10th Trimester: Primary Spine Care
“You do these rotations and you meet all kinds of people, and as you get to know them, you like them, which means you also have a feeling like they’re an ordinary human being, and the fact that somebody you like is doing something you find pretty cool, you start imagining, well maybe I could do that. The biggest reasons that people choose their fields is they meet people that they like, and they end up wanting to go into that field.” -Atul Gawande
When I wrote last, I left you at the close of my last trimester on school premises, after seeing 250+ patient visits, and earning an honors externship in Providence, RI. In a whirlwind week, I was fresh off of the plane from The National, a huge chiropractic conference put on by the Florida Chiropractic Association. One thing was on my mind: what was I going to do after my upcoming graduation, months away now?
I arrived in Providence in my dad’s pickup truck, loaded with the bare essentials. I had arranged a place to live by Skype after finding a roommate-wanted listing on Craigslist, and basically badgering her landlord into letting me show up on three days notice. From my paved and fenced backyard on Federal Hill I realized I’d never been to Providence and never lived in the city- any city! All I had to prepare me was a place and a time: Rhode Island Spine Center, Monday at 9 AM. I set up my bed, made some dinner, and smoothed out my white coat to be ready for the morning.
Rhode Island Spine Center is in an unassuming building at the northern edge of Providence. When North Main Street crosses into the city of Pawtucket, the very first thing you pass is the clinic (and I did pass it at first, too, because like I said, unassuming). He has been in the same office for years, as the neighborhood has changed from Pawtucket’s post-industrial feel to the outward creep of Providence’s East Hill, home to Brown University and those drawn to its influences. As an indicator, an old Macy’s warehouse across the street was leveled while I was there, giving a brief view of the river valley below before being replaced by a shiny, new L.A. Fitness facility.
The front office is like any other professional office, though the table in the reception room has two enormous binders among the usual magazines- research papers by the clinic director dating back to the early 1990’s. From a large back room was the sound of physical therapist Josh Randall already seeing his first patient of the day as I was directed down the hall to Dr. Murphy’s office. With no hesitation, he introduced himself and showed me to the intern desk- then grabbed a patient chart and got right to business with telling me the backstory of the first case of the day.
Don Murphy keeps busy generally, and my time at his office found him particularly engaged in a number of pursuits. He graduated from New York Chiropractic College in 1988, and was deeply engaged in constant literature reviews pursuit of clinical best practices since he was a student. Ultimately he opened the RI Spine Center in 1995, helped found the Primary Spine Partners in 2012, and during my time there he was in the process of establishing a new spine program with regional health system Care New England.
Clad in his usual blue scrubs and white coat, adorned with a patch for his faculty position at Brown University’s Alpert Medical School, he never stopped moving long. Patients were generally booked in back-to-back appointments, and short breaks were the time to update their patient records and write reports to referring primary care providers. Lunch was for conducting business and conference calls, and when the last patient was done, he took out the trash and headed home to his family. Rumor has it that the early morning crowd at his local gym would find him already on the stationary bike, reading the latest spine research while he pedaled.
In the clinic
As for me, I spent the first few weeks absorbing the process of clinical care in the office. Generally, new patients’ first visit was about 45 minutes. It started with a history of the problem that brought them in and the rest of their health. Next was a physical exam to rule out pathology and determine the most likely cause of the problem. Using that information, Dr. Murphy would give the patient a diagnosis and an explanation of what that meant, and his recommended course of treatment. Then he guided the patient through a strategy for controlling the complaint themselves on a daily basis. This gave most patients a sense of control over their own situation by the time that he saw them at their second appointment and began with any doctor-performed treatment.
One of my favorite patients was a firefighter for the city of Providence, who I’ll call Dave. His back pain had started while lifting equipment, and when he started, he had a hard time walking because of pain in his low back and one leg. At his first visit Dr. Murphy diagnosed him with a lumbar disc derangement, the most common source of low back pain. He showed him what we call an “end-range loading” activity and a mobilization for the sciatic nerve. In office treatment consisted of Cox lumbar distraction manipulation and assisted nerve flossing. Though Dave had to take a few weeks off from work (“I can’t wait for this to be better, I’m so bored!” he would tell us), he saw gradual improvement, returning to walking without a support within two weeks, and returning to work within the month. He resolutely wanted to avoid surgery, and once symptoms were better controlled, he continued to come in less frequently for a progression of exercises to help prevent recurrence of the issue.
Now, I find every case interesting, and I saw everything from simple spinal joint dysfunction to longer-term care for spinal stenosis among aging patients. Another case particularly other stood out for the circumstances. One morning my friend sent me a link to the podcast Reply All, with a link to an episode called “Blind Spot,” posted without comment. In it, a woman who works as a photographer develops a strange constellation of symptoms that starts with a sensation of her eye bulging… and eventually leads to partial vision loss, crippling pain, facial numbness, and muscle twitches. I started the episode on my drive to the clinic, but arrived before the diagnosis.
That morning at work a woman came in to work who also had a unique combination of symptoms. She had a deafening ringing in one ear, and headaches. She had seen doctor after doctor, endured test after test, with no results. She arrived at Dr. Murphy’s after finding an old article online which he had written in his early career. And, when he was done, that ringing had decreased significantly. His diagnosis? Tightness and congestion in a muscle that helps move the neck, the sternocleidomastoid muscle, or SCM.
SCM syndrome, I learned while finishing the podcast at lunch, was also the culprit in the photographer’s distressing symptoms in the podcast. According to Dr. Murphy’s writing, the muscle is full of nerves that are related to balance and a number of reflex functions including of the eye. In both cases, after ruling out other diagnoses with similar symptoms, the doctor was able to help the patient overcome this problem over a number of weeks. These were among the many patients with unique cases who we saw each week.
I didn’t spend all of my time at the Spine Center, though. Mondays and Wednesdays I started my morning in the auditorium at Rhode Island Hospital for the interdisciplinary Spine Conference, and then either neurology or neurosurgery grand rounds. Here I sat alongside the medical students from Brown University, the residents, academics, and the treating physicians themselves. These conversations generally focused on the most difficult cases, ones that deviated from the textbook expectations and required extra discussion before proceeding.
For me, it was advantageous to discuss the full progression of care for patients, from the most conservative approaches to the most invasive, from diagnosis to treatment to rehabilitation and return to daily life. This included patients I might commonly see in practice, presenting with trouble walking, or headaches. For a given low back pain case, an appropriate pathway to care might start with modifying activities, and proceed to exercise, manipulation, medication or injections, and some form of surgery, depending on the level of intervention required. There was a lot of back and forth on what the best procedures would be for good outcomes, which really illustrated that multiple routes to care can be reasonable for any problem. Writing this now, this debate seems intuitive, but it can be eye-opening from the perspective of a student, used to knowing the “right” answer in exams.
I saw hospital specialists’ work in action while shadowing in the neurology department and elsewhere. I got to sit by and talk to doctors and patients during EMG and nerve conduction tests, evaluating for conditions like carpal tunnel and other nerve entrapments, as well as multiple sclerosis. The neurology staff and residents turned out to be a fun, if overworked crowd, who knew good places to catch a drink, oysters (obligatory Rhode Island fare), and local bands (then they would head straight home to attend to the rare and treasured activity of sleeping). Spending time with them helped me to understand their perspective on patients which we might co-treat, and their clinical reasoning.
My clinical experience in Rhode Island was wildly valuable. Back at my apartment on Federal Hill, though, the last traces of class were in a stack of projects for our last formal course, “Marketing Strategies for Healthcare Professionals.” This class was time-consuming, but the assignments were excellent. Covering a number of topics from previous healthcare business classes, we applied principles of ROI, market analysis, competition assessment, and other strategies to create ethical, pragmatic practice marketing plans. Additionally, Dr. Napuli emphasized the need to serve your community fully, so our work also included planning a philanthropy project in the practice’s region. As someone who had long planned to run my own business, I was able to use the products of these assignments to create fully functional components of my actual business plan.
What did I learn from the experience? To start, I gained an incredible insight into one of the most skilled, knowledgeable, and forward-thinking conservative spine care practices in America. I had the opportunity to genuinely learn from a variety of types of practitioners about the best care for patients with spinal disorders. But I also answered a my primary question from the past year:
I knew, for sure now, that I wanted to be a Primary Spine Practitioner.
Brendan McCann is now a graduate of New York Chiropractic College, and a doctor of chiropractic working as a Primary Spine Practitioner in Manchester, NH.
Donald Murphy is Director of Primary Spine Care Services for Care New England Medical Group. You can learn more about Primary Spine Practitioners’ role in Dynamic Chiropractic or in more detail in this journal article. His two (excellent) clinical texts are available on Amazon.
Love and luck goes out to my classmates, now practicing in clinics around the continent. Thank you for all the support. I’ve enjoyed writing about our shared experience and hope to continue having stories to tell as we improve health and healthcare in the next generation.