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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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Experience:

I have had a couple of appointments in which patients cannot speak English and have brought a relative to translate for them. On one occasion I had a 60-year-old female visit for low back pain and shoulder pain, who was unable to speak any English, but had brought her son in to translate for her. This process was very difficult and took a very long time. There were a lot of times that the questions were lost in translation, so it took a lot of re-wording/rephrasing and hand signals/gestures to obtain the information that I needed from the patient. Although the patient did not speak English, I picked up on a few non-verbal cues that implied to me that she did not understand the need for some questions. I took the time to explain to her why I was asking some things, including that it helps me to understand what is causing her pain. I explained the medical history and general health questions would help me establish if she was safe to examine, highlighting that her health is the main priority, and I would need to work out if she was in the best place for her care. I also explained that if there were any sensitive or private questions I would warn her in advance, before asking, in case she was uncomfortable discussing this in front of her son (e.g., questions relating to menopause). She advised that she understood and then seemed more at ease throughout the case history taking process. Eventually, this patient was referred to her GP, as she had lots of un-investigated systemic symptoms, so I was not able to treat her at the time.

Reflection:

This experience was probably on the higher end of the scale in regard to adapting my communication approach. It really tested my vocabulary, and ability to reword and rephrase in order to ensure the patient fully understood the appointment process, as well as obtaining the required information. Though the appointment took much longer than usual, I had to allow time for her son to understand what I was saying, in order for him to translate, allow the patient to answer, and then have him translate back to me the answers. There were times it felt quite tedious for everyone but ultimately, the patient’s health and care remained primary and we were able to conclude all of the relevant information and navigate her to the right place, to optimise her care and management.

Action:

Reflecting on this experience has helped me to prepare for similar situations that may arise in future, and shown me the extent of my vocabulary and rephrasing ability. In future, I would like to have more images or diagrams available which I think will help with communication for all patients.

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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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Experience:

A new patient, 23-year-old female presented to the clinic with headaches. There were 2 additional female observers in the room and 1 female tutor. As the case history developed, she expressed that the recent exacerbation of her headaches was related to a particular trauma. Based on the patients change in tone and body language, I picked up that she may not have been talking about a physical trauma. Before she continued, I asked the observers to leave the room to allow more privacy. When the observers had left the room, I asked if she would mind telling me if it was physical or emotional trauma. She confirmed it was an emotional trauma. I asked her if she was comfortable talking about this with the tutor and me in the room and reassured her that any information shared would be confidential. She said she did want to mention it because she had suspicions of her own, about it relating to her headaches. I advised her to only say what she felt comfortable with. I put my pen down and gave her the space she needed to voice what she wanted to. Ultimately, the emotional trauma that the patient had experienced seemed to be the cause for the exacerbation of her symptoms. We discussed the physiological impact that extreme stress can have on the body and I explained what I could do from an osteopathic perspective to treat or help her. We discussed potential talking therapies, which may help give her some relief of the things she had been holding in or that she described she had been “shelving” until more convenient time, as she had other priorities to deal with. I asked her if she was getting any support at home and she said she was which I was glad to hear.

Reflection:

Reflecting on this experience has made me appreciate the need to show patients they are in a safe and secure environment, to enable them the freedom and space they need to express their concerns and values.

Action:

Not all patients are forthcoming with their expectations, concerns or values and in future I will take the necessary steps to create an environment where patients can always feel they can voice these freely, and securely.

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The Eight Principles of Patient-Centered Care - Oneview Healthcare

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There are Eight Principles of Patient-Centered Care highlighted in research conducted by the Picker Institute and Harvard Medical School.

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

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Experience:

I had been treating a 3-year-old boy at the clinic for glue ear; this has been diagnosed by his GP. The patient’s mother was familiar with the ESO clinic, and showed good understanding of the aims and limitations of osteopathic treatment for him. I treated the patient cranially under the guidance of my tutor and would always advise the patients mum about the potential responses to treatment – he would often be very mucousy after his treatments.

On one occasion at clinic, reception told me that the little boy’s mum had called because he had a headache and was vomiting and she was concerned that this was a result of the treatment (2 days prior). I had a very busy day at clinic that day and said I would call her back as soon as I could. When I finally had a chance, before calling, I asked a tutor for some advice. He was very helpful and I felt more prepared to speak to the patient’s mum.

I advised her that when I have treated her son cranially, I have used what we call ‘indirect’ techniques, where we contact certain areas of the body and offer it an opportunity to change if it wants to, with the intention of helping it improve (e.g., softening areas of restriction to allow for better drainage). I assured her there is no direct or forceful manipulation of his skull bones. I advised her that patients’; children, or adults; can respond to the treatment in a variety of ways and we revisited how he is usually emitting a lot of mucous from his nose after his treatments, which she was familiar with. We had a brief discussion where the mum volunteered her experience, and how she responds to treatment, and we talked about how different patients can have different levels of sensitivity to treatment. When we got back to the topic of her son, I advised that his headache and sickness are not out of the realms of impossibility in regard to treatment response, but I also recalled that he had some hives on his tummy at his last appointment. This is something I had seen a few times with him, and his mum had told me before that he gets them when he is coming down with something like a bug or virus. I advised that it could be possible he has caught something, and that if she is worried, she should visit his GP, and to feel free to call me if she had any other questions or concerns, or if she thought I might be able to help in any way. The patient’s mum was grateful of our discussion, as was I, and it was calm and non-confrontational. At the next appointment, the little boy’s mum advised me that he had come down with a bug but still appreciated the conversation we had.

Reflection:

This experience was very insightful and enabled me to practice explaining things to patients in greater depth. It also highlighted the importance of explaining things in a way that patients can understand, and covering the potential negative side-effects to osteopathic treatment. I have been able to reflect on this experience a lot, and also by discussing this experience with my tutors, it has deepened my knowledge about cranial osteopathy too. I have learned a wider scope of treatments I could apply for cases such as this, to avoid any potential nastier outcomes (like vomiting), including other treatment approaches; such as the diaphragms to help with congestive build-up.

Action:

In future, I will endeavour to be clearer about potential side-effects of different types of treatment, adapt my communication accordingly, and encourage any questions.

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Osteopathy is one of only two complementary and alternative medicines (CAMs) that are regulated under UK law. The other is chiropractic.

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

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Experience:

I recently had a 79-year-old man visit for severe shoulder pain, following his reverse shoulder replacement. Communication was quite difficult with this patient and I had some reservations about his capacity to give consent. Fortunately, he had his wife with him who was very helpful during lots of the communication, and information relevant to his case. His wife had advised that she was very familiar with the ESO clinic, and had a good understanding of the protocols. Despite this, I still felt it necessary to obtain clear consent from the patient himself. There were some things about his expression that made me unsure he was listening or understanding fully what I was explaining.

Before I was able to finish explaining the examination process to him, or gain informed consent, he started standing up to start showing me some movements. I advised him to please sit down but he kept trying to pursue the examination, although I hadn’t asked him to do anything yet. He said “no, I don’t mind, you do what you need to do”. I eventually told him that I need him to sit for the examination and that I did not want him to stand, and he finally sat back down.

When he was sitting and I felt I had his full attention, I had a slow and clear conversation about consent. I advised him that I need to make sure he understands why I would like to do an examination and what it would involve. I said that “I can see you are eager to proceed but it is important that before that, you understand what I would like you to do and why”. I felt the patient took me more seriously and listened to me with more intent. I included his wife in this conversation, who showed a good understanding that I was trying to achieve informed consent. She was very supportive throughout my explaining to the patient of the risks of examination. Since the patient seemed to have calmed down, I felt he showed much better capacity to give informed consent, agreed to continue having considered everything I had explained, and we proceeded to a slow and careful examination.

Reflection:

This was a good experience for me, that presented potential challenges I may face in future with obtaining informed consent. Upon reflection I am glad that I managed this patient in this way, as opposed to accepting his comments such as “you do what you need to do” as informed consent, as I did not believe that this quite cut it.

I have also reviewed the GOsC fitness to practice report, which features some incidents where consent has not been clearly obtained. This has informed me of potential consequences related to a lack of consent from patients.

Action:

I will always set clear milestones for consent between each step of the appointment process to ensure informed and procedural consent are achieved before continuing. I will continue to review the GOsC fitness to practice report, to keep my mind open about any potential examples where consent may have faltered.

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Fitness to Practice Report - Consent Extracts

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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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Experience:

One of my continuing patients is a 63-year-old female who I have been treating for hip pain or any other complaints she may come in with. She attends monthly appointments and I have been treating her for quite a long time. I have had many conversations with this patient about things she can do to optimise her health, yet she has trouble with self-management.

Psychosocial factors impact this patient’s ability to want to do things for herself to get better.  Since the loss of her husband, she suffers with demotivation, particularly in regard to things that may be beneficial for her. We have built a good rapport and she knows that I will continue to give her supportive advice.

To name a few, we have discussed topics surrounding:

Exercise – rehabilitative and promotion of a healthy lifestyle

Support groups/socialising

Seeking GP advice

Diet

The patient never adheres to exercises (however simple, or convenient I try to make them for her), and does not take good care of herself. It is sad to see, but the patient is completely compos mentis, and shows full capacity to make decisions for herself. She admits that she knows she ‘should’ but does not. This patient is also a good example of someone I have good rapport with, yet maintain clear professional boundaries with, which are respected by the her too. She expects that I will always give her advice about ways to optimise her health and wellbeing, despite that we both know she is unlikely to act upon such advices.

Reflection:

By reflecting on this case, I feel it has strengthened my ability to fulfil my duty in supporting patients in self-care, as although the patient seems unwilling to take my advice, I do not aspire to ‘give up’ on her, nor any other patient.

Action:

I will always try to find new or convenient ways to encourage patients to take an active part in their wellbeing, no matter how small the steps are to begin.

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

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

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The reception staff at ESO would often give new patients some “prep” information, which would include that they might be asked to remove some items of clothing and explain why. At the time of their appointment, I would never assume that patients received this information, or that they would be comfortable in doing so, so always provide a description of what to expect at the beginning of the appointment.

Experience:

I have had an array of experiences relating to modesty options but am always happy to accommodate the patient. I have had patients prefer to keep their vests, t-shirts, trousers/leggings on and some bring a change of clothes with them. Although patients are often happy to be in their underwear, this is not something I automatically assume, nor ever will. I have not experienced a scenario in which a patient has wanted to remain fully clothed but would respect this regardless. I also do my utmost to ensure the patient does not feel like they are causing any issue affecting the examination/treatment process by wanting to keep their clothing on.

I recall observing a patient who appeared to panic when the student advised they may be asked to remove their clothes. The student was a young female and the patient a 21-year-old male. He said that he didn’t know he would have to be undressed and that reception told him just to wear something comfortable. The student handled this very professionally and was reassuring to the patient, advising him that it was ok and that she could accommodate whatever makes him most comfortable. She offered a male chaperone and said that she could ask any observers to leave if it made him more at ease. The patient seemed very relieved that he could keep his trousers on.

Reflection:

Sometimes, before I leave the room to allow patients to undress, they voice their insecurities e.g, scars/skin conditions etc. I always try my best to reassure them and make sure they don’t feel judged or need feel insecure in the professional environment. These experiences make me appreciate that although we as practitioners are used to seeing patients undressed all the time, for them it may be a unique experience or feel quite unnerving.

Action:

I believe strongly in patients feeling comfortable in the treatment room as it can help them feel relaxed, which always helps with treatment too. I will always strive to make my patients feel that they can be honest about their level of comfort and accommodate their preferences. In future practice, I think it would be helpful to provide patients with some “what to expect” information, to give them an opportunity to bring a change of clothes if they would like to.

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Relevant extract from my “what to expect” speech for new patients

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

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

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Experience:

At the beginning of third year, one of my first patients had been previously diagnosed with fibromyalgia. She was visiting as she did not want to always assume that her pain was as a result of her fibromyalgia, and wanted to see if there was anything we could do to help with pain management. I treated this patient regularly for pain and stiffness in her shoulders and neck. After some time of seeing the patient regularly, I reviewed her case and sought advice from the tutor as I felt discontent with her progress. She would visit weekly, experience 2 days of post-treatment soreness, have <2 days of reduced pain and then return to her usual pain levels for the remaining 3 days of the week. The tutor shared their opinion about “fibro patients” and encouraged me to have a conversation with the patient at her next appointment about how to optimise her health, following research. At her next appointment I discussed my findings with the patient (document attached). The patient seemed very deflated by this discussion and very reluctant to want to take part in any exercises, or lifestyle adaptations that may contribute to her feeling better. The patient never returned after this appointment and I was very disappointed. When I advised the tutor, they made some derogatory comments, insinuating that this was typical of patients with fibromyalgia and they often become dependent on their practitioners.

Reflection:

When I reflect on this experience, I feel so disappointed that the conversation I was led to have with the patient, resulted in the anticipated outcome of the tutor. It felt very unfair and from the tutor’s perspective, as though it was a positive outcome, that I no longer had to ‘endure’ her dependence. I worried for my patient’s mental health, and that she thought I might have been trying to ‘get rid’ of her.

Action:

I have learned to forgive my naivety at the time, and the importance of how such a bias opinion can impact the patient. In future, I will instead try my best to empower patients, to encourage them want to play an active part in their health, recovery or management. I also feel I would be able to recognise this type of bias from others, or any unconscious bias of my own by reflecting on my practice, and be able to correct this or act accordingly.

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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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There is always so much to learn in osteopathy as there are so many aspects to consider including (but not limited to!)

anatomy, pathology, biomechanics, osteopathic principles, the 5 models of osteopathy, techniques, psychology, and clinical methods.

All these components contribute to the foundation and clinical application of osteopathy. How each practitioner uses these in their clinical approach can be so diverse but at the core is the patient’s health. Each of these elements tend to pop up at different stages throughout practice yet none seem to precede the other (except patient safety!). I feel patient safety (red flag, health concerns etc.) did not get enough emphasis throughout some of the earlier stages of the course and that this felt more ‘concreted’ during 3rd year in clinic.

I have utilised my knowledge in clinic and exams, and by passing, reaffirms that I have the capability to apply my knowledge to support my practice. In future, I will always research or revise areas that I feel unsure of or ‘out-of-practice’, to make sure the patients care is not compromised in any way.

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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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Experience:

During a continuing appointment, the patients partner advised she had noticed a lump on his back. I palpated the lump but did not feel confident enough to be able to give an informed opinion about what I thought it might be. I could not find my tutor for quite some time, so advised my patient to visit his GP about this. He seemed to be reluctant to see his GP as he said he feels like he is ‘always bothering’ them, so I offered to write a letter of referral. When the patient left, I relayed this information to the tutor who said I should have come to find him, to which I replied that I did, and made the decision to refer him to his GP because I was in a position where I didn’t know what else to do. After debating this in further depth, I was advised to call the patient to let him know that I wouldn’t be writing to his GP after all, and instead at his next appointment (1 week later) I would be able to ask an experienced tutor to have a look at it for him to give their opinion. The patient seemed happy about this and I updated the notes accordingly. I did not see the patient again, but my understanding is that the he did return to the clinic, but with a different student as the schedule changed; I am glad that I put clearly on the notes that the lump was to be investigated by a tutor.

Reflection:

Upon reflection, I feel I did what was right at the time, based on the fact no one was available and the patient was clearly concerned. However, I agree with the tutor who advised that as the patient was returning in 1 week, he should still be ok, and to utilise the experienced practitioners we have at our disposal. Since this experience I have not hesitated to make sure I ask tutors for a second opinion where I feel something may fall outside of the limits of my training. Examples include a swollen lymph node on a baby, and an anterior throat swelling (potential goitre).

Action:

I understand entirely the impact this may have on patients’ health and will never hesitate to be honest with my patients and refer them where I feel my competence or intervention, as a practitioner may be insufficient.

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B3. You must keep your professional knowledge and skills up to date.

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B3. You must keep your professional knowledge and skills up to date.

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Experience:
During preparation for FOPE/OSPE exams has always been a good opportunity to discuss outside of clinic how others might approach clinic scenarios. This is something I have always enjoyed and I am always eager to ask what has sculpted their opinion or conclusion. I will often perform my own research in addition, to make my own conclusion.

Reflection & Action:
This experience has been invaluable to the construction of my becoming an osteopath and I look forward to networking in future with other practitioners and actively completing my CPD.

I follow useful relevant pages on social media to keep anatomy and physiology relevant, which often inspires areas for research, or revision.

https://www.youtube.com/@osmosis/featured

https://www.youtube.com/@JohnGibbons

https://www.youtube.com/@RehabScience

https://www.youtube.com/@DoctorNajeeb/featured

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osmosis osmosis.org pathophysiology pathology education "medical school" "nursing school" medicine health nursing "medical education" physiology pharmacology

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Osmosis.org is a leading medical & health education platform with an audience of over 3 million current & future clinicians & caregivers. Our vision: Everyone who cares for someone will learn by Osmosis! Our YouTube channel features general consumer health videos to educate the public about important medical concepts.

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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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Experience:

An 83-year-old male patient presented at the clinic with posterior hip pain. He said that his relative who worked in sports advised him that it was his gluteal muscles and we carefully discussed that this could be the case, but examination would yield more accurate results. The patient had been diagnosed with hip OA by medical imaging, which was the working diagnosis hereon, but had been exacerbated by some recent gardening and increased activity. When we discussed his management, the patient asked me if he should get a TENS machine. I answered honestly, that I was unfamiliar with their effectiveness, and could not advise if it was suitable for him, but would endeavour to do some research to see if this might be useful for him by his next appointment.

Following some research, I found there is conflicting evidence supporting TENS machines though a recent meta-analysis suggested it can be used in conjunction with core treatment with little adverse effects (Johnson et al., 2022). Ultimately, I decided to follow the NICE guidelines, which advise against use of TENS for osteoarthritis and advised the patient to seek advice from his GP (NHS, 2022) as he still seemed quite eager to try it.

Reflection:

Following this experience, I appreciate the significance of researching information accordingly, in order to optimise patient care.

Action:

I will always ensure I stay up-to-date with relevant guidelines, and perform adequate research for up-to-date evidence in order to fill in any gaps in my knowledge, so I can provide informed advice to patients.

https://www.nice.org.uk/guidance/ng226/chapter/Recommendations#non-pharmacological-management

https://www.nhs.uk/conditions/transcutaneous-electrical-nerve-stimulation-tens/#:~:text=If%20you%27re%20thinking%20about,they%20think%20it%20could%20help.

https://pubmed.ncbi.nlm.nih.gov/30725873/

https://bmjopen.bmj.com/content/bmjopen/12/2/e051073.full.pdf

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1.3.1 For all people with osteoarthritis, offer therapeutic exercise tailored to their needs (for example, local muscle strengthening, general aerobic fitness).

1.3.2 Consider supervised therapeutic exercise sessions for people with osteoarthritis.

1.3.3 Advise people with osteoarthritis that joint pain may increase when they start therapeutic exercise. Explain that:

doing regular and consistent exercise, even though this may initially cause pain or discomfort, will be beneficial for their joints

long-term adherence to an exercise plan increases its benefits by reducing pain and increasing functioning and quality of life.

1.3.4 Consider combining therapeutic exercise with an education programme or behaviour change approaches in a structured treatment package.

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Osteoarthritis in over 16s: diagnosis and management

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1.3.1 For all people with osteoarthritis, offer therapeutic exercise tailored to their needs (for example, local muscle strengthening, general aerobic fitness). 1.3.2 Consider supervised therapeutic exercise sessions for people with osteoarthritis. 1.3.3 Advise people with osteoarthritis that joint pain may increase when they start therapeutic exercise.

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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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Experience:

Though the steps of this standard are practiced and met each day at clinic, we have tutors to overlook our work or provide an experienced opinion when suitable, or needed. By passing my clinic exams every term I am able to feel assured that I am meeting these criteria without the consistent support of the tutors.

Reflection:

Reflecting on these results shows my growth as a capable and safe clinician.

Action:

I will always aspire to improve in any areas that I can, by reflecting on my clinic performances.

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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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Experience:

When covering or taking over another student’s patient, it has proven really difficult at times to read the handwriting. Where there is information on the notes that cannot be read, I have had to check with the patient. I have seen this happen during observation, in which a patient seemed irritated to have to go over old ground/repeat information to another. This is not a big inconvenience but an inconvenience none-the-less, that could be avoided if notes are legible. I have worked hard on making sure my notes are comprehensive and legible and completed by the end of the appointment. It can be difficult when patients are booked back-to-back so I try very hard to complete notes as efficiently as possible during the appointment as opposed to at the end.

Reflection:

I am able to understand the importance of legible notes and having them completed promptly.

Action:

In future I want to continue working toward comprehensive, legible notes and understandable short-hand which may speed up my note-taking process during the appointment. Furthermore, this will add to less note-writing at the end of the appointment.

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

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Experience:

I have needed to write a number of referral letters for various reasons. I have had one occasion where I was almost left to my own devices to write a referral letter to a patient’s GP, and the tutor who was helping me with this case had gone home. When I asked another tutor for help, he disagreed that a letter was necessary and advised that because he did not agree he could not help me. I felt a bit stuck and didn’t know what to do and the tutor who suggested the letter was not going to be back in the clinic for a few days. I wrote the letter to the best of my ability, and eventually found a third tutor who agreed to review it for me. He said it sounded concise and clear and agreed to sign it on behalf of the absent tutor.

Reflection:

This situation was stressful as I was eager to make sure what I had written was acceptable. When the third tutor approved this letter, I was very relieved and it was reassuring to know I had the ability to write a letter without any help, to an acceptable standard.

Action:

I will keep a record of letter templates to help me write them in future, so if I ever feel stuck with what to write I can refer back to this. I would also always ask a colleague or peer to proof-read it for me if I felt necessary.

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

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

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Patient safety is something I feel very strongly about. I want my patients to feel comfortable in the treatment room and be able to trust that confidential information shared remains that way. I have felt comfortable reporting any concerns I have had to clinic management at the ESO. We are continuously reminded about the importance of gaining informed and procedural consent from patients, and a lack of communication, understanding or valid consent is the core of many complaints against osteopaths.

Experience:

In third year, I was treating a 40-year-old female patient for neck pain, and the tutor (male) entered the treatment room. He wanted to posit a different approach and told me to treat the patient’s pericardium. The patient was in her underwear, supine on the couch and the tutor proceeded to perform the treatment without consent. His contacts were on her upper ribs and costal margin. I noticed immediately that the tutor had not obtained consent from the patient and he started to approximate his hands with the patient’s breast tissue between his contact. I interrupted the treatment and asked the patient if she was comfortable with this and if she was ok. The patient said it was ok but I didn’t feel that it was with real conviction and I felt very uncomfortable about the whole situation. After the tutor left the room, the patient voiced that she did not have much confidence in his approach. When I returned to the team room after the appointment the tutor was very rude to me and I sensed he was annoyed that I interrupted his treatment to ensure the patient was comfortable. After this encounter I reported my concerns to clinic management who recorded this accordingly. I do not know what the outcome was, or how this was managed ‘internally’ but my patient did not return to the clinic again.

Reflection:

This experience has stayed with me for the remainder of my time at the ESO and upon reflection I am glad that I interrupted; in hindsight I actually wish I had interrupted sooner than I did.

Action:

I am still very disappointed by the type of behaviour this tutor exhibited and in future will not hesitate to stand up for patients where I feel something inappropriate may be, or have been taking place.

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Raising a concern, which includes whistleblowing, is when you speak up or provide information about something you believe could be putting others at risk.

Every healthcare professional, including osteopaths, must put patients' interests first and act to protect them. This means that if you have concerns about the care or safety of a patient, or the actions of a colleague, you must do something.

Reporting concerns to the GOsC

The Complaints section on our public website explains how to raise a concern or make a complaint to us if you think that a patient is at risk of harm because of an osteopath's behaviour.

You can contact us on 020 7357 6655 x224 or email regulation @osteopathy.org.uk

Reporting concerns to other regulators

If the practitioner is a member of another statutorily regulated profession you should contact the appropriate regulator. You will find contact details for the other health and social care regulators on our public website.

Not sure about raising your concerns?

Raising concerns about a colleague can be challenging, but osteopaths have a professional duty to do so when they believe a patient's safety is threatened.

1. Ask yourself the following questions:

Would I be concerned if this health professional were treating my family or friends?

Is the person's worrying behaviour repeated?

Does the person's behaviour pose a risk to children or vulnerable adults?

What might happen in the short-term or long-term if I do not raise my concern?

If I was asked to so do, could I justify why I did not raise this concern?

2. If you raise your concern with us we may be able to provide protection under the Public Interest Disclosure Act 1998. For further information see our Handling Whistleblowing Concerns Policy.

3. Seek advice and support from the organisations below.

Sources of advice

What the Osteopathic Practice Standards say

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

Read the full guidance in the Osteopathic Practice Standards. If you are the principal of a practice you should ensure that there are systems in place to enable your staff to raise concerns about risks to patients, and you should also ensure that your staff know how and when to use those systems.

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Raising a concern, which includes whistleblowing, is when you speak up or provide information about something you believe could be putting others at risk. Every healthcare professional, including osteopaths, must put patients' interests first and act to protect them.

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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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Experience:
I have always had quite high cleanliness and hygiene standards, which has only been further reinforced by the COVID-19 pandemic. We have had, and continue to follow strict cleaning protocols to maintain cleanliness in the clinic. I have also reported hazards to clinic management including couch roll which was left on the heaters, and carpet that has come away from the floor presenting a trip-hazard to patients.

Reflection:
These are things that I strongly believe should not be neglected for the sake of laziness/inconvenience of others and should be addressed sooner than later.

Action:
I will continue to practice this in future and would expect the same from any future colleagues.

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Workplace health, safety and welfare - HSE

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Workplace health, safety and welfare: The law, shared workplaces, safety signs and emergency procedures

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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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Experience:

The COVID-19 pandemic was a testing time for all and when we returned to clinic after lockdown, we had to adapt to the new protocols to ensure the safety of everyone. This included wearing PPE and strict cleaning procedures, some of which we still practice now. There were and still are varying opinions surrounding this topic among students and patients, and occasionally patients would refuse to wear masks. This was challenging at the start because it meant I was obligated to have a conversation about a sensitive topic.

I recall the first time this happened to me - a patient arrived in their mask but she removed it as soon as we were alone in the treatment room. She said that she found it unnecessary and that it made her hot and uncomfortable. I agreed that it might be uncomfortable but it was the protocol for patients to wear masks in order for the appointment to proceed. The patient said that now we were on our own in the treatment room that she shouldn’t need to wear it. I felt very uncomfortable and a bit unprepared about what to say so I left the room to seek support from the tutor. After speaking with the tutor, I felt more confident about how to approach this situation. When I returned to the treatment room, I advised the patient that although the PPE may be hot and uncomfortable, I was wearing mine to protect patients who may be more vulnerable or those who may live with vulnerable people, from transmission of infection. The patient was quite resisting to wearing PPE and I advised that I cannot put the health of my other patients at risk by continuing to treat her if she does not wear her PPE. Eventually the patient agreed to wear her mask and we were able to continue with the treatment.

Reflection:

Although this was awkward at the time it was really helpful in learning how to manage situations like this in future and was good practice for this. It also made me aware of the importance of feeling well informed about public health issues so I can give informed advice about these things to patients in future. There have been other examples since, including advice about smoking while pregnant to patients in maternity clinic, and mental wellbeing for lots of other patients too.

Action:

I will always stay up to date with relevant guidelines associated with public health, and with recent research to be able to provide well informed advice to patients.

https://www.nice.org.uk/guidance/published?ngt=Public%20health%20guidelines&ndt=Guidance

https://www.gov.uk/government/collections/health-matters-public-health-issues

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Published guidance, NICE advice and quality standards | Guidance | NICE

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Browse the complete list of all our published health and social care guidance, including guidelines, NICE advice and quality standards

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

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

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D1.1 A lack of integrity in your practice can adversely affect patient care. Some examples are:

1.2 subjecting a patient to an investigation or treatment that is unnecessary or not in their best interests.

Experience:

I have been guided appropriately at clinic a few times in order to navigate patients to alternate treatment options/management plans where osteopathy has either not been sufficient, or that they require alternate treatment first, in the interest of being ethical in practice. Some examples include pain reduction and inflammation control. One patient that comes to mind was a patient with fibromyalgia who was attending weekly appointments for 1-2 days of pain relief. I had a discussion with this patient about how best to optimise the effects of treatment and that other contributing factors need be addressed in order to control her pain. Another example was a patient with a baker’s cyst who was very reluctant to take medication but we had a careful conversation about seeing his GP about getting the swelling under control (perhaps by medication) so I can treat him more effectively as my treatment was very limited by the amount of swelling of his knee.

Reflection:

These have been good experiences that have enabled me to practice being honest about the limitations of treatment and how osteopathy fits in multi-disciplinary care.

D1.2 You should now allow misleading advertising or information about you and your practice.

During the coursework where we had to respond to a complaint letter, we had to review the advertising standards authority for osteopaths. This was very insightful and since, I have noticed things here and there relating to other osteopaths advertising on social media. I am glad to realise this has stuck with me and that I know I will review the ASA carefully before making any inaccurate claims about osteopathy. Having my partner work in advertising is also very useful as I can ask him about anything marketing-related, to ensure honesty and integrity is maintained throughout all elements of practice.

https://www.asa.org.uk/advice-online/health-osteopathy.html

https://www.osteopathy.org.uk/training-and-registering/how-to-register-with-the-gosc/professional-indemnity-insurance/

https://www.iosteopathy.org/members-zone/insurance-products/professional-liability-insurance/

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Note: This advice is given by the CAP Executive about non-broadcast advertising. It does not constitute legal advice. It does not bind CAP, CAP advisory panels or the Advertising Standards Authority.

Osteopaths are trained in therapeutic approaches that are suitable for a broad range of individuals, including pregnant women, children and babies. Osteopathic care is delivered through a range of interventions which may include onward referral, health management advice, manual therapy, exercise therapy and others. Osteopaths adapt their therapeutic approach depending on the individual needs of the patient and their presenting complaint. Manual therapy techniques employed may include articulation and manipulation of joints and soft tissues.

Osteopaths have been regulated by statute since 1993 by the General Osteopathic Council (GOsC) and may refer to conditions for which medical supervision should be sought if they hold convincing evidence of the efficacy of their treatments.

Which medical conditions can osteopaths claim to treat?

Based on evidence submitted to CAP prior to November 2016, the ASA and CAP accept that Osteopaths can claim to treat the following:

Arthritic pain
Circulatory problems
Cramp
Digestion problems
Fibromyalgia
Frozen shoulder/ shoulder and elbow pain/ tennis elbow (lateral epicondylitis) arising from associated musculoskeletal conditions of the back and neck, but not isolated occurrences
Headache arising from the neck (cervicogenic)
Joint pains
Joint pains including hip and knee pain from osteoarthritis as an adjunct to core OA treatments and exercise
General, acute & chronic backache, back pain (not arising from injury or accident)
Generalised aches and pains
Lumbago
Migraine prevention
Minor sports injuries
Muscle spasms
Neuralgia
Tension and inability to relax
Rheumatic pain
Sciatica
Uncomplicated mechanical neck pain (as opposed to neck pain following injury i.e. whiplash)

If marketers use different medical terms to describe one of the above conditions, they may be asked to provide evidence to demonstrate that this description is generally agreed to have the same meaning as that approved condition.

Which medical conditions can osteopaths not claim to treat?

Any conditions that are not reflected above are likely to be problematic unless the marketer holds robust clinical evidence to support their claims.

Are claims to treat babies, children and pregnant women acceptable?

As regulated health professionals, osteopaths may refer to treating specific population groups such as pregnant women, children and babies. However, at present there is a limited or negative evidence base for the effectiveness of osteopathy in treating conditions specific to those groups, such as colic or morning sickness.

Consequently, references to treatment for symptoms and conditions that are likely to be understood to be specific to babies, children or pregnant women are unlikely to be acceptable unless the marketer holds a robust body of evidence.

Where an adequate evidence base has been established for the efficacy of osteopathic treatment for particular conditions in the general population, claims that do not materially depart from those already deemed acceptable by CAP and which describe interventions that are consistent with osteopathic practice, are likely to be acceptable.

The ASA has recently carried out a review of advertising claims in relation to the treatment of babies, children and pregnant women using osteopathy which explains in more detail the types of claims (including phraseology) that are likely to be acceptable and those that are not. Osteopathy: ASA review and guidance for marketing claims for pregnant women, children and babies.

Can I call myself a "Doctor"?

Claims such as "Dr" and "Doctor" are likely to be understood to mean that the Osteopath holds a general medical qualification. As such, Osteopaths not holding such a qualification should avoid references to "Dr" or claims that are likely to have the same meaning.

Updated on 2 December 2016.

More on

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Advertising Standards Authority | Committee of Advertising Practice

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Note: This advice is given by the CAP Executive about non-broadcast advertising. It does not constitute legal advice. It does not bind CAP, CAP advisory panels or the Advertising Standards Authority. Osteopaths are trained in therapeutic approaches that are suitable for a broad range of individuals, including pregnant women, children and babies.

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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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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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Professional Boundaries

Experience:

A colleague of mine was receiving gifts from one of their patients, since Christmas in year 3. At first, I thought it was a nice gesture but over time our team started to notice that the gifts were continuing and becoming a bit more obscure. Another colleague confronted the student about it, who said that the patient (also female) had a mental condition that affected how she understands certain situations, and the student felt it was difficult, and had concerns over how the patient would react to the rejection. An argument ensued in which the student receiving the gifts did not seem to understand that enabling this behaviour was crossing the professional boundary.

Reflection & Action: I have never received gifts from patients, and this situation confirmed to me that I am glad not to have! This also enlightened me, and upon reflection I feel confident in setting clear professional boundaries.

Experience:

In 4th year, I sensed one of my male patients ‘fishing’ for personal information about me during his treatment. It seemed he wanted to know my relationship status and it felt very out-of-context and made me feel very awkward. I managed to swerve the conversation by changing the topic. I reflected on the situation and wanted to ensure that I hadn’t misinterpreted that it had come from somewhere innocent and decided to share this with my tutor. The tutor reassured me that I had handled it well and that if I felt comfortable, I could see how the next appointment went before handing him to a male practitioner. At the next appointment, I ensured I had an observer and the appointment was fine. The tutor and I discussed how to carefully manage situations like this in future, and that I could refer the patient to a colleague who may have more appropriate specialities that suit their condition, in order to optimise their treatment.

Reflection:

This experience reassured me that there are ways of handling patients who may overstep the professional boundary.

Action:

If this happened in future, I would feel comfortable referring patients to a male or alternate colleague without it being awkward or making the patient feel uncomfortable.

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Over the past few months, we have looked at a range of scenarios to help you consider the types of boundaries issues which might arise in practice, and how these might be addressed and managed.

We have showed how using the Osteopathic Practice Standards (OPS) can inform and support decision making. And how considering these issues helps support your own reflection and continuing professional development in applying the OPS to actual practice, particularly in the areas of communication and consent, and professionalism.

We know from the NCOR analysis of concerns and complaints data, and our reflections on this, that concerns and complaints relating to boundaries are on the increase. Boundary issues might be sexual in nature, but this is often not the case, and we have tried to illustrate how potential boundaries scenarios may arise in other areas too.

I hope that the cases we have looked at in this series have been helpful and thought provoking, and that they have led to some interesting discussions with your colleagues. We plan to return to this subject later this year, and develop some further scenarios to illustrate how the OPS can help us navigate effectively through the challenges of practice.

You can review the whole series of scenarios. Or take a look at one or more below:

Scenario 1: Potential personal relationship developing with a vulnerable patient.

Scenario 2: Patient decides to leave osteopath some money in their will. (Plus response to Scenario 1)

Scenario 3: A commercial relationship with a patient. (Plus response to Scenario 2)

Scenario 4: Arranging to meet up socially with a patient. (Plus response to Scenario 3

Scenario 5: Meeting a former patient by chance while out one night. (Plus response to Scenario 4)

Scenario 6: Being asked out by a patient. (Plus response to Scenario 5)

To round off the series, here is the response to scenario 6, published in December:

My response to Scenario 6

There is nothing in this scenario to suggest that the osteopath has acted in an unprofessional way, nor encouraged the patient in his now openly stated attraction towards her. Once again, we can look to standard D2 of the OPS and its guidance to consider how the osteopath might manage this situation.

D2.5.4 states that it is the osteopath's responsibility not to act on feelings of sexual attraction to or from patients. The osteopath in this case is certainly not considering taking the patient up on his offer of a drink, and is looking for a way to turn him down gently.

D2.5.5 states that if a patient 'displays sexualized behaviour', you should seek advice from a colleague or the professional body (the Institute of Osteopathy) as to the most appropriate course of action. The key issue outlined is that if you cannot remain objective and professional, then you should refer the patient to another healthcare practitioner.

The challenge will be to clearly and professionally explain to the patient that she must decline his offer of meeting socially, and that the therapeutic relationship needs to be based on clear professional boundaries. She needs to consider whether she does feel able to continue treating the patient, and even if she does, let him know that if he prefers, she could refer him to a colleague to continue his treatment. Standard A7 applies here too. The guidance to A7 makes it clear that you are not obliged to accept any individual as a patient, but if you do, and then feel that you cannot continue to provide the good quality care to which they are entitled, you may decline to treat them further and refer them to another osteopath or healthcare practitioner. Reasons given as examples in the guidance include where patients are aggressive, where they seem to lack confidence in the treatment you're providing or if they have become overly dependent on you.

So the osteopath needs to consider whether she feels able to continue providing good quality and objective care and, if not, offer to refer the patient elsewhere. She is not obliged to continue treating a patient who has or continues to behave inappropriately towards her, or who makes her feel uncomfortable in this way.

Please do get in touch if you would like to share your reflections on any of the scenarios or any of the issues raised, or if you have ideas for scenarios you would like us to consider in the future. Please email: standards@osteopathy.org.uk

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Series Review: Thinking about professional boundaries: what would you do?

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Over the past few months, we have looked at a range of scenarios to help you consider the types of boundaries issues which might arise in practice, and how these might be addressed and managed. We have showed how using the Osteopathic Practice Standards (OPS) can inform and support decision making.

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

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

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Experience:

I have noticed that some patients (especially continuing) are very blasé about consent and shared decision making. Some patients tend to have a “just get on with it” attitude which I appreciate comes from a good place, but makes it very difficult with gaining consent. I have noticed that as patients become more familiar with the appointment process, they tend to want to brush over consent, aims and outcomes of treatment, or alternative treatment options, including no treatment. This standard also resonates with the coursework complaint letter response we had to write.

Reflection:

As I have grown as a clinician, I have learned to ensure that patients are listening to what I am saying, and ensuring that they understand, such as that they may feel soreness after treatment. I often advise that they can contact me if they have any concerns or unordinary outcomes to treatment/examination. This has also helped me become a bit more assertive in practice to ensure that patients understand that I am fulfilling my duty of candour, and that they take it more seriously.

Action:

I will strive to ensure that if anything goes wrong in the process of my patients care that I will fulfil my duty of candour with honesty and integrity, and work with them to come to the best remedy or outcome.

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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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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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Experience:

In year 2, we were assigned coursework in which we had to respond to a complaint letter. I have experience handling complaints in my clerical role, however when I reviewed the marking criteria/assessment brief I soon realised that the entire process was completely different. There were so many details we had to cover that I originally overlooked resulting in my failing of this module. When I had to re-submit this, it made me appreciate all of the things we had to cover.

Reflection:

Although it did not seem much like a perfectly “genuine” example of a response to a complaint, it forced me to review lots of different things, like the OPS, and advertising standards authority, which was very helpful. In addition it has made me familiar with how to assist patients with their complaint procedure if required.

Action:

Upon resubmission I passed with a much higher grade and will keep this document to remind me, or help me if I were to experience any complaints or challenges in future. I hope I never have to, but I would feel confident in my ability to cooperate with the complaint process.

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An important part of our work is dealing with concerns and complaints about osteopaths. We publish the outcomes of complaints made to us in our Annual Reports and our Fitness to Practise Annual Reports.

Complaints may come from:

members of the public, including patients

other osteopaths

employers of osteopaths

students of osteopathy

other health professionals.

Every osteopath in the UK must be registered with us and must follow our Osteopathic Practice Standards, which set out the standards and guidelines for the safe and competent practice of osteopathy

Concerns and complaints about osteopaths

Many concerns can be resolved directly with the osteopath in question. However, we want you to contact us immediately in any cases in which the osteopath is:

acting in a dishonest, indecent or violent way

working under the influence of alcohol or drugs

having a personal relationship with a patient

examining or treating a patient without their consent

incompetent (when an osteopath's work fails to meet the standards we set in our Osteopathic Practice Standards.)

If you are a patient and have other concerns about the treatment you have received, or the way your osteopath has behaved, the best person to talk to first is usually the osteopath in question. Many concerns arise from misunderstandings and it is often helpful to discuss your concerns with the osteopath first.

If you would prefer not to do this, you may be able to discuss it with another osteopath in the practice. Ask about the practice's complaints procedure: all osteopathic practices should have one. If there is no one else in the practice, another osteopath may be able to give an opinion. Most will be pleased to help you.

If you are not satisfied that your concerns have been properly dealt with, or if you want further advice, you should contact our Regulation Department on 020 7357 6655 x224 or email regulation@osteopathy.org.uk. We are here to help you with any concern or complaint you may have about an osteopath. There is also further information in our leaflet How to complain about an osteopath.

What we can investigate

We have a legal responsibility to look at complaints if:

an osteopath's behaviour falls below the standards set out in our Osteopathic Practice Standards

an osteopath is guilty of professional incompetence because their work fails to meet the standards we set in our Osteopathic Practice Standards

an osteopath is convicted of a crime - if this happens, we will look at the conviction to decide whether it affects the osteopath's ability to practise

an osteopath's physical or mental condition is seriously affecting their work - if an osteopath has a health problem, we will consider how it affects their ability to practise.

Fitness to practise

The term fitness to practise means that osteopaths should have the necessary knowledge and skills to perform their job effectively, they should have the health and character to practise safely and competently, and they can be trusted to act legally and responsibly.

Our Regulation Department is responsible for establishing and maintaining the standards of professional competence and conduct. It handles complaints about the fitness to practise of osteopaths on the Register, which can lead to a hearing before the Professional Conduct Committee (PCC).

Our Fitness to Practise reports, published annually, includes details of the decisions made by the PCC and any sanctions applied. When the committee investigates an allegation and decides that it is not well-founded, the osteopath can ask for this to be recorded in the next Fitness to Practise report.

Feedback

Did you find the information you were looking for? Let us know at webfeedback@osteopathy.org.uk. Your feedback will help us to improve this website.

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An important part of our work is dealing with concerns and complaints about osteopaths. We publish the outcomes of complaints made to us in our Annual Reports and our Fitness to Practise Annual Reports. Complaints may come from: members of the public, including patients other osteopaths employers of osteopaths students of osteopathy other health professionals.

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

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Experience:

There have been a few emails from reception reminding students to return their files to reception after their appointments. Some students have left patient notes lying around in team rooms. There have also been times I have picked up forms to use then found they have been party-filled in.

Reflection:

This makes me feel very uncomfortable and it is always unclear if these notes are intended to be filed or discarded.

Having previously worked in a clerical environment I already have a strong understanding of the careful management of patient/client information, which I have carried with me into the clinic environment. If I have needed information from patient records for assignments, I have requested these from reception so they can be redacted beforehand. Where I have half-filled in forms and patients have cancelled or not shown up, I have always ensured these forms are handed in to reception for shredding.

Action:

The careful handling of patient records or information is something I will continue to practise.

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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.

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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.

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Experience:

I have abundant experience in meeting, interacting with and forming friendships with people of various backgrounds, ages, and races. I am also a dedicated ally to the LGBTQ+ community. I have furthermore enjoyed my time in women’s health clinic seeing pregnant and post-natal patients, and children’s clinic where I have treated patients between 6 weeks to 17 years old.

I have thoroughly enjoyed meeting all the different personalities at clinic, some have been more challenging than others. Some patients enjoy conversing during the treatment and I am happy to listen and am glad they feel safe and comfortable enough that they can decompress. There have been occasions in which patients have voiced their opinions about politics or religion, which are two topics I personally have always been very private about.

On one occasion a patient expressed quite a strong opinion about politics that made me feel very uncomfortable. I did not know how to respond so remained silent until they changed the topic. I was very shocked but maintained my composure until they left and discussed this with the tutor after, who reassured me that I handled it in a positive way and that by saying nothing at all I was not enabling their behaviour, nor making myself vulnerable to a difficult conversation.

Reflection:

This is something I don’t look forward to happening in practice, but this experience has made me feel confident that it will never affect my treatment approach to patients, their health is still the priority.

Action:

I will always endeavour to reflect on my performance in clinic to ensure that all my patients are treated fairly and equally. I have no aspiration to discontinue complying with equality and anti-discrimination law.

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Information and guidance on the Equality Act 2010, including age discrimination and the Public Sector Equality Duty.

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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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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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Experience:

Choosing osteopathy was not an overnight choice of mine. The discontent I was experiencing in my previous role led me to want a career that I felt passionate about with higher satisfaction. At 28, I decided to embark on a 5-year journey to become a qualified osteopath, which involved a lot of sacrifices, including being long-distance from my family, partner and dog, as well as a financial sacrifice which was scary. This reinforces the importance of not doing anything to spoil it. I am able to have fun without abusing drugs or alcohol, and already have a very discreet social media presence.

Along the way, I have heard rumours that some of my peers have behaved questionably outside of the professional environment, seemingly putting osteopathy quite low on their priority list. This concerns and frustrates me, as by acting in certain ways they tarnish the profession, which I find very selfish. To my understanding, such behaviours have been reported to the relevant staff and dealt with accordingly. I hope that the consequences are sufficient that they learn from it and start to manage their behaviour outside of the clinic better.

Reflection & Action:

Hearing about this kind of thing reinforces to me that I wouldn’t want to be like those students, however if I were to witness anything like this first-hand, I would not hesitate to follow the necessary steps to ensure the good reputation of osteopathy is upheld.

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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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Experience:
We don’t have any involvement with financial dealings at clinic. I’ve had a look at some of the complaints on GOsC which is a useful place to gain insight into the kind of things that are brought to GOsC.One case involved an osteopath being reported for being dishonest about the success of their business to investors.

Reflection:
This was really interesting to review as it did not seem to be a direct report to GOsC, e.g., a patient complaint, but because of their criminal offence relating to creating a false or misleading impression relating to financial dealings. This reinforces the importance of being honest and highlights the consequences for those who choose not to be.

Action:
I will aspire not to be one of those people, by maintaining honesty and professionalism in my financial dealings.

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

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

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Experience:

As we have been reaching the end of 4th year, we have been needing to hand over patients to the current third years so have been completing handover forms which summarise the patients for the next practitioner.

In 3rd year I used to struggle with how to complete the continuing patient forms, despite knowing what to discuss with the patient in the room, I always felt they seemed a bit too vague. One of my tutors taught me how to complete my notes more comprehensively by asking me “what would you want it to say if it wasn’t your patient and you needed to read it?”.

Reflection & Action:

This really helped me recognise what was relevant and important to have down on the recent notes. Since then, I have often been complimented by other tutors on my note taking and will endeavour to maintain this level of professionalism.

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

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

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Experience:

In clinical integration lectures in year 1 & 2 we learned about all the different places/health care associates we may be able to refer or navigate our patients. We would usually discuss this at the end of the case, or as an integral part to the management plan. When I started clinic in year 3, I soon learned that these referral considerations sit much higher in the appointment process and have far more value and importance than what we had previously interpreted. I learned at clinic that I may need to refer patients in order to ensure they are safe to examine/treat, or to investigate their condition.

The first referral I had to make was an insightful example of a patient presenting to an osteopathic clinic with musculoskeletal symptoms, but who required referral upon examination. One of the earliest patients I saw in year 3 was a postman, presenting with neck stiffness and marked right UEX weakness. Upon physical examination he had depleted myotomes of 3 levels I was guided by the tutor to refer him for medical imaging. I was advised that his results found that he had a bone spur in his CSP that was barely touching his spinal cord, yet providing severe unilateral symptoms. Eventually he was referred to a neurosurgeon by the tutor. This made me appreciate the importance of referrals in the context of diagnosis rather than just treatment/management.

Reflection:

This was an important lesson that has helped sculpt my appointment process, making patient safety primary and always considering referral where necessary. I have since referred patients for an array of health concerns, or to other practices to contribute to their overall health. This includes sports masseuse’s, talking therapies, fibromyalgia groups, and local groups for new parents who have felt isolated or lonely.

Action:

I will continue to stay up-to-date with guidelines and research relating to various musculoskeletal presentations that may require deeper investigation to optimise treatment options and keep patients safe.

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1. Benjamin M Davies , academic clinical fellow and specialist registrar neurosurgery 1,

2. Oliver D Mowforth , medical student, 1,

3. Emma K Smith , specialist registrar general practice, 2,

4. Mark RN Kotter , clinician scientist , and consultant neurosurgeon 1

1. 1Academic neurosurgery unit, Department of Clinical Neurosurgery, University of Cambridge, Cambridge, UK

2. 2School of General Practice, NHS Health Education East of England, UK

Correspondence to MRN Kotter mrk25{at}cam.ac.uk

What you need to know

Consider degenerative cervical myelopathy in patients over 50 with progressive neurological symptoms, such as pain and stiffness in the neck or limbs, imbalance, numbness, loss of dexterity, frequent falls, and/or incontinence

Perform a full neurological assessment as early symptoms are subtle and non-specific

A magnetic resonance imaging (MRI) scan is essential to detect degenerative changes in the cervical spine and cord compression

Time is Spine: Refer patients with suspected DCM promptly to a specialist for consideration of spinal surgery, as delayed diagnosis can lead to residual symptoms and functional disability

What is degenerative cervical myelopathy?

Degenerative cervical myelopathy (DCM), earlier referred to as cervical spondylotic myelopathy, involves spinal cord dysfunction from compression in the neck. 1 Patients report neurological symptoms such as pain and numbness in limbs, poor coordination, imbalance, and bladder problems. Owing to its mobility, the vertebral column of the neck is particularly prone to degenerative changes such as disc herniation, ligament hypertrophy or ossification, and osteophyte formation. These changes are more common with age 2 ( box 1) and are often collectively termed spondylosis ( fig 1). 3

Box 1

Why is it missed?

Non-specific and subtle early features that overlap with other neurological conditions can delay the diagnosis. 9 Incomplete neurological assessment by professionals 10 with a poor awareness of the disease 11 further contributes to delay. A retrospective study of medical records of 42 patients in Israel who underwent surgery for DCM noted an average delay of 2.2 years (range 1.7 months to 8.9 years) from initiation of symptoms to diagnosis. On average, 5.2 ±3.6 consultations were required before a diagnosis was made. 10 Forty three per cent of these patients had symptoms of numbness and pain in hands, and were initially diagnosed and sometimes treated for carpal tunnel syndrome. 10 In our clinical experience, the diagnosis of carpal tunnel syndrome, especially when diagnosed bilaterally, is often incorrect and DCM usually accounts for these symptoms.

Why does this matter?

Spinal cord compression results in progressive neurological decline and affects quality of life. 12 Left untreated, it can lead to tetraplegia and wheelchair dependence (data on how many patients with DCM progress in this way are unavailable). Surgical decompression can halt the disease progression, however, the regenerative capacity of the spinal cord is limited and any damage is often permanent. Delayed treatment leads to poorer outcomes and lifelong disability. Findings from the AOSpine series (746 patients with DCM) indicate that treatment within six months of symptoms offers the best chance of recovery, 13 but this time frame is some way from current average diagnosis times. 10

How is it diagnosed?

Detecting early DCM can be challenging. A high index of suspicion, alongside a comprehensive neurological examination is advised. Box 2 outlines common symptoms and examination findings in DCM.

Box 2
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How is it managed?

Often cord compression is an incidental finding and at least initially does not cause symptoms. 2 Reassure the patient that no further management is required at this stage but advise them to report any symptoms promptly in the future.

Guidelines from AOSpine 1an international community of spine surgeons advise that all patients with DCM should be assessed by a specialist surgeon, who might fall under the remit of neurosurgery or orthopaedics. The guidelines use the modified Japanese Orthopaedic Association score, which classifies patients as having mild or severe symptoms based on arm, leg, and bladder function. 1 Surgery is recommended in patients with moderate or severe DCM and in those with disease progression. Treatment of symptoms (for pain, for example) and regular follow-up might be offered for patients with mild, stable DCM.

The AOSpine series showed that decompressive surgery can halt disease progression and enable meaningful, albeit limited, recovery across a range of measures including pain, function, and quality of life. 15 The optimal timing of surgery is debatable because the progression of disease is poorly understood. 9 Preoperative physiotherapy should only be advised by specialist services 1; neck manipulation is strictly contraindicated as it might cause further damage. 16

It is not possible to predict the long term outcome of surgery. Maximal recovery occurs at around 6-12 months. Residual symptoms beyond this are likely to be permanent and should be managed appropriately. Functional deficits are common, and include falls and reduced mobility, incontinence, depression, sleep deficits, and struggles with self-care, and often the most troublesome symptom is pain. Discuss with your patient that complete resolution of pain is unlikely. Neuropathic analgesia and anti-spasticity medication can be offered to manage the pain. Early referral to specialist pain clinics is often helpful.

Ask patients to report any worsening or new symptoms or signs as untreated levels of the cervical spine might further degenerate and cause spinal cord compression.

Footnotes

This is one of a series of occasional articles highlighting conditions that may be more common than many doctors realise or may be missed at first presentation. The series advisers are Anthony Harnden, professor of primary care, Department of Primary Care Health Sciences, University of Oxford, and Dr Kevin Barraclough, School of Social and Community Medicine, University of Bristol. To suggest a topic for this series, please email us at practice{at}bmj.com .

Acknowledgments: Research in the senior author's laboratory is supported by a core support grant from the Wellcome Trust and MRC to the Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute. MRNK is supported by a NIHR Clinician Scientist Award.

Disclaimer: This report is independent research arising from a Clinician Scientist Award, CS-2015-15-023, supported by the National Institute for Health Research. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.

I confirm that we, the authors, have read and understood the BMJ policy on declaration of interests and have no competing interests to declare.

All authors have contributed to the development, drafting and revision of this article and agree to its submission.

Provenance and peer review: commissioned; externally peer reviewed.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/.

View Abstract

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What you need to know A 54 year old man presents with neck stiffness for about a year. He complains of numbness in his fingers and difficulty buttoning up his shirt, which has not improved following surgery for carpal tunnel syndrome. Of late, he has experienced unsteadiness and has started to use a walking stick after sustaining falls.

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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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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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Experience:

During third year, I had to take some time off to take care of my mental health. I was exhausting myself to excel and in turn failed to maintain a healthy work-life balance. I became reclusive and fatigued, which started to have a negative impact on my mental and physical health. I noticed this was impacting my performance at clinic, when I was struggling to concentrate and felt my communication with patients had weakened, which I consider one of my biggest strengths. I contacted the relevant staff at the ESO and my GP to discuss taking the necessary steps to recuperate. It was a difficult time as I knew I needed the time off to recover, but was frustrated and worried about losing clinic hours. I felt very guilty for missing clinic, and worried a lot about burdening my peers while I was away. I also had to apply for mitigation for two exams. I felt torn and instinctively wanted to use the time to be productive for uni work, though I knew it was supposed to be for me to get better.

When I came back, I realised the importance of rest; my ability to focus and communicate effectively returned. My peers were very understanding and reassured me that they had not felt burdened by my absence. Mitigation for the exams was approved and I sat them in the summer instead. I felt disappointed by clinic management when discussing making up my missed hours; during the time of my absence, I was reassured that it would be ok and the hours can be made up accordingly, however further down the line I felt a sense of disappointment and feared that my accumulated hours would warrant a “discussion about professionalism”, which made me feel very anxious and reinforced my feelings of guilt.

Reflection & Action:

Working in osteopathy, we are continuously orienting treatment and management plans around the 5 osteopathic principles, and utilising the biopsychosocial model. This experience made me realise that it is equally as important to take this approach to one’s self, as a practitioner. This experience has enabled me to recognise any signs or patterns of behaviour that may indicate I need to readdress my work-life balance in order to stay healthy for my patients. Furthermore, it has reinforced that I will acknowledge and reassure peers or patients who may be going through a similar experience that they need not feel any guilt in taking the crucial steps to get better and improve their health in all aspects. This is something I will continue to practice in future.

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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.

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When registering with GOsC I was able to gladly report that I have never been subject to any disciplinary investigations. I have always been able to confidently provide a clear DBS check wherever required. I have reviewed some of the complaints on the GOsC website and recognise the consequences of criminal activity result in removal from the register.