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A5 reference:
Alkatan, M. et al. (2016) ‘Improved function and reduced pain after swimming and cycling training in patients with osteoarthritis’, Journal of Rheumatology, 43(3), pp. 666–672. doi: 10.3899/jrheum.151110.

B1 reference:
Slattengren, Andrew H., et al. "Best uses of osteopathic manipulation." Journal of Family Practice, vol. 66, no. 12, 2017, p. 743+. Gale Academic OneFile, link.gale.com/apps/doc/A522584534/AONE?u=anon~261926f7&sid=googleScholar&xid=e2f0c697

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The Gibbs reflective cycle represents the way in which i analysed and reflected upon my performance for the adherence of each OPS.
With the use of this reflective cycle it enabled me to identify any areas in different scenarios that i would do differently upon re-occurrence of the same or a similar situation.
with the use of the Gibbs reflective cycle i was able to identify the how the situations made me feel and where i could improve upon each scenario leading to an action plan and an overall better attainment of each OPS.

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A female patient attending the ESO clinic presented to myself with symptoms of posterior/lateral hip pain. At the time of the presenting symptoms i was only covering for one of my colleagues and assumed that afterwards the patient would go back to seeing him to continue her management/treatment plan.
Due to this case being a cover patient i did not perform a thorough examination of the patient and decided to follow and continue with a similar treatment method my colleague was originally taking.
The following week the patient returned to clinic but was attending an appointment with myself rather than her previous practitioner. when presenting the case to my tutor i found myself confused and struggling to explain/justify the diagnosis i had given.
Prior to the patients actual appointment i had a discussion with the tutor about the examination lacking in certain areas.
Upon realizing the lack of care i had showed the patient i felt embarrassed of my performance as a practitioner and that i did not offer the patient the best care possible from myself, identifying lower standards of care shown by myself i then had the responsibility to explain what had happened to the patient and why i needed to complete a full examination of her and her symptoms. After an explanation was given to my relief she was very accepting and understood why i had to re-examine her.
This experience taught me that i should treat all patients no matter how long i will be seeing them or what diagnosis has been given to complete a full examination and make sure that i agree with the diagnosis or alter it and the subsequent management/treatment plan.

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After the first experience of not completing a full examination upon a cover patient and identifying the importance afterwards, the next time i had to cover a patient of one of my colleagues i made sure that i completed a thorough examination of the patient which led to me disagreeing with the diagnosis previously given towards the patient. The fact that i conducted a full examination on the first appointment between myself and the new cover patient meant that i felt confident in what i needed to explain to the patient and how i could provide the best care for them going forward. unfortunately i did see this second patient again as he went back to his original practitioner. However, i did notice that after my consultation with the patient in the following treatments his original practitioner had changed the management plan to best suit the diagnosis i had given the patient. This made me feel happy as i felt i had contributed towards the best possible care of the patient.

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Although i have not experienced any patient attempt to test the boundaries between a patient and practitioner relationship, One of my colleagues experienced a patient attempt to add her on various forms of social media and made inappropriate comments within the consultation upon the first second and third appointments.
my colleague sought after some advice from myself and i feel i advised correctly by telling her to possibly hand him over to a different practitioner (male) and to simply inform him that any contact through social media would not be appropriate or coincide with a professional relationship.

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On the ESO website there is a clear link for which patients can follow if they wish to make formal, informal or GOSC related complaints. The image below shows the complaint procedure found on the ESO clinic website giving clear instructions to patients wishing to make a complaint.

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One of the assignments during my studies at the ESO was to perform a case report upon a patient that i had myself seen whilst in clinic. To do this i first needed to gain consent from the patient for permission to use their case and to explain the purpose of the case report. Doing so i also informed her that it would be completely confidential and no one would no way have any way of identifying her as of reading the case report produced by myself. It was at this point she was once again asked for her permission which she fortunately granted me.

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Throughout my time in the ESO as a student practitioner i have treated a variety of patients with vast differences in age, culture, race, gender and sexual orientation. gaining this experience in my time at uni and previously i have become aware of various different beliefs that i may not believe in myself. Being aware and passing no judgment of these differences makes it easier to build trust with patients even if they have different views, opinions or beliefs to myself as i have still maintained my utmost care for each patient without prejudice towards them.
Although i haven't experienced a scenario where a patients values or beliefs have conflicted my own in way that effected treatment or management i am aware of the anti discrimination laws set in 2010 and i will look to continue to abide by these laws to prevent any discrimination by myself towards anyone that has different beliefs and culture to my own.
This legislation benefits both myself and my patients going forward as it will allow for the best possible management of the patient whilst still maintaining their cultural beliefs.

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As a student practitioner i have experienced various different people asking me to treat them privately outside of the ESO clinic and although tempting, i have maintained my professionalism by making sure the influence of money did not cloud my judgment which meant that i either advised them to make an appointment with a qualified and registered osteopath or to the ESO so that they could treated correctly and safely within the sufficient environments.

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With the use of social media becoming ever popular across a number of platforms and i myself being a user of some form of social media. It has become important to myself and towards the representation of the profession that i do not post anything online that would appear unprofessional or potentially make the public have any doubts towards the profession. A way in which i have prevented this was by deleting any posts by myself that could've been considered as not professional towards myself or the profession.

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Due to being a student and a student practitioner i have not had any experience in dealing with financial part of being an osteopath as of yet.
The only theoretical experience i can reflect upon would be that of the business plan i had to create as part of an assessment whilst studying at the university. The business plan required myself to conduct some research surrounding the types of advertisement and financial clarity that other osteopathic clinics promote.
If/when the chance for myself to obtain my own clinic or produce my own advertisement i would make any financial dealings clear and concise to any potential patient should they see the advertisement or costs for services or products.
in the link below is the business plan as previously mentioned.

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Within the clinical environment i have been lucky enough to have experienced this with a very helpful group of colleagues that i work with every time i am in the ESO clinic. This support from the group and myself does not just involve helping each other with assignments that are due in towards the course but also way that we help benefit each other into becoming better potential osteopaths.
The ways in which we have helped each other throughout our time together include holding online teams discussions about theoretical cases and how we each would manage and treat them individually. Along with this we have consistently given each other constructive feedback upon how each of us could improve our case history taking, patient handling, examination and treatment techniques. This has helped myself progress as a student practitioner massively.
Along with the help towards becoming better osteopaths there has been occasions where we needed to cover each others patients due to working on an alternating week system during the COVID-19 pandemic. working on this alternating week system meant that we had to pair up with another practitioner so that on our weeks off the patients that required treatment/management could still receive care from someone that already understand their condition and prognosis. Working through this process really helped me understand the benefits of communication and working as a team as it made the whole process of caring for the patients a lot easier.

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A young female patient presented in clinic to myself complaining of dizziness and regularly being lethargic/lacking energy. After a thorough examination and questioning of her systemics and cranial nerves the results were inconclusive to support any real benefits from having osteopathic treatment. This led to the onward referral to her GP for further testing, more specifically blood tests.
Upon contact with the patient after she had seen the GP and received the blood test results the conclusion was that she was anaemic and had multiple vitamin deficiencies.
At the time of her presenting to myself due to the inconclusiveness of the examination, i myself was confused with what was causing her symptoms but after a discussion with my tutor and hearing of her diagnoses i was relieved that i had done the right thing by not treating and referring her onto someone better suited to diagnose and treat her symptoms.
The knowledge i had of other healthcare practitioners roles helped me decide the best course of action and onward referral for this patient, giving her the best possible care for her symptoms available.

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Throughout my two years of clinical experience at the ESO the COVID-19 pandemic has also occurred meaning that for myself to prevent possible transmission of the virus to any of my patients i have needed to conduct regular testing to know if i had COVID or not. The reason why i conducted regular testing and not just relying on whether i had symptoms or not was due to the fact that i could have it without presenting any symptoms. this meant that the safest way to determine whether or not i had COVID-19 was to regularly test myself with the government testing system.

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See reflection as no evidence or experience has been gathered for this OPS.

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At the ESO one form of assessment  is the CEX assessment and is a snippet of the students performance in clinic with a patient.   It is done in both a formative and a summative structure (one for grading and the other for feedback).
Within a CEX some of the feedback i received surrounded my clinical examination and as a result was given the borderline fail grade. (feedback shown below).
This was particularly stressful for myself as i wanted to achieve a better grade but more importantly be a better osteopath by improving my patient handling during the examination stage.

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I approached this constructive feedback by practicing with my colleagues how to make my handholds more comfortable and to take better care of patients whilst examining them. This improved my clinical examination skills shown by future CEX results (shown below)achieving the meets expectation mark.

Upon leaving the ESO to ensure that my skills do not become less effective and uncomfortable for patients when they're in my care the feedback from each patient and my colleagues when they observe me with patients will be vital to ensure the patients are still comfortable and my handholds are effective.

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Taking a patients case history and recording the osteopathic procedures and results followed such as systemic health, diagnosis, treatment, management, advice and consent given is something as a student i have practiced throughout the four years continuously.
Initially the hardest aspect of keeping a comprehensive recording of everything, was doing so within time restraints meaning that i would often rush the recording of information making my handwriting difficult for others to read.
This difficulty for other people to read my hand writing was picked up by my clinic tutors meaning that i needed to make a conscious effort to make my hand writing neater and easier for my colleagues to read if they needed to.
Due to this occurring at the start of third year i have improved the efficiency of recording notes whilst maintaining the neatness of the writing improving both timekeeping and comprehensive recording of notes.

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As a student practitioner it is imperative to understand my limitations as to what i can and cannot treat in relation to a patients symptoms and diagnosis'.
An experience in relation to this would be one of which a patient presented to myself with neurological symptoms into both lower extremities and a progressively worsening urinary incontinence. with those symptoms in mind i had to be aware of the possibility of this being a case of cauda equina syndrome.
Knowing severity of this, i was aware that if this was in fact the case then my treatment modalities would've been ineffective if not possibly more damaging towards the patient. This led me to the route of referring the patient to accident and emergency to get a subsequent  MRI scan.
This scenario was a fairly uneasy one as it was the first emergency referral i had encountered in my time as a student practitioner. It required some assistance from the tutor in how to approach the patient with the correct information and severity of the situation they was in.
Along with the assistance from the tutor i needed to make sure that the information on the emergency referral letter was neat and comprehensive so that the A and E consultant understood the situation.

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During my time in clinic i have not yet experienced at any point concern for the welfare of my patient whether adult of child.
However the image below shows the certificate for recognizing and preventing FGM, indicating that i have the ability/capacity to identify the possibility of my patients welfare being effected.

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With a large portion of my clinical experience occurring during the same period as the COVID-19 pandemic, there has been a large emphasis on making sure that between every patient the treatment rooms are sanitized and cleaned to make it safe for the next practitioner and patient using it.
Along with sanitizing the rooms i have been using the PPE provided by the ESO along with the COVID protocols to ensure that each patient/colleague of mine is as safe as possible in relation to their hygiene and consequently their health.
Not only was the responsibility for my patients health but this would also effect myself and the people around me due to the contagious nature of COVID-19 therefore increasing the importance of maintain a safe and clean clinical environment.

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A young female patient presented in clinic to myself complaining of dizziness and regularly being lethargic/lacking energy. After a thorough examination and questioning of her systemics and cranial nerves the results were inconclusive to support any real benefits from having osteopathic treatment. This led to the onward referral to her GP for further testing, more specifically blood tests.
Upon contact with the patient after she had seen the GP and received the blood test results the conclusion was that she was anaemic and had multiple vitamin deficiencies.
At the time of her presenting to myself due to the inconclusiveness of the examination, i myself was confused with what was causing her symptoms but after a discussion with my tutor and hearing of her diagnoses i was relieved that i had done the right thing by not treating and referring her onto someone better suited to diagnose and treat her symptoms.

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During the four years attending the ESO i have attended a wide variety of lectures and tutorials to help develop my skills as an osteopath, so that i could safely treat patients within a clinical environment.
Due to what i feel was a limited amount of lecture time spent on the bio-mechanics within the first two years, understanding the 'normal' ranges of motion in terms of degrees a joint 'should' be able to move in different vectors was initially a challenge for myself within the 3rd year (1st clinic based year).
Becoming aware of this lack of knowledge was very stressful for myself as a tutor asked what degrees various joints could move in certain vectors and at the time i did not know the answers. This was stressful for myself as it would be considered fairly basic knowledge for an osteopath to know/understand.
Being aware of this lack of knowledge meant that for myself to become a better/safer osteopath i needed to do some personal learning and research so that i properly understood the bio-mechanics of the human anatomy. Doing this has enhanced and improved my osteopathic skills over the two years of clinical experience.
on reflection of this situation i feel i handled it as positively as i could have done by identifying the area of which i was lacking knowledge and after buying and reading the book shown below to enhance my knowledge of the bio-mechanics in the human anatomy. I feel it developed my knowledge as an osteopath

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within the start of third year a further area of knowledge which i felt was lacking was knowing when manipulation was beneficial to the patient and their subsequent condition. identifying this me to do further to improve my knowledge surrounding the subject. Below is a link to just of the many articles i have read to improve this knowledge with the aim of making me a better/safer osteopath.

https://go.gale.com/ps/i.do?id=GALE%7CA522584534&sid=googleScholar&v=2.1&it=r&linkaccess=abs&issn=00943509&p=AONE&sw=w&userGroupName=anon%7E261926f7

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As a student practitioner it is imperative to understand my limitations as to what i can and cannot treat in relation to a patients symptoms and diagnosis'.
An experience in relation to this would be one of which a patient presented to myself with neurological symptoms into both lower extremities and a progressively worsening urinary incontinence. with those symptoms in mind i had to be aware of the possibility of this being a case of cauda equina syndrome.
Knowing severity of this, i was aware that if this was in fact the case then my treatment modalities would've been ineffective if not possibly more damaging towards the patient. This led me to the route of referring the patient to accident and emergency to get a subsequent  MRI scan.
This scenario was a fairly uneasy one as it was the first emergency referral i had encountered in my time as a student practitioner. It required some assistance from the tutor in how to approach the patient with the correct information and severity of the situation they was in.

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after referring the patient i felt the need to improve my knowledge of the cauda equina syndrome with further research surrounding the symptoms, medical examinations/scans and the treatments of the condition itself.
Below is a link in which is used to identify areas that lacked knowledge of the condition.

https://patient.info/doctor/cauda-equina-syndrome-pro

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As a student practitioner and a possible qualified Osteopath in the near future it has always been important myself and the welfare of my patient to maintain a high standard of knowledge and skills.
Maintaining this high standard is done via regular reflection upon my skills and performance whilst with patients and also practicing with my colleagues.
The regular reflection allows myself to identify weaknesses and areas to improve in examination, treatment and knowledge.
Throughout the two years the rarity of performing systemic examinations such as respiratory and abdominal screens led to my skills within these aspects of being an osteopath to decline.
Acknowledgment of this decline was timely and relieving as within the following week of revising and practicing these skills a new patient attended the ESO clinic that required a respiratory examination to rule out any underlying pathologies. Due to the recent practise of the respiratory examination when the patient attended i asked to the tutor to observe my examination and provide feedback for areas of improvement. When the feedback was received the tutor stated that it was competent but i still needed to improve on the percussion aspect of the examination. To maintain a good standard

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Throughout the four years as a student, having regular exams on my skills has helped identify what aspects of my training i need to improve upon to become a better osteopath. In the image below you can see that i scored very low in whilst being assessed on my communication skills.
This was not something i enjoyed but was definitely something that i feel i have benefited from in the long term.

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Throughout the four years as a student attending the European school of osteopathy (ESO) various lectures/lecturers advised to always have the interests of the patients in mind throughout the treatment and management of each patient.

Alongside the teachings within the four years at the ESO clinical environment the forms used for an initial patient contain a section regarding the 'goals and expectations' of the patient.
Evidence is shown below of a patients response to that section which required myself to spend slightly more time explaining how her injury was caused, what she could do to prevent the injury from reoccurring and the various different treatments with the best outcomes for her specifically.
What stood out and resonated for myself in this situation was how appreciative the patient was at the end consultation for simply taking time to explain her injury to her and the options available to her.

Along with the use of the forms supplied by the ESO clinic, maintaining a treatment and management plan for each patient individually is something that i have improved upon with experience, as within the start of the third year i struggled to identify the specific needs for each patient due to being nervous which affected my communication skills. Preventing me from understanding the clear needs and expectations of each patient.
As my experience grew my nervousness decreased and with further practice and reflection upon my communication skills i identified that i needed to follow up with further questions rather than just relying on filling out the box on the form shown below. This also enabled me to build better rapports with my patients and allowed better understanding of their specific needs.
Now at the end of the fourth year i feel confident upon understanding each of my patients individual needs and concerns but i will continue to develop these skills by using the Gibbs reflective model and continuously aiming to improve and develop my communication skills.

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Throughout the two years within the ESO clinic i have treated and had consultations with a large variety of patients with different temperaments, ages and views. This required me to alter my communication to best suit which ever patient was in front of me. One  of the most difficult situations i found was whilst consulting with a child patient (11 year old boy). This particular situation was difficult as the child was not engaging in the conversation himself which led to myself just aiming the questions at the mother throughout the duration of the case history.
During this scenario this made me feel slightly awkward for the child and concerned that i might not have been getting the correct information due to the mother answering the questions.
Upon reflection of this situation i identified that in the future i needed to alter the way in which i spoke to the child patient to engage more with him by using more relaxed terminology and relating some of the questions to the sports in which he played in his free time. By doing so within the next treatment session i was able to build a better relationship with the patient and no longer relied on the mother to answer the questions.
After i had seen the patient i had a better understanding of the benefits of trying to relate my questions and to alter my form of communication to match that of the patient as this will make them more responsive.

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Good communication between patient and practitioner is something that i have always needed to be mindful of.
During my third year in the course i found difficulty in being able describe the anatomy and physiology to patients in Layman's terms so that they could understand what was occurring and why certain muscles or joints were effected with their condition/injury. The difficulties i found came when i was simply trying to describe certain muscles or joints to the patients.
This has lead to me trying a variety of techniques to find the best way of communicating to each patient.
The techniques in which i tried were; simply describing the anatomy and physiology to patients which only worked with a very small amount of my patients, using the physical models, demonstrations, and the use of the labelled posters on the walls in the clinic rooms. I had tried each different type of communication with different patients, by doing so i identified that each patient needs different forms of communication meaning that each patient responded differently to the varying forms of communication.

One of the most effective ways i have found to communicate with patients is with the use of diagrams and posters of anatomy and physiology, as this allows clear concise communication with less chance of language becoming a barrier. The diagrams used are on the walls within each clinic room which make it easy to identify which structure within the musculoskeletal is effected by their injury/condition.
After i had identified my weakness in simply describing to the patients it made me feel embarrassed but led to the attempts of using other techniques. Shown below is the posters that are within each clinic room which allowed myself to clearly identify the structures which were effected to each patient.
With a number of patients stating to me after treatment or consultation that the use of the posters gave them a visual image as to what areas of their bodies were effected and treated during the subsequent treatment sessions.

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As a student practitioner i have always aimed to inform patients of the treatment techniques i feel would benefit them and i would like carry out. In this moment of the consultation the patient is made aware that they can freely object to any or all forms of treatment. In my time at the ESO clinic i have only experienced one patient objecting to having a high velocity thrust (HVT). His objection came after he was informed of the risks that this type of technique has. His objection meant that treatment needed to be adjusted so that it didn't go against his wishes, this was done by replacing the HVT with an articulation of the joint instead. During this experience i felt comfortable in altering the treatment plan of the patient whilst still achieving the goals made between myself and the patient.

Although i now feel confident upon gaining valid informed consent i was not always completely competent in doing so. feedback i had received in a CEX within the third year identified that i needed to work on having a more thorough consent process. Receiving this feedback gave me a push to practice my consent process with my colleagues and led me to becoming better at explaining effects of treatment and how certain treatments may make the patient feel.
Below is the feedback received from the CEX.

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The image below shows a CEX that occurred half way through 4th year. It shows that i am where i should be at this current time and that my communication and consent gaining skills have improved since the last assessment.

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Within the treatment and management of each patient, advice concerning their hobbies and lifestyle choices may be given to the patient to help aid in their recovery or to reduce the risk of further injury or worsening symptoms.
My personal experience of this during my short time as a student practitioner, would be that of concerning a patient that was an avid runner, and used various forms of exercise to help with her mental well -being. During the management of this patient the diagnosis that she had was Osteoarthritis of the right hip. Advise was given by myself for her to reduce the amount of running she did and to potentially replace it with swimming. When this idea was suggested to her initially she did respond negatively but once i had explained how the effects of running may cause the symptoms to worsen her outlook changed.
It was also explained to her that she does not have to follow my advice but it is to simply make her aware of the possibility of her choices making her symptomology worse.
upon reflection of this situation i felt as if i handled it competently by allowing the patient to make her own decisions, but still giving her the information she needed to be aware of the possible consequences of still running.
Below is an article which shows the benefits of swimming for patients with hip osteoarthritis.
By giving the patient the correct advice towards swimming and how it would be beneficial to her i feel i helped even further aid her recovery/managment of her pains and symptoms she initially presented with.

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Prior to the COVID-19 pandemic it was common practice for the student practitioner to have colleagues in the treatment room to observe the process of; case history taking, examination and treatment. For this to go ahead consent would need to be gained from the patient so that observers could be in the room. The majority of patients usually agreed to being observed by my colleagues, with myself having only one experience where the patient did not want more than myself to see them undressed.
In this situation i became aware of their discomfort to being undressed in front of others, which prompted myself to offer a medical gown and to inform my colleagues that they weren't allowed in the room to observe.
From the patients first consultation i understood the patients discomfort with being undressed in front of others which led to me telling my colleagues they could not observe this particular patient prior to them coming in, preventing putting the patient in a second awkward position.

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Throughout my time as a student practitioner i have had little experience with my culture or beliefs conflicting that of a patients in a way which has prevented myself from treating or examining them.
One experience i have had was with a new female patient that was unaware she was going be examined/treated by a male practitioner. After being made aware of the processes about to take place i asked if she was happy to continue with the consultation. She responded by stating that she would only like to see a female practitioner as she did not feel comfortable with a male examining and treating. In this situation i then informed the clinic reception and my tutor to reorganize an appointment for the patient where she could see a female practitioner as no female practitioners were available at the time.

in this situation i feel i handled it as well as i could have done as although i would've been comfortable and professional in treating/examining her she did not feel comfortable which made have had adverse effects upon the treatment or examination. This was an eye opening experience for me as it made me aware that some people aren't always comfortable being treated by the opposite sex. this is something i may have to deal with throughout my career  meaning that this situation was a valuable experience for myself and an important learning curve to not just assume that all patients would be comfortable to be treated by myself.

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After receiving the feedback that my communication skills needed to be improved it is something that i practiced with my colleagues and tutors throughout my two years within the clinical environment.
the image below from my end of fourth year exam results show that my communication skills have improved since the second year.
This made me feel pleased knowing that my practice had helped enhance my communication skills with patients.