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Today I observed a third year treating a continuing patient of theirs.
It was apparent that they had a good rapport and got along. However, at some point their conversation came on to political topics. They had diverging opinions on the topic and were both quite vocal about them. I felt quite uncomfortable hearing them discuss this as I thought it was a delicate topic and not one appropriate in a clinical setting.

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Results and Feedback Coursework Essay Professional Skills year 1 term 1

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Results and Feedback Coursework Essay Professional Skills year 1 term 1

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Case history taking exercise

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Anatomy Skin and Fascia Essay year 1 term 1

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Anatomy Skin and Fascia Essay year 1 term 1

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I recently had a conversation with a colleague and friend of mine, he was telling me that his second ever patient offered him cash during a consultation, on top of what he had paid at reception for the consultation.

My friend refused the money, whilst admitting that it was tempting to accept it as a student on a budget.

Having not been faced with a situation like this myself at clinic, that conversation made me reflect on how it is essential to abide by the rules and financial etiquette of whatever professional environment I might find myself in in the future - for questions of fairness and integrity.

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This patient is a 65 yo woman, it was a takeover case. The patient's file was daunting as it mentionned the patient's five benign brain tumours, osteosarcomma and other worrying past medical history elements. Having never met the patient, not taken their case history and only having 40 min with them, I was apprehending the consultation. However it went very well and tutor's feedback was:
- overall very good
- came quickly to a good diagnosis
- had good idea of what could be from CH, did appropriate and specific examination, did not over examine
- good outcome of treatment, especially for ligament sprain (considering poor blood supply)

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I had my first ever patient in my induction week (september 2019), and they rebooked for the following week.
However, between my induction week and the following one I developed very acute low back pain.
The pain levels I was experiencing allowed me to go to lectures and clinic, but I did not feel capable of treating patients because of the physical demands it might represent.

I therefore asked a colleague from my clinic team to cover for me for that patient's second consultation. I talked her through the case, making sure she received all the relevant information.
She accepted and was happy for me to observe part of the consultation - which allowed me to explain to the patient myself why I was not able to be her practitioner that day and it also allowed me to know exactly how my colleague had managed the patient.

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Reflection and tutor feedback year 3 term 1

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Reflection and tutor feedback year 3 term 1

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About frozen shoulder patient:
- I was confident in my diagnosis
- Good rapport with the patient
- Good impression on the patient who said "she knows what she's doing"
- Tutor was taken up by other student with a diffcult case, so I dealt with mine with independence and autonomy
- Tutor agreed with management plan
- I led the session, managed it well
- Tutor trusted me to perform a cervical wheel without supervision

Feedback different tutor, same case:
- Good communication with patient
- Confident in diagnosis and treatment plan
- Good to have progress with adhesive capsulitis
- Overall above what is expected at this point in the course

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Reflection and feedback NP year 3 term 2

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Reflection and feedback NP year 3 term 2

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18yo - LBP and lower CSP pain

Feedback
- Need to "poke" harder
- Take good history but don't know what to make of it after
- '"Consciously incompetent" exactly where should be right now
- Tutor completely took over, both examination and treatment
- Tried side-roll and dog even though was not yet comfortable with them, but because I didn't want tutor to completely take over, tutor said set ups were good but need to "go for it more"
- Both mother and girlfriend were observing, could have kept things more in line, controlling their interventions, not let things go off track
- Need to take control more

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A clinic teammate had a new patient who was a foreigner. They came from my home country and did not speak English very well.
My colleague  asked me to come in the consultation in case he would need me to translate for them.
The challenge in moments where I needed to translate was to not overstep and to make sure the practitioner-patient relationship and trust was unchanged.
I found my colleague managed the situation very well and did not need my help that much in the end - and overall good communication was achieved. But I did ask him once the patient had left if he felt like I had overstepped at all, which he reassured me that I hadn't.

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Feedback tutor year 3 term 2 New Patient

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Feedback tutor year 3 term 2 New Patient

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Due to the Covid-19 pandemic, quarantine rules were set up for people entering the UK.

In September 2020 I spoke to an ESO colleague who was just arriving back in the UK and told me that they did not believe those rules were appropriate and therefore did not intend to respect them.
I encouraged them to respect the rules and quarantine, as they were required to by law, for the safety of their patients and peers. I also brought up to their attention that if they were caught, it would have a negative impact on them, the clinic and university, their patients and potentially the profession.

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58 year old female - headaches

This patient presented with temporal headaches and bilateral upper arm paraesthesia.
All neuro testing was clear, and palpation of scalenes trigger points reproduced the temporal pain and the arm paraesthesia.
I therefore diagnosed bilateral active scalenes trigger points and treated with ischaemic compression, as advised by my tutor.

The patient reacted very well to this treatment approach twice - her headaches improved immensely and she was very pleased.

However, on the fourth consultation she reported having had a headache worse than hers usually were. She reported scalp tenderness and pain behind the eye.
She was not correlating that headache to the treatment, but I was honest with her and told her that although she had reacted positively to that treatment before, there was a possiblity that the treatment had irritated structures (particularly neck neurovasculature), causing her those recent symptoms. I deeply apologised in case that was the cause. She was not angry at all and happily agreed to be examined.

After a cranial nerve test revealing nothing abnormal and an examination revealing possible C2 nerve root irritation, I established she was safe to treat. With her consent, I treated very conservatively and asked her to give the clinic a call 3 days later to update me.
I advised her to contact her GP if the headache came back or worsened.
When I had her on the phone 3 days later she felt better and was grateful.

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year 4 term 1

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Case history taking exercise.

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Patient consultation reflection year 4 term 2

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Patient consultation reflection year 4 term 2

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This reconsultation patient was a 72 year old man with a straightforward presentation of lateral epicondylitis, but with an extensive medical case history. On top of having much information to deliver, the patient was very chatty. He enjoyed asking me questions about myself and telling me about personal details (for example his dog etc) during the case history. This led to the consultation running over the allotted time.

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I wrote down the list of exercises with short descriptions and repetitions/times whilst my patient was getting dressed. I thought it would be useful to write it down for them as we gave the patient a lot of new information during the consultation, they would have been likely to forget how and how much to do the exercises.

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Patient consultation reflection year 4 term 1

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Patient consultation reflection year 4 term 1

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9 year old male - multiple clicking joints

This was my first child patient able to give consent, previous ones were all babies. So for the first time I had to gain consent from both the parent (mother) and the patient.
In order to get informed consent I had to adapt the terms I was using. Even further than just using layman's terms as I do with adult patients who do not know medical/anatomical terms.

Gaining both of their consent was easily done when both said yes. However, when it came to discussing what the patient would wear during examination and treatment, it was obvious that the little boy was uncomfortable with the idea of being examined in his underwear. His mother said "No no it's fine he can be in his underwear."
I then decided that I would examine him in the shorts he was already wearing - that put him at ease and he consented to the examination and treatment.

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Patient consultation reflection year 4 term 2

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Patient consultation reflection year 4 term 2

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8 year old female - excessive throat clearing and extensive LEX ROM
Comes in with her mother.

This patient is very chatty and enjoys consultations a lot.
Given that she is very comfortable with the clinical environment, and that I have built a good rapport with her, I find gaining consent in a fluid way quite easy. I do make sure that with every consent gaining question I ask the patient first and then ask her mother.

I have also had to adapt my language with this patient. First of all because she is a child, and therefore less likely to know words such as common anatomical terms. But also because treatments usually consist of a GOT lymphatic drainage routine focused around the face and throat. This technique might seem strange to some and requires a lot of explanation, even with adults. I therefore adapted terms, for example replacing "lymph" by "liquid clearing up the body's waste", and explained to her where the "drain" where all of it goes is, etc.

She understands everything about the treatment and thouroughly enjoys it!

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Over the 2 years in clinic, I have been praised by tutors for having tidy and clear patient notes.

Although I do this spontaneously, as I find much easier to navigate through legible notes, I do make a point of it because on some occasions, when I have had to read colleagues' notes, I struggled to get all the information from them when they were not legible enough. Those instances often resulted in a team effort (me, my tutor and my group) to decipher what was recorded.

Photo: patient notes example

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A colleague who took over a patient I had seen once told me my notes were very legible and made it easy for him to take over the case.
However I have also been told by tutors and peers that my handwriting is quite small, making it a little difficult to read at times.

Although I must admit that, as I knew the patient would see another practitioner after me, I had made a particuliar effort to write my notes clearly.

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Today I was faced with a difficult case.
A 72 year old male presented with 10 year old low back pain, potentially resulting from a spinal fracture sustained from a fall at work.
The patient reported worringly high pain levels and claudication. Moreover, his blood pressure was elevated despite being on hypertension medication. My tutor suggested I examine my patient and take the blood pressure again afterwards.
Because of a complicated case history, a chatty patient and the patient's pain levels, the consultation overran the allotted time. By the time I came out of the consultation my tutor had left clinic. I had to ask another tutor who was still on the grounds to come help me on an aspect of my examination I was unsure/worried about and wanted confirmation on (absent dorsalis pedis pulse).
After the examination I was still unsure what the diagnosis was. Additionally, my tutor was gone so I did not finish my notes or get them signed today.

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I have been seeing a baby patient over several months during my fourth year.
She was born at 29 weeks and was diagnosed with an absent septum pellucidum at birth.

Although so far she is developing appropriately for her corrected age, and is a globally healthy and happy baby (the initial symptoms of reflux and difficulty sleeping have greatly improved with treatment), because of her congenital brain condition and severe prematurity and the lack of face to face visits she has with her peadiatrician, we have offerred to the mother to bring her baby to clinic monthly to monitor her development.
We are mainly doing so by testing her reflexes at every consultation.

The mother happily agreed to do so and we agreed to report to her our findings by email to enable her to share them with the baby's medical care team.

(See attached a screenshot of an email to the mother)

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Patient consultation reflection year 4 term 3

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Patient consultation reflection year 4 term 3

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This patient was an 84 year old man complaining of acute knee pain.
I saw him three times and as he had quite poor hearing and memory, his wife came in with him.
This presented two challenges.

The first one was to make sure he was still put at the centre of the questioning and very much felt like the patient, even though a large part of the information was delivered by his wife instead of him. I did so by speaking a little louder and enunciating more than I usually would. I also directed every question to him first, and had his wife answer it if he could not remember the answer. This was facilitated by the wife's attitude. Whenever he did not hear/understand my question, he would turn to her and she would repeat it and give him the opportunity to answer it himself first.

The second challenge was to gauge whether he was cognitively able to give informed consent, and gaining said consent from him directly and not from his wife.
This came down to a judgement call from me and my tutor. We came to the conclusion that he was able to deliver consent as he was very alert to what was happening and, although his memory of long passed event failed him at times, he did not seem confused about his presenting complaint and what was going on during the consultation.

During the most recent consultation with this patient, I gave him exercises to strengthen his right knee, as he has not been using it as much as his left one due to pain. This was interesting to do as I had to adapt to my patient's age and abilities. I therefore opted for exercises he can do fully supported or with minimal movement and instability.

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A 9 yo male presented to the clinic with multiple 'clicking' joints - hips, knees, shoulders, neck, fingers.

During the examination, we found him to be almost 'too' flexible, but still found some TSP restrictions and what felt like tendon movement rather than joint cavitation over the knee.
A hip MRI had been done and revealed no structural abnormalities.

During the first consultation we discussed the possibility that physiotherapy might be more suited for the treatment of this patient's complaint, as we were suspecting hypermobility - and osteopaths are good at 'making things move more' more than the opposite. Indeed, the patient seemed to need more strengthening exercises than mobility work.
We discussed with the boy and his mother the delays they might experience in getting a physiotherapy appointment by going through the NHS versus if they went private.

In the meantime, they were both happy for us to treat the restrictions we had found and see if that would make any difference.

On the second consultation, the patient reported very minor improvements.
The mother said that she had gotten in touch with a private physiotherapist that specialised in infantile hypermobility who could see the patient soon. My tutor and I therefore advised them to take that direction of treatment instead, whilst still offering the option of getting treatment of the ESO clinic if they wanted to.
The agreed management plan was to treat the boy osteopathically once more and not rebook unless they felt the need to at a later date.

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Complaints and concerns against osteopaths

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Complaints and concerns against osteopaths

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Reference:
Carnes, D., 2016. What Can Osteopaths Learn From Concerns And Complaints Raised Against Them? A Review Of Insurance And Regulator Reports. International Journal Of Osteopathic Medicine, 22, pp.3–10.

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Reference:
McIntyre, C., Lathlean, J. & Esteves, J.E., 2019. Reflective Practice Enhances Osteopathic Clinical Reasoning. International Journal Of Osteopathic Medicine, 33–34, pp.8–15.

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32 yo female - neck pain with right arm paraesthesia

With today's new patient I asked my tutor to treat the consultation as a CCA mock exam. The patient presented with acute right sided CSP pain and pins&needles in the three middle fingers.

I diagnosed C7 radiculopathy. The management plan discussion with the patient included me being honest with her by saying that this condition at this level was quite rare and that it was likely to take a while to recover, weeks maybe months, even with treatment helping the healing.

After the consultation the tutor said it would have been a CCA pass, some feedback they gave me was:

➸ As the patient was quite acute I could have done less testing and only stuck to the minimum that meant my patient was safe to treat.

➸ Again because the patient was so acute and treatment was quite short, I should have avoided re-testing after treatment, as the examination's provocative tests had already irritated the structures.

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Today I observed a teammate's consultation with a new patient.

The patient came in with an imaging report diagnosing him with Subacromial Impingement resulting from a fall he had sustained 2 months ago.

My colleague's diferential diagnoses included
➸ Subacromial Pain Syndrome (SAPS)
➸ SLAP lesion
➸ GH instability
➸ Adhesive capsulitis

Whilst my teammate discussed his examination plan, the tutor suggested it was unnecessary to test for SAPS - with a SAPS cluster. The tutor asked my opinion about it and I disagreed with them.
Because in my eyes, as osteopaths, even if the patient comes in with a diagnosis from another practitioner, we cannot treat them for that condition without having found evidence for it in our own examination.

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In clinic, every time I come across (patients/colleagues' patients/discussions with tutors) a topic I have not heard about before, or feel I need to revise, I write it down on this list on my clipboard. I then go through that list at the week-end.

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Only several months into clinic was I made aware that there is a special intimate area consent form provided by the clinic. I have not had to use it since learning about it, but will use it in the future, when needed.

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As a practitioner, I often get asked advice from patients, but also from relatives and friends.

I have had numerous friends and family ask me what they should do about a certain ache or pain without me being able to take a proper case history or examine them. Patients have asked for medication advice, such as "which NSAID is more suited to me", and dietary advice: "which foods should I eat to help with inflammation".
Moreover, when a patient has a poor diet and/or is overweight, it is tempting to give them dietary advice. However, as I do not have a nutrition degree, I don't give dietary advice.

And although it's quite disappointing for them when I refuse to give advice or when I suggest they discuss with a different person/practitioner, I am very aware that without a case history (friend and family) or with the degree I am doing, there is some advice I cannot give - especially if my knowledge on the topic is limited.

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I had a cover patient today. She had the same last name as another patient of mine - that I had been seeing for a few weeks -, I then hypothesised that she might be his wife.

During the consultation with this cover patient I understood that it was very likely that I was indeed treating her husband.
It was very tempting to ask her his name to find out for good, especially as it was amusing that I had randomly been allocated both of them as patients. However, I was very aware that I needed to comply with GDPR and thus kept all information confidential. Additionally, even if she had known that I was her husband's practitioner, it was not my place (only his) to share with her any information shared in consultations with him.

I am particularly aware of this issue, as a tutor has recently told me a story of a patient of theirs who did not want to tell their wife they went to the osteopath.
This to me was unthinkable, it made me further realise that we have to respect patient's wishes and it highlighted that we have to keep all patient information private unless allowed or asked to.

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I have been seeing a 55 yo male patient weekly, over the past few weeks.

During the first consultation he disclosed he had anxiety related to clinical settings and "white coat syndrome", but that his pain was so bad that he booked in at the ESO clinic in spite of his anxieties.

He initially presented with low back pain, which resolved completely in two sessions. On the third session he came with TSP pain, which had resolved by the next session. On the fourth consultation he complained of CSP pain. On the fifth consultation I told him he might not even need to book back in as his CSP issue had improved immensely. But he answered "No I'll probably still book back in because I just enjoy it." And indeed he came back the following week, saying he had no pain at all anymore.

I then became a little worried that he was becoming somewhat treatment dependent and was now coming in just because he was now comfortable with me, trusted me, was enjoying the treatments and the company.

However in the end I discharged him, telling him that I didn't think he needed to re-book, unless his pain came back later. I was happy to see that he agreed with me and he has not rebooked since.

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https://www.gov.uk/discrimination-your-rights

https://www.gov.uk/guidance/equality-act-2010-guidance