent graduate of the Canadian Memorial Chiropractic College. He graduated from the University of New Brunswick in 2017 with a Bachelors of Sciences.