The light at the end of the tunnel

I am very close to graduating. Just a few weeks and I will be off to preceptor in Massachusetts and then before I know it, I will be graduating. My entire class has been in a flurry of activity trying to get ready for all these changes. During this tumultuous time, however, it is important to remember where we have been.

One of my friends recently started a discussion board on the school's blackboard server. This discussion brings us back to one of the age-old questions of chiropractic. One of the questions we would have debated back in quarter 3. Now, though, we have a basis for debate. At this point in our careers we are clinicians. We see actual patients and actual results. Looking back at the last 4 academic years, I can see the faulty thought processes, the ideas that didn't pan out, and--fortunately--the topics whose core truths came to fruition.

All of this got me thinking about some things I wish I could have told my lower-quarter-self. These might be helpful to all of you as you are starting your Palmer education.

School is a hurdle.
Don't get frustrated with school. It is hard, it is harrowing. Invariably, some professors will not be your favorites. Some classes will seem like a waste of time. Some days will go by extremely slowly. Etc, etc. Remember that at the end of these few short years, you will be a doctor and try to see the bright spots between the frustrations. Just get through it.


Educational settings are polarized.
This is true of all institutions, but especially true in chiropractic. This is due largely to the fact that those who want to teach typically have a highly-developed paradigm. They are also extremely willing to share it--otherwise, they would not have chosen to do this job. Because of this, the subjective information received during school can be confusing, contradictory, and frustrating. Just remember that while practicing, it's the doctor and the patient--no tests, no professors, no paradigm impeachment.

Principle #6: Time.
Traditionally, life (with a decidedly chiropractic slant) has 33 principles. The only one I know well enough to use regularly is principle #6 (paraphrased): "All processes take time." This is true in all aspects of life, certainly not only chiropractic. While you are a student, remember that assimilation of information takes time, adjusting to a new schedule takes time, and becoming a clinician takes major time. Don't stress.

Think about these things as you move forward... so will I.

On the topic of "knowing"

Yesterday I was at the pool in my apartment complex. Many students live there, so it is common to see other Palmer people. I did not know the two girls I saw there yesterday. As the sun streamed onto the patio, I could hear their words wafting over me; I could tell they were in 3rd quarter. The gist of the conversation was that an upcoming test would be "straightforward." It suddenly occurred to me that I was once like that too. I once thought things were simple.

The 3rd Quarter Change
While in quarter three, it is easy to think that information is coming together. In reality, it is... but not in the way I once thought. In quarter three, I was at the stage where I was starting to know things--about anatomy, about physiology, about some chiropractic techniques, about physical exams. I synthesized this information and began to make some clinical prediction rules for myself. I thought I could give all sorts of advice. So did these girls. They were advising each other on various topics from sunburns to headaches, using the vocabulary that they had just made vernacular. It made me smile with the bittersweet nostalgia that a parent might feel--children becoming adults, students becoming doctors.

The problem with this change is that it isn't complete. Quarter 3 is the end of the first academic year. One year into the curriculum, students know enough to be dangerous and cocky. I did too. There are three more times this happens. After qtr 5 when all the chiro techniques have been learned, after qtr six when anatomy lab ends, and after the first part of boards when everyone is an "expert" on microbiology and pathology. At each of these times I felt like I ruled the world. Little did I know how much more there was to learn.

Now
Patients make all the difference. No one presents like a textbook, no one will comply with a treatment plan without patient education, and unfortunately, no one knows the things students take for granted. All of this is valuable information to know, but it also makes an interesting distinction: as I have reached the terminal end of my education, I know enough to know that I don't know much of anything.

A New Frontier
I love star trek. The thing I love most about it is the idea that we can explore new places and discover things for which we do not have even a concept. I feel like this experience is well paralleled by Palmer Florida. Before setting out into space, humans have no idea what is out there. We can't conceive of things we have never been exposed to. There is a certain amount of certainty to this position. We know a variety of things and we don't even have language for anything else. It isn't until we get into the upper quarters that we realize being in school means essentially nothing. Practice is a big galaxy full of things we have never even thought of. Luckily, as a student I learned all the information I am going to need eventually, but I will never again be arrogant enough to think that I "know" anything for certain.

The other day, I was talking to my mentor in the clinic, Dr. Beres. She made a very interesting point. One of the most interesting things about evidence based practice is that it changes all the time. Since new things are being discovered and proven through research and experience constantly, it is never wise to scoff at anything. Anyone who says he/she has "the way" to practice is misguided and conceited, because no one can know what is out there in the healthcare "galaxy" without a vehicle for traveling there. A student's best vehicle is openness to realize how little we actually "know."

Too Long

I haven't blogged in a ridiculously long time. Sorry readers! As my life in the clinic has ramped up, I have been forgetting things. I suppose that is reflective of a very good problem--having plenty of patients!

The last time I wrote about the clinic I was rather overwhelmed. In retrospect, I can  see that everyone felt that way when we started. At the time, however, I felt like it was just me--drowning in a sea of paperwork. Now, everything is starting to seem easy, and it feels so fantastic.

The most fantastic thing about clinic is seeing patients. This is what we have been waiting for, after all...  And even better than seeing patients is seeing patient become well. I have learned a few things over the last several months about patient care, which I think are worth sharing.

Less is usually better
As part of a conservative care plan, we sometimes get into a habit of giving everyone all the modalities we can possibly think of. We do this because we have learned such a large body of information about care. We think, "well, if one thing is good, then everything must be better!"  Humans are like this in general, just think of crash dieting and weekend warriors to get the picture. In my experience with patients--however brief--I have noticed that the less I do, the better the outcome. Careful decision-making between treatment interventions leads to more patient-centered, specifically-tailored care, which can only be beneficial. So instead of employing all your tools at once, methodically choose a few and carefully measure the outcomes. Which brings me to my next point...

A Better Understanding of Evidence Based Care
During the younger quarters of Palmer Florida, the term "Evidence Based Care" gets thrown around a lot. Unfortunately, it got sort of a bad connotation among some members of my class. This was mostly due to a misconception of its components. Due to its name, some of us started to believe that it included only those treatment modalities which have been irrefutably scientifically proven. In reality, these fully-studied treatment interventions account for only 1/3 of the Evidence Based Care Model. Another third is supplied by clinical experience of the majority of the profession. So if a specific technique or treatment model has been shown to "work" by a significant portion of the population, it is included in the EBC Model. The last third--and what I consider to be the most important aspect--is made of patient goals and expectations. This portion is so important, it needs its own heading...

Patient Goals/Expectations
During undergrad, in my study of Medical Anthropology, I saw countless studies on patient beliefs and care outcomes. One of the themes that ran through these is the relationship between patient involvement and positive outcome in conservative care. When people feel like they have an important "job" to do during their care plan, they seem to improve more quickly and more completely. All this being said, in the EBC Model, we give patients the tools they need to be a partner in their own healthcare journey. Tools which will get them to whatever goal they have. This goal may be simple--to get out of pain, to run a mile, to pick up a child without difficulty--but these goals can also be more complex. (ie. losing weight, feeling "well," increasing athletic performance.) No matter what the goal, the EBCM Practitioner will assist the patient in meeting those goals, all the while, educating the patient on all relevant aspects of healthcare. This gives us a title, in addition to diagnostician, clinician, and technician, which I believe to be the most important of all: Teacher. After the goal is met, the patient may be released from care, or may set a new goal. Either way, the patient is responsible for a portion of their wellness and therefore, empowered to make decisions and get well.


In addition to these exciting revelations I've had these last few months, I have made some neat plans. One of which includes a student work Visa for India!

Clinic Abroad Trips
Here at Palmer Florida, when a student reaches quarter 10, he/she can apply for a clinic abroad trip.  These trips go to a variety of developing nations and provide primary and chiropractic care to residents of these nations at no cost. Each of these trips lasts around 3 weeks and includes about 20 students, which some from each of the Palmer campuses. In June, I'm leaving for India. I'm very nervous, actually, which not my normal state. I'm excited too, though. I am looking forward to practicing my primary care skills in an environment where I may be the first doctor these patients have ever seen. During the trip, I hope to blog about the experiences in here. It is something I would have wanted to read about as a prospective student.


So all in all, I think that the clinic has majorly changed me--both as a clinician and as a person. My paradigm has been more solidly established, and I'm looking forward to finishing my requirements and implementing some of the things I have learned into my practice in real life. I only have to wait until December 16th, 2011. :) It gets closer every day.

Remembering Quarter 1

I've decided to start a series of blogs where I recall each quarter and try to give my readers a sense of what these were like. My poll has shown that people mostly want to know what daily life is like... so that's what I'm going to do!

The Schedule
My first week at Palmer I was already overwhelmed. After my first day I went home, called my mother, and cried. This being said, I didn't remember this. I had to look at my journal entries to remember. To me, forgetting the pain and stress of that week, seems like fairly good proof that things improved quickly. By the time we got to week three or four of the term, I was used to the schedule. In undergrad, I took a heavy course-load, sometimes taking 21 or 22 credits a term, but compared with the 30+ credit load here at Palmer, it was nothing. I was not emotionally ready for all the extra hours in class mixed with the stress of being 1500 miles away from home. I'll show you a picture of my schedule during that first quarter... at the time, I thought it was pretty intense.



The People
I think the most important thing was starting to get closer to my class. Due to the nature of our program, the people who are in your class from the beginning are the people you will be with forever. So my friends now have seen me every week day (and lots of weekend days too) for the last two and a half years. Getting to know these people in first quarter was invaluable. We had a few mixer-type events to get us to know each other, but I think the major catalyst was that no one knew anyone else either. We were all together, facing a very strenuous program, hoping we would make it. That breeds familiarity. It's strange to think that the soon-to-be-doctor sitting next to me was once a girl who I didn't know. My friends who have already graduated tell me that these friends become colleagues and references forever.

Expectations
One of the hardest things for me to contend with is a mismatch between my expectations and reality. When I originally applied to come to Palmer Florida I had an idea of what the students would be like. Narcissistically, I thought they would be like me. I thought they would be coming to chiropractic for largely the same reasons I was, I thought we would have the same goals, etc. When I actually arrived, however, I found that my class could not be more academically and personally diverse. There were people who had never been adjusted, music and theater majors, second-career students, business men and women, and so many versions of practice paradigm I could write an entire entry on them. At first, I found this disconcerting, but as time went on, I came to see it as an asset. These people, from such disparate backgrounds, quickly began to make alliances and each add distinct points of view and skill sets to every endeavor. My worries soon melted away into admiration for even the most unusual members of my class.

Putting it all together
By the time the end of first quarter came, I had almost forgotten my anxiety at its start. Getting through that first round of classes--and doing well--was a huge confidence-booster and knowing how the next quarter would go was comforting. Although I still had a long way to go, I felt fantastic about my accomplishments and went into break feeling more motivated than ever to succeed in my time here. The nicest thing about our schedule is that each term only lasts 11 weeks. No matter how stressed I am, I know that I can push through for just 11 weeks and I'm confident that you can too!

Look for Quarter 2 Reflections in the near future! :)

Day to Day

Hello everyone! I received a letter from one of my readers the other day, which brought up some interesting questions. He asked me about our schedule, part-time work, and the scheme of quarters 1 to 4 specifically. I think everyone could benefit from hearing the answers, so here we go!

Scheduling
Like other medical programs--allopathic, osteopathic, naturopathic, dental, etc.--you will be in classes between 30 and 36 hours per week. This is related to the number of credit hours allocated to the particular term, meaning that a student here takes the credit-hour equivalent of an entire year of undergraduate work every 11 weeks. Unlike undergrad, however, school here becomes a student's full time job. The schedule is essentially Monday through Friday 7:30am to 4:30pm with some breaks. Here is a link to the current quarter schedule: http://www.palmer.edu/uploadedFiles/Pages/Academics/_pdf/Florida_Campus/Winter_2011_Curric_Schedule.pdf Because each student is prepared for this scholastic experience to be his/her job, everyone seems to adjust to the schedule quite well.

Working
On the tours I give, I usually recommend that people not have jobs, even in a part time capacity. Because of the scheduling I mentioned above, each student already has 30+ hours of "work" every week. Additionally, studying will take up a large chunk of time, as will exercising, errands, eating, and sleeping. By the time all these are added, there is very little free time remaining. All this being said, some students do manage to keep a few hours a week open for work. One student in my class teaches anatomy lab at Daytona State College, another student works one night a week in retail. A more popular option is work-study. These jobs take place on campus for between 4 and 10 hours per week. These jobs are usually administrative in nature, but can also include working in the cadaver lab, or becoming involved in student government/campus guides association, etc. These jobs won't pay your bills, but they will certainly give you a few extra dollars a month.

Quarters 1-4
Despite how it might seem, quarters 1-4 actually encompass more than one complete year of academic study. Due to the way our schedule is structured throughout the year, each three quarters = one academic year. So quarters 1-3 are very similar. They include the study of the spine, the neuroanatomy of the spinal cord and brain, and introductory classes in embryology, histology, physical exam, and manipulative therapy. Once this is completed, quarters 4-6 include the rest of the body systems from the abdominal cavity to the distal extremities. The schedule for all six of these quarters (these first two years) is quite similar. 5 days per week, 8-ish hours per day, for 11 weeks at a time. Even the third year, quarters 7-9, has a similar schedule. The real difference comes in the last year of the program when students are in the clinic.

So what does all this mean?
Are students here tired? Yes.
Are students here stressed? Yes.
Are students here happy? YES!
Despite the challenges of attending school here--or attending any graduate healthcare program--students are typically pleased with their education. By the time the end of the quarter comes, some people are near falling apart, and I have felt that way myself... but somehow I always make it through and now, looking back from 10th quarter, the pain and stress has all melted away from my memory. Luckily, humans have a very short memory for pain.

The Bottom Line
This program is challenging, but it's completely doable. If you're excited about what you are studying and if you're driven to do well, you will be absolutely fine.

Keep reading and keep asking questions! :)
--Christabella

Transitioning

Hello readers!

Today I'm feeling wistful about the coming year and especially about seeing my first round of out-patients as an intern so I've decided to touch on clinic requirements and the experience of the Palmer Clinics.

Mentors
As an intern at the Palmer Clinics, I have a mentor. My mentor, Dr. Beres, is the primary instructive person for me and about 10 other interns. We come in on rotating shifts, though, to get the largest portion of her time possible. This system actually makes everything much easier. In the past, interns would have to chase down doctors who floated from place to place within the clinic. Now, the only person who ever needs to sign my papers or approve my work is my specific mentor. In 8th quarter, students have a meet-and-greet with these clinic mentors and are able to choose one based on that doctor's specific practice model and philosophy. There are a wide variety of doctors available, so choose wisely!

So many numbers!
At the Palmer clinics, a spreadsheet of requirements for graduation will become your best friend. While this has changed slightly over the last couple of years, the idea has remained the same: 25o patient encounters and 1025 hours of clinic time to graduate. Beyond this, though, there are a myriad of other numbers that are sometimes not discussed on tours or on the website because they are specific and complicated enough to cause a lot of nervousness. Let me break these down for you and give you a sense of how your time in clinic will be spent.

• 250 patient encounters (200 must be non-students, 75 must be observed and assessed, 200 must contain a spinal manipulative technique, 30 must include a non-adjustive therapeutic such as ultrasound or rehabilitation exercise)
• 25 Case Management Reviews (completed on new patients with your specific mentor)
• 15 different case types (according to diagnosis and management)
• 30 assessed radiology encounters (up to 13 of these may be assists, meaning the intern will be the assistant to another intern who ordered the films)
• 1025 hours in the clinic minimum
• 10 cases of high complexity (live)
• 20 cases of high complexity (simulated)
• 55 clinical labs/diagnostic studies (25 urinalysis, 20 hematological, 10 chemical cultures)

So those are the numbers... now before your head starts spinning off, remember that while seeing 250 patients, most of these things will just happen naturally. In a population of 250 people, at least 10 of them will be complex... in fact, most of them will probably be "complex" it's just up to you to write up the paperwork. If, however, you find yourself in a position where one of these requirements is not filled, there are a few other options to consider.

Outreach Clinic
Palmer has set up three clinics outside of our two normal outpatient clinics meant to provide a valuable service to struggling members of our community. These clinics offer no-cost service to a variety of people from different socioeconomic levels. It's fantastic for them, but it's also fantastic for us because these clinics are BUSY. At any time during 10th to 13th quarters, interns can go out to one of these clinics, portable table in hand, and start lending a hand. These patients tend to have more complex problems, which makes them ideal candidates for "case of higher complexity" and "radiography candidate" titles.

Clinic Abroad
One of the fantastic opportunities Palmer students have is the ability to go into developing countries and deliver care. Between quarters 10 and 13, students from all three campuses come together for several weeks and have a chance to hone their skills. Not only do students develop better manipulative skills on these trips, but they have a chance to practice a myriad of primary care procedures since many of the patients have never seen a doctor before. Because our care is so rare and valuable to these people, students who elect to attend clinic abroad typically finish the remainder of their 250 encounters during the trip. In my opinion, this is a side bonus to the fantastic work of assisting those who are in desperate need of medical attention.

Once you've finished up these numbers...
You're ready to graduate....or go on preceptor. The preceptor program is available to students in 13th quarter who have finished all their clinic requirements by the middle of 12th quarter. On preceptor, the student can choose from dozens of doctors located all over the country and globe, and practice in that doctor's office for the last three months of their Palmer career. These internships are invaluable since many students find their jobs this way. It's also a great way to see what practicing in a different type of office is like. While the Palmer Clinics are a great educational tool, seeing a private practice in action is a totally different experience, and one that I think is incredibly valuable.

Day to Day of Clinic Life
The first time I went to visit the clinic during 9th quarter, I was completely overwhelmed. There were interns all over the place, papers almost flying through the halls, and door after door of patient rooms, treatment bays, and complex machinery. I could barely believe that I would ever adjust to its layout and intensity. Soon, though, the hallways became familiar, the people recognizable, and the machines operable. So the bottom line is to spend as much time as possible in the clinic before it is required. With the right attitude, and a little work, the experience of an intern should be a lovely journey of discovery: every day, taking one step forward toward becoming someone who can be trusted with patients' health.

Good luck to all of us! :)

Negatives

During my tours, people are constantly asking me, "what is the down-side of going here?" I guess this is because I seem so positive. People want to test my sincerity, I suppose. Well, I've compiled a list of negatives about Palmer for all the nay-sayers... but I have to warn you, I am full of optimism and wistfulness... Here we go!

Newer isn't always better
We boast one of the newest chiropractic college campuses in the country. As far as architecture and space functionality, being new is fantastic. In other respects, however, it is more challenging. A new school means new curriculum, new professors, and lots of challenges. In my time at school the curriculum and various policies have changed more times than I can count. This can be confusing and, at times, frustrating. However, most of these changes benefit the students in the long run. Occasionally, it is not soon enough to benefit me specifically, but remember, anything that benefits the students of tomorrow eventually benefits the profession as a whole.

Chiropractic is full of questions
This is both a positive and a negative. Because our profession was founded only a little over 100 years ago, we are still children on the healthcare continuum. This leads to all sorts of questioning, arguing, and debating about where our profession should be heading in the coming years. While debate is the spark of innovation, it can also be disconcerting for a student about to graduate and embark on his/her own journey. As a student it is important to remember that once you go out into the world, your decisions are your own. This is as true clinically as it is philosophically and in business. Luckily, to combat this potential problem, we have a diverse group of faculty who have a wide range of opinions on the development of our profession. From these, any student should be able to create a personal practice paradigm.

Paperwork, Paperwork, and more Paperwork...
Entering Palmer College means signing your name 1000+ times before even entering the clinic. It also means learning an entire system of record keeping that--in all likelihood--will not even be close to the records you will keep in your practice. I recently saw my first student patient in the clinic and I was overwhelmed with the tedious nature of the forms/files/folders I had to complete. The overwhelm sets in when one realizes that he/she has not been properly informed on how to complete all this paperwork... He/she may have even seen all these forms before, but knowing exactly how one's overseeing doctor wants them done is another topic. This can be frustrating, since our clinical skills are highly developed by the time we enter our last year... I would like to believe that our record keeping skills are just as well-developed... but they are not. (You can see, I'm rather impassioned about this...) Anyway... it is very frustrating to feel like I am swimming in papers... but I also know that no matter how detailed the notes I will be required to take after graduation, there is no way they will be as detailed as this. Therefore, I'm learning the worst-case scenario to be better prepared for the real world. That's something I can feel good about. :)

I think that's it.
Knowing that these are the worst thing about my education, I feel pretty good. There is nothing that I cannot overcome or make an excuse for, so I know I made the right decision. If any of you have any questions, please feel free to email me any time. I love getting emails from my readers!

In Health,
Christabella
ccherub@gmail.com