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1. Business plan reflection 04/05/21.
For our latest piece of coursework we had to produce a business plan, including an in-depth look at the market, what services we would offer, financial planning and advertisement.

Although I do not plan on opening a clinic of my own for a long time this allowed me to reflect on a few important aspects of being an osteopath. What my niche would be? What makes a patient chose a specific clinic? What do people want from their osteopath?

It was also interesting to look at the advertisement standards and the things we as osteopaths are limited to say we can treat. I understand that for some practitioners this could be considered restrictive, but more importantly giving patients false information, or promising to treat conditions which osteopathy can not help, can be considered deceptive and dishonest. It is important that this list is kept too, so that osteopathy can be respected as a profession.

Although it may be far in the future that I will need to advertise osteopathy, I will definitely consider this when discussing how I can help patients not wanting to mislead patients, it is important to be clear and upfront about how we may help them.

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1. Professional boundaries reflection 18/04/21

I have not had any personal experience with this standard, however I can see how it poses a few challenges for someone who may find themselves within this scenario. An osteopath should not abuse their power to be inappropriate or sexually involved with patients.  Despite this being seemingly obvious, this has been something I have seen on the GOsC  fitness to practise report more than once, suggesting its consideration must be taken seriously. The thought that an individual has done this is frightening.

It is important to maintain a clear professional manner with all patients. As stated within the OPS there is an imbalance of power in the practitioner- patient relationship, which makes starting a personal relationship complicated, even beyond the patient being under your care.

I will continue to maintain a strictly professional manner with all of my patients, to avoid any confusion or misinterpretation.

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1.Patient Reflection 22/11/19

I have seen a patient for the third time today, each time he starts the consulatation saying how he has seen improvement in the pain, however it was shortly followed by a new associated pain. From extensor hallicus longus tendinopathy, to plantar fasciitis to a subacute gastrostocs strain.
Due to the ongoing changes with his injury, we decided to take a step back from the acute injury and try a more global approach as there is clearly a greater mechanical promblem occuring.
I have found this frustrating, where by my treatment seemed to be effective however it was not tackling the primary problem, so there was not any long term relief.

I will aim to improve my knowledge of the anatomy and the biomechanics of the foot to try and get a better understanding of what's going on. I think in the future I will also try to take a more global approach from the start, especially in patients with acute pain, as you don't want to aggravate the acute pain causing structure, but may be able to offload strain to that area.

2.Observation Reflection 7/09/20

During summer clinic a member of my team had a 89 year old patient with LBP. There was no known onset and he had been experiencing dizziness, which he hadn't been to see his GP about. He also had a history of prostate cancer.

During the discussion prior to examination, we had discussed the screening questions for dizziness, and  the possibility of metastasis from the prostate to the spine.

During the examination it was observed that he had a pulsating mass in his abdomen and was referred to the GP to be seen urgently with a suspected AAA.

We were later called and told that he had a large AAA, and that he had metastases all over his body.

This was the first time that I had witnessed a patient being referred for something life threatening and it had got me thinking about how I would have handled this scenario. Would I have noticed his AAA? Would I have referred for possible metastasis?

It's hard to guess how I would have handled it, but it has really made me aware of the possibility of patients walking in with something more sinister. I really need to be thinking about the possibility of this with every patient that walks through the door.

When discussing this with a tutor they said that they refer any patient with a history of cancer and back pain which has no known cause. That also said that they screen for AAA with every older male with LBP. I had never heard of taking these precautions before, but I will definitely take this on board for the future.

I have also revised my screening questions for AAA, dizziness and other possible cardiovascular problems.

3. Patient Reflection 19/11/20

Last week I had a patient attend clinic presenting with a LBP with radicular pain into their R leg. The case history suggested this was due to a disc herniation. Upon examination I found that in addition to the radicular signs in the R leg, the patient also had significant weakness and diminished reflexes in the L leg. This was suggestive of a central disc herniation.

I informed the patient of the DD, and informed them of the symptoms associated with cauda equina syndrome so that they can head straight to a&e if these were to develop. My tutor and I decided that it was ok to do some gentle treatment, if the patient was happy with this.

This week the patient returned, I was with a different tutor and he had not seen any improvement. With my tutor we discussed the risks associated with bilateral symptoms, and we decided that it was best that we refer the patient for imaging, to better know what we were working with.

This highlighted to me the different clinical opinions on what is safe to treat and what isn't. The patient needs to be made aware of the risks. When there is uncertainty it is sensible to refer.

In the future, I will make sure the patient is fully aware of any risk of treatment. I will research the cause and risks associated with bilateral symptoms in the lower extremity.

OPS C1.3:  formulate an appropriate working diagnosis or rationale for care and explain this clearly to the patient.
C1.6: evaluate post-treatment response and justify the decision to continue, modify or cease osteopathic treatment as appropriate
C1.10: where appropriate, refer the patient to another healthcare professional, following appropriate referral procedures.

4.Takeover patient 12/04/21

Today I had a 67 year old male, grounds worker, present to the clinic with groin and anterior thigh pain. The patient had a previous working diagnosis of hip OA. For the examination we decided to use a neurological exam to be certain the pain wasn't coming from his back. This led to the findings of:

Hyperreflexia at C8, L4 and S1.

Clonus at S1 bilaterally

Hypo-reflexia at at C5 and C6

Ataxic gait

This suggested to us that he likely had a myelopathy, and needed referral for further investigation.

He did, however, also have pain on FADIR at the effected hip, with associated myalgia of the quads.

For this patient we had decided that he needed a referral to his GP as soon as possible. Upon discussion the patient reported the gait changes for 5 years, suggesting there is a slow progression of his symptoms. In addition, we noted that there was a clear musculoskeletal cause for his hip pain. Which has improved from osteopathic treatment in the past.  We discussed the referral with the patient and agreed that we would also be able to conservatively treat his hip.

With this case, I was glad to have identified the neurological findings - I could have taken the previous diagnosis, and missed identifying the serious pathology. In the future I will make sure I will always thoroughly test my patients, despite the diagnosis they may have been given.

It was also interesting to discuss whether it was safe to treat this patient. We had identified that he had both an upper motor neurone lesion, and osteoarthritis in his hip. As he had been experiencing these symptoms for 5 years we could deduce that this was not an acute myelopathy. As an osteopath I could gently treat the patient, a give him pain relief by focusing on his hip and Lex, without treating his spine, where the cause of the myelopathy could lie. In the future I will consider where I can help someone as an osteopath and when I need to refer them.

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

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

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1. Take over patient 02/09/20
During summer clinic I had a takeover patient. Upon examining the previous practitioners case history I struggled to read their hand writing, and they had failed to clearly show their examination findings. This meant I could not fully trust their working diagnosis and treatment plan. This then required for me to spend time asking the patient questions, and performing my own thorough examination to know that I could justify my treatment.

Although this was only a minor inconvenience to me, it made me think about how the case history would look in the case of a complaint. The practitioner would not have been able to justify their treatment approach.

This has definitely made me question how robust my note taking is, and if handed to another practitioner, or in the worse case scenario in front of GOsC for a complaint, could I substantiate my treatment plan. This is somewhat scary to think that in the busyness and rush of clinic and treating patients, we may fail to properly take notes, which may leave us vulnerable in the future.

In the  future, I will aim to complete the majority of the case history with with the patient, ensuring I include every finding, even when negative. I will aim to accurately and clearly present my findings.

OPS C2

2. CEX feedback  08/03/21

During my CEX my tutor highlighted that I had taken a thorough case history and recorded it well.

I am proud that this was noted as this is something I have struggled with. In the past I have stuck to the questions of SOCRATES, but now with experience I know this needs expanding and developing in order to fully understand the patients presenting complaint. I will continue to keep up this standard of questioning with my patients in the future, allowing time to get all the information needed in order to make a clear and concise differential diagnosis.

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1. Assessment feedback- Year 2
Points from the feedback that I have felt are important:
- I was happy to see that a number of the examiners felt that my techniques were well set up and engaged with the tissues.
-My knowledge behind some of the techniques could have been better to have shown a greater understanding. For example the aims of articulation.

I will work on the justification for my techniques, it is important that I can understand this myself, and also that I can explain why I am doing something to my patient.

2. Patient reflection 27/10/19
Today I observed one of my team members with a new patient, it was an 82 year old male who presented with pain in his arm. English was the patients second language so their son came in to help to translate. During the case history my team mate failed to ask if the pain in the arm was worsened by movements in the neck, a key question for determining if the pain could be radicular. Following examination my colleague concluded that it was in fact a cervical radiculopathy, likely caused by osteophytic growth.

The patient was Sikh and wore a turban. I felt that my colleague managed to adapt the treatment of the neck well around the turban, making sure that the quality of the treatment received was not effected due to the religion of the patient.

I can empathise with my colleague that when taking a patients case history in-front of 4 observers it can be particularly stressful, which can effect our performance. I can imagine that they were frustrated with themselves when someone else had to ask the question for them. However, having ability to apply your clinical knowledge in order to come up with an appropriate working diagnosis in vital (B1).

Following seeing how easy it is to forget something simple under pressure, I will continue to update my clinical knowledge, so that it becomes habitual to ask these questions.

I was, however, impressed that the practitioner did not feel awkward, or at least did not show that they felt awkward, working around the patients' turban when treating the neck. It is important that the patient does not feel as though their religious clothes are inhibiting the treatment that they are receiving, or that they are being treated differently because of this.

We are always told that we will need to find different ways of doing techniques, for example in the patient can't lie on their back, or if they are in a wheel chair, but we never think to practise these. I think my colleague seamlessly adapted to this situation and I would have been proud if I had performed the way that they did.

In the future I will make sure that no patient is treated differently because of their gender, religion, age or disability (D6). I will continue to work to understand the anatomy and how I can adapt techniques to new positions.

3. Self reflection 19/02/2019

During practise I have found that I am more in tune to what I am feeling and can therefore focus a technique on what it is supposed to be doing. For example, every technique we practise is the same as when practising a HVT, our goal of the HVT is to hear the audible 'pop'. When practising, even on each other, we should aim to have a focused and effective technique.

As I am gaining a better understanding of how the body moves and feels while I am using my hands, I find I have a greater drive to be effective in practise.

OPS B1.7: well-developed palpatory skills

4.Entering clinic for the first time post lockdown 17/08/20

On returning to the ESO for summer clinic following over 4 months off, I was very aware of the fact that I was unable to treat a patient for all this time. Although we had had plenty of time to focus on improving our knowledge, I felt like I had lost a lot of the practicality that I had gained during my time in clinic in third year: case history taking, clinical reasoning and the application of our knowledge in a real life situation.

I was concerned that I wouldn’t be able to gain what I had lost and progress to the required level by the end of 4th year.

I was also scared that I had lost a lot of my practical skills.

Following my first week I am feeling more confident, I feel that with each patient I gain more confidence in my ability. I am still aware that I need to put a lot of work in to improve my practical skills. I need to improve the fluency and accuracy of my examination.

In general I am pleased with myself, in general my patients have seemed happy with my treatments .

In the will make sure that I use the spare time that I have at clinic to practise and improve my practical skills.

5.Clinic reflection 11/09/20

I had a patient who presented with anterior shoulder pain when chest pressing. During the exam I was able to run through the orthopaedic tests but with no positive tests to suggest the pain causing structure, I was stuck.

My tutor at the time wasn't giving me any suggestions prior to treatment as to how I could help this patient and was short tempered when I found myself stuck on what to do. I found this frustrating and was holding back tears following the encounter with the tutor. I treated the patient and left clinic that evening feeling deflated and unsure of myself as an osteopath.

Following this scenario I have decided to tackle my lack of knowledge when treating shoulders. I have considered how they are complex structures and knowing the source of the pain extremely difficult without imaging. I have looked into the different models of classifying shoulder pain including the shoulder symptoms modifications model and the movement system model. Which considers looking at thoracic posture, scapular posture etc.

When I look back at the situation it now seems obvious to me that I should have considered these things. However, considering this was the first shoulder that I was treating in 6 months I resent the tutor for not giving me a gentle nudge in the right direction.

I am aware that by July next year I will be on my own treating patients and that I should start finding independence while in clinic now to prepare myself. Despite being disappointed in my performance that day, I feel I have  since then responded in the correct way, by focusing my study in this area so that the next time I get a patient with shoulder pain who doesn't fit an orthopaedic diagnosis, I won't freeze.

OPS B1.2:  knowledge of human structure and function sufficient to inform appropriate care
B1.10: problem-solving and thinking skills in order to inform and guide the interpretation of clinical and other data and to justify clinical reasoning and decision-making

6.Clinic reflection 16/09/20

Today I had my first baby in clinic, she was 12 weeks old and presented with torticollis.
The tutor encouraged me to take the lead with the case history, but she remained in the room. I found that after a few questions during the case history I froze and didn’t know what to ask, so the tutor had to take over. I think as I am unfamiliar with the norms of  pregnancy, birth and looking after a baby it was difficult for me to have a relaxed conversation with the mother. Prior to children’s clinic I had taken the time to study what could go wrong and how to do the examination, but I hadn’t thought to look over what is involved in the normal processes. I think especially when you are talking to a mother who is the ‘expert’ through her experience, it is easy to find myself caught out and uncomfortable during these discussions.
I will now spend some time looking over what a mother experiences when pregnant and through birth and cover what the normal birth processes are. I think being able to discuss this with mothers is something which will also take time and some experience, which I will hopefully gain throughout children clinic, as it is such a different experience to normal clinic and treating musculoskeletal disorders.

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1. Clinical Observation Reflection 14/05/18
Today during clinic observation, I watched a third year take a new patient. It was 35 year old woman who had recently given birth. On arrival she said she didn't know that she would need to undress to her underwear, she said this was ok and verbally consented but visually she was uncomfortable with the situation. The practitioner recognised from the patients body language when she was uncomfortable, addressing this by allowing her to keep her clothes on where possible and using a blanket to make sure she didn't feel exposed.

It was good to see that the student was observant of the patients discomfort and acted on this. Before they acted allowed the patient to cover up it was uncomfortable to observe while the patient was feeling so awkward.

From this I learnt how important it is to read when someone may feel vulnerable, without them saying it, so that they feel comfortable with the treatment. In the future I will make sure that patients are aware that they may need to undress before attending the consultation, and if not, give them options other than being in their underwear, working around the patients needs. (OPS A1)

2. Tutor feedback 16/03/21

Following 6 weeks of children clinic with a tutor they gave me some written feedback:
"What I have observed that went well:

Asks relevant case questions.

Good checking back of facts, good questions re growth and bowel and bladder, good asking if there is anything else the mum wanted to add.

Nice reassurance to mum that she can feed or do what the baby needs during the session.

Good questions regarding 3rd stage of labour.

Good exploration of detail to get a clear picture of sleeping pattern.

Good questions regarding after vaccines and how baby was-can add in whether they had a fever as this is common.

What I observed that could be improved:

Ask ideas, concerns and expectations separately to gain accurate answers.

When asking about the pregnancy remember general health, working, pain, extra tests/scans, bleeding, blood pressure, any issues.

During 3rd stage questions can ask about bleeding and placental retention.

Systemic respiration questions-add in coughs, chest infections/colds, any general breathing issues.

CVS screen-cold hands and feet can be asked as well as colouring ie. blueness or mottled."

This feedback is from taking a new patient case history of a 6 week old. I felt like I listened well, gathered data well and enabled the mother the opportunity and the time to say everything she wanted to say. I also feel it is important that when treating babies that I make sure the mother knows that she is in control, should the baby get upset or she would like to stop the consultation, or wants to feed or change her baby that she can.

This reflects the OPS A1, whereby I have given my patient the time to say everything she needs to, taken the time to listen and have accommodated for the need of the patient e.g. by treating while feeding.

I could have however enquired about the ideas, concerns and expectations separately, giving the patient the opportunity to express all of these. As it is important to address and to accommodate all of these which can all be equally important. This reflects the OPS A1.3.

3. Case reflection 05/05/21

Today I had a patient present in women's health clinic. She was 35 weeks pregnant and had neck pain. Within in the initial discussion she reported having being diagnosed with general anxiety disorder, this had effected her within the last year with specific concerns regarding her health. One year prior to her presentation, she had become concerned about having a neurological disorder to the extent that she had seen a neurologist privately. All tests came back negative.
She was now very concerned about her neck pain and she believed that something serious was going on. Her midwife had her attend hospital for a psychological assessment regarding her anxiety over her pain.
She had also attended a physiotherapist that told her her pain should be better within a week, when it didn't this heightened my patients anxiety.

On examination, I found that there was a musculoskeletal cause of the pain meaning the patient was safe to treat.

Given the patients anxiety, I allowed her time to express her concerns.  Following examination, it was important to spend time explaining her symptoms, making sure she understood the differential diagnosis, so that it didn't heighten her anxiety. It was also important that I managed her expectation, meaning that if she wasn't completely better in a weeks time that this wouldn't cause her further distress.

I enjoyed this case as my patient visibly relaxed after my explanation of her pain and during the treatment. It was good for me to adapt to her mental health throughout the consultation and allow her additional time to listen to her concerns and address any questions she may have. (OPS A1).

What I would have liked to improve on in this scenario is my time management, I would have liked to address my patients concerns without having over run. I also found that I allowed the emotional distress of my patient to stay with me for too long. Whereby I continued worry about the case, how she was effected and what more I could have done for her for too long. (OPS B1.11).

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1. Clinic observation 7/1/20
While observing a member of my team with a new patient, there was a young female that presented with lower back pain. She was currently under investigation with doctors for suspected Cushing syndrome. On research we found that this could be due to a benign or malignant tumour. It was decided that she was not safe to treat, and she should come back once there is a better understanding of what’s going on. The student tried to have the discussion with the patient but the tutor ended up taking over. I would have personally struggled to find the right way to explain this to the patient. You have to be sensitive so not to scare the patient, but at the same time be realistic, the patient would have likely googled the syndrome and would know what we knew. It was important to not be condescending.

I found this situation particularly difficult, and think I would have struggled if it were my case. The young girl had been to a number of different therapists and had undergone a number of tests to understand what was going on in her body. It was difficult to not be able to give her any answers and to send her away with no treatment, especially when it is someone that young with so much going on.

The tutor had a great way of communicating with her, and she left seeming positive. I would like to be able to communicate with people like that, it is especially important when someone is potentially vulnerable - a role in healthcare is likely to see situations like this often. It is really important that we don't let a patient leave feeling scared and helpless following news like this, but it also important that you inform them of why you cannot treat them.

I will work on how I explain thing to patients, potentially practising my communication before stepping up to have difficult conversations like this with real patients.

OPS A2

2. Clinic reflection 11/11/20

In children’s clinic today I had a continuing appointment with a 4 week old baby I had seen the week prior. The parents brought her into clinic for silent reflux which was causing her discomfort and led to her being unsettled. I was guided by my tutor throughout and felt the examination and treatment went ok.

I noticed that there was a generally tense atmosphere with the parents; the way they described their babies presenting complaint used extreme language which suggested they were very anxious and concerned. They asked many questions with the general theme of ‘is my baby normal?’ The baby seemed healthy and I was able to assure them that, for example, the fontanelle was normal. Despite having no reason for concern and with my tutor beside me, it felt like a lot of responsibility to be advising parents on the health of their baby. There is so much to learn when treating children and babies, and for me to feel confident in giving any advise I will need to improve my knowledge, so I am confident to pick up when something is wrong.

I felt these parents needed a great deal of reassurance. It was also important that we thought about the language we used when discussing our findings, to make sure that they weren’t taken out of context and considered as a serious health risk. I took the time to explain that the words we were using such as ‘compression’ may sound scary, but they were only descriptors of what we were feeling, and not a sign of a serious problem. This patient definitely tested my communication skills and made me conscious of the way I was using my words, and how they could be perceived. This was challenging and somewhat overwhelming but felt it went ok. However, at the end the mother asked “if she doesn’t have treatment, what would be wrong with her in later life?”. This told me that there was still some miscommunication. In the future I will need to regard patients individually and assess which points I may need to emphasise or where further explanation is required, so that they can make informed decisions about the care they receive.

OPS: A2

3. Patient reflection 23/09/20

During children’s clinic today I had an 8 year old child present with hyper-mobility, which was giving her difficulty when walking and writing at school.
I was really happy with how this went, the tutor took me to the side after and told how well I had done with my communication and interaction with the child. I think I had done well to include the child in the discussion, during the case history and during the explanation of what hyper-mobility was. I was proud of how I had dealt with the child when she had gotten upset because of how the condition was effecting her life.
Overall this was a positive experience for me, when in a completely new situation as I don’t have any experience with children, I felt I adapted to the situation well.
OPS A2.3 You should be sensitive to the specific needs of patients and be able to select and utilise effective forms of communication, which take these into account.

4. Patient reflection 5/10/20

Today I had a patient present to clinic with a complex case history. She was 30 years old, had been experience LBP since she was 20, and now had a wedge fracture of T7. Her medical history also included:

Endometriosis, with multiple laparoscopies.

Ovary removed

Naproxin, given for LBP for 6 months lead to a ruptured bowel. Which required a emergency bowel resection

An unknown bleeding condition.

T7 wedge fracture

Under investigation for Osteoporosis

Under investigation for crohns

Palpitations and breathlessness

Pins and needles in arms and legs bilaterally

I felt ok to take the case history, and was happy with how I managed to do it while having everything clear to present. We decided that we would be ok to continue with examination. The tutor agreed that we would be able to treat her as she was currently under investigation with her GP. Although we would not be able to fit it in to this session.
However, I was required to have a frank disscussion with the patient, as she had a chronic and complex history it was important for her to know that we aren't going to be able to 'cure' her. It was important that we informed her of her options and let her know that we would be able to treat her and give her exercises to help with the mechanical problems we had found which could offer her some relief and give her more control to meet her goal of being more active, but there was clearly something more systemic going on that she would likely need medical help with.

I think I handled this situation ok, I believe that being able to smoothly and clearly discus these things the way that I would like to be able to will come with experience. I was comfortable to speak with my patient in this way, which is something I would not been comfortable to do a few months ago.  However, I would like to improve my professional manner so that I can be more reassuring to patients.
OPS A2.4: You should share accurate and relevant information with patients, and encourage them to ask questions and to take an active part in decisions about their treatment and care.

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1. Patient reflection 30/10/19
I had a Relatively simple case with a new patient, however I found that despite having the knowledge to give him the correct information and advise, I lacked the confidence in my knowledge. Instead of taking the lead in the care for my patient, I let my tutor take over. I need to be able to trust in myself to deliver the information that the patient needs in a way that they understand. I will work on communicating with my patients, I also need to continue studying in depth so that I have the knowledge to help my patients. (OPS. A3)

2. Communication with patients 3/12/19
I thought that this table is a good reminder of how we should use our language wisely when communicating with potentially vulnerable people. Using words like ‘chronic’ and ‘damage’ could cause a negative effect on a patients ability to heal. A patient may hear a word like this and think the worst.
If a patient has a more educated, positive outlook on their health, it may encourage them to engage more with the healing process.
For example if a patient is told they have degeneration, they may be inclined to stop moving, in fear of the degeneration getting worse.

The OPS (A3) states we need to give information in a way the patient will understand. The use of the language found in the table will easier to understand for the patients, and shouldn’t result in misinformed panic. I will aim to improve the language that I use infront of patients

3. Case reflection 05/05/21

Today I had a patient present in women's health clinic. She was 35 weeks pregnant and had neck pain. Within in the initial discussion she reported having being diagnosed with general anxiety disorder, this had effected her within the last year with specific concerns regarding her health. One year prior to her presentation, she had become concerned about having a neurological disorder to the extent that she had seen a neurologist privately. All tests came back negative.
She was now very concerned about her neck pain and she believed that something serious was going on. Her midwife had her attend hospital for a psychological assessment regarding her anxiety over her pain.
She had also attended a physiotherapist that told her her pain should be better within a week, when it didn't this heightened my patients anxiety.

On examination, I found that there was a musculoskeletal cause of the pain meaning the patient was safe to treat.

Given the patients anxiety, I allowed her time to express her concerns.  Following examination, it was important to spend time explaining her symptoms, making sure she understood the differential diagnosis, so that it didn't heighten her anxiety. From listening to her experience with the physiotherapist this highlighted how important it was that I managed her expectations, meaning that if she wasn't completely better in a weeks time that this wouldn't cause her further distress.

I enjoyed this case as my patient visibly relaxed after my explanation of her pain and during the treatment. It was good for me to adapt to her mental health throughout the consultation and allow her additional time to listen to her concerns and address any questions she may have. (OPS A1).

What I would have liked to improve on in this scenario is my time management, I would have liked to address my patients concerns without having over run. I also found that I allowed the emotional distress of my patient to stay with me for too long. Whereby I continued worry about the case, how she was effected and what more I could have done for her for too long. (OPS B1.11).

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1. Assessment feed back (Year 2)
(See PDF attached) I was happy to see that the examiners noted that most of my techniques were well set up and engaged with the tissues. A reoccurring theme for most stations was that examiners commented on my good introduction and explanation to the patient, however I had failed to continuously ask consent throughout. As stated within the OPS consent is an ongoing process. If a patient consents to examination, this doesn't automatically give you their consent to treat them for example. In the future I will work on giving my patients continued informed consent for each element of the consultation.

OPS A4.

2. Consent:Palpation and treatment of ‘intimate areas’ 27/08/20
While at clinic I had a patient with an adductor strain, this required palpation end eventually treatment which involved contacting the patients groin. Prior to the examination I explained to the patient that we would need to contact the groin area, in order to assess the origin of the muscle, to gain consent. The tutor was present to act as a chaperone and I asked the patient to place their hand over there genitalia to avoid inappropriate contact.

Following treating this patient I was discussing consent with another tutor, he brought up the fact that within the ESO, the policy states that when contacting intimate areas you should gain written consent specifically for treatment of these intimate areas. I was not sure if the groin came under this category.

Within the OPS (A4.9), it states that “It is particularly important to ensure that your patient understands and consents to the proposed examination or treatment of any intimate area before it is administered. Initiate areas include the groin, pubis, perineum, breast and anus..... some patients may not have come prepared for such a procedure and you should offer to conduct this at a subsequent appointment, and offer a chaperone.”

I think that as a student of osteopathy where you have become so used to practising on each other, you may forget that the groin is considered an intimate area that some people will not be comfortable with you contacting. I believe that in this situation my patient was informed of what was going on, and was comfortable for the examination, however in the future I will consider what further measures I can take. I will consider taking that time to gain written consent to ensure that that patient has understood the suggested treatment.

3. Discussion with tutor 14/01/21
While at clinic I had a discussion with a tutor about a recent scenario they had, where an elderly male had attended their clinic, due to the pandemic their wife wasn't able to enter the consultation with him. During the case history it became apparent that the patient had memory difficulties, and was unable to recall basic information, about their complaint and their medical history. The tutor had to decide whether the patient could understand why they were there and the information given to them in order to make an informed decision about treatment.

This scenario made me realise how hard it is to ascertain the capacity that a patient has to gain consent. You cannot assume that because someone is old, and may have minor difficulties with memory, that they do not have the capacity to understand and consent to examination and  treatment.

In the future I will pay attention to how my patient is able to answer questions during the case history, and make sure that they have understood what I have said before allowing them to consent to treatment.

OPS A4.

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Bubendorf, L., Schöpfer, A., Wagner, U., Sauter, G., Noch, H., Willi, N., Gasser, T. & Mihatsch, M., 2000. Metastatic Patterns of Prostate Cancer: An Autopsy Study of 1589 Patients. Human Pathology, 31(5), pp. 578-583.

GOsC, 2018. Osteopathic Practise Standards. Available at: https://standards.osteopathy.org.uk/themes/safety-and-quality-in-practice/ [Accessed 6th April 2021]

Internet 1, 2015. What to do if you're worried a child is being abused: Advice for practitioners. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/419604/What_to_do_if_you_re_worried_a_child_is_being_abused.pdf [Accessed 14th October, 2020]

Internet 2, 2020. Gibbs' Reflective Cycle. Available at: https://www.ed.ac.uk/reflection/reflectors-toolkit/reflecting-on-experience/gibbs-reflective-cycle
[Accessed 5th may 2021]

Mannerkorpi, K. & Iversen, M. D., 2003. Physical Exercise in Fibromyalgia and Related Syndromes. Best Practise & Research. Clinical Rheumatology, 17(4), pp. 692-647.

NHS, 2019. High Blood Pressure: Overview. Available at: https://www.nhs.uk/conditions/high-blood-pressure-hypertension/
[Accessed 12th November 2020]

Reims, K. & Ernst, D., 2016. Using Motivational Interviewing to Promote Healthy Weight. Family Practise Management, 23(5), pp.32-38.

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1. Clinic Discussion 27/09/19 During clinic today there was a new patient, she had a long case history with an extensive medical history. We all felt her attitude to her health was catatrophising. She has been given the diagnosis of fibromyalgia earlier in the year, to which she said there is no cure and its not going to get better. She seemed forlorn.

We went on to discuss how the patient attitude can effect their physical wellbeing. Would the patient be functioning better without being told by her doctor that she had this syndrome without a cure?

This patient should have been referred to a specialist for her fibromyalgia and made aware of ways she can improve her wellbeing. I have attatched a paper which looks into how someone with fibromyalgia can use exercise to reduce pain and fatigue.

I would like to improve my knowledge on conditions like fibromyalgia and ME, so I can better understand how I may be able to help patients, and what else there is to offer patients like this outside of osteopathy. I will do some more reading on the available research, so I can give patients an evidence based treatment.

2. Patient reflection 12/02/20

Today I had patient who was suffered with wide spread chronic pain following an accident in 2008. I found the presentation quite daunting especially since the patient appeared generally exhausted and forlorn. She had recently stopped working and had been very stressed, she was unable to sleep for very long each night.
I felt overwhelmed and like I wouldn’t be able to help her as much as I would’ve liked to.
I was able to give her a global treatment and diaphragmatic breathing to go home and do, as she was very tensed and rigid from holding in her stress and from not moving due to pain. - this was the first time I had seen the extent of which stress could have on someone, she really struggled at the beginning with breathing into her stomach.

I will look into how I can help my patient deal with stress, as I have seen the impact of psychosocial factors on her pain.

(OPS A5)

3. Patient reflection 7/12/20
Today I had a continuing patient, this patient had been coming to the clinic for years, he has osteoarthritis effecting the mobility of his ribs, so seeks treatment in order to improve his breathing. I had a discussion with the patient that he may also have COPD given his history of repertory infections and shortness of breath, therefore I would like him to see his GP. The patient was adamant that he did not want to see his GP, he had experienced anxiety and panic attacks with hospitals in the past and was happy with the treatment he was receiving in the clinic and felt like it significantly improved his breathing.

I had to respect my patients feelings and decision, despite disagreeing with this. We had to come up with a compromise, in that we agreed to measure his blood saturation and chest expansion at every appointment. The patient agreed that if these every dropped below normal levels that he would go to his GP, but in the mean time he would be able to get osteopathic treatment.

It is hard when you want to help your patient as much as possible, but they don't agree with how this can be done. I had followed the OPS in encouraging him to seek healthcare from others, and when I accepted his decision regarding this. However, it is important to consider in the future when the boundary of him refusing medical treatment becomes unsafe to treat osteopathically.

4. Patient reflection 14/04/21
Today I had a patient you presented to the clinic with mid-thoracic pain, with the working diagnosis of muscle fatigue. Within the case history she noted that she had gained a bit of weight over lockdown and asked if this could have contributed to the pain and if she should lose weight.

I explained to my patient that I can not be sure that losing weight will decrease her pain, but it is important to eat a healthy varied diet and to exercise regularly. I explained that increased weight can create increased strain to muscles and ligaments.

Discussing lifestyle changes with patient is not normally something that I feel comfortable with. In this case it was made easier by the patient bringing up her weight, however, I do not think I would be comfortable to start this conversation. I feel that people tend to be aware if they are over weight, so it would feel potentially rude and condescending to bring this up, on the other hand, it is important to educate people on how this may be effecting their body and how they can live a healthy lifestyle.

I remember a tutor in the past suggesting that if you have an over-weight patient who you think you could benefit from losing some weight, you could try simply asking them "is their anything that you can think of that you could do to help with your pain?" - suggesting that some patients may know that losing weight can help, and you can develop the conversation from there. This made me think back to a tutorial on motivational interviewing: https://www.aafp.org/fpm/2016/0900/p32.html

This uses a goal-orientated communication style. So you guide the conversation, in a understanding and empathetic way, getting the patient to highlight what has worked for them in the past, what might have gone wrong and ultimately guide them towards a plan.  This could be a useful tool when supporting patient in caring for themselves.

In this case I could have been more empathetic to my patient, considering that the lockdown was a hard time. I could have help the patient consider how she could go about losing weight in a way that works for her, whether this meant finding an exercise that she likes, joining a weightless group or even discussing this with her GP.

In the future I will consider this approach when discussing a lifestyle change like weight change, I will appreciate the fact that they may have struggled with this in the past, and work with my patients to find a way that they feel they will work with them to lose weight.

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Abstract

Fibromyalgia and related syndromes are characterized by chronic pain and fatigue. This chapter identifies the types of exercise that are effective for these patients and provides recommendations for exercise prescriptions. Based on a systematic review of randomized controlled studies of exercise, we suggest that low-intensity aerobic exercise, such as walking, can improve function and symptoms. Aerobic exercise performed twice a week at moderate intensity can improve aerobic capacity and reduce tenderness. Pool exercise can improve function, distress and symptoms. Strength training at adequate load can improve strength without exacerbation of symptoms. Most patients tolerate low-intensity exercise. High-intensity exercise should be undertaken with caution. Due to the large variability of functioning and symptom severity in patient populations, exercise prescriptions should be individualized and should include a long-term plan to maximize functioning and wellbeing. Studies with larger populations, allowing subgroup analyses regarding benefits and adverse effects of programmes, are needed.

Exercise Perception and Behaviors in Individuals Living with Primary Immunodeficiency Disease.

Sowers KL, Litwin BA, Lee ACW, Galantino MLA. Sowers KL, et al. J Clin Immunol. 2018 Feb;38(2):174-184. doi: 10.1007/s10875-017-0472-9. Epub 2018 Jan 6. J Clin Immunol. 2018. PMID: 29307028

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national center for biotechnology information

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Physical exercise in fibromyalgia and related syndromes - PubMed

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Fibromyalgia and related syndromes are characterized by chronic pain and fatigue. This chapter identifies the types of exercise that are effective for these patients and provides recommendations for exercise prescriptions. Based on a systematic review of randomized controlled studies of exercise, we ...

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1. Clinical Observation Reflection 14/05/18
Today during clinic observation, I watched a third year take a new patient. It was 35 year old woman who had recently given birth. On arrival she said she didn't know that she would need to undress to her underwear, she said this was ok and verbally consented but visually she was uncomfortable with the situation. The practitioner recognised from the patients body language when she was uncomfortable, addressing this by allowing her to keep her clothes on where possible and using a blanket to make sure she didn't feel exposed.

It was good to see that the student was observant of the patients discomfort and acted on this. Before they acted allowed the patient to cover up it was uncomfortable to observe while the patient was feeling so awkward.

From this I learnt how important it is to read when someone may feel vulnerable, without them saying it, so that they feel comfortable with the treatment. In the future I will make sure that patients are aware that they may need to undress before attending the consultation, and if not, give them options other than being in their underwear, working around the patients needs. (OPS A1)

2. Consent:Palpation and treatment of ‘intimate areas’ 27/08/20
While at clinic I had a patient with an adductor strain, this required palpation end eventually treatment which involved contacting the patients groin. Prior to the examination I explained to the patient that we would need to contact the groin area in order to assess the origin of the muscle to gain consent. The tutor was present to act as a chaperone and I asked the patient to place their hand over there genitalia to avoid inappropriate contact.

Following treating this patient I was discussing consent with another tutor, he brought up the fact that within the ESO, the policy states that when contacting intimate areas you should gain written consent specifically for treatment of these intimate areas. I was not sure if the groin came under this category.

Within the OPS (A4.9), it states that “It is particularly important to ensure that your patient understands and consents to the proposed examination or treatment of any intimate area before it is administered. Initiate areas include the groin, pubis, perineum, breast and anus..... some patients may not have come prepared for such a procedure and you should offer to conduct this at a subsequent appointment, and offer a chaperone.”

I think that as a student of osteopathy where you have become so used to practising on each other, you may forget that the groin is considered an intimate area that some people will not be comfortable with you contacting. I believe that in this situation my patient was informed of what was going on, and was comfortable for the examination, however in the future I will consider what further measures I can take. I will consider taking that time to gain written consent to ensure that that patient has understood the suggested treatment and offering them a chaperone.

3. Clinic reflection 12/11/20

Today I observed a colleague with a new patient. When they moved onto examination, they asked the patient to undress to her underwear. It was me, the male practitioner and the male tutor observing for the examination. The patient made a series of small comments  about being uncomfortable being undressed in front of men. The tutor picked up on this and allowed the patient to put on her leggings.

The practitioner could have allowed the patient to remain in her leggings as it was not necessary for the examination. They also could have picked up on how uncomfortable the patient was.

I think that when possible I will allow my patients to remain clothed, with a reminder to wear loose or stretchy clothes before attending their appointment. I think it is important that the patient is comfortable during the appointment. If a patient is uncomfortable and  aware of their body this will reflect negatively on their experience and will also hinder the physical benefits of treatment as they may be hesitant to relax.

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1. CEX 13/12/19
I had a new patient for my exam. He had acute back pain, was late and was not in a good mood. I was happy with how I dealt with this, keeping the structure of the case history, despite the patient not wanting to answer questions. I was able to empathise with him being stressed and in pain, and he eventually apologised fo the way he was acting.

I should have been more thourough with a bit of my questioning, with the daily pattern and with the systemic regarding the prostate.
I also need to work on the informed consent. The patient was very keen for treatment, but despite this I should have discussed alternatives; including the possible different approaches to treatment.

I was able to maintain a professional manner despite my patient being rude and angry. It is important that as a practitioner I can treat all my patients with respect despite any differences we may have, however, it is also important that I have boundaries and am able decline treating a  patient when I no longer feel comfortable with them, making sure I protect myself.

This experience has given me confidence in my ability to remain professional no matter how difficult the patient may be.  However, next time I will aim to ensure that this will not distract me from maintaining the standard of my work, and I will not let the patients manner stop me from asking the questions required to ensure that they are safe to treat.

2. Patient Reflection 18/12/20
Today while at clinic I had to cover a colleague's patient. I was a bit shocked to greet a 6ft 4 male with multiple tattoos, at reception.  He had a 'tough guy' look that I felt some what intimidated by.  I treated him like I would any other patient, and when it came to talking with him he was a very kind, gentle mannered man, who openly discussed his beliefs in Buddhism. This was the complete opposite of what I had expected.

I am now embarrassed to admit that I had prejudged this patient on his appearance before having properly spoken to him. I know that this is something that you should never do, but I allowed my ideas of how a burly, tattooed man would act, take over. Although I firmly believe that I would  never treat a patient differently for how they look or what they believe in, I am still disappointed in myself for judging someone on this.

This patient has definitely proven to me that it is wrong to have any prejudices, and has completely destroyed any that I may have had associated with someone who is heavily tattooed. In the future, I will keep this in mind and will never judge anybody before getting to know them .

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1. Patient reflection 15/10/20
Today I saw one of my continuing patients. She receives regular 'maintenance' treatments due to back pain. She has also expressed to me that she has become very stressed recently as her husband is suffering from undiagnosed dementia. The pandemic has heightened her anxiety as her husband does not understand social distancing rules and is at a greater risk of becoming unwell. In addition to this she has begun the process of becoming his official carer which has ben a long and arduous process for her.

For my patient, receiving osteopathic treatment is her time to relax and care for herself. However, I feel that given her current distress she needs more help than I am capable of providing.  Seeing her husband deteriorate and caring for him in the isolation of the pandemic has been very challenging, and although I can offer a listening ear she needs more support for her metal health. I had the discussion with her regarding seeking out help in the form of counselling or a support group, which she agreed would be a good idea.

I am sure I will come across many cases in the future where my patients will openly discuss their struggles. It is important that I am empathetic and caring, but I need to remember there is only so much I can help with. I need to recognise when a patient requires help with their mental health and know that I am limited as an osteopath in the treatment of this.

In the future I will always listen to patients, paying attention to when they may need help which I cannot provide.

2. Takeover patient 12/04/21

Today I had a 67 year old male, grounds worker, present to the clinic with groin and anterior thigh pain. The patient had a previous working diagnosis of hip OA. For the examination we decided to use a neurological exam to be certain the pain wasn't coming from his back. This led to the findings of:

Hyperreflexia at C8, L4 and S1.

Clonus at S1 bilaterally

Hypo-reflexia at at C5 and C6

Ataxic gait

This suggested to us that he likely had a myelopathy, and needed referral for further investigation.

He did, however, also have pain on FADIR at the effected hip, with associated myalgia of the quads.

For this patient we had decided that he needed a referral to his GP as soon as possible. Upon discussion the patient reported the gait changes for 5 years, suggesting there is a slow progression of his symptoms. In addition, we noted that there was a clear musculoskeletal cause for his hip pain. Which has improved from osteopathic treatment in the past.  We discussed the referral with the patient and agreed that we would also be able to conservatively treat his hip.

With this case, I was glad to have identified the neurological findings - I could have taken the previous diagnosis, and missed identifying the serious pathology. In the future I will make sure I will always thoroughly test my patients, despite the diagnosis they may have been given.

It was also interesting to discuss whether it was safe to treat this patient. We had identified that he had both an upper motor neurone lesion, and osteoarthritis in his hip. As he had been experiencing these symptoms for 5 years we could deduce that this was not an acute myelopathy. We could have referred the patient and justified not treating them, however, as an osteopath I could gently treat the patient, and give him pain relief by focusing on his hip and Lex, without treating his spine, where the cause of the myelopathy could lie. In the future I will consider where I can help someone as an osteopath, when I need to refer them and if the two can be used in adjunction to each other, meeting all of the patients needs.

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1. Barefoot talk 21/03/19

I attended a barefoot talk which ran over a number of techniques.
It was really helpful and I learnt a lot of new techniques.
Most importantly for me, I learnt the importance of using your body while treating. Firstly it allows you to relax your hands, so that you can palpate better, and it is far more comfortable for the patient. Secondly, it is way more efficient for your body, looking after yourself in the long run when you'll have to be treating lots of patents within a day.

2. Reflection 03/06/20

Over the course of the lockdown I have found that I have had additional time to study things of my interest. I have regularly watched online seminars including discussions with orthopaedic surgeons, specialists on shoulder pain and osteopaths with special interest in a number of different areas. This has has made me realise that there is so much that I am excited to continue learning about after university finishes.

I know that we are obliged to take part in regular CPD when qualified as osteopaths. I see that this is so important as there is so much for us to know as osteopaths in order to provide the best care. I look forward using this time to study things that I feel passionate about in order to provide the best possible care for my patients.

3. Discussion with tutor 19/01/21

Today during an online tutorial our tutor challenged us to explain the management of a number of different DD's, in terms of what are the surgical options, what are the conservative options and which has the best prognosis. My knowledge on this was a bit rusty, and I struggled to know which medical options were best.

It is important that we stay up to date on the available research so that we can advise our patients on all the available approaches to their care and what will have the best outcome.

In the future ongoing research is required to stay up to date with the options available for my patients. I will continue to study throughout my career, giving myself time to develop my knowledge.

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1. Case report 19/04/21
For one of latest pieces of course work we were required to pick a case of interest from one of our specialist clinics and produce a case report on this.

I chose to present a patient from the children's clinic that presented with pain in her back, knees, hands and feet due to hyper-mobility.  It was an interesting opportunity to look in depth at a case that I had taken, and compare my management and treatment the available research, and consider what I would do differently next time. Treating hyper-mobility mainly involves strengthening and management of pain - something which  can be challenging when I have mostly learnt how to mobilise joints. The research taught me that some mobilisations and soft tissue can be relevant to ease the load of mobile joints.

I was good to be able to lay out the case, and how I managed it and be proud of what I did. What I would like to improve next time would be making the exercises more fun and engaging for an 8 year old. Struggling with pain can be difficult enough as an adult, for a child who should be able to keep up with her friends in the playground, it must be very frustrating and upsetting.

I regularly take the time to reflect on how I have performed with patients, considering what I have done, performing further research around the conditions they may have or to better understand their presenting complaint. I think in the future it could be helpful to do a similar in-depth presentation of a patient, especially a more complex case, to allow myself to fully reflect on all aspects of the case, from my case history taking to the management (B4).

One of the important things about producing the case report was maintaining the patient confidentiality. In order to take the patients notes home I made sure took a copy with all personal information blanked out. Additionally when doing the write up any information which would have enabled my patient to be identified was removed. (OPS D4).

2. Reflecting
I have found that taking time to reflect on different scenarios has been a helpful tool allowing me to both learn from my experiences, and to process my emotions and feelings. Below is an example of a portfolio entry from a scenario which left me emotional and drained. It really helped for me to break the situation down, look at what happened, understand why I felt the way that I did, and to prevent something like this happening again.

In general when reflecting, I have applied the Gibbs model. This is discibed nicely at: https://www.ed.ac.uk/reflection/reflectors-toolkit/reflecting-on-experience/gibbs-reflective-cycle
I have found this to be the most useful model. It felt natural to break down my reflections into the categories, following the thought process of what happened, how did this make me feel and how will I  improve for next time.

Beyond completing reflections as part of the course, I will continue to write down my thoughts and feeing in order to continue learning  and developing myself as an osteopath.

Clinic reflection 11/09/20

I had a patient who presented with anterior shoulder pain when chest pressing. During the exam I was able to run through the orthopaedic tests but with no positive tests to suggest the pain causing structure. I was stuck.

My tutor at the time wasn't giving me any suggestions prior to treatment as to how I could help this patient and was short tempered when I found myself stuck on what to do. I found this frustrating and was holding back tears following the encounter with the tutor. I treated the patient and left clinic that evening feeling deflated and unsure of myself as an osteopath.

Following this scenario I have decided to tackle my lack of knowledge when treating shoulders. I have considered how they are complex structures and knowing the source of the pain extremely difficult without imaging. I have looked into the different models of classifying shoulder pain including the shoulder symptoms modifications model and the movement system model. Which considers looking at thoracic posture, scapular posture etc.

When I look back at the situation it now seems obvious to me that I should have considered these things. However, considering this was the first shoulder that I was treating in 6 months I resent the tutor for not giving me a gentle nudge in the right direction.

I am aware that by July next year I will be on my own treating patients and that I should start finding independence while in clinic now to prepare myself. Despite being disappointed in my performance that day, I feel I have  since then responded in the correct way, by focusing my study in this area so that the next time I get a patient with shoulder pain who doesn't fit an orthopaedic diagnosis, I won't freeze.

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1.Takeover patient 12/04/21

Today I had a 67 year old male, grounds worker, present to the clinic with groin and anterior thigh pain. The patient had a previous working diagnosis of hip OA. For the examination we decided to use a neurological exam to be certain the pain wasn't coming from his back. This led to the findings of:

Hyperreflexia at C8, L4 and S1.

Clonus at S1 bilaterally

Hypo-reflexia at at C5 and C6

Ataxic gait

This suggested to us that he likely had a myelopathy, and needed referral for further investigation.

He did, however, also have pain on FADIR at the effected hip, with associated myalgia of the quads.

For this patient we had decided that he needed a referral to his GP as soon as possible. Upon discussion the patient reported the gait changes for 5 years, suggesting there is a slow progression of his symptoms. In addition, we noted that there was a clear musculoskeletal cause for his hip pain. Which has improved from osteopathic treatment in the past.  We discussed the referral with the patient and agreed that we would also be able to conservatively treat his hip.

It was important that we produced the letter as promised in good time and sent it to his GP. Firstly, as it is our duty to get the patient the care that is needed as quickly as possible, and secondly it shows good professionalism and reliability. In the future I will always perform task like this as quickly as possible, I would hate to feel undependable when a patient is in need of help.

The patient also asked for a copy of the letter, I provided this straight away, but I felt it was important that I took the time explain the letter as it included words like 'ataxic' and 'myelopathy'. It is our duty to provide the patients any notes or letter written about them on request. In this case I was happy to do so, but I was wary of language that may be triggering and provoke fear and concern in my patient.

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1. Tutor discussion 14/10/20

While in children's clinic today, our tutor brought up the topic of child abuse and what to do as a practitioner if we suspect something. This is such an important topic for us to discuss, and if I were to find myself in a scenario where I suspected the abuse of a child, I would be terrified and not know what to do.

Together as a group we were able to pick up on a few signs of abuse such as bruising, burns, being withdrawn and a child that may flinch with sudden movement or with a fear being touched.

However, when asked what we would do in this scenario, we didn't know. Call the police? Social services?

What to do if we only have a small suspicion?

It is hard to now how to act in these scenarios, but with a small bit of research I have found so many resources offering advise, what signs to look for and who to contact. In addition to this, there are a number of charities which offer support and advise to those who have experienced some kind of abuse. I have attached a booklet from the gov website with advise for practitioners.

I have fortunately not seen a child or adult in this scenario. As scary or saddening the situation might be, I would like to be able to act fast and know who to contact. In the future, I will make myself aware of the local social services where I will be practising. I will be perceptive to any signs of abusive in any of my patients.

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1. Returning to clinic post lockdown 18/08/20.

Returning to clinic following a pandemic has been challenging in many aspects. Having spent the last 4 months in isolation, it feels weird to be surrounded by people again.

Something which I am particularly apprehensive about is keeping my patients safe. I feel a lot of responsibility for my patients health, especially when they are considered vulnerable. I am very attentive to my hygiene practices, with regards to thoroughly cleaning clinic rooms, wearing PPE and making sure I wear clean clothes for each session.

I feel a lot of pressure to be safe, and feel it is important that I do my best to ensure that I keep my patients safe.

When looking back I would do the minimum between patients, changing the paper on the couch and washing my hands. I think experiencing the pandemic will have changed my hygiene practices in the long term, I think it is polite and respectful to take good care to clean the room between patients. I also think in the future if I have a cold I will wear a mask, as it seems courteous to protect our patients from illness especially since we have such close contact and prolonged contact.

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1. Clinic Observation 17/11/17
Today was my first observation in clinic. I observed a third year student take a new patient case history. They observed that that patient was flushed red in the face, and upon measuring their blood pressure found a measurement of 200/125 mmgHG. This blood pressure is considered extremely high, and posed a risk to the patients health, therefore they could not receive treatment and were told to go and see their GP immediately.

In clinic they measure every patients blood pressure on the first appointment. This is important as if someones blood pressure is high this increases the risk of adverse reaction to treatment. I have since done some research and found that  if a person has high blood pressure this increases their risk of stroke, peripheral artery disease, kidney failure and vascular dementia.  According to the NHS website 15% of men and 13% of women have undiagnosed high blood pressure (NHS 20219. This makes me realise how important it is for us to do health checks on our patients as they may have something they are unaware of which could pose a risk to their health and be a contraindication to treatment.
In response to this I will look up what the management of blood pressure is depending on how high it is, and consider other things we can do to make sure our patients are healthy and will respond well to treatment.

I recognise how important it is for us as practitioners to examine our patients for pathology and know how to act on this, helping our patients to maintain their health and wellbeing.

2. Patient reflection 21/10/19
I had a patient with a history of  prostate cancer, following the case history my colleagues and tutor had pointed out that I was not thorough enough with my questioning. My knowledge was lacking around the subject to know what I should have been asking. I have since researched prostate cancer and am now aware how important this knowledge is, especially with the risk of metastases in areas like the bone and spine, something which a patient may present with what they beleive to be musckuloskeletal pain. I need to be aware of risks such as this for the safety of my patients.

OPS: C6

Below is an article which examined the metastatic patterns of prostate cancer and identified the route of transfer via the venous drainage.

3.Patient reflection 14/04/21
Today I had a patient you presented to the clinic with mid-thoracic pain, with the working diagnosis of muscle fatigue. Within the case history she noted that she had gained a bit of weight over lockdown and asked if this could have contributed to the pain and if she should lose weight.

I explained to my patient that I can not be sure that losing weight will decrease her pain, but it is important to eat a healthy varied diet and to exercise regularly. I explained that increased weight can create increased strain to muscles and ligaments. It is also important to consider all the other health benefits from losing weight.

Discussing lifestyle changes with patient is not normally something that I feel comfortable with. In this case it was made easier by the patient bringing up her weight, however, I do not think I would be comfortable to start this conversation. I feel that people tend to be aware if they are over weight, so it would feel potentially rude and condescending to bring this up, on the other hand, it is important to educate people on how this may be effecting their body and how they can live a healthy lifestyle.

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Abstract

The prognosis of prostate cancer is mainly determined by thepresence or absence of metastases. Nevertheless, the metastasic pathways in prostate cancer are not entirely understood. Among 19,316 routine autopsies performed from 1967 to 1995 on men older than 40 years of age, the reports from those 1,589 (8.2%) with prostate cancer were analyzed. Hematogeneous metastases were present in 35% of 1,589 patients with prostate cancer, with most frequent involvement being bone (90%), lung (46%), liver (25%), pleura (21%), and adrenals (13%). Several lines of evidence suggested the existence of a backward metastasic pathway through veins from the prostate to the spine in addition to classical hematogeneous tumor spread via the vena cava. First, there was an inverse relationship between spine and lung metastases, suggesting that metastasis to the spine is independent of lung metastasis. Second, the maximum frequency of spine involvement occurred in smaller tumors (4 to 6 cm) as compared with the maximum spread to lung (6 to 8 cm) and liver (> 8 cm), suggesting that spine metastases precede lung and liver metastases in many prostate cancers. Third, there was a gradual decrease in spine involvement from the lumbar to the cervical level (97% v 38%), which is consistent with a subsequent upward metastasic spread along spinal veins after initial lumbar metastasis. The results of this study show that bone, lung, and liver are the most frequent sites of distant prostate cancer metastases. Besides the cava-type of metastasis through lung passage, there are strong arguments for the existence and clinical significance of a backward venous spread to the spine, which is likely to occur early in the metastatic process.

View full text

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Metastatic patterns of prostate cancer: An autopsy study of 1,589 patients

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The prognosis of prostate cancer is mainly determined by thepresence or absence of metastases. Nevertheless, the metastasic pathways in prostate cancer are not entirely understood. Among 19,316 routine autopsies performed from 1967 to 1995 on men older than 40 years of age, the reports from those 1,589 (8.2%) with prostate cancer were analyzed.

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1. Adverse reaction to treatment 17/02/21
Last week I had a baby as a new patient, the mother was having difficulty with breast feeding and was told that osteopathy may be able to help. She had had a traumatic birth, where the babies head had become stuck which required the use of forceps.

Upon examination I identified that there was some compression of the cranial vault and tension within the anterior cervical fascia.

I explained my findings to the mother and treated using gentle IVM techniques. The treatment finished early as the baby had become unsettled.

When I returned a week later to the children's clinic the tutor explained to me that the mother had called the day following her initial appointment as her baby had been really unsettled. She had rung 111 and the GP. Fortunately the GP had told her that it was likely a reaction to the treatment and not to worry, despite this being out of character for her baby.

We had to be honest with the patient, this was likely a bad reaction to the treatment, and despite having warned the mother of the risks of treatment, she had still become distressed by her baby's reaction. Fortunately, the baby has settled down after a day and the mother was happy to come back in for further treatment.

This time my tutor assessed the baby, noting that there was a side shift in the OA that I had likely missed when treating.

It was unfortunate that the baby had such an adverse reaction to treatment. It was very upsetting for me to hear that I had had this effect on a baby when I had only wanted to help.

This case also showed me how important it is to warn patients of potential adverse reactions to treatment, in this case a baby becoming unsettled. I had told the mother the potential risks to treatment but she had still become distressed. If I hadn't described this to her before the treatment this could have been far more distressing for the mother and placed us at a greater risk of a complaint, as it would would mean the patient had not been fully informed before consenting to treatment.

In the future I will always have an honest discussion with patients that they may feel worse before they feel better.

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1. Adverse reaction to treatment 17/02/21
Last week I had a baby as a new patient, the mother was having difficulty with breast feeding and was told that osteopathy may be able to help. She had had a traumatic birth, where the babies head had become stuck which required the use of forceps.

Upon examination I identified that there was some compression of the cranial vault and tension within the anterior cervical fascia.

I explained my findings to the mother and treated using gentle IVM techniques. The treatment finished early as the baby had become unsettled.

When I returned a week later to the children's clinic the tutor explained to me that the mother had called the day following her initial appointment as her baby had been really unsettled. She had rung 111 and the GP. Fortunately the GP had told her that it was likely a reaction to the treatment and not to worry, despite this being out of character for her baby.

It was important that the tutor was there to receive the call of the mother and talk through the concerns that she had.

With every patients I say that they may experience some increased pain or soreness following treatment, or in the case of a baby, they may become unsettled, which can last up to 24 to 48 hours, if it persists past point to call in to the clinic. It is important to make the patient aware that they can contact you if they have any concerns or any complaints, as you will likely be able to reassure them or conciliate them directly before they get to the point of wanting to make a formal complaint.

If I find myself in a position in the future where a patient is wanting to make a complaint or is unhappy, I will first try to mitigate the situation with the patient by communicating with them and trying to understand why they may be unsatisfied.

I am also aware that you need to make patients aware of the fact that they can complain to the GOsC directly.

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1. Patient reflection 24/09/20
At clinic recently I have been treating a married couple. They have both been coming in separate appointments over the course of a few weeks now.

When talking with my patients it has been important that I do not discuss either of the patients with their husband or wife. It can seem odd as they seem to openly share information with each other about their consultations.  But I know that there may be something which they may not want to share with each other and it would be going against the practitioner patient confidentiality if I were to mention this. To avoid any disclosing of information that the patients may not want share with their spouse, I have explained to them that I am not able to discuss either of their presenting complaint to the other, and they have understood this.

I think it was good to set this boundary with my patients, rather than not answering their questions, I explained why and they accepted this. If I face a similar scenario in the future I think that I will do the same, and set a boundary early on in the consultation.

(OPS D5.1.4)

2. Case report 19/04/21
For one of latest pieces of course work we were required to pick a case of interest from one of our specialist clinics and produce a case report on this.

I chose to present a patient from the children's clinic that presented with pain in her back, knees, hands and feet due to hyper-mobility.  It was an interesting opportunity to look in depth at a case that I had taken, and compare my management and treatment the available research, and consider what I would do differently next time. Treating hyper-mobility mainly involves strengthening and management of pain - something which  can be challenging when I have mostly learnt how to mobilise joints. The research taught me that some mobilisations and soft tissue can be relevant to ease the load of mobile joints.

I was good to be able to lay out the case, and how I managed it and be proud of what I did. What I would like to improve next time would be making the exercises more fun and engaging for an 8 year old. Struggling with pain can be difficult enough as an adult, for a child who should be able to keep up with her friends in the playground, it must be very frustrating and upsetting.

I regularly take the time to reflect on how I have performed with patients, considering what I have done, performing further research around the conditions they may have or to better understand their presenting complaint. I think in the future it could be helpful to do a similar in-depth presentation of a patient, especially a more complex case, to allow myself to fully reflect on all aspects of the case, from my case history taking to the management (B4).

One of the important things about producing the case report was maintaining the patient confidentiality. In order to take the patients notes home I made sure took a copy with all personal information blanked out. Additionally, when doing the write up any information which would have enabled my patient to be identified was removed (OPS D4).

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1. Patient reflection 27/10/19
Today I observed one of my team members with a new patient, it was an 82 year old male who presented with pain in his arm. English was the patients second language so their son came in to help to translate. During the case history my team mate failed to ask if the pain in the arm was worsened by movements in the neck, a key question for determining if the pain could be radicular. Following examination my colleague concluded that it was in fact a cervical radiculopathy, likely caused by osteophytic growth.

The patient was Sikh and wore a turban. I felt that my colleague managed to adapt the treatment of the neck well around the turban, making sure that the quality of the treatment received was not effected due to the religion of the patient.

I can empathise with my colleague that when taking a patients case history in-front of 4 observers it can be particularly stressful, which can effect our performance. I can imagine that they were frustrated with themselves when someone else had to ask the question for them. However, having ability to apply your clinical knowledge in order to come up with an appropriate working diagnosis in vital (B1).

Following seeing how easy it is to forget something simple under pressure, I will continue to update my clinical knowledge, so that it becomes habitual to ask these questions.

I was, however, impressed that the practitioner did not feel awkward, or at least did not show that they felt awkward, working around the patients' turban when treating the neck. It is important that the patient does not feel as though their religious clothes are inhibiting the treatment that they are receiving, or that they are being treated differently because of this.

We are always told that we will need to find different ways of doing techniques, for example in the patient can't lie on their back, or if they are in a wheel chair, but we never think to practise these. I think my colleague seamlessly adapted to this situation and I would have been proud if I had performed the way that they did.

In the future I will make sure that no  patient is treated differently because of their gender, religion, age or disability (D6). I will continue to work to understand the anatomy and how I can adapt techniques to new positions.

2. Patient Reflection 18/12/20
Today while at clinic I had to cover a colleague's patient. I was a bit shocked to greet a 6ft 4 male with multiple tattoos, at reception.  He had a 'tough guy' look that I felt some what intimidated by.  I treated him like I would any other patient. When it came to talking with him he was a very kind, gentle mannered man, who openly discussed his beliefs in Buddhism. This was the complete opposite of what I had expected.

I am now embarrassed to admit that I had prejudged this patient on his appearance before having properly spoken to him. I know that this is something that you should never do, but I allowed my ideas of how a burly, tattooed man would act, take over. Although I firmly believe that I would  never treat a patient differently for how they look or what they believe in, I am still disappointed in myself for judging someone on this.

This patient has definitely proven to me that it is wrong to have any prejudices, and has completely destroyed any that I may have had associated with someone who is heavily tattooed. In the future, I will keep this in mind and will never judge anybody before getting to know them .

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I remember the first week at the ESO being given a speech by a senior member of staff. I remember being told that we are now osteopathy students, we are a part of the profession and we should behave like this in clinic, in our social lives and on social media. Being new and naive this terrified me, I immediately went  home and cleared anything remotely unprofessional from my Facebook page.

While I may have been over zealous  in first year, I understand the importance of maintaining a professional standard in a work environment, and out, where patients can still form opinions of you and your profession. I recognise that I need to be seen as a trustworthy individual and any behaviour going against this may effect my patients confidence in me. For this reason, I only have professional relationships with patients and keep my personal life private.

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1. Take over patient 02/09/20
During summer clinic I had a takeover patient. Upon examining the previous practitioners case history I struggled to read their hand writing, and they had failed to clearly show their examination findings. This meant I could not fully trust their working diagnosis and treatment plan. This then required for me to spend time asking the patient questions, and performing my own thorough examination to know that I could justify my treatment.

Although this was only a minor inconvenience to me, it made me think about how the case history would look in the case of a complaint. The practitioner would not have been able to justify their treatment approach.

This was also inconvenient for the patient, he missed out on time for treatment as there had been poor communication between practitioners, therefore impeding him getting the treatment he needed.

This has definitely made me question how robust my note taking is, and if handed to another practitioner, or in the worse case scenario in front of GOsC for a complaint, could I substantiate my treatment plan. This is somewhat scary to think that in the busyness and rush of clinic and treating patients, we may fail to properly take notes, which may leave us vulnerable in the future.

In the  future, I will aim to complete the majority of the case history with the patient, ensuring I include every finding, even when negative. I will aim to accurately and clearly present my findings.

Also, when passing a patient between practitioners I will aim to discuss the case with the other practitioner in order to make the handover a more smooth transition.

2. Handing over a patient 21/04/21
As we are nearing the end of the fourth year I am starting to hand over my patients to third year students to continue with their care. I have one patient who has been coming to clinic for a long time, and gets very anxious at the thought of changing practitioner.

The patient had been asking lot's of questions as to who will be taking  over as their practitioner.

Before handing over the patient, I contacted the third year, explaining my patients concerns and debriefing them on the case, regarding what treatment types she responds well to and what she doesn't. This way I could hand over the patient confidently, knowing that they would be taken care of, and that her concerns would soon disappear.

I think by discussing the case with the third year I made the transition smoother for the patient. In this scenario, this was only really done as the patient expressed anxiety and concern. However, I think it would be beneficial to have a discussion between practitioners every time a case is passed on, I think every patient should have the right to a smooth transition between practitioners, without having to undergo rigorous questioning every time.

In the future I think I will make it a habit to discuss with other practitioners that are sharing patients with me, whether they are an osteopath, a sports massage therapist or a physio therapist. By openly communicating between practitioners we can enhance the care that we give our patients (D9).

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1. Clinic Observation 16/05/19 While observing in clinic a patient arrived complaining of lower back pain. The patient seemed very unwell, with a fever and malaise.
They had previously seen their GP who had referred them to the clinic to rule out mechanical back pain, as they were unsure if there was any pathology behind the pain.
It became obvious that the patient was in a lot of pain, and required further investigation from their GP, as it was looking like visceral referred pain. The patient was referred to their GP and could not be treated.

I felt this situation was a good example of how different healthcare providers can work together, the GP being unsure about the source of the backpain, used Osteopathic knowledge to rule out any mechanical back pain. (OPS D10).

In the future I will be happy to receive patients which have been referred from other healthcare practitioners, whether they are unsure of the source of the pain or if they believe manual therapy can help.

2. Referral reflection 24/05/21

Today I had patient that I had referred, come back to see me for treatment in clinic. I had referred the patient as I had found that he had upper motor neurone lesion symptoms including hyper-reflexia, clonus and an ataxic gait. We thought that he most likely had cervical myelopathy.

The patient reported to me that he had recently received the date of his referral to the neurologist, and didn't require to talk to the GP.

It was good to see that my patient was receiving the care he needed. It felt good that the GP had trusted my findings and had referred straight away without having to retest him. It made me feel important as a primary healthcare practitioner knowing that our service can take some strain off the NHS. This had saved the GP some time and had decreased the time of my patient getting the referral.

This experience showed me how important a symbiotic relationship between the NHS and osteopathy is. A mutual respect between professions is only going to improve the care that patients are receiving. It is important that we are able to communicate our concerns effectively to GPs, and that these are taken seriously

In the future I will feel confident when referring patients to their GP, knowing that the time I am able to spend with my patients is a valuable resource. I will continue to take the time to screen my patients health for any pathology or concerns, and make sure that I present my findings clearly when writing a referral letter, ensuring that communicating with healthcare professionals is a smooth experience.

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1. Discussion in clinic 02/02/21

A colleague of mine came into clinic today following an accident which required his arm to be in a sling. They had a continuing patient which they wanted to see still, stating they can treat them with one hand and that it can be an exercise based appointment. The tutor argued that this is potentially wrong for a couple of reasons, the first being that they should look after themselves and allow themselves to rest and heal, secondly that they will not be able to offer the patient the same quality of care which they normally receive. They agreed to ring the patient and give them the choice. They opted to delay the appointment until they could receive a proper treatment.

While in the student clinic, this scenario is frustrating but does not have the same consequences getting injured while in practise will. When unwell in the future I can imagine that it would be tempting to push through, treat your patients and be able to continue earning. However, this puts your patients at risk if you are ill with a communicable disease, or it means that you are unable to offer them the treatment they need. It can also be considered dangerous for the patient, if you are unwell and exhausted you may find that you are unable to perform as well, potentially missing something important.

It is important to put your own health first, in the case of my colleague they could have hurt their arm further, or slowed the healing process, meaning they couldn't work for even longer. It is also important to consider that there is only so much you can put yourself through until you put yourself at risk of burnout.

In the future, I will consider my own health. This is an important consideration for both me and my patients, making sure I can both maintain my well-being and also ensuring my standard of care does not falter.