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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.” (GOsC 2018 p.16)

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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.” (GOsC 2018 p.16)

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Year 3 Online Clinic Exam Feedback

Please see attached exam feedback.

I thought I did really well in this exam to was surprised to receive 54%. From the feedback and speaking to the examiners I realised some areas I need to improve on. These included: considering and questioning for other diagnosis (even if the presentation seems clear, it is important to be able to justify why I have ruled out other diagnoses!); as well as better systemic questioning, as I was quick to accept urinary changes were due to increased drinking due to boredom.

From this feedback, in clinic I want make sure I am not concluding a diagnoses too early on. I must make sure to ask specific questions to help justify why I have chosen a particular diagnosis but that I have also considered and ruled out others. Additionally I want to improve my systemic follow up questions, as I feel like I know what questions to ask, but if I receive a positive response I am unsure how to progress. Therefore I am going to speak to my clinic tutors and also do my own independent learning into systemic questioning and why we are asking these questions/ what positive answers may suggest.

Year 4 CEX 1 Feedback

Please see attached feedback.

I was really happy with the exam today. It really increased my confidence in terms of my ability to autonomously manage a patient. I received really positive feedback in regards to my overall performance.

Year 4 Children’s Clinic Tutor Feedback

“What I have observed that has gone well:

Good summarising of facts back to parent for clarity.

Good listening skills.

Asked for clarity on conditions that did not know.

Very nice enquiry into breastfeeding and gained a good appreciation of how this was going for the mum just by chatting about it. You have an ability to be open and honest about your level of knowledge and to listen which will get you a long way in finding out a lot of information rather than pretending you know more than you do and not asking. This has always been my approach, and I have gained much by following it so I would encourage you to continue with this attitude.

What I have observed that could be improved:

Be aware of different feeding positions when breastfeeding so can ask mothers if these influence feeding either through pain for mum or effectiveness of baby's technique.

Ask ideas, concerns, and expectations separately so can gain accurate responses to these.

When asking about pregnancy include BP issues and bleeding in your questions.

Umbilical cord-ask about healing of baby's umbilicus and when it was cut.

If APGAR score is unknown ask about colour, breathing and movements at birth of the baby, if known.

Ask colour and smell of urine and stools as well as consistency of stools to gain full information on this.

CVS-ask about temperature and colour changes in hands and feet.”

On reflection of this feedback, I know that my knowledge in children’s clinic is limited. We have suffered in terms of lectures and observations due to lockdown so my knowledge was already behind, and I feel like I have neglected this specialist clinic due to focusing on general clinic. I am going to improve my knowledge in regards to pregnancy, labour and paediatrics to ensure better questioning and management of my patients. This is important for me as the job I have been offered after I graduate would like me to treat children and therefore I need to ensure I have sufficient knowledge to do so.

Year 4 diary entry:

"On Wednesday evening in clinic, I had a new patient. I’m not too sure where to start... It was a very useful learning experience for me. The patient was a 26 year old male who was a very big character. He had ADHD. He was very loud, spoke a lot and wasn’t afraid to say how he felt... He presented with back pain. There were many red flags in his presentation, including: a recent trauma to the back, constant pain and night pain. He also said nothing relieved the pain and admitted to taking 5 paracetamol the night before due to the 10/10 pain. From this we were not happy to treat due to the red flags for a potential spinal fracture, so wanted to refer the patient for an X-ray. I knew this would not go down well, as it was clear in the case history he didn’t know what an osteopath was and had just come to be treated, not answer lots of questions. He did not respond well to what I had to say... he wouldn’t stop talking, saying he didn’t need an X-ray, it was a waste of his money- he shouldn’t have to pay, he knows he just needs treating and its a muscle problem... It was hard work and I was quite overwhelmed... it could have gone one of two ways. I could have fallen a part and cried (honesty it was quite a lot to take in!!), but instead I thought no I have to be firm with this patient and hopefully he will walk away and get the X-ray because that’s what he needs to be safe! So I explained it all to him as well as I could and finally it ended with him saying he will take the referral and get an X-ray.. whether he did or not who knows but I feel like I did my best and hopefully he listened. I walked away proud of how I dealt with the situation and it definitely showed me how some patients can be.. however its so important for us to make it clear we are allied trained health care professionals and must follow guidelines and be safe and not be manipulated by the patient. It also taught me there are lots of characters and you never know who’s going to walk through the door..."

On reflection of the above diary entry, I demonstrated I was able to adapt my communication style throughout the consultation to best communicate with this patient and deliver the best and most appropriate care. This was important as I felt that if I had not done so, the patient would not have listened and understood the need for further medical investigation. I have learned the importance of the need to adapt communication styles to what is best for your patient.

Also, I made the decision not to assess this patient based on the information from the case history. There was enough information for my to make an informed decision that this patient was not safe toe examine. This taught me the importance of the case history to gather as much information as possible, as if I would have missed information, I could have been really unsafe. Additionally, the patient was very pressurising for my to treat. I am glad I was not intimidated into doing as the patient said. It is important to remember the difference between shared decision making and doing what the patients wants us to do against our professional opinion!

Overall, this patient experience has taught me the importance of screening for red flags and acting appropriately in regards to the management of the patient. As well as the importance to effectively communicate the process and management plan to the patient.

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

# data[].attributes.body
ChrioGeek, 2020. Back & Leg Pain. Available at: https://www.chirogeek.com/index.html [May 25, 2020]

Dubois, B., & Esculier, J. 2020. Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine, 54(2), pp.72-73.

GOsC, 2021. Complaints. Available at: https://www.osteopathy.org.uk/standards/complaints/ [April 5, 2021]

GOsC, 2018. Osteopathic Practise Standards. Available at: https://www.osteopathy.org.uk/news-and-resources/document-library/osteopathic-practice-standards/updated-osteopathic-practice-standards/updated-ops-01092018.pdf [Accessed January 10, 2019]

Internet1, 2018. Physiotutors. Available at: https://www.youtube.com/user/Physiotutors [Accessed March 10, 2018]

NHS, 2020. Medicines A to Z. Available at: https://www.nhs.uk/medicines/ [Accessed January 15, 2020]

NICE, 2021. NICE Guidance. Available at: https://www.nice.org.uk/guidance [Accessed November 7, 2020]

NICE, 2020.  Osteoarthritis: care and management. Available at: https://www.nice.org.uk/guidance/cg177 [Accessed March 15

NICE, 2019. Hypertension in adults: diagnosis and management, Available at: https://www.nice.org.uk/guidance/ng136 [Accessed May 2, 2021]

Physiopedia, 2020. Patellofemoral Pain Syndrome. Available at:

https://www.physio-pedia.com/Patellofemoral_Pain_Syndrome [Accessed December 29, 2020]

Rolfe, G., Freshwater, D., Jasper, M. 2001. Critical reflection in nursing and the helping professions: a user's guide. Basingstoke: Palgrave MacMillan.

Thomson, O. P., Petty, N. J. and Moore, A. P., 2013. ‘Reconsidering the patient-centeredness of osteopathy’. International Journal of Osteopathic Medicine, 16(1), pp. 25–32.

WHO, 2010. Benchmark for Training in Osteopathy. Available at: https://www.who.int/medicines/areas/traditional/BenchmarksforTraininginOsteopathy.pdf [Accessed October 5, 2019]

Zielinska N., Podgórski, M., Haładaj, R., Polguj, M. & Olewnik, L., 2021. Risk Factors of Intervertebral Disc Pathology—A Point of View Formerly and Today—A Review. Journal of Clinical Medicine, 10(3), p.409

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“D1. You must act with honesty and integrity in your professional practice.” (GOsC 2018 p.20)

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“D1. You must act with honesty and integrity in your professional practice.” (GOsC 2018 p.20)

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Discussion with tutor in clinic year 3:

Someone in my tutor group stated they want to try a technique on a patient because they want to practise the techniques they learned this week in class. This started a very interesting conversation about what forms a treatment plan for our patients. Our tutor said a justification for the techniques we use should not be based on what we want to do but what is best for our patient, as this would be putting our interests above the interests and need of the patient. Treatment plans should be patient centred not practitioner centred. We discussed the importance of involving our patients in the treatment plans, finding out what treatment they best respond to. Of course, this then started the discussion of the difference between shared decision making and patient involvement to not taking any responsibility and asking the patient what they want you to do, which would not be professional.

From this discussion, I have learned the importance of a patient centred approach to treatment plans, by putting the patients interests first. In the future I will try to ask myself when forming a treatment plan as to whether my patients best interests are in mind, or my own because that's the treatment plan I want to do.

'Recognising the patient-centeredness of osteopathy' (Thomson et al. 2013)

I am doing research for my dissertation. I am learning the difference between a patient centred approach and a practitioner centred approach. An article (Thomson et al. 2013) discusses the importance of practising with a patient-centred approach and questions Osteopathy's relationship with this approach.

This article has taught me the importance and meaning of practising using a patient centred approach for the benefit of my patients.

I will try and make sure i am practising using a patient centred approach, not a practitioner centred approach to accelerate the care of my patients.

Year 4 diary entry:

"A mother came in with her baby to children's clinic. She explained she wanted to come to get her baby checked out. The complaint was that her 7 month old baby was learning forward when held to stand. On examination the baby was a very well developed happy and health baby. Therefore the consultation involved reassuring the mother. I explained there was no need to come back for another appointment however explained the mother is welcome to book in if she ever has any other concerns, as I did not want the patient to feel disregarded.

On reflection,  I feel like I did the right thing by being honest with the mother and explaining that there is no need for further osteopathic treatment as it would not be justified."

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

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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.” (GOsC 2018 p.6)

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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.” (GOsC 2018 p.6)

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Year 1 clinic observation

Please see attached observation evidence.

I observed a consultation. The student asked if the patient was comfortable with fully undressing, explaining why it may be necessary. The patient was not happy with fully undressing down to his underwear as he presented with back pain. The practitioner respected the patients decision and explained why it may be helpful for the patient to take their top off and the patient was happy to do so. The student respected their patients wishes and gained informed consent. The student communicated really well and made the patient feel comfortable throughout.

This observation taught me that not all patients are comfortable with undressing down to their underwear ad it is important to respect patient preferences, as well as gain informed consent by explaining everything to the patient.

Year 2 diary entry:

"I was observing in clinic today. I observed a third year who had a take over patient. The had been receiving a very functional based (mainly cranial) treatment style. The student was not confident in cranial treatment, as she explained she did not understand the approach and could not palpate the cranial rhythm (I found this situation interesting as I also am struggling with cranial lectures). She also stated she did not want to learn this style of treatment. In the consultation the patient explained she liked the gentle approach to treatment, mentioning how cranial had really helped. The student was quite stressed as she did not want to disappoint the patient however explained she did not want to con the patient by providing an ineffective treatment due to her lack of skill and belief in that approach. However the tutor suggested keeping to the treatment plan and practising her cranial. Therefore the student accommodated her patients wishes and treated functionally.

This patient came in with certain expectations due to their previous experiences and the student decided to try and accommodate the patience wishes. However afterwards she felt very disappointed as she explained she felt like she did nothing in the cranial treatment and therefore felt like she did not effectively care for the patient. This was the first time she was asked by a patient to treat cranially so she explained she struggled with how to respond as she was in a dilemma of providing effective patient care using techniques she was confident in and meeting the patients needs.
She tried to accommodate for her patients wishes by treating functionally however she felt like her patients care was compromised as she did not feel her cranial treatment was effective as she wasn't able to feel or do anything.

Reflecting on this I feel that I have learned the importance of reflecting on whether you can accommodate to your patients wishes and if not then the importance of being open and honest to allow for the best care for that patient. The student could have explained her patients treatment options, including transferring to a different practitioner that practises using cranial. I feel like this would have provided her patient with the best and most honest care, allowing for shared decision making.

From this observation, I plan to prepare to respond to patients who request or ask about techniques that I may not chose to use when I start clinic. I will make sure to be honest (and respectful of the approach) and offer recommendations of other practitioners if they decide that is the treatment they wish to have."

Year 3 diary entry:

"I had my third patient today! I walked away from my last two patients not feeling like I did my best, however I feel really happy after this patient. The patient was a middle aged Indian lady who brought her husband along. However the patients husband was very over powering and wouldn't allow his wife to speak- even though her English was quite good so she was able to communicate with me. I could read from my patients face that she was finding it quite frustrating. I felt quite uncomfortable as of course I did not want to be rude to the chaperone however I also wanted to care for my patient and listen to what they had to say.

I felt like I handled the situation really well as I was able to allow the patient to speak for herself and direct the attention to the patient, without being rude to her husband. I could see the patients attitude positively change as the attention focused on her. I found this dynamic quite difficult however I received really positive feedback from my tutor and colleagues.

Additionally, as English was not the patients first language I had to adapt my communication skills with the patient, to ensure she understood my questions and allow me to gain informed consent. I feel like my experience living in Germany really helped me in this situation as I got quite used to communicating with people who were not fluent in English in an effective way. My tutor was really impressed with how I adapted my communication skills for this patient.

Overall, I am really proud of how I handled the consultation today and have learned a lot from this experience, mainly how important effective communication is, not only for the purpose of consent but also for the comfort, care and understanding of the patient. Also, how communication is more than just verbal, it's your body language, your facial expressions, how engaged you are etc. Lastly, I have learned how important and effective adapting my communication skills are with patients, every patient is different and its a great skill to be able to adapt communication appropriately.

Todays consultation was assessed, I gained really positive feedback on my communication, professionalism and respect."

Year 4 diary entry:

"I had a continuing patient in clinic today. I feel like we have built a good patient practitioner relationship. She forgot her shorts. I explained if she would prefer she can keep her jeans on for todays session. However she said she was fine being in her underwear. During treatment I gained informed consent to articulate the hips supine. However I noticed as I lifted the leg the patient seemed uncomfortable, therefore I asked if she was okay. She laughed and said how there used to be blankets. I stopped and apologised that there wasn't any blankets and suggested the option of not doing that particular technique if she would prefer. However my patient insisted it was fine as I am also a female and she doesn't mind.

On reflection, I was able to pick up on my patients unspoken signals and respond appropriately to make sure my patient was comfortable and gain informed consent. However, I did walk away thinking I should have thought about an alternative to a blanket, like using the couch roll or her cardigan, this could have made her more comfortable. In the future I will be sure to be more prepared in providing a replacement for a blanket when I am performing techniques that may expose patients, and rather than ask if they are ok, act upon their unspoken signals to avoid any further discomfort.

I have learnt a lot about communication with this patient. She suffers from auto immune diseases, chronic pain and anxiety. She has had to shield for the past year and is currently only leaving the house when necessary. Therefore coming to see me is one of the few times she leaves the house. She admitted to feeling quite anxious because of it. She is a creative writing student and is really passionate about literature.
I started asking about her favourite books etc and I noticed she really enjoyed speaking about it. I realised she also really enjoys being listened to, so that exactly what I have been doing: listening, asking questions and being empathetic, supportive and also just having a laugh with her to make coming to see me enjoyable.

On reflection, by listening and really getting to know my patient I have been able to create a really comfortable and enjoyable environment for my patient that she says she looks forward to every week. I have learned the importance of really getting to know my patients and making them feel special and listened to, as well as the impact we can have by providing an individualised service to our patients. I will continue to get to know my patients and show a true interest in their lives as I believe it is really important."

Year 4 FOPE Exam Feedback

Please see feedback attached.

I am really pleased with the feedback and marks I received in regards to my communication in this exam. This was our final techniques exam of the course and I am pleased to have finished with a first. I had often struggled with these types of exams just to the intense nature and unrealistic setting, which sometimes affected my overall performance. However it was nice to see I have progressed and was able to compose myself under the stress of the exam and still effectively communicate with my patient. I feel like these exams have taught us how to perform in a professional and caring manner even under high levels of stress and pressure. This is important, as however stressful the situation may be, it is vital to effectively communicate and care for patients.

Some constructive feedback from this exam in regards to my communication includes: discussing treatment options with the patient seated instead of lying on the couch. I understand this would be a more professional form of communication and I will take this feedback on board. Additionally: I should slow down a bit when communicating important information with patients to ensure they can take the information in. This is important as we want to make sure the patient fully understands and that we are gaining informed consent, so it is important the patient understands and has time to consider their options.

Overall, I will continue to communicate effectively with patients as I did in this exam. Also, I will take the constructive feedback on board to further improve my communication skills with patients in practise.

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

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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.” (GOsC 2018 p.6)

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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.” (GOsC 2018 p.6)

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Year 2 Clinic Observation

Please see attached evidence.

Year 3 diary entry:

"I had my first patient today. I was so nervous, I felt sick. Our entire group observed, I was so worried I would make a fool of myself. My tutor stayed with me the entire time so I felt supported. I was thinking more about not messing up rather than thinking about my actual patient! It was hard enough thinking about the process, that I don't think I fully engaged and cared for my patient as best as I should have. The case ended up being quite complicated, so my tutor took over. The patient was in agony and we thought it was because of a kidney infection. I did not expect this, I felt quite overwhelmed I was happy my tutor took over- where was the simple mechanical back pain for my first patient? The patient cried, my tutor handled it really well. She was really empathetic and supportive. I could see how thankful the patient was for the support and care."

On reflection of this diary entry, my nerves got in the way of my ability to effectively communicate with this patient. However I would have expected this as it was my first patient. I plan to work on my confidence and focus on the patient not my own nerves with future patients.

It was also really helpful to watch my tutor and how she communicated with the patient. She was so calm, empathetic and supportive. She explained why we could not treat her and that she needs to urgently go to the doctors so the patient fully understood. I could tell the patient completely trusted my tutor and was thankful for the support. I feel that being able to effectively communicate with patients is key in order for them to trust and cooperate with you as a practitioner.

Year 3 diary entry:

"I had my third patient today! I walked away from my last two patients not feeling like I did my best, however I feel really happy after this patient. The patient was a middle aged Indian lady who brought her husband along. However the patients husband was very over powering and wouldn't allow his wife to speak- even though her English was quite good so she was able to communicate with me. I could read from my patients face that she was finding it quite frustrating. I felt quite uncomfortable as of course I did not want to be rude to the chaperone however I also wanted to care for my patient and listen to what they had to say.

I felt like I handled the situation really well as I was able to allow the patient to speak for herself and direct the attention to the patient, without being rude to her husband. I could see the patients attitude positively change as the attention focused on her. I found this dynamic quite difficult however I received really positive feedback from my tutor and colleagues.

Additionally, as English was not the patients first language I had to adapt my communication skills with the patient, to ensure she understood my questions and allow me to gain informed consent. I feel like my experience living in Germany really helped me in this situation as I got quite used to communicating with people who were not fluent in English in an effective way. My tutor was really impressed with how I adapted my communication skills for this patient.

Overall, I am really proud of how I handled the consultation today and have learned a lot from this experience, mainly how important effective communication is, not only for the purpose of consent but also for the comfort, care and understanding of the patient. Also, how communication is more than just verbal, it's your body language, your facial expressions, how engaged you are etc. Lastly, I have learned how important and effective adapting my communication skills are with patients, every patient is different and its a great skill to be able to adapt communication appropriately.

Todays consultation was assessed, I gained really positive feedback on my communication, professionalism and respect."

Year 3 Diary Entry:

"I received my mark and feedback for my end of year clinic assessment today. I was really disappointed in the grade as I've been working so hard and thought I did well. I spoke to a tutor who knows me well, and asked what I'm doing wrong! Well, how I can improve. I knew he would be honest as he is a really experienced tutor and examiner.

He explained that exams are about learning the 'exam game' or process. He also told me not to focus on the grade. He told me he knows I work really hard and it does show. He helped me to understand its not about the grade I get, as that's just a snap shot. Its about myself as an osteopath.

It was really nice as he said the caring empathetic and communication side is something he can tell comes natural to me. Which he said is a really important part to being a good osteopath.

I really needed to have that conversation as I was really doubting myself. It was nice to hear such positive feedback about my natural communication and people skills."

Year 4 diary entry:

"I had a new patient today. We decided she was not safe to treat without a family member who knew her medical history as she had been diagnosed with dementia and was unable to answer many questions. My tutor took over and explained to the patient why we are unable to treat today and how she can rebook with a chaperone. The patient really understood and responded well.

On reflection, it was really helpful to watch my tutor communicate with this patient in an effective way. She was very sensitive to the specific needs of my patient, explaining everything in a way she could understand. She explained things in a logical way, focusing on explaining the safety of the patient and how having a family member there would help us get all the right information. Rather than stating the patient had dementia and therefore we could not treat, which I feel would have been very upsetting and degrading for the patient.

This experience has taught me the importance of communicating in a way that is sensitive to the needs of the patient."

Year 4 diary entry:

"I had a new patient today. On examination I found she had some hypermobility in certain joints which I felt may be contributing to her presenting complaint. I explained my findings to the patient in a way she could understand. At first she seemed quite concerned as to what that meant as I used the word hypermobile. I explained what a hypermobile joint meant so my patient fully understood. This reassured my patient and eased her concerns. I also explained how this may be related to her presenting complaint and how she may benefit from rehab strengthening and stability exercises. I made sure my patient understood throughout and asked if she had an questions. We discussed rehab exercises, and formulated a rehab plan my patient was happy with.

On reflection, I think I should have explained hypermobility before using the term, so the word did not worry my patient as much as I noticed it initially did. In the future I will avoid using medical terms before explaining the term first.

Additionally, I feel like I was able to communicate effectively with this patient, explaining my findings in a way my patient would understand and asking if she had an questions/ understood. This was important as if I would have simply said my patient had hypermobility without explaining, she could have left worried and googled the term, resulting in further worries and concerns. Therefore this demonstrated how important it is that your patient truly understands what you are telling them and that they don't leave with questions.

I also incorporated my patient in formulating a rehab plan, to ensure it would best suit my patient. I feel like this increased the chance of my patient engaging in the rehab programme as not only did she understand why she was doing the exercises, but she also decided which exercises would best suit her. From this case,  have learned the importance of working in a partnership with my patients, so I know they are fully on board and understanding the process as they are taking an active part in making decisions about their treatment and care."

Year 4 FOPE Exam Feedback

Please see attached exam feedback.

I received really good feedback and marks in regards to my communication in this exam. I feel communication is a vital aspect of being an osteopath and therefore try my best to communicate effectively with patients. I am very happy the examiners were happy with my communication skills. This exam feedback demonstrates my ability to effectively communicate with patients. I will continue communicating in the same effective way in practise.

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

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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.” (GOsC 2018 pp.20-22)

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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.” (GOsC 2018 pp.20-22)

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Year 2 Clinical Integration discussion:

In clinical integration today we were speaking about the appropriate way to deal with an upset/ crying patient. The tutor said she would not hug a patient as it is not professional. She said to read the situation and if appropriate a simple hand on the shoulder is a nice professional was to show empathy, as well as verbal and body language empathy, to maintain a professional boundary.

I struggled to understand how I would be able to stop myself from hugging someone who is crying, as I have only experienced people I am close to crying to me, and of course I would hug them and I would not have to be professional. However, I understand I am entering a profession where we must keep professional boundaries with patients, so it is important for me to take this advise on board and behave in a professional manor with patients.

When I start clinic, if a patient cries to me I will be sure to act in a professional empathetic way to show support without crossing any boundaries.

Year 3 Clinic Discussion:

My tutor in clinic today said she always addresses patients by their last name. This conversation started as I had a teenage patient, so said I would address them by their first name, and my tutor said I shouldn't as that's not maintaining a professional boundary. She advised me to address all my patients by there last name to set a professional boundary.

I am not sure how I feel about this discussion. I understand the importance of maintaining a professional boundary and addressing someone by their last name is definitely a good component of that. However many patients ask me to call them by their first name. I understand that I should not have said I will address them by their first name before gaining their consent, however I believe if a patient has a choice then that should be respected and there are still other ways to maintain a professional boundary.

In the future I am going to address all my patients by their last name and if asked to call them by their first name I will respect their wish. However children, I am still unsure what the best approach is. Therefore I am going to speak to some different osteopaths to ask how they approach this situation to best maintain a professional boundary.

Exam Feedback

Please see attached exam feedback commenting on my professionalism. I often receive good feedback and marks in regards to my professionalism. I will continue to be professional in practise as I understand the importance.

Feedback includes:
FOPE exam- please see 'Communication and Professionalism' section
Specialist Clinic Feedback
Clinic exam feedback

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

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“D3. You must be open and honest with patients, fulfilling your duty of candour.” (GOsC 2018 p.22)

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“D3. You must be open and honest with patients, fulfilling your duty of candour.” (GOsC 2018 p.22)

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Year 4 diary entry:

"I saw a continuing patient today. On the initial chat I asked how the patient felt after treatment. She explained how she felt a bit sore as I warned her she may experience.

On reflection, this patient fully understood the risks of treatment as I had explained them to her before she consented to have treatment. Therefore she was not surprised when she felt a bit sore after treatment.

If I would not have explained the risks to my patient, she may have turned up to the follow up appointment feeling quite annoyed and confused as to why she experienced the discomfort after treatment.

This has demonstrated the importance of explaining the risks of treatment to patients, to ensure fully informed consent is gained and prepare the patient so they are not surprised when they feel a bit sore or achy after treatment- as this is normal and common."

This reflection uses the Rolfe model of reflection (Rolfe et al. 2001).

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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.” (GOsC 2018 pp.22-23)

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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.” (GOsC 2018 pp.22-23)

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Year 2 'Respond to a letter of complaint' course work feedback

Please see feedback attached. This was a useful learning experience as I had to appropriately respond to a complaint, something which I had never done before. I received good constructive feedback. For example, I was polite and appreciative of the patients feedback; I supplied the patient with appropriate information and resources; I explained myself in a non-defensive way and fairly justified myself; I showed reflection and understanding. I learnt how to effectively respond to a complaint and will use these skills in the future if I encounter any complaints.

GOsC Complaints (GOsC 2021)

I understand the recommendations set by the osteopathic council in regards to complaints. The website states that many complaints can be resolved with the osteopath themselves unless the osteopath in question is:

"acting in a dishonest, indecent or violent way

working under the influence of alcohol or drugs

having a personal relationship with a patient

examining or treating a patient without their consent

incompetent (when an osteopath’s work fails to meet the standards we set in our Osteopathic Practise Standards)" (GOsC 2021)

If a patient asks me about how to make a complaint about myself or another osteopath I will make sure to follow the guidance set by the osteopathic council.

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

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“D5. You must respect your patients’ rights to privacy and confidentiality, and maintain and protect patient information effectively.” (GOsC 2018 pp.23-24)

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“D5. You must respect your patients’ rights to privacy and confidentiality, and maintain and protect patient information effectively.” (GOsC 2018 pp.23-24)

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Year 3 Clinic Discussion:

In clinic we were discussing when it is appropriate to break confidentiality. My tutor said he has had to do this once with a patient who would not take any help but said they were suicidal. My tutor explained how he phoned the GP as he felt in this circumstance he was protecting his patient from harm and therefore could break the confidentiality rule. I agreed and understand there are certain situations where we must break confidentiality if appropriate. I have learned the importance of confidentiality however the higher importance of protecting our patients and therefore understand the responsibility we hold to decide when we must break the rule of confidentiality for the greater good.

Year 4 Diary entry: "I have had a very interesting morning... I had a new patient who was an 81 year old lady. From the beginning it was very difficult to communicate with this patient. She was unable to tell me much about why she had come in today and information on her medical history. She disclosed she had dementia and also said she likes to drink alcohol, stating she had already drank (at 9am). We decided she was not safe to see without a chaperone, as we did not have the relevant information, as well as she fact she had drunk alcohol. Therefore we phoned her family and explained the situation. However the patient asked us not to tell her family she had drunk alcohol this morning as they would tell her off... I was in a situation of keeping confidentiality so I did as the patient asked. I also wrote this in the notes.

On reflection, I did keep patient confidentiality, as I respected the patients wishes to keep certain information from her family.
However, I did wonder whether that was the right thing to do as my patient implied she was an alcoholic. Also, as she was diagnosed with dementia does that change the rule of confidentiality? I wondered whether I should have asked more questions about my patients alcohol in take, to figure out if she was in fact an alcoholic, as I have a duty to protect her from harm and provide her with care/ support. However as my patient struggled to remember and answer many questions, becoming quite angry at times, I wonder if this would have been appropriate.

This was definitely a challenging situation, however my tutor was impressed with how I handled the situation and said I did the right thing to keep the information confidential at the request of my patient. I have learned that every situation is different and we are faced with challenging situations, however it is important to act in a professional way and base out decision off of our clinical judgement and practise standards.

Year 4 diary entry:

"I had to copy patient notes today for an exam. As I was taking the notes out of clinic, I made sure to anonymise the patients same to ensure I was keeping my patients confidentiality.

I understand maintaining patient confidentiality is really important and will continue to respect my patients rights to their privacy and confidentiality."

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

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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.” (GOsC 2018 p.25)

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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.” (GOsC 2018 p.25)

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Year 3 diary entry:

"I had a patient today who was very forward in sharing their political views and opinions which were different to mine. I did not feel comfortable with some of what the patient was saying as I did not want to have a political debate with a patient but did also not want to agree. Therefore I changed the conversation and manage to avoid discussing anything  controversial. Despite not agreeing with this patients views I understand everyone is entitled to their own opinion. I have no trouble with individuals having different views to me and would not treat a patient differently due to their views.

On reflection, I am happy with how I dealt with this patient as I was able to avoid any political debates with the patient and remained professional and did not discriminate against them due to their differing political views.
I will continue to treat all patients with equality and not discriminate against patients- I will also continue to avoid any conversations of controversial nature- like politics!"

Year 4 diary entry:

“A continuing patient of mine told me today that she has a girlfriend. She went on to explain her church has made it very clear they are not happy about her sexual preference. She really enjoys the church community but from this feels very discriminated against, I could see she was very upset about the situation. I showed empathy and support.

On reflection, I found it very upsetting that someone was being discriminated against based on their sexual preference. I could see the impact this had on my patient. I intend on never discriminating against a patient based on their personal sexual preference.”

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

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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.” (GOsC 2018 p.25)

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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.” (GOsC 2018 p.25)

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Year 1 Introduction week talk:

A member of staff spoke to us today about how we now represent osteopathy and this university and therefore have a responsibility to uphold the reputation and behave appropriately. She suggested making our social media private as well as abiding by the law and behaving respectfully in public as even when we are not at uni we are still representative of the profession.

I instantly made my social media private. However this discussion did worry me. I questioned myself as to how I'm allowed to behave. Of course, I have no worries about illegal activity but I wondered about simply going out socialising, getting drunk- can I still do that? I concluded I was over analysing it. Making my social media private gives me privacy from patients looking me up and therefore protects me. I looked up the osteopathic practise standards to better understand the expectations of the profession. I now better understand what is expected of me and will make sure to represent the profession by continuing to be a nice respectful law abiding member of society.

COVID-19 Pandemic Reflection

There are many rules because of the current pandemic. For example, maintaining a social distance from those outside of your household and not going round other peoples houses. Many people in my peer group do not have professional responsibilities, and therefore were breaking many of the rules. I found it very challenging to stick to the rules, especially when many around me were not. However I understand my professional responsibilities as an osteopath. Not only will it look bad on the profession if I am breaking the rules, but I could put my patients in danger, and have a responsibility to protect them.

I will continue to adhere to the government rules in regard to the pandemic, to ensure I am keeping myself and my patients safe and representing the profession in a good light.

DBS Check

Before starting clinic in year 3 I had a DBS check.

I am currently waiting for a DBS check to be completed, this will allow me to register with the General Osteopathic Council when I graduate.

I understand the responsibility to not find myself in trouble with the law and ensure I am applying for DBS checks when appropriate.

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

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“D8. You must be honest and trustworthy in your professional and personal financial dealings.” (GOsC 2018 pp.25-26)

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“D8. You must be honest and trustworthy in your professional and personal financial dealings.” (GOsC 2018 pp.25-26)

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Year 4 diary entry:

"A mother came in with her baby to children's clinic. She explained she wanted to come to get her baby checked out. The complaint was that her 7 month old baby was learning forward when held to stand. On examination the baby was a very well developed happy and health baby. Therefore the consultation involved reassuring the mother. I explained there was no need to come back for another appointment however explained the mother is welcome to book in if she ever has any other concerns, as I did not want the patient to feel disregarded.

On reflection,  I feel like I did the right thing by being honest with the mother and explaining that there is no need for further osteopathic treatment as it would not be justified."

Year 4 diary entry:

"I had a new patient presenting with coccyx pain. Based on the current evidence the best management for coccyx pain is a coccyx cushion and education on sitting posture. Therefore I explained this to the patient. I gave the patient the option of hands of treatment to help with pain reduction muscle tightness. The patient consented to treatment. We agreed to a follow up appointment to see if the management had helped. The patient returned the following week with significant improvement from the coccyx pillow. I therefore suggested the patient continue with the self management and did not pressure the patient to book for another appointment as I did not believe treatment would be justified.

On reflection, I recommended a product that I believe (due to the evidence and highly regarded opinion amongst colleagues) would be beneficial to my patient. I will make sure to only recommend products I feel will be beneficial to my patients. Additionally I was honest with my patient about the best management for her and therefore avoided my patient unnecessarily spending money on osteopathic treatment. I will continue to be honest with my patients and not pressure them into unnecessary treatments."

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

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“D9. You must support colleagues and cooperate with them to enhance patient care.” (GOsC 2018 p.26)

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“D9. You must support colleagues and cooperate with them to enhance patient care.” (GOsC 2018 p.26)

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Year 3 diary entry:

"I took over a patient from a year 4. The previous practitioner summarised the patients record for me. I really appreciated this level of help from the previous practitioner. It made it much easier to understand the patients case and highlighted the relevant information.

This has taught me the importance of working together with colleagues to enhance patient care. As the previous practitioner not only made my life easier by writing a summary on the patients case, but also helped to provide a high standard of care for her patient, as she wanted to make sure the next practitioner understood the patients case, needs, and management- which I believe is really important. If I ever have to handover a patient to another practitioner, I will be sure to provide the same level of care to my patient and support for my colleagues."

Year 4 diary entry:

"A member of our clinic group didn't feel very well today during clinic however had a patient. I said that I would cover her patient so she could go home and rest. She was really appreciative. We were praised for the team work seen in our clinic group. We are a really supportive good team that works well together.
I'm am really appreciative of having such a good clinic group as it has truly taught me the importance of supporting and working as a team with colleagues. Some examples of regular team work in our group includes: sending notes to each other; sharing our strengths with the group; setting up rooms if someone is busy; providing effective and useful feedback; giving each other a pick me up when needed etc.
I hope to take the team work ethic on to my life as a graduate osteopath, as I have learned the importance of working in a team to not only benefit ourselves as professionals but also the quality of care for our patients."

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

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“D10. You must consider the contributions of other health and care professionals, to optimise patient care.” (GOsC 2018 pp.26-27)

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“D10. You must consider the contributions of other health and care professionals, to optimise patient care.” (GOsC 2018 pp.26-27)

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Year 3 diary entry:

"I have noticed that there are some individuals who believe osteopathy can heal the world, and insult other professions/ the medical profession. I do not agree with this at all. I believe osteopathy has a place in health care, like many professions do. However I believe one of the most important parts of our role is liaising with other professions to best care for our patients. I would never insult the GPs as a whole as I could not imagine the stress and work load they are put under. I respect them and hope they respect me too.
I am going to continue to respect other professions and work as an allied health professional to make sure my patients are receiving the appropriate care, as osteopathy cannot always work alone."

Year 4 diary entry:

"I am seeing a patient who has Crohns, AS and fibromyalgia. She is on a lot of medication however really benefits from osteopathic treatment as well.  She was advised by her GP to start coming to an osteopath several years ago and has noticed a significant improvement to managing her symptoms.
It was nice to hear a GP recommending osteopathy and the patient seeing the benefits of both medication and manual therapy to best manage her conditions. It was nice to see how osteopathy can really work as a part of a care package for patients with chronic conditions.
I have learnt the importance of the medical professions working together to best care for our patients. I will continue to support osteopathy working as a part of multi-modal care for individuals in need."

Year 4 diary entry:

"In clinic today we were discussing the importance of giving patients their treatment options, including outside of osteopathy. This including seeking advise from the GP on possible pharmacological management. Another student was not happy about this, as they believed osteopathy shouldn't promote medications, pain relief in particular. This started a debate.
I agree pharmacological management has a place and it should be a shared decision between the patient and their medical practitioners. However I realised I had never given this option to my patients, as I did not think I was allowed to suggest medication. However there is a difference between telling a patient to take pain killers to giving them the option to seek advise from their GP.
On reflection, I have decided that I should start giving my patients more treatment options, not just explaining how osteopathy can help and giving them the choose to chose it or not, and then later on discussing referral if need be. I should outline the different types of management for their diagnosis and explain the recommended guidelines.
I realised I was not very confident on the guidelines of management for different conditions. Therefore I have started using the NICE guidelines (NICE 2021) to better understand how to inform my patients of their treatment and management options."

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

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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.” (GOsC 2018 p.27)

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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.” (GOsC 2018 p.27)

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Year 4 diary entry:

"I took some time off of clinic this term, which was decided by both myself and the clinic management team as most appropriate. My boyfriends mother unexpectedly passed away. It was just awful. I couldn't even think about uni, my head was not in the right frame of mind at all. Not only did I need time to cope with my own grief, but most importantly I had to be there to support my boyfriend.

On reflection, it was so important I took those couple of weeks off for not only mine and my loved ones own health and wellbeing but also for my patients and colleagues. I was in no situation to be at the clinic seeing patients, I would not have been able to provide the standard of treatment expected, as I needed to look after myself and my boyfriend and his family first. After having some time off I was able to come back in a better frame of mine. Although of course I was not 100%, therefore some days if appropriate I was allowed to go home, which I thought was really important as some days I was in no shape to treat patients. Most importantly, I was proud of how open and honest I was as it can be hard to talk about and ask for help, but I knew if I didn't I would just crumble and it wouldn't be fair on myself and the clinic.

From this experience I have learned the importance of making sure that I am okay. If not, the importance of being open and honest with colleagues and yourself that it is not appropriate to be in clinic and see patients, as I do not want to jeopardise the patients care."

Year 4 diary entry:

"I tested positive for COVID-19 yesterday so am having to isolate for 10 days which means I am unable to go to clinic. As soon as I felt unwell I got tested and isolated in accordance to the government guidelines.

I made sure to follow the government guidelines and isolate and get tested as soon as I felt unwell. I understand the severity of this pandemic and the responsibility I hold being a front line health care worker. I would not want to pass the virus on to my patients and colleagues and put them at risk. I feel like I have demonstrated responsibility in following guidelines and protecting my patients from my poor health. I will continue to protect my patients and colleagues health by continuing to follow government guidelines and test myself using the available lateral flow tests weekly."

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

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“D12. You must inform the GOsC as soon as is practicable of any significant information regarding your conduct and competence, cooperate with any requests for information or investigation and comply with all regulatory requirements.” (GOsC 2018 p.27)

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“D12. You must inform the GOsC as soon as is practicable of any significant information regarding your conduct and competence, cooperate with any requests for information or investigation and comply with all regulatory requirements.” (GOsC 2018 p.27)

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DBS Check

Before starting clinic in year 3 I had a DBS check.

I am currently waiting for a DBS check to be completed, this will allow me to register with the General Osteopathic Council when I graduate.

I understand the responsibility to not find myself in trouble with the law and ensure I am applying for DBS checks when appropriate.

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“C2. You must ensure that your patient records are comprehensive, accurate, legible and completed promptly.” (GOsC 2018 pp.16-17)

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“C2. You must ensure that your patient records are comprehensive, accurate, legible and completed promptly.” (GOsC 2018 pp.16-17)

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Year 3 diary entry: "It is Christmas clinic so we are having to cover patients for those who are off this week. I covered one patient today however I found the situation quite stressful. I looked at the notes before the consultation and really struggled to read them. The hand writing was very unclear which made it very difficult to comprehend. It was very frustrating as I had to waste a lot of time trying to translate the notes as I did not feel safe or comfortable going into the consultation without reading the patients notes. I ended up having to clarify many thing with the patient as I did not fully understand their case and did not feel safe without fully understanding the patients notes. It has made me realise the importance of making my notes very clear for many purposes, including for the ease of other professionals (and patients if they request!) and the safety and quality of care for patients. Going forward, this situation has definitely made me more aware of my own notes and making sure they are clear and concise for others to read and understand."

Year 4 diary entry:

"We had a discussion about note taking and what is expected in CCA. I realised I am not doing my patient notes to the best standard. I often just write a 'lower extremity neuro screen' and 'NAD' next to it for example. I realise I need to be much more precise in my note taking. This will make it much easier for others to read but to ask monitor progress and understand my notes when looking back better.

I am going to start writing my patient notes as if every patient is an exam, and then I hope with will become a natural process to me that I continue to do."

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

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“C3. You must respond effectively and appropriately to requests for the production of written material and data.” (GOsC 2018 p.17)

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“C3. You must respond effectively and appropriately to requests for the production of written material and data.” (GOsC 2018 p.17)

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Year 4 diary entry:

"I had to refer a patient to the GP last week because of her headache being post traumatic as well as some other factors we were not happy with. I therefore wrote a draft of the letter the next day and sent it to my tutor to be checked. I did struggle to write the letter alone, as this was a complex case and I was unsure of how to structure the letter. My tutor didn't end up giving me feedback until 5 days later, therefore the letter was finally sent out today, a week later. I felt bad for not providing sufficient care of my patient so I phoned them to check in and inform her of the delay.

On reflection, I feel like my patient was let down as a letter of referral was not produced in an appropriate amount of time and the patient was left waiting in pain for further investigation and help. A letter should have been sent as soon as possible, preferably the same day or next day to provide a high level of patient care. In the future, I will try my best to get referral letters sent out as soon as I can, however I understand this is harder in a student clinic as the letter has to go through many stages before being sent out. I hope this is made much simpler when I qualify and I will make sure to write referral letters as soon as I get the chance, avoiding any delays to best care for my patients.

I also struggled to write the letter autonomously, and my tutor made many changes. I therefore feel I should improve my skills of letter writing. I am going to do this by observing others when they write referral letters."

Year 4 diary entry:

"I had to refer a patient for high blood pressure. Isolated clinic blood pressure of 170/100, with no other cardiovascular signs, so we warranted a GP referral most appropriate. Therefore we decided to write a letter to the GP. However, I went into clinic today and was told the letter was only just sent off two weeks later. I was really quite disappointed and questioned my method of referral. Of course this can happen with the student clinic as the letter required signatures etc so there are often delays. However was this the best referral for the patient? We discussed as to whether we should have simply written his blood pressure reading down for him to take to the GP with him. I thought this would have been a better action plan as then the patient could have been seen the next day and appropriately investigated/ managed. However my tutor argued by using a letter we know the GP will definitely know about the blood pressure reading, as can we trust the patient will go to the GP... However I believe by writing down the blood pressure and telling the patient to call their GP straight away would have been a much more effective form of care for this patient. Of course, if we sense the patient will not go to their GP, then an additional letter would also be appropriate. I have learned that referrals should be based on clinical judgement as to what mode is best for our patient, and letters should be sent out as soon as possible!"

Year 4 diary entry:

"My patient reported in the initial consultation that her GP has suggested she may have PCOS and the need of investigation. However due to COVID my patient has been unable to book an appointment and has not heard anything from her GP.

After discussion with my tutor and the patient, we decided it would be best to write a referral letter to the GP to try and speed up the process for my patient. I wrote the letter the same day and it was sent off the next day.

On reflection, this has shown good management in my ability to produce a letter quickly and efficiently for my patient. I feel like I am improving in my understanding of how to produce and format a letter to a GP."

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

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“C4. You must take action to keep patients from harm.” (GOsC 2018 pp.17-18)

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“C4. You must take action to keep patients from harm.” (GOsC 2018 pp.17-18)

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Safeguarding Training

Please see safeguarding training certificates attached. These online courses were carried before starting clinic in third year. The courses were based on preventative safe guarding and FGM. I found them very informative and eye opening to the responsibility we have to protect patients from harm. I also realised how little I knew about safeguarding, especially FGM which was something I had never come across before. I feel like after completing the courses I am much more informed on how to safeguard my patients. I will make sure to use the knowledge I have gained from these courses and look out for any signs my patients might be at risk of harm.

Year 4 diary entry:

"I had a new patient today. She was 17 years old. During the case history she mentioned how she suffers from anxiety. Her mum also added she used to self harm. It was the first time I had experienced this type of situation. I didn't want to upset the patient but I knew I had a responsibility to follow up with questions to make sure my patient was ok and not at risk. I asked questions like how she was currently coping, how she manages her anxiety and asked if she is still in a place of self harm. Luckily my patient was managing well and received help and no longer self-harmed. She was really appreciative of me making sure she was okay and listening to her.

On reflection I am really proud of how I handled the situation to make sure my patient was no longer a harm to herself and making sure she was managing ok. I now have an important role to play to continue to make sure my patient is not putting herself at risk, since she trusted me with personal sensitive information. Of course I would approach it in a sensitive way, for example every session check in with how she has been in relation to her mental health and show care and support so she feel able to trust me and hopefully if she was at risk I would be able to notice and take appropriate action."

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

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“C5. You must ensure that your practice is safe, clean and hygienic, and complies with health and safety legislation.” (GOsC 2018 p.18)

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“C5. You must ensure that your practice is safe, clean and hygienic, and complies with health and safety legislation.” (GOsC 2018 p.18)

# data[].attributes.body
Year 4 diary entry:

"It has been a year since the beginning of the COVID-19 pandemic. We now have very efficient hygiene standards: PPE, cleaning of rooms after every patient, airing out rooms, and sanitising between patients and during appointments if appropriate. This practise is very important and has been taken very seriously since the beginning of the pandemic. However, when looking back to pre-covid times, it is quite shocking to think about the sanitation and hygiene standards of the student clinic. There wasn't always sanitiser accessible, we never cleaned the couches and the couch covers were used for the entire day! Therefore, on reflection of this OPS I would argue that we (the student clinic as a whole) and therefore myself did not appropriately apply to this OPS before the pandemic. I believe this pandemic has made many of us, including myself realise the importance of maintaining effective hygiene standards. I will therefore continue to keep a high level of hygiene standard in clinic, even post pandemic, as its vital to stop any spread of infection and provide a sanitary safe environment for my patients."

This reflection uses the Rolfe model of reflection (Rolfe et al. 2001).

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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.” (GOsC 2018 p.18)

# data[].attributes.subject
“C6. You must be aware of your wider role as a healthcare professional to contribute to enhancing the health and wellbeing of your patients.” (GOsC 2018 p.18)

# data[].attributes.body
Year 3 diary entry:

"I observed a member of my clinic group today. Her patient opened up to her and said she has been really struggling and its getting out of control and she's not sure what to do. She was experiencing a lot of stress in her life and her mental health was suffering. My colleague dealt with the situation really well. She was really supportive and empathetic. She asked some questions to ensure she was not a danger to herself. She then provided the patient with some options of how to get help and the types of help, including going to the GP for support and also the option to go to a counsellor/ therapist. The patient was really thankful and explained she didn't think about getting help as she's form the generation that they just got on with it. She seemed really thankful and I could see she really took the advise on board.

On reflection of this experience, I realised the role we can play I supporting patients, if it is out of our skill set, by guiding them in the right direction to enhance their health and wellbeing. This patient had clearly not thought about seeking help and was going to continue to suffer, so providing her with support allowed her to consider her options and (hopefully) seek the help and support she deserves.

Overall, I understand the impact mental health can have on individuals health and wellbeing. Therefore I understand I have a role to look out for patients who are struggling and point them in the right direction."

Year 4 diary entry:

"One of my patients admitted to putting on weight as he is not doing any physical activity anymore. He explained he has lost motivation since the gym had shut because of lockdown. I understand the importance of physical activity and maintaining a healthy active lifestyle and weight. I therefore decided to speak to the patient about considering other forms of exercise that doesn't involve the gym. I spoke to the patient about what his options are and what he may enjoy. I recommended Joe Wicks YouTube channel and the couch to 5K programme, as they are motivational programmes that can be done without any equipment or gym. I made sure to approach the situation in the form of a motivational conversation, not a lecture that would make him feel bad.

My patient returned the following week and said him and his wife have started the cough to 5k programme and are really enjoying it. He reported feeling better and more motivated already.

This experience taught me the impact we can have on patients by simply speaking to them about topics such as exercise and speaking to them about their options. I will continue to contribute to enhancing the health and wellbeing of my patients by providing motivation, education and options to them."

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

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“B1. You must have and be able to apply sufficient and appropriate knowledge and skills to support your work as an osteopath.” (GOsC 2018 p.13)

# data[].attributes.subject
“B1. You must have and be able to apply sufficient and appropriate knowledge and skills to support your work as an osteopath.” (GOsC 2018 p.13)

# data[].attributes.body
Year 1 diary entry:

"In class I always work with the same person as I am most comfortable with her. An assistant of the class noticed this and advised we work with a variety of people in the class to improve our palpation skills as every body is different. She explained this will help us understand what is 'normal' and not. I worked with another student that day and really struggled and they were so different in shape and size to who I normally work with. This definitely made me realise the importance of working with different students in class.

On reflection, I have learned the importance of working with a variety of people. I am going to take this feedback on board and start putting myself outside of my comfort zone and work with different student in the class to better improve my palpation skills on a variety of body shapes and sizes, and improve my ability to know what is normal or not."

Year 1 Pathophysiology Exam Results

Overall this year I have received 77% in Pathophysiology. This has demonstrated my ability to learn the course content and apply it in exams. I intend on using the knowledge I have gained in the lectures and apply it to my knowledge and skills as an osteopathic practitioner.

Year 1 Anatomy Exam Results

Overall I received 88% in anatomy. I understand the importance of osteopaths understanding the human anatomy and therefore intend to continue to work hard and learn anatomy so I can apply my knowledge in practise.

'WHO: Benchmark for Training in Osteopathy' (WHO 2010)

This document has helped me through my osteopathic training to better understand the osteopathic principles, models and contraindications to practise.

The contraindication list is extremely long, however it is very useful as it helps to break down relative and actual contraindications for different treatment approaches. I feel this is vital to know to ensure safety in practise and a good reference point to help support practise.

Year 3 diary entry:

"During treatment of a shoulder pain presentation, my patient reported chest pain. I made sure to ask all cardiovascular questions, took their blood pressure and pulses and nothing abnormal was reported or found. My tutor advised assessing the pectorals major and its insertion point onto the humerus. On examination, a patient had tenderness on the anterior humerus just below the great tubercle (where the muscle attaches), pectoral major was tender on palpation and stretch. I realised that I had missed considering the pectoralis major muscle when assessing the patients shoulder.

On reflection, I need to remember my anatomy when assessing patient, as although she did not come in presenting with chest pain (where the pec belly is located) she did have pain on the shoulder region where the pec inserts. Therefore I am going to review all of the muscles and insertions and when assessing patients I am going to be more aware of what anatomy is under my hands on palpation.

Additionally, on reflection I was able to demonstrate effective management in terms of assessing whether the patients chests pain was cardiovascular or mechanical. This was really important for the safety and appropriate management for my patient."

Year 3 diary entry:

"I asked a tutor to look at my C/D lift as I am finding it very hit and miss as to whether it is effective or not. He said I was not using enough traction and was putting my back leg too far backwards and therefore making the patient too kyphosed.

Therefore from this feedback I am going to practise my C/D lifts more, and use more traction, by leaning back to prevent my patient from being hunched over."

ChiroGeek Website (ChiroGeek 2020)

I discovered a website today which has really helped my understanding of back pain and the anatomy of the spine. I was getting quite confused as I was revising over the different types of back pain, and happened to come across this website. A doctor of chiropractics in America created the website with information for physical therapists based on updated research.

On reflection, I was getting confused when revising as I did not fully understand the mechanics and anatomy of the spine. I learned the importance for my own learning to understand the pathophysiology and anatomy of the conditions to better be able to understand the diagnosis and how to differentiate between them- for example referred and neuropathic pain.

This has impacted my future practise as I now understand the spinal mechanics and the different presentations of back pain based on the pathophysiology.

Year 3 diary entry:

"I had a patient today who had an extensive list of medications. My tutor asked me about them and I realised my knowledge on medications is lacking.

It is important to have a basic understanding of medications and actions, so I can be safe in practise as some medications have effects that may contraindicate treatment, as well as side effects which may be present in patients.

I therefore have decided to start reviewing common medications and their side effects. I am going to use the NHS website (NHS 2020) as they have a list of medications with relevant information. Additionally, when a patient presents with a medication I have not heard of, I will research it.

Year 4 diary entry:

"I struggled to make a clinical judgement today as to whether I was safe or not to treat a patient. My patient had a blood pressure of 170/100 with no other cardio vascular symptoms. They presented with lower back pain. I was aware of the NICE guidelines to hypertension (NICE 2019) which recommends assessing cardiovascular risk and investigation to target organ damage, I was also aware it was not a medical emergency that required a ambulance and that the patient simply needed to visit their GP, however what I did not know was whether I could asses or treat for their musculoskeletal complaint. My tutor was telling me to be autonomous which I found very frustrating as I had never been in this situation before and wanted some guidance. I made the decision not to treat and refer to the GP, however my tutor told me to examine to diagnose the patient.

I walked away feeling quite confused as to what the right thing to do was, as there are no guidelines as to whether its safe for osteopaths to treat or not! Its based on clinical judgement, which I was told after speaking to many tutors.

On reflection, I feel like I need to improve my clinical judgement making skills. I rely on the tutors/ guidance too much. Therefore I have decided along with my tutors to be more autonomous in clinic, to make decisions and be more confident in myself as we are soon to be on our own. I am also going to speak to tutors about what they would have done and why to better my knowledge and understanding of when its safe to treat and not in regards to blood pressure."

Year 4 diary entry:

"The last time I was home I diagnosed my dad with patellofemoral pain syndrome due to his presentation. I encouraged my dad to buy tape for his knee cap which helped. I worked on the knee for pain relief, lateral quads as they were tight, hip to increased ROM and take the load of the knee and encouraged my dad to build the strength in his medial quadricep. However my dads knee pain continued. Therefore I researched further into the knee and patella-femoral pain syndrome.

In clinic the week before I went home I was learning to assess a squat. Therefore I decided to assess my dads squat. I noticed he demonstrated increased pes planus in the foot on the side of the knee pain. He also reported increased knee pain when his shoe soles wear out. On examination I noticed increased internal rotation of the tibia and increased mobility of his ankle and foot. On assessment his ankle/foot proprioception was also worse on that side too. I concluded I wanted to better stabilise and increase proprioception of the foot/ankle to try and help the knee pain. The physiopedia page on patellafemoral pain syndrome (Physiopedia 2021) supported the link between the above signs presented in my dad and the diagnosis.

On reflection of this experience, I have learned to look more globally and the importance of understanding biomechanics and to look at what may be causing the pain. More specifically I have learned the importance to look at the feet when someone presents with knee pain. Therefore I plan to better improve my understanding of the biomechanics of the foot and how to best rehabilitate and treat the feet/ankles.

Additionally, whenever I go home I always practise on my dad because he asks me too as he wants treatment, but also because he is such a good learning tool. I feel my knowledge and skills improve a bit each time. This is an example of that."

Year 4 CEX 3 Feedback

Please see attached feedback.

Positive feedback included the ability to differentiate and support the exclusion of a vascular event. However, under exam pressure I was not confident I'm my explanation. Therefore I need to work on having confidence in my knowledge.

Developmental feedback included understanding the different types of pes planus the management. Therefore my agreed action plan is to research pes planus, learn how to differentiate between the types and learn disorders associated with pes planus.

Year 4 FOPE feedback

Please see attached feedback.

I just received my FOPE feedback. I am so happy I received 70% overall.

I generally received really positive feedback in relation to my knowledge skills and performance in the exam. I feel like I did well in this exam as I have worked really hard over the last four years.

Points I have taken on board from the feedback include: review how chrohns disease can affect tissue quality; give patient time to take in information I have given them before expecting a response.

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

# data[].attributes.headline
“B2. You must recognise and work within the limits of your training and competence.” (GOsC 2018 p.14)

# data[].attributes.subject
“B2. You must recognise and work within the limits of your training and competence.” (GOsC 2018 p.14)

# data[].attributes.body
Year 3 diary entry:

"I had a really lovely phone call from a patient today. She called up to thank me for my support and to let me know that the surgery went really well. I was seeing her in clinic for a suspected hip labral tear. She was in agony and treatment was not helping, which was really affecting her as she was a competitive kettle bell lifter and exercise was really important to her. Luckily she has private health care and we made a shared decision that osteopathic treatment was not helping so she required referral to an orthopaedic surgeon. At the time I remember feeling ashamed, like I had let the patient down by not helping her with my treatment, however the phone call today made me realise that's not the case! We have a wider role as a allied health professional. Osteopathy can only help so much and it is important to give our patients the best care available to them, and sometimes that is not osteopathy, therefore we must know our limits. The patient calling me up to thank me for all my help also showed that patients don't necessarily expect us to do everything, they just want to get better and if we can play a role towards helping them, then we are doing a great job.
This case had made me truly realise the importance of working in my limits and knowing when I need to refer on to provide the best care for my patients. I want to make sure I give the same quality of care to all my patients in the future and make sure I work within my limits and not feel ashamed if I am not the best source of care for a patient!"

Year 4 diary entry:

"It was my mock CCA today. My continuing patient was a 65 year old lady who has been coming to the clinic since her 30s. I have been seeing her since third year, treating her mainly for hip OA. She comes in every three weeks and has done for a long time. At the beginning of the appointment I asked how she was doing, she ended up crying and opening up that her hip OA is really affecting her and preventing her doing basic tasks, she was worried it will get so bad she wont be able to care for her husband anymore. I didn't feel comfortable with treating her as I do every three weeks and sending her off again to then see her in the same situation three weeks later, that isn't good enough.

I reflected on the guidelines (NICE 2020) and decided to discuss with my patients other options of care, such as speaking to a surgeon about a hip replacement, as osteopathic care did not seem to be doing enough for this patient. She agreed so I wrote a referral letter.

Reflecting on this, I felt like I did the right thing today as I noticed my limits of helping this patient. However, this is the first time I had ever spoken to this patient about the option of referral for a hip replacement and I have treated her almost every three weeks for a year. Therefore I feel like I could have given my patients her options of treatment and spoken about her options earlier on. Going forward, I have learned that it is important to make your patients aware of their treatment options and the importance of working within my limits, which although I did do today, I wonder if I could have helped refer this patient on before now- so in the future I will work more on reflecting on whether my patients are getting the best treatment from me and allow patients to be apart of that shared decision making process."

Year 4 diary entry:

"We are coming to the end of year 4 now, it is crazy to think I am going to be a qualified osteopath soon- well I hope so! Today really showed me I am learning to work within my limits and know when to refer on to best meet the needs of my patients.

I have been seeing this 18 year old patient for a few weeks now, it has been quite a complex biopsychosocial complaint, therefore I was doing a lot of research and speaking to different tutors to make sure I fully understood this patients case and how I can help. The musculoskeletal complaint was improving with treatment and the patient was really thankful.

However she came in last week in agony, stating her entire body is in pain and how tired she is. She also suffers from quite bad anxiety and her sister has fibromyalgia. She also explained having morning stiffness lasting around half an hour (I understand inflammatory conditions are generally longer than half an hour however I was still not completely happy as it added to a bigger picture). She said this was quite common for her and was investigated when she was 13 but was told she has hypermobility (although she did not present as hypermobile?) and was discharged without any support- which had clearly affected her, I really noticed how appreciative she was for my care and time spent explain everything it her and helping her. This made it quite hard for me to deny treatment as I knew she was in so much pain and really wanted some help, however I noticed my limits and safety boundaries- I am not sure what is causing her pain therefore I am not safe to treat!

On examination she had widespread pain on palpation and overall weakness in the entire lower extremity- however this was not myotomal but widespread with no other neurological signs. Due to the complexness of the case and being unable to make a clear working diagnosis, it was evident I had to refer this patient and she required investigation into her complex chronic pain presentation. Today I phoned her up to check in and let her know the referral letter has been sent. She was very appreciative for the support, and said she was prescribed painkillers by A&E which were helping.

On reflection, I was worried I was letting the patient down by not providing momentary pain relief however I need to understand I have to be safe and what I did was the right thing to do for my patient and my own protection as a practitioner. And even though the patient did not get hands on treatment, she was so thankful we had spent the time and effort making sure she was getting the treatment and investigation she deserves.

Therefore I will continue to know my limits, seek advise and help from colleagues and know when to refer on when the situation is out of my competence as a practitioner."

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

# data[].attributes.headline
“B3. You must keep your professional knowledge and skills up to date.” (GOsC 2018 p.14)

# data[].attributes.subject
“B3. You must keep your professional knowledge and skills up to date.” (GOsC 2018 p.14)

# data[].attributes.body
Physiotutors Youtube Channel (Internet1 2018)

I have discovered a really helpful YouTube channel which uploads up to date videos with information on the most up to date research.

I feel it is really important to access information from  wide variety of reputable resources to improve my engagement to learning. I am finding learning through YouTube a really useful tool.

I have set a goal to go through all the channels videos. I am going to try and watch a video a day.

OPS (GOsC 2018):

The osteopathic practise standards have been updated and will apply in 2019. Therefore this gives me time to read and understand the new regulations to ensure I comply to them in the teaching clinic.

Maitland's Mobilisation Lecture

Today in techniques we learned about Maitland's mobilisations, which are the different types of articulations which have different aims. The lecturer explained the importance of writing the different grades in our notes so our notes are clearer as to what we did and what the aims of our treatment were.

I found this really interesting as I have often questioned what we are actually doing with osteopathic techniques! I realised I didn't fully understand the aim of treatment and how to apply different techniques for different aims. I believe its really important to have a grading system like this for the clarity and understanding of notes when read by other practitioners, including outside of osteopathy.

I am going to start using the theory when treating patients and also make sure I record the grade of mobilisation in my notes to improve my note keeping.

Barefoot talk: Red flags
Year 4 diary entry:

"I attended my first barefoot talk today. It was on red flags for lower back pain. Funnily enough I was really excited because, well I like things black and white, I like to follow rules, and I thought this would provide me with a perfect algorithm to know when to refer. But of course it wasn't. It actually made me realise that our job isn't black and white at all. Its all based on clinical judgement, on gathering information and deciding what's best for that patient.

Sadly it made me realise that people do miss things, it happens a lot because its so easy to do. It taught me the importance however of staying up to date and informed on red flag signs and monitoring my patients. A lot of the time we just ask the red flag questions on the initial consultation, so what about the patients that have been coming regularly for years? Its important to keep the red flags at the front of our minds so we don't miss anything- it could be life or death for that patient!

I attended this barefoot talk to help keep my knowledge up to date and learn from someone really experienced and knowledgeable. I really enjoyed it and will definitely attend more barefoot talks."

Year 4: Lumbar Disc Herniation Presentation

Please see attached the presentation and feedback.

I received really good feedback on this piece of work. From this piece of work I have learned a lot about the presentation, management and treatment of disc herniations. I will take the knowledge I have gained from this project into clinic with me.

Risk Factors of Intervertebral Disc Pathology (Zielinska et al. 2021)

I found this 2021 review on the risk factors of disc pathology, when researching for the presentation. The review elaborated on the multi-causative risk factors of disc pathology, including genetic risk factors. What I found most important to help guide my practise was the non- genetic risk factors. The review summarised that the non- genetic risk factors usually accelerate the process of degeneration and therefore proposed preventative methods, such as: having a healthy BMI and avoiding smoking.

From this review, I have learned the preventative methods to best delay the chance of disc pathology. I will therefore try to educate my patients on these risk factors and encourage such behaviours. I will also use the risk factors to help with my diagnoses.

Barefoot talk: AS
Year 4 diary entry:

"There was a barefoot talk yesterday on Axial Spondyloarthropathies. I am so glad I decided to attend because it really taught me a lot. I not only realised my knowledge was quite poor on AS, but also there are some outdated views that are still taught- for example, AS is much more common than we think and unfortunately takes a long time to diagnose! Also, it is not more dominant in men but rather equal amongst men and women, and unfortunately many women are misdiagnosed with fibromyalgia.

I found the talk really interesting and definitely learned a lot. It made me realise the important role we have as primary health care practitioners to be informed on these conditions and be able to spot them to allow our patients to get the right care and support, as well as the important role we can also play in helping to treat these patients manage their symptoms."

PEACE AND LOVE article (Dubois & Esculier 2020):

This article explained the new management for soft tissue injuries in the acronym of 'peace and love', which explains not only the initial management but also the rehabilitation post the sub-acute phase. I found this approach to soft tissue much more helpful in the long term management, as the other soft tissue acronyms (for example RICE) only address initial protocols. It was also interesting that this new approach suggested the avoidance of ice and anti-inflammatories. I have struggled with the on going debate of whether ice is useful for soft tissue injuries. This article discusses the importance of inflammation for repair, as well as the lack of evidence to support the use of cryotherapy.

I found this article really useful as it supplies clear guidance. I will therefore address my patients who present with soft tissue injuries with this approach as it is the most up to date management of soft tissue injuries.

Year 4 diary entry:

“A tutor asked me to quote the guidelines for frozen shoulder today. I was not confident in my answers. He advised that I revise the guidelines on common musculoskeletal presentations to inform my practise.

As allied health professionals I understand I have a duty to know and practise in accordance to up to date guidelines to best support the care of my patients. I realise I am not aware of all of the guidelines and therefore risk misinforming my patients, and not giving them the best treatment.

I will ensure i am up to date and confident in my knowledge on the common musculoskeletal diagnoses NICE Guidelines (NICE 2021).”

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

# data[].attributes.headline
“B4. You must be able to analyse and reflect upon information related to your practice in order to enhance patient care.” (GOsC 2018 p.14)

# data[].attributes.subject
“B4. You must be able to analyse and reflect upon information related to your practice in order to enhance patient care.” (GOsC 2018 p.14)

# data[].attributes.body
Year 1 Reflective Write Up Assessment Feedback

Please see attached feedback.
This piece of work involved reflecting on my personal development over year one as a student osteopath. I received good feedback in regards to my reflections.

Year 3 diary entry:

"I have really been struggling with my confidence recently. I don't feel good enough and keep beating myself up and worrying about everything. A colleague in my clinic team noticed I am really harsh on myself and has told me it is a really bad way of reflecting because its not doing anything about the situation- I'm just making my self feel worse and its a vicious cycle! She has told me to start reflecting in a more positive way. A way that will help, not make things worse.

I really needed this support from my friend to get me out of this negative self doubting cycle. I realised how I was reflecting was not effective. It was over analysing my every move and worrying about the silliest of things which has just been making me an anxious worrying mess! I know i am a very reflective person, which is really good, if done correctly!! Which is the most important lesson here.

Moving on from this I have set myself a goal of improving the way I reflect to improve my confidence and development as an osteopath. I will write down the event and write down what i did well, and what I could improve on and then an action plan to better improve myself. Then instead of focusing on the negatives, I will focus on the action plan!"

Exam Feedback- Year 3 Clinic exam

Please see attached throughout this document exam feedback over the four years of this course. I make sure to read my exam feedback and reflect on how I can improve, as displayed throughout this document.

I sometimes struggle with feedback as I work hard and always want to get a good grade. An example of this was my end of year 3 clinic exam. I thought I did really well so was shocked to be marked at 54%- I felt embarrassed, like i had let myself down. Before reading the feedback I cried and could not understand why I was marked so low. I emailed the examiners asking what I did wrong as I didn't understand, I couldn't accept or understand the feedback on the mark sheet. The examiner helped me understand the feedback. After listening to the feedback I better understood what I did that prevented me from getting a higher grade. I was quite tunnel vision in my diagnosis.

On reflection, I feel I was too quick to get upset and in denial about my grade. I often feel like grades define me, and put pressure on myself to get top grades. This experience has taught me to listen to feedback, as it may help to understand how to improve. I am going to try and focus on the feedback from exams rather than just the grades. I need to learn that grades do not define me, but rather feedback will help me improve and develop as a practitioner.

Year 4 diary entry:

"In order to improve myself as an osteopathic practitioner I have been making regular diary entries reflecting on my clinic and osteopathic teaching experiences, as well as asking for regular feedback from both colleagues and tutors. I make sure to read and understand the feedback in order to learn and better myself from it.

This has been a really significant part of developing myself as an osteopath as I am always reflecting on my actions and how I could do better. This motivates me to work hard and be the best practitioner I can be. I used to just focus on my grades not the actual feedback, as well as shy away from asking for colleague and tutor feedback as I was nervous to be criticised. However, I realised this was not an effective way of developing and improving and becoming the osteopath I want to be. I have noticed a significant difference in my confidence and development since reflecting more.

Additionally, I have made sure to reduce the negativity in my reflections. It is very important to reflect and think of how I could have done it differently, but not focus on that aspect and beat myself up. Rather except it happened and look at is as a learning experience and plan how I am going to not let it happen again. This outlook has significantly helped my self confidence as a practitioner, as reflections should be a positive way of developing myself, not a way to make myself feel useless.

Overall, I have learned the importance of being reflective to help with my development as an osteopath. I will continue to be reflective and write a diary into my professional career outside of the university, as I have seen the significant improvements it has made on myself as a practitioner."

Year 4 CEX 3 Feedback

My result was changed from 60% to 55% as my examiner reflected on the exam and decided I did not fit into the above box on my shared decision making. I was initially disappointed but decided to ask for further feedback as why he changed my mark and how I can improve.

He explained as I did not understand how to examine the difference between static and dynamic pes planus and therefore could not explain the management for my patient to allow for shared decision making. Instead of getting upset and focussing on the grade, I took the feedback on board and understood my examiners reasoning. I am going to learn how to differentiate between static and dynamic flatfoot and the appropriate management for the different types.

On reflection, I feel like I have displayed my development in focusing on understanding my feedback, rather than the grade. I have learned the importance of listening and understanding my feedback and acting on it to improve my patient care.

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

# data[].attributes.headline
“A3. You must give patients the information they want or need to know in a way they can understand.” (GOsC 2018 p.7)

# data[].attributes.subject
“A3. You must give patients the information they want or need to know in a way they can understand.” (GOsC 2018 p.7)

# data[].attributes.body
Year 1 diary entry:

"The lectures have been very hot on the topic of consent. We are learning a lot of medical terms however have been told to continue using the layman's terms when practising to prepare for clinic as patients of course will not understand words like 'scapula' or 'clavicle'. Therefore when I practise I am going to use the layman's terms when communicating with my 'patient'."

Year 2 Clinical integration exam feedback

Please see attached feedback.

In this feedback the examiner commented on: good communication skills, providing the patient the opportunity to ask questions, warned patient tests may be provocative and informed consent was gained throughout. The examiner suggested the need to explain the risks and benefits of treatment.

Overall I am really happy with this feedback showing my ability to communicate effectively with the patient, giving them the appropriate information. However, I must remember to explain the risks and benefits of treatment. My action plan from this feedback is to review the risks and benefits of treatment to ensure I can provide the right information to my patients.

Year 4 diary entry:

"I am currently preparing for my CCA mock exam. I have been reading the marking criteria and I have realised I am not fully explaining everything to my patients and giving them all of their options. I do not regularly offer my patients a chaperone and I do not always give my patients all of their treatment options.

On reflection, I feel like I struggle to remember to say everything to the patient and feel like they will think I am wasting their time, however it doesn't actually take as long as I think and it is vital part to make sure I am adhering to the OPS. It is really important I start making these a regular part of my conversation with patients as it is important to give my patient their options to allow for the best informed consent and shared decision making.

I have also learned I am not fully informed on all of the treatment options for different diagnoses and therefore plan to start researching alternative treatments to osteopathy (in accordance to the guidelines) so my patients are fully informed before they consent to treatment."

Year 4 diary entry:

"I saw a continuing patient today. On the initial chat I asked how the patient felt after treatment. She explained how she felt a bit sore as I warned her she may experience.

On reflection, this patient fully understood the risks of treatment as I had explained them to her before she consented to have treatment. Therefore she was not surprised when she felt a bit sore after treatment.

This has demonstrated the importance of explaining the risks of treatment to patients, to ensure fully informed consent is gained and prepare the patient so they are not surprised when they feel a bit sore or achy after treatment- as this is normal and common."

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

# data[].attributes.headline
“A4. You must receive valid consent for all aspects of examination and treatment and record this as appropriate.” (GOsC 2018 p.7)

# data[].attributes.subject
“A4. You must receive valid consent for all aspects of examination and treatment and record this as appropriate.” (GOsC 2018 p.7)

# data[].attributes.body
Year 1 GOT exam feedback

Please see attached feedback.

I received 100% in the GOT exam. I am so happy. I worked really hard for this exam.

Feedback included excellent consent gained throughout. I am going to continue to use this level of consent gaining in my future exams and practise.

Year 3 diary entry:

"I was talking to a member of staff today. She explained how important it is to get used to obtaining informed consent as so many practitioners are getting into trouble because of not explaining things to patients and therefore not gaining consent. She explained how many of her friends, who qualified a long time ago admitted to not gaining informed consent in adherence to updated guidelines.

This conversation taught me the impact not gaining informed consent could have on my career! It could end it, or at least lead to complaints and investigations. It also taught me the importance of staying up to date with guidelines, as they do change, and we are expected to know and adhere to them.

I am going to start asking tutors to watch my consent to ensure I am gaining appropriate informed consent from my patients. Also, I am going to make sure I keep up to date with the guidelines to ensure I continue to obtain informed consent throughout my career."

Year 4 diary entry:

"I had a lovely patient today. I treated her when she was pregnant, then her new born baby and today her post pregnancy. I have a really good relationship with her. She presented in clinic today with coccyx pain. Therefore I wanted to examine her coccyx and pelvic floor. I explained the process fully and gained informed consent and also due to the area being intimate also asked the patient to sign a consent form. I am really happy with the standard of my consent today and understand it could have been very easy due to how open the patient is to have not maintained the standard I did. This experience taught me the importance of consent and how no matter how good your relationship with a patient is, the standard of consent must still remain high. I will continue to keep the standard of my consent high to protect my patients and myself."

Year 4 FOPE Exam Feedback

Please see exam feedback attached.

I received very good feedback in this exam in regards to my ability to gain informed consent. I understand the importance of gaining informed consent and therefore make sure I explain everything to my patient in a way they will understand, and give them their options so they can make an informed decision. I am pleased the examiners saw my ability to gain informed consent. I will ensure I maintain a high standard of gaining informed consent in practise.

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

# data[].attributes.headline
“A5. You must support patients in caring for themselves to improve and maintain their own health and wellbeing.” (GOsC 2018 p.10)

# data[].attributes.subject
“A5. You must support patients in caring for themselves to improve and maintain their own health and wellbeing.” (GOsC 2018 p.10)

# data[].attributes.body
Year 2 diary entry:

"I was observing in clinic today and we had a really interesting discussion. A tutor was explaining to us the importance of not only treating patients in the treatment room but also supporting them in looking after themselves outside the treatment room. He explained that patients see us for half an hour, and there are plenty of half an hours they don't see us. He explained our job is so much more than just treating them in that half an hour. We have a responsibility to support their lives, their wellbeing outside of the treatment room- that's how we can truly help our patients.

I found this conversation really interesting and important. It made me realised osteopathy is more than just treating tight muscles and stiff joints, it is about supporting patients to live a healthy happy life. As allied health care professionals we have a responsibility to support our patients in caring for their health and wellbeing outside of the treatment room. I feel like we can have a much bigger impact on patients lives if do this.

I am going to remember this conversation and try and take this advise with me when I start treating patients next year."

Year 3 diary entry:

"I have taken over a patient who has been coming to the clinic for years. She had multiple files. She is a lovely elderly lady who is riddled with arthritis. She is very overweight. I have been seeing her for a couple of months now. She comes every three weeks for a treatment. I know that this patient would benefit from losing weight and moving more, however I have found it quite hard as to how I would communicate this to my patient without being offensive.

On reflection, I have let my own worries about offending the patient potentially effect the quality of care I have given her. I understand why I felt this way, as it is a sensitive topic, however if it is approached in a professional and sensitive way, it doesn't not have to be offensive. It could actually really help the patient.

From this reflection, I am going to speak to tutors about how they would approach weight with patient so I am best prepared. I am going to try and support this patient to improve her own health and wellbeing, as I feel like this would be a significant factor in helping to improve this patients quality of life."

Year 3 diary entry:

"It was the last day of summer clinic today. I discharged a patient I have been seeing for the last few months because she came in pain free and was really positive to continue with her rehab/ lifestyle advise. I have been treating her for TOS with lower brachial plexus involvement. My patient was a very stressed lady who held a lot of muscular tension. Treatment involved not only hands on passive treatment but also most significantly supporting the patients wellbeing- listening to her and her worries and providing self care, such as simply taking time for herself (having a bath to relax) and trying yoga and deep breathing exercises to help destress and look after herself. I found this the most effective aspect of treatment, as the patient gradually felt less stressed and happier in her self and her pain continued to decrease. It was very evident that she really appreciated the support and knew she needed relaxation but almost felt guilty for it, so was happy to be 'prescribed' self care.

On reflection, I feel like without addressing my patients stress management she would not have improved as significantly. This case has highlighted the importance of taking a patient centred (putting the patient first, not the ego of the practitioner) approach to treatment. Osteopathy to me is not about just passively treating the patient, its so much more than that.  I have seen the effectiveness of working with a biopsychosocial approach. I feel like this aspect is sometimes missed, I have been very focused on what I can do for my patients in the treatment room- which is of course still important! However, we can also do so much more in supporting them outside the treatment room, giving the advise, rehab, motivation etc. to maintain and live a happy healthy lifestyle.

Therefore I will now approach everyone of my patients in a biopsychosocial patient centred approach, encouraging them to take an active approach in their care and giving them the support and knowledge they need to do this!"

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

# data[].attributes.headline
“A6. You must respect your patients’ dignity and modesty.” (GOsC 2018 p.10)

# data[].attributes.subject
“A6. You must respect your patients’ dignity and modesty.” (GOsC 2018 p.10)

# data[].attributes.body
Year 1 diary entry:

"I observed in clinic today. The patient of the student I was observing undressed down to his underwear. The student asked if the patient could undress down to his underwear or gave the option of wearing shorts, keeping his trousers on or having a gown. We left the room whilst the patient got undressed. I noticed that the student used a blanket to cover the patients pelvic area throughout the treatment. This was especially important as the patient was wearing baggy underwear and the student was doing techniques which involved moving his hips.

I feel like the student really protected the modesty of the patient by using a blanket. I also thought the student gained informed consent in regards to the patient undressing, so they did not feel like they had to undress to their underwear.

Overall, this observation has taught me the importance of preventing the patient experiencing any discomfort, as they are in a vulnerable situation and it is important to provide patients with their options instead of just asking them to get undressed."

Year 4 diary entry:

"I had a continuing patient in clinic today. She forgot her shorts. I explained if she would prefer she can keep her jeans on for todays session. However she said she was fine being in her underwear. During treatment I gained informed consent to articulate the hips supine. However I noticed as I lifted the leg the patient seemed uncomfortable, therefore I asked if she was okay. She laughed and said how there used to be blankets. I stopped and apologised that there wasn't any blankets and suggested the option of not doing that particular technique if she would prefer. However my patient insisted it was fine as I am also a female and she doesn't mind. On reflection, I did gain informed consent however reflecting on this OPS I am not sure I fully respected my patients dignity and modesty. I had never been in this situation since not having blankets in the treatment room. Although there are no blankets, on reflection I could have offered the use of couch roll or her jumper. Therefore in the future I will better act on patient cues of discomfort and fully respect their modesty and dignity."

Year 4 diary entry:

“During todays consultation with my continuing patient, I asked my patient if she would mind taking her T-shirt off, and explained why. She admitted to not wearing an appropriate bra, and asked if she could just pull her t shirt up so i could see her back. Of course I respected my patients wishes.

This was important as i made sure to respect my patients modesty and work around the situation to still provide a high standard of care.

I will continue to respect my patients wishes and work around the situation, as i would never want to make a patient feel like they have to get undressed if they do not want to.”

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).

# data[].attributes.headline
“A7. You must make sure your beliefs and values do not prejudice your patients’ care.” (GOsC 2018 p.11)

# data[].attributes.subject
“A7. You must make sure your beliefs and values do not prejudice your patients’ care.” (GOsC 2018 p.11)

# data[].attributes.body
Year 3 diary entry:

"I had to refuse treatment to a patient today and terminate the consultation very early on. I was covering for a colleague and the patient made it very clear straight away he was not happy about it- although he said he was verbally... When I was asking the patient some questions he got very aggressive and clapped in my face, saying I should have read his notes and he shouldn't have to answer questions!

I was quite overwhelmed and quickly left the room. I got quite upset as for the first time I felt quite threatened by a patient. I conformed with OPS A7 as I denied a patient for being aggressive. Which I believe was really important as we must protect ourselves as we can be very vulnerable when alone in a room with patients, so its important to use our instincts and know when we have to protect ourselves from harm. However, as this is a student clinic my tutor was able to deal with the patient and ask them to leave. This made me question what I would do if I was on my own... how I might deal with a patient, what I would say as I was so upset I don't think I could have spoken to them.
This is the first time so I understand it was a shock and perhaps I will get more confident in this...

However from this experience I have learned to be very careful and keep a very professional barrier between myself as a practitioner and my patients and if I ever feel uncomfortable the appointment should be terminated. I have also learned that I would like to work in a clinic with others, so I am never alone in these types of situations and therefore am protecting my safety as a practitioner."

Year 4 diary entry:

"On Wednesday evening in clinic, I had a new patient. I’m not too sure where to start... It was a very useful learning experience for me. The patient was a 26 year old male who was a very big character. He had ADHD. He was very loud, spoke a lot and wasn’t afraid to say how he felt.

He presented with back pain. There were many red flags in his presentation, including: a recent trauma to the back, constant pain and night pain. He also said nothing relieved the pain and admitted to taking 5 paracetamol the night before due to the 10/10 pain.

From the presentation we were not happy to treat due to the red flags for a potential spinal fracture, so wanted to refer the patient for an X-ray. I knew this would not go down well, as it was clear in the case history he didn’t know what an osteopath was and had just come to be treated, not answer lots of questions.

He did not respond well to what I had to say... he wouldn’t stop talking, saying he didn’t need an X-ray, it was a waste of his money- he shouldn’t have to pay, he knows he just needs treating and its a muscle problem... It was hard work and I was quite overwhelmed... it could have gone one of two ways. I could have fallen a part and cried (honesty it was quite a lot to take in!!), but instead I thought no I have to be firm with this patient and hopefully he will walk away and get the X-ray because that’s what he needs to be safe!

I explained it all to him as well as I could and finally it ended with him saying he will take the referral and get an X-ray.. whether he did or not who knows but I feel like I did my best and hopefully he listened.

I walked away proud of how I dealt with the situation and it definitely showed me how some patients can be.. however its so important for us to make it clear we are allied trained health care professionals and must follow guidelines and be safe and not be manipulated by the patient. It also taught me there are lots of characters and you never know who’s going to walk through the door..."

On reflection of this diary entry, this patient's personality was quite challenging however I feel like I was able to still deliver the same quality of care and not discriminate. I can imagine many people would have struggled with that patient- I definitely did! He would not listen and thought he knew best, it was very challenging for me to effectively communicate and try to make the patient understand the need for referral. However I tried really hard to make the patient understand, as I thought it was important he got the care everyone deserves.

I could feel my own opinions and judgements of this patients nearly affecting the quality of his care. However I knew that this patient, like every other patient, had come for my help and I wanted to deliver the best care I could to help him. So I put my judgements a said and tried my best to provide a high quality of care for this patient, as I do with all my patients.
I have learned from this the importance as a professional to put all my pre judgements and opinions of patients aside and provide the same high quality service I do with all my patients.

These reflections use the Rolfe model of reflection (Rolfe et al. 2001).