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

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

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A 1.2. You should be alert to patients’ unspoken signals; for example, when a patient’s body language or tone of voice indicates that they may be uneasy, experiencing discomfort, or anxious and vulnerable.

A 1.3. Patients will come to you with different experiences and expectations. You should try to accommodate their wishes as much as you can without compromising the care you can provide. If you cannot accommodate their wishes, you should explain why you are unable to do so.

This reflection has been carried out using Rolfe et al. (2001) reflective model.

WHAT?
My continuing patient was a 51 years old man. He presented with upper cross syndrome and group somatic dysfunction of T4-T8. He used to come every three weeks, so I had plenty of techniques that I was using to influence different structures. Although, every time I started with soft tissue work on his trapezius and erector spinae muscles, other techniques varied depending on the day and my examination findings.

During the second appointment, I mentioned to him that he could benefit from a spinal manipulation using a high-velocity thrust (HVT) technique. I explained to him the process, mechanism and risk factors of the technique. Although, he was not completely comfortable with what he heard about the technique, he was willing to try. I asked one more time if he was sure about proceeding, to gain his informed consent. During the next session, he mentioned he did not feel comfortable after I performed the HVT technique and asked me not to use it again.

Another time at the end of the appointment he asked me if next time I could use a stretching technique, I used to do on the top of his back. He said he really enjoys and benefits from having it done. I was not quite sure what technique he meant, but I told him that I would think about it. I mentioned that I still need to think if that technique is still an appropriate one to use.

SO WHAT?
Accommodating that patient’s needs and addressing his fears helped me creating a better patient-practitioner relationship. Those situations showed me how important it is to communicate with patients clearly, explaining to them everything. I was really happy that my patient felt comfortable with telling me what he likes and what he prefers not have done during the appointment.

NOW WHAT?
I will keep reminding them that they always can ask me to change the technique I am using or even stop me during the treatment. I will always make sure that my patients feel comfortable during the appointment and I will try to address their expectations. If they are difficult or impossible to meet, I will clarify why and ask the patient to come up with more realistic treatment goals.

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

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

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WHAT?
In the children’s clinic, I was treating a baby, whose parents were foreign. Judging by their accent and their surname, I was able to guess the country they were coming from. At the beginning of the appointment, I asked them if I was correct guessing their country of origin, as it was probably the same as mine. After confirming my speculations, I explained to them that my tutor would be popping in and out during the appointment, so we cannot speak mother tongue when then the tutor is in the room. They understood that and were happy to proceed in English. However, during the case history, I noticed that probably not everything was clear to them, as they asked me to rephrase some questions. The baby’s father always wanted to make sure that he understood everything correctly, repeating what I said. When the tutor left the room I asked the parents if they wanted me to clarify in our mother tongue anything we discussed in English. They did admit that not everything was clear to them.

When I went back to the team room, I shared my thoughts with my tutor and she advised me to use our mother tongue with the parents. By doing so, I was able to gain informed consent for different parts of the appointment and various techniques. However, whenever the tutor was coming to the treatment room, we were switching to English.

SO WHAT?
I am glad I noticed some language barriers when talking to the parents in English and that they admitted that not everything was clear to them. Therefore, we were able to change the way we were communicating. When speaking our mother tongue, the mother of the child became more present in the conversation, asking more questions, as she did not feel comfortable doing so in English.

NOW WHAT?

I will try to keep asking my patients if they understand everything I say. I will rephrase my questions or explanations if they patients are not sure what I meant. If there is ever a language barrier, I will try to use simple words or possibly even translator. If that will not work, I will probably need to refer the patient to a different practitioner that can communicate with them clearly.

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

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

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A 3.3. If you propose to examine or treat a patient who has difficulty communicating or understanding, you should take all reasonable steps to assist them. For example, make use of an appropriate interpreter if the patient communicates in a different language to you. If you are unable to communicate sufficiently with the patient, you should not treat them.

The situation I am presenting refers to the same foreign couple, as in the OPS A.2., described above.

WHAT?
During the case history and examination, I noticed that mostly the father of the child was speaking and integrating with me. Although, the mother was listening actively, she was not really engaged. Even when questions were addressed to her, it was her husband replying to them. It made me think that either he was controlling without letting her having a say in their marriage or maybe she was just not feeling comfortable speaking English. Therefore, I asked the same questions in our mother tongue and then she replied to them all. After that, she kept asking questions when something was not clear to her. Speaking our mother tongue, she definitely opened up and was sharing different stories from the baby’s first weeks. I was happy that she became much more comfortable and engaged in the conversation, as I stopped thinking about any abusive behaviour coming from her partner.

SO WHAT?
That situation showed me how important it is to fully understand your patients and for them to be able to comfortably share their experiences. My understanding of the situation and family dynamic would be completely different if I had not managed to speak directly to the mother of the child.

NOW WHAT?
Informed consent is extremely important and practitioners should always make sure that their patients know what they agree to. Therefore, if I was not able to communicate with my patients clearly and if there was any language barrier that cannot be overcome by asking someone to translate during the appointment, I would decide not to treat that patient. It would be for their benefit, which they should understand.

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

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

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WHAT?
A 34-week pregnant woman came to see me, complaining of low back and pelvic girdle pain. Although, she spoke good English, she was foreign, so I must have been aware of the language I was using. Throughout, the appointment I kept asking her about her comfort and pain levels. For the examination and treatment purposes, I needed to contact her buttocks, thighs, groin and pubis. I made sure that she fully understood what I asked her to do and that my explanation of the process was clear. I told her that she could keep her leggings on and if anything was uncomfortable for her, she could always stop me from examining further. After a successful examination, I described which treatment techniques I would like to use and their mechanisms. I also mantioned what changes in her body I would like to achieve at the end of the session. I addressed all her questions and made sure she was satisfied with my answers. For each part of the appointment and each contact/technique, I gained hers informed consent.

SO WHAT?
Different areas can be very sensitive to some patients, usually they include buttocks and thighs. Palpating an intimate area such as the pubis and groin can be really uncomfortable and feel inappropriate. Although, my patient did expect to be examined, she was surprised by how thorough the process was. Additionally, I asked if she would like to use a blanket or a jumper to cover any parts of her body that she did not want to be exposed.

NOW WHAT?
I am happy that I addressed all my patient’s questions and thought about offering a blanket for her exposed body parts. However, in the future, at the beginning of the consultation I should include information about a chaperone that can be present in the room if the patient wishes to have one. I should practise verbalising the formulae, because asking for consent to examine or treat intimate areas still causes me problems and slight embarrassment.

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A5. You must support patients in caring for themselves to improve and maintain their own health and wellbeing. (Evidence 1)

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A5. You must support patients in caring for themselves to improve and maintain their own health and wellbeing. (Evidence 1)

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WHAT?
A continuing patient of mine, who is 48 years old, struggles with weight loss and anxiety. Additionally, he lost his job due to the COVIS-19 pandemic and is unemployed since then. Due to his anxiety, he finds it very difficult to get vaccinated and after reading a lot of articles and research, he is still not convinced what to do. Recently, he stopped coming as regularly, as before the pandemic. He explained that he always had his counselling session one week and the other week was planned around his osteopathic treatment. He suffers from chronic pain in his upper back, so regular appointments help with maintaining his comfort levels.

We discussed his exercise history and activity levels. Additionally, we talked about different ways of helping him lose weight. He loves going for long walks, but unfortunately, they aggravate his pain. Changing for shorter, but more frequent or more dynamic walks did not appeal to him. However, he did agree to do some exercises that I recommended to him. Additionally, he used to be on different sorts of diets, but nothing helped him. Being money aware he said that changing his diet and eating habits is really difficult for him. Furthermore, since he became unemployed, he cannot afford to come to the clinic every two weeks and also he must have stopped seeing his counsellor. After he shared that story with me, we had a long chat about different discount possibilities that the ESO clinic offers. Additionally, I asked if he was interested to see any counsellor or psychotherapist free of charge, but he replied saying that he developed a deep relationship with his previous counsellor and that he was not willing to share his life stories with anybody else.

SO WHAT?
Recently, I have been thinking about him, as he has not come in for more than two months. I am worried about his general condition, and his mental state.

Although, his complaint is quite straightforward, he is the most complex and difficult case, I have ever had. He is extremely aware of any new techniques I am using, so I always need to make sure that I provide a long explanation of why I am changing or adding a technique. He is very sensitive to pain and touch. Asking for consent and keeping records of his pain levels during the treatment is really important. With him, I learned to follow a treatment routine, changing my techniques only on rare occasions.

He remembers every conversation we had, so I try to surprise him with questions about some details that we discussed during previous treatments. It makes him very happy and he feels appreciated. He realised that I always listen to him and remember his stories.

NOW WHAT?
Building a relationship with patients is important, but special connections take time. Only when patients trust us, as practitioners, we are able to influence their life. I know that with some patients I have created a bond, whereas with others we could not find common language. However, I will keep trying to be more engaged, especially during a long or a difficult day. I will keep motivating patients and supporting them in things that are important to them and can improve their health.

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

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

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This reflection was written according to the Gibbs reflective cycle.

DESCRIPTION
My patient was a 74 years old woman complaining of low back pain.

At the beginning of the consultation, I explained to the patient every step of the appointment and I informed them that I may ask her to undress to her underwear for examination and treatment purposes. The patient understood everything and was happy to proceed. After taking her case history, I stepped out of the room asking the patient to undress to her underwear. To my surprise, when I came back, she was dressed exactly the same and just her jumper was taken off. She stayed in long skirt and vest on. I assumed that it was her comfort level and did not ask her to undress further. During the examination, when it was difficult to see the movement of the spine or to palpate muscles, I asked if it was fine to roll her vest up and she was happy with that.

FEELINGS
I was surprised that although I thought, I gave straight instructions to my patient, she managed to understand them in a different way. That showed me that in a clinical setting “underwear” can mean different things depending on a person.

EVALUATION
That experience made me realise that I should always make sure that my patient understands exactly what I mean. Therefore, I can address any misunderstanding and correct my patient if they interpreted something in a wrong way.

As during the appointment, the patient felt comfortable and was happy to roll her vest up or roll her skirt down, maybe, I should have asked her if she was happy to take them off for examination purposes and then put them back on for treatment.

ANALYSIS
I probably should have clarified with the patient if she was too uncomfortable to take the vest and skirt off, or if she just misunderstood my request.

Several reasons may have led to that communication issue. This could be misunderstanding, stress, anxiety, personal insecurity, different culture or background.

CONCLUSION
As osteopaths, we need to recognize any discomfort that our patients may experience, including the fear to undress. We should always protect their dignity and modesty. Furthermore, I need to always make sure that I address patients’ needs properly, by providing a blanket, gown or just simply by treating them with their clothes on.

ACTION PLAN
In the future I will:

- clarify my requests if the patient understood them wrong,

- continue to treat patients within their comfort level,

- offer a blanket or a gown to cover exposed body parts

- leave the room when the patient is undressing or putting their clothes back on.

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A7. You must make sure your beliefs and values do not prejudice your patients’ care. (Evidence 1)

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A7. You must make sure your beliefs and values do not prejudice your patients’ care. (Evidence 1)

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WHAT?
An eighteen years old girl, who just started studying at a university, came to see in the clinic. She was suffering from general aches after working out too hard at the gym and sitting at the desk for long hours. Being students around the same age, we bonded quite quickly. She shared with me that in two days she was going on a skiing trip and she really needed to be back in shape. She told me about her very intense training plan that she follows at the gym. She also mentioned that that day was supposed to be a really important “leg day”, the last one before leaving for the holidays in France. However, she asked for my opinion about her going to the gym straight after the treatment. I did tell her that she might be sore after the appointment and that her body needs time to adjust and heal. I added that a heavy leg day would not be recommended for that day. I showed her some exercises that she could do instead of the gym session and told her that her training should be less intense than it was at that time.

At the end of the appointment, I wished her a lot of fun when skiing. She replied stating that she definitely would be enjoying herself, as she would be drinking and partying for the whole day, when skiing. That information alerted me, as drinking and skiing can lead to very serious consequences. Unfortunately, we were already outside of the treatment room and there was hardly anything I could have done. I just told her to be sensible and careful and maybe party in the evening instead of during the day when skiing.

SO WHAT?
Firstly, I was really surprised that she took my training advice very seriously and changed her gym plans. Being in very rigorous training and attending gym 6 days a week, it must have been difficult for her to skip a session. I was proud of myself that a person who knows more about working out was still happy to listen to my advice. It boosted my confidence as a practitioner and showed that I am respectable even if I am not an expert.

Secondly, I was shocked that she trusted me so much that she revealed her drinking plans. Although, I believe that drinking alcohol while skiing is very dangerous and irresponsible, it is not forbidden. I am aware that many people do so, and I could have not banned that girl from doing that. When she left the clinic, I was disappointed I did not manage to talk with her about the issue for a bit longer. I felt I did not warn her enough. Yet, my gut feeling was telling me that in that case, she would not listen to my recommendations.

NOW WHAT?
Although, I did not agree with drinking and skiing, at the same time I cannot stop anyone from doing so. Especially, when I am not witnessing it first-hand. If I had the possibility of seeing that girl once more before her trip, I would definitely warn her about the consequences of that behaviour. However, I would not say what I would do in her situation, as I am not entitled to do so.

As osteopaths, we must ensure the best quality of care for our patients, but our own values and attitudes cannot influence our patients’ choices.

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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. (Evidence 1)

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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. (Evidence 1)

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WHAT?
Above is attached a part of a mark sheet from year 4 CEX, containing feedback from a continuing patient consultation.

The patient came in complaining of excruciating headaches that started 2,5 years ago for no apparent reason. The headaches presented as side-locked, in a left temporal and retro-orbital location. The duration of episodes varied between 10 to 40 minutes. Although they never occur during the night, the patient realised that his headaches were present throughout the autumn. Headaches could make him feel desperate at the time of the attacks. He was experiencing trigeminal autonomic symptoms such as lacrimation and conjunctival injection. During the attack, he was also restless and in need of a walk. He would also express rocking movements whilst the attacks occur. There were no vision or hearing changes, no memory loss or confusion associated with those attacks. He had an MRI scan 2 years ago which was unremarkable.

SO WHAT?
Although, I have learnt about headaches before, at that time I was not confident taking the case history. Due to stress, I forgot some important questions and some key elements of cluster headaches. However, at the end of the session, I was convinced of the type of headache that the patient was presenting with. It was also difficult for me to communicate with the patient. He did not reveal some information when I asked the question, but did mention that to my tutor.

NOW WHAT?
After the CEX I reviewed different headache descriptions and the examination process. Now, I am much more comfortable with patients who come suffering from headaches and I can confidently take their case history.

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

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

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Above is attached a part of a mark sheet from year 3 CEX, containing feedback from a continuing patient consultation.

WHAT?
My new patient was a 69 years old retired man. He was complaining of lower back pain that he developed over the last couple of months. When I was taking the case history, he was talking a lot, also revealing his personal life. Although, I did not want to interrupt him, at some point I needed to remind him of the question I asked. During the first part of the consultation, I noticed some possible yellow flags, as he seemed to have family problems and did not cope well with retirement. I felt that he came more for a conversation and empathy than for a treatment. However, as that consultation was my exam, I had to proceed with the routine without letting him talk for a long time. During the treatment, I listened more to his stories and reassured him that some things take time.

SO WHAT?
In my opinion, I showed him understanding and I tried to address his needs as much, as I could. I am aware that I do not have any counselling training and I cannot give psychological advice to my patients. Quite often I do not even know what to tell them, when they reveal some personal details about their family. I knew that my patient wanted to talk to someone, to share his story and experience and I wanted to give him that opportunity. However, my tutor told me that I should neither engage in that conversation nor give him any advice. I know it was an exam, but unfortunately, I could not agree with my tutor.

NOW WHAT?
In the future, if a patient comes with a big psychological background and I will feel that they need someone to talk to I will probably change my approach. I will put my notes down and I will fully concentrate on their story. After graduation, I will not have any exams, or a tutor to whom I will need to explain myself to. That will allow me to treat my patients differently. I will allow my patients to open up and speak about their private life, if that is what my patient will need the most. I will not state my opinions or give any advice, but I will be there for them. In my opinion, if a patient wants to share their story, it means that they have trust in the practitioner and they feel comfortable around them. Sometimes someone listening to their story is all they need to heal.

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

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

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WHAT?
My certificate from a Continual Professional Development (CPD) course that I attended at the beginning of my 4th year, is attached above.

I attended a maternity workshop during which we covered different examination and treatment approaches for pregnant women. It was really eye-opening and I learnt a lot from a very experienced osteopath, who was running the lecture. Seeing him so engaged in teaching and sharing his knowledge was very inspirational.

At the end of my third year and throughout my 4th year, I was regularly attending Barefoot talks held at the ESO campus. They covered different topics and I always tried to find something I was particularly interested in. Although, I usually attended talks dedicated to pregnancy and children, I also enjoyed going to lectures about the holistic approach that is applied in osteopathy. Seeing new techniques and ways of treating patients, helps me find my own examination and treatment style.

SO WHAT?
It is very important for me to be up to date with recent research and new techniques or exercises. Apart from general osteopathic knowledge, it is crucial for me to learn more about a field in which I want to specialise. In my opinion, being interested in a subject makes it much easier to learn. Therefore, remembering new information and applying them in the clinic setting comes naturally. Becoming passionate about children’s health and constantly deepening my interest in that subject is something I really enjoy.

NOW WHAT?
I will keep attending different CPD courses to grow as an osteopath and enlarge my knowledge. Hopefully, directing my interest in a narrow area of expertise, will help me become a well-trusted specialist. I am motivated to deepen my passion for treating children and their health conditions.

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

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

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WHAT?
At the end of the first year of this degree, we were supposed to write a reflective essay about our perception of what we have learnt and been through so far. In my work, I included some thoughts from observing 4th years in the clinic. I talked about the possibility of developing different skills and techniques throughout the year. Reading it again, at the end of my four years Master’s degree, showed me how much I grew over these years. My perception of case history, consent and diagnosis has changed completely.

Additionally, in the coursework, I was referring to my clinic book that I had with me during observations in the clinic. Some things that I wrote in there are quite shocking to me now. As an example, I wrote: “Patients don’t really care about all little details during the appointment. I understand why so many are surprised when someone wants to lower the couch for them when it is the end of the treatment. I think that it’s difficult to perform a treatment and care about other things at the same time. Therefore, it’s observer who sees those little mistakes.” Coming back to it now, shows how important experience is. When I am treating patients, I always make sure I lower the couch at the end of the session, I always ask if they want pillows, or what to do with their glasses. Currently, it is difficult for me to imagine how not to care about all those details.

SO WHAT?
Although, I know that there is a gap between first-year students and fourth years, I keep forgetting how big it is. By reading reflections from the beginning of my studies, it seems impossible that I changed and developed so much without realising it throughout the years. I always think I can notice changes in my behaviour or skills development. If there is something worth noticing, I will write it down and reflect on it in detail. However, after realising how much I evolved without being aware of it, I think I will change my mind and I will start reflecting on myself more often. It is important to notice changes either positive or negative. I would never say that reading my own reflections would be so mind-blowing. After seeing that I grew and developed as a practitioner, I feel more confident and happy about my progress. At the same time I cannot wait to see what reflections next years will bring.

NOW WHAT?
Seeing how much impact that experience had on me, I will try to create a journal with reflections on my practice. Hopefully, I will be consistent and my thoughts will help me grow. It might be worth having a list of things I would like to improve and achieve. Then, after a year, to look back at it and see how much has changed.

For quite some time I have been trying to start journaling, but I could not commit myself to it. After seeing many benefits that this assignment brought, I hope I will finally start reflecting on myself more. I will try to dedicate at least a couple of minutes every day or even every week to think about what happened and what I would like to improve and achieve during the next day or week.

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

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

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I attached my marksheet from a third year practical exam from a structural station above.

Throughout the years we had lectures on the osteopathic evaluation of a patient, followed by techniques lectures that we adequate to the evaluation findings. In the second year it was extended by clinical methods lectures, which involved different orthopaedic testing, specific for each working diagnosis. The module also involved cardiovascular, respiratory, abdominal and neurological screening.

Having that knowledge, I was confident performing different orthopaedics tests and treating patients in the clinic. In the 3rd and 4th year I had exams, where I had to apply all my medical and osteopathic knowledge according to a specific osteopathic approach. In three stations: structural, visceral and cranial, I had to perform a quick evaluation of a patient followed in front of me, followed by an appropriate treatment and management plan.

As seen on the feedback sheet above, after my exam in the third year I had a lot of things to improve and work on. Some of my techniques were not effective and I did not perform any functional testing. Furthermore, my case history was basic, but it might have been due to the exam time pressure. This year (4th year) the examiners did not even let me talk about the case history during the exam. I found it confusing, as that’s one of the mark sheet requirements. However, as I still attempted to explain the diagnosis, I hope, I will get marks for that.

I am glad that I received constructive feedback after the exam, so I was able to reflect on my performance and improve elements that were not good enough. When I see my patients now, I always try to stay focus and treat effectively. I concentrate on a tissue quality and movement. Hopefully, when I gain more experience and I will be able to become even more specific.

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C2. You must ensure that your patient records are comprehensive, accurate, legible and completed promptly.

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C2. You must ensure that your patient records are comprehensive, accurate, legible and completed promptly.

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Every time I see a new or a continuing patient in the clinic, I take case history and notes. For the initial consultation my notes include detailed case history with description of the complaint, past medical history and systems screening. It is followed by my examination routine and its findings, any potential flags or concerns and agreed treatment and management plan. There is also space for any additional notes and guidelines relevant to the case.

The sheet for a following patient is much shorter and includes quick catch up/ case history,  examination, treatment plan and a part for any additional reflections.

Both new and continuing patient’s sheets have special space for the working diagnosis that we think is appropriate for the patient. Before giving the file back to the reception we must ensure that our tutor has seen and signed the notes. If something is incorrect or missing, tutors usually tell us to include or change information.

During the evaluation and examination of my patient I usually do not write my notes, but I write them after the consultation. It already happened a couple of times that I forgot to write the examination part down and then I was not sure about some findings. I try to work on that and write my notes during or straight after the session, so they are complete. However, I am aware that I am still struggling to always finish my notes on time and that is something I want to improve on.

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C3. You must respond effectively and appropriately to requests for the production of written material and data. (evidence 1)

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C3. You must respond effectively and appropriately to requests for the production of written material and data. (evidence 1)

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The process of referring a patient at the ESO clinic has several steps. Firstly, a student, a tutor and a patient must agree on writing a letter and the patient must give their written consent. After that, the student may proceed with formulating the letter, which is later corrected by the tutor, rewritten by the student and saved in the patient’s electronic database. Later on, the letter is being printed out and sent to the clinic admin, who is editing any grammar or structural errors. Then, it is being printed on a headed paper and given back to the student, who needs to check the letter again. If everything is correct, the paper is being signed by the student and the tutor. At the end, together with the patient’s consent form, the letter is being sent to the GP, or another agreed person/institution. If the patient requests, it might be given to them as well.

Writing a referral letter demands special skills and knowledge. The letter must be formulated good enough for the recipient to have understanding of our concerns and speculations, but it should not involve any statements that are above our training skills. As osteopaths need to work within out limitations and let other specialists confirm some uncertainties.

I am aware that I need to formulate my letters better and I intend to improve my writing skills.

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C3. You must respond effectively and appropriately to requests for the production of written material and data. (evidence 2)

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C3. You must respond effectively and appropriately to requests for the production of written material and data. (evidence 2)

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WHAT?
A 31 years old patient of mine was complaining of headaches described as side-locked, in a left temporal and retro-orbital location. The duration of an episode was sudden in onset and varied between 10 to 40 minutes. After taking a detailed case history, I diagnosed him with cluster headaches. Management of that type of headaches might be difficult and requires special training. Therefore, I decided to refer that patient to the National Migraine Centre, as they have consultants specialised in the cluster headaches. After formulating the letter, I sent it to my tutor, as it was already a holiday time and we did not manage to do it in the clinic. My tutor corrected any mistakes that I made. Overall, she was happy with how I structured the letter. After that, I sent the letter to the clinic admin and proceeded with the standard operating procedure of the letter writing and referring a patient. At the end the letter was send by post to the National Migraine Centre.

SO WHAT?
During these two years that I have been practising in the clinic, I had to refer several patients for different reasons. Some of them were as urgent as a suspected abdominal aortic aneurysm (triple A). However, others were not as immediate and were more of a safety check or an MRI/CT scan request, to support or exclude a diagnosis. As I struggled with writing some of them, I was really glad that my tutors were always happy to help me. Their support mean a lot to me.

NOW WHAT?
I am grateful for my tutors’ feedback on how to formulate referral letters. I will continue to work on improving the articulation of my thoughts.

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

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

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Before coming to the clinic as a practitioner, I had to complete safeguarding and first aid courses. During both courses we covered topics related to the clinical settings. To my surprise the first aid course was immensely interesting and ran in a way that all information was easy to remember.
As both courses were really important and crucial for clinical settings, I plan on redoing the courses every couple of years.

On the other hand that OPS can be applied purely in the clinic room. I must ensure that the treatment room is safe, all unnecessary objects are by the walls, including chairs when a patient is laying down on a bench. I need to support my patients, when they have difficulty moving around and make sure that they don’t fall off the couch. Constantly checking with a patient and keeping them safe is part of my duty. When treating babies, I always try to have one hand on their body, so if anything happens I can react quickly. If I need to take my both hands off the baby, I ask the parent to hold or to support the baby.

Recently, I have been treating a 9 months old baby. During the treatments he is very active, constantly moving on the couch. Last time, he pushed himself off the couch a couple of times. Fortunately, he did that in my direction, so I managed to catch him every time.

That was the first time, I witnessed how dangerous treatment couches can be for young children. Looking back, I think, I should have asked a parent of that baby to help me keep them safe. In the future, I won’t risk that much and I will ask the parent to support the baby.

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

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

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https://www.iosteopathy.org/wp-content/uploads/2021/02/Infection-control-and-PPE-in-osteopathic-practice-1-Feb-21-V7.pdf [Accessed May 15th, 2022].

To minimise the risk of infection transmission and follow the guidance published by the Public Health bodies of the UK, The Institute of Osteopathy (2021) published its summarised recommendations. It included anyone who is working within 2 metres of patients, and has no COVID-19 symptoms, being rated as medium risk.

The recommendations include:

- using and changing fluid-resistant surgical masks (IIR) after every patient,

- single-use of nitrile gloves,

- single use of aprons per patient,

- use of visor and/or eye protection on a risk assessment based i.e if a patient cannot wear a mask or during the techniques performed close to the patient’s face

Looking back, I am glad that many recommendations were implemented at the ESO clinic. Although, I did not agree with all of the requirements, I know they were made to protect us practitioners and our patients. Therefore, I always made sure to respect the rules and to keep a window open during every session. If a patient was too cold, I opened the window widely, as soon as the patient left. Furthermore, after each session I cleaned the treatment couch, pillows and all the surfaces, by spraying them with a disinfectant. Then, dispose of all rubbish in a 'black bag' waste bin.

Since the guidelines changed, we are required to wear masks in the clinic, but other personal protective equipment is optional. I was really relieved, when they decided not to give rid of the masks, as I still feel anxious being too close to a patient’s face. However, probably in the near future, it will change and I will stop using them.

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

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

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WHAT?
I recently attended a talk, which was prepared by an ESO graduate, a well renowned osteopath, who specialises in sports osteopathy. He currently practices in a multidisciplinary clinic that is owned and run by him.
In his lecture, he explained how his clinic works and how important it is to work in a good team. Knowing doctors, physiotherapists and specialists from different fields are extremely important and beneficial. It allows better care of patients and possibly quicker referral process. He talked about cases where a quick referral to a doctor and then co-operation with different physiotherapists in his clinic, led to amazing results from his patients that were greatly injured.

SO WHAT?
I was amazed how knowledgeable the lecturer was. He was speaking with real passion and gave us a lot of encouragement and motivation. I would love to work in his clinic or to find someone with his experience, to become my mentor. The connection and relationship that he has with his patients are admirable. He is very caring, so he wants the best service and referral possibilities to be available for his patients.

NOW WHAT?
I hope that after graduation I will manage to work in a multidisciplinary clinic, as in my opinion, it sounds very fascinating. From my experience, I know how important for a clinic it is to have different services to offer, as some patients need a multimodal approach. In the future, I hope, I will be able to open my own clinic and I will do my best to provide a variety of options for the patients.

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

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

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Sometimes, I use cranial techniques to treat my patients, especially those who are very anxious or stressed. To some of my patients, the approach is not new, but many of them have never heard about it. Therefore, I always try to explain in easy language what I want to do and how I hope to achieve it. With cranial techniques, I find it very difficult, as the approach is not research-based and different people show different outcomes.

I always explain to my patients why I think they may benefit from the cranial approach and tell them that they may feel or sometimes even see different things i.e. shapes or colours. Then, if they have any questions, and if yes, I try to address them. At the end, I ask if they want to proceed with the treatment and if they are not comfortable with the cranial approach, I can choose other techniques.

I find it particularly tricky with treating babies. Usually, after a consultation during which I have treated cranially, I can feel changes in the baby. However, it is difficult to explain that to the baby’s parents, especially if they are coming for another time and they have not seen any changes in the baby’s behaviour. I always tell them that although I feel changes in the baby’s movements it may take some time for it to be more noticeable for them.

Once, I had a situation, when for a couple of weeks I have been feeling slight changes in the baby, but its parents could not notice anything and they were becoming discouraged. After a month they came in very happy telling me that suddenly the baby changed a lot and does not look uncomfortable anymore. That information made me feel really proud.

I am aware that I need to improve my explanation of the cranial approach, so my patients understand it fully and, therefore; give informed consent.

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

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

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I was observing my friend who was seeing a continuing patient, who was a 28 years old man. During the initial consultation, she said she did not feel comfortable with him alone in the room and that is why she asked me to chaperone.

The session went smoothly with no uncomfortable moments for me. I engaged in a conversation they were having and we had a moment of a laugh. However, I recognised why she was nervous around the patient. He looked quite intimidating and presented himself as a nice, but a very confident person. Being not much older than we were, and telling us about his past relationships, created weird energy in the room.

At the end of the session, I went back to the team room and my colleague walked him to the reception. When she came back, she looked a bit disturbed, and when I asked what happened, she showed me a 50-pound note. She explained that at the reception the patient asked how much we earn per patient and when she told him that nothing, as it is a teaching clinic, he looked surprised. After that, she said “bye” to him and wanted to go back to the team room. Just about that time he put something in the flies she was holding and she did not look at it before coming back to us.

After she explained the whole story, she mentioned that at the end of the initial consultation he was enormously grateful for her help. After the first treatment, he already felt better and wanted to thank her. She replied saying that seeing that he was better is enough for her and that we do not really accept any “thank you” gifts from patients.

She didn’t know what to do with that money, so as a group we discussed different options. We said that first of all, she should have not accepted it, but it was difficult, as she did not see what he was putting in the files. After a discussion, we had another conversation with our tutor and we decided that she could buy some snacks for the group. It was too late to give money back to the patient, as he did not rebook another appointment.

If a situation like that one happened to me, I would probably buy something for the whole group and would not spend it on myself. However, to prevent situations like that, I would establish and maintain clear professional boundaries with my patients, clearly showing that I cannot accept any rewards for treating them. Maybe, that is why I have not have any confusing and difficult situations with patients. Therfore, I will continue to keep professional boundaries with all of my patients.

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

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

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As a part of the initial consultation, I must state and explain my working diagnosis to the patient. Also, that should happen when I change a diagnosis between the sessions with the returning patient.

However, sometimes when I forget or if I am not entirely sure what I want to write down, I do not discuss it with the patient. Also, I think that some patients are not interested in the diagnosis that we give. It might be because they are not aware that we are actually diagnosing them with i.e. a lesion or a condition. When I explain the diagnosis to my patients, I feel uncomfortable, because often it sounds severe, when it is usually not. I am aware that I must work on the wording and explaining the diagnosis, as it is an important skill that in my case needs improving.

In the future, I should pay more attention to that part of the consultation and try to feel comfortable discussing it with my patients.

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

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

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Although, fortunately, complaints do not happen often, I need to be prepared to respond to them. The ESO clinic has its special Complaint Policy for the patients if they are dissatisfied with the treatment. In my second year, I had an assignment, for which I had to reply to a complaint letter. I asked some of my friends, who were already treating patients in the clinic, how would they react and if there was any particular way of replying to that letter. Their feedback was really useful for me.

In my opinion, informal complaints happen more often and hopefully, if they occur I will be able to address them during the appointment. Sometimes, they happen because a patient understood something wrong or did not realise how the clinic works. It happened to me once that the patient wanted to be treated by my tutor and when we said that it was not possible they were really dissatisfied, but agreed to proceed with the treatment performed by me.

Additionally, sometimes patients don’t realise that we may ask them to undress and palpate their intimate areas. Therefore, to prevent any misunderstanding, it is really important to clearly explain the process to the patient and always ask for their informed consent.

Hearing about complaints that some patients made, and experiencing them once, I will always make sure that my patients are fully aware of the process of the appointment. I will continue to tell them that they can always ask me to change a technique if they feel uncomfortable or if they don’t like it. Additionally, I always tell my patients that they can stop me at any point or refuse to have a treatment. The ESO Complaint Policy is straightforward and I like its format. Therefore, in the future, I will possibly use it as a frame to create something similar for my clinic.

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

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

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I was seeing a new patient, a 58 years old woman, who came to the clinic complaining of migraines. The migraines presentation was quite straightforward and it didn’t take me a lot of time to diagnose it.

However, during the case history, she started revealing some personal details. She didn’t want to complain about her family, but in her presentation, with my tutor, we noticed some yellow flags. Therefore, my tutor started asking a bit more about her family and personal life. After revealing a bit more, the patient started crying, saying that it was the first time someone listened to her in a very long time. She said that she was feeling overwhelmed and that we understood how she feels when she experiences migraines. It was the first time someone believed that she has been having them. That statement surprised us and my tutor asked me to leave the room for 5 minutes, as she needed to have a private conversation with that patient. Later on, my tutor explained that possibly my presence, as a young student, did not allow the patient to open up completely and that we needed to hear the full story, in case we needed to inform special services.

In the end, we referred the patient, but she left the clinic with tears in her eyes. She was extremely grateful for the possibility to talk and share some parts of her life. She explained that it was really difficult for her to cope when her family was not supportive, saying that she was exaggerating the symptoms.

In my case history, I did mention some family-related yellow flags, but I did not write any personal details of the stories she shared with us. In my opinion, it was really important for the patient to have the possibility of opening up with no judgement coming from us.

I am happy with how we handled that case with my tutor. Although, I wanted to stay in the treatment room all the time and be with the patient, I understand why my tutor wanted me to leave the room for a short bit.

In the future, I will keep monitoring my patients if they reveal any concerning details. However, in their files, I will not include any details, but just the reason for general concern. If a situation will be urgent or alarming, I will report it somewhere appropriate, as it is my duty to keep patients from harm.

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

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

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Equality Act (2010) The Stationery Office Limited, London. Available at: https://www.legislation.gov.uk/ukpga/2010/15/pdfs/ukpga_20100015_en.pdf [Accessed May 14th, 2022].

In 2010 the Labour Government introduced the Equality Act to legally protect people at work and other places from discrimination and disadvantage. The Act includes protected characteristics such as age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation.

Equality is one of the human rights and as osteopaths, we must respect all our patients without judging them. Treating them without prejudice will allow us to gain their trust and develop a better relationship. There is nothing wrong with recognising or noticing diversity, as long as it does not change or influence our behaviour towards the other individual.

In my practice, I will continue to always respect the Equality Act and the diversity of people. According to the OPS A7. “You must make sure your beliefs and values do not prejudice your patients’ care” it is illegal to refuse service to someone or treat them differently on the grounds of one of the 9 protected characteristics mentioned above.

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

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

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Before going to the clinic as an observer and a practitioner I had to provide my DBS check. It was to ensure that I can be safely left alone with patients and that I will not cause them any harm. It is important for patients to feel safe in a treatment room, as they are in a vulnerable position. As a practitioner, I must not use my position against patients, and I should never behave in a patronising way.

Furthermore, outside of the practice, I should also behave responsibly and professionally. By doing so, I can gain and/or keep my respectful position. No one would like to see their osteopath in any kind of embarrassing situation. The way we act is the way people see us. Even one controversial act can ruin our reputation and even our future.

Therefore, it is advised not to have close relationships with patients outside of the clinic. However, if our patients are our friends, we should be cautious. We need to have in mind that in the treatment room patients need to respect and trust us. That might be difficult if someone is being seen as a careless and irresponsible person outside of the clinical setting.

I will continue to remain professional outside my practice and be extra careful if I have close relations with some of my patients. That might be difficult if I live in an area close to the clinic, as mostly, that is where patients live as well. However, I will try to separate my private and work life.

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

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

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Above, I attached a part of my business plan, which was my 3rd year assignment.

D8.1. You should charge fees responsibly and in a way which avoids bringing the profession into disrepute.

In the third year, I had to create a business plan for my future clinic.

I really enjoyed writing the business plan. Learning about my possible competitors was very beneficial for me and showed me new possibilities. I look in-depth at their services and prices, which was eye-opening. After a price assessment and comparison, I came up with a treatment fee that would be placed in the middle of my competitors’. I decided not to put it as one of the lowest, because I am planning on opening the clinic after I gain the necessary experience. Therefore, even though I will be new in the neighbourhood, I hope, I will quickly gain patients’ trust due to my experience and that they will be happy to come to my clinic.

I found my business plan to be highly rewarding and prospective. Therefore, when I will be opening my clinic, I will probably use some elements of it to create a new one. I am glad we had a bit of business training, but in my opinion, it would be more beneficial if that module was extended.

By creating the business plan, I learnt a lot about things I was never aware of. I had to calculate insurance costs and the General Osteopathic Council fees, together with other necessary expenses. Also, I had to come up with a competitive strategy and marketing plan. I found those things fascinating and they made me realise that I need to learn much more about management and business before opening my own clinic.

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

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

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At the end of the fourth year, students usually hand over patients to colleagues from the year below. Sometimes, a patient requests a type of practitioner that they would like to be assigned to and sometimes, the practitioner thinks of a suitable replacement. However, quite often patients end up being randomly assigned.

The ESO clinic has a special handover sheet that we can fill in with a patient’s details including: name, date of birth, presenting complaint, secondary complaint, working diagnosis, treatment to date, and any other additional comments. Additionally, there is space to write who is handing over the patient to whom. I find that sheet very useful, and when I got assigned to a patient from a graduated student, that paper helped me a lot. In a clear and combined way, it shows all the important information about the patient.

As my turn to hand patients over will come soon, I have already started thinking, to whom I would like to assign my patients. I want to make sure that they are happy with my choice and that they feel comfortable with a new practitioner. If possible, I may ask the new person to observe, how I treat during one or a couple of appointments. It will allow them to get an understanding of the patient’s dynamics and it will also be an opportunity for them to start a new patient-practitioner relationship. I hope my patients will be happy with the new practitioners, but if not, then there is still enough time to find another person.

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

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

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As an osteopath, I must be aware of my role within the context of healthcare as a whole. Although, osteopathy can greatly strengthen the healthcare sector, osteopaths must work within our limits. It means that we need to treat other professionals with respect and consider their benefits for our patient’s good. By working in partnership with other healthcare providers, we may be able to speed up the referral process and provide better care for patients. We should always put the well-being of our patients first. Only after working collaboratively with other specialists, we can say that we really looked at the holistic approach to body and health.

As previously stated in the reflection of the OPS C3 and C6, I definitely respect other healthcare providers. In the future, I do want to work collaboratively with many specialists, because to my mind, it is immensely beneficial and important for patients, as well as for us. By working with others, we can share our concerns, but also knowledge. We can constantly grow and develop our skills as practitioners.

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

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

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This OPS was especially important to me during the COVID-19 pandemic. Many guidelines were created to protect our and patients’ health. Osteopaths, along with other healthcare providers were advised to do the COVID-19 rapid lateral flow test. It ensured that we were not infected by the SARS-CoV-2 virus and were fit to practice. Additionally, before entering the clinic, patients’ temperature must have been taken, they needed to put protective masks on and then reply to some questions, related to the COVID-19 symptoms. Only after having all negative responses and the body temperature within the normal range, there were able to enter the clinic.

Those procedures were really important to me and I am pleased that they were implemented. They made me feel safer, as I knew I was not harming or infecting my patient and neither were they. When it happened that my housemate or I had a positive test result, we never went to the clinic. Even though we felt fine, we did not want to put our patients at risk. Although now the rules have changed I still feel that we should self-isolate, if we or someone close to us was just tested positive.

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

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

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WHAT?
When coming to the clinic as a practitioner, I agreed to respect the Student Fitness to Practise procedures created by the ESO,  and followed by the General Osteopathic Council standards. The procedures aim to provide a safe environment for patients and trust in the profession. If there is a concern that the student may not be medically, physically and psychologically well enough to treat patients, then a case might be created. It will be investigated in many aspects and different people will get involved. If the student does not agree with the final decision, they may appeal against the decision of the Fitness to Practise Panel. Nonetheless, if a student must suspend their studies or withdraw permanently, the ESO will provide mental and academic support to show them the options that they have.

SO WHAT?
Throughout my studies and when practising in the clinic, I was aware of the Student Fitness to Practise procedures. I always respected them, making sure I always feel well treating the patients.

NOW WHAT?
I will continue to provide safe and respectful surroundings for my patients. I will always make sure to be medically, physically and psychologically fit to treat patients.

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Equality Act (2010) The Stationery Office Limited, London. Available at:https://www.legislation.gov.uk/ukpga/2010/15/pdfs/ukpga_20100015_en.pdf [Accessed May 14th, 2022].

Gibbs G., 1988. Learning by Doing: A Guide to Teaching and Learning Methods. Oxford: Oxford Polytechnic.

GOsC, 2018. Osteopathic practice standards | General Osteopathic Council. Available at: https://www.osteopathy.org.uk/news-and-resources/document-library/osteopathic-practice-standards/updated-osteopathic-practice-standards/ [Accessed May 18, 2022].

The Institute of Osteopathy, 2021. Infection control and Personal Protective Equipment (PPE) in osteopathic practice. Available at:

https://www.iosteopathy.org/wp-content/uploads/2021/02/Infection-control-and-PPE-in-osteopathic-practice-1-Feb-21-V7.pdf [Accessed May 15th, 2022].

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

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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. (Evidence 2)

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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. (Evidence 2)

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Above is attached my year 4 CEX feedback sheet.

I find it difficult to ask many follow up question due to the time pressure during the exam. However, I know how important that is. Therefore, I need to work on that and trust my gut feeling that is usually telling me to ask more in-depth questions.

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A7. You must make sure your beliefs and values do not prejudice your patients’ care. (Evidence 2)

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A7. You must make sure your beliefs and values do not prejudice your patients’ care. (Evidence 2)

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That OPS can be also applied when thinking of different osteopathic approaches. I have learnt many cranial, visceral and structural techniques that I am happily applying when I treat my patients. However, some tutors strongly recommend using only the structural approach. Although, I know that the cranial approach is not for everyone, I do not think that as students we should be discouraged from trying it. At the end of the day, I should perform the best treatment for my patient and my tutor’s beliefs should not influence that. Therefore, I will continue using all approaches when treating patients.

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A5. You must support patients in caring for themselves to improve and maintain their own health and wellbeing. (Evidence 2)

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A5. You must support patients in caring for themselves to improve and maintain their own health and wellbeing. (Evidence 2)

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I am seeing a patient who is quite overweight and is constantly trying to lose a couple of pounds. I was surprised when I discovered that she likes talking about her training programme and diet. She also told me that I should motivate her along the way. Now that she shared that with me, I always make sure to ask how her training is going, encouraging her to keep going.  I also ask if she managed to lose any weight and if she is still managing the tough diet.