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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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What ?

A female patient presented to the ESO with diffuse shoulder pain. I had suspected sub-acromial impingement due to number of indications, primarily positive painful arc and Hawkins Kennedy as well as reduced flexion and abduction both passive and actively. I had considered adhesive capsulitis as a differential but did not have the experience to be certain. I treated the patient over 4 sessions, over which time the patients pain got worse. There had been no improvement to their range of motion. This ultimately led to me reviewing the case history and performing further testing.

Onset had been traumatic, whereby a masseuse had taken the shoulder into maximal flexion and applied a thrust posteriorly with the elbow flexed. Upon palpating the coraco-acromial ligament, the patient was positive for suspected sprain.  Passive testing showed a severe reduction in abduction and external rotation when compared to the non – affected side. The shoulder also showed signs of instability, with a positive GH sheering test. This led to me to consider a new diagnosis of traumatic adhesive capsulitis with concomitant ligamentous sprain.

So what ?

The incorrect diagnosis, inevitably led to a delayed referral. Superior prognosis has been shown with hydrodilation which could have been sought in the first session, 8 weeks prior. I had to be honest with the patient, explain the process and how I had arrived at the original diagnosis and explained possible treatment options.

The patient ended up relieved and thanked me for revisiting the finding and changing my consideration. I had anticipated a negative response, which was far from the reality.

Now What ?

We ended referring the patient to her GP with a recommendation for hydrodilation. This interaction not only taught me that acting honestly is largely appreciated by the recipient

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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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Description:

The same patient that presented in my experience under (A3) presented with symptoms of Cauda Equina; including but not exclusive to saddle anaesthesia, urinary retention, sensation change and bowel movement anaesthesia which had progressed in the previous 9 months.

Feelings:

I specifically remember asking the questions and the answers being positive. These are questions that previous to this experience had always yielded a response was negative. I recall logic and emotion clashing. This led me to ask the same question two or three times as my clinical learning contrasted with my expectation of the answer.

Evaluation:

In retrospection, I am pleased I do not ignore these palpable red flags. After consultation with my tutor, we opted to refer. The patient subsequently had a positive finding for CES by MRI and later had the relevant surgery.

Analysis

This case highlighted the importance of trusting clinical guidelines which are taught to assist in presentation like this. It further highlighted the importance to trust my instinct and seek further medical help.  The patient was rather disappointed to not receive treatment. However, prioritising the patients’ health over their request for treatment was the correct thing to do.

Conclusion

This case highlighted that application of sufficient knowledge is vital, particularly in the presence of red flags.

Action Plan

I will continue to revise systemic conditions and their MSK presentations. I also plan to develop a checklist for red flags during history taking. In future cases, I will be more confident in pausing treatment to ensure patient safety.

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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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What ?

Tutor Feedback following a continuing patient highlighted the level of professionalism displayed with patients.  It was remarked that I maintain professionalism whilst also being amenable and build rapport in an open manner.

So What ?

Creating professional boundary has been important to me since beginning the course. I have worked as a sports masseur and personal trainer alongside the course. I decided early that I would not treat close friends and family during this time. This was a decision I made, because I felt it comprised the professional barrier.

Now What ?

This is something I will continue to develop and work on. Whether this relates to the language I use, how I gain consent or explain treatment. I want my patients to feel at ease, comfortable and trusting.

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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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Concrete Experience

During an observation in fourth year, I watched a patient take a case history from a patient who had presented to the ESO with lower back pain. during case history, the female disclosed an extensive and complex medical history (Mitral valve prolapse, symptoms of Cauda Equina including bladder sensation changes and a constant feeling of pressure, multiple discs prolapses including thoracic and cervical). The patient was  in her 30s and her appearance and case history seemed incongruent. Upon further systemic questioning it seemed she had a familiar history of cancer and diabetes. It was during this point the patient said, “ My parents were exposed to the Chernobyl disaster everyone has cancer”.  It became immediately apparent that the extent of our knowledge was not sufficient in assisting with the patient’s complex case history.

Reflective Observation

As the case history unfolded, I recall feeling that it was outside of osteopathic scope to treat. However, following protocol the patient presented with symptoms of cauda equina. It was agreed with the tutor and practitioner that referral was required. It was in those protocols that the practitioner was able to guide from an osteopathic stand point.

Abstract Conceptualisation

This case history highlighted the level of my clinical competency. It was apparent that the depth of the case was outside osteopathic scope of practice. However, reliance on health care protocols helped point the patient in the right direct.

Active Experimentation

The case further highlighted the requirement to improve my knowledge of red flags and when treatment is appropriate. Whilst the case was unnerving, it demonstrated the importance of referring treat with an underlying uncertainty.

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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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What? I have never had a direct experience relating to a complaint and consequently, it was upon reviewing OPS standards in the reflection process that having a complaints procedure in anticipation of an event was prudent.

So What ? This prompted me to review the National Council for Osteopathic Research advise on dealing with complaints.

Now What ? During student clinic I will be subject to the ESOs complaints policy. I also have a position at an established practice upon graduation with their own internal policy. I will ensure I am up to date on these policies in the event of a complaint.

Evidence: https://ncor.org.uk/practitioners/practitioner-information-communicating-benefit-and-risk-in-osteopathy/dealing-with-patient-feedback-and-complaints/#question4

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National Council for Osteopathic Research

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Dealing with Patient Feedback and Complaints - National Council for Osteopathic Research

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Get advice for practitioners on dealing with patient feedback, and how to use feedback effectively.

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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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Description: During my third year, I had always sought to treat based on the techniques I both preferred and excelled at. I was eager to try some high velocity thrust and work within the biomechanical / structural model. However, one of my earlier patients came in with chronic lower back pain. She had been suffering for several years with intermittent back pain. Whilst there was undoubtedly structural element to the patient’s complaint, during the case history It became apparent that she was under a significant amount of stress. This extended to her work and personal life. Consequently, I took a different approach to treatment, and it was the first time I had ever considered treating the patient how they seemingly needed to be treated as opposed to what I was good at.

Feelings: I remember distinctly feeling out of my comfort zone. Treating cranially to help with the patient’s stress levels was something unfamiliar to me. I persisted at it felt the right thing to do for this patient.

Evaluation: In retrospection, the patient has become a regular patient and has been forthcoming with her praise of the treatment approach. I still work structurally but we end each session with cranial treatment. I feel that improvements in her symptoms largely relate to this part of the process. Whilst it is difficult to quantify, the patient feedback suggest that this has significantly helped reduce her pain. I recall discussing this with experienced practitioners who echoed this sentiment .

Analysis:  This experience taught me the emphasis of really considering a patient’s case history and treating based on the outcome. Historically, I would have prioritised clinical process and offered structural treatment with rehabilitation advise.

Conclusion: This case defined the moment where I experience a shift in my osteopathic philosophy and treatment. Helping reduce the patient’s pain by working indirectly on her stress levels appeared to have a huge impact. Subsequent session both the patient and her daughter would comment on how she “feels lighter” and that she had “stopped taking so much pain medication”. This was achieved with very little structural work.

Action Plan: In subsequent consultations I will continue to remain curious and actively listen to patients, concerns and preferences.

Evidence: Anheyer, D. et al. (2017) ‘Mindfulness-Based Stress Reduction for Treating Low Back Pain’, Annals of Internal Medicine, 166(11), p. 799. Available at: https://doi.org/10.7326/m16-1997.

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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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Description:

During a busy clinic, I had written notes up in the student room for my tutor to sign. I had been quite busy and was behind. Consequently, I had begun presenting my patients to the tutor in the reception area as they were passing. The tutor reminded me of confidentiality and asked me to come into a private room to discuss.

Feelings

I was frustrated by my poor time keeping, which inevitably led to me potentially disclosing information in the reception is not something Id typically do.

Evaluation.

This was a bit of a wakeup call, early on in my third year that I cannot discuss patients’ medical history in public. Whilst it was not something Id typically do, It did highlight how good timekeeping and producing my notes during the consultation would prevent me from rushing and making silly mistakes.

Analysis

It reinforced the importance of discretion at all times. Just because a conversation is clinical doesn’t mean it’s appropriate to have it in public. Patients place trust in us to protect their information, and even unintentional breaches can damage that trust. Particularly given the case was somewhat sensitive in its findings.

Action Plan

I try to ensure my notes are done on time and within the clinic session to avoid rushing. I am typically aware enough and understand the importance of patient confidentiality that this would not happen. However, this situation highlighted that even with the best of will, mistakes can happen under pressure. That pressure was self-imposed and is within my control by better timekeeping.

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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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Concrete Experience

My first ever patient in clinic presented with an acute disc prolapse. The patient had recorded a VAS of 10/10 and had consequently booked an emergency appointment. Upon testing the patient was positive  (+ve) on both slump, SLR and was showing reduced S1 reflexes as well as reduced myotomal strength in the S1/L5 distribution. A diagnosis of disc herniation was put forward.

Reflective Observation

Listening to the "Words Matter" podcast on my drive in had highlighted the impact of specific language. I had particularly been drawn to this and connected to the podcast because of a personal experience with an injury before deciding to become an osteopath. I remember thinking at the time, as soon as the practitioner had said I was ok, it was as if the pain subsided. The podcast reinforced the physiological benefit of using mitigating language and offering optimism. The patient had a history of LBP and a previous practitioner (GP) had given him the impression that his back was “crumbling” due to “wear and tear” he had stated “My back is just shot... I think”. I took the time to explain that wear and tear was normal and advised that the disc will heal (typically within 16 weeks) This event was not permanent.  I gave the patient Mckenzie exercises to further integrate a sense of control.

Abstract Conceptualisation

This reflection has led me to understand that language can be a powerful therapeutic tool. Phrases that imply fragility or dysfunction can raise fear whereas supportive, optimistic language can enhance a patient’s confidence and outcomes. I’m now more conscious of aligning my language with the principles of person-centred care, ensuring that my communication is clear and non-alarming. Whilst also being grounded in evidence-based solutions.

4. Active Experimentation

In my future clinical interactions, I will continue to critically evaluate the words I use and remain curious about their impact. I aim to listen attentively. I will also continue engaging with resources like the "Words Matter" podcast to refine my communication style further.

Link: https://www.droliverthomson.com/the-words-matter-podcast/

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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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What ?

I have treated variety of patients from various ethnical background, religions and age groups. Consequently, Whilst I would not wish to diminish this to a singular experience. I had on experience whereby I treated female patients who was unable to undress for religious reasons. Accordingly, I respected her right and focused my diagnosis on case history and active and passive testing and adapted my treatment appropriately.

So what ?

I am aware that working around patient’s values is not only a legal requirement but a moral obligation.

Now what ?

I will continue to treat people fairly and equally. This is something I find comes somewhat natural as a social individual. However, I will try to best to treat all patients equally.

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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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Description of the experience

I recently had an elderly patient presented with a suspected achillies tendinopathy.  I had initially considered a rehabilitation programme which would consist initially of isometric and eccentric loading exercises for the soleus and achillies. I had conducted the relevant safety test to rule out an achillies rupture and felt this treatment approach was appropriate.

When discussing the case with tutor, it was suggested I offer the patient an ultrasound scan. It was explained to that patient that there was a very low chance of rehabilitation causing further damage to achillies, however a scan could mitigate the risk.

Reflection

The scan was considered to determine the severity of the damage to the achillies. I had initially failed to consider this given the nature of the injury. It was not a typical presentation that would concern me enough to offer an ultrasound, particularly given the cost was £85.

When reflecting on this, this case I had never consider it appropriate to offer a scan for a non-traumatic tendinopathy.

Learning

When presenting the option to the patient. I explained the risk of rupture was very low based on our assessment. I then explained the cost of ultrasound would be a relatively costly alternative. The patient immediately opted for the scan and was happy we had offered it. The patient health outweighed the cost and gave me direction on rehabilitation.

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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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Situation

During an initial consultation at the ESO, a patient began with the case history by documenting their experience with previous healthcare providers, being a physiotherapist and their GP. They had remarked that all the physio therapist did was “give two exercises” and the GP had simply prescribed analgesics which had not been effective.

Action

I decided to hear the patient out yet focused my questioning on the complaint more than their frustration. Whilst I agreed that the care had appeared suboptimal, I was also aware that the patient’s frustration may have led to exaggeration. Consequently, I navigated the conversation towards a positive.

Result

By taking the patient through the full assessment, case history, full range of testing and treatment, as well as giving some additional exercise and lifestyle advice, the patient left feeling satisfied and optimistic about their prognosis. More importantly, their mannerism and tone had changed drastically from how they had entered, being more positive.

Reflection

By simply applying the process taught throughout the ESO under tutor’s guidance I was able to leave a positive impression of osteopathy on the patient, without the need to discuss their previous experience. This highlighted to me that, the processes are there for a reason and offer a reliable method to deal with the majority of osteopathic encounters

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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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What?

During the third term of 4th year clinic, I had a patient present with alarming symptoms of Cauda Equina. The patient had presented to the clinic with cervical pain, however during the consultation the patient expressed a history of suspected CES. He had previously had a scan, taken 9 months prior and was cleared, however his symptoms had since progressed. It was clear that the patient needed urgent referral for a second MRI. I calmly explained that we would not be able treat him today and using the concepts I learn in my experienced relating to A2 ; explained that he should present to A&E. I also wrote to the patients GP to cover all basis and gave the gentleman a CES card.

The patient had the scan, which was positive for CES and was scheduled for surgery shortly thereafter. However, between the appointment and surgery date the patient attempted to book back in and get treatment for the cervical complaint. The patient had successfully booked in without mine or my tutors’ knowledge. Upon seeing the patient list, we asked the receptionist to cancel the appointment. The patient was disheartened ask asked for me to email the reasons why. (Email attached).

So what?

In this case, importance can be attributed to severity of the condition. Whilst the patient had presented with cervical pain it was more important that we refer him for urgent care relating to cauda equina. It was highly important the patient understood exactly why we could not treat him and the reason why he should present to A&E.

Now what?

This case taught me the importance of clear, concise information particularly in the case of life altering conditions. I will continue to ensure that important information if conveyed to my patient in a manner that can be easily understood.

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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 ?

The first time I had a patient refuse treatment after explanation of their diagnosis was completely new to me. I had not witnessed this in my observations or even in my own practice while doing sports massage concurrently alongside studying. The patient had presented with lower back pain which appeared to be related to; upon examination a chronic disc issue. After some discussion with the patient on possible treatment approaches the patient decided they would prefer to be referred to their GP before receiving any treatment.

So what ?

This highlighted that not all patients present with an expectation of manual treatment. In this case, the patient was more concerned about diagnosis and prognosis. Until this case, I had worked on the assumption that all patients came in for treatment.

Now what ? In future, I will always seek to offer patients the full scope of which osteopathy can assist and present all options available. This will ensure patient cooperation and decision making and hopefully given a sense of control to the patient during my consultations.

Reference: https://www.osteopathy.org.uk/standards/guidance-for-osteopaths/adjunctive-therapies/

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Adjunctive therapies - General Osteopathic Council

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Osteopaths apply a broad range of treatment practices and many incorporate adjunctive or supplementary therapies or other forms of care or treatment into their practice. Some osteopaths also undertake other work unrelated to health and care.

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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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Concrete Experience:

A patient presented to the headache clinic with a complex migraines. Upon examination, it was noted that there was some cervical instability at C1/C2 which could be addressed with exercises over time. Exercises were given based on my tutor’s experience and sent by email as a backup to the in-session instructions. It was clear that rehabilitation could have a more profound impact than manual therapy alone. Using my background as a personal trainer, I was able to give relevant queues to help the patient perform the exercises appropriately and safely.

Reflective Observation:

Feedback from the patient was positive upon receiving guided exercise advise. The patient initially struggled to perform some of the exercises effectively, with poor proprioception. However, after some queues the patient was able to perform them appropriately and was grateful for the guidance. After 10 weeks of bi-weekly session with the relevant exercises the patients’ migraines reduced in severity and frequency.

Abstract Conceptualisation:

This experience reinforced the requirement to not only promote patients to support their own health but also to teach patients to do so with the correct advise. This helps ensure adherence and safe form.

Active Experimentation:

In future, I will seek to apply my knowledge of rehabilitation and exercise, as well as further developing my understanding in this field with further research and CPD.

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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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Concrete Experience

During my 4th year, I treated an elderly patient who had been experiencing lower back pain. The assessment required observation of active spinal movement to give an accurate diagnosis. I asked the patient to undress as far as they felt comfortable. It became apparent that having three observers in the room made the patient feel uncomfortable, particularly when it came to examination. I politely asked the observers to leave, however the patient still preferred to keep her vest top on.

Reflective Observation

Whilst the patient did not verbally express their discomfort, it was apparent from her body language that she did not feel entirely relaxed. This promoted me to inquire further. In hindsight I should have checked with the patient whether she was happy with the number of observers before bringing her into the clinic room.

Abstract conceptualisation

This interaction highlighted the need to be forthcoming with patient consent, particularly in this case surrounding modesty. It further highlighted the need to be clear in asking permission. This enables the patient to feel in control and have their boundaries respected.

Active Experimentation

I now tend to narrate what I’m doing with patients, and this is not just related to modesty and dignity. I tend to explain their diagnosis, prognosis and treatment to ensure my patients dignity is maintained as well as their comfort levels. I have found this also bolsters my own learning and highlights gaps in my knowledge.

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

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

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Description:

I was initially drawn to osteopathy because of a preference to natural, conservative treatment measures.  I had a patient present to the clinic who was prescribed two forms of medication.  An ACE inhibitor for high blood pressure and beta agonist for low blood pressure as well as a statin for cholesterol. Upon seeing the medication list, I was frustrated why someone would be medicated for both high and low blood pressure. I advised the patient to get a medication review but refrained from sharing my views on the matter.

Feelings:

I felt frustrated that my patient was being medication for both high and low blood pressure. It seemed counter intuitive. In reflection my frustration demonstrated my strong beliefs that medication can be over prescribed. Particularly precautionary medications such a statins and or blood pressure medications.

Evaluation:

In hindsight I could have offered some natural solution to help reduce cholesterol and balance blood pressure. Simple advice would suffice and could extend to exercise and basic dietary advice. The patient did get a medication review, and the GP had missed that two medications were being used for one condition. This highlighted that some of my bias’s may have merit, however they should be expressed professionally and be evidence based.

Analysis:

This taught the importance of separating personal opinion and evidence based outcomes, whilst also ensuring that the patients’ health is prioritised

Conclusion:

I learnt that I could maintain professionalism and compassion without imposing my own bias on patients.

Action Plan:

I will strive to continue to learn with an open mind without compromising my own or GOSc’s ethics.

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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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What?

During children’s clinic I had a new patient in for a checkup. There was no direct complaint and no direct concerns. Consequently, my notes were sparse and did not adequately present these findings. The next session I was absent and one of my colleagues had to cover the patient. They had a difficult time inferring my notes and spent a lot of time revisiting work that had already been done but not recorded. This prompted a discussion with my tutor to improve my notes.

So what ?

Naturally, my approach is patient centric and as a result my notes have been the one thing that suffers. I have a tendency to lose myself in the consultation and fail to take adequate notes during. I have since made a conscious effort to improve taking shorthand notes during the consultation.

Now what ?

My next CEX after this consultation produced result that were recorded as “Above expectation” for recording of findings. My plan is to continue to ensure my notes are recorded during the consultation and each section is filled out adequately. Not only for my colleagues but for my follow up session with patients.

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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 ? A fourth-year presentation was required for a one of two conditions. I chose sub-acromial impingement due to have a number of patients whom I had diagnosed. However, I was aware that my knowledge was somewhat limited despite the given diagnosis.

So what? I produced a poster presentation which I received a 90% grade for. The presentation was a combination of evidence-based discussions and application of osteopathic principles and treatment.

Now what ? I now feel I have sufficient and up to date knowledge to diagnose and treat sub-acromial impingement or refer where appropriate. The process of researching the condition also gave me a framework for future research. This process efficacy if supported by the respective grade and gives me confidence in the procedure.

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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 ?

During an early CEX, it was noted that my differential diagnosis was weak in relation to a shoulder complaint. Secondary to this, the test I used to rule out specific conditions was lacking.

So what ?

Consequently, I developed a revision methodology whereby I would produce illness scripts for conditions, then summarise with the relevant special test (if one existed) to rule that condition in or out. I began with the shoulder, given this was the highlighted area of weakness. However, I have applied this strategy to all areas of the body. Since then I feel as though my MSK differential has improved significantly.

Now what ? I would like to apply this to non-MSK conditions and improve my understanding of systemic  or visceral related conditions were a MSK diagnosis cannot be established. I will also continue to improve my MSK diagnosis, utilising my patients’ complaints as a vehicle to develop further.

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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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The Event:

A patient presented to the clinic with left shoulder pain, both anterior and posterior in the supra-scapular region. On initial examination the patient presented with reduced range of motion in the left shoulder on both active and passive testing. In particular shoulder abduction, flexion and external rotation. The patient presented with a painful arc. This led to an initial diagnosis of sub-acromial impingement which the patient had four sessions. No improvement was noted which led to me to question the accuracy of the diagnosis.

Reflection:

On the fifth visit I explained to the patient that the diagnosis was perhaps part of the picture, but we would expect some improvement. I revisited the diagnosis and performed further testing. At this point, I noted a significant reduction in external range of motion when performing passive testing of the shoulder. It became clear that there was a hard end feel and that the reduction in range was likely due to bony morphology. It was also noted that the caraco-acromial ligament was tender on palpation with the shoulder extended. I asked the patient about the onset which was traumatic in nature. This led to a change in diagnosis to suspected caraco-acromial ligament sprain predisposed by bony abnormalities in the shoulder. We sent the patient for a ultrasound which confirmed a ligament sprain.

Influencing Factors

My initial diagnosis was clouded by my clinical findings. Test A = result A. However, this was an oversimplification with a test that lacks in both sensitivity and specify. It was when I returned to osteopathic evaluation with through active and passive testing that the picture became clearer. Whilst I identified the error it was my tutor’s input which helped refine my testing and offer options differential diagnosis. Another major influencing factor can be attributed to simple curiosity. I took the time to think about the anatomy, slow down and understand the presentation.

Could I Have Dealt with It Better?

I initially overlooked passive testing as a diagnostic tool. At this point I had invested a lot of time into orthopaedic test and had biased my diagnosis based on their findings. In hindsight the combination of both is more appropriate. This also highlighted a lack of specific anatomical knowledge which needed to be revisited.

Learning

This case represented a breakthrough in my osteopathic journey. Whilst it improved my shoulder differential diagnosis and testing. The outcome of the case was one that could be applied to my entire osteopathic philosophy. Since this case, I have revisited the basics from year 1 and 2. Understanding my anatomy and really applying active and passive testing with thought and consideration with the benfit of the new contexts I have learnt in year 3 and 4.

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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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What ?

I have never had a request from a patient or healthcare provider for specific data or material. I am familiar with writing clinical notes and reports during my student placements,though these have not yet extended to formal data requests. I do, however, have a previous history of replying to legal / data request following a ten-year career as a RICS accredited surveyor. Similarly, the Royal Institution of Chartered Surveyors offer similar guidelines to that of the General Osteopathic Council by which legal request are subject to specific timelines.

So what?

Reflecting on this, I am aware of this shortfall. However, My previous legal experience is extensive and will help me adapt to any request received pertaining to formal data request.

Now what ?

As I transition into practice, I will seek guidance from my prospective employer and obtain relevant feedback when responding to any formal request for written material. Similarly, if any such requests are received during my stay at the ESO, I will seek guidance from my tutors to respond appropriately.

Evidence: https://www.rics.org/profession-standards/rics-standards-and-guidance/conduct-competence/client-relationships-and-handling-data

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Find support and advice on how to apply the Rules of Conduct for your practice in this area.

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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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The event:

The same experience discussed within B1 can be learn from and applied with relation to C4. A male patient presented to the ESO with cervical pain, however upon case history taking it was apparent that he had symptoms of cauda equina.

Reflection:

The patient was given a cauda equina card and advised to present to A&E with immediate effect. It was also decided that we would write to the patients GP to ensure that we had covered all basis. The patient signed the relevant consent letter. The patients GP responded quickly and referred for an emergency MRI.

Influencing Factors:

The patient seemed reluctant to present to A&E which prompted the GP referral. This ended up being the correct procedure as the patient failed to present to A&E immediately and was later contacted by his GP with the MRI referral.

Could I Have Dealt with It Better?

Our concerns were shared with the patients in an urgent, yet calm manner and the referral letter was sent out immediately thereafter. Perhaps, I could have been more forthcoming with my concerns and prompted the patient further. overall, I am happy with how this was dealt with. Particularly considering the patient has since had decompression surgery,

Learning? This experience taught me that osteopaths will be exposed to potentially life-threatening conditions. These scenarios, up until this case were hypothetical in a learning based environment. I am grateful to have had the opportunity to assist the patient and get him the correct care. This will help me trust not only my intuition but clinical guidelines in future.

Evidence linked to B3 (redacted referral letter)

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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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What?

This cannot be limited to one isolated experience. I always strive to keep my practice safe, clean and hygienic by disinfecting  regularly and changing the couch paper between each patient. I often have fully booked clinics and ensure that adequate time is left between appointment to carry out basic cleanliness. ( see CEX result displaying adequate time keeping.

So What?

I am aware that when I am in practice, I will require adequate public liability insurance and will continue to ensure hygiene is up-kept in my clinic.

Now What ?

If I have any concerns of my responsibility, I can review health and safety law at UK Health and Safety Executive

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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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Description:

A 57-year-old female presented to the ESO sports clinic with severe posterior heel pain due to a previously diagnosed Haglund’s deformity (HD). Symptoms were debilitating and had worsened significantly. My assessment proposed HD with secondary retrocalcaneal bursitis. Given her goal of returning to running, I referred her to her GP for a second surgical opinion and provided a multi-phase management plan that spanned pre- and post-operative care.

Feelings:

I felt a responsibility beyond symptom relief, to support the patient’s long-term functional goals. While the presentation was familiar, her frustration and the severity of pain pushed me to reflect more deeply on the contributing factors that impacting her wellbeing, including footwear, biomechanics, and post-surgical rehabilitation. I felt confident in my manual therapy skills but cautious in making a surgical referral.

Evaluation:

The referral was appropriate, ultimately leading to surgery that improved her function. Manual therpay along with exercise reduced swelling and improved mobility. The patient responded well to the progressive rehab plan. One challenge was ruling out infection post-surgery, which was resolved through careful questioning and collaboration. The situation highlighted the importance of continuity of care, lifestyle advice and communication with other healthcare providers. .

Analysis:

This case highlighted our role as more than a manual therapist. By recognising the limitations of conservative care and the potential benefit of surgery, I contributed to the patient's long-term health outcome. I also supported her beyond the treatment - addressing footwear (shoes that did not have hard backs), educating on self management strategies and facilitating biomechanical recovery. This improved my understanding of OPS standard C6.

Conclusion

Overall, I feel satisfied with my clinical reasoningand referral decision.

Action Plan (If it arose again, what would you do?)

In future, I’ll aim to:

Strengthen communication where possible with other healthcare providers and continue using evidence-informed exercise programming.

Evidence. This was documented in my case study report which received a grade of 90%. OS743_CW1

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D9: Support colleagues and cooperate with them to enhance patient care.

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D9: Support colleagues and cooperate with them to enhance patient care.

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What happened?

A 47-year-old female presented to headache clinic suffering from suspected cough headaches. The patients  symptoms were debilitating, including postural induced nausea and fatigue which would result in severe headaches.

What did you do ?

was decided with my tutor. This led to a finding of spontaneous intercranial hypotension, which indicated a thoracic dural tear.

Whilst osteopathy could note directly treat the suspected dural tear; it was decided with the patient that we could attempt to improve her symptoms and comfort levels.  I have worked with a variety of tutors to help the patient and called upon the experience of multiple colleagues to help alleviate the patient’s symptoms. In these sessions I have also worked with students who exceed my ability in areas such as cranial treatment.

Whilst I continue to develop my own skills with my patients, with this particular individual I thought it more important to call in help. When facing a life debilitation condition, patient relief superseded my own requirement to develop certain skills.

What was the outcome?

This patient continues to come to clinically to assist with symptoms while investigations to find the dural tear continue.

What did you learn?

This case highlighted how the scope of osteopathy can be used to address complex presentations.

Email of patient feedback attached.

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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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What ?

A patient  presented to the ESO with proximal calf pain and ankle  stiffness following surgical repair of the lateral collateral ligaments. They patient had been assigned to physiotherapy, but had presented to the ESO with a hope to  combine manual therapy with on-going rehabilitation.

So what ?

To ensure adequate care, I reviewed the patient to exercises. The physiotherapist had given a range of proprioceptive exercises as well as eccentric soleus and gastric exercises. They had also provided a timeline with relevant repetition and progressive loading, which had been adjusted and personalised over a number of sessions. The quality of the treatment appeared optimal. Consequently, I gave my opinion on some of the exercises that I preferred with the caveat that the current treatment was more than sufficient and explained these were a personal preference.

Over the next few sessions, the patient acted relayed information between me and the physiotherapist as we shared ideas and worked in tangent for the best outcome.  Not only did this confirm some of my own ideas towards rehabilitation, I learnt a number of new evidence based protocols for ankle rehab from the health care professional.

Now What ?

The patient has since returned to triathlon and has been injury free. This case taught me the benefit of combined therapy in improving patient outcomes. This case can be extrapolated out and applied to multiple complaints.

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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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What ?

Whist I have not been unwell during clinic at the ESO, I am aware of GOsC standard that any communicable diseases that may prevent me from practising should be cleared by a medical advisor before returning.

During the Covid pandemic in year one, I was exposed to PPE including gloves, mask and gown. If necessary, these can be worn in practice to prevent transmission of minor infections. Guidance has been posted to the student VLE. ( attached as evidence )

So What ?

Any illnesses that may prevent me from practicing for an extended period. I should informed GOsC and return when my GP informs me.

Now what ?

I will continue to follow this guidance as and when necessary.

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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 ?

During first year we was tasked reviewed GOsC guidance regarding complaints or misconduct. This process highlighted the importance of transparency with GOsC and patients when consideration. We was then required to draft a response to a complaint letter to a simulated compliant and include the relevant GOsC regulation.

So what

This process required review of the relevant GOsC policies in order to the pass the relevant marking criteria.

Now what ?

Should any issues arise in future regarding my competency or conduct, I will ensure to re-review GOsC policy to assess for any updates to regulatory requirements.