Research

The Effects of Clinic Abroad Programs on Intern Public Health Attitudes, Cultural Authority and Confidence in Clinical Skills: A Pilot Survey

James Boysen, DC

 

Dana J. Lawrence, DC, MMedEd, MA

 

Dustin Derby, MSEd, MS, EdD

 

author email    corresponding author email   

Topics in Integrative Health Care 2011, Vol. 2(1)   ID: 2.1007



Published on
March 30, 2011
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Abstract

Background: Palmer College of Chiropractic offers a Clinic Abroad program for senior students to provide humanitarian services to underserved populations.

Objective:
To develop a survey which would capture differences in intern confidence in physical exam, diagnosis and manipulation skills and attitudes about public health and cultural authority between those who attended Clinic Abroad and those who did not.

Methods:
A pilot survey was developed by adapting surveys on manipulation and public health. Cultural authority questions were an original development. The survey was tested on a class of Palmer College of Chiropractic 9th trimester students. A focus group was conducted post-test for survey clarity and content.

Results:
Twenty-nine students completed the survey, including 16 who had participated in Clinic Abroad. As a whole, the students showed confidence in physical exam, diagnosis and manipulation skills. They also disagreed they should perform public health tests but agreed they should perform public health screenings. Most feel they have cultural authority for a wide range of human conditions. Differences were seen between groups on certain manipulation skills, public health screenings, immunizations and cultural authority.

Conclusions:
This survey demonstrates the possibility of exploring differences in senior chiropractic student’s physical exam, diagnosis and manipulation confidence and attitudes of public health and cultural authority.

INTRODUCTION

Palmer College of Chiropractic’s Clinic Abroad Program provides a unique opportunity for senior-level chiropractic students. The students receive a clinical, educational and cultural experience while providing quality humanitarian care to underserved health care areas in the US and worldwide. Trips last from 12- 20 days and 4 or 5 trips are planned during each trimester break, for a total of 12- 15 trips per year.1 Program goals and objectives include:

•  Provide a quality clinical education in a unique environment

•  Broaden the educational experience acquired in the classroom

•  Increase the cultural awareness of students leading to the development of mature and experienced professionals

•  Further develop the humanitarian and service orientation of doctors of chiropractic

•  Promote the chiropractic profession and Palmer College to the world.2


Students obtain adjusting and physical examination credit toward graduation. A minimum of 250 chiropractic adjusting encounters are needed to fulfill graduation requirements as well as to meet accreditation criteria.3 Ansari and Killinger reported seeing approximately 800 patients over a 6-day period involving 24 students during 1 overseas trip.4 This intensive experience is thought to alter student physical exam skills, manipulation skills and self-confidence.5 This building of student confidence by clinical experience has also been reported by Hecimovich, et al.6 There are currently no studies on the demographics of clinic abroad patients, but 2 initial studies of off-campus and outreach teaching clinics suggest differences in patient demographics between an on-campus clinic patient population and those off-campus.7, 8 It is reasonable to assume that clinic abroad patients have different demographics, chief complaint and disease presentations than patients seeking care at chiropractic teaching clinics. These different clinical settings and diverse patient population also have the possibility of influencing student public health attitudes and their perception of cultural authority. Perception of cultural authority for this paper is defined as whether chiropractors view themselves as primary-care providers or portal-of-entry providers.9

The aim of this study was to conduct a survey and focus group examining differences between students who participate in clinic abroad trips and students who do not on their self-perceived physical exam, diagnosis and manipulation skills as well as their public health and cultural authority perceptions.

METHODS

Overview



An 82-item survey was developed to explore the differences between senior students who participated in Palmer College of Chiropractic’s Clinic Abroad program and those who did not. The 3 domains included confidence in clinical skills, public health attitudes and cultural authority. Sub-domains of confidence in clinical skills examined physical exam, diagnosis and manipulation skills.

Study Design and Population



This study utilized a convenience sample of 9th trimester students who attended an “Evidence-Based Chiropractic” class on December 16th, 2010 at Palmer College of Chiropractic. Palmer’s IRB approved the survey as exempt. With the instructor’s permission, a paper form of the survey was handed out at the end of class, with time left to complete it; the option was available for students to take the survey with them to complete later, deposit the survey into an interdepartmental envelope and use the interdepartmental mail system. All students, whether they attended Clinic Abroad or not, were asked to complete the survey. The students were allowed enough time at the end of class (15 minutes) to complete the survey, the questions were simple and short, and no identifiers to the students were collected. This sampling strategy netted 29 of the 38 students who attended the class (16 who went on Clinic Abroad). This sample may not be representative of the overall student population that attends Clinic Abroad since approximately 100 students from 3 campuses participate. 

Description of Instrument



Initially, 5 demographic questions were asked on gender, age, marital status, race and expected debt at graduation. Most of the domain questions were formatted in a 4-point Likert-type scale using “strongly agree”, “agree”, “disagree” and “strongly disagree”.  A few questions required a categorical scale of time in the form of “once per week”, “once per month”, “once every 4 months”, “once every 6 months”, “once per year”, and “never”. The first domain about clinical confidence included 4 questions on confidence in physical exam skills, 4 questions on confidence in diagnosis skills and 17 questions on confidence in manipulation skills. The 17 questions on confidence in manipulation skills were adapted from work by Bisiacchi.10 The next domain about public health attitude included 8 questions on screenings/exams, 9 questions on providing counseling to patients, and 3 questions on immunization were all adapted from work by Hawk.11 Another 8 questions on public health were about donating to service organizations. The third domain on cultural authority included 4 questions on specialization adapted from the discussion of Nelson.9 Eleven questions on cultural authority were developed on consultation, such as do the students feel patients should first consult with a chiropractor for different conditions such as low back pain, neurologic conditions, cardiovascular conditions, etc. Seven questions were developed on first responding, such as do the students feel that patients should see a chiropractor first for blood pressure testing, physical therapy, dietary counseling, etc. Two questions examined scholarly activity plans both present and post graduation.

Focus group



A focus group was conducted post-trip and post-survey to improve the instrument. In the original survey, 7 students responded “yes” to the question about willingness to participate in a focus group. Contact information of email address and phone numbers were provided by 6 students. Email, phone and text messaging was used to contact the students for the focus group. The instructor of the class where the survey was handed out announced and asked for student participation the day of the focus group. Pizza was provided as an incentive. Two students attended and participated in the focus group held on January 13th at 6:00 pm. It should be noted that the 2 who attended the focus group were non-participants in Clinic Abroad. Due to the small number of focus group participants, their opinions may not be representative of the group as a whole. Questions for the focus group included if the group participated in Clinic Abroad, why they did or did not go, the look, wording and clarity of the survey, defining cultural authority, unasked survey questions and how to delineate between portal-of-entry and primary-care-giver.

General comments were that the survey was well organized and easy to follow. Both thought the areas of confidence, public health and cultural authority were covered. When queried about what additional questions needed to be asked, the group thought asking if the students were intending to preceptor as 1 additional question and why the students were choosing the profession of chiropractic as another question. The group questioned how the survey could distinguish between portal of entry and primary care. The answer from the group was that they have been taught in class that they are both and it can also depend on the state in which the chiropractor chooses to practice. In order to try to separate out the difference between primary care givers vs. portal of entry, the suggestion was made to give different scenarios and see if the students would agree or disagree with it.

The information from the small group was taken into consideration and may be incorporated into a future survey.

Data Analysis



Data were collected and delivered to the data manager for data entry. Data were analyzed by SPSS version 17.0, (Chicago, IL). Counts and frequency of the baseline characteristics for the group as a whole was determined, with the exception of age, in which mean and standard deviation was calculated. Due to the small number of participants in this survey, counts were used to distinguish the difference between the Clinic Abroad group and the rest according to reporting standards in Lange and Secic (12). A rank sum test (Mann-Whitney U test) was performed to examine differences those who participated in Clinic Abroad and those who did not.

RESULTS

Demographics



Of a total of 38 students who attended the class, 29 surveys were completed. Approximately 5 students took surveys with them and were not returned. Response rate was 76% (29/38). Baseline characteristics (Table 1) show that the students as a whole were primarily male (79%- 23/29), single (62%- 18/29), white (86%- 25/29), and in their late 20’s (m= 27.5, SD=4.22).

Table 1.  The convenience sample demographics of a class of 9th trimester students of those who participated in Clinic Abroad trips at Palmer College of Chiropractic, Davenport, IA (n=29).
 

Clinic Abroad

 
 

Yes

No

Total

Gender
 
 
 

Male

12
11
23 (79%)

Female

4
2
6 (21)
 
 
 
 
Agea
26.8 (3.45)
28.4 (5.02)
27.5 (4.22)
 
 
 
 
Marital status
 
 
 

Married

5
5
10 (35)

Widowed

0
0
0

Divorced

0
0
0

Separated

0
1
1 (3)

Never married

11
7
18 (62)
 
 
 
 
Race
 
 
 

American Indian or Alaska Native

0
1
1 (3)

Asian

0
2
2 (7)

Black or African American

0
0
0

Hispanic or Latino

0
1
1 (3)

Native Hawaiian or Other Pacific Islander

0
0
0

White

16
9
25 (86)

Listed as Number (percent) unless otherwise noted

a Mean (standard deviation)


Confidence



Students were generally confident in their physical exam of the neck and low back and less confident of physical exam of the extremities and visceral areas. There was no statistically significant difference between those who went on Clinic Abroad and those who did not in physical exam or diagnosis.  Those who responded with “agree” to “strongly agree” in confidence in physical exam and diagnosis are summarized in Table 2. Statistically significant differences were noted in Table 3 in confidence of manipulation between the Clinic Abroad participants and those who did not go in areas of thoracic prone (p=0.043), drop table thoracic (p=0.043), drop table lumbar (0.048), and all Activator style manipulation (cervical p=0.010, thoracic p=0.004, lumbar p=0.004).

Table 2.  The percentage (number) of students who answered “agree” and “strongly agree” in a 9th trimester class at Palmer College of Chiropractic to the following statements (n=29).
 

Agree to strongly agree

I feel confident about my physical examination skills for the:
 
  Neck

93 (27)

  Low back

96 (28)

  Extremity

69 (20)

  Visceral

62 (18)

I feel confident about my diagnostic skills for the:
 
  Neck

100 (29)

  Low back

96 (28) 

  Extremity

69 (20)

  Visceral

52 (15)

Chiropractors should perform the following for all patients in the appropriate age/sex/risk category:
 
  Glucose screening

59 (17)

  CBC/screening panels

69 (20)

  Blood cholesterol tests

59 (17)

  Prostate exam/PSA (men 50+)

28 (8)

  PAP test (women)

21 (6)

  Testicular exam (men)

21 (6)

  HIV test (if risk factors present)

34 (10)

  Blood lead test (for high risk patients)

48 (14)



Table 3.  Median answers, mean ranks and Mann-Whitney U test of a convenience sample of 9th trimester students at Palmer College of Chiropractic in Davenport Iowa between those who participated in a Clinic Abroad program and those who did not (n=29).

“I feel confident
about my skills in:”
Clinic
Abroad
Median answera
Mean ranks
U
Z
p-valueb
Cervical supine
Yes
1
13.53
80.5
-1.207
0.227
No
2
16.81
 
 
 
Cervical chair
Yes
2
15.81
91.0
-0.620
0.535
No
2
14.00
 
 
 
Thoracic prone
Yes
1
12.75
68.0
-2.026
0.043
No
1
17.77
 
 
 
Side posture push
Yes
2
13.91
87.5
-0.783
0.433
No
2
16.27
 
 
 
Side posture pull
Yes
2
14.47
95.5
-0.406
0.685
No
2
15.65
 
 
 
Drop table cervical
Yes
1.5
14.50
96.0
-0.380
0.704
No
2
15.62
 
 
 
Drop table thoracic
Yes
1
12.75
68.0
-2.026
0.043
No
1
17.77
 
 
 
Drop table lumbar
Yes
1
12.81
69.0
-1.981
0.048
No
1
17.69
 
 
 
Wrist
Yes
2
14.16
90.5
-0.634
0.526
No
2
16.01
 
 
 
Elbow
Yes
2
14.06
89.0
-0.707
0.479
No
2
16.15
 
 
 
Shoulder
Yes
2
14.72
99.5
-0.208
0.835
No
2
15.35
 
 
 
Ankle
Yes
2
12.62
66.0
-1.768
0.077
No
2
17.92
 
 
 
Knee
Yes
2
14.13
90.0
-0.670
0.503
No
2
16.08
 
 
 
Hip
Yes
2
14.06
89.0
-0.708
0.479
No
2
16.15
 
 
 
Activator style cervical
Yes
1
11.47
47.5
-2.592
0.010
No
3
19.35
 
 
 
Activator style thoracic
Yes
1
11.06
41.0
-2.910
0.004
No
3
19.85
 
 
 
Activator style lumbar
Yes
1
11.06
41.0
-2.910
0.004
No
3
19.85
 
 
 

a Median answers from a 4-point Likert-scale 1= strongly agree to 4= strongly disagree.

b Based on Mann-Whitney U test (p=0.05). Statistically significant values which are bolded represent higher agreement of students who went on Clinic Abroad.


Public Health



Students who participated in Clinic Abroad and those who did not were not statistically different in their public health screenings and exams. Those who responded with “agree” to “strongly agree” in performing exams and screenings are summarized in Table 2. Statistically significant differences in those who participated in Clinic Abroad and those who did not were noted in counseling patients in areas of stress reduction techniques (p=0.020), tobacco risks and cessation (p=0.006), breastfeeding and diet in pregnancy(p=0.012), skin cancer prevention (p=0.028), substance abuse and cessation (p=0.036), and sexually transmitted disease (STD) prevention (p=0.016) and are shown in Table 4. Statistically significant differences were noted in immunization (Table 5). While both the Clinic Abroad participants and non-participants were in general agreement that chiropractors should provide both pro-and-con immunization information, the Clinic Abroad participants agreed with a median answer of 1, “strongly agree” vs. 2, “agree” for the non-participants (p=0.001).

Table 4.  Median answers, mean ranks and Mann-Whitney U test of a convenience sample of 9th trimester students at Palmer College of Chiropractic in Davenport Iowa between those who participated in a Clinic Abroad program and those who did not (n=29).

“Chiropractors should provide counseling to all patients in the appropriate age/sex/risk category on:”
Clinic
Abroad
Median answera
Mean ranks
U
Z
p-valueb
Musculoskeletal risk reduction
Yes
1
14.22
91.5
-0.739
0.460
No
1
15.96
 
 
 
Dietary modification
Yes
1
13.22
75.5
-1.559
0.119
No
1
17.19
 
 
 
Injury prevention
Yes
1
14.72
99.5
-0.281
0.779
No
1
15.35
 
 
 
Stress reduction techniques
Yes
1
12.22
59.5
-2.321
0.020
No
2
18.42
 
 
 
Tobacco risks and cessation
Yes
1
11.63
50.0
-2.744
0.006
No
2
19.15
 
 
 
Breastfeeding and diet in pregnancy
Yes
1
11.81
53.0
-2.514
0.012
No
2
18.92
 
 
 
Skin cancer prevention
Yes
1
12.22
59.5
-2.194
0.028
No
2
18.42
 
 
 
Substance abuse and cessation
Yes
1
12.38
62.0
-2.096
0.036
No
2
18.23
 
 
 
STD prevention
Yes
1
11.91
54.5
-2.402
0.016
No
2
18.81
 
 
 

a Median answers from a 4-point Likert-scale 1= strongly agree to 4= strongly disagree.

b Based on Mann-Whitney U test (p=0.05). Statistically significant values which are bolded represent higher agreement of students who went on Clinic Abroad.


Table 5.  Median answers, mean ranks and Mann-Whitney U test of a convenience sample of 9th trimester students at Palmer College of Chiropractic in Davenport Iowa between those who participated in a Clinic Abroad program and those who did not (n=29).

“Chiropractors should provide information on immunization:”
Clinic
Abroad
Median answera
Mean ranks
U
Z
p-valueb
Both pro AND con
Yes
1
11.00
40.0
-3.186
0.001
 
No
2
19.92
 
 
 
-con only
Yes
4
14.43
71.0
-0.735
0.463
 
No
3
12.42
 
 
 
-pro only
Yes
4
14.07
76.0
-0.452
0.651
 
No
3
12.83
 
 
 

a Median answers from a 4-point Likert-scale 1= strongly agree to 4= strongly disagree.

b Based on Mann-Whitney U test (p=0.05). Statistically significant values which are bolded represent higher agreement of students who went on Clinic Abroad.


Cultural Authority



Statistical significance was also reached in cultural authority (Table 6). Those who went on Clinic Abroad were stronger in agreement than those who did not participate that chiropractors are primary care givers (p=0.013) and treat most complaints directly (p=0.009).

Table 6.  Median answers, mean ranks and Mann-Whitney U test of a convenience sample of 9th trimester students at Palmer College of Chiropractic in Davenport Iowa between those who participated in a Clinic Abroad program and those who did not (n=29).

“Chiropractors:”
Clinic
Abroad
Median answera
Mean ranks
U
Z
p-valueb
Are primary care providers
Yes
1
11.88
54.0
-2.489
0.013
No
2
18.85
 
 
 
Treat most complaints directly
Yes
2
11.66
50.5
-2.601
0.009
No
2
19.12
 
 
 
Are conservative NMSc specialists
Yes
2
13.88
86.0
-0.879
0.380
No
2
16.38
 
 
 
Are portal of entry for non-NMSc conditions
Yes
2
14.31
93.0
-0.529
0.597
No
2
15.85
 
 
 

a Median answers from a 4-point Likert-scale 1= strongly agree to 4= strongly disagree.

b Based on Mann-Whitney U test (p=0.05). Statistically significant values which are bolded represent higher agreement of students who went on Clinic Abroad.

c NMS= Neuromusculoskeletal


DISCUSSION

It has been suggested that serving different locations broadens the clinical training of the student by providing diversity in patient populations and clinical settings.7 The Palmer Clinic Abroad trip to underserved populations does provide this clinical experience.

Hecimovich stated that confidence in skills was important in patient outcomes, while Bisiacchi concluded that half of the respondents at Life University’s College of Chiropractic were confident to begin their clinical experience.6, 10 Spegman identified 2 areas for faculty to increase student confidence: “convey respect” and “real world learning”.13 The Clinic Abroad experience allows the chiropractic student to experience a focused 1-2 week “real world” experience.  Our study showed a possible difference in confidence of those who participated in the Clinic Abroad humanitarian trip over those who did not which may show the effects of a “real world” experience.

Students on a dental humanitarian and educational trip noted that the opportunity allowed the students to work with faculty in a relaxed and mentoring atmosphere while practicing and increasing their dental skills.14 The chiropractic experience may be similar. However, the aforementioned study stated nonparticipants clinical skills were equal with their fellow participating students at the end of their training. There is no evidence yet to show if students from Palmer’s trips feel increased confidence at the end of their clinical training compared to those who do not.

Chiropractic’s role in public health has been discussed in a collaborative summary document.15 The document’s authors stated the desire for the profession to focus on current public health care opportunities across a large range of venues to realize a vital share of this growing niche. The Clinic Abroad group trended higher agreement in an interest for public health contribution which will hopefully continue once the students open a practice. It has been shown that chiropractic students’ attitude on public health concepts can change after taking a course on community health.16 The experience of a Clinic Abroad trip may create a similar change in the students’ attitude on public health- this study demonstrated trends to support that idea.

The students were in favor of providing both pro and con information on vaccination while they disagreed that pro-only or con-only information should be provided. These findings are similar to the surveys conducted by Hawk and Busse, who found than most chiropractic students were not adverse to vaccination, but Busse found the student’s anti-vaccination attitude increased in the latter years of the program.11, 17 

Our population of students, especially those who went on Clinic Abroad, seemed to agree that chiropractors are both primary care givers and portal of entry practitioners. On the surface, this seems to be a contradiction, how can they be both?  Since most students answered the survey indicating patients should see the chiropractor first for most conditions, it may be that the students view themselves as the “hub” of patient care with the decision to treat the patient with the condition or refer elsewhere or co-manage the patient. Future studies may want to identify which conditions chiropractors feel they should treat and which they should refer/co-manage. It is also not known whether the public views the chiropractor as a primary care giver or portal of entry.

Study limitations



This small study was limited by numbers; it may not be generalized to the student population. It may also be helpful to administer the survey pre-and-post Clinic Abroad to see if the student experience changes their attitudes. This survey was also only administered to students at Palmer College of Chiropractic in Davenport, IA while not surveying the other 2 Palmer campuses (Palmer West and Florida) who also participate in Clinic Abroad. It is probable that this study did not capture the experiences of the students on all the Clinic Abroad trips, so it is not known if the students differ in their responses depending on trip destination. Student confidence may not equate to competence, this study did not attempt to identify the relationship between the 2. It is also not known if the differences that exist in confidence, public health attitude and cultural authority would continue to graduation and beyond.

CONCLUSION

This study demonstrated the ability to assess chiropractic students’ perceptions of confidence in clinical skills, public health and cultural authority attitudes. A larger scale study with a survey pre-and-post Clinic Abroad experience is possible to explore differences in the Palmer senior student population. If there are differences shown, it may also be possible to survey the student population to see if any differences continue through graduation.

Conflict of Interest



The authors declare no conflict of interest.

Acknowledgements



The authors wish to thank Dr. Cheryl Hawk for her active involvements and contributions during the study. We also wish to thank Lance Corber for data entry into SPSS, Dr. Hawk for permission to adapt her public health questions, and Dr. Bisiacchi for permission to adapt her confidence in manipulation skills survey.
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References

1.   

Clinic abroad program. Palmer College of Chiropractic’s website web link Accessed September 15, 2010

 [ Full-Text Link ]

2.   

Palmer Chiropractic Clinics clinic abroad program handbook October 2010. Palmer College of Chiropractic’s website. web link. Accessed February 27, 2011.

 [ Full-Text Link ]

3.   

Wood K. Palmer College of Chiropractic Syllabus, Summer trimester, Palmer Chiropractic Clinics 2010



4.   

Ansari M, Killinger L, Round table discussion: a clinical chiropractic teaching and learning experience abroad introducing students to chiropractic care in an interdisciplinary international setting. J Chiropr Educ 2000;14(1):57-58



5.   

Barber V, Ring T. Poster presentation: A pilot investigation into the role of a foreign clinical outreach trip in chiropractic students’ clinical confidence. J Chiropr Educ 2003 Spr;17(1):48



6.   

Hecimovich M, Volet S. Importance of building confidence in patient communication and clinical skills among chiropractic students. J Chiropr Educ 2009;23(2):151-164



7.   

Morschhauser E, Long C, Hawk C, et.al. Do chiropractic colleges’ off-campus clinical sites offer diverse opportunities for learning? A preliminary study. J Manipulative and Physiol Ther 2003;26(2)70-76



8.   

Stevens G. Demographic and referral analysis of a free chiropractic clinic servicing ethnic minorities in the Buffalo, NY area. J Manipulative and Physiol Ther 2007;30(8):573-577



9.   

Nelson C, Lawrence D, Triano J, et al. Chiropractic as spine care: a model for the profession. Chiropr Osteopat 2005 Jul 6;13:9



10.   

Bisiacchi D. Self-perceived skills in confidence: and investigative study of chiropractic students in the early phases of a college’s clinical program. J Manipulative and Physiol Ther 2010;33(3)201-206.



11.   

Hawk C, Long C, Perillo M, Boulanger K. A survey of US chiropractors on clinical preventive services. J Manipulative and Physiol Ther 2004;27:287-98.



12.   

Lang T, Secic M. (1991). How to report statistics in medicine: Annotated guidelines for authors, editors and reviewers. Philadelphia, PA: American College of Physicians.



13.   

Spegman A, Herrin S. Chiropractic interns’ perceptions of stress and confidence. J Chiropr Educ 2007;21(2):129-37



14.   

Bimstein E, Gardner Q, Riley J, Gibson R. Educational, personal and cultural attributes of dental students’ humanitarian trips to Latin America. J Dent Educ 2008;72(12):1493-1509



15.   

Johnson C, Baird R, Dougherty P, et al. Chiropractic and public health: current state and future vision. J Manipulative Physiol Ther 2008;31:397-410



16.   

Rose K, Ayad S. Factors associated with changes in knowledge and attitude towards public health concepts among chiropractic college students enrolled in a community health class. J Chiropr Educ 2008;22(2):127-137



17.   

Busse J, Wilson K, Campbell J. Attitudes towards vaccination among chiropractic and naturopathic students. Vaccine 2008;26:6237-6243