# data[].attributes.body
Brignardello-Petersen, R., Guyatt, G.H., Buchbinder, R., Poolman, R.W., Schandelmaier, S., Chang, Y., Sadeghirad, B., Evaniew, N. & Vandvik, P.O., 2017. Knee Arthroscopy Versus Conservative Management In Patients With Degenerative Knee Disease: A Systematic Review. BMJ Open, 7(5), p.e016114.

Downie, A. et al., 2013. Red Flags To Screen For Malignancy And Fracture In Patients With Low Back Pain: Systematic Review. BMJ (Online), 347.

GOsC, 2018. Updated Osteopathic Practice Standards - General Osteopathic Council. Available at: https://www.osteopathy.org.uk/news-and-resources/document-library/osteopathic-practice-standards/updated-osteopathic-practice-standards/ [Accessed May 9, 2021].

Internet2, 2016. Arthritis In Knee: 4 Stages Of Osteoarthritis - IBJI. Available at: https://www.ibji.com/blog/orthopedic-care/arthritis-in-knee-4-stages-of-osteoarthritis/ [Accessed January 10, 2021].

Internet1, 2013. “Differential Diagnosis: Approaches And Pitfalls - A Pediatric Case-Bas” By Zev Waldman And Mary Ottolini. Available at: https://hsrc.himmelfarb.gwu.edu/elearning/22/ [Accessed January 6, 2021].

Mugunthan, K., Doust, J., Kurz, B. & Glasziou, P., 2014. Is There Sufficient Evidence For Tuning Fork Tests In Diagnosing Fractures? A Systematic Review. BMJ Open, 4(8).

NHS, 2020. Amitriptyline: A Medicine Used To Treat Pain And Prevent Migraine - NHS. Available at: https://www.nhs.uk/medicines/amitriptyline-for-pain/ [Accessed January 11, 2021].

NICE, 2019. ABPM Or HBPM Clinic BP Hypertension In Adults: Diagnosis And Treatment. Available at: www.nice.org.uk/guidance/NG136 [Accessed January 8, 2021].

NICE, 2015. Gastro-Oesophageal Reflux Disease In Children And Young People: Diagnosis And Management NICE Guideline. Available at: www.nice.org.uk/guidance/ng1 [Accessed March 21, 2021].

NICE, 2014. Osteoarthritis: Care And Management Clinical Guideline. Available at: www.nice.org.uk/guidance/cg177 [Accessed May 12, 2021].

Reed, M.B. & Thomson, O.P., 2021. “Who Am I To Disagree?” A Qualitative Study Of How Patients Interpret The Consent Process Prior To Manual Therapy Of The Cervical Spine. International Journal Of Osteopathic Medicine.

RMIT University, 2010. REFLECTIVE WRITING: DIEP. Available at: https://www.dlsweb.rmit.edu.au/lsu/content/2_AssessmentTasks/assess_pdf/Reflective journal.pdf#:~:text=Reflective writing aims to get,writing%2C using a DIEP strategy.&text=to describe%2C interpret interpret interpret,D – Describe objectively what happene [Accessed May 12, 2021].

RMIT University, 2015. RMIT_DIEP_strategy_accessible_2015. Available at: https://emedia.rmit.edu.au/learninglab/sites/default/files/Writing_academic_reflection_accessible_2015.pdf [Accessed May 12, 2021].

Selles, C.A., d’Ailly, P.N. & Schep, N.W.L., 2020. Patient-Reported Outcomes Following Arthroscopic Triangular Fibrocartilage Complex Repair. Journal Of Wrist Surgery, 09(01), pp.058–062.

Toney, C.M., Games, K.E., Winkelmann, Z.K. & Eberman, L.E., 2016. Using Tuning-Fork Tests In Diagnosing Fractures. Journal Of Athletic Training, 51(6), pp.498–499.

Verhagen, A.P., Downie, A., Maher, C.G. & Koes, B.W., 2017. Most Red Flags For Malignancy In Low Back Pain Guidelines Lack Empirical Support: A Systematic Review. Pain, 158(10), pp.1860–1868.

Verhagen, A.P., Downie, A., Popal, N., Maher, C. & Koes, B.W., 2016. Red Flags Presented In Current Low Back Pain Guidelines: A Review. European Spine Journal, 25(9), pp.2788–2802.

Xu, Q. et al., 2017. The Effectiveness Of Manual Therapy For Relieving Pain, Stiffness, And Dysfunction In Knee Osteoarthritis: A Systematic Review And Meta-Analysis. Pain Physician, 20(4), pp.229–243.

# data[].attributes.headline
"A1 You must listen to patients and respect their individuality, concerns and preferences. You must be polite and considerate with patients and treat them with dignity and courtesy." (GOsC 2018, p.5-6). 

# data[].attributes.subject
"A1 You must listen to patients and respect their individuality, concerns and preferences. You must be polite and considerate with patients and treat them with dignity and courtesy." (GOsC 2018, p.5-6). 

# data[].attributes.body
Accumulation of evidence:

Year 3:
First patient experience:
My first patient was clearly very anxious about her current symptoms after reading a letter from another healthcare professional, where they suspected cervical stenosis. My tutor helped me to realise how important it is not only to do a thorough examination and case history, but also to allow her to express her fears. Then we can hopefully help ease her concerns (within reason).

In the stress of my first patient I was so focused on being thorough and getting my testing correct, that I personally found it very difficult to achieve a high level of communication. The communication was more of a challenge than I had anticipated, I was frustrated by my performance. I feel these feelings of frustration arose from the trait of being very critical of myself. However, with more experience it will become easier to adapt my communication.

The patient left much more relieved than when they had arrived (mainly due to reassuring words from my tutor). This made me realise how incredibly important it is to have that communication and understanding of their concerns. On reflection, this may not have been due to a lack of communication skills but due to a lack of knowledge, meaning I was unable to communicate effectively regarding the condition.

I aim to improve this skill and ensure to reflect after consultations about not only the hands-on aspects but also the communication.

Year 4:
Year 2 student providing feedback:

A year 2 student observed my team in clinic, this student came to observe my new patient. This case had a few sensitive issues involved, such as a stillbirth, a recent death in the family and opening up about her mental health. I asked for feedback regarding this as this is such an important area within Osteopathy to handle correctly. She said that she really liked how I handled the situation.

I feel like I handled it in a caring and professional manner. The most important aspect I learnt from this was that having a colleague observe can really aid development and help you to analyse the situation after. We were able to have a conversation after where we both mutually learnt from the experience. From this I realised how much I value teamwork as I feel like it can provide great learning opportunities.

Understanding this is vital for my development as it may alter the way I approach future learning by working more as a team to gain insights of how to improve our communication. Implications for future practice include continually offering to my peers the opportunity to observe. This could aid both mine and the observers' development. With an aspect as important as communication, this needs to be adapted to each patient and each situation.

Continued feedback on this could aid my understanding of how to handle multiple scenarios. I will aim to gather this in the future by inviting colleagues to observe.

Term 1 children's clinic feedback (material attached):

During this term I only had one child patient, this was a 5 month old baby. Prior to this, in summer clinic I had a 9 month old baby as a new patient. This feedback was based solely on my consultations with the 5 month old baby.

I was very engaged with this 5 month old baby and they seemed to interact with me too. It was great to see that the tutor also picked up on my friendly approach as this was something I really tried to focus on. This highlighted to me that with experience it becomes easier to perform all aspects of the consultation to a higher standard. For example, despite interacting with both mother and baby throughout the case history this was still thorough and relevant.

This will affect how I analyse my performance, if I have not had extensive experience in that area I will consider this.

In the future I aim to build on this experience by not only having more patients within the clinic but also observing more of my peers to see how they approach this continuous multi-tasking. In term 1 I feel I was quite frequently requesting advice from tutors regarding communication, I aim to become more autonomous in this aspect.

Paediatric clinic referral (self-reflection):
I had a 5 year old patient, with quite a concerning presentation of leg pain. Which was presenting with the red flag of night pain. At 5 years old this patient was confident and able to express his concerns and worries to me as a practitioner.

This was an opportunity for me to adapt my communication and listening skills to consider the views of both the mother and child and I feel I handled this well. The mother was very grateful for my explanation and giving her time to ask questions. I was proud that even though my tutor offered to explain for me, I asked to have the chance to explain first and was happy for the tutor to add to this. I feel this displayed autonomy.

This referral could have been a very distressing experience for the mother as she was worried she had delayed the process of going to the GP as she didn't think this was a concerning presentation. However, with reassurance of more likely outcomes such as growing pains we could see the mother start to relax.  This highlighted to me that although we understand why we are referring and the less concerning explanations for the pain, we must ensure to explain all of this to the patient to ease concerns.

In the future I aim to improve my communication when referring.  I will continue to try to handle these difficult situations with more autonomy to improve my performance in this aspect.

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"A2  You must work in partnership with patients, adapting your communication approach to take into account their particular needs and supporting patients in expressing to you what is important to them." (GOsC 2018, p.5-6).

# data[].attributes.subject
"A2  You must work in partnership with patients, adapting your communication approach to take into account their particular needs and supporting patients in expressing to you what is important to them." (GOsC 2018, p.5-6).

# data[].attributes.body
Accumulation of evidence:

Year 1:
Observation reflection:
During my observation, there was one patient who needed constant reassurance during the treatment. She was constantly asking "is it normal to feel this?", it was clear the patient was anxious.

It was interesting to see this relationship of trust between the practitioner and patient develop as I had not previously witnessed such a relationship. The practitioner constantly explained it was nothing to worry about and I could see the patient relax slightly with every reassuring comment. The patient's anxiety had an impact on the treatment at the start  as she would tighten up and prevent movements occurring even though consent had been gained. It was therefore vital for the practitioner to build this trust. This reassurance had a very clear impact as the patient was becoming more relaxed throughout so enabling a more comfortable environment for the patient.

This highlighted to me that although as a practitioner we know when a response to examination/treatment is alarming, the patient may not and this may cause some anxiety. However, on reflection if the practitioner had explained a little more about the expected effects throughout treatment prior to starting treatment this could have potentially prevented this. However, the practitioner adapted very quickly.

In terms of implications for my future practice, I aim to explain thoroughly the effects of treatment, and will practise this with my peers.

Year 2:
Observation reflection:
Whilst observing in clinic I observed a relationship between a patient and a practitioner that I truly hope I can achieve one day. It was evident that the patient had a lot of respect and trust in the practitioner. Also, the practitioner listened to all the patients worries and concerns and addressed them all throughout examination and treatment.   Many areas of the patient's body were causing her concern, so the practitioner ensured that the patient was happy with the way the appointment had gone and gave her the opportunity to ask questions. The patient was very happy to talk to the practitioner about her life and the practitioner seemed interested, it was clear that the patient felt like at that time they were important to the practitioner.

As a second year observer I had a lot of admiration for the practitioner. I learnt valuable communication skills.
I believe my relative lack of experience could have added to this admiration as I simply could not picture myself achieving a treatment environment like this.

The most important lesson I learnt from this is that the hands-on skills are very much only a part of the treatment. I had always been aware of this, but this experience highlighted this for me. This will be vital in future development.

When I get into clinic, I plan to take the time to get to know the things in life that are important to my patient to help them feel listened to.

Year 3:
First patient experience:
My first patient was clearly very anxious about her current symptoms after reading a letter from another healthcare professional, where they suspected cervical stenosis.

The patient left much more relieved than when they had arrived (mainly due to reassuring words from my tutor). This was disappointing for me as I felt my communication had frequently received positive feedback. I felt like the tutor supported the patient more when expressing what was a priority for them.  However, with more experience this will become easier to adapt my communication to each patients' individual needs.

On reflection, this may not have been due to my communication skills. This could have been due to a relative lack of knowledge of the condition compared to my tutor, therefore I was unable to communicate and reassure  as effectively as I should have. This experience highlighted the importance of having good communication and a good partnership with the patient.
This will be vital in future practice.

I aim to improve this skill and ensure to reflect after consultations on my ability to adapt communication and consider their individual needs.

CEx 1- formative:
My tutor believed that I had good patient communication. This was with a continuing patient with lower back pain.

This was particularly rewarding and reassuring for me as in previous experiences I have been frustrated at the quality of my communication. It was motivating to see that from my continued reflection on this aspect I had improved.

I believe this improvement occurred due to past experiences of disappointment with this aspect,  it then became a focus of mine.  This is therefore valuable for my development to note these improvements.

In the future, I aim to improve on this aspect and gain further feedback. I think more feedback from tutors would be very beneficial as recently I have been receiving more feedback from peers. This would help to bring more new perspectives and advice.

Final clinic exam- Online (material attached):
We had an online clinic exam where the tutor acted as a patient.

At first, it was difficult to adjust to interacting in this way. I had practised this multiple times with peers so this was something I really focused on in this exam. I believe this contributed to the positive feedback received on this aspect.

This highlighted to me that if adapting to a new way of practising in the future seems daunting, that continued practise of this can definitely help with confidence. For example, when adapting to a new clinic environment once I leave the teaching clinic. This has been a vital part of my development as I believe it will give me more confidence in adapting to new situations.

I aim to take this experience with me when joining a clinic team after graduation.

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"A3  You must give patients the information they want or need to know in a way they can understand." (GOsC 2018, p.5,7).

# data[].attributes.subject
"A3  You must give patients the information they want or need to know in a way they can understand." (GOsC 2018, p.5,7).

# data[].attributes.body
Accumulation of evidence:

Year 1:
Peer Feedback (material attached page 1):
Feedback was provided from peers about consent, explanation and the evaluation process. The feedback highlighted that as a practitioner I asked "is it OK?" to the patient throughout the consultation.

However, despite receiving such positive feedback about my communication this process made me realise how difficult it can be to explain the examination process in a professional but also simple way. In addition to this there is the added challenge of adapting between model and colleague communication.

This highlighted to me the importance of self-reflection in addition to peer and lecturer feedback. As I was more critical of myself regarding the ease at which I delivered this information I am now able to improve upon this aspect that my peer may not have noticed.

My learning action plan following this will include not only gathering further peer or lecturer feedback but also analysing how a situation made me feel as a practitioner.

Year 2:
Final Integration exam (material attached-page 2 and 3):
After the exam I knew my treatment station was much worse than my evaluation. I knew I had forgotten to explain the risks like I had for evaluation.

I was aware that this is vital, but I am now also aware that under the pressure of an exam it can be much easier to forget parts of our verbal communication. Despite this, this was very disappointing for me.

I realised this after that station and still had one station to go, I feel this also impacted the final station of the exam as I was becoming stressed. I have definitely learnt that under pressure it can be easy to miss aspects.

I aim to improve on this as I know it is vital to deliver to every patient and I must be able to adapt to the exam situation. I plan to continue practising this communication so that even under pressure it can be delivered.

Year 3:
Final Osteopathic skills exam (material attached- page 4):
My communication was described as clear and very good. The education I provided my patient regarding the injury process would help to inform shared-decision making and therefore patient partnership. The exercises given were appropriate and described well, which is important to aid accurate completion.

Therefore, this information was delivered in a way that they can understand, I was pleased with this. This made me reflect on previous clinical experiences where patients had returned and admitted they could not remember the exercise instructions. The apparent improvement in my communication is therefore very motivating.

This highlighted the importance of explaining this to ensure patient understanding and safety too.  This awareness will be an asset as a practitioner.

This will inform my future consultations by providing clear exercise prescription with the use of exercise sheets to aid understanding.

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"A4 You must receive valid consent for all aspects of examination and treatment and record this as appropriate." (GOsC 2018, p.5,7).

# data[].attributes.subject
"A4 You must receive valid consent for all aspects of examination and treatment and record this as appropriate." (GOsC 2018, p.5,7).

# data[].attributes.body
Accumulation of evidence:

Year 1:
First practical exam feedback (material attached page 1-3):
I received positive feedback regarding my consent gaining. This was consistently scored high on in all three stations that I have attached as evidence.

Whilst this was rewarding, I understand that the expectation for consent will probably become increasingly difficult as I have heard  from peers and lecturers that the expected standard will be higher as we enter the teaching clinic. I feel that in the lead up to the exam I focused more on the knowledge required rather than practising the communication.

This will be key in my development as looking at the marks available for communication highlighted to me its importance.

I aim to improve not only my knowledge but also my consent gaining in the future practise sessions.

Year 3:
First patient reflection:
In my first patient, I missed key aspects of communication such as explaining risks and benefits of examination, this was therefore performed by my tutor.

I definitely realised that under the pressure of the clinic environment it is very easy to forget one of the steps of the consent process when explaining the examination.  Within previous exam situations my consent gaining has always received positive feedback; however, in this scenario I should have performed better. This was disappointing as I had previously been proud of my communication skills when gaining consent.

I am sure that with practise this will become natural. This has definitely made me more aware of this with future patients and I will focus on this more.  On reflection, I must consider that this was a completely new scenario for me, so expecting this high level was probably unrealistic.

In terms of an action plan, I intend to ask for more feedback on this aspect by my peers observing more.

Year 4:
Paediatric CEx ( material attached page 4-5):
My consent and shared decision making was viewed as above expectation, it was highlighted that my explanation provided before gaining consent for examination was good.

As previously mentioned in other reflections the improvement in my communication in exam situations has been very rewarding.

I feel that more experience in children's clinic and more autonomy has contributed to this improvement. This autonomy skill will be very valuable in the future. However, more precise questioning within the case history could have been asked.

In the future, I aim to continue to not let other areas of the consultation decrease my overall performance but strive to focus on all aspects simultaneously as all are important.

Collecting patient perspective for case report:
For the case report, we had to ask the patient to provide their perspective. I gained informed consent and explained the intended use of this information and emphasised that the write up would be anonymous. I ensured that this was adhered to and removed any identifying information from the written material they provided.

I lacked confidence in myself that I knew how to gain appropriate consent for this, and checked with my tutor my verbalisation of this prior to the consultation. In hindsight, I should have had greater confidence in myself as the tutor was very pleased with my explanation.

This highlighted the importance of not just being able to deliver the routine consent process but being able to receive valid consent for more unique situations. This could be a useful skill in my future career, for example with  permission to share feedback provided from patients.

In the future I aim to continue to make sure to attain to the high level of consent required for all aspects of the consultation. I also aim to have more confidence in my communication skills, as I can see how much these have developed so I should aim to become more autonomous in this.

Reflection on informed consent:
As we are nearing the CCA, consent and shared decision making has become a large topic of discussion as this is not only vital to pass the exam but also for future consultations.

I came across a very interesting but also distressing qualitative study. This study found themes following semi-structured interview analysis. The experience of the patients within the consent process in advance of cervical spine manual therapy were analysed. These experiences were united through the situational disempowerment theme (core theme identified) (Reed & Thomson 2021).
It is important to consider that this was conducted at a student osteopathic clinic; however, high standards should still be delivered.

This study led to many questions regarding my own consent process and I really attempted to analyse how patients experience the consent process. On reflection I did realise that patients often do say "you know best" and maybe I need to improve my response to this. I am not completely sure of how I usually respond to this, potentially highlighting that I haven't given this enough attention. But I aim to inform the patient that it is entirely their decision if this is a treatment they want to try, and if they feel that there is anything else I can inform them on I am happy to do so.
This will be key in my development as the thought of the patient feeling disempowered is quite upsetting and not a feeling I would wish on anyone.

I plan to alter my response to statements such as "you know best" in order to help the patient feel empowered. I should offer this communication prior to gaining consent to help prevent these feelings. Therefore, I still feel there are slight gaps in current knowledge regarding the best consent process. I feel that I will need to continually reflect on this and research for any new developments.

References:

Reed, M.B. & Thomson, O.P., 2021. “Who Am I To Disagree?” A Qualitative Study Of How Patients Interpret The Consent Process Prior To Manual Therapy Of The Cervical Spine. International Journal Of Osteopathic Medicine, 0(0).

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"A5 You must support patients in caring for themselves to improve and maintain their own health and wellbeing."(GOsC 2018, p.5,10).

# data[].attributes.subject
"A5 You must support patients in caring for themselves to improve and maintain their own health and wellbeing."(GOsC 2018, p.5,10).

# data[].attributes.body
Accumulation of evidence:

Year 3:
Final Osteopathic skills exam (material attached):
My communication was described as clear and very good. The education I provided my patient regarding the injury process, would help to inform shared-decision making and therefore patient partnership. The exercises given were appropriate and described well which is important to aid accurate completion.

I am proud of my positive feedback as I know it is vital. I also realised that in previous clinical experiences the provision of exercises was not as much of a priority as it should have been. I am disappointed I have not considered this enough previously.

This will be key in my development as it enabled me to reflect on why we offer these exercises. This can help the patient to improve their health and wellbeing outside of the treatment room and can make the benefits of treatment more profound and longer lasting.

In the future, I aim to be able to achieve this high standard of advice for all conditions, including ones I am less experienced with in the clinical setting.

Year 4:
Patient lacking enthusiasm to exercise:
In clinic I had a patient expressing a lack of motivation to exercise even though she was aware of the importance of this. She reported that she was aiming to lose weight but struggled with motivation.

I found it difficult to see the patient lacking this motivation. As a practitioner I aimed to find ways of keeping active that could be of interest to the patient. I offered multiple options and this sparked a willingness to do some specific exercises. I clearly explained to her the benefits of this and she was keen to perform them consistently.

This highlights to me that in order to meet this standard, the patient must be considered as an individual.

I will take this awareness into future practise when supporting patients in this aspect.

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"A6 You must respect your patients’ dignity and modesty." (GOsC 2018, p.5,10).

# data[].attributes.subject
"A6 You must respect your patients’ dignity and modesty." (GOsC 2018, p.5,10).

# data[].attributes.body
Accumulation of evidence:

Year 1:
Observation reflection:

During observation, there was a  patient who was 18 and clearly anxious about treatment. When asked to undress to underwear he appeared very uncomfortable, this was picked up by the practitioner and the situation was handled very well. His modesty and dignity was respected and he only removed his shirt, it was clear to see he was much more comfortable with this.

The most important aspect of this for me as an observing first year was the ability of the practitioner to adapt to the needs of the patient as I had not previously seen this before. This experience means that in the future I will have insight into how to handle this.

This respect shown here in my opinion enabled the remaining consultation to have a more comfortable environment, if this was not so swiftly adapted to this could have led to the patient feeling uncomfortable and affected the remaining consultation. I feel I have learnt the importance of being able to adapt to situations and being able to pick up on non-verbal cues.

This will definitely impact my future consultations, when explaining aspects of the treatment to patients I will ensure to listen to their verbal opinion but also look for non-verbal cues.

Year 3- Summer clinic:
Respecting modesty without blankets:
Since returning to clinic after the start of the COVID-19 pandemic there were multiple challenges. In third year, I often used blankets to protect patient modesty. Therefore, to adapt to this situation I have been offering patients items of their clothing such as a jacket to enable them to feel more comfortable.

This adaptation to situations is also highlighted in another reflection about online communication with a simulated patient. It was rewarding to see this ability to adapt continued within my practice on the return to clinic.

I feel that this adaptation was vital for my patients as they were adapting to a new clinic environment. I could see one of my patients was quite distressed at the thought of not having  a blanket during hip examination/treatment as they had previously expected and experienced within the clinic. This ability to adapt had beneficial consequences  regarding the remaining consultation as the patients were more relaxed throughout. I am pleased to see this skill continually develop, as patient modesty and dignity is vital to protect. It was also rewarding to achieve this as I had admired my colleagues approach to this in the previous reflection.

I aim to continue finding ways to make patients as comfortable as possible during consultations.

Patient not comfortable removing certain items of clothing:
This patient was uncomfortable with removing certain items of clothing. This patient was also not comfortable with the thought of the cameras so I reassured her that these were switched off.
This patient become visibly and verbally distressed when cameras were mentioned, I noticed this immediately and consequently went to turn the cameras off while the patient was filling in forms at reception. I then reassured the patient they had been turned off before even entering the room.

I felt like I asked the question about removing items of clothing in a very sensitive manner and also made her feel comfortable that her response is completely understandable and respected. It is rewarding to see that adapting has become a frequent theme within my reflections; this is of great importance to me as an individual.  This experience allows me to see my personal development in this.

If I had waited until we were in the room to turn them off this could have led to the patient losing a bit of trust as she had specifically requested to not be on camera. This swift adaptation enabled the patient to build trust.

As with previous reflections I will continue to strive to make patients as comfortable as possible, this will have profound effects on my consultations.

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"A7 You must make sure your beliefs and values do not prejudice your patients’ care." (GOsC 2018, p.5,11).

# data[].attributes.subject
"A7 You must make sure your beliefs and values do not prejudice your patients’ care." (GOsC 2018, p.5,11).

# data[].attributes.body
Accumulation of evidence:

Year 3:
COVID-19 Vaccine patient interactions:

The COVID-19 vaccine provided a discussion topic that was often mentioned by patients. I observed a patient expressing beliefs that I personally did not agree with. However, I respected the fact that everyone would have had different experiences and read different information.

This was initially difficult as I had never had such strong emotions in the clinical setting. I also reflected that if I was made aware of more information in the future my opinion may alter, so I was keen to understand that opinions on such a new topic can develop.

This was particularly important to me as a practitioner as it enabled me to see the importance of adapting to situations with strong emotions involved. I adapted to this by trying to change the subject of conversation subtly.

In future practice, I aim to improve this skill further of moving away from topic areas involving strong emotions where views may differ. However, being respectful when these topics do arise.

Year 4:
Management of COVID-19 pandemic interactions:
The management of the COVID-19 pandemic was a frequent discussion initiated by patients. In these discussions there were very strong statements made by patients.

This provided a challenge in terms of responding to this due to the strong opinions raised. In response to this I managed to change the subject to bring it away from such a controversial topic. I respected the fact that everyone is entitled to their own opinion and I did not let this prejudice the care of my patient in any way. This is similar to a previous reflection.

The COVID-19 pandemic discussions with patients enabled me to improve my response to difficult questions. This will be invaluable in future consultations.

I will continue to gain experience with this, and aim to improve my handling of the situation to make it as comfortable as possible for the patient and I.

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"B1 You must have and be able to apply sufficient and appropriate knowledge and skills to support your work as an osteopath." (GOsC 2018, p.12-13).

# data[].attributes.subject
"B1 You must have and be able to apply sufficient and appropriate knowledge and skills to support your work as an osteopath." (GOsC 2018, p.12-13).

# data[].attributes.body
Accumulation of evidence:

Year 1:

Feedback from first practical exam (material attached page 1-3):
This exam covered Osteopathic evaluation, Osteopathic technique and Osteopathic concepts. Positive feedback for knowledge, skills and performance included that I had a methodical approach to my observation and good accuracy of testing. Also, my anatomical and treatment knowledge and was good.
Improvements included needing to slow down during the treatment. Further, precise improvements on specific techniques were mentioned.

In general I was very pleased with the feedback, but also found it a very helpful learning experience as I could see where I could improve. I was also relieved as this was my first practical exam.

This ability to deal with positive and negative feedback and take this on board will be invaluable in the future to aid my development.

From my feedback, I plan to be more conscious of my technique completion and I plan to ask lecturers and assistants for more feedback on my technique performance.

Reflection on Pathophysiology mark:
I achieved 100% in the second exam.

I came out of the exam not feeling very confident as I could see the multiple choice options were designed to make you doubt yourself. This lack of confidence definitely affected my perception of this exam.

This suggests to me that maybe I need to have a bit more belief in myself and this aspect of pathophysiology may be something that I learnt very thoroughly. I learnt from this experience to trust the hard work that I continually put in and I hope to carry this into future examinations. However, not only into exams but also into clinical environments, I need to be able to trust the knowledge that I have strived to gain.

I plan to have this higher level of trust in my ability.

Reflection on anatomy result:
I achieved 85.5.% in the exam.

After the exam I felt disheartened as I had worked really hard and I didn't feel it went very well. However, now I realise I must have been focusing on the negatives during the exam. This shares a similar theme to a previous reflection.

This therefore highlights that self-confidence is an issue for me at this stage in the course. Being aware of this will help with analysis of future exams.

I aim to improve upon this and enter exams feeling confident and proud of the hard work.

Year 2:
First High Velocity Thrust (HVT) experience:
The first HVT that we learnt was the lumbar side roll.

At first as people around me were achieving the "pop", I was so keen to achieve this too. However, it was only when I revisited it a week later I realised that I had been so worried about achieving the "pop" that I had not focused as much as I should have on the set up. So that time I spent longer setting up the HVT and getting the traction before applying the force. Then I heard the "pop". Also, after receiving reassurance from assistants in the class I realised that just because the "pop" isn't heard doesn't mean the technique wasn't effective. I am aware that I may have felt frustrated as I am a perfectionist.

This will help me when practising as there are still many times when I can't achieve it. From this experience, I definitely learnt that these skills take time to develop.

Therefore I will aim to only strive for perfection once I have gained enough experience and practise, therefore not expecting too much of myself too early.

Clinical methods lecture reflection:
This is a reflection about this lecture in general during the first term:

This is the first term of having this lecture and I can already see how much of a benefit it will be when we enter clinic. This lecture has made me feel more prepared as we have gained vital skills.

This lecture has taught me so much in one term. The cardiovascular exam and respiratory exam were very interesting to learn and  I can see they are vital when we start clinic. From this lecture we have gained vital skills such as case history taking, differential diagnosis, red and yellow flags and so much more.  This lecture is definitely making the thought of starting clinic less scary and aiding my development onto this next step.

I aim to continue my high level of enthusiasm in this lecture and gain any further knowledge I can from it.

Anatomy essay reflection:
For an anatomy assignment we had to write an essay.

I put a lot of time into this essay, I can remember getting frustrated as the instructions kept changing, causing me to alter my essay many times. However, I am impressed with how I dealt with the disappointment of being told I needed to change and add to my essay. I turned my frustration into determination to show how much work I had put in. Any time spent on anatomy knowledge would not be wasted as this is a vital part of being an Osteopath.

I realised I was not very good at trying to solve problems myself, coming straight from school I am used to receiving a lot of help. This was key in my realisation that I must adjust to the fact that now we have to be more independent in our learning.

I aim to improve this skill of independence.

Clinical integration reflection:
This lecture involves teamwork when discussing patient cases.

I thoroughly enjoy this lecture as it brings all our knowledge together and applies it to a real case. This year as I have been doing a lot more independent research it has been very rewarding to see this is benefiting me. I am much more aware of non-MSK conditions than I was last year. For example, the lecturing assistant was impressed when I mentioned a pancoast tumor in the list of DDs and was able to discuss this. This is very motivational for me to continue this further research as I can see it is helpful.

This will be key in my development as this motivation to my improve knowledge could be carried through the course.

I aim to continue my contributions to group discussions in this lecture.

Reflection on my self-development with coping with stress:
This second term had a large volume of exams.

I feel that this second term highlighted to me how far I have come in terms of managing my stress. I ensured to take more time to take myself away from studying but continued to work hard. With many exams in a short space of time, I was worried about how drained I would feel. But throughout this exam time I was the most calm I have ever been during an exam period. I think this showed me how I am developing and getting better at balancing my life.

I feel this will be vital in my future as an Osteopath to continue to look after myself well as well as my patients.

Therefore, I will strive to keep this balance.

Final pathophysiology result (material attached-page 4):
We received our overall pathophysiology result.

This mark, although not my highest mark was the one I was most proud of. After the script concordance test I was very frustrated as I felt it didn't reflect all the work I had put in, and I knew I would have to get quite a high percentage to get a first in this subject which was the goal I had set myself. I am proud that I used my disappointment and frustration to my advantage and used it to motivate me more.

This has shown me that even though some exams do not go as well as others it is important to stay focused and not give up. This perseverance will be invaluable.

I aim to continue to strive for high marks regardless of any set backs.

Year 3:

Osteopathic skills exam (material attached- page 5)
It was highlighted that I demonstrated a range of knowledge (Osteopathic, anatomical and physiological). I could also provide justification for my proposed examination and treatment routine.

Despite achieving high marks in first and second year, I always doubted that as the standard expected became higher my marks would fall. It was great to see the development in my knowledge to meet this new standard.

This will be key in my development as I could see that I could improve my knowledge to the level expected from a third year student. This will aid my future development as I can see that I am able to improve to meet the standards expected of me.

I can use this experience to have greater confidence in my skills, and this will alter the way I feel when entering new levels of learning.

Year 4:

Medical student presentation:
This reference was recommended to me by a tutor.

I think it explores the differential diagnosis skill in a very interesting way. The identified biases are important to consider. Also, the importance of taking a step back after formulating the diagnosis to ensure you have reached the decision in the best way and to reflect on the decision making process throughout this was emphasised (Waldman & Ottolini 2013). The presentation also highlighted how to make information more concise (Waldman & Ottolini 2013). This was particularly helpful for me. In my CEx spoken feedback  it was mentioned that with nerves I don't tend to get straight to the point.

Therefore, this resource has been very helpful in my development as a practitioner and this will definitely be useful to me in clinic.

I will use this to aid my differential diagnosis process in the future.

References:
Internet1, 2013 “Differential Diagnosis: Approaches And Pitfalls - A Pediatric Case-Bas” By Zev Waldman And Mary Ottolini. Available at: https://hsrc.himmelfarb.gwu.edu/elearning/22/ [Accessed January 6, 2021].

Clinic tutor feedback from term 2:
"What I have observed that has gone well:

I have observed you asking relevant case questions that have shown thought around the presenting symptoms and gained you important information.

You have gained good clarity on detail of cases.

Good consent gaining for examination involving mum and making her feel like she can do what she needs for the baby.

Good explanation of exam process as go along and good consideration of baby's needs.

Always professional manner.

Effective treatment skills."
My reflection:
It was very rewarding to see that I have gained clarity on details of cases. This was highlighted in my feedback from term 1 that this needed to be improved on. I particularly focused on this aspect in the build up to my children's clinic CEx and it was great to see that this improvement was carried across other cases in general not just my CEx. It was very motivating to see that the extra work I had put in and research into the common conditions presenting in children's clinic had been noticed.

In regards to future development, this ability to reflect on feedback and make the necessary changes will be vital in my Osteopathic career.

I aim to continue this high standard of reflecting on feedback to improve my skills.

Contradictions in the management of blood pressure:

Within the teaching clinic there were many contradictions between clinic tutors regarding the management of blood pressure.

I understand this is because it is on a case-by-case assessment and knowledge should be applied keeping this in mind. However, I found it quite stressful that I was not entirely sure of the correct process when handling blood pressure. As on follow-up treatments with a different tutor they would recommend different management, and this would be quite confusing. However, I completely respected this and realised it could be a result of each tutor having different personal experiences. I have realised from this that maybe I panic when I see high blood pressure, as I am unsure of how to best manage this.

Therefore, I searched for clinical guidance in this area and found an extremely helpful 2 page summary. This provided the precise readings and the best management for this. For example, if the clinical reading is 180/120 mmHg  or above we should enable that patient to be assessed for target organ damage and this must be done as soon as is possible to achieve. And there were certain symptoms that along with this blood pressure would require same-day referral for a specialist review (for example papilloedema and symptoms that are life-threatening). Management for clinic readings between 140/90 and 179/119 mmHg was also provided such as offering monitoring of blood pressure (ambulatory) (NICE 2019). This was a key point in my development as I noticed how there are contradictions in this profession and that is acceptable due to multiple factors. However, I also noticed that I must be more autonomous in my learning and not always look to tutors for guidance. I feel this will be important for future development as I will increase my knowledge base to help clinical  judgements. This will benefit me in the future, as in the teaching clinic this will allow more autonomy and justification for my reasoning. This will also allow more confidence in future clinical situations.

This will alter the way I react to contradictory information, as I plan to research to help avoid confusion.

References:

NICE, 2019. ABPM Or HBPM Clinic BP Hypertension In Adults: Diagnosis And Treatment. Available at: www.nice.org.uk/guidance/NG136 [Accessed January 8, 2021].

Osteoarthritis reflection:
Potential OA  is very commonly diagnosed in a clinical setting. However, a tutor advised me to investigate more into the stages of OA and how this causes pain. A useful website I found described stages 0-4 and the treatment for each stage (Internet2 2016).

Up until this point in my development I was unaware of the stages of OA, but I now realise how important this is clinically. Also the ability to describe how this is causing pain is vital for patient understanding. I felt disappointed I had not considered this in enough detail.

This learning experience was very valuable as it enabled greater understanding of a very common condition.

For future development, I aim to think on a deeper level of the pathophysiology of conditions, as this can be vital in determining the prognosis.

References:
Internet2, 2016 Arthritis In Knee: 4 Stages Of Osteoarthritis - IBJI. Available at: https://www.ibji.com/blog/orthopedic-care/arthritis-in-knee-4-stages-of-osteoarthritis/ [Accessed January 10, 2021].

Second Summative CEx (material attached-page 6-7):
The fluency of the case history was highlighted.

This was a presentation I had never experienced before, it was great to receive the feedback that I was able to conduct a fluent case history and have the appropriate knowledge and skills to do so. Reflecting back over my clinic experience, this was definitely a difficulty for me in the past, adapting to presentations that I had never encountered.

This skill has been developed throughout my time in the teaching clinic. This will be invaluable in my future career as there will be many new conditions that I am exposed to.

I will continue to improve my knowledge base to enable me to cope with these situations.

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"B2 You must recognise and work within the limits of your training and competence." (GOsC 2018, p.12,14).

# data[].attributes.subject
"B2 You must recognise and work within the limits of your training and competence." (GOsC 2018, p.12,14).

# data[].attributes.body
Accumulation of evidence:

Year 3:

First patient experience:
My first patient had widespread neurological symptoms and a diagnosis from imaging suggesting cervical stenosis. However, symptoms were progressing. In this situation although very much guided by the tutor it was vital to gather all the necessary information to aid the referral.

Having this patient as my first patient has made it very prominent in my mind that we must know when to refer. I feel this was quite an overwhelming experience for my first patient experience.

I feel this will be a key point in my development, by having this highlighted from the start this will aid me in knowing my limits in the future.

I aim to further investigate the management of cervical stenosis.

Year 4:
Paediatric clinic referral:
This child had a presentation suggestive of growing pains. However, due to the red flags present such as night pain, it was vital to refer to the GP for potential imaging. This would ensure that the more sinister diagnoses are ruled out first, then we can have more confidence in our potential clinical diagnosis.

This decision was made with little input from the tutor, which I was proud of. I am becoming more autonomous as I am aware it will not be long until I am potentially the only practitioner in the room. This lack of autonomy has been pointed out by tutors in feedback so is something I need to more consistently apply.

This awareness of the importance of autonomy will aid future practise and will help me become more independent.

I strive to continue to be autonomous, not only in regards to referral but in other aspects of consultations.

Barefoot talk- pathology in back pain
I attended a talk from a physiotherapist regarding the red flags in back pain.

This highlighted that the criteria for referral is not always clear and red flags are not necessarily accurate. This talk encouraged us to listen to our gut feeling, this has also been emphasised by  multiple clinic tutors. However, other tutors appear to be much more comforted by the lack of red flags than others. This continued difference in opinion throughout the teaching clinic has been difficult to adapt to as I have been unsure of how much confidence to have in the red flag system.

In addition to previous research I have found as can be viewed in another reflection, it was helpful to gain another opinion. This talk was from a physiotherapist so gaining another approach to this was extremely beneficial to ensure a wide knowledge base to form my clinical judgement. Knowledge from this talk is definitely knowledge I will carry forward, to ensure I provide the best care possible for patients. I feel this talk arrived at a key time in my development, as it reminded me that even though we may be very knowledgeable of red flags we still need to listen to and trust our gut as it is not as simple as ruling out red flags.

This will definitely change my opinion regarding the amount of trust I place in the red flag system.

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"C1 You must be able to conduct an osteopathic patient evaluation and deliver safe, competent and appropriate osteopathic care to your patients." (GOsC 2018, p.15-16).

# data[].attributes.subject
"C1 You must be able to conduct an osteopathic patient evaluation and deliver safe, competent and appropriate osteopathic care to your patients." (GOsC 2018, p.15-16).

# data[].attributes.body
Accumulation of evidence:

Year 1:
First practical exam feedback (material attached-page 1-3):

In terms of quality and safety, positive feedback included that I explained procedures well to the patient and gained consent clearly. Further, that I constantly checked if the patient was in pain.
However, it was suggested that during the full body observation I should ask if the patient is alright and engage with them more. And it was also suggested that I was simply going through the motions.

I was disappointed by this, however I feel this may have happened due to the exam situation and feeling time pressure.

This feedback will enable me to make improvements to these skills that will aid future practise.

I aim to improve this aspect by applying this to more of my colleagues in lectures and really observing for any asymmetries etc.

Year 2:
Debate in clinic:
When I was observing in clinic I witnessed a very interesting debate between a tutor and a student. The student argued that the patient's lower back pain was caused by the prostate cancer. However, the tutor's argument was can we objectively test that? Also he argued the pain was MSK as the pain was reproducible upon movement. This then also sparked a debate on if we claim the pain is caused by cancer is it ethical and safe to treat? The theory behind a lot of Osteopathic techniques is to improve the flow of fluid (e.g. lymphatic flow) so it could be argued we may spread the cancer. Both the tutor and student agreed that there should be limited movement in treatment- lots of soft tissue stretches and gentle oscillation. Also by saying we are treating a pain caused by cancer are we in a way claiming we can treat cancer? This was mentioned in the discussion.

This was very interesting to observe and definitely raised a lot of points for me to think about in terms of safety and ethics.

This learning experience highlights the many different approaches to Osteopathy and that I must be able to justify my approaches.

I intend to ask other tutors their opinion of this to help me to formulate my own opinion.

Year 3:
First patient reflection:
In my first patient, I unfortunately missed key steps in the consent process.

I definitely realised that under the pressure of the clinic environment it is very easy to forget one of the steps of the consent process when explaining the steps of examination. I am sure that with practice this will become natural.

But this has definitely made me more aware of this with future patients and I will focus on this more.

In terms of an action plan I intend to ask for more feedback on this aspect by my peers observing more.

CEx formative (material attached-page 4):
I received a mark where I had met all criteria.

Overall, I was happy at this stage to have met all the areas that were seen. However, I hope that with experience I can improve on this and reach a higher standard. I was slightly disappointed to not achieve an above on any part, but I think in hindsight this was too much to expect at this stage in my development.

This will be beneficial as this was only formative so now I can push to improve on the summative one.

I aim to continue to strive for higher performance, not only for exams but continually through clinic.

Research methods and statistics exam:
This exam enabled me to really assess the quality of the present research on a particular subject.

This scrutiny is an aspect I have previously struggled with so this improvement being noticed was very rewarding.

This scrutiny can be continued into research I do in the future. This improvement in scrutiny can contribute to the safety as well as the quality of my practice.

I will consequently be more aware of the quality of the information I am researching.

Reflection on red flags in low back pain:
I conducted further research into red flags in lower back pain.

As an Osteopath, managing patients with lower back pain will be a common occurrence. Therefore, it is paramount that we are not only aware of the red flags but also that we have an understanding of how accurate these red flags are. This is very important for patient safety. However, when researching the validity of these red flags after a discussion with a clinic tutor prompted this, I found it concerning that these red flags are not particularly accurate. I also had many questions due to different clinic tutors having differing opinions on the value of red flags, with some gaining more comfort from their absence than others.  I therefore wanted to gain further understanding.

A review in 2013, concluded that despite many red flags being advocated within guidelines in screening for malignancy or for fractures, only a limited number have available evidence of being informative. This study suggested a revision of numerous guidelines available at the time is required (Downie et al. 2013).

I found another review of guidelines from multiple countries. Fracture red flags that were presented by most guidelines included trauma (major/significant) and steroid or immunosupressor use. For malignancy, most presented cancer  history and unintended weight loss as red flags (Verhagen et al. 2016). These are commonly used red flags that are mentioned in the clinic setting.
However, unfortunately this review concluded that between the included guidelines (low back pain), there was an insufficient consensus regarding the red flags that should be advocated. Also the red flags recommended lacked evidence regarding their accuracy (Verhagen et al. 2016).

Furthermore, a systematic review concluded that multiple malignancy red flags advocated within guidelines for low back pain have an unclear diagnostic accuracy (Verhagen et al. 2017). This systematic review is high within the hierarchy of evidence so can be viewed as a high-quality source of information.

This is concerning to me as a student and future practitioner as it highlights the need to consider multiple red flags but even despite this we should always be cautious in order to be safe. And potentially it is unsafe to seek reassurance from the absence of red flags.

This will aid me in my development to seek multiple opinions from experienced tutors and research further, as I feel this is vital to know for patient safety.

This will alter my view of cases with an absence of red flags in the future.

References:
Downie, A. et al., 2013. Red Flags To Screen For Malignancy And Fracture In Patients With Low Back Pain: Systematic Review. BMJ (Online), 347.
Verhagen, A.P., Downie, A., Maher, C.G. & Koes, B.W., 2017. Most Red Flags For Malignancy In Low Back Pain Guidelines Lack Empirical Support: A Systematic Review. Pain, 158(10), pp.1860–1868.

Verhagen, A.P., Downie, A., Popal, N., Maher, C. & Koes, B.W., 2016. Red Flags Presented In Current Low Back Pain Guidelines: A Review. European Spine Journal, 25(9), pp.2788–2802.

Year 4:
CEx formative (material attached-page 5-6):

I conducted a neuro screen even though there were no reported neurological symptoms. Numbness in the obturator nerve distribution was found.

I felt this was necessary to be safe and because the patient may not be aware of a loss of sensation for example. In the neuro screen I did identify an area of sensory abnormality which the patient had not previously mentioned. This along with other information warranted the advice to ring the GP.

In this case, this decision led to a referral. If I had not completed the neuro exam due to the lack of neurological symptoms this could have led to these symptoms being missed. This evaluation was therefore thorough, the justification for completing this highlighted my competence in this area. This thorough examination skill will aid future practise and enhance patient safety. This has furthered my progression into a more competent practitioner.

I plan to continue to make my examinations as thorough as possible, this could involve asking peers and tutors for any further examination suggestions.

Headache talk by a Neurologist:
I attended a talk by a consultant neurologist regarding headaches. This talk discussed red flags within headache cases.

As this was presented by a neurologist I was expecting the terminology used to be unfamiliar. However, it was reassuring to discover that the terminology we have used within headache clinic is very much the standard terminology.

Attending this talk and the knowledge gained will aid my future practice by enabling greater awareness of the safest practice in headache patients.

I plan to increase my knowledge regarding headaches including learning more details about the types of headaches.

CEx Children's clinic (material attached- page 7-8):
Within my feedback included the need to ask more precise questions within the case history.

In this case this was particularly important as the issue was projectile vomiting. It was important to find out the frequency to determine if this was a red flag. I had asked if this was every time to which the answer was no. However, I should have asked the exact frequency to ensure to monitor this correctly. I therefore wanted to research the implications of this questioning. If projectile vomiting was occuring frequently this could have indicated pyloric stenosis (NICE 2015). This highlighted the importance of the precise nature of the questions required in the case history. I feel my questions had been too general as my knowledge behind why I was asking that question was low.

This realisation that I must improve the quality of my questioning will be vital in my development.

My action plan is to improve this understanding of paediatric conditions to further improve my questioning.

Reference:
NICE, 2015. Gastro-Oesophageal Reflux Disease In Children And Young People: Diagnosis And Management NICE Guideline. Available at: www.nice.org.uk/guidance/ng1 [Accessed March 7, 2021].

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"C2 You must ensure that your patient records are comprehensive, accurate, legible and completed promptly." (GOsC 2018, p.15-16).

# data[].attributes.subject
"C2 You must ensure that your patient records are comprehensive, accurate, legible and completed promptly." (GOsC 2018, p.15-16).

# data[].attributes.body
Accumulation of evidence:

Year 3:
Verbal feedback from tutor:
Verbal feedback was provided from our tutor in the first term about the importance of legible note taking. I had to cover for a colleague.

Due to the illegibility of the notes, this was very challenging. This highlighted to me how this could have impacted safety as I could have missed vital information before treating this patient. I therefore had to ask multiple clarification questions to ensure safe practise, this was quite distressing to achieve within the 40 minutes. To ensure that this would not happen if a colleague had to cover for me I asked my tutor to provide feedback on the clarity and legibility of my notes. He reported the notes were completed to a very high standard.

This awareness will be vital in the future, including within the teaching clinic as patients are frequently covered by colleagues.

I plan to continue this high quality of records.

Clinic exam online (material attached)

My examiners described my data gathering as "excellent".

This would therefore enable comprehensive and accurate notes.
Due to this being a new scenario in regards to a clinic exam, it was rewarding to see such feedback.

This format was online, therefore this continued quality (and therefore safety) within an online consultation can be carried into my future career to still ensure high quality data gathering regardless of the environment.

I aim to continue this high quality of data gathering to ensure comprehensive notes.

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"C3 You must respond effectively and appropriately to requests for the production of written material and data." (GOsC 2018, p.15,17).

# data[].attributes.subject
"C3 You must respond effectively and appropriately to requests for the production of written material and data." (GOsC 2018, p.15,17).

# data[].attributes.body
Accumulation of evidence:

Year 4:
Children's clinic referral:

A case at clinic required a referral, unfortunately there was a considerable gap between letter completion and signing.

With the alternating weeks in clinic it can be easy to have larger gaps with this. I was disappointed in myself when a letter had been waiting at reception to be signed by the tutor and I felt that I had almost let the patient down as I did not inform the tutor that this was at reception. However, I aim to be much more proactive with this to avoid another situation like this.

This has prompted me to strive to complete letters immediately and print as soon as possible with the aim to achieve both signatures on  day of completion. This will be valuable.

This will therefore alter my approach to referral letters in the future.

Another clinical referral reflection on improvement:
This referral process was much swifter, the letter was written within an hour of the consultation ending and was signed that evening in clinic, ready to be sent off.

Although still frustrated that I did not provide this same standard of care in the prior case, it is reassuring to see this skill develop.

This development will be vital to ensure future patient safety.

I plan to continue to make letter writing and signing a priority, as it should be. I intend to apply this time pressure to all my referrals.

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"C4 You must take action to keep patients from harm."(GOsC 2018, p.15,17).

# data[].attributes.subject
"C4 You must take action to keep patients from harm."(GOsC 2018, p.15,17).

# data[].attributes.body
Accumulation of evidence:

Year 3:
Reflection on safeguarding course prior to entering clinic (material attached):

We completed safeguarding courses prior to entering clinic.

This training really opened my eyes to the responsibility that an Osteopath has. And that a Osteopathic consultation  is definitely not purely focused on their presenting complaint but the wider picture and situation must be considered in order to potentially protect the patient from harm.
I was disappointed in myself that I had not given this enough thought in the past.

However, I feel this realisation came at the right time to ensure safety when entering clinic. This will be key in my development as it really allowed me to see the impact on people's lives we can have.

I will carry this knowledge and awareness into future clinical experiences.

Year 4:
My first headache patient was currently taking amitriptyline, I went on to question if this appeared to affect her mood. To this the answer was yes. Therefore, I had to question this further and ask if this ever caused extreme negative emotions that could lead to consequences.

I was proud of this interaction, as a side effect of amitriptyline is suicidal thoughts (NHS 2020), it was vital to question this to potentially protect the patient from harm.

This will be key in my development as my tutor praised my communication and knowledge in how to protect this patient. The patient also seemed grateful for the concern and understood the importance of such questions.

For future development, I aim to become more aware of other medication side effects as this could help to protect patients from harm.

References:
NHS 2020, Amitriptyline: A Medicine Used To Treat Pain And Prevent Migraine - NHS. Available at: https://www.nhs.uk/medicines/amitriptyline-for-pain/ [Accessed January 11, 2021].

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"C5 You must ensure that your practice is safe, clean and hygienic, and complies with health and safety legislation."(GOsC 2018, p.15,18).

# data[].attributes.subject
"C5 You must ensure that your practice is safe, clean and hygienic, and complies with health and safety legislation."(GOsC 2018, p.15,18).

# data[].attributes.body
Accumulation of evidence:

Year 3 and 4:
Return to clinic during the COVID-19 pandemic:

There were many new cleaning protocols in place following the return to clinic.

Despite having prepared prior to my return by reading through all guidelines and information provided, I feel like at the return to clinic in the summer I found this all very overwhelming as it was so new. However, this became easier throughout summer clinic as I was constantly checking the latest guidance and received good feedback from tutors. I aimed to continue to be up to date even through the summer break to make my return easier.
I was pleased that by my return in year 4 I had become more familiar with the situation including PPE and cleaning protocols. I feel that regardless of how stressed I felt as an individual I always maintained a professional manner to the patient.
I ensured to comply with all relevant safety guidelines and thoroughly cleaned treatments rooms to provide a safe environment.  I feel that a major responsibility during this pandemic was reducing spread as much as possible. This pressure was sometimes overwhelming, however I believe the clear guidance from clinic made this process much easier to follow and therefore safer.

I know this can help to protect my patients so will be of value in the future.

I aim to continue to keep up to date with all applicable guidelines.

Reflective model used:

This reflection has been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"C6 You must be aware of your wider role as a healthcare professional to contribute to enhancing the health and wellbeing of your patients."(GOsC 2018, p.15,18).

# data[].attributes.subject
"C6 You must be aware of your wider role as a healthcare professional to contribute to enhancing the health and wellbeing of your patients."(GOsC 2018, p.15,18).

# data[].attributes.body
Accumulation of evidence:

Year 4:
Offering support to parents in children's clinic:

A mother presented to clinic with her 3 month old son, and disclosed in the case history that she is medicated for depression. I asked the appropriate questions to assess the situation. I then followed this by providing the opportunity to point her in the direction of further support if needed.

I feel that by providing this opportunity it can definitely enhance the well-being of the patients. I was proud that I managed to consider the family unit as opposed to focusing on the presenting complaint of the baby. This was vital in this case to ensure that the mother was receiving the appropriate support she needed. I was fully aware of my limits in this and instead gave her the opportunity to help her in finding appropriate support.

This was a vital development in me as a practitioner.

I aim to continue to consider the wider picture as it can be easy to focus on the presenting complaint and miss these key opportunities to provide guidance on further support available to the patient to help their decision-making in how they wish to proceed.

Mental health during the COVID-19 pandemic clinical experiences and tutor feedback:
I have frequently had patients reporting decreased mood due to the pandemic and the feeling of being alone or fed up. I offer these patients the opportunity to explore support that is available to them.

This will enhance their decision-making process and help them feel supported in doing so. I have definitely been made aware of the negative consequences on mental health of patients during the pandemic and I will continue to be aware of local support options to be able to provide these to patients. However, I am disappointed that I previously was considering referral to other professionals and had not thought about the benefits of resources.

These resources could be a preferred option so it is vital I research this. This awareness of the need to find resources could help to provide this support to more patients.

This has been mentioned by tutors that they think I handle these situations well but I must strive to find resources.

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"D1 You must act with honesty and integrity in your professional practice."(GOsC 2018, p.19-20).

# data[].attributes.subject
"D1 You must act with honesty and integrity in your professional practice."(GOsC 2018, p.19-20).

# data[].attributes.body
Accumulation of evidence:

Year 4:
Patient case reflection:

A 50 year old male presented in clinic  with acute wrist pain. After further questioning and examination, my tutor and I discussed that there may be a Triangular Fibrocartilage Complex (TFCC) tear.
Instead of providing Osteopathic treatment, we decided that immobility and a steroid injection was the best option for the patient. This involved a referral to the GP.

It was great to realise that the patient was still satisfied with the consultation despite not receiving Osteopathic care. Instead this  patient was happy with the honesty, gaining an understanding and having a management plan outlined to him.  We also provided the option that once the pain had settled in approximately 3 weeks, he could return if he wished to aid the rehab process.
I lacked knowledge on the management of this condition.  So I decided to look into further studies about the management.
I found a study that concluded that treating TFCC injuries with an arthroscopic procedure resulted in functional outcomes that were satisfactory (Selles et al. 2020). This study had a sample size of 51 and investigated multiple procedures (Selles et al. 2020). This sample size could be considered a strength as well as the investigation of multiple interventions.

Investigating potential options available to my patients will help to ensure optimal patient care and provision of suitable options.
This would help me to be more honest when discussing treatment and management options with my patients as I would have more knowledge to support this.

I will aim to carry out this important research on management of conditions to ensure I am acting with honesty.

References:
Selles, C.A., d’Ailly, P.N. & Schep, N.W.L., 2020. Patient-Reported Outcomes Following Arthroscopic Triangular Fibrocartilage Complex Repair. Journal Of Wrist Surgery, 09(01), pp.058–062.

Children's clinic case reflection:
I had a patient in children's clinic where the mother had been advised to see an Osteopath by a Health Visitor to see if we could help with feeding issues due to a slight tongue-tie. However, on assessment there were limited findings. We ensured to explain this to the mother and reassured her. We also informed her that only 1 or 2 further treatments would be advised as there were very limited treatments we felt we could do to help.

This demonstrated acting with integrity and I reflected on this after. I feel like sometimes as a student there is a pressure (put on by myself) to find things to treat to show the quality of my testing. However, it is just as important to point out when there are not many things to treat and therefore reassure the patient.

This awareness will be of value in the future, by not trying to find ways that Osteopathy can help if it is very unlikely to have any benefit. My approach to this must change to aid my development as a practitioner.

I plan to alter my approach to this accordingly, by not placing pressure on myself to find treatable examination findings.

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"D2 You must establish and maintain clear professional boundaries with patients, and must not abuse your professional standing and the position of trust which you have as an osteopath."(GOsC 2018, p.19-20).

# data[].attributes.subject
"D2 You must establish and maintain clear professional boundaries with patients, and must not abuse your professional standing and the position of trust which you have as an osteopath."(GOsC 2018, p.19-20).

# data[].attributes.body
Accumulation of evidence:

Year 1:
Feedback from first practical exam (material attached-page 1-3):
This exam included Osteopathic Technique, Osteopathic evaluation and Osteopathic concepts. In terms of professionalism, positive feedback included that I explained to the patient well and was complimented on my mannerism. It was also mentioned that I was professional and aware of boundaries. Improvements included to use more professional language (avoid words such as "nice") and to ensure to always use words the patient can understand.

In general, I was pleased with the feedback. However, this highlighted to me the difficulty in both being professional and using words that the patient can understand. I was disappointed I had not been able to achieve this.

This awareness will aid my future communication between colleagues and patients.

From this I have developed an action plan to practise my communication with my peers more within the practical classes.

Reflection on my personal development:
We conducted multiple personality tests within a lecture.

This was an interesting experience for me as this highlighted how aware I am of my characteristics.

This prompted some reflection on my personal development, I know I have genuine interest in the feeling of others and I reflected on how I must be aware of this when I enter clinic.  I think it is really important as a practitioner to know yourself. As I know I care a lot about others, I must ensure that in clinic I do not take patient's problems as my own problems.

This will alter how I approach patient discussions in the future.

Year 2:
Observation reflection:
This is a reflection about a student whose patient told them that since their last treatment they had been diagnosed with prostate cancer. This was clearly a very emotional situation for the patient and he was devastated.

The practitioner handled the situation very well in my opinion and still managed to gain information that he needed about the cancer such as the stage without getting too emotionally involved. But it was clear to the patient that he was very sympathetic. I thought this was very professional. Also, he focused on the only positive bit of news about his diagnosis, that it hadn't spread. I personally think he handled the situation very well, being sympathetic but not too emotional. He still gained the information while maintaining respect for the patient.

This will be key in my development as it provided me with experience in these difficult situations before entering clinic myself. It enabled me to analyse how I would approach a situation like this in the future. I will take into consideration what I have learnt from this experience. A key point that I learnt is to allow the patient to talk, silence isn't necessarily bad after the patient discloses such information. It can take time to formulate the most appropriate response.

I will carry this with me throughout my career.

Year 3:
Peer feedback from observation:
A colleague observed my continuing patient and reported that I remained professional.

This patient is very jokey and very talkative so it can be quite hard to keep the consultation moving at a good pace and keep the professionalism. Considering this, it was really great to hear that my colleague thought I remained professional and managed the consultation well. This has been challenging as this patient can become very chatty and discussion can take unexpected turns.

Receiving this feedback will give me more confidence when encountering similar situations.

This will support my consultations both within the teaching clinic and in my future career.

Year 4:
Year 2 student feedback:
A year 2 student observed my team in clinic, this student came to observe my new patient. This case had a few sensitive issues involved, such as a stillbirth, a recent death in the family and opening up about her mental health. I asked for feedback regarding this as this is such an important area within Osteopathy to handle correctly. She said that she really liked how I handled the situation.

I felt like I handled it in a caring and professional manner. The year 2 student also complemented my professionalism. Looking onto previous reflections, it is rewarding that this professionalism skill that has developed through observing peers and gaining feedback has been continually developed to result in such positive feedback.

It will be vital to uphold that professional manner in future consultations. So gaining feedback on this will further my development.

I plan to continue to gain feedback on my professionalism in multiple scenarios.

Children's clinic feedback term 1 (material attached-page 4):

The tutor observed both a friendly and professional side within my consultations.

This suggests that I balanced this appropriately. This was rewarding as I think in children's clinic it can be difficult to control the balance between interacting with the child and keeping a professional side too.
Despite receiving positive feedback, this was a challenge for me. I definitely struggled with not getting too distracted by interacting with the baby that the professional procedure of my usual consultations were affected. I did feel that at the start of children's clinic my consultations were a bit chaotic and disorganised, I feel this was due to being overwhelmed by such a new interaction style as I have not had much experience with interacting with children of this age.

This ability to balance this will aid my future consultations not only within children's clinic.

I plan to improve this with more children's clinic consultations and observing my peers handling of these situations.

Term 2 children's clinic feedback:

"What I have observed that has gone well:

I have observed you asking relevant case questions that have shown thought around the presenting symptoms and gained you important information.

You have gained good clarity on detail of cases.

Good consent gaining for examination involving mum and making her feel like she can do what she needs for the baby.

Good explanation of exam process as go along and good consideration of baby's needs.

Always professional manner.

Effective treatment skills."

The feedback regarding my professional manner was great to see, as I was struggling with this personally. It was great to see the feedback improve from "generally professional" to "always professional manner".

This was from the same clinic tutor, so the improvement was highlighted.

I will continue to strive to always maintain that professional manner.

Mock CCA feedback (material attached- page 5):
We had a mock CCA exam involving one new and one returning patient. Feedback included both the ability to form a good rapport also whilst remaining professional.

This was fulfilling I have previously found it difficult particularly when nervous to uphold a professional manner. As I am nearing the end of this course it is reassuring to receive this feedback.
This mock CCA was a very distressing situation for me as I realised the end of the course was approaching and I needed to be able to perform under this pressure. I think I was expecting too much of myself as I am a perfectionist and failed to take  into account the added pressure of simply the word CCA being mentioned. I was proud to uphold a professional manner despite the distress I was experiencing.

This development regarding my professionalism will enable me to remain professional in stressful environments. With further experience I can complete this with more ease.

I plan to ask tutors to observe more of my consultations to help me perform under this pressure.

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"D3 You must be open and honest with patients, fulfilling your duty of candour." (GOsC 2018, p.19,22).

# data[].attributes.subject
"D3 You must be open and honest with patients, fulfilling your duty of candour." (GOsC 2018, p.19,22).

# data[].attributes.body
Accumulation of evidence:

Year 4:
Providing prognoses:
Within the clinical setting on the first consultation I frequently provide an estimate of the number of treatments I think would be appropriate. For example, I stated 2-3 treatments for a baby with a slight neck rotation preference but I did emphasise that this was only an estimate. On the third consultation the tutor and I discussed that a further consultation may be beneficial. I discussed this with the mother and she reported that she had understood it was only an estimate and was happy to attend the 4th treatment.

I was proud of my communication, as If I had not provided the information that this was an estimate and will depend on the progress, this could have been distressing for the mother. She may interpret this as the presenting complaint progressing into something more concerning requiring further treatment. I feel like my extensive communication prevented any feelings of receiving misinformation.

This learning experience highlighted that this is a key part of the consultation.

I aim to apply this approach to future consultations.

Year 4:
Diagnoses changing:
In the teaching clinic, diagnoses can frequently change with different tutors but also as symptoms change over time. However, when this happens I do apologise to the patient for any confusion this causes. I then explain how this can happen as we monitor the progress.
Patients respond well to this.

However, on reflection to avoid any situations where the patient feels they have been wrongly informed I should highlight that this is a working diagnosis and may be altered in the future as we gain a greater understanding of the presenting complaint. I feel it can be quite distressing as a student to have to change the diagnosis after receiving another tutor's opinion.

I now feel that emphasising that this is a working diagnosis at the start could make it less distressing for the patient and I. This learning experience highlighted this for me.
Therefore, if patients in the future would not be so understanding this could avoid the feelings of wrong-doing. However, I still think it is polite to apologise for any confusion as many patients do educate themselves on the working diagnosis. Therefore, altering this can lead to confusion especially if they felt the original diagnosis really matched their symptoms.

My action plan to resolve this flaw in my communication is to emphasise that this is a working diagnosis that may alter as treatments progress.

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"D4 You must have a policy in place to manage patient complaints, and respond quickly and appropriately to any that arise." (GOsC 2018, p.19,22).

# data[].attributes.subject
"D4 You must have a policy in place to manage patient complaints, and respond quickly and appropriately to any that arise." (GOsC 2018, p.19,22).

# data[].attributes.body
Accumulation of evidence:

Year 2:
Letter writing essay- responding to a letter of complaint:
We had to respond to a letter of complaint for a coursework task.

I learnt from this process how easy it can be to become quite defensive when someone criticises you. But this letter writing enabled me to spend time thinking about the best way to approach it. I learnt to acknowledge the weaknesses without admitting fault, alongside maintaining the professionalism and abiding by the OPS as this was a key feature of the assessment. This was a challenge for me, as this was a new task.

The process of practicing this letter writing will be very helpful for me in the future, allowing me to respond in an appropriate manner and complying with the OPS. I had not previously been aware that I could become so defensive, so it was vital this was highlighted to me at this stage in my development. This allowed reflection of this before applying this to a real clinic scenario.

This will alter my approach to letters of complaint, if I receive them in the future.

Reflective model used:

This reflection has been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"D5 You must respect your patients’ rights to privacy and confidentiality, and maintain and protect patient information effectively." (GOsC 2018, p.19,23). 

# data[].attributes.subject
"D5 You must respect your patients’ rights to privacy and confidentiality, and maintain and protect patient information effectively." (GOsC 2018, p.19,23). 

# data[].attributes.body
Accumulation of evidence:

Year 3:
Patient not comfortable with cameras:

This patient was not comfortable with the thought of the cameras so I reassured her that these were switched off. This patient felt that the cameras were an invasion of her privacy.

This was important in my development as I had not previously experienced this with patients, they were happy to have the cameras. However, this patient looked visibly concerned at the thought of being on camera. I was pleased with my ability to adapt to this.

This highlighted to me that privacy can be a very individualised term that can have different meanings for everyone. This learning will aid my future approaches within the clinical setting. I must not expect certain responses from patients based on previous experiences. This was definitely a learning point for me as a practitioner.

I intend to take this awareness into future consultations.

Year 4:
Gaining patient perspective for a case report:
For the case report, we had to ask the patient to provide their perspective. I gained informed consent and explained the intended use of this information and emphasised that the write up would be anonymous. I also made a record of this informed consent within the notes.

I ensured that this was adhered to and removed any identifying information from the written material they provided.

This enabled confidentiality and privacy to be maintained. I was proud of the quality of the consent gained.

This experience in this different scenario will aid my ability to deal with further information I gather in the future such as feedback questionnaires.

I hope to continue this high level of consideration when handling patient information.

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"D6 You must treat patients fairly and recognise diversity and individual values. You must comply with equality and anti-discrimination law." (GOsC 2018, p.19,25).

# data[].attributes.subject
"D6 You must treat patients fairly and recognise diversity and individual values. You must comply with equality and anti-discrimination law." (GOsC 2018, p.19,25).

# data[].attributes.body
Accumulation of evidence:

Year 4:
Patient not comfortable removing certain items of clothing:

This patient was uncomfortable with the thought of removing items of clothing. This patient was wearing a hijab and a long length outfit and was not comfortable removing any items of clothing. However, she was happy to roll the sleeves up. This patient was also not comfortable with the thought of the cameras, so I reassured her that these were switched off. This patient specifically requested a female practitioner and reported being concerned that she was unsure of who would be watching the camera, so would not be alright with this.

I feel like I asked the question about removing clothes in a very sensitive manner and also made her feel comfortable that her response is completely understandable and respected. These individual values were respected and adhered to.
The fact I could see the patient really appreciate her individual values being respected made me feel proud as a practitioner.

I felt this built a relationship of trust with the patient that will be vital in future consultations.

In terms of future development, it would be important to continue to consider the importance and individuality of this to make patients feel comfortable.

Reflective model used:

This reflection has been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"D7 You must uphold the reputation of the profession at all times through your conduct, in and out of the workplace."(GOsC 2018, p.19,25).

# data[].attributes.subject
"D7 You must uphold the reputation of the profession at all times through your conduct, in and out of the workplace."(GOsC 2018, p.19,25).

# data[].attributes.body
Accumulation of evidence:

Year 3:
Reflection on my clinic team experiences-tutor feedback:
My group is continually praised for the courtesy it displays to each member. During discussions we always ensure everyone has a chance to speak and no one is interrupted. This has been mentioned by multiple tutors. We also aim to ensure to show courtesy when choosing rooms, for example always offering the larger room to those with new patients.

I am proud to be a part of this group as it makes the clinic environment much more pleasant. I also feel like we have all had a part in creating this environment.

This will aid future colleague interactions within the teaching clinic and within the working environment.

I will use this experience when joining a new clinic team post-graduation.

Reflection on upholding the reputation throughout the COVID-19 pandemic- clinical experiences:

The COVID-19 pandemic added a whole new standard regarding our behaviour both in and out of the work place. As key workers we were able to return to study.

While this was a privilege, it was a challenge as it meant we were having patient contact when cases were the highest. This added stress to the adherence of the guidelines. It was hard to adjust to all the changes and guidelines but something I completely understood the importance of and was committed to adhering to. This is definitely a standard I aimed to adhere to even before this pandemic  but this brought a whole new dimension in regards to expected behaviours. I am proud of the way I stepped up during this difficult time and focused on upholding that reputation that I feel is important to protect.

This ability will be vital in my career as we continue to navigate our way out of this pandemic.

For the future, I plan to continue to uphold this reputation as I move on with my career, and not let this become an area I become more relaxed with.

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"D8 You must be honest and trustworthy in your professional and personal financial dealings." (GOsC 2018, p.19,25).

# data[].attributes.subject
"D8 You must be honest and trustworthy in your professional and personal financial dealings." (GOsC 2018, p.19,25).

# data[].attributes.body
Accumulation of evidence:

Year 4:
Case reflection:
A 50 year old male presented in clinic  with acute wrist pain. After further questioning and examination me and my tutor discussed that there may be a Triangular Fibrocartilage Complex tear. Instead of providing Osteopathic treatment, we decided that immobility and a steroid injection was the best option for the patient. This involved a referral to the GP.

It was great to realise that the patient was still satisfied with the consultation despite not receiving Osteopathic care. Therefore, I did not falsely advocate that I felt Osteopathy could help. I worked with the patient's best interest and ensured he did not spend money on a treatment that was unlikely to provide any benefit. I am proud of my handling of this situation from an ethical prospective, this highlights that financial gain is not considered when formulating advice for patients.

This will be vital in future clinical scenarios to ensure I am a trustworthy practitioner. This may help with bringing new patients in, as word of mouth may spread.

I will continue to look at offering treatments (or no treatment) that I feel are most applicable to my patients to prevent them spending their money unecessarily.

Reflective model used:

This reflection has been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"D9 You must support colleagues and cooperate with them to enhance patient care." (GOsC 2018, p.19,26).

# data[].attributes.subject
"D9 You must support colleagues and cooperate with them to enhance patient care." (GOsC 2018, p.19,26).

# data[].attributes.body
Accumulation of evidence:

Year 2:
PBL assessment:
We had to work in a group for this assessment task.

This has taught me valuable communication skills. For example, I have learnt how being motivational within a group can have positive effects.  Also, I have learnt that everybody handles their work differently and if people leave their work until the last minute that doesn't mean they will not get it done. Although this was originally distressing as I am keen to complete work timely.

This learning experience helped me to become more patient and have a greater understanding that people may prioritise work differently to me.

In the future, I plan to continue this group work within the clinical setting as the benefits of this could be profound.

Year 3:
Peer feedback:
A colleague observed my continuing patient and provided some feedback, including areas to improve on my passive testing.

This patient is very jokey and very talkative so it can be quite hard to keep the consultation moving at a good pace and keep the professionalism. Considering this, it was great to hear that my colleague thought I remained professional and managed the consultation well. It was also really beneficial to have been given some help on some areas of my passive testing that he felt I could improve- such as focusing as well on the movements not just the pain and remembering to watch the patient's face more.

This will aid my development as I can improve on this aspect by practising with colleagues.

I plan to ask this colleague to review my passive testing in the future and to gain further feedback.

Further feedback from passive testing:
The colleague mentioned in the previous reflection observed a new patient of mine. I specifically requested feedback on passive testing and my colleague noted improvements. It was pointed out that I engaged more with the patient and with the tissues while passive testing.

This made me feel proud and also it was rewarding for my colleague to know his feedback had been acted upon. I feel this really encouraged this colleague to continue providing feedback confidently as he could see it be used well.

This will be beneficial for my future development and also my colleagues' as I feel this will enhance our understanding of how to best provide and act upon feedback.

I will therefore continue to value feedback to improve my patient care.

Verbal feedback from clinic tutors:
Many clinic tutors have noted my clinic teams ability to cooperate well and work as a team.

At the start as I was aiming to understand my colleagues more, I was quite nervous about providing negative feedback to colleagues as I was afraid to criticise. I feel this was influenced by members of my group having previous experience before this course that I did not have.  However, with reassurance from my team and their emphasis on how important honest feedback is, I have started to improve this. I was disappointed in myself that I didn't feel comfortable providing this at the start as I feel my clinic group would have responded very well to this and it could have aided our development. However, I am pleased I have gained more confidence and do this more readily. I almost feel guilty that my team offered me both positive and negative feedback that enabled me to develop whereas I focused on the positives without criticism.

This awareness of how difficult I find providing negative feedback will be important to consider in the future. This learning experience will be vital to support my future interactions with colleagues.

In the future, I aim to be confident providing both positive and negative feedback in order to improve patient care.

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"B3 You must keep your professional knowledge and skills up to date" (GOsC 2018, p.12,14).

# data[].attributes.subject
"B3 You must keep your professional knowledge and skills up to date" (GOsC 2018, p.12,14).

# data[].attributes.body
Accumulation of evidence:

Year 4:
Tuning forks research:

We were set independent work  after an online clinic session.

I was intrigued that the accuracy of using tuning forks for fractures was questioned. I had previously not questioned this, however with this contradictory information compared to previously taught material I wanted to research further. We were provided with one link.
Provided paper:
This paper concluded that testing with a tuning fork has some value in regards to excluding fractures. However, this method did not have adequate reliability or accuracy for widespread use in the clinical setting (Mugunthan et al. 2014).
However, this study only had 6 studies included so I searched for other papers.

Unfortunately another review I found only had a sample size of 6 studies also. This study concluded that the included studies suggested that the use of a tuning-fork in testing to rule out fractures has some value. This study also highlighted again that strong supporting evidence is insufficient to support current testing using a tuning-fork. Further, this test was identified as not being accurate (statistically) in fracture diagnosis for widespread use within a clinical setting (Toney et al. 2016).
This highlighted to me to think critically in regards to the tests that I adopt in clinic. It has also taught me that I should further my knowledge and skills by further looking into the validity of the tests I choose. Adopting more valid tests could improve my clinical performance. Also, by having this knowledge, it could aid me in making better clinical decisions.

I plan to continue to apply this high level of thought and research to the tests I choose.

References:
Mugunthan, K., Doust, J., Kurz, B. & Glasziou, P., 2014. Is There Sufficient Evidence For Tuning Fork Tests In Diagnosing Fractures? A Systematic Review. BMJ Open, 4(8).

Toney, C.M., Games, K.E., Winkelmann, Z.K. & Eberman, L.E., 2016. Using Tuning-Fork Tests In Diagnosing Fractures. Journal Of Athletic Training, 51(6), pp.498–499.

Knee OA-ensuring knowledge is up to date:
I have recently had 2 new patients presenting with pain associated with Knee Osteoarthritis. One patient was seeking a surgical opinion and wanted maintenance treatment before this, whereas the second was not currently in this process.

As this condition was frequently on my mind in the teaching clinic I wanted to research to ensure I am providing the best advice.  This research was important to me as unfortunately both of these patients reported feeling fed up and annoyed at their body aging and I really wanted to be able to provide the most suitable advice. They found it frustrating that the body could not do what it used to.

This was really eye opening to me that although conditions like this are common we should not underestimate the psychological impact of this. This really emphasised the importance of further research to ensure I am offering the most up to date advice to patients.

I looked at the NICE guidelines for Osteoarthritis and this provided helpful information regarding management of patients with this. For example, included exercises should be both strengthening of the local muscles and aerobic fitness exercise in general. It was recommended to consider stretching and interventions such as manipulation as an addition to the provided core treatments. In regards to referral, it is recommended to conduct a referral to enable consideration for surgical intervention prior to established limitations in function that are also prolonged and prior to severe pain. Also interventions intended to aid weight loss in obese or overweight patients are recommended as a core treatment  (NICE 2014). This was a key addition to my knowledge as one of my patients had already decided for herself about the knee replacement and was exploring that option, however, the other patient was looking more to me to guide her to the best option. On reflection, I feel like we did make the best decision to try conservative management first. Both of these patients also mentioned an awareness that they would like to lose weight. On reflection, I should have perhaps given more advice regarding this area. I find situations like this quite uncomfortable as you can see the patient is already conscious of their weight.

I also wanted to research the different management options to see if there are differences in the outcome. A systematic review concluded that patients with degenerative knee disease that had knee arthroscopy did not have profound improvements in function or pain levels in comparison to those receiving conservative management in the longer term (Brignardello-Petersen et al. 2017). This was interesting the read as I feel that many patients feel like surgical intervention is the only way to see relief from symptoms. It will be helpful in future treatments to be aware of this knowledge when answering patient questions. However, it is important to apply this knowledge carefully and still considering the patient as a whole.

As I plan to help provide relief via manual therapy I wanted to find up to date research to support this. I feel like I communicated well that I am unable to cure the arthritis but together we can help manage the symptoms. A recent systematic review and meta-analysis which is high within the hierarchy of evidence suggested that there is evidence (preliminary) to suggest that manual therapy may be both safe and effective in decreasing pain, reducing stiffness, and improving the physical function in patients with knee osteoarthritis (Xu et al. 2017). This was a relief to come across such evidence, as I would not feel comfortable offering this treatment if I did not feel there would be any benefit to the patient.

However, this will be key in my development as this is only preliminary evidence so I will continue to look for up to date research on this condition that we commonly see in clinic.

I will continue to research the effects of Osteopathic treatment on a range of conditions.

References:

NICE, 2014. Osteoarthritis: Care And Management Clinical Guideline. Available at: www.nice.org.uk/guidance/cg177 [Accessed May 12, 2021].

Xu, Q. et al., 2017. The Effectiveness Of Manual Therapy For Relieving Pain, Stiffness, And Dysfunction In Knee Osteoarthritis: A Systematic Review And Meta-Analysis. Pain Physician, 20(4), pp.229–243.

Brignardello-Petersen, R., Guyatt, G.H., Buchbinder, R., Poolman, R.W., Schandelmaier, S., Chang, Y., Sadeghirad, B., Evaniew, N. & Vandvik, P.O., 2017. Knee Arthroscopy Versus Conservative Management In Patients With Degenerative Knee Disease: A Systematic Review. BMJ Open, 7(5), p.e016114.

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"D10 You must consider the contributions of other health and care professionals, to optimise patient care."(GOsC 2018, p.19,26).

# data[].attributes.subject
"D10 You must consider the contributions of other health and care professionals, to optimise patient care."(GOsC 2018, p.19,26).

# data[].attributes.body
Accumulation of evidence:

Year 3:
Progressive symptoms requiring referral:
I had a patient presenting with cervical spine pain and headaches. These headaches originally appeared cervicogenic in nature. However, the symptoms progressed to weakness in jaw movements and sensory symptoms. Therefore a referral was needed.

I was proud of the way I monitored the headaches, as tutors often say that with continuing patients it can be easy not to be as thorough in the  discussion part. This highlighted to me that we must monitor progress very thoroughly and check for any changes.

This will be invaluable in future practice. If in the first consultation concerns are eased and no red flags are present that does not mean we can become more relaxed with the questioning.

This will inform the quality of discussions I have prior to treating continuing patients.

Year 4:
Working alongside other healthcare professionals in children's clinic:

In children's clinic there was a young baby that was struggling to gain weight.

They were recommended to try Osteopathy to see if any issues in jaw tension could affect feeding. I was proud of the way I kept informed of recent interactions with the health visitor and pediatrician as this was vital to ensure this patient was cared for well.

This highlighted to me the benefits of multi-disciplinary care. The mother was grateful that I was constantly checking how recent appointments had been with other health and care professionals.

This ability to work in a multi-disciplinary team and keep updated with outcomes will enhance the care of patients in the future.

Referral for potential failing hip resurfacing:
I had a patient present with knee pain. However, in the case history it became evident that the hip required a referral. This patient had a resurfacing procedure 14 years prior and a dislocation 10 years ago. This hip was feeling progressively unstable and making progressively loud sounds.

I feel it can be overwhelming to consider both the patient's priority and other issues that are mentioned in the case history. I am disappointed that in the first consultation I focused on the knee and did not ask enough questions about the  hip. This was corrected in the follow-up consultation.

This ability to consider multiple aspects will be vital in future practice. I have learnt how focusing too much on one aspect can affect the care of the patient.

I aim to alter my approach to this in the future and not focus too heavily on the primary complaint as this could affect my overall management of the patient.

Continuing patient experiencing emotional distress:
I had a patient that came into the treatment room and explained that she had received some bad news prior to the appointment. She said that she is finding dealing with this very hard. I checked that she feels she has support around her and gave the opportunity to point her in the direction of further support.

I was proud of my ability to listen to the patient and respond appropriately. It was great to see the patient felt supported in this.

This will aid future development as this was an unexpected situation as this bad news had only just been received.  My ability to swiftly offer this support was valued by the patient.

I will continue to also focus on mental health alongside MSK conditions.

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.body
My reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

Reference:
RMIT University, 2010. REFLECTIVE WRITING: DIEP. Available at: https://www.dlsweb.rmit.edu.au/lsu/content/2_AssessmentTasks/assess_pdf/Reflective journal.pdf#:~:text=Reflective writing aims to get,writing%2C using a DIEP strategy.&text=to describe%2C interpret interpret interpret,D – Describe objectively what happene [Accessed May 12, 2021].

# data[].attributes.headline
"D11  You must ensure that any problems with your own health do not affect your patients. You must not rely on your own assessment of the risk to patients." (GOsC 2018, p.19,27).

# data[].attributes.subject
"D11  You must ensure that any problems with your own health do not affect your patients. You must not rely on your own assessment of the risk to patients." (GOsC 2018, p.19,27).

# data[].attributes.body
Accumulation of evidence:

Year 3:
Online consultations (material attached):

The format of this clinical exam was online. My examiners noted that my manner was professional.

I thought it would be a challenge to remain entirely professional when the communication in this exam was completely different to a clinical scenario. I felt this manner was achieved by practising this with peers.

This could aid my development into a future practitioner. I can transfer these skills into telephone or video consultations in the future. These consultations could be needed in the future if mine or the patients' health prevents a face to face consultation.

In the future, I aim to have more experience with these consultations as this may provide patients more options.

Year 4:
Self-isolation:

I had been informed that I had been a close-contact of someone who had tested positive for COVID-19. Therefore, this meant that entering clinic would be unsafe.

I feel I reacted to this with appropriate urgency and rang the teaching clinic as soon as it opened to inform them of the situation. This enabled my patients to be covered. I am proud of the speed to which I acted on this and I was efficient with replying to any emails regarding this.

I think this highlighted that there can be unexpected situations within practice and it is important to inform the necessary people as soon as possible. From this I learnt that with efficient organisation skills it can enable colleagues to adapt to the situation and cover appointments.

In the future, I will continue this approach and will aim to support colleagues who are unable to work in any way I can.

Reflective model used:

This reflection has been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).

# data[].attributes.headline
"B4 You must be able to analyse and reflect upon information related to your practice in order to enhance patient care."(GOsC 2018, p.12,14).

# data[].attributes.subject
"B4 You must be able to analyse and reflect upon information related to your practice in order to enhance patient care."(GOsC 2018, p.12,14).

# data[].attributes.body
Accumulation of evidence:

Year 1:
Feedback from first practical exam (material attached- page 1-3):
This exam covered Osteopathic evaluation, Osteopathic technique and Osteopathic concepts. Positive feedback included that I had a methodical approach to my observation and good accuracy of testing. Also, my anatomical and treatment knowledge was good.
Improvements included needing to slow down during the treatment. Further, precise improvements on specific techniques were mentioned.

In general I was very pleased with the feedback as it was the first practical exam, but I also found it a very helpful learning experience as I could see where I could improve.
This was my first experience of analysing my feedback from a practical exam. At first I was overwhelmed by all the feedback as in total it was approximately 9 pages. I had not previously had such extensive feedback. However, I broke it down into manageable parts and then was able to create a clearer plan of how I can make these improvements.

This ability to deal with large volumes of feedback will be of value in the future. This will help to improve vital skills needed in Osteopathy.

From this, I plan to continue to break down my feedback into manageable parts to enable this to be acted on appropriately.

Video reflection:
I analysed my completion of a Quadratus Lumborum inhibition.

I feel that I was generally pleased with the technique I was using when inhibiting the Quadratus Lumborum. I personally feel the main strength was how I was constantly checking if my patient was comfortable, both by verbally asking and also by looking at my patient’s face for any sign of discomfort. I also felt I applied a reasonable amount of pressure, so I think I achieved the aim of the technique and I personally felt the muscle relax during the inhibition. This suggests my treatment was effective. My feedback was that my posture was quite good, but I personally felt I could have been standing straighter. The feedback was that the way my hands were positioned was effective as my sensory hand was below my motor hand. To improve, I could have had the couch slightly higher to improve my positioning and stop me bending so much, this will help to increase the economy of the movement. Furthermore, I feel that I should have moved my patient closer to me to allow more comfortable positioning and allow me to easily carry out the inhibition technique, further increasing the economy of the movement.

This ability to reflect on feedback will be invaluable to help to improve my technique application in the future.

I will apply these corrections in future practical classes. I feel the economy of my movement was effective as I had straight arms and used my body weight to apply the pressure.  In conclusion, I can see the areas that need improving but I am generally pleased with my technique.

Year 2:
Clinical integration mark reflection (material attached- page 4-5)
The first page of the feedback was very positive with very high marks. The second page contained much more constructive criticism.

When analysing this feedback, I almost completely ignored the positives and instead was disappointed by the negative feedback and focused on this.

This again highlighted to me that throughout year 2 I have been too critical of myself. This awareness will be vital in the future, as this must be improved to analyse feedback in the optimum way. I must be prepared to also reflect on why patients may have provided positive feedback within the clinical setting.

I aim to improve my approach to this when reflecting on feedback in the teaching clinic.

Year 3:

CEx- formative (material attached-page 6):
In the feedback it was highlighted that I must improve my long term management of this patient.

It was very helpful to have an area pointed out to me to improve. I know my knowledge of exercises and long term care of patients isn't optimum. I felt disappointed that I could not provide this to a high standard. I was aware of the importance of this but I feel like I have not been prioritising this in my learning. This could be reducing the continued impact of treatments so it is vital to spend time researching this.

This recognition of the limitation in my practise will aid my future research and my priorities for future learning.

I am now interested in developing this part of my knowledge to hopefully improve on this next time. I plan to create clearer and more appropriate management plans for my patients within the teaching clinic.

Children's clinic feedback (material attached-page 7):
I received some feedback about how to expand my case history taking.

This feedback was really useful, as this process still feels so new with a baby, having precise feedback like this will enable me to make those clear changes. I was very grateful, as this will be key in my development.

I realise now that feedback with clear examples can really enable improvement and reflection. It also aids understanding of the feedback. I did think that my case history was lacking in detail in some areas so this will really aid my development.

I plan to include these questions as routine within my child case history taking and research further questions associated with specific differential diagnoses.

The standard of my reflection and the challenges faced throughout:
My reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1). This approach entails 4 steps. Firstly describing, then interpreting, followed by evaluating and finally planning (RMIT University 2010).

At the start of this course, I feel my reflections would often interpret the event but I would struggle to create an action plan. This would often leave me feeling disheartened after reflection rather than motivated. However, now I find reflection very motivating. I feel my ability to reflect has massively improved. This document was a massive help in improving my style of reflection.

I have learnt from this that I like to follow step-by-step guidance. Although this could be viewed as a weakness that I require this precise guidance to feel confident, I feel it makes my work more structured by thinking in this way. I feel a limitation of my approach was that I found a model that I could work well with and failed to look for alternatives that may have been even more suitable. However, the awareness of how I prefer to follow guidance will be valuable in future learning.

Therefore, for future development I aim to explore more reflective models to aid the reflection within my continuing professional development.

I also found another source with more detail quite helpful to expand on my understanding of how to apply this model (RMIT University 2015).

References:

RMIT University, 2010. REFLECTIVE WRITING: DIEP. Available at: https://www.dlsweb.rmit.edu.au/lsu/content/2_AssessmentTasks/assess_pdf/Reflective journal.pdf#:~:text=Reflective writing aims to get,writing%2C using a DIEP strategy.&text=to describe%2C interpret interpret interpret,D – Describe objectively what happened. [Accessed May 12, 2021].

RMIT University, 2015. RMIT_DIEP_strategy_accessible_2015. Available at: https://emedia.rmit.edu.au/learninglab/sites/default/files/Writing_academic_reflection_accessible_2015.pdf [Accessed May 12, 2021].

Reflective model used:

These reflections have been based on the university model named the DIEP strategy adapted from a previous publication by Boud et al (Boud et al. 1985 cited RMIT University 2010, p.1).