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.
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:
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
Writing with originality, generosity, compassion and purpose, Dr. Noah Volz imparts valuable lessons in an entertaining, engaging and snappy way―backed by a wealth of experience. As an author, chiropractor, and entrepreneur, he has started and run multiple companies and has been the host of the DC2Be Revolution YouTube channel and podcast.