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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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C1. From the SOCRATES model to symptom oriented questioning 

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C1. From the SOCRATES model to symptom oriented questioning 

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Being new to patient handling and having to remember all the important questions can be stressful. The SOCRATES model is a very convenient way of starting to take case histories to remember the must ask questions, however over time when developing a system to distinguish between conditions, which is different from one joint to the other, in order to gain clarity and efficiency in the practitioner’s mind both questioning and note taking change.
Similarly, examinations go from practiced routines from boxley to specific examinations being combined to discern from one diagnosis to the next, depending on each individual patient.
Observing limitations or gaps in knowledge is easier when being surrounded and observed daily by peers and osteopaths, in future practice, this will have to be done autonomously and regularly to ensure the safety of patients.

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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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In September of 2021, during the first weeks of clinics as a third year, I was amongst the first to have their first patient, I had been apprehending this during my time off in summer as I had no prior professional experience dealing with clients paying money and expecting a service in a certain amount of time, I did not really know what to expect from my first patient.
After I finished to explain the process of the consultation and as I was going to ask what her complaint was, my patient told me that she was Punjabi, which is an ethnic group from Pakistan and the north of India, explaining this meant there was little to no undressing allowed in public in her culture, certain parts of her body could not be touched, and she could not remove big metal bracelets she had on her wrist or her headscarf. This added significant pressure to me as I was used to models undressing down to boxers or shorts without batting an eye at school, and this is not something I expected to encounter with my first patient. Her complaint was pain at the right ankle, and because she couldn’t roll up her trousers as it was part of her culture and they were very tight, it was challenging for me to assess her knee and hip as her jeans were restricting movement.
This lead me to being stressed when diagnosing, interpreting findings and treating efficiently, and also because the patient didn’t communicate very much. As the consultation ended though, the patient thanked me for a good first experience with an osteopath.
This first patient experience highlighted how vital respecting patient’s preferences and assuring their mental and physical comfort is during each consultation, and it is my duty as a future osteopath to adapt my knowledge and skills to each individual patient in order to assure this.

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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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In October 2021, after a few months in clinic, I got assigned my first foreign patient, he was a young Polish lorry driver who had jumped from his truck with a kitchen set. He presented to the clinic with lower back pain and shooting pain down his left leg, from his facial expressions it was clear he was in a lot of pain, however when asking him what type of pain he was feeling, when he was feeling it, there was a very clear language barrier, when asked a question that the patient wouldn’t understand, he would politely nod along or say “yes, pain here”, most of the communications were accompanied by hand signals and facial expressions which made process of gaining informed consent and partnership particularly challenging.
After a few months, the patient was in less pain, and being much more familiar with each other and our accents made communication and support much easier.
This experience highlighted how critical adapting to every individual patient is, and how appreciative people can be when time is taken to make sure their needs and concerns are taken into account.
In the future, this will be a key element of my practice, working in partnership with every patient and making sure they understand the tests, treatment, diagnosis and management as well as the support there is around them in order to establish a healthy patient-practitioner partnership and the best overall possible support for every individual patient.

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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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Being clear and adapting to the recipient’s level of knowledge on the matter, and checking the understanding of the patient regularly is vital for every consultation. For example in this letter the word “dysfunction” was interpreted as the guardian’s son being “dysfunctional” however the patient’s guardian kept this to herself until writing the letter. If the theoretical practitioner had addressed the issue during the consultation, by understanding the guardian’s confusion through non verbal communication, like a facial expression of surprise, or asked if everything that was said made sense, this issue could have been avoided in the first place.

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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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Being a foreign student at the ESO, and being new in clinic, gaining informed consent was originally a big concern for me, as I was unsure wether I was being clear explaining the aims of testing and treatment, due to my english, but as well due to the transition between medical lingo with tutors, lecturers and peers, and layman’s terms for patients. Additionally, I was not sure the treatment I was doing would have a tangible effect on my patient, therefore I did not want to “oversell” my treatment due to my lack of practice. This was a challenging step as this required me to gain a much more deep understanding of conditions, and the benefits of treatment.
Originally, trying to get informed consent from patients would be an uncomfortable moment for me as I would be reciting some lines I had learned in order not to blank in front of patients. Over time, and after having worked on anatomy, my english, differential diagnosis, I feel more and more confident with patients gaining and recording consent in a more fluid and natural way. In future practice, it will be key to further work on this aspect as for example patients in different countries have different expectations of treatment, different levels of understanding of anatomy, osteopathy and english, and it is the practitioner’s role to facilitate communication and the gaining of informed consent, for the safety of both the patient, but also the practitioner and/or their practice.

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An Evidence-Based Framework for Strengthening Exercises to Prevent Hamstring Injury - PubMed

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

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

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Affiliations

¹ Department of Rehabilitation, Nutrition and Sport, La Trobe Sport and Exercise Medicine Research Centre, Melbourne, VIC, Australia. matthewbourne88@gmail.com.

² School of Exercise Science, Australian Catholic University, Melbourne, VIC, Australia.

³ Department of Rehabilitation, Nutrition and Sport, La Trobe Sport and Exercise Medicine Research Centre, Melbourne, VIC, Australia.

⁴ School of Exercise and Nutrition Science, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia.

⁵ School of Health, Sport and Professional Practice, Faculty of Life Sciences and Education, University of South Wales, Wales, UK.

Affiliations

¹ Department of Rehabilitation, Nutrition and Sport, La Trobe Sport and Exercise Medicine Research Centre, Melbourne, VIC, Australia. matthewbourne88@gmail.com.

² School of Exercise Science, Australian Catholic University, Melbourne, VIC, Australia.

³ Department of Rehabilitation, Nutrition and Sport, La Trobe Sport and Exercise Medicine Research Centre, Melbourne, VIC, Australia.

⁴ School of Exercise and Nutrition Science, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia.

⁵ School of Health, Sport and Professional Practice, Faculty of Life Sciences and Education, University of South Wales, Wales, UK.

Abstract

Strength training is a valuable component of hamstring strain injury prevention programmes; however, in recent years a significant body of work has emerged to suggest that the acute responses and chronic adaptations to training with different exercises are heterogeneous. Unfortunately, these research findings do not appear to have uniformly influenced clinical guidelines for exercise selection in hamstring injury prevention or rehabilitation programmes. The purpose of this review was to provide the practitioner with an evidence-base from which to prescribe strengthening exercises to mitigate the risk of hamstring injury. Several studies have established that eccentric knee flexor conditioning reduces the risk of hamstring strain injury when compliance is adequate. The benefits of this type of training are likely to be at least partly mediated by increases in biceps femoris long head fascicle length and improvements in eccentric knee flexor strength. Therefore, selecting exercises with a proven benefit on these variables should form the basis of effective injury prevention protocols. In addition, a growing body of work suggests that the patterns of hamstring muscle activation diverge significantly between different exercises. Typically, relatively higher levels of biceps femoris long head and semimembranosus activity have been observed during hip extension-oriented movements, whereas preferential semitendinosus and biceps femoris short head activation have been reported during knee flexion-oriented movements. These findings may have implications for targeting specific muscles in injury prevention programmes. An evidence-based approach to strength training for the prevention of hamstring strain injury should consider the impact of exercise selection on muscle activation, and the effect of training interventions on hamstring muscle architecture, morphology and function. Most importantly, practitioners should consider the effect of a strength training programme on known or proposed risk factors for hamstring injury.

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national center for biotechnology information

# data[].attributes.attachment_link.title
An Evidence-Based Framework for Strengthening Exercises to Prevent Hamstring Injury - PubMed

# data[].attributes.attachment_link.description
Strength training is a valuable component of hamstring strain injury prevention programmes; however, in recent years a significant body of work has emerged to suggest that the acute responses and chronic adaptations to training with different exercises are heterogeneous. Unfortunately, these researc ...

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Injury prevention programs that include balance training exercises reduce ankle injury rates among soccer players: a systematic review - PubMed

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Being at the ESO clinic and being around knowledgeable tutors is the perfect opportunity to explore rehab options and observe with time, what sort of exercise is suited to each type of patient. There is a large amount of exercises available in the literature, which is still exponentially growing alongside the evidence based approach of osteopathy. Exercises are a very useful tool to begin to put the patient’s health into their own hands and manage their condition, their symptoms, are or pain levels on their own, and additionally, lowering the likelihood of re-injury. It is vital to keep updated on new exercises in order to tailor exercises to each individual patient’s needs in future practice and be able to explain them in the clearest way possible.

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Affiliations

¹ Department of Physical Therapy, Faculty of Applied Medical Science, Umm Al Qura University, Makkah, Saudi Arabia; Discipline of Exercise and Sport Science, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, Australia; Department of Sport, Exercise and Health, Faculty of Medicine, University of Basel, Basel, Switzerland. Electronic address: wsattar@uqu.edu.sa.

² Department of Physical Therapy, Faculty of Applied Medical Science, Umm Al Qura University, Makkah, Saudi Arabia; Department of Physical Therapy, King Abdullah Medical City, Makkah, Saudi Arabia.

³ Department of Physical Therapy, Faculty of Applied Medical Science, Umm Al Qura University, Makkah, Saudi Arabia.

⁴ Department of Sport, Exercise and Health, Faculty of Medicine, University of Basel, Basel, Switzerland.

⁵ Department of Physical Therapy, Faculty of Applied Medical Sciences, Najran University, Najran, Saudi Arabia.

⁶ Discipline of Exercise and Sport Science, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, Australia.

Free article

Free article

Affiliations

¹ Department of Physical Therapy, Faculty of Applied Medical Science, Umm Al Qura University, Makkah, Saudi Arabia; Discipline of Exercise and Sport Science, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, Australia; Department of Sport, Exercise and Health, Faculty of Medicine, University of Basel, Basel, Switzerland. Electronic address: wsattar@uqu.edu.sa.

² Department of Physical Therapy, Faculty of Applied Medical Science, Umm Al Qura University, Makkah, Saudi Arabia; Department of Physical Therapy, King Abdullah Medical City, Makkah, Saudi Arabia.

³ Department of Physical Therapy, Faculty of Applied Medical Science, Umm Al Qura University, Makkah, Saudi Arabia.

⁴ Department of Sport, Exercise and Health, Faculty of Medicine, University of Basel, Basel, Switzerland.

⁵ Department of Physical Therapy, Faculty of Applied Medical Sciences, Najran University, Najran, Saudi Arabia.

⁶ Discipline of Exercise and Sport Science, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, Australia.

Abstract

Question: What is the effect of injury prevention programs that include balance training exercises on the incidence of ankle injuries among soccer players?

Design: Systematic review of randomised trials with meta-analysis.

Participants: Soccer players of any age, sex or competition level.

Interventions: The experimental intervention was an injury prevention program that included balance training exercises. The control intervention was the soccer team's usual warm-up program.

Outcome measures: Exposure-based ankle injury rates.

Results: Nine articles met the inclusion criteria. The pooled results of injury prevention programs that included balance training exercises among 4,959 soccer players showed a 36% reduction in ankle injury per 1,000 hours of exposure compared to the control group with an injury risk ratio (IRR) of 0.64 (95% CI 0.54 to 0.77). The pooled results of the Fédération Internationale de Football Association (FIFA) injury prevention programs caused a 37% reduction in ankle injury (IRR 0.63, 95% CI 0.48 to 0.84) and balance-training exercises alone cause a 42% reduction in ankle injury (IRR 0.58, 95% CI 0.41 to 0.84).

Conclusions: This meta-analysis demonstrates that balance exercises alone or as part of an injury prevention program decrease the risk of ankle injuries. PROSPERO CRD42017054450.

Keywords: Ankle injury; Balance exercises; FIFA; Injury prevention programs; Soccer; Sports injury.

Cited by

Editorial: Acute and chronic changes in postural control in response to different physiological states and external environmental conditions.

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athletic injuries* / prevention & control

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national center for biotechnology information

# data[].attributes.attachment_link.title
Injury prevention programs that include balance training exercises reduce ankle injury rates among soccer players: a systematic review - PubMed

# data[].attributes.attachment_link.description
The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site. The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

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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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My previously mentioned first patient came in with a complaint a the ankle, and due to my lack of experience in clinic and working over clothes, I potentially visibly felt uncomfortable during treatment doing soft tissue on the patient’s tibialis anterior over their trousers, I didn’t want the situation to seem uncomfortable but also could not help myself, this was due to my own “inexperience” however this could be misinterpreted by the patient.
Having improved my palpation skills and also practiced on multiple patients (pregnant, elderly, acute etc..) with all their clothing still on.
I would feel much more comfortable handling a similar situation. Going forward, respecting patient’s modesty and dignity should be done throughout the consultation and outside of practice If this were to impact the treatment or findings for example by clothing, it is important to inform the patient so they can make an informed decision on the matter, alternatives should always be presented such as a modesty gown, a modesty towel or the options of still having treatment or no treatment. The patient’s dignity and modesty should always come first.

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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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During the second term of the fourth year, a fifteen year old patient came in complaining of multiple pains at different areas of the body, which at this age with no trauma rang a little bell in my head thinking this was unusual. After further questioning , I learned his mother had been diagnosed of muscular dystrophy only a few years prior to the consultation, which had started with a rectal prolapse, which the fifteen had just suffered from only a few weeks again prior to this appointment. The patient and his mother were suspecting he may be suffering from the same condition but nothing was confirmed, and the patient’s mother wanted her son to choose whether he wanted to do the relevant testing or not. The patient’s expectations from the consultation was to get a diagnosis, and to get a professional’s point of view on wether he was maybe suffering from muscular dystrophy.
After three treatments no improvement was found, being honest with this patient with the suspicions even-though he was so young, and this would affect his whole life. When explaining findings to the patient, it was important to explain everything very simply, being careful with the words used to not panic the patient, it was important to keep in mind the patient was looking for an explanation for his pain and would ultimately overall benefit from knowing how to manage his condition from a young age. The patient appreciated the honesty and reacted in a very mature way although affected by the news, he is still getting treatment at the clinic for his MSK presentation, for neck pain and soreness due to a previous trampoline trauma and will be investigated for muscular dystrophy in the summer of 2023 as he will then be 16 which is the legal age to be put on the waiting list.
Keeping honest and being integral with every patient no matter the consequence is very important, without significant data it is sometimes better not to say anything as the patient may over interpret what is said, this decision is easier to make with a tutor beside me. This clinical decision will be have to be done autonomously in future practice, and discretion, empathy and sensitivity will be vital components of handling any kind of situation of the kind.

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B1. You must have and be able to apply sufficient and appropriate knowledge and skills to support your work as an osteopath

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B1. You must have and be able to apply sufficient and appropriate knowledge and skills to support your work as an osteopath

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This was a particular low for me in clinic, I had prepared myself a lot for the theory aspect of the CEX however I had not practiced enough at that point of the course, I was still hesitant when doing a test as to the exact position of the patient, and getting caught up with which next test or treatment would be more convenient or best. Developing a routine for both aspects was an essential part for me to start to feel more relaxed with patients, and allowed me to listen to the patient more, look at for non verbal signs, and be able to apply and demonstrate my knowledge with much less pressure.

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In contrast, this was a big high for me, I used all the feedback my tutors had given me over the two years in clinic. Contrary to other cases in the past, preparing this patient was quite straight-forward as little to no further exploration was needed (systemics, medication, diagnosis), as I have gotten into the habit of reviewing and understanding every patient’s case when getting in in clinic every session, this allows me to refresh knowledge and makes every appointment, as well, this makes certain patients feel heard and supported when learning that their case is regularly reviewed even outside of consultations. This will prove more challenging in future practice as there will be more patients than currently at the ESO clinic, however will certainly remain essential.

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The Benefits and Limitations of Evidence-based Practice in Osteopathy

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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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“Being an osteopath” is a very broad term due to the number of approaches and the combination of approaches, but it is important to consider the limits of each field and of our competence as osteopaths, to consider the limits in research in every field. Additionally, staying informed on the advancements and the new research in other health and care to not only be able to present different options when osteopathy is not beneficial for a patient, but also when another option could be more beneficial to them or even in concurrence with osteopathy.

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The Benefits and Limitations of Evidence-based Practice in Osteopathy

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Evidence-based practice (EBP) arises from evidence-based medicine (EBM). The latter represents a movement of thought born in the second half of the 19th century, while the EBP is born since the new millennium, represented by different scientific figures and professional associations.

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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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This first barefoot talk for me was a real eye opener in that osteopathy is a non-stop learning experience, there were osteopathic students even from year 1, up to 4 and osteopaths that had graduated 10+ years ago. After talking to some osteopaths and attending the day long presentation/practice session, I got a big motivation boost, the anxious side of me was relieved to see even after years of graduating, you can still learn a lot from the body, through constant practice and reviewing of theory.
This was the first lecture I was attending that did not take into account which level of osteopathy you are, and this reassured me as even-though I did not understand everything, this was also the case for most people in the room, seeing the whole room being very interactive and every one completing each other’s knowledge reinforced my passion for osteopathy and changed my view on “learning” significantly. Additionally due to the “isolation” resulting from going into private practice when compared to being around peers and osteopaths daily for 4 years, CPD will be a vital part of remaining at the forefront of research as well as remain in communication with other osteopaths.

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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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My handwriting historically has always been a little rushed, and my note taking very personal. Coming into third year, handling patients and writting down notes consistently, I noticed that sometimes I was unable to understand my own notes or even handwriting. Additionaly, on more than one occasion, I had to cover a colleague’s patient because they were out, and was unable to understand their notes, which lead to wasting time asking questions to the patient again, or having to do extra tests which sometimes lead to a bit of frustration from the patient.
I found especially moving away from the SOCRATES model it was challenging to make the most important aspects of the case stand out which was the next step to making notes as legible and thorough as possible.
With final exams approaching tutors push us to be more thorough with our notes. However in future practice assessing notes will have to be done autonomously and on a regular basis to make re-reading recent and old case files as straightforward as possible for me or in case another osteopath in the practice needs to cover for me, or in case of any complaint one day.

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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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During the start of my clinical experience, a patient that I had seen once previously for a lower back / hip complaint, who had come in appropriate clothing started coming in less and less covering clothing. The patient’s underwear was less and less covering as well as transparent, this situation had to be addressed after multiple times, as I felt uncomfortable testing/palpating certain areas like the hip or when palpating for muscle tension.
This situation had to be handled with sensitivity and with professionalism however in a natural way so the patient would understand what clothing is appropriate for a consultation without potentially feeling ashamed as she did not do anything wrong. This was situation where I felt myself grow, I handled this situation with a lot more confidence and maturity than I would have in the past, this experience showed me how setting limits/boudaries should not be viewed as a confrontation but actually like a mutual understanding which should be respected by both parties for both their comfort.

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C2 My handwriting/note taking (3rd Year, 1st term)

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C2 My handwriting/note taking (3rd Year, 1st term)

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One year on from the backlog recovery plan: what next for NHS waiting lists? | Institute for Fiscal Studies

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

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

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In the initial few months of my clinical experience at the ESO clinic, writing referral letters was a big apprehension as if not good enough, it could impact my patients in a negative way so I would heavily rely on tutors for every letter.
Over time getting accustomed to the lingo, as well as learning to be quick and effective with letter writing has proved to be vital for patient outcome as waiting lists are long especially in post-covid times where NHS waiting lists are very long and not every patient can afford private care. Therefore regularly going back to the guide to letter writing, being to the point but thorough when writing the letter as well as being quick in sending it is going to be vital for patients to get the help or imaging they need as soon as available in future practice.

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Introduction

One year ago, NHS England published its plan to tackle the backlog of elective care, which had surged following the onset of the pandemic. Since then, as widely expected, waiting lists for NHS treatment in England have continued to grow, increasing by around 1 million between February and November 2022 to just shy of 7.2 million incomplete treatment pathways. In this report, we examine whether the NHS is on track to achieve the challenging ambitions laid out in its backlog recovery plan and present a number of different scenarios for waiting lists over the next two years.

The NHS has made meaningful progress in its efforts to reduce the number of patients waiting a very long time for treatment. But progress against its overall treatment volumes target has been far more limited. The ambition is to increase treatment volumes to 30% above pre-pandemic levels by 2024-25. As it stands, our judgement is that this is highly unlikely to be achieved - not least due to the lingering effects of COVID-19 and other pressures on the system. As a result, waiting lists are - in our view - unlikely to start falling rapidly any time soon. Instead, our central expectation is that waiting lists will more or less flatline over the next year, and fall only gradually from mid 2024. We present a number of scenarios to reflect the considerable uncertainty around this.

This is the final part in our three-part series on NHS performance. In the first part of the series, we examined how our previous set of scenarios compared with what subsequently happened to waiting lists. In the second part, we compared NHS funding, resources and treatment volumes with pre-pandemic levels, and explored the factors that could explain some of the ongoing challenges within the health service.

The backlog recovery plan

What was in the plan?

The backlog recovery plan, published in February 2022, included a number of ambitions (not formal targets) for elective care. The headline aim was to increase elective activity to around 30% more than pre-pandemic levels by 2024-25, with an increasing portion of this to be delivered outside of hospitals.

Alongside this, there were other specific ambitions around the numbers of people waiting a long time for treatment, which have been the main focus of the health service to date. These included a stated desire to eliminate waits over two years by July 2022, to eliminate waits over one-and-a-half years by April 2023, to eliminate waits over one-and-a-quarter years by March 2024, and to eliminate waits over one year by March 2025. Other ambitions focused on waiting times for diagnostic tests, cancer referrals and outpatient appointments, which we do not focus on in this piece.

Just a few weeks ago, the new Prime Minister reiterated the importance of NHS waiting lists for his government, making a reduction in waiting lists one of his five key priorities for 2023. Notably, unlike the objectives in the backlog recovery plan, this targets the size of the waiting list itself, rather than treatment volumes from the waiting list.

What has happened since the plan was released?

We first consider how NHS waiting list performance has compared with the ambitions of the plan, starting with the target to increase elective activity by 30% above pre-pandemic levels. Figure 1 shows the number of patients treated from the waiting list in 2022 and 2019.

Between January and November 2022, the NHS treated 6.6% fewer patients from the waiting list than it did over the same period in 2019. Both the number of admitted and the number of non-admitted (outpatient) treatments were substantially below their 2019 levels over the period. There has, however, been some progress over the course of the year. In November 2022, the number of patients treated from the waiting list rose substantially above 2019 levels for the first time. The NHS treated 1.55 million patients from the waiting list in November 2022, compared with 1.48 million in November 2019, an increase of 4.8%. This comes on the back of steady, if modest, increases in monthly treatment volumes since July.

The latest month of data are encouraging, but it remains the case that the NHS has struggled to make any meaningful progress against its headline target of increasing elective activity (which includes treatments from the waiting list) by 2024-25 to 30% above pre-pandemic levels. As we will discuss in the next section, some of the increase in elective activity will take place outside of hospitals, and so will not show up in these treatment volume statistics. And it is possible that increases in treatment volumes were always expected to be back-loaded, with more rapid increases in 2023 and 2024. But, nonetheless, the failure to increase elective treatment volumes to date means that an already challenging target has become even more so - since there is now less time to increase activity before 2024-25 - and has, in our judgement, become even less likely to be achieved.

We next consider the number of long waiters, the only ambition in the plan that had a 2022 deadline. Figure 2 shows how the number of people waiting more than one year for NHS treatment has changed between February 2022, the month the backlog recovery plan was published, and September 2022, the most recent month with complete data available (in October and November 2022, Frimley Health NHS Foundation Trust and Manchester University NHS Foundation Trust failed to report complete data, making a comparison of the distribution of waiting times impossible). Figure 3 shows the total number of people in each wait-length category between November 2019 and November 2022 (for which more complete data, with estimates for the missing trusts, are available).

The recovery plan included the ambition that the NHS would eliminate waits of more than two years for treatment by July 2022. Figures 2 and 3 show that this has largely been achieved - the number of people waiting for more than two years (the right-most bar in Figure 2 and the purple line in Figure 3) fell from 23,300 in February 2022 to 2,200 in September 2022, a reduction of 90.4%. By November 2022, the (estimated) number waiting more than two years had further fallen to 1,400, a 93.9% reduction compared with February 2022. While the number has not strictly reached zero, this should be viewed as a success for the NHS - it was never likely to completely eliminate these waits, as some of the treatment needed is very complex, and some patients may choose to wait longer.

However, the numbers in other target groups - for whom the deadlines are further into the future - have continued to grow. The ambition was to eliminate waits of between 1.5 and 2 years by April 2023, for instance. But the number of people waiting in this group grew from 45,200 to 48,500 between February 2022 and September 2022, an increase of 7.4%. Similarly, the number of people waiting between 1.25 and 1.5 years increased from 86,000 in February 2022 to 115,300 in September 2022, an increase of 34.0%.

In fact, the total number of people waiting more than a year for treatment has risen from 300,000 in February 2022 to 410,000 in November 2022, an increase of 35.8% (Figure 3). Prior to the pandemic, this number was effectively zero (1,845 in February 2020). It is true that the deadlines for eliminating these waits have not yet passed, and the NHS may yet successfully meet them. But the fact that the numbers in these groups have continued to grow illustrates the broader challenge: while waiting lists are continuing to grow overall, it is not mathematically possible for the NHS to reduce the number of people waiting for all time periods. Instead, it can only prioritise reducing some groups, such as those waiting more than two years, while other parts of the waiting list continue to grow.

Moreover, while it was a success to identify and reduce the number of people waiting more than two years, this was a relatively small group - at its peak, there were about 24,000 people waiting for more than two years. For comparison, in November 2022, there were 47,500 people waiting between 1.5 and 2 years for treatment and 357,600 waiting between 1 and 1.5 years. While these numbers might still appear modest relative to the size of the overall waiting list (more than 7 million) and to the aggregate number of treatments each month (around 1.5 million in November 2022), this is in part a reflection of how much the waiting list has grown. 400,000 people waiting for more than a year would have represented more than 17% of the total waiting list in January 2010 and 9% of the list in February 2020, versus less than 6% of the list now. In any case, the shift towards targeting patients waiting longer than a year still represents a step up from the challenge to date.

Taken together, one year on from the publication of the backlog recovery plan, NHS performance against the plan's objectives has been mixed. The number of people waiting longer than two years has been dramatically cut, and the target of eliminating waits of more than 1.5 years by April 2023 remains within reach. At the same time, more concerningly, there has been little sign of a surge in elective treatment volumes, which puts at risk the headline ambition to increase elective activity levels by 30% above pre-pandemic levels, and makes the next round of long-waiter targets more difficult to achieve.

What next for waiting lists?

We now consider what could happen next to waiting lists, and update our previous scenarios for NHS waiting lists in England, to reflect the experience of the past year. To construct these scenarios, we must make assumptions about the number of people joining and leaving the waiting list each month. We first outline the range of assumptions we make, before showing what they imply for the potential future path of waiting lists.

Patients leaving the waiting list

The backlog recovery plan included the aim to increase elective activity by 30%, relative to pre-pandemic levels, by 2024-25. But the plan explicitly allowed for changes in how this additional activity was to be delivered: in other words, it would not necessarily mean 30% more hospital treatment pathways. In particular, the NHS planned for increased use of advice and guidance services. This initiative allows GPs to consult with specialist doctors (consultants) before or instead of a referral to hospital, with the goal of reducing the number of referrals that are made. Figure 4 shows the number of advice and guidance requests made each month between January 2019 and December 2022.

The number of advice and guidance requests has increased from 42,700 in January 2019 to 114,000 in December 2022, an increase of 167%. Using advice and guidance, NHS England projects that it will avoid an additional 1.1 million waiting list pathways in 2022-23, and 1.4 million in 2023-24 and 2024-25. Although there has been a large increase in advice and guidance requests, the NHS is still a fair way off achieving these projections. In the first nine months of 2022-23, there were 660,000 more requests than in the first nine months of 2019-20. Some of these requests will still result in a referral: they will not all translate into an avoided waiting list pathway (for which the target for the year is 1.1 million). Avoiding 1.4 million additional waiting list pathways in 2023-24 and 2024-25 implies that the overall number of requests will need to continue to grow rapidly in order to exceed that number by some margin.

According to the National Audit Office, although the backlog recovery plan referred to an increase in activity of 'around 30%', the operational target is for a 28.8% increase by 2024-25. After accounting for the (planned) increase in use of advice and guidance, this requires a 20.9% increase in elective activity levels, relative to 2019-20. Although substantially easier than having to increase volumes by 30%, this remains a challenging target.

Table 1 shows the three scenarios we consider for waiting list treatment volumes. We take as our starting point the average treatment volumes between September and November 2022, where NHS treatment volumes were just below 2019 levels (97%). In the first scenario, the NHS achieves its objective of increasing treatment volumes by 20.9% above pre-pandemic levels. But this requires achieving the equivalent of 10.3% annual growth in treatment volumes between now and March 2025 - an incredibly high growth rate. For comparison, between February 2015 and February 2020, treatment volumes grew by an average of 2.9% per year.
Table 1. Scenarios for waiting list treatment volumes Note: Annual growth rates are calculated as the annualised growth rate from the average treatment volumes between September and November 2022 and the required treatment volume in March 2025. We assume that treatment volumes as a percentage of 2019 levels grow at a constant rate from the average of September to November 2022, to 26.0% above 2019 levels in March 2025 (the end of 2024-25) for 'achieve target' scenario, 14.6% above for 'medium growth' and 7.2% above 2019 levels for 'sluggish growth'. Source: Authors' calculations using NHS England Referral to Treatment Waiting Times data and figure 2 of National Audit Office, 'Managing NHS backlogs and waiting times in England', November 2022, https://www.nao.org.uk/reports/managing-nhs-backlogs-and-waiting-times-in-england/.
Given this, we consider two additional scenarios for treatment volumes. In our 'sluggish growth' scenario, we assume that the NHS increases treatment volumes by 2.9% per year (the average growth rate observed over the five years pre-pandemic) between now and March 2025, which would take treatment volumes in 2024-25 to 6.2% above 2019-20 levels. In our 'medium growth' scenario, we assume that the NHS increases treatment volumes by 5.9% per year (double the pre-pandemic rate, sufficient to return to the pre-pandemic trend - see below), implying 2024-25 treatment volumes 12.0% higher than in 2019-20. After allowing for the (planned) increase in advice and guidance, these would take overall activity levels in 2024-25 to 14.2% and 20.0% above 2019-20 levels, respectively. These increases would fall short of the ambition in the recovery plan, but would - as we show below - still be substantive by historical standards, and would still be challenging to deliver amidst an array of wider pressures on the service.

For context, Figure 5 shows how treatment volumes have changed since 2007, as well as the pathway of treatment volumes implied by each of these three scenarios. The black dotted line shows the pre-pandemic trend (i.e. the trend had the pre-pandemic growth rate of 2.9% per year continued from the start of 2020). This is an estimate of what might have happened had the pandemic not occurred. The yellow line shows that in order to deliver on the ambitions of the backlog recovery plan, activity would need to grow at a much faster sustained rate than has been achieved at any point since 2007 (when comparable records began), to a monthly total of more than 1.7 million completed pathways by late 2024. This means that by the end of 2024-25 the NHS would treat 200,000 more patients per month than if treatment volumes had continued to grow in line with the pre-pandemic trend. The NHS would need to go above this pre-COVID trend in order to 'catch up' on any care missed during the pandemic. The blue line, which shows our medium growth scenario, is much closer to this counterfactual level of treatment volume.

Receiving treatment is not the only reason people leave the waiting list. People also leave because they have died, no longer need treatment or have received private treatment. We assume that each month 3% of people on the waiting list leave for these other reasons. This is approximately the level that this 'other outflow' has been since 2021. This is lower than the rate pre-pandemic, but because of the much greater size of the waiting list, this means a roughly similar number of individuals leaving the waiting list each month as pre-pandemic.

Patients joining the waiting list

To allow for uncertainty over the level of demand, we also make a range of assumptions about the number of patients joining the waiting list. As well as reducing the amount of elective treatment the NHS needs to deliver, advice and guidance requests are intended to reduce the number of people joining the waiting list. In our past analysis of possible paths for waiting lists, we assumed that there would be a surge in demand as some of the 8 million or so patients who missed joining waiting lists during the pandemic returned to seek care. However, there has been no such surge. In light of this, we assume here that there will be fewer new patients joining the waiting list than we did in the past. Forecasting demand for elective treatment is difficult in part because demand itself depends on the size of waiting lists. With higher waiting lists, patients may be less likely to bother to seek NHS treatment, and GPs may be less likely to refer patients onto waiting lists.

Table 2 shows the three scenarios we consider for the number of people joining the waiting list. We take as our starting point the average between September and November 2022, where the number of new patients joining the waiting list was 97% of 2019 levels. In our 'catch-up demand' scenario, we assume that the number of people joining the waiting list will grow to be 8% higher in March 2025 than in March 2019; in our 'medium demand' scenario, we assume that it will be 4% higher; and in our 'stable demand' scenario, we assume that it will be no higher than in March 2019. Across 2024-25, this would equate to an 8.5% increase in the number of new patients relative to 2019-20 ('catch-up demand'), a 5.3% increase ('medium demand') and a 2.0% increase ('stable demand'), equivalent to annual growth of 5.4%, 3.7% and 2.0%, respectively.
Table 2.Scenarios for number of new patients joining the waiting list each month Note: Annual growth rates are calculated as the annualised growth rate from the average number of new patients joining the waiting list between September and November 2022 and the required number of new patients joining the waiting list in March 2025. Source: Authors' calculations using NHS England Referral to Treatment Waiting Times data.
Waiting list scenarios

Figure 6 shows four scenarios for waiting lists, based on different combinations of assumptions. The green line shows what has actually happened to waiting lists between December 2019 and November 2022. The other lines then project forward what could happen to waiting lists between December 2022 and March 2025 under different scenarios.

The yellow line sets out our central scenario. In this scenario, we assume that the NHS does not achieve the target in its backlog recovery plan, but instead follows our medium growth scenario, treating 12.0% more patients from the waiting list in 2024-25 than in 2019-20. We think that it is unlikely the NHS will achieve its full target, given that this would require double-digit annual growth in treatment volumes, but that it will still succeed in dramatically increasing treatment volumes above what it is managing now and what it was managing pre-pandemic. We assume that the number of patients joining the waiting list grows according to our medium demand scenario, reaching 4% above 2019 levels by March 2025. Under these assumptions, waiting lists would more or less flatline during 2023, before starting to fall more steadily from mid 2024. The Prime Minister's commitment to reduce waiting lists would be narrowly missed this year.

The blue line sets out a scenario where the NHS hits its treatment target, but there is catch-up demand. This means that treatment volumes reach the elective recovery target of 20.9% above pre-pandemic levels, but the number of patients joining the waiting list reaches 8% above 2019 levels by March 2025. In this scenario, waiting lists fall from the middle of 2023, and fall faster than in our central scenario, reaching 6.3 million by the end of 2024-25.

The red line sets out a scenario where the NHS again hits its treatment target, but demand is stable - whether due to tighter rationing by the NHS or by patients themselves. In this case, we assume that the number of patients joining the waiting list in March 2025 is no higher than in 2019. Waiting lists fall much faster under this scenario, reaching 4.8 million by the end of 2024-25. This shows the importance of the number of patients joining the list for determining the trajectory - in the blue and red scenarios, the NHS treats the same number of patients, but the outcomes differ because the number of patients joining the waiting list is different.

Finally, the purple line sets out a scenario where the NHS manages only sluggish growth in treatment volumes and faces medium growth in demand. In this case, we assume that the NHS can only increase its treatment volumes to 6.2% above its pre-pandemic levels, and that the number of patients joining the waiting list grows to 4% above its 2019 level by the end of 2024-25. In this pessimistic scenario, waiting lists continue to rise over the whole period, though at a slightly slower rate than they have grown over the last two years.

Table 3 shows what could happen to waiting lists under each combination of our three assumptions around treatment volumes and number of patients joining the waiting list. The coloured sections line up with the scenario in Figure 6 with the same colour. There is less uncertainty about the level at which waiting lists will peak: provided that the NHS increases treatment volumes sufficiently, our analysis suggests a likely peak of between 7.5 and 8 million. That peak could occur in mid 2023 or mid 2024, depending primarily on how quickly treatment volumes can be increased. Notably, this would be nothing close to the 13 million peak which then Health Secretary Sajid Javid warned of as a possibility in July 2021. This reflects just how few of the 'missing' pandemic patients have subsequently joined the waiting list for care.
Table 3. Range of scenarios for waiting lists Note & source: See Figure 6.
There is much more uncertainty around the level of waiting lists come 2025. In our central scenario, the overall size of the waiting list in March 2025 would be more or less identical to what it is now. In the best-case scenario that we consider (for waiting lists, we should stress - not necessarily for population health), the waiting list could be as low as 4.8 million by March 2025 (though this would still be above pre-pandemic levels); in the worst case that we consider, it could be more than 9 million.

Conclusion

One year on from the publication of the backlog recovery plan, NHS performance against the plan's ambitions has been mixed. The only hard deadline that has passed - for waits of more than two years to be eliminated by July 2022 - has been (more or less) achieved. But progress against more distant ambitions has been limited. The NHS has until April 2023 to eliminate waits longer than one-and-a-half years. Although the number waiting this long has increased by 7.4% (to 48,500) since the plan was published, this remains very much achievable in the remaining time available.

The more fundamental challenge is that the NHS has so far struggled to increase the number of people it is treating from the waiting list each month. As a result, the overall size of the waiting list has continued to grow - as has the number of people waiting for more than a year for treatment.

The headline ambition of the recovery plan was to increase levels of elective activity to substantially above pre-pandemic levels. If the NHS can deliver on this ambition, and increase treatment volumes by 20.9% by 2024-25 (or around 30% after accounting for planned increases in advice and guidance), then waiting lists will likely start to fall from the middle of this year. But this would require double-digit growth in treatment volumes over the next two years. This would be difficult to achieve even in a normal year, but the continued pressures faced elsewhere by the NHS mean that, in our judgement, this is highly unlikely to be achieved.

Instead, our central judgement is that the NHS will be able to increase treatment volumes significantly, but by less than planned. In this case, we would expect waiting lists to more or less flatline for the next year, and start falling slowly but steadily from the middle of next year.
There is nothing remotely certain about this. But our assessment is that for waiting lists to start falling meaningfully this year - as the Prime Minister has all but promised - it would require one of two things to happen. One, the NHS achieves a truly remarkable increase in how many patients it manages to treat. Or two, the number of people joining the waiting list for treatment stays unexpectedly low - whether because they do not think they need NHS care or because they are unable to access it.

Max joined the IFS in 2020 as a research economist in the Healthcare Sector, with a focus on the NHS labour force.

Ben is a Senior Research Economist and an editor of the IFS Green Budget. His work focuses on the health and social care system and UK fiscal policy.

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One year on from the backlog recovery plan: what next for NHS waiting lists? | Institute for Fiscal Studies

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One year ago, NHS England published its plan to tackle the backlog of elective care, which had surged following the onset of the pandemic. Since then, as widely expected, waiting lists for NHS treatment in England have continued to grow, increasing by around 1 million between February and November 2022 to just shy of 7.2 million incomplete treatment pathways.

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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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One day in clinic at the end of third year, I got assigned a last minute patient, she was in agony since the day before, following a thoracic manipulation from a colleague. Following the manipulation, the patient was left stuck on the couch, with immense amounts of back pain and pins and needles down both her arms. The patient was obviously worried when this happened however she had been made aware of the risks before, as well, when this happened, my colleague explained what happened to her and what she can do to get pain relief.
To my surprise, with the amount of pain the patient was in, the patient was not mad at all, she explained to me she had been “briefed before” and accepted to have the manipulation done.
She mentioned multiple times how she was not mad at the colleague or the clinic, this is due to transparence before and after a technique, no matter if the news is good or bad, the patient deserves to know what is going on or what they are putting themselves and their body through. For future practice, its important to notice that if the patient hadn’t been made aware of all the risks of manipulation, or did not get adequate support following it, this situation could have escalated much more.

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Understanding the Code: the duty of candour - PubMed

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The Duty of Candour indicates that every health and care professional should be open as well as honest when something goes wrong with treatment, whether it causes harm, distress.

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Understanding the Code: the duty of candour - PubMed

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A key recommendation of the Mid Staffordshire Inquiry (Francis, 2013) was to establish a culture of openness in all health services through a duty of candour. A professional duty of candour is a key requirement of the Nursing and Midwifery Council’s revised Code (2015). It requires all district nurs…

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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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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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In second year, we were asked to respond to a complaint letter, where a whole previous consultation was being misinterpreted by a patient due to lack of clear communication at the time of the appointment. This coursework highlighted how vital being able to explain the treatment aims, risks and benefits to patients in the first place.
Additionally, being clear and adapting to the recipient’s level of knowledge on the matter, and checking the understanding of the patient regularly. For example in this letter the word “dysfunction” was interpreted as the guardian’s son being “dysfunctional” however the patient’s guardian kept this to herself until writing the letter.
Additionally being able to respond to a complaint in due time, considering the plaintive’s arguments and answering with professionalism and sensitivity and adapting the lingo to who is being addressed is key to resolving a misunderstanding or complaint.

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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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The recent Covid pandemic has left a big impact in our society, and with the guidelines changing every few weeks/months, when it got to the end of the pandemic, some of my peers and I felt a little uncomfortable just returning to normal life not worrying about covid, and it potentially affecting our friends, families, friend’s families. Consequently, we were still thorough in wearing masks in and out of clinic, cleaning the couch with covid spray between every patient, opening windows, The pandemic showed how protecting everyone around us can be done by everyone through personal and professional hygiene. This pandemic gave us all a sense of responsibility with hygiene to keep everyone safe around us and on a personal level made me realise the direct impact this could have on someone’s life. This will have to be kept on top of for every patient in future practice and following national/local guidelines should always be done, as well as staying updated with them as we have seen during the pandemic.

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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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The Data Protection act of 2018 states that anyone using personal information or data should thoroughly respect the “data protection principles”, ensuring that data is used transparently, fairly and lawfully.

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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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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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Due to osteopathy becoming part of primary healthcare and osteopaths in the UK seeing more and more patient who would normally see their GP, it is important to be able to interpret common imaging as well as blood tests and medical diagnoses.
One day in clinic, a patient asked me to help him interpret, after some hesitant and quite rough explanations I went to fetch my tutor who was able to explain everything with much more detail, this situation was particularly uncomfortable, as it is quite normal for my tutor to know more about imaging however from a personal point of view this made me feel quite incompetent, seeing such a clear limitation in my knowledge of that area showed me that it would be challenging to work within the healthcare profession if not able to interpret anything from them that comes my way. This will limit my knowledge of the patient, and result in being less safe a certain treatments or recommendations may indeed not be advised for this patient.
Additionally this will allow them to understand what they are dealing with, as well as if they should seek further medical attention for their safety.

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Perceived Discrimination, Coping Mechanisms, and Effects on Health in Bisexual and Other Non-Monosexual Adults - PubMed

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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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In healthcare, discrimination can impact the prognosis, mental and physical health, some marginalised “communities” are still not understood by all which may in turn affect their health and safety. Therefore in any case of potential prejudice by a medical professional, it is probably in both party’s interests to be referred. This situation has never happened to me as I have always had an indiscriminate will to care for all, however in the event this were to ever happen, referring to another competent medical professional would be beneficial for the sake of the patient’s health and my professional safety.

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The .gov means it's official.
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The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Affiliations

¹ Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA, USA.

² Department of Health Studies, American University, Washington, DC, USA.

³ Division of Psychiatry and Behavioral Sciences, Montefiore Medical Center, Bronx, NY, USA.

⁴ Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA. sabra.katz-wise@childrens.harvard.edu.

⁵ Department of Pediatrics, Harvard Medical School, Boston, MA, USA. sabra.katz-wise@childrens.harvard.edu.

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Affiliations

¹ Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA, USA.

² Department of Health Studies, American University, Washington, DC, USA.

³ Division of Psychiatry and Behavioral Sciences, Montefiore Medical Center, Bronx, NY, USA.

⁴ Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA. sabra.katz-wise@childrens.harvard.edu.

⁵ Department of Pediatrics, Harvard Medical School, Boston, MA, USA. sabra.katz-wise@childrens.harvard.edu.

Abstract

Bisexual individuals experience unique discrimination related to their sexual orientation, which may increase their risk of adverse health outcomes. The study goal was to investigate how bisexual and other non-monosexual individuals experience discrimination, understand how they perceive discrimination to affect their health, and examine the ways in which they cope with discrimination by analyzing responses to open-ended survey questions. The sample included 442 bisexual and other non-monosexual adults, ages 18-68 years (M = 28.97, SD = 10.30), who either reported a bisexual identity or reported attractions to more than one gender. Gender identities included women (n = 347), men (n = 42), and transgender/non-binary individuals (n = 53); 29% of participants were currently located outside of the U.S. Participants completed an online survey, including three open-ended questions regarding their experiences with discrimination, how discrimination affects their health, and methods used to cope with discrimination. Themes related to perceived discrimination included: double discrimination of bisexuals and other non-monosexual individuals by heterosexuals, lesbian and gay individuals; bisexual invalidation and erasure; and sexual victimization. Themes related to the perceived effects of discrimination on health included: impact on mental health; impact on physical health; and effect of discrimination in healthcare. Themes related to coping with discrimination included: social support; resilience; and identity-specific media consumption. Findings demonstrate that bisexual and other non-monosexual individuals' experiences of discrimination can be additive, based on other marginalized facets of identity, including race/ethnicity, gender, and socioeconomic status. Our findings have implications for advancing bisexual health research from an intersectionality framework.

Keywords: Bisexual health; Bisexuality; Coping mechanisms; Discrimination; Sexual orientation.

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national center for biotechnology information

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Perceived Discrimination, Coping Mechanisms, and Effects on Health in Bisexual and Other Non-Monosexual Adults - PubMed

# data[].attributes.attachment_link.description
The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site. The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

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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 coming into clinic, I did not have much professional experience, especially managing patients and having to uphold the reputation of a practice. This experience has taught me the importance of managing certain personal aspects such as nails, hair, beard and clothing in and out of clinic. Additionally the importance of managing sleep, conduct when going out in public, as this has an impact on patient’s perception of me but also on my workplace and on osteopathy as a whole.

Maidstone being a relatively small town, seeing current and old patients outside of clinic is quite a common occurrence, some patients will want to talk more than others outside of clinic, some patients have even asked colleagues for their phone numbers or social media, which over time has taught me to keep a balance between good manners and professionalism with patients in and out of clinic.

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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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As outlined by my business plan, prices will be determined based on the average pricing of the market around my practice, with some allowances made for less financially free patients. I will never take advantage of a patient and make them come back more than they need to for financial gain.

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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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With osteopaths now being being a primary healthcare professionals, and the NHS being saturated following covid, the profession is seeing more and more patients with undiagnosed pathologies as they are not able to see their GP.
Even though it is not our role to treat these pathologies, it is expected of us as osteopaths to look out for undiagnosed  pathologies or progression, and be aware of which medical professional to refer to, and the lingo and format to use when writing to them. Referring a patient should be done in due time, but can also involve the patient getting treatment at the same time as being investigated for something else, this clinical judgment will have to be done autonomously in future practice, but can only happen through knowing what the investigation (from the GP or specialist) and pathology involve, if it is safe to treat the patient at the same time or in their best interest.

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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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Towards the end of my first year in clinic, I started getting some signs of irritation of my sinuses and feeling low in energy, at the time I did not think much of it since a lot of my classmates were experiencing similar symptoms. I went to clinic wearing a mask just in case for patients and peers, however when I got home and even more the day after, I got a headache, runny nose, and lost my smell and taste shortly after, I decided to take a test and it turned out positive.
Being positive for Covid and unknowingly spreading it was one of my biggest fears during the pandemic, thankfully after telling my peers and patient I saw that day, none of them were tested positive. Even though no one was tested positive apart from me, and my symptoms were not very significant, I should not have only relied on my own judgment and should have tested prior to going to clinic. This way of handling situations for any health concern will have to be done consistently in the patient’s best interest, some patients have a low immune system therefore it is important to treat every patient the same and not taking unnecessary risks.

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During my first attempt at first year, I was often concerned with what people thought of my technique and how much I knew, over time, as my confidence grew I saw how feedback is a vital aspect of being an osteopathic student, and it is up to me to change my view of feedback, to not see it as something personal but an opportunity to grow and better myself, I appreciate how welcoming feedback and even asking for feedback from tutors and peers has allowed me to grow a lot as an osteopath, in my confidence with different techniques such as manipulations (HVTs) but also how and which exercises to suggest to patients, the way I express myself, the way I present myself.
The two CEX feedback papers posted above have a year and a half of interval between them. I was was very happy to see at the end of fourth year was when I got my best result for a CEX ever! I applied all the feedback I had got over the two last years and clinic and used it to grow in confidence especially in an exam setting. Something I observed quite early on in the course for people in clinic and am also guilty of, is always asking what I could have done better, when also asking what was done well should not be discarded, recognising strengths contributes to overall confidence as a healthcare professional.