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Application writing for ESO (03/04/2018)

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Application writing for ESO (03/04/2018)

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Can curiosity make you the worst patient ever treated osteopatically? As a matter of fact, I think so.  I myself am proof of that. I was a lucky child having a mother who is osteopath. Whenever something was wrong with me she was able to heal me or support my healing process even if I wouldn´t stop peppering her with questions about what she was doing and why she was touching certain points.

Osteopathy is something that has always been there in my life. I loved to listen to my mother´s stories about her work; they were full of inspiration and made me absolutely fascinated by this wonderful profession. I also had the pleasure to meet her colleagues who inspired me about so many things and came to be like mentors in so many different ways.

I have had the wish to study osteopathy for a longer time now but I just recently found out about ESO as my mother came back from a SCCO continuing education where some ESO instructors taught. After doing some research I get the impression that your school really conveys osteopathy just as I would like to learn it - that it is more than just working the body in a purely physical way.

During the past three years that I have spent studying dancing professionally at Iwanson International School of Contemporary Dance I got more in touch with the human body.  We did have some basic anatomy lectures, but what gave me most knowledge was exploring how my body works everyday by myself.

I have always been happy to give my colleagues a „treatment“ even though I did´t have any formal education in osteopathy and just tried to feel intuitively what they needed.. My colleagues and friends often said that my „treatments“ helped and that they were feeling better afterwards.

I am an artistic spirit. Almost every kind of music inspires me and I feel like dancing is my natural way of moving. I love to laugh and spend my time with souls that enrich one another. These things make me feel love which I want to share. I believe that my purpose of existing is to share, and how could I do it better, fuller and more beautifully than through osteopathy?

Nowhere I think.
Sometimes in life certain things simply feel right. Getting the chance to study osteopathy in ESO really feels like one of them. That would be my dream.
So here I am -the maybe worst patient but hopefully a passionate future osteopath.

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I always try to make my studies as fun and artistic as possible.

I think everything in life is art. What you do. How you dress. The way you love someone, and how you talk. Your smile and your personality. What you believe in, and all your dreams. The way you drink your tea. How you decorate your home. Or party. Your grocery list. The food you make. How your writing looks. And the way you feel. Life is art.

- Helena Bonham Carter

... How you study. How you draw bones. The way you design your padlet. How you treat your patients. Life is art.

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

In most of our classes we learn how to behave appropriately in practise, please GOSC and don´t break any rules.
We learn how to always ask for permission, act just right to please the patient and never cross any lines, that might make the patient feel uncomfortable.
When I am observing at the student clinic, I can see the extremely respectful pattern of treating the patient is applied by most students of the ESO. Sometimes I even get the impression that the asking for consent is even too much for the patient and prevents him/her to relax.
I have also experienced the other extreme during one barefoot club meeting where a very successful practitioner was presenting and demonstrating his concept of treatment and diagnosis.
He told us things like that if the patient doesn´t follow his instructions concerning lifestyle changes, change in the nutrition and resting he is not willing to treat them. In my opinion this philosophy does not show great respect for the individuality of each patient, taking in account the validity of different lifestyle choices.
When he was showing us what his treatment looks like on one ESO student he didn't ask for consent to contact her and as well did not ask her to perform a HVT technique on her cervical and thoracic spine. He made a clear point that he never treats differently than that. One might think that it is a different situation in a school of osteopathy as everyone knows what an HVT is and that correctly performed it should not be dangerous for the patient. Even though I have been talking to one of my colleagues who told me that she definitely would have not been happy with him performing an HVT on her and especially not on the cervical spine. In addition to that HVT techniques can be risky for women who are on contraceptive medicaments as it impacts the bone turnover and leads to vulnerable bones that are prone to damage.
I have to say, that even if I think that asking for too much conscent can be disturbing I was slightly shocked by his dominance over the patient.
Experiencing these two extremes I think the right thing to do for me personally is somewhere in the spectrum in between that.
Sometimes the strict regulations and the forcing to ask for consent all the time questions my presence of common sense and empathic feeling for the patient. When the person you are treating is obviously alright with the practitioner contacting him/her than I don´t think that it is necessary to keep on asking for consent. I do understand that it is better to be too careful than not caring at all especially when a practitioner hasn´t got very much experience treating, as well as gaining a feeling for the patient. Therefore I do understand why this topic is handled that strictly in the ESO. In general it is a sign of a good education, if we don´t get only taught techniques and treatment but also patient comfort, because a good treatment has only half of his worth when the patient does not feel safe and cared of in the practise.

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Where attention goes, energy flows (17/04/2019)

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Where attention goes, energy flows (17/04/2019)

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

“Where attention goes, energy flows” could also describe one method of treating I am interested in. One of my favourite osteopaths that I like talking to always tells me how he focuses on the health in the body rather than the problem. If I understood him right he finds the point in the body that is in dysfunction and connects this point with the healthy rest of the body. He tries to bring the flow from the surrounding tissues into the problematic parts using soft techniques inspired by BLT and biodynamic medicine. When I asked him why he is treating like this he answered that he does not want to focus his attention on the problem because his aim is not to make the problem worse.

When I thought about that it made so much sense to me understanding that energy follows our intention. We want to address the self-healing mechanism of the body like it is described in A.T. Stills four osteopathic principles, so therefor we need to focus on spreading the flow of the health in the body keeping the unhealthy body part in mind.

I am very aware of the fact that I probably will spend the next few years focusing on illness and issues what can go wrong with the body because it is important to build up a brought spectrum of knowledge about how the human body works and what can go wrong with it. But as many people say, the true work begins after the education, when you are responsible for yourself to keep learning and educating yourself. For then I already know what kind of postgraduate courses I might be interested in – a lot of cranial, biodynamics and BLT.

It makes my heart smile seeing the profession of an osteopath as a human loving health flow increaser who has a profound medical knowledge about the body that keeps her/him rooted and makes her/him a safe practitioner- and that's what I want to be, a safe and loving osteopath.

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Movement is life. I am moving so I am. This principle is true in many layers of health and Osteopathy.

Let´s take a look at the movement on a cellular basis - gas exchange, nerve impulses, fluid exchange, transport through the body. Even if the body is at rest there is a lot going on every second. The cellular movement is required to ensure life of the whole organism. If just one transport mechanism is inhibited it can lead to death. In the James Bond movies there is a pill that can kill anyone within seconds to minutes by just stopping the sodium potassium pump. That prevents the membrane to keep its potential to depolarize and therefore no action potential can be transmitted. The nerve impulses that make us move and breathe stop so the person poisoned with cyanide dies. We can see how much impact such a small structure that you can´t even see with the bare eye has on if an organism dies or not.

If we move on looking at the organs at the human body, we see that what keeps them healthy is movement. Jean-Pierre Barral, who is the develloper of visceral manipulation distinguishes between mobility, motricity and motility of the organs, that he states all to be key to good organ health.
Mobility describes the movement of the organ in his surrounding e.g. the movement of one visceral structure to another, or one organ to a structure of the musculoskeletal system.
Motricity refers to passive changes in the position of the organs that result from arbitrary motor activity by the locomotor system.
Motility describes the intrinsic movement of the viscera itself. There is a theory that the embyotic movement remains stored in the structure´s tissues and is continuously repeated.
We judge the tissues´ health by its ability to move. In our visceral classes so far we have been testing the suspensory ligaments of the stomach and liver, in fact we were testing the organs´ mobility. I am really looking forward to beeing able to also perceive the motility one day.
Not only visceral structures are healthy when they are moving. We keep on testing joints, muscles, cerebrospinal fluid and basically the whole body to find movement and where it is absent. In the treatment we try to make these structures move again. We try to increase the internal movement as well like circulation, lymph and gas exchange.

In my opinion we don´t only move the patient passively with our hands we try to connect with the patient´s body and try to move as one.
Whenever I watch experienced Osteopaths treating their patients I marvel at the synchronicity with their patient. They become one moving unit. It almost looks like an improvised dance, that I like to do called Zouk (see in the video). It is fully improvised and wors so well because there is one leader (practitioner) and a follower (patient). Still the leader is a follower in the same time because he listens to the response of his follower and subconsciously predicts how the follower would like to move.
For me Osteopathy has a lot of similarity with Zouk. The practitioner is leading the patient by  his own movement, listens in the same how the patient´s body responses and follows the patient by adjusting himself.
I had the pleasure to join when my mother´s osteopath gave her a treatment. He asked me to softly contact her head while he worked on her hip. Just after I made contact with my mother´s head he brought my awareness to my posture which was slightly shifted to the right. He also explained me that my posture is just an extension of the tension from my mother´s hip. During the treatment I tried to just consciously observe whatever was happening. While the osteopath was working on the hip I could detect a warmth in my right hand and after a while I felt how her body is pushing me away to release the contact. It really felt like having a conversation through movement with the body, just like in dancing.
Afterwards he let me contact my mother´s hip just the way I have been taught to do it in GOT treatment: hip flexed over 110° and soft contact under the SI-Joint. He told me to just focus on being still but fluid in my own body and follow the patient´s movement. I managed to archieve a softness in my own body, which took me a lot of concentration so I could not fully receive information from my mother´s hip. He felt that and just softly guided me with his hand on my back. It felt a bit like a very gentle dance trio. I think it will take years of practise to be as sensitive as him and find my own way of connecting to the patient´s body.

Regarding the soft techniques and palpation skills I think that a good osteopath is someone who has mastered the listening so much that he can predict just by the response of the tissues how far he can go without the patient beeing in pain. Of course sometimes the osteopath has to push through the patient´s comfort zone but he does that with full awareness.
A good osteopath is someone who dances with the patient´s tissues having a continuos conversation with them.

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☯  Zouk Training - Xandy Liberato & Evelyn Magyari

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Mind Maps are always very useful as I can recall the content by imagining the picture that I drew.

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

Recently I have been reading a book called “The celestine prophecy”. It is about a manuscript that has to be found, which contains “insights” that lead to spiritual awakening and higher vibration of energies maintaining a state of love. Some of the insights inspired me also in my view of osteopathy.

One idea that I especially liked is that energy flows in everything that is. We can expose ourselves to things or people that give us energy for example nature or a loving environment. Other things like stress, fights or in general draining people make us feel depleted, they steel our energy. Energy is described as something people are constantly fighting for amongst each other instead of finding some higher source in nature, love, movement etc. It is described as the reason for all conflicts on earth. When we make someone else feel inferior by winning over him or her in a fight it gives us energy but drains his or hers. This person will then try to win over someone else´s energy using his own way of being superior to someone else. When we instead open our heart and project our love to someone or something than this person receives energy without us ending up being depleted. The person receiving energy feels stronger, clearer, more intuitive, healthier and vibrates generally on a higher level. In a state like that we are more likely to treat the next person we meet in a nice way, which will increase his energy level as well.

When we remember that concept in the back of the head while giving a treatment I think we can reach better results and have a huge impact on our patient´s wellbeing and in the same time make the world a little bit of a better place. “Where attention goes, energy flows”. If we consciously give the patient energy through being in a loving state towards them, listen carefully and let our full attention be with them they will feel this and be recharged after the treatment. We would not drain our energy either because we are willing to share our energy while being in a loving state.
OPS A1 describes how we as Osteopaths are supposed to treat patients. The idea of energy exchange between humans explains the background to that standart in my understanding and how the loving and accepting behaviour towards patients plays an important part of their healing having the same value as the actual osteopathic techniques we are applying in the treatment.

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When the beauty of osteopathy reveals to me (15/04/2019)

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When the beauty of osteopathy reveals to me (15/04/2019)

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Osteopathy has been a part of my life from very early on as my mother has started a course when I was seven years old. The holistic view on the human body seemed as the normal one since I have actually started to think about health and wellbeing. I grew up in an environment where it became obvious for me to look at the body as a whole when healing, taking time for the patient and rather understand why the health of a patient was restricted than putting a label on the cocktail of signs and symptoms.

I have always been convinced about the approach to the human body that are described in the 4 principles of osteopathic philosophy (The body is  unit; Structure governs function; The rule of the artery is supreme; The body possesses self-regulatory and self-healing mechanisms), even if I could not really understand it before I started my studies. When I think back to a time six month ago, it was just clear to me that everything in the body is connected. It made sense to me that if there is one problem in the body, it might be very likely that another structure suffers as well.

In the process of the studies I feel like more and more of this truth reveals to me and I can finally understand what I was just trusting to be the truth before.

I am very thankful I can be on that course learning how the body works in such a holistic way. Often I hear stories (especially from my grandmother) how doctors send her to other specialists over and over again. Medicine, how it is taught apparently does not teach the students to connect the findings to a bigger picture and draw conclusions thinking outside the box of signs and symptoms.

The beauty and importance of connecting was shown to me once in the Barefoot Club Talk with Howard Beardmore. He explained how rashes on the skin can be an indicator that the organ underneath is anaemic as all the blood runs superficially in the skin and muscles. A general healthcare practitioner might send the patient with the rash to a dermatologist, who would probably find nothing and prescribe some creams to ease the symptoms. The sign of the body saying: “Listen, something is not alright.”, would be ignored and the patient would continue living with an obstruction of his health. This way of treating is not healing, it´s hiding. An osteopathic approach to the same problem would be to gather all the information about the patient that might be important, including lifestyle, nutrition, past surgeries, etc. combine it with palpation of the tissues and draw conclusions keeping this particular human in mind. It´s pretty much the contrary to ticking boxes of signs and symptoms in a multiple choice manner and seeing what medicine fits the best.

Another time the beauty of osteopathy revealed to me when I was thinking about why the symptoms get worse 24-48 hours or even more after the treatment. My conclusion is that the body was actually healing itself. In pathophysiology we learned that the symptoms of illness we have because our body is fighting inflammation. What we do though in our modern world is to stop the signs of inflammation, in fact to stop the self healing mechanism. The osteopath awakens the bodie´s power to heal itself again so we “get worse”. In fact we get better and just temporarily feel worse.

Rumi once said: “The cure for the pain is the pain”. Even if he probably meant his quote more on a psychological than a physical level it really summarizes what I want to say. To heal someone we must encourage the body to do the work and go through the healing process, even if it might be uncomfortable.

I experienced that phenomenon on my own body. I have had a light but constant cough over a period of half a year that wouldn´t go away. When I went to see my osteopath he basically just worked on my chest while holding my head. After a couple of minutes of stillness I started coughing heavily and secreting fluids through my nose, eyes and mouth and also started to sweat. The next two weeks I spent in bed with fever and all other symptoms of a flu. When I started to get better the light cough I had been suffering of before was gone completely. This experience is probably one of the inspiring reasons I started osteopathy.

It´s not only the technical part of maintaining health that I really love about this profession but it´s the time and energy we are taught to give our patients that really inspires me. In a world where people are stressed, always in a hassle I sometimes get the feeling that osteopathy is one of the islands of peace that remain. The treatment is the time for the patient where someone really listens, really cares about their wellbeing, asks questions, makes them reflect and lets them arrive in the now. It´s not that no other healthcare practitioner cares but mostly the traditional medical system does not provide sufficient time to treat holistically. An osteopath has the freedom to decide what is best for the patient – how much talking, listening, motivating and manual therapy he needs to make the client heal and grow.

Therefore I am thankful being on my never ending way to be an osteopath, being amazed and inspired by its beauty day by day the more I experience, learn and know about it.

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

As the theme of asking for conscent is quite a big theme for me I always keep thinking about it. Whenever I meet an osteopath who has practised for many years I ask about his opinion about it.
When I went back to Germany in my easter holidays I had the chance to talk to a practitioner that i really trust and who has helped my already many times with any issues I had. I thought he would be really interesting to talk to about that theme because he never ever has asked me for conscent for anything. Still I never had the feeling that he is dominating me or doing something against my will because he always appeared to be very aware of the limits that my body showed him. It almost felt like he was asking my tissues for conscent without needing me and my mind as the post officer for that communication to work. My mother who has known him for many years as a collegue and friend told me that he even treats strict muslim woman in a burka who don´t want any other practitioner to contact them.
So that´s why I was very keen on his opinion about asking verbally for conscent throughout the treatment session. He told me that he feels that asking for conscent disturbes the fluidity of his work and makes it unsmooth. In addition to that he thinks that too much conscent could trigger the patient´s mind to think that there might be something wrong whereas there is nothing to be uncomfortable about or fear. He also never lets the patients sign a paper or anything because "it feeds the worries where there is nothing to worry about". In his opinion a constant asking for conscent is contradictive to the essence of osteopathic treatment so he would struggle working in a country as strictly regulated as the UK.
I think that I do resonnate with his philosophy and I am very keen to improve my palpation skills until my  communication with the patient´s tissues does not necessarily  require any words anymore, gaining conscent non verbally and having a clear feeling for my patient´s boundaries.

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OPS A7 alias "the blank paper attitude" (22/04/2019)

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OPS A7 alias "the blank paper attitude" (22/04/2019)

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

Whenever people tell me about their health issues and problems or pains they experience in their body I always find myself wondering why they didn´t go and see an osteopath and keep recommending it. From my point if view it´s an obvious thing to do, to see a healthcare practitioner that treats my body as a whole. I see osteopathy as the thing that almost always works even if nothing else seems to solve my health problem as I experienced the power of Osteopathy many times on my own body.
I come from a family background where osteopathy has been used as the remedy for anything and where we only go and see the GP if it´s unavoidable.

I don´t like to admit that I sometimes feel like I know better than other people how to live their live and forget in the moment that there is so much I don´t know about other people. Maybe they are struggling with earning money for living, have many other duties that take most of their time or maybe they just prioritize other things than caring for their health in life.

I have to remind myself that how I live it is not the norm and that other people with different lifestyles have a reason for their actions or non-actions and that their views and values are perfectly equal with my own.

My job as a practitioner is to draw the bridge between their and my values and expectations to figure out how I can help them best not radiating my own ideas and believes towards them. Patients come to receive a treatment from me, so I am the one who has to adapt to whoever walks through my door. I like to compare the state of mind that I should be in with a blank paper so we try to see every patient and their issues from a neutral perspective unfiltered by the practitioner´s self.

I will keep trying to put myself in the people´s shoes that I am talking to and figuring out what advice is actually beneficial to them in their current situation, keeping my own way of living and thinking aside to a certain extend. In that way I can already practise and challenge my communication that I will have with the patients in future.

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Osteopathy as evidence based practise (20/04/2019)

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Osteopathy as evidence based practise (20/04/2019)

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Recently I had a chat with one of the lecturers of the ESO. We were talking about if osteopathy is an evidence based practise.
He asked me about my opinion on it. I was very sure in my answer that it can´t be evidence based as not all the techniques we do are researched scientifically and proven. In my opinion we can see what works for us and what not by  treating many patients and seeing the results. Observing the patients´ reachtions to our treatment and then seeing patterns that let us draw conclusions. I find it very limiting to call osteopathy evidence based. I want to put my energy in improving the patient´s health not in researching if the techniques that I am using are evidence based.
My teacher in contrast had a strong opinion that you need to be able to proof that what you are doing is evidence based, so if you ever get a complaint you can justify why you were doing certain techniques and why you think they are beneficial in one particular case.
Osteopathy has been develloped by studying the human body in depth, drawing conclusions from it and trying out. It has been develloped to something that beautiful as it is nower days without being evidence based and has helped many many people to get well. It´s the nature of osteopathy to communicate with the body, observe the reactions, draw conclusions and adjust the treatment to the bodie´s response. Of course it is interesting to research and proof the effect osteopathy has but I don´t think we should try to limit ouselves to evidence based techniques, because in my opinion that is not what osteopathy is about. I think osteopathy is about improving our "palpation library" by feeling and comparing many bodies, drawing conclusions from it, having a wide understanding of human anatomy and physiology, learning to be more and more empathic and keep being open and curious to new ways, ideas and philosophies.

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I found an interesting study called "Correlation Between Standardized Patients’ Perceptions of Osteopathic Medical Students and Students’ Self-Rated Empathy ".
The study has been carried out in America accessing first, second and third year students of osteopathy. It has shown that the student´s self assessment about how empathic they acted varied from the patient's perception. The first year students thought they were more empathic than the patients actually perceived them to be, where the interpersonal skills of second and third year students seemed to be much better according to this study.
This study has made me reflect on the way we are taught at ESO. In the first year I feel that the main focus is about communication with the patient and consent asking. We are always taught how it is important to gain consent "for our own safety", to protect us against eventual problems with GOsC.
I feel bothered when we are taught consent in a context like that - in a context of trying to avoid being displayed to GOsC by a patient. This approach has nothing to do with the intention of the patient's well-being. If the school really wanted us to learn empathy and interpersonal skills there are many other ways how the learning process could be approached. We are constantly told off for not asking for consent instead of doing exercises that challenge our interpersonal skills. Forced context asking does not teach us anything, in contrast it numbs the empathy. As an example when I am practising with my fellow students asking for consent feels forced and wrong because my feeling tells me that they are alright me contacting them. By still doing the whole process of asking for permission I feel like being far away from improving my communication and understanding for other human beings and exactly this is what patient partnership should be about -not fitting in some sort of form that is GOsC approved.
Obviously the study shows how the interpersonal skills improve over time, so my idea for the ESO clinic would be that patients have to fill out questionnaires regarding the practitioner´s performance and how well treated they felt so the student can work on his interpersonal skills more specifically and get to know more about how his/her patients perceive him/her.
I think that I am at a good starting point regarding my empathy towards people. Many people tell me that I am very considering for other people's needs and thoughts. Still I noticed that I sometimes overlook a lot of things when I am driven by certain ideas or tasks I need to fulfill. I could imagine that it might be a challenge for me the first times in clinic to be focused on finding where the patient´s issues come from while being 100% aware of how she/he might feel. Therefore in the beginning it might be better to ask a bit too much for consent than too little.

References:
McTighe, A. J., DiTomasso, R. A., Felgoise, S., Hojat, M., 2016. Correlation Between Standardize Patients’ Perceptions of Osteopathic Medical Students and Students’ Self-Rated Empathy. Original Contribution, 116(10), pp. 640–646.

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Connection between professional and private life (27/05/2019)

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Connection between professional and private life (27/05/2019)

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

Case: A first year student is arrested for drink-driving, and loses their driving license for a year. He doesn’t tell the School, but someone makes a comment about it in class and the incident is reported. How should this be managed by the School?

During a lecture we were talking about professional boundaries. We were splitted in groups and each group had to present one special case together with their thoughts about it.
The incidence above triggered a lot of discussion between us students and catched my interest the most.
The case has been presented in a satiric way by the group in charge, showing the complexity of its circumstances. Discussing what should happen to the student who has been drink-driving the group suggested two options: 1) "Non of the school´s business" or 2) "Put the student in a pillory". Even if the group´s suggestions weren´t meant completely seriously, it showed that it is definitely a theme to be discussed, the solutions for this case reaching from one extreme of the spectrum to the other.
In the beginning I was completely on the side of "Non of your business", so it triggered my anger when the teacher told us that this case was reported to GOsC by the school. I was convinced that in my private life I can do whatever I want and that it does not have anything to do with my profession as an osteopath. After class I left, still not agreeing with what I just heard.
Over the past six month learning more about the profession, regulation and myself I came back thinking about that case. I can understand now why it actually does have to do something with the profession. The action of drink-driving shows a lack of responsibility which is essential in the job of an osteopath. One could argue that this case could be  a direct mirror of how much resonsibility will be shown later on in the professional life and therefor should be reported.
I am a person that doesn´t like any higher instance to tell me what to do or not to do, that is why I feel so triggered by hearing that a student is reported to GOsC because of what he/she is doing in his/her private life. I feel someone is taking away my freedom. When I think about it a bit longer though I understand that no one is taking away my freedom as I don´t want to do any of those things that could be reported to GOsC anyway. As the patient´s well-being should always be in the centre of attention, such regulation just makes sure that only responsible people work in the osteopathic profession.
When I feel triggered by something in the future I should ask myself what it is really that triggers me in order to evaluate if it is a real problem or just a problem that I´ve created in my head.

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My way of studying the blood  supply (26/05/2019)

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My way of studying the blood  supply (26/05/2019)

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Here is a way that helps me a lot to study the blood supply. I always struggled following all those little vessels and it felt like a big mess in my head. Making a nice drawing helps my brain to relax so the information goes in much easier. Also having to consciously trace the routes of the vessels helps me remember a lot.

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Today I have been in clinic for observation and I noticed that my way of looking at the patient and analysing has changed a lot since the last year. There was a very charismatic man who suffered from post-traumatic-stress disorder. The reason for coming to the clinic was injury to his right side of the body after a bomb had exploded just next to him a couple of years ago. The patient was walking on crutches and sometimes used a wheelchair. Throughout the treatment I noticed that he was not really interested in making a change, meaning taking time for himself, going out for a walk, creating a space for his breathing excercises, etc. He always seemed to have a reason why asking for help or saying no to family was not possible or relevant. In his belief he was able to cope with everything and asking for help was not in his mind because "he is strong enough to endure".
Anyway the practitioner kept suggesting ways of how to make time for himself, which he all rejected.
One conversation that I had with one of my highly appreciated osteopaths came into my mind. He had explained me that he always treats a patient only up to a point that they want to reach and not further until a point that they could reach (see illustration). According to him, we should not push a patient further than she/he is ready to deal with. This really makes sense to me as I have often experienced that people hold onto different symptoms or issues because it is something like their anchor, giving them stability, even if it often is not a very helpful pattern. By trying to push the patient beyond their comfort zone too far, while the patient is not ready for it, we would risk destabilizing them.
Having this conversation in mind I asked the practitioner after the treatment if she thinks that her patient wants to come off his crutches at all or if there is a possibility that he actually does not want to get better.
I learned that her tutor from the week before had made exactly the same point, which resulted in a whole discussion what to do with this patient and how to change the approach.
Learning that the tutor had picked up on exactly the same thing felt really reassuring and gave me a little confidence boost. I felt like I see the patients with more depths now that just their physical problem and I will focus more on looking them in a deeper way in my future observations.

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C4. You must take action to keep patients from harm

Last year I completed a safeguarding e-learning course which I found very useful.
I learned how to recognise people with risk of radicalisation, which in the beginning I did not think was really my scope to deal with. However, after having completed the course and started working in clinic, I realise that we as manual therapists have a great opportunity to pick up on early signs of radicalisation and refer the patient to get the needed support. I learned that radicalisation often comes from the need to belong, have a purpose and connect -needs that can be met in alternative ways. Being able to see patients on a regular basis gives us an excellent opportunity to check in with them and evaluate if they may be needing additional help such as psychological support or inspire them to take up activities that give them meaning.
Luckily I have never been in a situation where I felt like the patient was prone to any extremist activities or was at risk of harming themselves. Despite having familiarised myself with the safeguarding procedures at the ESO, I recognise that acting correctly in these situations would still be a challenge for me, particularly because I am reluctant to act against the patient's wishes, which sometimes would be necessary. What I will do is to think out different scenarios and discuss with my colleges how they would act in certain situations to gain a sense of preparedness.

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The epiphany of informed consent (27/02/2021)

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The epiphany of informed consent (27/02/2021)

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

I used to be very reluctant in the past even to hear the word "consent". This probably stems from how it was taught in the first two years, as well as my personal background. What I had understood from the lectures is that whenever we want to do a technique or contact the patient we need to ask if it was okay. I found this very disruptive to the treatment flow and actually unempathetic, because I saw it as something we needed to do in order to save ourselves from being struck off by GOSC.
Then in the beginning of third year we had a lecture in the clinic induction week about informed consent and for the first time I understood what consent actually means. It is not about asking the patient for consent for everywhere we would like to contact them, but having them on board for our treatment plan or giving them alternative treatment and practitioner options. They will also know the possible risks of treatment and can decide whether ot not the suggested treatment plan suits them. They should also be told that they have the power to withdraw their consent at any time, if they change their mind. This way treatment can be very empowering to the patient since they have the opportunity to decide what is going to happen to them.
Having understood what informed consent actually means I am totally on board with it and am implementing this concept to the best of my ability, with the aim of improving my communication skills in this area further.

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Recognising the need for multidisciplinary care (01/07/2021)

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Recognising the need for multidisciplinary care (01/07/2021)

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

This reflection will be base on my reflection "The Can and Want" in column A (17/02/2020).
The previous reflection describes a scenario where I was an observer in second year in clinic. To summarise I had the perception that this particular patient was not able to fully recover, because a part of him maybe subconsiously did not want to completely heal. It seemed like his presentation had become a part of his identity.
My conclusion to this scenario was that we should not attemt to heal a person beyond the point they want to go, because it would stirr up unwanted reactions. I based my thinking on the imput of my own osteopath who I had the honor to observe.
Reflecting back I see that my view on that has changed and I also would interpret the words of my osteopath in a slightly but significantly differnt way. Now, I dont't think we could stirr up anyone with attemting to achieve the best possible outcome, I simply think that the patient might slow or stop their healing process if they are not ready to move on and process underlying possibly psychological components.
I think what my mentor try to convey is, that we should not get frustrated if our patient does not heal as we expect.
In my reflection from last year, my conclusion is that we should simply not try harder and let the person deal with their growth in their own time.
Now, however I understand that there is an alternative. Step one would be to recognise this underlying blocking pattern, and consider whether or not we are able to set approproate impulses for the patient to grow out of them. If the answer is no, it does not mean that we can't help this patient, since help CAN be referring the patient to someone who might be able to support the patient in a better way.
Looking back I probably had the belief that I should be able to heal everyone, and if I can't no one else would be able to either. Throughout my first year in clinic I somehow along the process realised that putting the patient first would mean to acknowledge that I can't help everyone in the best way for them.
I also feel a shift in my professional identity that has moved from magic healer to supportive clinician. Even though I full heartedly believe in the magic power of touch and think I will be able to help many people as I keep improving my skills, I very much see the value of discussing alternative treatment options as well to make sure my patient gets the most appropriate management.

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Political views in the treatment room (25/04/2021)

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Political views in the treatment room (25/04/2021)

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

Recently I was observing a colleague treating a patient in the student clinic. The patient seemed to have strong opinions regarding a multitude of topics, particularly about national stereotypes and brexit. I perceived his statements to be quite generalising, since he was asking each of us observers where we were from and made a conclusion about our personality following that information. I realised that I felt triggered and upset by some of his accusations, as a little bit torn internally since I knew that we are not supposed to let individual values or beliefs interfere with our attitude towards the patient. Since I was only observing I additionally found it difficult to respond to presumptions this patient directed towards me, since I felt it was not my place to interact extensively with him. If he would have been my patient I am unsure how I would have handled this situation without having a grudge that could interfere with best intentions towards him.
My colleague who was treating this patient chose to handle the situation with humour which I found worked very well. When the patient asked him if they had any parties where he came from (eastern Europe) he made a joke that they did not, since they don't have any electricity there. I am unsure whether the patient understood that it had only been a joke, however it was an efficient way of diluting the tension that had built up in the room, as well as to amuse oneself and not hold a grudge toward this patient.
Interestingly a couple of weeks after this encounter I was treating a very opinionated patient myself, who seemed to dislike Germans. Not ideal, considering that I was born there. While the patient inspected me with a frown I chose to just catch the situation with: "Oh well, looks like you will have to deal with me now", which he seemed to find funny. I felt relieved that this method was working indeed. I felt that by using humour I could distance myself from taking his comments personally. Later during the treatment he told me about his necklace and how it has served him for many years without breaking. To this I responded: "Seems like good quality, it must have been made in Germany".  Since then we have been on good terms, he seems to be happy to seeing me and I feel like his attitudes towards nationality don't interfere with me having his best outcome in mind. I will keep using humour in situations where I need to distance myself from patient's attitudes if appropriate. I recognise that he could have taken my jokes badly, so I am aware that some sensitivity is required when managing patients like this.

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The difficulty in recognising the limits of my work and communicating that (12/10/2021)

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The difficulty in recognising the limits of my work and communicating that (12/10/2021)

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B2. You must recognise and work within the limits of your training and competence.
2.1. If not, you should consider:
seeking advice or assistance from an appropriate source to support your care for the patient

I have one patient in the student clinic that I have seen over the past couple of months. She is a young, sporty female who seems to be very body conscious.
On initial consultation she was very keen on "toning up" and recompositioning her body, because she was going to go to America in a month time, where she wanted to look good in a Bikini. As a result of that she over exercised and ate a restrictive diet. She presented with LBP with the onset in the gym. I did my best to educate her about the damaging effect of starvation on the metabolism, sympathetic state and tissue healing as well as how crucial rest is for recovery but also for body recomposition. I shared some scientific resources (Huberman Lab Podcast) that explained these processes in a more detailed fashion. I had the feeling she really listened to me and when she came back the next week she said she had started to eat carbs again and did some rest days where she just went for a walk or did yoga.
Because I had a good feeling about her complying with my suggestions I chose to trust that she is treating herself better, gave lots of reassurance about her body as far as my level of expertise allowed me to. A couple of weeks later she booked an appointment when I had a different tutor, who asked me how I could know that she is coping fine and does not need psychological support by a qualified therapist. I realised that I could not justify very well why I thought she was fine, since it was more of a gut feeling in combination with that she said she was eating well, she did not seem to lose weight during the time she saw me, sometimes mentioned that she had treated herself to a nice takeaway and seemed to develop a more healthy relationship to food.
Now, I do recognise that I should have probably encouraged her to see a psychotherapist on the very initial stage, since I am not really educated to deal with eating disorders as such, neither with their accurate diagnosis. I also see that an eating disorder is far more than just a behaviour around food, but is more an entire mindset that goes deeper into ones psychology relating to self-love, control and beliefs about one-self. While I do think that I communicated my concerns about her nutrition and exercise habits quite well, next time when I have a patient where I suspect an eating disorder I will be more prone to recommend a collaboration with a psychological therapist to the patient.

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Am I supporting my patients passivity in their care? (12/06/2021)

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Am I supporting my patients passivity in their care? (12/06/2021)

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A5. You must support patients in caring for themselves to improve and maintain their own health and wellbeing.
1.1. Supporting patients in caring for themselves may include providing information on the effects of their life choices and lifestyle on their health and wellbeing.

There is a patient that I took over from a previous 4th year student, who has been coming to the student clinic for more than 10 years for maintenance. Over the years  she has progressively getting worse up to a point where she is wanting to do more imaging to see if there is any damage.
To begin with it did not occur to me to try and change things up with her and just continue to provide the type of treatment that she wanted and expected. However, after discussing with my tutor and learning about pain science over time I realised that I am not really helping her to actually get better, but just promoting her passivity with short term symptomatic relief.  When I took her over I really did not know much about sensitisation, pain science and pain related to tissue damage, so I assumed that her pain must be caused by some sort of tissue damage. Then, in the end of third year I have been inspired a lot by Lorimer Moseleys and Peter O'Sullivans work, who made me aware of the multidimensional nature of pain with pain prognosis being heavily dependent on beliefs regarding pain equals tissue damage, fear-avoidance, kinesiophobia and catastrophization and that evidence suggests moving away from a purely biomechanical model (Mannion et al. 2001; Woby et al. 2007). In our osteopathic curriculum there has been emphasis on the BPS model, however only now I start understanding what it actually means and how to adress it. I realised that my role as an osteopath sometimes is to provide reassurance for patients that pain does not equal tissue damage and that it is safe to move despite pain, investigating where unhelpful beliefs come from and adressing them. That is a really powerful position that I had some reluctance to claim to begin with. I did not feel qualified or knowledgeable enough to tell someone that there most likely is no persisting tissue damage and that I have ruled out anything more sinister. Becoming more and more familiar with red-flag signs and symptoms I am becoming more comfortable with providing reassurance to patients that they will get better and that it is safe to move, as well as working together with them in creating a plan how to regain function required for things that are important to them.
With my patient in this case, I was giving my best to find strategies for her to incorporate movement into her life. We agreed now that she takes up swimming again. Additionally I gave her some gentle bodyweight exercises like squats and lunges that we are aiming to build up in repetitions over time. I am yet exploring the field of giving the patient relevant and fun exercises to change their beliefs about pain and empower them to move and pretty much treat themselves. I have particular interest in functional exercise, like Fighting Monkeys (Rootless Roots) who are adressing movement in a functional, playful way. Taking some of their concepts from seminars I am attending will help coming up with fun and relevant movement for my patients.

References:
Darlow B, Dean S, Perry M, Mathieson F, Baxter GD, Dowell A. Easy to Harm, Hard to Heal: Patient Views About the Back. Spine (Phila Pa 1976). 2015 Jun 1;40(11):842-50.

Mannion AF, Junge A, Taimela S, et al. Active
therapy for chronic low back pain: part 3. Factors influencing self-rated disability and its change following therapy. Spine 2001 ; 26 : 920 – 9 .

Woby SR, Urmston M, Watson PJ. Self efficacy mediates the relation between pain-related fear and outcome in chronic low back pain patients. Eur J Pain
2007 ; 11 : 711 – 18 .

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D5. 1.1.You must respect your patients’ rights to privacy and confidentiality, and maintain and protect patient information effectively.keeping confidential your patients’ identities and other personal information, and any opinions you form about them in the course of your work

I have been treating another ESO student for the first time in our student clinic. We had previously got to know each other and shared some common friends. During treatment she had made a comment that I found really funny. Without thinking I had shared what she had said to our common friend, since I was sure that she would not mind.
Retrospectively I realised that I had broken confidentiality, since I had passed on information from the treatment to a third party. I felt guilty and naive for not having thought about my professional role in this, so I apologised to her. Even if she did not mind, I will be more cautious in the future, especially in our student clinic where it is common to treat friends/acquaintances.

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You can only consider something when you know of its existence. (27/12/2021)

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You can only consider something when you know of its existence. (27/12/2021)

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

One thing I still struggle with in clinic is knowing what other health care options I could suggest to my patients. My learning curve in third year was mainly focusing around learning how I can help the patient best. On the way I did learn about basic alternative management options such as steroid injections, basic musculoskeletal surgeries, dry needling and some other forms of therapy. However, I appreciate that I have no real life experience in terms of how much alternative management has helped the patient and therefor struggle recommending them confidently to patients, especially when there is ambiguous scientific evidence about them.
I also acknowledge that there are so many treatment modalities out there that I haven't even heard of.
What I do on a daily basis to broaden my knowledge is via making my own flashcards that are discussing one condition with its pathophysiology, prognosis, management guidelines and osteopathic considerations. Studying this way has definitely helped a lot in terms of having a framework for exploring alternative managements based on the available guidelines. I suppose more knowledge will come naturally as well through persistent exposure and learning from patients experiences.

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The power of: "Don't worry, you will get better." (09/11/2021)

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The power of: "Don't worry, you will get better." (09/11/2021)

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B1 1.2 You must have and be able to apply sufficient and appropriate knowledge and skills to support your work as an osteopath. These should include a knowledge of human structure and function sufficient to inform appropriate care.

Over the last 6 weeks, I have seen a patient who initially presented with very acute back pain. She had unilateral radicular symptoms that worried her a lot, thinking that her back was damaged. She believed that certain normal daily life activities had "done her back" and that she would not get better. If I would have seen this patient a year ago, I would have worried a lot myself and thought that if the pain is so intense, there must be something significantly wrong. Luckily though, over the course of third year our pain science lectures, tutorials from tutors and independent research has shown to me how pain levels do not equal severity. I knew that weakness or complete sensory loss were more severe than intense pain and knew when I should be referring. In this moment of emotional upset by the patient, I was able to stay calm and conduct a neuro-exam, which did not show any weakness or complete sensory loss. Having all this positive evidence of how the patient's body is still functioning despite the pain levels was really powerful in reassuring the patient that she will get better. The treatment then was fairly simple, consisting of pain modulating myofascial release and gentle mobilisation techniques. We did some breathing exercises together to help relax the anterior and posterior musculature of the abdominal wall, that were guarding the back and encouraged her to continue practising those together with as much movement as she can tolerate. She was progressively getting better and after 5 weeks she came to the treatment pain-free, jumping and very happy. She had been following all advice and had been moving around a lot. The patient was convinced that it was me who "sorted her out". Considering that my hands on skills are probably still in progress and that I had not used lots of sophisticated techniques, I was strongly doubting that the manual treatment had "fixed" the problem. Even research shows that manual treatment does not have a clinically relevant effect compared to Sham treatment in back pain patients (Lavazza et al., 2021). Concluding, I think that my patient attributed her recovery to me, because she stopped worrying after our initial consultation, which sped up her recovery alias self-healing mechanism, placebo or whatever people choose to call it. I can really see the significance of knowing the red flags, expected prognosis and ability to communicate effectively to the patient and convincing them that it is safe to move, which I am continuously striving to get better in. One recourse that I found inspiring in the process of becoming a better communicator is linked in the beginning of this post. https://www.youtube.com/watch?v=sUANsPdkkEU&t=1s

References
Lavazza, C., Galli, M., Abenavoli, A., Maggiani, A., 2021. Sham treatment effects in manual therapy trials on back pain patients: A systematic review and pairwise meta-analysis. BMJ Open

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OA Wear & Repair: an Osteoarthritis knee story using healthy linguistics

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Best practise-fixing patients vs. empowering patients.

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Best practise-fixing patients vs. empowering patients.

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D1. You must act with honesty and integrity in your professional practice.
1.4. A lack of integrity in your practice can adversely affect patient care. Some examples are: prolonging treatment unnecessarily

There are different approaches of targeting a patient's presenting problem, varying from pure pain education, biomechanical treatment or pure rehab approaches that I have witnessed in clinic.
Last week in the student clinic I have taken part in a tutorial with a tutor (Tutor A) that very much believes in the biomechanical approach and who's treatment consists of "fixing" restrictions of joints to restore optimal function. He does tell his patients that they have "problems" if he finds a joint restriction that need to be fixed with manual therapy. Even though the biomechanical explanations of tutor A's approach really did make sense to me, telling the patients that they had a "problem" did not resonnate with me at all. I felt it was creating a dependency on the practitioner to sort out their problems. This type of communication could be seen as unnecessarily prolonging the treatment.
On the other hand, this biomechanical approach really did work for that tutor so he was relying on anecdotal evidence, which also is a type of evidence, even if it's not very high on the Hickert's pyramid.
Later in the day I had a patient with another tutor (Tutor B).
I attempted to apply everything I had learned from the tutorial and I felt I had done a thorough examination that provided a good basis for treatment. The tutor I was working with however, did not agree at all with this approach and would not let me explore it, because he believed that there always must be an underlying weakness/ impaired neural firing for a joint to go in dysfunction and therefor bases most of his examination on functional and muscle testing. He told me that by just working on the joint restrictions, I am actually not helping the patient at all. He also was relying on anecdotal evidence. While I could also see his point of argumentation I felt quite irritated that I was not allowed to explore and apply the way of treatment that we have been taught the past 3 years in Boxley and some tutors in clinic. He was asking of me to perform an examination and treatment with a completely different approach that we have never been taught.
Following this day of contradictions, I realised that everyone just tries their best and works with an approach that works for them. Determining if someone is prolonging the treatment unnecessarily is therefore really hard to judge. However, current evidence suggests an inconsistent relationship between biomechanics and clinical presentations (Tan et al. 2021 and Talk by Greg Lehman). Telling the patient that something is wrong with them biomechanically therefore is not best practise, especially since negative beliefs about one's own body are correlated to a worse prognosis (Wertli et al, 2014). In the same time it is clinically not really useful to say that the offered treatment has not been shown to be effective, considering the great importance that placebo and contextual factors have (Rossettini et al., 2018).
While the biomechanical approach still has its place, even if it's just to give meaning or an understandable connection to their presenting complaint to the patient or provide a framework for the osteopath to evaluate the patient's body, I will still be careful what language I use when speaking about my findings. I will be using positive communication, focusing more on what they can do, as supposed to telling them what's not working and hopefully reducing dependency and unnecessarily prolonging treatment.

References:

Rossettini, G., Carlino, E., Testa, M., 2018. Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain. BMC Musculoskeletal Disorders.

Tan JS, Tikoft E, O'Sullivan P, Smith A, Campbell A, Caneiro JP, Kent P. The Relationship Between Changes in Movement and Activity Limitation or Pain in People With Knee Osteoarthritis: A Systematic Review. J Orthop Sports Phys Ther. 2021 Oct;51(10):492-502

Youtube talk by Greg Lehman: https://www.youtube.com/watch?v=yPKVykhFOcc

Wertli MM, Rasmussen-Barr E, Weiser S, Bachmann LM, Brunner F. The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review. Spine J. 2014 May 1;14(5):816-36.e4.

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When Biomechanics DOESN'T Matter | Greg Lehman SDPS2018

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C2. You must ensure that your patient records are comprehensive, accurate, legible and completed promptly.
2. Your notes should be contemporaneous or completed promptly after a consultation (generally on the same day).
Last week I received feedback from a tutor who saw me filling in my examination notes out of the treatment room. He said that I am not complying to the GoSC regulation because my notes could be inaccurate if I don't do them right away. However, according to the Practise Standards, we are required to fill in the notes on the same day. I find that my flow is interrupted and my connection to the patient is lost when I keep consulting my notes throughout the examination. I value, that my full attention is on the patient during the examination and so far I never struggled to recall my findings.
Therefore I choose not to take that feedback and focus on connecting to the patient during my examination.

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

Last week I saw I new patient who was a Sheikh and very obviously from a different cultural background. It was quite apparent that he was used to telling what to do so he was expecting that he could talk to me in the same way and order what I was supposed to do. When I told him the process of how this consultation is going to work he insisted on saying: "No, please just fix my foot, shoulder and wrist. Just give me a treatment right away."
At first I was taken aback and felt shy, because this usually is my first reaction when someone speaks to me with authority. However, I pulled myself together and made sure to stand my ground by politely outline the rules of how the consultation works in this student clinic, such as that I need to take a thorough case history to first find a diagnosis and if appropriate do some treatment and the reasons for that. He seemed irritated and reacted with facial expressions that I found quite rude. I was very close to just send him home, because of this behaviour because I felt like my good intention towards him fading. I tried to remind myself, that he  is probably not used to not have his orders followed and shift my reaction from being irritated to curious of how I can get this patient on board -but with my rules. I told him (with a little bit of charm) that if he wants to get a treatment he will need to cooperate, if not he can also go to a massage place. He then finally chose to cooperate but kept pointing me to other body parts that he wanted me to push and massage, even if the treatment time was already over. I just kept reinforcing that I won't be able to address everything today but that we can look at it next time.
In the end I was grateful to have had an experience with such a difficult patient, especially because authoritative people usually scare me. I felt proud of myself to having stayed grounded and stayed with my boundaries, because I think the reason I resent someone or get annoyed about a person when I personally let others cross my boundaries. So even if I perceived this patient to be rude at times it felt like I had my protective wall and his behaviour did not really affect me, which was a new experience for me.
I learned that it helps if I have this mental wall of: "this is your stuff - and this is my stuff " in my head, which I will be pulling up if any similar future situations arise.

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Feedback on other side: "Very good communication, consent, explaining assessment to the patient."

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Feedback on communication skills CEX (17/01/2022)

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Feedback on communication skills CEX (17/01/2022)

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

Something I had been struggling with in the beginning of children's clinic is that I was too careful to not impose my findings into the patient up to a point where I was reluctant to describe and communicate my findings to them at all. This was not helping them to trust me and I was mainly relying on my tutor to tell them the findings. However, I mostly did not like the language that was used by the tutors, which included words such as: "strain, torsion, compression" etc. From the parents' reactions I could tell that these kind of words caused some worry and anxiety regarding the health of their child. I did not think this choice of words was necessary.
I have put a lot of thought in previous weeks into how to best communicate the findings in children's clinic to the parent and found out through trial and error how to best approach this. Now, whenever I attempt to explain my findings I make sure to firstly reassure the parents saying things like: "Your baby seems very strong and engaged, that's what we like to see." Then I move on to say what we could help with and suggesting (not imposing) a reason for why we find what we find. "We found some tension in ..., this may be due to the position in the womb/birth process. This is nothing to worry about and I believe we can help to resolve some of this tension." Finally I always make sure to check in with the parent, since they are the expert on their baby: "Does that resonate/make sense to you?"
Since I started implementing this communication style, I feel like my partnership with the parent very much improved.
Last week I had my CEX in children's clinic. I received very good feedback, particularly regarding my communication and explaining my findings to the patient, which I was happy about, seeing that I had put in a lot of thought into this area. I will keep improving the way I speak to patients/parents, because it is such a potent and powerful tool in terms of the patients recovery.

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

Over the years I have noticed that I have learned and expanded my view towards communication in clinic a lot.
Coming from an osteopath family, I had strong views regarding the professional identity of osteopaths, as well as how they should be communicating with their patients. Whenever I went to my osteopath I was used to briefly chat about why I have come today, then do a quick assessment and then get into treating. In my experience there was no such thing as making and/or communicating a particular diagnosis, treatment plan, likely prognosis or explanation of what is going to be done. What I did perceive though was a deep communication between the osteopath and my tissues which occurred through touch. I enjoyed this safe space at the osteopath where someone would just listen and communicate with my body and I felt like I learned something about myself -physically or mentally- everytime I went to the osteopath. Sometimes the osteopath would also just speak to me and barely do a physical treatment, which I was confused about at first but when I left it felt like that speaking about my experience, issues, life was just what I had needed. While there was not a lot of space for me to verbally decide what I wanted, I really felt deeply cared for and as if the osteopath had listened and responded to what my being needed without me having to verbalise or even understand it.
Having these positive experiences I felt quite resistant to the idea of shared decision making and having to talk out everything. From my experience, it was taking away from actually being with the patient, listening to the tissues and adopting an intuitive approach. While part of me still thinks that this approach is the best for certain patients and circumstances, I have learned that people present to me with worries, uncertainty about the best approach and the need of discussing their options with them. Especially in UK, where the primary health care is not as efficient as in Germany, there are a lot more patients who need to be screened for serious pathology and patients who have not been seen by anyone else. In Germany people often come to the osteopath when other "rational" approaches have not worked, so there is a lot of space for the "intuitive" approach.  I realised that I was assuming that everyone would like to be treated like I do. In reality though, I never presented to the osteopath with serious pain, I needed reassurance about, but saw my osteopath more as someone who would support my health and healing process.
I now recognise that patients who come to us for primary care, have different needs such as giving them a reason for their pain, discussing treatment options, giving them a likely prognosis and educating them what else they can do to help themselves. I also learned, that asking my patients what exactly they want from me is actually pretty awesome. My to go question now is: "What it is it that you need from me?". I get all sorts of answers ranging from:  "I need to know why I am in pain." to "I just need a calm treatment today". I feel like I can much better give to everyone what they need as supposed to imposing my own perception of what I think they need is. Like this I can combine the positives from my experience with my own osteopath as well as my experience in the student clinic.

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A. Communication and patient partnership

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This theme sets out the standards relating to communication, the formation of effective patient partnerships, and consent. Patients must be at the centre of healthcare and must be given the information that they need in order to make informed choices about the care they receive.

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Up to date professional skills and knowledge (12/03/2022)

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Up to date professional skills and knowledge (12/03/2022)

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

In my experience it is pretty easy to keep developing and maintaining skills and knowledge as a student, because it is the student's job to do that.
For me this job does not stop though with finishing the course, quite contrary it provides me with the opportunity to dive deeply into branches of osteopathy and find my own style as a practitioner. I feel like in this course I have acquired a good base knowledge, study skills and critical thinking which provides me with the ability to develop further in specific areas of choice. In the past I used to think I would do all the SCCO modules and develop my cranial skills, however my interest has perked in a variety of different areas such as movement based approaches like rehab/movement culture. My plan for after graduation will be to travel and on the way ask a broad range of osteopaths to let me observe them treat their patients for a day. Like this I will get exposed to a variety of approaches and can see which way of treating, communicating and approaches resonates with me most.
In terms of keeping up with the latest available research I study most of my management strategies from the Brukner and Khan (2015) book, which is very helpful because it also states alternative management options which are non-manual based. It has helped me with suggesting alternative options to patients to gain informed consent. I also follow social media sites that share newest insights from studies like the BJSM instagram page. Like this I can keep up to date with minimal effort and time investment so that I can actually stick to the commitment of staying up to date. I will also plan in a specific time per week to do self study and look up things that have come up during the week.

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

Since starting clinic it has happened shockingly often to me that I study a particular subject on the weekend and then during the week a patient comes to me complaining of exactly this symptom.
So it was recently when I had studied all possible causes of vertigo, how to differentiate and rule out red flags. The following week I had two patients coming to see me who were suffering from vertigo. I was able to perform my safety screen pretty well on one of those patients, however the other patient had concussion related vertigo which I had not really looked into. While I did some testing according to what I have learned I was not sure about the concussion specific tests and my tutor seemed to be ok with my management anyways. However I could feel myself a bit insecure and was not sure if I had managed the patient appropriately, which was not a great feeling. I then went home and researched appropriate management and screening. I realised I had not tested memory and did not perform the vestibulo-oculomotor motor screening, which was part of the SCAT5 tool for concussion evaluation. The next time I filled in the missing parts of the appropriate screening according to the SCAT5 tool. Having done all this research helped my confidence when I saw the patient the second time. She reacted positively when I told her that I would like to do some further tests, that I had missed last time. I perceived that she felt cared for since I had done extra research for her specific case.
What I take away from this experience is that it is completely fine to not know everything as long as I aim to learn more and do my research particularly if it is relevant to my patient.

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Respecting patients' dignity and modesty

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Respecting patients' dignity and modesty

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

Coming from Germany my perception of providing adequate modesty options was very different to what is expected in England. In Germany it is normal to go to the manual therapist and undress to the underwear straight away, without questioning it. When I came here, I needed to learn that most people especially in clinic have very different needs when it comes to communicating why it is important to undress.
When I started working in the student clinic I was probably acting a little too conscious, up to a point where I was scared to ask the patient to get undressed. I felt really uncomfortable saying: "Can you undress... or can you take off your..." In fact the patient most likely didn't mind and I was making this big thing in my head out of it.
As I went through this awkwardness with the patients a couple of times I decided I needed to change my attitude and find ways how I can communicate the need to undress without being awkward.
Now I usually tell my patient that it would be the easiest for me if they would feel comfortable to undress ... (particular items of clothing). If they are wearing loose leggins I usually don't ask them to remove them, unless I need to observe their skin or do sensory testing of the lower limbs and I let them know that they can bring shorts for the next time if they would feel more comfortable like that. Every following appointment I just ask them to get changed in their "treatment outfit" so I don't need to go through the details every time. Most people don't mind undressing and if they do, I let them know that my main goal is for them to be comfortable and try and find modesty options that work for the both of us.

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

Recently a patient presented to me with neck pain and dizziness, who had a history of breast cancer in the previous year.
She was taking letrozole as a long term post breast cancer treatment, which often causes dizziness as a side effect. However, on further questioning the patient described that she felt dizzy particularly on neck extension and upward rotation. The symptoms were not reliably reproducible and were absent in the treatment room.  I decided, with the agreement of my tutor to offer conservative treatment without neck articulation techniques.
While the patient's neck pain and ROM improved, she reported on the next consultation that she had experienced dizziness post treatment. I then decided to write a referral letter to her GP and ask for his consideration of possible vascular compromise to the head. On the treatment I focused on other areas than her neck and offered gentle suboccipital inhibition only to avoid any further risk. The next treatment she came back with no dizziness at all for the past two weeks but had not been to see her GP yet.
I questioned myself if I had possibly overreacted, since dizziness post treatment could be related to a change in autonomic tone or postural hypotension reactions, particularly since dizziness could not be reproduced reliably in and out of the treatment room. I don't know the outcomes from the GP yet, however upon reflection on the event I think it was the better thing to be a bit too careful than care less, when I don't have much experience with a specific presentation.

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

Recently a 60 year old female patient presented to me with pain in her right forearm and lateral 3,5 fingers as well as pins and needles in her hand. She came to see me for an unrelated complaint but mentioned this symptom in the case history. She had had a mastectomy in the past year and was still treated with letrozole to prevent recurrence of breast cancer, which can have pins and needles often due to carpal tunnel syndrome as a side effect. She mentioned that she was told by her physio therapist that she possibly had carpal tunnel syndrome and was waiting for her steroid injection. However, according to her something with the referral had gone wrong and the injection was delayed for 6 weeks.
I asked her if someone had tested or explained for this given diagnosis and she did not seem to have had a lot of clarifying conversations with her healthcare professionals. Apparently they were not even sure it was carpal tunnel syndrome, but was offered a steroid injection anyway. I felt it was my role as a healthcare professional to help her understand what was happening and explaining her the management options she had.
Upon testing, the pain and pins and needles were not reproducible with phalens and reversed phalens test, however she did feel increased pins and needles on stretching the soft tissues over the brachial plexus. I suggested that the pins and needles may be due to the scar tissue from the recent mastectomy, which made sense to her. I also explained the referral process for a steroid injection according to the NICE guidelines which recommends starting with a 6 weeks programme of conservative treatment before seeking out more invasive methods like steroid injections or decompression surgery down the line. Possibly this was the reason her steroid injection was delayed.
We agreed on trying to help the symptoms first with conservative treatment, such as releasing her right UEX myofascial chain and if it made no difference after 6 weeks we could still discuss alternative options, such as the steroid injection. She seemed very happy that someone had actually examined her and explained her what options she had.
This was the first time I felt like I was a real healthcare professional that can support patients in their decision making. This was only possible for me because I had researched alternative managements of various conditions, that goes beyond manual therapy. Before, I did not really see the point in doing this because I thought that it was not my role to discuss alternative management with the patient since they came to see me for a treatment and not for a chat. Especially in the UK though where osteopathy often ends up to be primary health care (unlike in Germany where patients get quick advise about their management options from their GPs and orthopedic surgeons) I do see a lot of value in knowing alternative management options to be able to give the patient balanced advise. Especially in third year I did find myself unsure and clueless on what to recommend to patients in terms of alternative managements, so I feel satisfied that I have improved my knowledge. It gives me a more grounded and wholesome feeling as a healthcare practitioner and I intend to keep on learning.

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

Since the Corona Virus pandemic, hygienic measures have naturally been very strict. However, I have noticed in my first two pre pandemic years, couches were not cleaned at all and every patient was laying on the same couch cover. After each treatment only the couch roll was changed, but patients still had skin contact with the underlying couch cover. Thinking back to this I find it quite unimaginable how this was accepted as adequate hygiene measure.
I have been thinking on how I would ensure adequate hygiene in my future practise and I will probably use towels that I change after every patient, clean the couch and wash the towels on a high temperature.

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C3. You must respond effectively and appropriately to request for the production of written material and data. To achieve this you will need to:

1. produce reports and referrals, and present information in an appropriate format to support patient care and effective practice management

Sometimes I am unsure on how to appropriately word a referral letter, in terms of how much should I suggest to the GP what I think needs to be done. Various tutors have differing opinions, for example some think we should request particular tests (such as MRI, inflammatory marker tests etc.), whereas other tutors think that GPs do not like it to be told what to do. I have mixed feelings about this: On the one hand I think it is very beneficial to communicate our concerns very clearly to the GP and by suggesting a particular type of test, our concerns become more clear to the GP, reducing miscommunication between healthcare practitioners. On the other hand I realise that we as manual therapists know less than a GP regarding what else could be going on with the patient's health. By requesting a particular examination we could miss an alternative diagnosis and also may sound silly advising the GP on what to do. So far I have refrained from telling the GP what to do, also because I don't feel very experienced yet. Probably the relationship with GPs will also change once I graduate and get to know the GPs in the area.

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Friendly smalltalk or washing away professional boundaries? (28/02/2022)

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Friendly smalltalk or washing away professional boundaries? (28/02/2022)

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

I sometimes struggle with how much personal information I can disclose to a patient, when they specifically ask me about my own life. Patients often ask me for example where I live, if I have a partner, how my exams are going and other things about my life, which I most often find very sweet and it also helps to build a good patient partnership. However, whenever they ask me these things I am aware that I should not be talking so much about me and secondly it really depends on who is asking me in terms of if there is a risk of crossing professional boundaries. When it's elderly people who seem lonely ask me these things I usually don't mind because I recognise that coming to the osteopath is a way for them to get some social interaction. I usually try to ask them back and tell me about something from their youth that makes them happy.
I once treated a patient who was seen by my romantic partner who is also an ESO student and she expressed to me that she really did not like him. It was not a problem for me, since I appreciate that two people sometimes just don't have a good dynamic and I could see why they would not get on. Later in the treatment she asked me if I had a boyfriend and I panicked a little bit, so I lied to her that he is living in Bristol, which was the closest to the truth since he actually is from Bristol. Since then she keeps asking me when I will see my boyfriend again and I have to keep lying. I feel bad for lying but in the same time I don't want to make her feel bad for talking badly about my partner, because it would affect our professional relationship.
Reflecting back on it, there is a professional and polite way of saying that I would rather not talk about it, which could however make a big thing out of an innocently meant question. I could have said as well that he is a fellow student, without mentioning that it is her previous practitioner which would be lying a little bit less.
In summary I feel that it highly depends on the patient, where the risk of crossing professional boundaries is and should be carefully evaluated with each patient personally.

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

In second year we were required to write a response to a complaint letter we received from a patient. The patient had complained about us being deceitful and dishonest because she had heard that cranial osteopathy, that her child received during treatment does not actually work. However, her child has been feeling better since the last consultation.
At first it was really difficult for me to respond to that letter because I thought that this woman was really silly for complaining even if the treatment had obviously worked. I then wrote an -in my head- polite response and gave it to my friend who is an working osteopath for proofreading. He told me that my letter sounds quite passive aggressive. I kind of agreed with him but had no idea how to change it since I lacked the communication skills. He suggested a couple of tweaks in my introduction, which made a big difference. This way, I thought the patient would feel heard instead of blamed or dismissed.
Over the first lockdown I stumbled over the book Nonviolent communication by Marshall B. Rosenberg. I was so fascinated by this way of communicating that I read it in two days. It made me understand that the tweaks to my letter that my friend suggested were based on nonviolent communication. Having dived into this topic changed the way I communicate in private but especially in the clinical setting too. I realise that most issues happen when one party does not feel heard or feels like their needs are not being met. Every emotional outburst and dissatisfaction has an unmet need at its root. By trying to ask with curiosity instead of judgement what another's problem is, establishes a fertile ground for actually hearing what someone's expectation is and in case of a complaint understand where the expectation has not been met.
I did not receive a real complaint yet but I can imagine that it will be harder to not take the accusations personally and stay in a place of responding and not reacting. However, I am practising every day, which hopefully will serve me to avoid complaints or help me deal with them in the future.

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Where does my private life stop and my professional life start? (31/03/2022)

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Where does my private life stop and my professional life start? (31/03/2022)

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

During this Covid pandemic the population, including me was following the government guidelines. However, since July 2021 almost all restrictions have been lifted, putting the risk assessment in the practitioner's hands. I have been struggling deciding for myself to what extend I can engage in the available social activities that I feel very passionate about, such as partner dancing, since I did not want to put vulnerable patients at increased risk. In the same time I did not want to prevent myself for forever from pursuing my passions beyond my degree, so I found myself in a real dilemma. The first time I went out for some social dancing therefore was only in November, but still I had mixed feelings about it. I decided for myself it was ok to go if I made sure to test myself every day before seeing patients, to minimise the risk of transmitting Covid to my more vulnerable patients. This made me understand over and over that we as healthcare practitioners need to take so much responsibility even outside our working hours.

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

I have a colleague that has a very different approach to treatment than I do. His strength is patient education based on words, whereas my personal approach that comes more naturally to me is communicating through touch.
I had observed him once treating a new patient with acute pain due to a radiculopathy and sensitisation. When he asked me for feedback I told him that I felt that he was overeducating and that if it would have been me as a patient I would have felt frustrated because I would have wanted the practitioner to just be with my tissues and not speak all the time trying to suggest things.
This led to a fruitful discussion with my colleague about what makes us choose or gravitate towards different modalities (like words or touch) to interact with the patient. We found out that it is probably due to our own ways of perceiving/interacting/communicating with the world. My colleague for example naturally takes a rational approach to the world, which manifests in him wanting to understand things with his mind. He also mentioned that when he would go and see an osteopath he would want the practitioner to explain everything and spend a lot of time talking about his problem. Me, on the other hand I am quite the opposite. My main form of interacting with the world happens through physical sensation and experience. If I would see an osteopath I would want them to speak as little as possible and just let me feel and experience the treatment.
I understood that I was judgemental about osteopaths or colleagues who had a different way of interacting with the world than me, because it simply did not make sense to me not having touch and experience as the prime sense. I doubted that they could be successful osteopaths, because "osteopathy IS about touch". Now, however, after having had this discussion with my friend, I understand why not every patient responds to my intuitive touch either and why it sometimes feels like I am communicating with a wall instead of a body. Different people have different channels of how information makes sense to them.
This conversation with my colleague shed a light on why I simply could not connect with some patients in the way I was used to. I now see the value of having different routes of communication but also colleagues with different strengths and approaches than myself, that I could refer my patients too if needed. Concluding, I think it's quite beautiful how we all have different ways of approaching the same issue and how we can complement each others' strengths and weaknesses.

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

1. You should not place pressure on a patient to commit to unjustified treatment.

I think, even though I am not receiving any money from patients in clinic yet, I sometimes struggle telling them that I would recommend that they come back to see me again, because I feel like I am taking the choice of them what to spend their money on.
For me there is also this underlying insecurity of not being worth the money people are spending on me. When I did other jobs like teaching dance it was incredibly difficult asking for money for my work, even though I know that I am generally doing a good job. I feel fear of being perceived as demanding, arrogant or egoistic for making people pay me. I know it's irrational, so I always brace myself and ask for the money I think I deserve anyways. Over the years I have been getting better at it.
What concerns osteopathy, I feel un unease about risking getting people into situations they don't want to be in. In the student clinic I always give patients the option to either book in straight with reception or make a phone call to book an appointment, so they have the opportunity to not book back if they did not like the session or want to try something else instead of rebooking with me. I am aware though that the rebooking process might be dependant on my future employer and that it might be me who has to rebook them straight after treatment.
Recently I had a phone call with my ex housemate who graduated last year and is working as an associate now. He told me about the struggles he had in the clinic since his boss has been asking him to pre-book patients for the entire treatment course (e.g. 5 treatments in advance). He also is supposed to call patients and get them to rebook even after the treatment course was finished to do some "maintenance". I felt really repelled by the sound of that, because it sounded like a business project rather than healthcare to me. While I am aware that we as osteopaths need patients to make money to live, I felt deeply that the priorities and values in his bosses clinic were severely skewed. I might have a flowery vision of the future as a working osteopath, but I believe that good intensions coming from a desire to help the patient in a way that is best for them will always win. I think that when I start my interview process for a future job I will ask lots of questions to my future employer regarding the clinics general core values, as well as practical aspects like the rebooking system. As a personal action plan, I will keep working on improving my sense of self worth, which will probably integrate with time and the number of patients I helped.

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D3. You must be open and honest with patients, fulfilling your duty of candour.
1. If something goes wrong with a patient’s care which causes, or has the potential to cause, harm or distress, you must tell the patient, offer an explanation as to what has happened and the effects of this, together with an apology, if appropriate, and a suitable remedy or support.

Yesterday in clinic I agreed to do a role play with my tutor, where he was a patient who came back to see me again after having had a bad treatment reaction. In the way I was responding I recognised that I was trying to save myself from the patient believing I did something wrong. What I mean by that is, that instead of asking further questions about when the new symptoms came on, how severe they were, how it influenced the patient's life, what other activities they have been doing in the past week, I just gave a big speech of reassurance. According to the feedback I received, this speech contained good content and covered many points I needed to cover, such as giving the patient an explanation to what happened, reassurance that damage is very unlikely despite increased symptoms and offering a way of managing this new presentation together. However, I should have asked more questions first and showed that I was curious and cared about the patient's complaint. I very much agreed with the received feedback. I do think that in real life with a real patient I would have asked more questions, because there is a different level of care if you are genuinely worried about someone and don't "just" perform a role play. I do think this exercise was really useful to me and gave me a deeper level of awareness how important it is to let the patient express their concerns and show them that you care, instead of just saving yourself. In that way it is not me against the patient, but the patient and me together against the problem.