“It's the most important work we will ever do”: Chiropractic students, servicelearning experiences at a day laborer center in California

Service learning in institutions of higher learning provides students with an enhanced, hands-on, community-focused educational experience.^1–4  In chiropractic education, service learning often takes the form of short-term projects and international service trips in which students treat patients in locations where there is limited or no access to chiropractic care.^3,5–9  In 2009, Life Chiropractic College West launched Mission Trip: America, later renamed Service Trip: America (STA), to provide monthly free chiropractic services at a hiring hall for day laborers in San Francisco and to “extend the spirit of the school's traditional international mission trips to the American home front.”¹⁰  STA was structured around the college's commitment to service and the program founders' social justice–based vison of health care and health promotion based on social health determinants as well as access to care. STA's mission is to promote the health and well-being of underserved individuals through service provision, cooperative learning, and collective action with local community-based nonprofit organizations.^10,11  STA also aims to educate the community and increase public awareness about chiropractic.⁷ 

From 2009 to 2019, until the 2020 COVID-related hiatus, approximately 200 student volunteers participated in STA and provided free chiropractic care to more than 700 patients during monthly site visits at a Day Laborer Program (DLP), a nonprofit hiring hall in the San Francisco Bay Area.⁷  The DLP provides referrals to employment and social services to an underserved, mostly male population of low-income manual laborers, many of whom speak primarily Spanish and may be homeless or marginally housed. Day laborers often have limited or no access to regular sources of health care^12–15  and may perform heavy labor without the assistance of proper equipment.¹⁶  Individuals show up at the DLP to register for work assignments that become available that day. When the STA clinic is on site, laborers can sign up to receive free chiropractic care. The number of patients seen during any given STA site visit is largely determined by the number of DLP clients and student interns who are present.

STA is staffed by a team of volunteers: the program director, a faculty member who serves as the supervising licensed chiropractor, and students who serve as assistants or interns. Students and faculty sign up for the monthly site visits. About 30 currently enrolled students are approved to participate at any given time. The team brings records, adjustment tables, and other supplies for the 4- to 5-hour chiropractic site visits. Assistants conduct outreach to DLP clients, greet and register patients, conduct orientations and give health talks, manage patient files and patient flow, conduct initial patient intake, and complete other forms as needed. Interns review patient health history, conduct physical exams and assessments, perform adjustments, and complete Subjective, Objective, Assessment, and Plan (SOAP) notes. Only students who have completed the appropriate coursework and have been cleared to treat outpatients at the health center may serve as interns at STA. Students who are not yet qualified to treat outpatients may serve only as assistants. To participate in STA, student volunteers must be currently enrolled with a grade point average of at least 2.5 and trained in the provisions of the Health Insurance Portability and Accountability Act (HIPAA).^10,11 

We met with the STA program director to support the program's ongoing quality improvement activities¹⁷  and its goal of maintaining the mission of the program through continuing reevaluation.¹⁰  This report focuses on the STA's service-learning objective of enabling students to experience service by providing free chiropractic care to underserved populations. We present information that we obtained during a mixed-methods process evaluation.¹⁸ 

Site visit summary sheets and interviews served as data sources. Records of 104 monthly site visits were recorded from 2009 to 2019. We abstracted the following information: number of student interns and assistants present, number of new and return patients treated, and types of health conditions seen by interns. Patients' presenting conditions were recorded in monthly site summary reports by type but not quantity. For example, if 4 patients presented with lower back pain, this condition was recorded only once on the summary sheet. The summaries also included comments taken from patient evaluations and staff observations and recommendations.

STA volunteers were informed about this project by the program director through the STA program email list volunteers. Anyone interested in participating contacted us directly. We obtained informed consent and conducted 30- to 45-minute semi-structured interviews using interview guides that evolved iteratively throughout the project.¹⁹  We asked participants to describe their experience in STA: what was learned and how the program affects students, faculty, and the larger community. We also asked about the program's strengths and challenges and for suggestions going forward. We spoke minimally and probed as needed for more detailed information and conducted interviews until saturation.²⁰  Interviews took place via GoToMeeting teleconference (LogMeIn Inc., San Francisco, CA, USA). The software provided transcripts, which we then checked against the audio recordings and corrected as needed.

We tallied yearly averages of the numbers of patients and volunteers, the percentage of new and repeat patient encounters, and the average number of patients seen by each intern per site visit. Although we did not have patient frequency data on presenting conditions, we reviewed the summary forms for the different types of conditions noted each month and grouped them into categories.

Three authors (FS, MS, DHO) read through 3 transcripts to develop a coding scheme for thematic analysis.^19,21  We used deductive and inductive processes to develop a codebook with main categories (themes) and subcodes. We had biweekly team meetings and made adjustments, then double-coded 2 additional transcripts. We achieved thematic concordance of 80%. Two authors (FS, DHO) then single-coded and discussed the remaining transcripts and selected typical and contradictory quotes, which were organized into a tabular matrix of quotations.²²  We resolved differences by consensus.

We did not access or use HIPAA-protected patient health information or Family Educational Rights and Privacy Act–protected personally identifiable student information in this study. All interviewees provided informed consent. The project was reviewed and approved for exemption by the Life Chiropractic College West institutional review board.

From its inception in 2009 until 2019, the last year before the 2020 COVID-19 hiatus, the STA staff produced summaries of 104 site visits comprising 2272 patient encounters, including 3 DLP pilot site visits and 1 pilot visit to the Women's Collective at the DLP site. The number of site visits per year ranged from 8 to 11, and the average number of patients per site visit was 22. Return patients made up 60% to 85% (median 71%) of patient encounters (Table 1).

On average, 2 assistants and 3 interns attended each site visit, along with 1 licensed chiropractor or faculty supervisor and the program director. Interns treated a median of 8 patients (range 4–9) during the site visits (Table 2).

Day laborers in the DLP are typically male, but they are invited to bring family members to STA for chiropractic care. DLP female and male staffers are also encouraged to attend. Patient gender was not regularly recorded on the site summary forms until after the evaluation project began. In 2019, the only full year for which this information is available, 14% of patients were recorded as female (not shown in tabular form).

The presenting complaints of patients (Fig. 1) consisted mostly of musculoskeletal (MSK) issues, with many of these being assessed by interns as radiating from spinal involvement and responding favorably to chiropractic adjustment. Other physical health problems were also commonly reported. In addition to the conditions mentioned above, which are routinely seen at chiropractic offices and teaching clinics, at the DLP site interns also saw chronic health problems exacerbated by such social health determinants as poor living conditions, violence, limited access to health care, chronic stress, and the extreme biomechanical loading resulting from heavy labor. These contributing factors were expressed in many of the functional-based presentations described during the history taking and in a basic neurologic analysis and review of systems. The physical, mental health, and psychosocial issues recorded on the site summaries illustrated profound and unique circumstances and needs of the population being cared for at the DLP by STA interns. This was further elucidated by program volunteers as they recalled examples during our interviews with them.

We interviewed 3 members of the faculty who served as supervising DC supervisors, and 9 former and current student volunteers. Four of the students served in the role of assistant only, and 5 as intern or both intern and assistant. All but 1 of the respondents attended multiple site visits, from 3 to more than 30. Eleven of the respondents characterized their experience as positive; 1 respondent was strongly critical. To protect confidentiality and reduce the risk of deductive disclosure, we do not report respondents' gender, current/past volunteer status, or the number of site visits they attended. Our analysis yielded several themes: learning, challenges, program strengths/benefits, and respondents' attitudes. We also report participants' advice for STA going forward. We present typical quotes from all of the individuals whom we interviewed. Unless otherwise noted, quotations represent the views of multiple participants.

This overarching theme was by far the most discussed by respondents and fell into 3 subcategories: knowledge/skill building, patients, and tasks. These were interconnected, and we present them together.

Assistants and interns performed educational and administrative tasks including outreach and patient intake. “We're from Life Chiropractic College West. We're offering chiropractic care. This is what the adjustment does. It's a basic intro.” Another explained, “We get the participants from the day labor program to come in and actually receive care. So, we have to communicate with those people … and we have to make sure that all of the paperwork is done according to … the guidelines of the program.” They also said that they gained valuable experience in maintaining records, assuring confidentiality, applying rules and guidelines, and clinic management.

Interactions with patients of low socioeconomic status and who spoke little or no English were described by half of the respondents as opportunities for learning how to communicate effectively with culturally and economically diverse patient populations. An intern who, like most of the volunteers did not speak Spanish, said, “You're learning how to communicate differently so [the patients] understand what you're saying … which then in turn was also a benefit for me because I had to really understand the concepts of what I was saying.”

Eleven of the 12 respondents said that at STA, interns see conditions that would not normally be seen at the college health center. These comments were consistent with the summary sheet information about conditions, shown above, that interns treated. A faculty supervisor said, “In this environment [students are] getting a chance to work with some very acute patients. We've had patients who have talked about things like suicide.” Another said, “A lower income population …, workers who had never had chiropractic care before but yet had a history of trauma or multiple traumas … an experience that [students] might not get at the health center at the college.”

Most students seemed particularly sensitive to patients' lived experience. This was reflected in comments such as, “[The patients] tell you about their daily life, which from some of the stories they told it was not a pleasant scenario for a lot of them,” and “a fair number were cut off from their families.” Most of the students we interviewed commented on what they described as effects of the lack of access to care. Typical comments included, “The most eye-opening thing was that in some cases we were the only type of health care that these people receive,” and “They were generally middle-aged men who have been doing physical labor for years and they had all kinds of injuries, … they have chronic issues, there things that they haven't gone to go see a doctor before.”

When asked why they participated in STA, 8 students and 2 faculty said they were motivated by their desire to help underserved populations or that they were committed to community service in general. Four students said that they wanted to gain real-world experience and the accompanying skills. One student said they joined STA to fulfill an academic requirement. Two of the faculty said that they wanted to enhance their teaching. A student assistant said, “To me it's the most important work we will ever do … the exact kind of work that I want to do as a chiropractor,” and another said, “[The experience] helped boost my confidence … I have to go with my instinct and trust that my fingers palpated something and that chiropractic works.” A faculty supervisor said, “It was great to serve that population. You know chiropractors in general are in service. And so it was very rewarding to be able to serve a population that otherwise probably wouldn't get the treatment,” while another commented, “This is my opportunity for me having trained these interns earlier … it's a great joy to see their growth … really rewarding personally and professionally.” Most of the students described their interactions and the DLP patients with compassion and understanding. A student said, “A lot of the people that were the patients in the clinic, were extremely hard-working some were homeless … it helped me empathize and just understand that people come from all walks of life.”

Comments about working with severely marginalized patients were not all positive. A student expressed wariness about working with homeless individuals: “Where [I live] there's 10 homeless people outside my house so, you know … we always kind of got to be on guard with them.” One said that patients “who are off the streets” might bring in “drugs or other harmful things.” Another said that some homeless patients' personal hygiene was an issue, but said, “I have made this commitment to be here and be a service. I want to give them chiropractic care. I'm going to do my best to serve.” More often, students said that they were grateful for the experience:

One faculty supervisor and 5 students said that their experience at STA either had or would influence their interactions with patients in their current or future practice, with 4 saying that they were committed to providing pro bono or affordable services.

Participants identified challenges that included the constricted physical space, language, and culture barriers, some of which were identified by faculty and students as contributing to the learning experience. Eight said they thought the program was underresourced, mentioning inadequate promotion at the school and lack of support for materials, parking, and administration. A student said, “Limited resources and things like that [are challenges] but truthfully I kind of feel like that kind of enriches the experience,” and another commented that “it's just a really great experience for everyone; [to learn] how it can be difficult to communicate if you're communicating with somebody that speaks a different language.” The bare-bones setup for the clinic was mentioned by 7 participants as challenging; 3 of these said they benefitted by this as well. A student said, “Sometimes the space is a challenge, [but] it's a great opportunity to see that really all you need is a broom closet and table to provide chiropractic care really, if you've got to make it work.” One student presented a more negative perspective:

Seven of the 12 interviewees described language as a challenge for patient-practitioner communication, with 4 commenting, unprompted, that this challenge proved to be a benefit in that they found effective work-arounds or learned other, nonverbal ways to communicate. Two of the remaining 5 said they were fluent in Spanish, and the rest either did not mention language issues or said it was not a substantial issue. Other frequently mentioned challenges were lack of adequate resources and the difficulties maintaining consistency with an all-volunteer team. A faculty supervisor explained that at the college health center, “an intern gets to work with the patient over time and gets more and more familiarity with the patient and the patient's condition, this is often a 1-time treatment between the intern and a patient.” A student said she should have more support from the college: “There's so much more she might like to do but it's just not possible with her two hands and two legs alone and her one brain.” Faculty supervisors and students mentioned times that site visits did not take place because there were no faculty or student volunteers, and at 2 visits, the faculty supervisor was there alone and treated all patients.

The ongoing presence at the DLP of the STA clinic, which took place 8 to 11 times/year, was repeatedly mentioned as a strength. A student said, “I think the fact that it was a monthly thing was really important … it offered access to healthcare to a lot of people that didn't have other than perhaps an ER.” Another pointed out the long-term nature of STA:

This consistency was ascribed to another program strength: the good leadership provided by the program co-founder and director who, like everyone else at STA, was a volunteer and who was present for 103 of the 104 site visits. A faculty supervisor said, “It takes a leader to keep this going. Applauds to her and she should be commended for her good and consistent work in maintaining this program.” Participants also talked about the benefits of STA for students, patients, and the larger community. Six respondents said that STA would benefit current students or had benefitted graduated students and their patients as they establish their own practice.

As part of the evaluative process, we asked respondents for advice about STA going forward. Suggestions included upgrading the facility, expanding to other community-based service organizations, increasing the frequency of site visits, providing transportation to the site, increasing outreach to garner more volunteers, providing more support to the STA administrator, and dedicating more institutional resources to the program. One student suggested partnering with other schools, including chiropractic, acupuncture, and others, to deliver integrative health care to underserved populations.

STA presents student volunteers with a wide range of real-world learning opportunities, including clinic management, navigating cultural and language differences, and experience working with patients and health conditions not often seen in the college health center. As is typical of chiropractic offices and chiropractic teaching clinics, presenting complaints of DLP patients consisted mostly of MSK types and other health problems that might or might not be related to MSK issues but are familiar to many practicing chiropractors as patient presenting complaints or comorbid conditions. These conditions were largely assessed, diagnosed, and treated during the patient encounter/visit within the chiropractic clinic. However, STA patients, as is typical of day laborer populations,^12–15,23  experience health and social disparities related to social conditions, discrimination, documentation, anxiety, stress, and cultural factors.

Faculty and students alike commented on trauma-based conditions, mental health issues, and complex cases as unique components of their teaching and learning experience. Language barriers and cultural differences presented volunteers with opportunities to learn about the role of understanding and cultural competence when working with a severely marginalized population. The beneficial effect of real-world experience on students' knowledge, skills, and social understanding appears to be a frequent hallmark of service-learning programs.^1–5  Others have found that service learning has been associated with higher grade point averages and increased graduation rates.^24–27  We did not access student records and cannot comment on the effects of students' participation in STA on academic achievement. However, it appears that for some students and faculty, the experience was profound. Consistent with others' findings that students in service-learning programs report an increased sense of civic responsibility and commitment to volunteerism and community service,^1,4  STA volunteers said that they were committed to working with underserved communities after graduation or that they had already incorporated community service and/or fee structures into their practice. For years after their participation in STA, graduates continued to contact the 2009–2019 program director Lori Pino, a co-author of this paper, about replicating STA in their area. Hopeful about the spirit of the program continuing much in the way it was originally intended, she sends a digital package of STA policies, procedures, and templates that could be modified and improved upon for years of dedicated service to come. Similarly, co-author and STA faculty supervisor David Currie reports that 3 of the college's graduates who were involved with the program have sought his advice and assistance to create a similarly designed outreach program for students and doctors to work with underserved populations in China in coordination with local hospitals. They deliver integrative health care comprising chiropractic, medical, and Traditional Chinese Medicine.

Our convenience sample of interviewees was small, but our findings are consistent with other reports that service learning supports students' understanding of social and contextual issues that affect marginalized communities as well as their commitment to volunteerism and expanding access to care.^1,24  The information we abstracted from the program documents was not collected to be used as research data. We understand and acknowledge the challenges of assessing information that was not collected for research purposes. Due to concerns about meaningful consent and community mistrust of research,²⁸  we did not examine medical charts or interview patients, nor did we access the evaluation forms that were collected from patients during each site visit, so we cannot comment on the patients' perspective in this report. Despite these limitations, we believe that there is value in reporting on this unique program that was founded in love and compassion, with the intent of providing services to severely marginalized populations with little access to health care. As service trips restart, the institution plans to work with the program coordinators to collect information for future analysis and evaluation while being mindful not to interfere with the delicate balance that can exist when working with marginalized and immigrant communities.²⁹ 

STA volunteers typically described their teaching and learning experience to be profound and in some instances transformational. In addition to the MSK and conditions commonly seen in chiropractic offices, students often worked with patients and conditions that they did not normally see at the college health center. Caring for the day laborers engendered a sense of being seen, heard, and validated not only for patients but also for those providing services. Although not generalizable, the results provide guidance for service trips going forward and for other community-based chiropractic service-learning programs serving marginalized and underserved communities.

We thank Carlos Lapresca for research assistance and categorization of conditions seen at STA.