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When I initially came into clinic, my palpatory skills were not very good, I would say this was mostly down to only practicing on fellow students who are all relatively fit and healthy young people, as well as this studying during the pandemic limited the amount of people I could practice on. This meant I had felt very little actual physical dysfunction with my hands. This meant to often be told what dysfunction felt like rather than feeling it myself (B1-1.7). As the months went on my skills improved and now I am able to locate dysfunctional tissue through palpation and testing. Throughout the numerous CEX's I had, both formative and summative, I was also told that I need to make my observations more global and not to just focus on the pain sensitive areas. I reflected on this and tried to adapt, which has led to me correctly diagnosing things such as radiculopathy's and peripheral nerve entrapment, rather than previously diagnosing a more structural issue local to the painful area (B1-1.8).
More adaption had to be made following on from the broken arm. Techniques had to be adapted to ensure they maintained both my safety and the safety of the patient. I had to choose different techniques to those I would have used before in order to maintain strength in the arm and effective treatment (B1-1.11). On a positive note, it led to me learning more techniques in more positions widening my skillset, as well as toughened me both physically and mentally as I had to work hard to ensure my arm remained strong both in and out of appointments, as well as think fast to quickly adapt techniques in the room to ensure treatment remained effective.

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B1. You must have and be able to apply sufficient and appropriate knowledge and skills to support your work as an osteopath.

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B1. You must have and be able to apply sufficient and appropriate knowledge and skills to support your work as an osteopath.

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This evening I was in evening clinic after just completing a busy afternoon session. I checked the computer to see I was not booked in to have any patients, but was happy to see I had a tutor who I had not had before so was looking forward to some new insight. However, roughly 5 minutes after the session had begun, a student from a different group came up saying that a patient was here and that no one in their group could take them. I volunteered to take the patient as I had no other patients that evening. The first few minutes of the consultation were a bit of a mess as I asked questions while reading the file but overall the appointment went well and the patient got good treatment. After finishing however, I found out that the student who came into the room in fact could have taken the cover patient and was assigned to take it, they just decided that they did not want to after the patient had already arrived. I thought this was highly unprofessional and was putting their own wants and desires over the patients needs. This is not something I would ever even think of doing as I would always take a patient should I be assigned them. Despite this unprofessional conduct however I knew it was essential to not let this standard slip.

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D1. You must act with honesty and integrity in your professional practice.

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You must have a professional indemnity insurance arrangement which provides appropriate cover in accordance with the requirements of the Osteopaths Act 1993 and the current Professional Indemnity Insurance Rules.

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Due to a broken/dislocated arm on 12.01.23 I was left unable to treat any patients for 8 weeks. My hands on skills were greatly impacted due to my right arm being in a cast and very swollen and weak.  For the first time since being able to treat patients I found myself unable to perform both testing and treatment, due to ulnar nerve damage my palpation skills were also greatly impacted. This led to feelings of incompetence and inadequacy as my peers were having to cover my patients despite me being there. I felt guilt due to the fact that I was adding to their workload in what was already a busy and stressful time, however I knew it was essential that both my physical strength and practical skills had to return to appropriate level before I could go hands on with patients again.

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C1. You must be able to conduct an osteopathic patient evaluation and deliver safe, competent and appropriate osteopathic care to your patients.

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C1. You must be able to conduct an osteopathic patient evaluation and deliver safe, competent and appropriate osteopathic care to your patients.

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On a number of occasions I have found myself unsure of what exactly is happening with a patient. I have found myself having confirmation bias on a lot of patients where I have suspected a diagnosis because I have seen it or learned about it previously. On these occasions I have had to seek out a tutor for their advice and have often learned that something completely different is what is in fact going on. Such as a time when I was working locally on an the peroneal/calf area of a patient due to pan around the Tibia, until a tutor informed me about sclerotomes which led to me switching focus to working on the lumbar spine and the patients symptoms improved (B2-2.2). This has led to me now looking more globally should my initial plan not get the outcome I wish for, as well as always seeking another opinion if I need to. This is an important reflection to maintain as it has been shown that confirmation bias is a problem in clinical settings that has the potential to effect patients.
https://www.proquest.com/openview/74886e7d990b64aa92c9e2c04846371d/1?pq-origsite=gscholar&cbl=18750&diss=y
Parmley, M.C. (no date a) The effects of the confirmation bias on diagnostic decision making [Preprint]. doi:10.17918/etd-1164.

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B2. You must recognise and work within the limits of your training and competence.

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B2. You must recognise and work within the limits of your training and competence.

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On a number of occasions I have either covered, taken over or taken a re-consultation patient and there has been information missing from their file. This can be things such as Date of appointment, order of appointments, the name of the student who took the consultation. Things that regard to the specific case such as examination findings or blood pressure, or indications that consent was obtained. While this has mostly just been a minor inconvenience that I attribute to students being stressed, it did make me consider the need to always find the time to fill out the right details and record everything, just as much for your own safety as for the patients.

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C2. You must ensure that your patient records are comprehensive, accurate, legible and completed promptly.

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C2. You must ensure that your patient records are comprehensive, accurate, legible and completed promptly.

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On one occasion, after 4-5 treatments, a patient began to disclose what I felt was fairly private and personal information. While I believe there was absolutely no sexual subtext to what they were saying and it was only intended to be humour and nothing more, I made sure to maintain a professional boundary throughout the entre appointment. I was not made to be uncomfortable by this encounter it was more for my own safety and for the sake of my own words not potentially being misinterpreted that I did not engage in this conversation and gently tried to navigate the conversation elsewhere (D2-5.2). In terms of reflecting on this experience, I became aware that after a number of treatments, the professional barrier may begin to drop as patients become more comfortable, but it is important to gently maintain those boundaries should it become possible that they may be breached.

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D2. You must establish and maintain clear professional boundaries with patients, and must not abuse your professional standing and the position of trust which you have as an osteopath.

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Not all crossing of professional boundaries will necessarily be an abuse of your professional standing. For example, sometimes it may support empathy and trust with a patient to disclose personal information or to treat a patient as an emergency outside your usual hours.

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Once entering the fourth year and being given the opportunity to treat a different type of patient and further expand my treatment approach and toolkit I was very excited. The prospect of treating children was both interesting and scary as I was highly inexperienced in that field, as well as Sports clinic being highly intriguing due to my interest in being involved in the sports world in the future. I believe I took both opportunities with great enthusiasm as shown in my CEX results (B3.1,B3.2), both of which I was very happy with. In terms of using this experience for the future I aim to take the same enthusiasm and open-mindedness shown in the specialist clinics to future CPD and mentorship I may receive in order to always be adapting and evolving my skillset.

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B3. You must keep your professional knowledge and skills up to date. – Osteopathic Practice Standards

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In the weeks returning back treating patients after breaking my arm, I felt it essential to let them know about the fact I had a recent injury due to the fact that, despite my best efforts, it may impact the consultation. This is not something I particularly wanted to do as I did not want to influence the patients confidence in me before I had even done anything, but I knew I had a duty to be honest to the patient about anything that may impact or influence their care. They were all very caring and understanding and for the most part my arm did not influence or impact any treatment. However it did create some anxiety as I knew if there was an impact then there may have potentially been complaints. This has made me aware of injuries in future and how they could impact my business.

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D3. You must be open and honest with patients, fulfilling your duty of candour.

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If something goes wrong with a patient's care which causes, or has the potential to cause, harm or distress, you must tell the patient, offer an explanation as to what has happened and the effects of this, together with an apology, if appropriate, and a suitable remedy or support.

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In year 2, we had to write an essay in which we respond to a complaint letter. I took some time and effort in writing this essay and received a mark of over 80%. I used the first 3 aspects of this particular OPS as general guidance when writing the letter. I kept the document and the feedback on the work to use as a future reference if I do happen to ever receive a complaint letter.

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D4. You must have a policy in place to manage patient complaints, and respond quickly and appropriately to any that arise.

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A complaint is an opportunity to reflect on the communication and standard of care that was given, and it may highlight areas of your practice that could be improved. A complaint which is handled well can also result in a stronger bond of trust between you and your patient, leading to improved patient care.

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CHILDRENS CLINIC CEX SCORE/FEEDBACK (B3.1)

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CHILDRENS CLINIC CEX SCORE/FEEDBACK (B3.1)

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Across the two years in clinic, we have had to do a couple of case reports on real patients at the clinic. Due to this, some information that could be considered personal was revealed. In order to do this, it was essential that all notes remained anonymous so that no personal private information was revealed. In all of the presentations the highest level of security was kept and all names were removed from any information written. It is important that this attitude is kept up in my future career as it has been shown that, despite knowing it is important, practitioners may not have the correct attitude towards it importance as they go on in their careers.

https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-022-00765-0#citeas
Tegegne, M.D., Melaku, M.S., Shimie, A.W. et al. Health professionals' knowledge and attitude towards patient confidentiality and associated factors in a resource-limited setting: a cross-sectional study. BMC Med Ethics 23, 26 (2022). https://doi.org/10.1186/s12910-022-00765-0

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D5. You must respect your patients' rights to privacy and confidentiality, and maintain and protect patient information effectively.

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You should have a written policy regarding retention, transfer and disposal of patient information and records, which should include whether it is your practice to retain them beyond eight years, or, in the case of a child, beyond their 25th birthday. Your patients should be made aware of this.

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A patient presented at the clinic today with various UMN symptoms and neurological deficit on more than 2 levels. As I knew this could be a potentially serious situation I was aware that a referral letter needed to be written quickly. I knew this letter also had to convey the essential information effectively and efficiently. Immediately after sending the patient home I wrote the letter to their GP including relevant symptoms from the case history as well as findings from the physical examination. The letter was competed and signed by the end of the clinic session. I knew at the time and also know for the future that in some more serious cases, urgency is required when writing letters as time may be of the essence.

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C3. You must respond effectively and appropriately to requests for the production of written material and data.

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develop mechanisms for storing and retrieving patient information, including financial and other practice data to comply with legal requirements in relation to confidentiality, data processing and storage, and requests for information from patients, healthcare professionals or other authorised parties.

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Experience at clinic may 17th 2018
While observing I saw a patient who would not seem to accept treatment in areas that she didn't believe were relevant to their presenting complaint. Their issue was with a swollen ankle and they asked questions and objected to treatment in their lumbar spine as they did not believe that treatment would be needed despite them not having any prior knowledge of osteopathy. This was clearly frustrating to the student practitioner but they were incredibly professional and kept a very calm demeanour while only performing treatment on the areas that the patient wanted them to. This experience made me think that there may be times when you might have to go against some principles of osteopathy when treating certain patients and adhere to only what they believe you should do despite you having the greater knowledge and being aware that you should treat the issue globally. This could mean that the problem may never be fully resolved but if the patient isn't comfortable with certain treatment then there is nothing that can be done as you must always put the  patients comfort first.

My own experience in 4th year. It is interesting to reflect on this entry I wrote in first year after having a similar experience of my own, I had a patient with a clear radiculopathy following all the relevant questions and testing. After explaining the condition to them and that my intention was to treat their back and not their leg, the site of their pain, they had a few objections and questions. Similar objections and questions to those I witnessed in first year. However I chose to further educate the patient in slightly more detail rather than doing exactly what they ask for, after further explanation the patient was happy to go ahead with the proposed treatment approach. When comparing this to my attitude in the original post, I think education and shared decision making is a far better approach compared with simply doing exactly as the patient asked even if you know a better treatment process.

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A1. You must listen to patients and respect their individuality, concerns and preferences. You must be polite and considerate with patients and treat them with dignity and courtesy.

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A1. You must listen to patients and respect their individuality, concerns and preferences. You must be polite and considerate with patients and treat them with dignity and courtesy.

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There was a patient in the clinic that had Crohn’s disease, she was very down about this fact and seemed to be set in the idea that she will never get better due to this disease. The student practitioner was very professional in dealing with this and accepting that she may only be able to help this patient osteopathically and not ever make her 100% better as that would be down to her psychologically. She was incredibly honest and straightforward with the patient about this though and let her know what the limit of her abilities was and respected her right to what the treatment goals were for her patient despite maybe privately believing she can do more to help her.

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This exam went well I feel, I used the feedback from the initial OSPEs to improve and I think I came along alot  more compared to the first practical exam. Only minor mistakes occurred and I found myself constantly being able to recite the theory and did not have to be prompted much. I think my skills have vastly improved throughout the course of the year and there has been a noticeable change in my ability and I feel much better in the course now.

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In second year, we undertook safeguarding training for noticing signs of potential FGM (C4.1). While this was a very serious and upsetting topic, I knew it was important to cover so as to ensure it is not missed in the future. While it was not content I particularly wanted to view or read about but I knew it was my duty in order to I offer the best standard I can in terms of patient safety, especially for those who are vulnerable such as children.

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C4. You must take action to keep patients from harm.

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In any circumstances where you believe a patient is at immediate and serious risk of harm, you should consider the best course of action, which may include contacting the police or social services (though see standard D5 regarding confidentiality).

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Experience at clinic April 20th

All observations have been positive experiences for me and I have seen nothing but safe and professional behaviour towards all patients. There was on patient that had to be provided extra caution as she entered the clinic unable to walk or do any basic movements due to incredible pain in her lower back, this lead to the tutor for that day, having to come in and take the lead on most of the treatment. He handled her with an expert level of care and safety while at the same time telling her what she needs in order to recover. I observed him treating her for well over an hour as he performed a gentle side lying oscillation technique with the lumbar spine in rotation and performing inhibition on the muscles around the lumbar spine. Despite her screaming in pain through parts of the treatment, after it was done she was incredibly mobile and walked out of there with virtually no problem. It gave me a great idea on the best way to keep patients comfortable and feeling safe despite pain they may feel during treatment.

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After writing an essay about a paper written about Osteopathic Ableism in year 2 I had a slightly different perspective on how I interpreted discrimination in osteopathy. I did not agree with most of the points made in the paper but I still understood the perspective as to where they were coming from. I understood that the profession  within itself is not a profession you could do if you had a physical disability but so are many other professions. I did not agree with what was said in the paper about the Osteopathic principles being fundamentally ableist, however it did open my eyes to a different ay of thinking which is always welcome.

https://www.sciencedirect.com/science/article/abs/pii/S1746068921001000

Andrew MacMillan,
Osteopathic ableism: A critical disability view of traditional osteopathic theory in modern practice,
International Journal of Osteopathic Medicine,
Volume 42,
2021,
Pages 56-60,
ISSN 1746-0689,
https://doi.org/10.1016/j.ijosm.2021.12.005.

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D6. You must treat patients fairly and recognise diversity and individual values. You must comply with equality and anti-discrimination law. – Osteopathic Practice Standards

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Throughout the two years at clinic, students have been absent for a number of reasons. I missed 2 weeks of clinic after Breaking and dislocating my elbow myself, not returning to actually treating patients for 8 weeks. However, throughout the process I ensured I maintained in communication with the clinic staff and my clinic team, keeping them updated as to my recovery and when they could expect me back, also providing information on cover patients if its required (D7-2.3). On a few occasions, particularly on holiday clinics, on number of other students failed to attend while also failing to let anybody know that they were not attending, this led to a lot of confusion and a lack of organisation when it came to covering patients. The lack of communication and courtesy shown was unprofessional and will surely not be tolerated in full time employment.

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D7. You must uphold the reputation of the profession at all times through your conduct, in and out of the workplace.

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The public's trust and confidence in the profession (and the reputation of the profession generally) can be undermined by an osteopath's professional or personal conduct. You should have regard to your professional standing, even when you are not acting as an osteopath.

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A patient offered to give me an additional financial tip following on from me discharging him due to him no longer needing treatment. Due to him initially being very acute to now being in no pain he was very grateful and offered money as a way of saying thank you. Due to me not being qualified yet I am not able to take any money for treatment.
Due to the timing of this being at the very end of the second term I was feeling financial pressure that normally occurs at the end of term especially with a cost of living crisis. However I still rejected the money as I knew it was the professional and correct thing to do. Despite me having financial issues I know that was the best decision to make as any potential negative outcome greatly outweighed any positive that may have arose from taking the money.

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D8. You must be honest and trustworthy in your professional and personal financial dealings.

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D8. You must be honest and trustworthy in your professional and personal financial dealings.

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While I was still in a sling after my elbow break/dislocation a number of my patients were covered by my colleagues due to me being physically unable to treat. However on a number of occasions I took the case history from the patients with my colleague in the room, I also provided patient management such as rehab and treatment plans. This provided good continuity for the patient as the approach and management was very similar despite me being unable to physically treat them. This good cooperation and teamwork often found in clinic made the patient care as optimal as it could be despite these challenging conditions.

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D9. You must support colleagues and cooperate with them to enhance patient care.

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If you are responsible for an associate or assistant, you should provide professional support and adequate resources for them so that they are able to offer appropriate care to their patients. You should not put them under undue pressure, or expect them to work excessive hours.

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A patient came to clinic complaining of right groin pain with a duration of 2 years with no apparent onset. Upon testing it was found she had less than 90° flexion with extremely limited int/ext rotation. Due to the duration and severity of her symptoms I deemed it best to discuss her options with her with a hip replacement being in my opinion the best course of action, due to the very low rate (5%) of patients suffering complications. A letter was written to her GP for further imaging and testing as well as advice given on surgeons, different types of surgeries as well as costs. This is due to the fact I deemed another health care professional, in this case a surgeon, to be a better option for this patient in order to achieve the best standard of care for her.
https://www.hey.nhs.uk/patient-leaflet/total-hip-replacement-benefits-risks-outcome/

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D10. You must consider the contributions of other health and care professionals, to optimise patient care. – Osteopathic Practice Standards

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Really informative presentation on adult ADHD! The way you have explained your osteopathic management and how you would adapt it to suit a patient with ADHD is really good- particularly the part about using treatments that provide instant reward like HVT's as I feel this is a great way to help the patient feel better psychologically as well as physically. I have a question regarding the osteopathic management slide- I understand that you will give at home rehab sparingly, but how else would you adapt it in order to improve
patient compliance?

Response: Thank you! To answer your question, home rehab programs could also be adapted to be constantly changing in order to keep interest. Another adaptation could be reward based exercise programs. In terms of forgetting appointments an automated alert system could be sent out to patients reminding them to do their home rehab exercises should they require.

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It has been challenging throughout the first few months of clinic due to the requirements of wearing PPE in order to prevent the spread of COVID-19. Due to high temperatures as well it has been particularly unpleasant with the plastic aprons acting as a blanket to trap in all heat. However it is important that the clinic is kept in line with UK Health guidelines as put in place by the government. This ensures protection for both myself and the patient despite the clear discomfort it brings with it.
The use of gloves made palpation difficult at times especially for the patients that required a more cranial approach. This was a tricky obstacle to overcome as it directly impacted my skills in both testing and treating, but was a requirement in order to keep patient safety as high as it could be. Reviews published since the pandemic showed that these PPE measures were effective to some degree however, so I would say that this discomfort was necessary in the interest of safety.
https://www.bmj.com/content/375/bmj-2021-068302
Talic, S. et al. (2021) ‘Effectiveness of public health measures in reducing the incidence of covid-19, SARS-COV-2 transmission, and covid-19 mortality: Systematic review and meta-analysis’, BMJ [Preprint]. doi:10.1136/bmj-2021-068302.

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C5. You must ensure that your practice is safe, clean and hygienic, and complies with health and safety legislation.

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C5. You must ensure that your practice is safe, clean and hygienic, and complies with health and safety legislation.

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Due to the previously mentioned arm break/dislocation, I was unable to effectively treat patients for at least 8 weeks, I was assessed by Both a physio therapist and in house at the clinic before I was cleared to treat patients. Despite the fact I was keen to return to treatment and seeing patients, I knew I needed to follow the advice and opinions of others and receive their clearance before I was safe to go hands on again. The lack of work combined with not being able to go to the gym left me feeling very purposeless for a few weeks. I did not now how important those things were for my mental health until they were taken from me, I knew that once I was able to treat patients again my feeling of purpose would return to some degree, so while I was very excited to return to treatment. I know that for both the safety of the patient and my own safety, I must be properly assessed and cleared before being cleared to treat again.

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D11. You must ensure that any problems with your own health do not affect your patients. You must not rely on your own assessment of the risk to patients.

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If you are exposed to a serious communicable disease, and you believe that you may be a carrier, you should not practise until you have received appropriate medical advice, and you should follow any advice you are given about suspending or modifying your practice.

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Today I took a new patient with 3 observers in the room. I was asking questions with regards to symptoms a patient was feeling, the symptoms indicated a peripheral neuropathy and when asked about things such as diabetes and B12 deficiency I was told that test had been ran and that they were negative. A combination of physical symptoms and a look of anxiety and embarrassment when the normal case history question of weekly alcohol intake was asked, led me to believe that this may be a case of alcoholism. I did not probe further in the case history with the observers in the room as I was cautious of making the patient uncomfortable. I instead left the topic and once I returned without the observers to continue the examination and treatment, I gently brought the subject up again and received far more information and detail with regards to their drinking problem now it was just us in the room(A2-3). I then gave some general advice such as seeking help from the various addiction services, confiding in close ones, finding hobbies such as exercise(A2-5.1,5.2). They seemed genuinely grateful to be able to talk to someone and I hope I conveyed that it was a non judgemental environment that only concerned their own wellbeing. Upon reflection, this situation made me more aware of the potential of sensitive situations that may arise during consultations and that they should be handled with care and addressed in the proper environment and not when there are a number of observers in the room.

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A2. You must work in partnership with patients, adapting your communication approach to take into account their particular needs and supporting patients in expressing to you what is important to them.

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A2. You must work in partnership with patients, adapting your communication approach to take into account their particular needs and supporting patients in expressing to you what is important to them.

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In the children's clinic I had a patient who was around the age of ten who came in with a complaint of constipation and after questioning, suffered from a number of different anxieties as well as learning difficulties at school. I knew I had to get any testing done in a way that kept her engaged so I made the active testing into a game that involved running and jumping as well as the normal movements. As well as using toys provided in the clinic to test neurocognitive development. They were able to communicate reasonably well with me but I also remained constantly checking with their mother that they were okay (A3-3). Once the examination was complete I explained to both them and their mother that my proposed treatment would not directly work on their bowel symptoms but I would instead be intending to work on the system as a whole with the intention of potentially relieving symptoms, but did not make any promises that I could not fulfil, as well as this I proposed 3 sessions and then we would evaluate as to whether there has been improvement or not (A3-1.2)

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A3. You must give patients the information they want or need to know in a way they can understand.

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You should discuss care options, encourage patients to ask questions, and deal with these clearly, fully and honestly. You should inform your patients of anticipated benefits as well as any material or significant risks associated with the treatment you are proposing, and confirm their understanding of these.

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When treating a 10 year old patient the process of obtaining consent was difficult as they had the capacity to be involved in the conversation and did get involved at certain points, but also withdrew at certain points due to shyness as it was disclosed it was suspected that they suffer from an axiety disorder. This made obtaining consent difficult, despite this I still made my best effort to involve them in the discussion (A4-17). Predominantly, the consent was obtained from their mother as I made the decision that they did not have the maturity required to fully consent for themselves, so the treatment was explained to both them and their mother and I tried to keep it as simple as possible to ensure they had the best understanding possible (A4-17). To reflect on this it was a difficult process however I believe I gained more patience from the process and a greater understanding of a different age group and what their capacity to consent may be. As well as this, it led to me doing further research into adolescent anxiety disorders and the challenges that can arise due to this.

https://jamanetwork.com/journals/jamapediatrics/article-abstract/383862
Ramsawh HJ, Chavira DA, Stein MB. Burden of Anxiety Disorders in Pediatric Medical Settings: Prevalence, Phenomenology, and a Research Agenda. Arch Pediatr Adolesc Med. 2010;164(10):965–972. doi:10.1001/archpediatrics.2010.170

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A4. You must receive valid consent for all aspects of examination and treatment and record this as appropriate.

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Valid consent does not always have to be given in writing by the patient. However, if you are proposing a vaginal or rectal examination or technique, written consent must be obtained and kept with the patient records. You may also consider gaining written consent for other procedures, particularly those relating to areas which the patient considers intimate.

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During the COVID-19 pandemic there was a lot of anxiety and unrest amongst patients as people were unsure of what the best options were for them in order to ensure they remained in the best health. Particularly amongst older patients I received questions from a few of them with regards as to whether coming to the consultation may be detrimental to their health, as despite PPE, COVID was still a threat. Despite not being sure myself I answered with what the Current guidelines were at the time as I believed them to be the best advice. Still to this day I am not sure whether that was the correct advice, but as myself and the clinic were both strictly adhering to the health and hygiene precautions I believe that still opening and offering services was the correct decision and all you can do is adhere to the government guidance and keep hygiene levels high at the clinic.

https://www.who.int/teams/epi-win/health-workers-and-administrators

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C6. You must be aware of your wider role as a healthcare professional to contribute to enhancing the health and wellbeing of your patients.

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C6. You must be aware of your wider role as a healthcare professional to contribute to enhancing the health and wellbeing of your patients.

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On numerous occasions I have provided patients with at-home rehab programs sent either via Rehab My Patient or PhysioTools, an example of which is shown in A5.1. This was often in conjunction with the patient themselves making a decision to become more active and begin to take steps in self improvement. With these exercise programs both encouraging general activity as well as strengthening weak areas implicated in pain sensitive areas (A5-1.2). On the opposite side of this I have also had patients who I have offered this to as well as treatment who have either said no, or said yes and then chosen not to complete these exercises. In these cases, as long as I had carried out my requirement in providing necessary information and my best advice on their lifestyle, I was respectful and remained supportive of them despite them choosing different options (A5-1.4).

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A5. You must support patients in caring for themselves to improve and maintain their own health and wellbeing.

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A5. You must support patients in caring for themselves to improve and maintain their own health and wellbeing.

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Today in clinic I had a new patient, with the rest of my team (4) as well as my tutor observing. The case history went by smoothly but once I had explained the examination process as well as that the patient may have to undress in order to expose the affected area. Despite this being disclosed before the appointment, this led to the patient looking rather anxious. I would attribute this to the patient being relatively overweight as well as there being multiple people in the room. Due to this the option of the modesty gown was suggested and taken up on (A6-2.4). I was not sure about continuing with observers but due to the tutors insistence, they remained for the entire examination.

Upon reflecting on this in fourth year, I would have had more confidence to suggest to the tutor that maybe they should not observe the examination to save the patients anxiety, rather than saying nothing. At the time I had more of an inferiority complex compared to now when I have a lot more faith in my own ability and judgement, as well as this I know that the tutors respect our opinions and views, which I may not have been aware of at the time of the initial post. As well as this, I am aware of the role that things such as anxiety play in patient pain perception and recovery, so it essential for the consultation to be as effective as possible, that th potential of these feelings arising is reduced.

https://www.sciencedirect.com/science/article/abs/pii/S0887618504000398
Feeney, S.L. (2004) ‘The relationship between pain and negative affect in older adults: Anxiety as a predictor of pain’, Journal of Anxiety Disorders, 18(6), pp. 733–744. doi:10.1016/j.janxdis.2001.04.001.

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A6. You must respect your patients' dignity and modesty.

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Patients will have different requirements for maintaining their dignity and modesty during a consultation, and you must be sensitive to these. Some of these ideas may have been shaped by a patient's culture or religion, but it is unwise to make assumptions about any patient's ideas of modesty.

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During a holiday clinic. I was required to takeover a patient that had allegedly been acting inappropriately toward a female student in a different appointment. This alleged behaviour had left the student feeling uncomfortable so I offered to take the patient instead as he was unlikely to repeat the behaviour with me. During the consultation he cautiously questioned me however I just said I did not know anything and I was just assigned the cover. He did try to explain the way he acted but again I just said I did not know. While I did not agree with the way that this individual had acted and would not be friends with a person who acted that way in my life outside of clinic. I remained 100% professional and treated them as I would any patient and the appointment went well, I saw the patient for 3 subsequent appointments before discharging them as they had become symptom free. All follow up appointments went fine without any issue. This attitude can be used in later life as when working I am bound to come across people who's behaviour I may disagree with, but maintaining professionalism can ensure they get treatment as long as they do not cross any personal boundaries.

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A7. You must make sure your beliefs and values do not prejudice your patients' care.

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The same quality of service and care should be provided to all patients. It is illegal to refuse a service to someone on the grounds of their age, disability, gender reassignment, marriage or civil partnership, pregnancy or maternity, race, religion or belief, sex or sexual orientation.

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Reflection from first year feedback compared to feedback in my final year:

Feedback from first practical assessment
Most stations gave very similar feedback. Telling me it was essential that I was more specific when applying theory I had learnt behind the techniques I was performing. Which I thought was a very fair assessment, in revision I spent more time trying to revise and perfect each technique than going over the theory. My lack of knowledge definitely lead to me losing composure and had a massive effect on my overall grade as my nerves lead to me subconsciously trying to over compensate and coming across as "casual". I also had chewing gum in which is bad according to all those assessing me so I will make sure I do not do that next time. I am very happy to have received this honest feedback as it has given me a much better understanding and scope on what behaviour as an osteopath in a working practice is expected.

Feedback from final CEX (C4.1)
Aspects of the consultation were performed well: *
You have a very good way of communicating efficiently and effectively with patients and are able to allow them the time to respond to questions whilst at the same time controlling their potential to wander slightly. Well managed. Also very good at tapering questions to the positives and negative responses. Clinical skills are very good and you siphoned off the most relevant differential diagnoses and also the most relevant tests to be performed in the time remaining.
Excelllent differentiating and very good knowledge of potential pathological and orthopaedic
conditions.

Reflection:
Over the four years my knowledge and skill have greatly improved as expected as well as my overall demeanour and communication skills. Nerves no longer play and element as I am confident in my own knowledge and ability. Using the feelings I felt in my first year as a point of reference compared to now is astounding in the difference. My theoretical knowledge has greatly improved following from that first exam as well as my practical skills and communication. As well as this I know chewing gum in an exam is a bad idea! Taking on what was overall negative feedback in my first exam led to me becoming a much better and confident osteopath in my final year

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B4. You must be able to analyse and reflect upon information related to your practice in order to enhance patient care.

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B4. You must be able to analyse and reflect upon information related to your practice in order to enhance patient care.

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I have not had to inform GOsC of anything during my time at ESO but I did have to inform the university as soon as I could about my arm. This is due to the fact I knew I would be unable to treat for a number of weeks. I knew the staff at clinic are very reasonable and understanding but I still felt a lot of anxiety about letting them know. I also felt anxiety about letting my clinic team know as they would have to cover for me. Once I returned to clinic I had to be subject to regular examinations and check ups before I was finally cleared to treat despite me being very keen to get going, I would imagine the process to be very similar if I was subject to any form of investigation into my conduct or competence. I would be very anxious and keen to get going again, but would have to comply with any necessary regulations before I did. I would hope nothing like that would ever happen to me, but if it did, I would think back to how I felt on a this time and try to find some relief from it.

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D12. You must inform the GOsC as soon as is practicable of any significant information regarding your conduct and competence, cooperate with any requests for information or investigation and comply with all regulatory requirements.

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D12. You must inform the GOsC as soon as is practicable of any significant information regarding your conduct and competence, cooperate with any requests for information or investigation and comply with all regulatory requirements.