Education and patient care in a chiropractic teaching clinic: An organizational approach to health and safety during the COVID-19 pandemic

The COVID-19 health emergency is unprecedented in modern times. The chiropractic profession needs information about the effects of COVID-19 on chiropractic education and the reaction of the chiropractic profession and the implementation of changes to chiropractic practice. We describe in this report the experience of staff and students at a chiropractic college teaching clinic in California responding to public health mandates and measures to reduce transmission of COVID-19 in our local community.

In early 2020 US federal, state, and county governments and public health officials were closely monitoring the developments and spread of COVID-19, continually revising public health guidelines and issuing updates.¹  As has been reported elsewhere, the California Board of Chiropractic Examiners did not provide recommendations regarding chiropractors as essential providers during the early stages of the pandemic that are covered in this report.²  In response to scant, changing information and guidelines our chiropractic college announced on March 11 that it had established a new “COVID Task Force,” that included executive-level and departmental campus and health center leaders, human resources, and the college attorney. The charge of the task force was to review and update the college community on the situation. In addition to emailing periodic announcements to share best evidence-based advice for personal protective procedures to stay safe, the task force also convened in-person and virtual town hall-style meetings that were open to the entire college community. A comprehensive description of the college's early response appears in Appendix 1 (online supplementary material).

We report on the organizational rapid response of our chiropractic college teaching clinic, to early pandemic COVID-related public health mandates. Our health center remained open to sustain access for chiropractic patients in our local community and to continue uninterrupted the clinical training and progress of our chiropractic interns. We aimed to describe the experience of individuals within our institution, and report their perceptions about the impact of the pandemic and related organizational changes on patient care, teaching, and learning.

We used a qualitative narrative approach³  and interviewed personnel and student interns who were present at the health center March–June 2020, and who volunteered to discuss the unprecedented experience of providing services during the initial “Shelter in Place” (SIP) stages of the pandemic, when the Governor and our county health department issued orders for individuals to stay at home except for essential activities.⁴  We recruited participants through email to the clinic faculty, interns' mailing list, flyers, and snowball sampling. Anyone interested in participating contacted the researchers directly. We interviewed all respondents who were present at the health center during the early stages of the pandemic: March–July 2020). We conducted 45-minute semistructured interviews⁵  with interview guides (Appendix 2, online supplementary material) consisting of open-ended questions focusing on the new clinic procedures and the processes of developing and implementing them. We asked participants to comment on challenges and successes, the impact on teaching and learning, and how their clinical experience during the SIP contributed to students' knowledge and clinical skills. We did not ask about participants' beliefs or opinions about the virus, health care generally, or chiropractic specifically. We spoke minimally and probed as needed to encourage participants to expand on their answers.⁶  We revised interview guides throughout this project as new information emerged and interviewed until we observed thematic saturation.

Both authors interviewed 8 of the15 participants via GoToMeeting videoconferencing (LogMeIn Inc, San Francisco, CA, USA). One author interviewed the remaining 7. The software provided automatic transcripts, which we then reviewed, corrected, and prepared for thematic analysis.⁵  We read the transcripts and manually segmented the text into themes using predetermined (deductive) and emerging (inductive) coding,³  which we refined throughout the project. We created a tabular data matrix⁷  to analyze the flow of conversational threads, or themes, that we summarized individually and as overall findings.⁸  We use the matrix to organize our findings and ensure that the quotes we present are representative of the full spread of participants. Both authors discussed the process, reviewed the coding, and resolved differences by consensus.

All participants consented to be interviewed for this project, which was approved by the Life Chiropractic College West institutional review board (#PIDN 2020-001).

During June and July 2020, we conducted 15 interviews with individuals who were present as soon as the health center reopened on March 23 or returned in the following weeks: 12 with health center personnel (staff, administrative, faculty) and 3 with student interns. We identified 7 main themes. Five corresponded to interview questions and probes: (1) Organizational processes and procedures; (2) Perceptions of safety; (3) Successful health center adaptations and responses; (4) Challenges; and (5) Mental health and well-being. Two themes emerged inductively: (6) Unanticipated benefits and opportunities and (7) Reflections on chiropractic philosophy and wellness. We also summarize participants' recommendations to the institution. We edited quotes for clarity and brevity and to minimize the risk of deductive disclosure, which is being able identify a particular respondent's identity from their responses.⁹  We present quotes that typify the themes, originate from multiple interviews, and unless otherwise noted represent the views of a variety of participants.

A key administrator described the initial process of developing the health center's COVID-19 safety procedures: On March 16, 2020, in response to the county's SIP mandate the chiropractic college campus was closed to all students, and all activities associated with teaching, research, and general administrative operations were moved online. The suspension of onsite activities of the “classroom side” of the college continued for the next several months. The college temporarily closed the health center to gather clinic faculty and staff who work in the health center to discuss how best to respond to the SIP order. In California, chiropractic was determined to be an essential service.¹⁰  The health center clinic remained closed for only 1 week to allow intensive planning and preparation of institutional policies and procedures to effectively and safely reopen the clinic to serve the community.

Clinic faculty and staff said that the process of developing and implementing the institutional response to the public health mandates was transparent and collaborative. Several respondents credited effective, inclusive leadership throughout the process. A faculty mentor said, “Everybody's stepped up…Even if you are working from home, you did something. We all helped us make it work.”

Comments regarding the development of new procedures were generally positive, although not everyone agreed with the mandates or the procedures themselves. There was some initial confusion about implementation. Faculty experienced new roles and duties, and participants frequently mentioned receiving regular communications about the pandemic and the safety procedures.

The transparent processes and ongoing communication contributed to participants' perceptions of safety. A staff member described feeling comfortable at work because the administration met with the entire health center group before working with the task force to develop the plan for reopening. Most participants said that they thought that the procedures were sufficient, effective, and responsive to changing mandates and new information. A faculty mentor said, “I would say that our screening at the college was more in depth than the screening I got [in other health care settings].” Another said, “I take all the precautions… We have hand sanitizing. So, I feel comfortable, or I wouldn't be there.” Six participants said that they felt safe as soon as they returned to the health center. Eight said that they felt fear or anxiety initially, and 7 of those 8 also said that they felt better over time as they observed the safety procedures that had been put in place and learned more about the virus and its mode of transmission.

Most participants understood the procedures, including changes to the environment (barriers, place markers), sanitation, masking, and limitations on the number of individuals permitted onsite or in enclosed spaces and the 30-minute time limit on appointments that was implemented as a result. Communication was key.

Some participants said that there could have been better communication. A faculty mentor said, “I was never given any direction as to whether to wipe down the tables with the sanitizer before the patient comes in or after.” Some said that receiving more information about the virus itself would have been useful.

When they were asked to reflect on “what worked well,” participants discussed the school's rapid response and reopening and the minimal interruption in providing patient care and chiropractic education. An intern said, “My patients are willing to get chiropractic care consistently. …I wanted to help them, provide consistent care.”

Participants noted improvements in patient management and clinic efficiency. A faculty mentor said “The patient flow has been really good at getting the patients in and out. I think it's going to be helpful for (the interns) in their practice.” An intern said that the procedures “made it more obvious what we're supposed to be doing and the order things need to go in.”

Administrators and faculty said that staying open enabled students to complete their clinic requirements and graduate on time. All 3 interns said that getting their adjustment and patient contact hours was 1 of the reasons they returned to clinic at the start of the SIP.

All but 1 participant experienced or observed negative mental health effects in themselves and others, “I was really scared at first [at the health center]…It was dealing with the public, the unknown … anxiety really kicked in… Outside, especially thinking about my family and everything really affected me.” A faculty mentor said “My nervousness didn't even come from the virus itself. I've been very frustrated and kind of angry about the whole thing, just because of how my life has basically been shut down.” Several participants said that they were concerned about transmitting the virus.

Participants talked about the importance of human connection and how the quick return to work helped to reduce their feelings of isolation and foster a sense of normalcy and well-being. A faculty mentor said, “I've been able to come to work and do mostly what I was doing before, which has really brought me a lot of peace during a super chaotic time, so grateful,” while an intern said “My life has basically been shut down… that was part of the reason I couldn't wait to go back to the health center because I'm kind of a workaholic and not being able to do it was making me crazy, being stuck at home all the time.”

Another intern said “As people start to come back, we have more time to talk to other interns and talk to the patients. So that human connection increases communication and also it reduces the fear of COVID.”

We did not interview patients for this project, but our study participants volunteered their own observations about their health center patients. Some patients stayed away, some were more afraid than others, and some were eager to return.

Participants described the logistical challenges of coordinating schedules and adapting to new safety and social distancing rules. The cancellation and rescheduling of the National Board of Chiropractic Examiners exams inconvenienced some students and delayed licensure for others. Some health center personnel reported feelings of unfairness and inequitable distribution of work responsibility between those who returned to the health center when it reopened and those who chose to work from home. Working from home also presented its own set of challenges for clinic faculty attempting to mentor and supervise interns remotely. A faculty mentor who was present onsite throughout the SIP described the increased workload: “I had the responsibility of overseeing everybody's interns, not just mine. I couldn't observe all of the interns adjusting their patients. I just didn't have the time to do that because I had to get on with the next intern.” Another mentor who initially worked from home before returning to the clinic said, “You get better teaching if [faculty] are there in person and can interact more with the intern and the patient directly 1-on-1.”

Participants said that patients were sometimes dissatisfied with the screening procedures, that the ability to care for patients was reduced, and that teaching and learning were affected by the time limits and social distancing. A staff member commented, “If patients had an appointment and they were prescreened, they were allowed in, but if they didn't, they weren't allowed… People get upset that we weren't allowing them on campus, and that we're actually telling them that they had to leave.” Interns could not treat as many patients, or the variety of patients as before.

Social distancing, particularly the restriction on the number of interns who could gather in their faculty mentor's office was another frequently mentioned educational challenge. One intern said, “Being able to listen in with the other interns and their questions or how they would deal with a certain condition with what technique, that's been kind of missing, for sure.” Social distancing had other effects on training:

Time constraints were mentioned by all participants as having broad effects on scheduling, appointment time, care provision, and learning, as well as being a source of stress and anxiety.

The majority of faculty and interns said, unprompted, that the 30-minute limit on appointments presented a substantial challenge to learning and patient care. A faculty mentor said, “That's probably what has been the biggest issue, keeping interns to the allotted time.” An intern worried that patients' experience would be diminished by the perception that their doctor was in a hurry. Faculty mentioned that the time limit had the practical effect of reducing what could be covered in 30 minutes by interns who are still learning and developing their clinical skills.

Some challenges were also described as beneficial. Over half of the faculty and 1 student said that the 30-minute time limit on appointments provided an opportunity for students to learn how to be more efficient, which in turn would benefit them throughout their careers. A faculty mentor said “I think it's good training. For years we told them, you have to do that, you got to go quicker. So now they're going quicker.” And another said, “I think it will [help them as they enter private practice]. It gives them a different perspective on managing numbers and managing care.” An intern, who otherwise was critical of the 30-minute limit said, “Being able to manage my time better, that's going to help me in the future in a practical and tactical way.”

About one-third of the participants said they thought that social distancing protocols provided benefit. Mandated restrictions on patient volume created more time for 1-on-1 discussions.

Most participants thought that interns' overall experiences during the SIP would benefit them in their future practice. Only 2 participants—1 intern and 1 faculty member—said that they did not foresee any long-term benefit.

Although we did not ask them about the vitalistic philosophy that guides our institution, participants described how their beliefs about chiropractic and wellness affected their experience during the pandemic. Some said they needed to reconcile their personal beliefs with compliance with public health mandates. Some explicitly disagreed with the mandates and sanitizing procedures but acknowledged the need to ensure that they were followed in the health center.

Others talked more broadly about the role of chiropractic. A faculty mentor said “Students who were there from the start felt the same as I did: value of chiropractic, self-care. They were not afraid, that's why they were here.”

Some participants said that in case of future pandemics they would recommend education and more information for all clinical staff and interns at the outset. A staff member said that if there are future pandemics, “The [clinical] staff that are not chiropractors, they don't have a background of health. I think educating [non-DC staff] at the very beginning… will help dramatically, to have data, training.” Others wanted more written direction about procedures. A faculty member who was present in the clinic while others worked from home said, “My colleagues who've decided not to come in are working from home are getting paid exactly the same that I'm getting paid…so, for me, there's an equity situation,” and suggested that that there should be equitable scheduling of on-site and remote work assignments. Many participants strongly recommended that streamlined patient scheduling and other administrative procedures be retained after the SIP ended. They commented about the improved communication, efficiency, and patient flow. A faculty mentor said, “Before…we had no idea who was scheduled because the interns would schedule with patients. Now, we can take a glance and see exactly who's going to be there, when the busy times are.”

In response to the COVID-19 pandemic and county and state public health mandates,²  our college health center closed for 1 week, convened meetings of diverse personnel, formed a task force, and rapidly implemented policies and procedures that conformed to the new and changing public health guidelines and regulations. To our knowledge, Life Chiropractic College West was 1 of the first chiropractic academic health centers to reopen for in-person treatment during a time that guidance from the federal and state-level governments, and state licensing boards was often unclear and contradictory, when it was provided at all.² 

During the early stages of the pandemic, internal challenges and external mandates necessitated some reduction in clinical services and affected teaching and learning. While this teaching clinic saw some impact on clinical services and teaching and learning in the initial stages, through collaborative planning and transparent processes, overall access to patient care was sustained, and interns were able to complete their clinical requirements. Moreover, participants said that returning to the health center provided a sense of normalcy and social connection that was missing elsewhere, and that their initial fear and anxiety diminished over time as enhanced safety procedures became routine. Participants reported unanticipated benefits that included improved time management for interns, and streamlined procedures for clinic operations that participants recommended be maintained at the health center beyond the end of the pandemic. That participants said their experiences during the pandemic expanded their understanding of chiropractic philosophy was unanticipated but is not surprising, given Life Chiropractic College West's overall vitalistic perspective.

Our findings are consistent with other reports of rapid responses to the pandemic. Chiropractic programs adapted instruction to meet their educational objectives. Some reduced or suspended in-person visits and transitioned to telehealth, others took measures to minimize the risk of COVID-19 transmission during clinical encounters.¹¹  Faculty internationally said that pandemic-related teaching accommodations had negative effects on students' psychomotor skills, while at the same time enhancing their understanding of theory and the role of manual therapy.¹²  Reports about the experiences of medical, physical therapy, and nursing students indicate that clinical education was similarly affected by the pandemic and the need to adapt to safety protocols and social distancing requirements that reduced students' patient contact hours and learning of usual procedures, while at the same time providing them with unique learning opportunities and new perspectives on clinical and community care.^13–15  Practicing chiropractors from 11 countries reported that they complied with regulations and mandates by adopting innovative strategies that enabled them to provide ongoing care, albeit sometimes in different or adapted forms and reduced numbers of patients,¹⁶  while others successfully transitioned to chiropractic telehealth formats by leveraging existing infrastructure, teamwork, and interprofessional relationships.¹⁷ 

This study has several limitations. The small convenience sample and short timeline make it impossible to measure effects on interns' grades or overall academic progression, or to compare them to students who delayed returning to the health center. Therefore, although interns and faculty mentors in our study said they saw potential academic and future professional benefit, we are unable to document this. Even though we explicitly committed to protecting their confidentiality and have no faculty responsibilities or administrative authority over interviewees, participants knew they were being interviewed by researchers from their own institution, possibly biasing their responses. In spite of this, they seemed to speak with a surprising level of candor. The findings from our small sample cannot be said to reflect consensus, particularly because only 3 of the 15 interviewees were student interns. Recruitment of students was difficult because we took steps (eg, no direct or repeated contact) to avoid pressuring them to participate. Nor are the findings generalizable beyond our institution or the unique circumstances of the early stages of the COVID-19 pandemic.

Like other institutions, our college adapted its policies and procedures as more became known about the virus and safety guidelines changed. In spite of substantial challenges, the rapid response and flexible approach in the early stages of the pandemic enabled the health center to fulfill the multiple missions of providing patient care, community support, and uninterrupted clinical education to student interns while conforming to public health mandates and guidelines. This is the first pandemic that most of us have experienced; it is not likely to be the last. The experience and lessons learned during the early stages of COVID-19 will help us respond to potential future changes during the current pandemic and prepare for future public health emergencies.

The authors thank Dr Scott Donaldson for providing access to health center personnel for recruitment and participation in this project. The authors acknowledge the work of the Life College of Chiropractic West COVID-19 Task Force, for providing campus-wide guidance on changing regulatory requirements and institutional needs.