Dr. Gowan is a 1991 graduate of the University of Houston and a 1995 graduate of Cleveland Chiropractic College – Kansas City. After three years of private practice in Houston, he was a full-time faculty member at Cleveland College from 1997-2005, and has remained an adjunct member of the faculty since joining the VA in 2005.

Gowan is married and has four children. He is active in church and scouting activities. He also coaches junior high boys’ basketball for Center Place Restoration School in Independence, Missouri.

Tell us about your typical day at the Kansas City Veterans Administration Hospital?

It is mostly filled with patient interaction. We see patients about every 15 minutes on return visits, with about an hour for new consults. The consult includes the history and exam, and in some cases an initial treatment as well. The one thing that’s unique about the VA is that we’re a specialty clinic. We’re not a portal-of-entry clinic in the sense that all the patients we see are screened beforehand, either by the primary care physician or another specialty clinic that is referring the patient for chiropractic.

That differs from private practice, which is the way most chiropractors in the United States function. It sounds like one advantage of your setup is when you first see the patient, you already know that the worst case scenario diagnoses have been screened out. Does this allow you to focus more quickly and intently on the sorts of things that are central to most chiropractic cases?

First, I want to emphasize that it is important for the chiropractors to remain a “direct access” and portal-of-entry profession. It is vital that we maintain this traditional role of chiropractic care while at the same time expanding our opportunities to integrate chiropractic services within the standard medical model at institutions such as the Veterans Administration.

Now, to answer your question, I find that the screening process works in our favor in the sense that it narrows our focus down to the typical musculoskeletal complaints that we deal with most in chiropractic. There are occasions where something comes up, where there’s a bit more of a nuance. When it does, we communicate this via our electronic medical records system, which is an open system that all providers at the VA can access information from. So that allows us to communicate concerns about, maybe, a patient having a visceral type of problem, or a deeper neurologic diagnosis that is invading into our musculoskeletal complaint. So we’re able to communicate that back and forth.

Since the VA setup as a specialty clinic differs from private practice, in that you are only seeing patients who are referred to you by their primary medical physicians, how is collaboration and cooperation among the different health professionals fostered and encouraged at the VA?

I did some of this preemptively. When I was first hired, I made it a point to go and communicate particularly with the primary care providers, because that’s where our initial source of referrals was going to come from. I also prepared a PowerPoint educational program on chiropractic that would be self-administered and I put that on the employee education system on the intranet at the VA. I think that actually got posted in such a way that it could be accessed by people at other VA facilities. That allowed other physicians throughout the specialty clinics, and even the residents rotating through in primary care, to access and view some basic information about chiropractic, our educational standards, our background, and our focus. It also provided the pathway on how to make a consult and gave an introduction to chiropractic and to chiropractic services within the facility.

This sounds like the kind of thing that chiropractors have long sought, to have it become ordinary for chiropractic to be an integral part of the overall health care delivery system. To what extent do the rotating residents, who are medical doctors, interact with chiropractors and observe chiropractors doing their work?

From a standpoint of observation, that’s been fairly limited, mainly because everybody’s busy doing their own thing. We’re hopeful that in the future there will be more direct interaction, but for now, at least at my facility, most of the interaction is indirect, via rumor, myth and legend, as well as by notes and records.

Are there also medical students, as well as residents, who come through the VA?

There are. Actually, one of the things that I wasn’t aware of is that the VA health system is the largest (for medicine and nursing) educational opportunity in the country. It performs the largest amount of research that is not funded privately. One of the core missions of the VA is to increase clinical education and research. Also, many of us in the VA have some sort of academic affiliation, with multiple chiropractic colleges. We’re really starting to fit into that system and be an integral part. It’s not a step-child mentality.

Does the Kansas City Veterans Administration Hospital have an affiliation with Cleveland Chiropractic College because you are on our faculty and work at the VA as well?

I was in a unique situation because when I first started at the VA in 2005, it was as a part-time employee. But I still was a fulltime faculty member at Cleveland Chiropractic College. Over time, that changed from where I was fulltime with Cleveland and part-time with the VA, to where I’m now full-time with the VA while still holding an adjunct position with Cleveland.

As part of this affiliation with Cleveland Chiropractic College, I know that some Cleveland students are able to go to the VA. What role do they play there? Is it mainly observation?

For the most part, it’s observational. They do get to interact with patients as far as assisting in history and examination. They’re able to attain some of their minimal clinical requirements for graduation. But the focus isn’t on their requirements as much as it is for an extension and an enhancement of their clinical educational experience.

In what ways would you say their educational experience is enhanced by having this rotation at the VA as opposed to other educational opportunities?

Some people might say that because it’s observational, it’s limited. What I’ve seen, and what I’ve heard in their feedback, is that it is completely different than the typical field clinic. Students are able to see how the chiropractic services can be integrated into a traditional medical model, and yet still maintain our distinct and unique position as a health care provider in the system. I think that’s number one. Number two is that they’re exposed to a different demographic of patients. Most of our patients at the VA have multiple comorbidities, complicating factors that are different from the presentations you would see in the typical private practice.

In the field, you will occasionally see a patient that has three or four comorbidities, whether it’s hypertension, diabetes, some sort of visceral situation, multiple degenerative changes, myelopathies or radiculopathies. In the VA, we see that regularly, in 75 percent or more of patients. In the field, you may see 10 to 25 percent of your population that way. On top of that, we have traumatic brain injury situations, spinal cord injury situations, so you have a special demographic. And, of course, you have the PTSD [posttraumatic stress disorder] and other psychogenic aspects that come along post-war. That makes a different mix.

Is it that veterans have poorer health overall compared to the general population? Or does the fact that you’re part of this integrated system, which includes primary care for all vets, mean that you draw on a broader portion of the population than a typical chiropractic practice?

I think it’s a little bit of both. One, I think it’s because the patients with that many comorbidities are typically in the medical model for those comorbidities. Within the VA system, there are frequent opportunities for a primary care provider to say, “I think chiropractic would be a good supplement for these other conditions we’ve been seeing you for, because there’s a musculoskeletal complaint with it. So why don’t you see the chiropractor for that.” The other thing is that the patients themselves are a little bit different. I don’t know how many of chiropractors in the field are going to be exposed to the amount of PTSD and traumatic brain injuries that we’re seeing, particularly in the veterans returning from Iraq and Afghanistan. So I think that it’s maybe a combination of both of those things.

While retaining patient confidentiality, can you talk about a case or two that you saw at the VA that was particularly satisfying?

There are always those nuggets, those gems that are beyond your expectations and remind you that the reason that you went into chiropractic in the first place is the reward of that patient interaction. I had an experience this past week with a veteran where, on paper, I would normally have thought, “What can I really do for this individual?” It’s someone who has been a paraplegic for 20 years, who had an incident where he fell and fractured T8, his eighth thoracic vertebra. It was unstable and ended up causing a cord contusion that led to a significant amount of bruising. Of course, at that time technology was more limited than what we have now, as far as proteolytic enzymes and other methods for decreasing the inflammation in the cord. He ended up being paraplegic, and also ended up with Harrington stabilization rods in the thoracic spine to stabilize the fracture. Ultimately, now, 20 years later, he woke one day with acute neck pain and a classic C5 radiculopathy into the upper part of the lateral arm. The bottom line is that by the time I was able to have the consult come to me, he had already had a Medrol [steroid medication] pack, so most of the acute inflammatory response, most of the acute symptoms were resolved. But he still had a very bothersome kink in the neck and some tingling in the upper lateral arm.

As I said, when I looked at it on paper and saw all the complications, I wondered how I could help this person. His imaging studies showed gross amounts of degenerative changes, and even a disc that was impinging on the nerve root at the lateral recess. But I had made a rule for myself that I would always see patients in person rather than looking at it and filtering it by the electronic consult. So we brought the person in. It turns out that he’s very active, very much engaged in his health, and is very aware of his limitations and his possibilities. Ultimately, his exams showed nothing that would be a contraindication to spinal manipulation of the cervical spine. While he was in his wheelchair, I applied his first chiropractic adjustment and there was instantaneous relief from the lack of motion and also a decrease of the tingling sensation he had in the upper arm.

That’s going to lead to a happy patient as well as a happy doctor.

Absolutely. It was a fantastic experience and it reminded me that we so often categorize our patients by condition and symptom rather than looking at them as individuals that are trying to survive in the environment that they’re in, whether it’s a physical environment, the emotional stressors of life, the lifestyle choices, whether it’s lack of water and too much coffee, or whatever it may be. So when you start interacting on that intimate personal level, it really does allow you to have interactions that are beyond the classic symptoms or conditions.

Do chiropractors working for the VA have to be military veterans? Do you think it’s helpful if they are veterans?

No, they do not have to be. I am not a veteran. Many of us who serve as chiropractors in the VA are not veterans and there are some who are. I know that the VA does give preference in hiring to those who are veterans, if there are two doctors with identical credentials. But they don’t limit hiring to veterans.

When I applied, it was a brand new program and no one in the VA knew much about chiropractic. I think I was approximately the 16th chiropractor in the country hired by the VA. But my thought at the beginning, and what still engages me in the process, is that it was an opportunity to serve a population that I have a lot of respect for. I think, in a way, this is my service.

So if a student, or a practicing chiropractor, felt called to this kind of service, the fact that they themselves had not served in the military would not be an impediment.

Not at all. And that is the same for the Department of Defense program, which is different and separate from the VA program. But again, there is a preference for veterans but no limitation to it.

How do you see the VA chiropractic program as expanding the role of the chiropractor in society?

When you graduate from chiropractic school, your main option is to put your shingle up on the wall somewhere, to open up shop as an independent businessman or businesswoman, an entrepreneur. You end up creating your own island. Your patients come over from what we might call the coast and the mainland, they come to the island and get their treatment, they leave, and they go on with life. But generally there’s very little collaboration with other professionals or even other chiropractors in the area. That’s been the traditional model of chiropractic practice.

We’re now in a situation, whether economically driven or because of patient demand, where we have an opportunity to extend beyond our island. This includes the VA, as well as other programs where we’re starting to see chiropractic introduced in settings where there have not traditionally been chiropractors, such as multidisciplinary clinics or pain management clinics. To me, the key to the future is to expand that area of the chiropractic profession. There are also educational opportunities that we might see as a result of our involvement at the VA. I know it’s a dream of some of us in the VA that we develop a true postgraduate residency program. We’re hopeful that that may come to fruition in the near future.

Is there anything else that we haven’t talked about that you think would be important to let people know?

I think that the VA program is having a tremendous impact on our profession. We are serving people that are in desperate need of chiropractic access and we’re increasing services to that population. It also is doing something that I think is very important for the profession in that it is exposing the profession in a different perspective. How many times does the chiropractic profession have the opportunity to interact with medical students prior to their graduation or medical residents that are going to go out there and be the potential referring sources to chiropractors in the field? And so there are, I am sure, pockets within our profession that see this as chiropractic heresy, that we’re “mixing with the enemy” in some regard. I really believe that chiropractic needs to be expansive, and look at ways that we see the modern health care system not as an enemy combatant to our profession, but rather something that we need to integrate in. We’re still going to have those isolated islands, those practitioners that go out there and do a fantastic job, and all their patients love to come visit their clinic, their island, if you will. They’ll continue to go and live productive lives and that’s great. But we need more options than that and so I see the VA as being a groundbreaking experience for us.

It seems to me that the VA and DOD programs, along with sports chiropractic, are the three key pivot points in the present evolution of the profession. The corporate world (chiropractic in the workplace) may be the next frontier, but these three are the front lines right now.

Regarding the military-related chiropractic programs, a primary difference between the VA and the DOD is that the VA has structure to it, whereas the DOD chiropractors are independent contractors. They’re not government employees so there’s less structure in the DOD program. It’s basically chiropractors that work at a base or at a medical facility within the Department of Defense, but less organizational structure with DOD.

But in military medicine, particularly in the battlefield but also stateside, there are salaried employees, aren’t there?

Absolutely.

But you’re saying that for chiropractors working with the DOD, their role is not structured that way.

That’s correct. While they’re integrated in the DOD system as far as patient care is concerned, they’re not integrated into the system as far as employment and administrative organization is concerned, certainly not as much as with the VA. Because of that, I think the VA program will have more of an impact on the future of the profession.

Daniel Redwood, DC, the interviewer, is Editor-in-Chief of Health Insights Today.