How To Transition From a Chiropractic Student in Clinic to Clinical Practice An Interview with Dr. Dino Pappas

Dr. Dino Pappas is a chiropractic physician, certified athletic trainer, and certified strength and conditioning specialist in Austin, Texas who did a talk at Logan College called “the transition from clinic to clinical practice and organizing your toolbox.” Can you recap that talk for us?

Dr. Pappas: There is no one roadmap to transition to clinical practice. Everybody's path is just a little bit different. Trying to figure out the right situation for you is challenging. After about four to five years in practice I went back to the chiropractic school that I graduated from and I did the presentation you mentioned where I talked about the life advice I learned along the way.

Noah: Did you feel adequately prepared when you got out of school or were there additional trainings or additional things you did to develop the clinical skills to work with complex cases?

Dr. Pappas: I was fortunate because I worked as an athletic trainer and I had a Sports Medicine background with the orthopedic skill set that is commonly found in traditional chiropractic practice. In school I realized I had so many more questions than I did answers so I found really good mentors. I'm going to plug my mentors here. Dr. Thomas Lotus and Dr. Brett Winchester helped mold me into what I am today and the hardest thing for young chiropractor like yourself is they're going to learn a lot of technique, soft tissue and reahab, but no-one will teach them how to integrate it into one comprehensive system. One of the things that helped me organize that toolbox and shrink that toolbox down was the McKenzie method. That sits at the core of how I evaluate and assess a patient and classify them. I find I get the best approach in the shortest amount of time and reproducible results. It's the scientific method applied to patient care and from that I branch off into different tools and techniques.
Noah: Can you talk about how you use McKenzie?

Dr. Pappas: One of the misconceptions about the McKenzie method is that it's just a set of exercises, that it’s extension, or it's flexion, but the reality is it's a system of evaluation for getting the relevant information in a concise format so you can process that and apply the right treatment whether it’s hands-on manual therapy or another approach. Many doctors have it backwards, we start with manipulation. We want patients to be active, we want patients to take ownership of the situation so shouldn't we start with exercise first and then eventually progress into more passive things.

In chiropractic we are told to manipulate first and ask questions later, so the method is based on a scientific method where you form a hypothesis and you assess it and you prove it right or wrong and either way you get information that helps you classify the pain mechanism. What is the pain driver? Is it tissue nociception? Is it centrally mediated pain? Is it from the peripheral nervous system? Is it from the autonomic nervous system? If you can classify the pain mechanism and if you can classify what condition is going on its more likely that you'll be able to apply the right strategy. It will lead you down the path to the right strategy.

Noah: What do you see is the future of chiropractic and what direction would you recommend for students?

Dr. Pappas: I keep it simple. What are you passionate about? I'm passionate about sports medicine and orthopedic injuries so that's what I structure my practice on. There was a study done in 2005 and it predicted the future of the chiropractic profession and it came up with four scenarios.

1. Chiropractors would do what they’ve always done and restrict practice to mostly manipulation. They will follow the traditional doc in box model. One doctor, in one office who does manipulation and does extended treatment plans. They predicted that over time that model would go belly up.  Karel Lewit said that if chiropractic restricted itself only to the thrust manipulation it would go the way of the dinosaur and this guy is the godfather of modern manual medicine.
2. Another possible future is that chiropractors grow into the area of comprehensive integrated neuro-musculoskeletal care. They become the point of access for conservative orthopedic and rehabilitation injuries. They will be the point of contact for the entry level into conservative spine care and there’s going to be a growing demand for that because of the opioid crisis. Because of evidence-based medicine and cost-effective outcomes with soft tissue injuries we are showing that conservative care by utilizing an evidence based chiropractor or by utilizing an evidence based physical therapist is a viable option for successful outcomes and rereducing out of pocket expense by keeping patients out of the orthopedist's office when they do not need to be in the orthopedist's office.
3. Chiropractors can become the wellness life doctors, not my words. They can become better equipped to be a primary care physician. As long as the scope in your state allows you to, primary care physicians that do simple things like take blood pressure, conservatively manage or co-manage diabetes and help with other conservative primary care issues are in demand. These chiropractors can help patients navigate an increasingly complex health care system and spectrum. There is a huge shortage of Primary Care Providers across the United States, especially in underserved areas. A well trained chiropractic physician in a primary care role can help fill some of this void.
4. The last thing was growth in geriatric care, because the American population is aging. That has to deal with the Medicare model which is not currently sustainable.

The two most logical and plausible scenarios are being the conservative soft tissue and rehab expert for the spine and other joint based problems along with being the conservative primary care physician.

Noah: In order for students to prepare themselves for this type of practice model what would you recommend?

Dr. Pappas: Find some good mentors, people that you know, like, and trust. Doctors that are highly respected in the industry. They will point you in the right direction.  If you're thinking about going into an integrative setting then set up your professional network and call up the primary care physicians, call up the orthopedist, call the neurosurgeons, and say I need to grow my professional network because I want to be able to find good people to refer to. I guarantee you they have no clue what a good legitimate evidence-based chiropractor does, just like you’ve never been exposed to neurosurgery, physiatry or other medical specialties. Build community. Develop a good referral network.
The common misconception that people make when they want to set up integrative relationships with medical providers in the area is that they are looking for too many connections. You're only looking for a couple. Quality is more important than quantity. If you have a relationship based off of communication and concern for the patient that turns into a good business relationship because you want to send your patients to the best in the area. Find the one or two good doctors in the area and hone that relationship. It is those one or two doctors that are going to build your practice and your reputation - it's a synergy, it’s a beautiful synergy to have.

Noah: I feel like there’s a psychosocial aspect, a personal development aspect of becoming a doctor and developing trust and developing rapport. How do you work with that?

Dr. Pappas: The patient-doctor relationship is an underappreciated part of being in clinical practice. How the doctor acts can either induce harm or can facilitate healing. What you say as a doctor makes a difference in the prognosis and the outcome for that patient. You have to remember that patients are scared because they don’t know what’s happening to them. Especially if it’s the second or third episode they may be afraid that they are going to be crippled. You have to find strategies in clinical practice to disarm them by telling them the truth and put a positive spin on it.

They don’t teach that in chiropractic school, they don't teach that in medical school and it's just being empathetic. Recognizing that you don't have all the answers, being honest, and doing your very best one patient at a time. People can respect that and you're human. You learn that there's some little tricks that you learn over time by having good mentors or using the right outcome assessment to realize there is a psychosocial issue at play. Reading books like “World of Hurt” or "Explain Pain" or other work on the psychosocial aspects of pain helps to learn the clinical art of what you say to the patient and how it makes a huge difference in the patient’s life.

Noah: You are constantly reassessing what works, looking at the research and integrating all the new information and synthesize it. Can you explain how you do that?

Dr. Pappas: It's a comprehensive evaluation and assessment in order to answer the four questions patients come with. These are:

1. How long is this going to take?
2. What’s the relative cost to me going to be?
3. Is this something that I'm going to have to learn to live with?
4. What are the potential complications that can occur?

I answer those questions. The first thing I do is introduce myself and say to them “I am here for you, there's only one person in this room I have to get it right for and that person is not speaking right now; so at any point in time please ask me any questions you have because this could be the first time you're hearing this.” Most doctors take it for granted because we have this body of information and we can flip into doctor mode and away from patient mode very quickly and lose the patient. When up front you show caring, concern and empathy patients are like, “wow this is actually somebody that's going to listen to me and answer all my questions.” At the end of the session I give them my cell phone number and invite them to get in touch with me if they need because I need to get this right for them so I make myself accessible in order to gain their trust.

Then I move into McKenzie mechanical assessment. What's going on? How do I classify the patient? Then I switch from talking about pain and start training positioning and working with what their goals are and that's a key piece of the history. What is keeping you from doing what you enjoy? What is the impact on your quality of life?

The transition from pain to performance comes somewhere between three to five visits. We focus on activities of daily living. That’s where we move into a functional movement screen or another specific sports specific screening. I see it as a pyramid and the concern and care is the foundation of everything.

There is a difference between lifetime care and lifetime treatment. Here's what I mean. I'm an advocate of lifetime care. I am NOT an advocate of lifetime treatment. That recommendation is usually not patient centered.

There is a difference with lifetime care vs. treatment. I want to earn your trust so that later in life when you tear your rotator cuff and you need surgery or you tear your ACL you'll come to me and ask me for referral. That's lifetime care. Lifetime care is when you trust me enough to help you make decisions with your health. In this case, it's coming to me first by trusting me and my expertise for the referral information.  

You come back in four or five years or whenever because you know, like, and trust me. I want that lifelong relationship, I don't want to treat you forever, but I want to care for you forever. I want that relationship to last longer the course of your treatment.

Noah: Thank you so much, I really want this profession to thrive.

See the full interview here: https://youtu.be/n4f0ipq1ho8