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

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The examination in viscera, fascia, and Balanced Ligamentous Tension (BLT) during the first year was uplifting, particularly as it affirmed that my patient handling was conducted in a courteous, friendly, and welcoming tone. The treatment was characterised by care, consideration, and respect for the patient. Unfortunately, the neurology examination did not reflect the same high standard as the three preceding assessments. The key difference was my insufficient mastery of the subject matter, which led to insecurity and, regrettably, the failure to uphold the model's well-being in a professional manner. My conduct during this encounter was inconsiderate and indefensible, and it was both humiliating and distressing for me as a clinician.

I subsequently reflected on the experience using Gibbs' Reflective Cycle. It became apparent that stress and pressure were the main contributors to the unfortunate outcome. The challenge lies in identifying precursors to critical stress states. Gibbs’ model assisted me in re-establishing structure in clinical processes to maintain control and perspective throughout treatment sessions. Specifically, I found that setting aside unresolved clinical problems until a solution is found was essential. Additionally, maintaining focus on the most relevant aspects from the patient’s perspective—without prematurely excluding other concerns—was extremely helpful.

Problem deconstruction also enabled the treatment to stay within the allocated time, with the added benefit that the patient was not subjected to over-treatment, and the volume of input remained manageable. I realised that I sometimes risk overwhelming the patient with excessive intervention, potentially undermining their ability to absorb and benefit from treatment.

Furthermore, I have become more aware of the importance of involving the patient. This is achieved by openly discussing emerging clinical challenges and sharing my reflections and proposed strategies. I occasionally refrain from performing aspects of treatment with which I am not yet sufficiently confident, instead committing to resolving such dilemmas—especially where patient safety could be at risk. It is essential to establish agreements with patients on how to proceed in such situations. These agreements must be made on a fully informed basis. When the available information is deemed insufficient, the appropriate course of action may be to offer the patient provisional options or recommendations.

My experience has shown that patients respond positively when I share my reasoning and considerations. Sincerity is rewarded with honest and open dialogue from patients, which enhances collaboration and improves the likelihood of successful outcomes. The ongoing challenge remains: to establish and maintain structure in one’s clinical practice.

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One of the most famous cyclical models of reflection leading you through six stages exploring an experience: description, feelings, evaluation, analysis, conclusion and action plan.

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Patients are individuals with unique views on their complaints as well as they have unique beliefs and expectations of their prognosis. It is important to tune into the patient's perception, expectations, and beliefs to establish a common ground of mutual understanding. It is beneficial to mirror your patient by using language and expressing yourself in a way your patient can understand you. Your attitude is furthermore important considering gaining your patient's comfort in communicating with you. Concern and acknowledgment of patient complaints can contribute to a healthy atmosphere between you and your patient. Finally, you need trust from your patient. This can be gained from the patient having faith in being heard and understood by you.

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Health Communication: Effective Strategies | Tulane University

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Health communication empowers people to stay healthy. Explore how Tulane’s Online Master of Public Health trains professionals to create health equity.

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

https://nap.nationalacademies.org/read/10027/chapter/1#iv

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Read “Crossing the Quality Chasm: A New Health System for the 21st Century” at NAP.edu

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Read chapter Front Matter: Second in a series of publications from the Institute of Medicine’s Quality of Health Care in America project
Today’s health ca…

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Therapy is enhanced by respect, dignity, and cooperation between clinician and patient. You need to establish a base where the patient finds value and faith in the treatment as well as the patient acknowledges they have an interest in getting better through active participation in the treatment. This can be done by an understanding of mutual responsibility in the treatment, where the patient is aware of you being independent of their feedback and reactions to treatment. Success in partnership can arise from setting achievable goals, that are important for the patient and give good meaning in the context of the patient's daily life living.

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Excerpt

Second in a series of publications from the Institute of Medicine's Quality of Health Care in America project

Today's health care providers have more research findings and more technology available to them than ever before. Yet recent reports have raised serious doubts about the quality of health care in America.

Crossing the Quality Chasm makes an urgent call for fundamental change to close the quality gap. This book recommends a sweeping redesign of the American health care system and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others. In this comprehensive volume the committee offers:

1. A set of performance expectations for the 21st century health care system.

2. A set of 10 new rules to guide patient-clinician relationships.

3. A suggested organizing framework to better align the incentives inherent in payment and accountability with improvements in quality.

4. Key steps to promote evidence-based practice and strengthen clinical information systems.

Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change.

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collabauthor(name='institute of medicine (us) committee on quality of health care in america'

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national center for biotechnology information

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Crossing the Quality Chasm: A New Health System for the 21st Century - PubMed

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Second in a series of publications from the Institute of Medicine's Quality of Health Care in America project Today's health care providers have more research findings and more technology available to them than ever before. Yet recent reports have raised serious doubts about the quality of he ...

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This article was inspiration for me to enhance my communication abilities. I aknowledge Patients are individuals with unique views on their complaints as well as they have unique beliefs and expectations of their prognosis. It is important to tune into the patient's perception, expectations, and beliefs to establish a common ground of mutual understanding. It is beneficial to mirror your patient by using language and expressing yourself in a way your patient can understand you. Your attitude is furthermore important considering gaining your patient's comfort in communicating with you. Concern and acknowledgment of patient complaints can contribute to a healthy atmosphere between you and your patient. Finally, you need trust from your patient. This can be gained from the patient having faith in being heard and understood by you.

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A1 A literature-based study of patient-centered care and communication in nurse-patient interactions- barriers, facilitators, and the way forward

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

READ MORE

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About Decision making and Consent Guidance

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In my earlier years, I was inclined to believe that what I did and said would be perceived by the patient in the same way I intended and experienced it myself. However, I found that patients’ behavior and responses to treatment did not always reflect the intended outcome of the intervention.

This became particularly evident in the feedback I received during practical exams at ESO, where I often felt I did not recognize myself in the role I was perceived to play as a practitioner. Discussions with fellow students and tutors in relation to patient cases and treatments highlighted a discrepancy between my own perception of a clinical situation and how the patient experienced my actions.

This realization was unsettling, as I consider it essential to establish a partnership with the patient in order to create the foundation for a successful course of treatment.

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The Guidelines on Informed Consent for Osteopaths have helped me navigate and address patients’ personal beliefs and misconceptions about osteopathy—many of which can be overwhelming or misleading. These beliefs must be taken into account during both examination and treatment. It is essential to clarify such myths and establish a mutual understanding of the purpose and nature of assessment and intervention.

This clarification may not always be achieved through verbal explanation alone, as some patients may struggle to fully understand spoken information. Their body language and behavior can often reveal anxiety or discomfort, even when verbal consent has been given. True consent must be grounded in the patient feeling safe, respected, and secure throughout the entire session.

In cases where patients have mental health challenges or complex conditions, the presence of a chaperone may be necessary. The chaperone should be someone the patient trusts and who is capable of recognizing situations that may be distressing or sensitive for the patient. The clinician must be able to use the chaperone’s presence to help interpret and respect the patient’s boundaries without crossing them.

Patient limitations—whether physical, psychological, or cognitive—may affect the ambition or scope of the treatment. As a clinician, it is crucial to be mindful of your approach, including the pace and intensity of both examination and treatment. The patient must experience the treatment as safe, considerate, and appropriate to their individual needs.

Treatment should be carefully tailored to the patient, avoiding a directive or authoritarian approach. Instead, the clinician should adopt a curious, supportive, and responsive attitude. Ethical considerations, cultural background, and patient preferences must always be respected when obtaining informed consent and designing a treatment plan.

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

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

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Obtaining informed consent during a course of treatment can be challenging, as one may become so focused on clinical reasoning and carrying out the intervention that the patient's engagement is unintentionally overlooked. Often, this becomes apparent too late—by which point the unfortunate consequence is that the patient is no longer fully on board with the “project.”

I have experienced this myself, particularly in situations where I struggle to navigate a clinical problem or feel under pressure during treatment—whether due to not achieving the intended outcome or simply running out of time.

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Over the course of the next three chapters, I shall explicate the implications that my rationalist account of autonomy has for informed consent. Informed consent requirements are ubiquitous in health care, and they are regarded as a cornerstone of ethical medical practice. It is also often treated as a truism that these requirements are to be justified by the principle of respect for autonomy. However, whilst this view is still widely accepted, it has recently been brought into question, with critics suggesting that informed consent requirements are neither necessary nor sufficient for safeguarding individual autonomy in the biomedical sphere.

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I found inspiration to work with both formal and informal aspects of obtaining consent from my patients through supervision techniques as well as collaborative discussions with fellow students regarding shared patient management and case reviews.

In daily practice, I rely on patient responses during treatment by actively engaging the patient in conversation and continuously observing their non-verbal reactions to both assessment and treatment. Additionally, I have found that patients benefit from recording parts of the session on their phone, as this enhances their ability to revisit and reflect on the information shared. Patients have expressed that having video clips or written information, as well as references to websites or relevant literature, increases their sense of security and supports their understanding of their condition and the treatment they receive from me.

It is crucial that consent is obtained on a well-informed basis. This can be achieved by inquiring about the patient’s understanding of the purpose of the treatment and the intended outcomes, based on their individual situation and preferences. Informed consent can also foster a sense of shared responsibility, encouraging the patient to actively collaborate in the course of care. Finally, I discovered that I could prompt myself to remember to obtain patient consent by placing it as the first item in my clinical note template, under the anamnesis section. In addition, I have practiced documenting in the patient record during treatment whenever the patient has not expressed a preference for specific examinations or treatment techniques.

The challenge of this approach lies in the need for structure and clarity. However, the advantage is that treatment tends to proceed more smoothly when the patient is well-informed from the outset and has provided clear consent. This clarity reduces unnecessary interruptions and promotes a shared direction between practitioner and patient.

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Eye 1: Focus on the Client

It is all too easy for us as therapists to see our clients in terms of their problems and how they might solve them. In so doing, we block ourselves from being able to empathise with the client, even though we may have their best interests at heart - we subtly objectify our clients. Focussing on the client may help you become more attuned to their motivation, needs and desires in the here-and-now of the therapeutic relationship. It can be an effective way of empathising with the client - experiencing the therapeutic relationship from their perspective.

The following questions are examples of how to focus on the client's experience:

1. How do they come into the room?

2. How do they sit?

3. How do they hold themselves?

4. How do they talk?

5. What might be their perception of you?

Eye 2: Focus on Interventions

Each of us only can only ever experience ourselves from the inside. That means there will always be aspects of ourselves that we are unaware of, things that only others see. Conversely, there are aspects of ourselves which we hide from others, and there are those which are hidden from ourselves and others. By focussing on the interventions you use with clients, you can discover hitherto covert aspects of your therapeutic relationships. You might begin by asking yourself the following questions to discover the hidden aspects of your therapeutic relationships:

1. Do you use a certain kind of intervention more than others? For example, if you ask a lot of questions:

1. For whose benefit are you asking?

2. What are you trying to discover?

3. Why?

2. What do you hold back and why?

1. Who are you protecting?

2. Who or what are you protecting them from?

3. If you could switch off the part of your mind that filters what comes out of your mouth, what would you say to your client?

1. What does that tell you about yourself?

2. What does that tell you about your perception of your client?

3. What does that tell you about the therapeutic relationship with your client?

Eye 3: Focus on Client-Therapist Relationship

When you and your client sit together in a session, you create something greater than the sum of its parts: a relationship. The therapeutic relationship is created in the here-and-now by both therapist and client and, in my experience, it is the vehicle of therapeutic change. Although the quality of the relationship is often the deciding factor in the therapeutic outcome, it is nonetheless an intangible, ever-changing experience which can be difficult to describe. To help you get perspective on a therapeutic relationship, it can be useful to consider of the relationship creatively using metaphor, or by taking a perspective view of it. For example you might start by asking yourself questions such as:

1. If you were shipwrecked on a desert island with your client, how would you each behave?

1. What would you do straight away to survive?

2. Imagine you've now been on the island together for a month. How are you each behaving now?

2. Think about your client's most recent session and imagine you are watching it as an observer. What do you notice about the client and counsellor?

3. If you were both animals, what would you be? (E.g. "I'm a cat and my client is a mouse.")

How do you interact with each other? (E.g. "The cat is chasing the mouse! ... I think my client wants to run away from me ... I think she's scared ... I hadn't thought of it like that.")

4. What do you imagine is the transference and counter-transference occurring in the relationship?

Eye 4: Focus on Therapist's Process

You have the luxury of experiencing yourself from the inside. You know yourself better than anyone else, you are the expert on you. Your "process" is the sum of your moment-by-moment thoughts, emotions, sensations and behaviour (e.g. your body language) in response to your client. If you can gain awareness of your process, you may discover an invaluable stream of "data" that provides an opportunity to learn much about the client, yourself and the relationship between you that was previously unknown to you. For example, you can use awareness of your process to discover what within you may be hampering the therapy.

It is important to note that focussing on your own process does not mean interpreting what you know about the client, it is about attending to your own experiencing of yourself in the here-and-now. If you would like to explore the subject further, I recommend you to read Chapter 7 in the book, Experiencing And The Creation of Meaning, by Eugene Gendlin.

Questions to consider for Eye 4 include the following:

1. How do you feel emotionally in response to your client?

2. What are your physical sensations in response to your client?

3. What thoughts to you have about your client?

4. Notice your body language in response to your client. What are you saying through your gestures?

5. What do you imagine the client is covertly telling you? (E.g. "Please fix me").

6. What are you covertly telling the client? (E.g. "I need to you to like me").

Eye 5: Focus on Therapist-Supervisor Relationship

What happens in the counselling room may be played out between therapist and supervisor subsequently. This is often called parallel process. For example, perhaps the therapist becomes angry, or tearful , or petulant, etc, when talking about his client and discovers that in fact his client is experiencing those same emotions. Parallel process may be more subtle though: recognising when you feel bored, defensive, or other less obvious emotions can help you understand the client-therapist system better. Parallel process may also operate in reverse - the relationship between you and your client may mirror what happens outside of your awareness between you and your supervisor! The following questions exemplify the kind of enquiry that helps you recognise parallel process:

1. How am I similar to my client?

2. What am I holding back from my supervisor?

3. How do I regard my supervisor when I talk about my client?

4. How to I regard my client in the sessions immediately after supervision?

Click here for an excellent article in Psychology Today on parallel process.

Eye 6: Focus on Supervisor's Process

One of my tasks as a supervisor is to turn my attention to my own process similarly to how you as a supervisee turn your attention to your process, as described in Eye 4. Focussing on my process helps me gain insight into parallel process, the quality of supervisory relationship and my "relationship-by-proxy" with your client, which is how I imagine your client to be, how I imagine the therapeutic relationship to be, and how I imagine I might interact with them, were I in your place. My focus on my process can help us identify how our relationship mirrors your relationship with your client in ways that would otherwise be unknown to you. For example, I sometimes find myself attributing feelings to the client that resonate well with my supervisee: "As you talk about your client, I notice I'm feeling very sad, I wonder how he might feeling?" "Yes, that's it, he does seem sad. He seems very sad". In this example, you can subsequently explore sadness with your client and allow him to let you know how he is feeling. Alternatively, we might discover that the sadness is mine, belongs to something in my past and has nothing to do with the therapeutic relationship, in which case I am able recognise that I am bringing something into my view of the relationship which doesn't fit. Remember: When using Eye 4 and Eye 6, you and I are not interpreting for the client, we are focussing on our own processes.

Eye 7: Focus on Wider Context

The wider context is the current and historical background of the client-therapist-supervisor relationship and is comprised of two important types of influence, which can be called Stakeholders and Ghosts.

Stakeholders are those elements of the wider context which currently influence the relationship. For example:

1. The organisation you work for (e.g. EAP work).

2. The regulating bodies we each belong to (e.g. BACP, UKCP, etc).

3. Ethical frameworks to which we are bound.

4. The wider system of people and organisations (influences) in the client's life (e.g. partner, children, parents, GP, psychiatrist, probation service, keyworker, etc).

5. The wider influences in my life.

6. The wider influences in your life.

Ghosts are those elements of the wider context which are no longer present, but who's effects remain in the lives of you, me and the client. For example:

1. Schoolteachers.

2. Deceased family members.

3. Significant events.

4. Other people in our personal histories.

It could be said that the seventh eye is the most important, if you take the view that we are the sum of our experiences, past and present. An understanding the external influences in the client-therapist-supervisor relationship can help you:

1. Work through impasse - when the therapy seems to be going nowhere, is it due to the unacknowledged influence of a ghost or stakeholder? (e.g. a therapist might be afraid of making certain interventions because they have a Core Belief which tells them it would be wrong).

2. Resolve ethical dilemmas (e.g. knowing whether or not a client is already in contact with their GP can help you decide when and how you might breach confidentiality).

3. Identify common themes across your client work (e.g. are there certain consistent aspects of the way you experience your clients, as the result of your upbringing?)

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Living Therapy - Counselling in Southampton

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It is all too easy for us as therapists to see our clients in terms of their problems and how they might solve them. In so doing, we block ourselves from being able to empathise with the client, even though we may have their best interests at heart - we subtly objectify our clients.

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

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

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Se "read more" under OPS på Gos

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The majority of my patients present with issues that can be attributed to their way of living and an unhealthy lifestyle, which is unfortunately often accompanied by low self-worth. The challenge lies in the fact that patients are not always equipped to manage a lifestyle that is off track, and they tend to seek treatment for their symptoms rather than addressing the underlying causes of their complaints.

As a practitioner, it is always easier to focus objectively on the specific area the patient is complaining about. However, the risk of this approach is that treatment outcomes are rarely successful when attention is limited solely to the body region or symptom location identified by the patient—especially without critically reflecting on the patient’s narrative. It is also important to be able to explain to the patient, for example, why you intend to address the lower back, even though the pain is located in the leg.

What is even more difficult, however, is explaining the connection between bodily pain and factors such as dietary habits.

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I learned from Gail Sowden at Keele University and Dr. Peter O'Sullivan how to better place myself in the patient’s situation by taking time to ask questions—not only about their symptom profile, but also about their personal interpretations and thoughts regarding their condition. This approach helped create a meaningful dialogue between the patient and me, making the patient more open to exploring both symptoms and causes within a broader perspective and a holistic approach to assessment and treatment.

Gail Sowden’s methodology also demonstrated its potential to support health promotion by uncovering the patient’s own resources. This was achieved by focusing on activities and functions that the patient either missed or expressed a desire to regain. In this way, health promotion and self-care were not imposed on the patient, but instead perceived as a path out of pain and dysfunction—driven by the patient’s own awareness and motivation.

The osteopathic approach has contributed significantly to my understanding of the relationship between structure and function in the body, thereby supporting a patient-specific and holistic model of care. Furthermore, one of the strengths of osteopathy lies in the fact that patients often feel genuinely cared for through the use of manual techniques. These hands-on techniques can promote a sense of well-being, enhance the patient’s motivation for health-promoting behavior, and encourage them to pursue the life they wish to lead.

I have particularly benefited from using fascial and cranial-sacral techniques in osteopathy to create a constructive environment for working from a broader, holistic perspective in patient care.

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

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

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It was a boundary-pushing experience that we were always required to be in our underwear during practical assessments and treatment exercises at ESO. This discomfort was compounded when we later transitioned to working with patient management in groups, where patients risked feeling exposed or objectified.

During my time in the military, undressing individuals was sometimes used as a means of humiliation and degradation, intended to control and dominate a person. Because of that, I have always been extremely cautious and sensitive about placing a patient in a similar situation.

In osteopathic practice, it makes clinical sense for the patient to be minimally dressed during examination, as this allows the practitioner to observe skin changes and detect possible structural abnormalities that might otherwise be concealed by clothing. The challenge, however, lies in helping the patient feel at ease in situations where some degree of undressing is required for assessment purposes.

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Ensuring that the patient was undressed during assessment was made easier by involving the patient in my intentions. I clearly explained why I needed to observe them in their underwear and reassured them that they were free to decline if they felt uncomfortable or uneasy. Referring to the observation as a clinical measure aimed at identifying possible irregularities relevant to their health and treatment helped the patient understand the rationale behind the request.

Additionally, engaging the patient in dialogue during observation and during standing palpation contributed to building trust. In the case of palpation, it was also essential to explain exactly where I intended to touch and to obtain the patient’s consent beforehand. I found that this approach prevented the patient from feeling objectified or inappropriately touched.

Patients were always offered the option to wear whatever clothing made them feel most comfortable during the treatment that followed. My ongoing priority is to create a safe and welcoming environment for the patient, using a polite and respectful tone and always respecting the patient’s preferences, regardless of their reason for seeking care.

Patients with mental health conditions or cognitive challenges can be more complex to manage than those with whom verbal communication is straightforward. In such cases, it is particularly important to be attentive to subtle signs of discomfort or uncertainty and to consider the presence of a chaperone during sessions.

It may be helpful to seek prior knowledge of any special considerations that need to be taken into account before the initial appointment. This information can typically be obtained from the person who referred the patient or from someone familiar with the patient’s circumstances.

A chaperone can be valuable in several roles: as an interpreter, as a guide to highlight potential concerns that might otherwise go unnoticed, and as a witness in the event of an unintended incident during treatment. Finally, the chaperone can help ensure that important information related to the care process is communicated and managed as intended, in the best interest of the patient.

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Aims to change the culture of SA health services by reinforcing the importance of treating patients with dignity and respect.

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

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

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

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

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The osteopathic approach introduces key theoretical frameworks such as Littlejohn’s biomechanics, Sutherland’s fascial and involuntary mechanism (IVM) concepts, and Barral’s approach to visceral manipulation. These paradigms were initially unfamiliar to me. My prior clinical training has been grounded in musculoskeletal, joint, neurological, pathoanatomical, structural, functional, and biopsychosocial models. The beauty of osteopathy lies in its inclusiveness—it not only embraces these familiar models but expands them by offering a more holistic understanding of bodily connectivity. Most importantly, osteopathy is inherently patient-centred, in contrast to the more symptom-focused orientation in which I was originally trained.

This broad treatment perspective, while enriching, also carries a significant responsibility. As a practitioner, one must be capable of managing and integrating multiple clinical dimensions simultaneously. At the same time, osteopathy offers a deeper insight into the patient and the complexity of their presenting concerns.

I have found particular value in Littlejohn’s model, which provides a clear and structured overview of the patient. It effectively serves as a map that highlights areas for potential attention, which can then be interpreted through biomechanical, neurological, circulatory, respiratory, metabolic, and biopsychosocial lenses.

My introduction to Barral’s work offered a welcome explanation as to why a strictly musculoskeletal approach was insufficient for certain patients, such as those presenting with chronic low back pain. I gained an appreciation for the interrelationship between the viscera, fascia, nervous system, and musculoskeletal system—connections that had not previously been part of my clinical repertoire.

The IVM model posed the greatest initial challenge for me. It was not until I began witnessing patient-reported improvements that I could accept the method’s clinical value, even if I did not fully understand the underlying mechanisms. Patient satisfaction became, in this case, a form of experiential evidence justifying the use of the technique. Since then, IVM has become an integrated component of my practice, and it represents an area of osteopathy in which I seek to deepen my theoretical knowledge and clinical competence.

As my scope of practice has expanded, so too has the responsibility that comes with treating patients. This underscores the importance of maintaining critical self-awareness in clinical work. In particular, it is vital to ensure that treatment choices are driven by patient needs and preferences, rather than practitioner habit or bias. Avoiding routine-based care and upholding a reflective, evidence-informed approach are essential to safeguarding the patient-centred ethos of osteopathic practice

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Key Themes in Clinical Supervision for Osteopaths

Reflective practice: Encouraging critical reflection on clinical encounters to enhance reasoning, self-awareness, and learning.

Boundary setting & scope of practice: Ensuring practitioners remain within professional limits and refer appropriately.

Support & wellbeing: Addressing emotional demands of practice, burnout prevention, and ethical dilemmas.

Competency development: Fostering advanced skills through guided feedback, especially for early-career osteopaths or complex cases.

I consider patient record audits, collegial consultations, in-clinic supervision, and case studies to be low-hanging fruits for monitoring and reflecting on my clinical interventions. Additionally, I have participated in separate annual audits focused on neck and low back pain in collaboration with other clinicians and hospitals. These initiatives facilitate critical monitoring of my clinical practice, inspire knowledge-seeking in areas where I may lack expertise, and help build a professional network that provides mutual support in areas where individual competencies may be limited.

I have completed a dedicated course on "Red Flags" and comorbidities within the General Medical Services (GMS) framework, in addition to profession-specific courses and continued education in physiotherapy.

In the clinic, I find it important to avoid relying solely on rote memory when structuring clinical reasoning. Therefore, the clinic is equipped with multiple anatomical illustrations and models, and I have access to reference materials on anatomical structures and their interrelations, as well as medical terminology and the treatment of various conditions with comorbidities in mind. The advantage of using such visual aids is that they significantly enhance patient education and understanding. However, the key lies in selecting models and illustrations carefully, so as not to appear intimidating to children or too detailed in ways that could alienate adults from different ethnic or religious backgrounds.

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Reflective Practice Models in Healthcare

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

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

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It can be tempting to assume greater therapeutic responsibility when a treatment course has been successful, or when a patient encourages the clinician to address issues that have not been effectively managed by other healthcare professionals. This inclination does not necessarily arise from a desire to align with the patient’s narrative, but rather from a genuine wish to help.

Within osteopathic practice, the range of potential interrelations and etiological explanations for bodily complaints is extensive. When combined with a naturally inquisitive approach to patient care, this can, at times, lead to a loss of clinical focus. In my own practice, I have occasionally found myself so absorbed in the search for underlying causes that I failed to maintain a clear thread of reasoning and, importantly, to cross-check information across clinical findings.

I found the use of an analytical reasoning model, SOAP, to be an invaluable aid. It enabled me to structure my diagnostic process, triangulate findings, and apply a critical lens to the interpretation of results. A lack of clinical competence became evident when my choice of tests yielded ambiguous results, which—when considered alongside the patient's overall presentation—did not cohere into a meaningful clinical picture.

In such situations, the ambiguity may stem from clinician bias, but it may also point toward systemic or multisystemic changes requiring further investigation by another healthcare professional. In some cases, conditions are identified that warrant referral without necessarily preventing the continuation of osteopathic treatment. What matters most is maintaining awareness of such findings and ensuring that the patient is sufficiently informed to make an autonomous decision about how to proceed.

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Washington (DC): National Academies Press (US); 2000.

Free Books & Documents

Institute of Medicine (US) Committee on Quality of Health Care in America .

Free Books & Documents

Washington (DC): National Academies Press (US); 2000.

Excerpt

Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDS--three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems.

To Err Is Human breaks the silence that has surrounded medical errors and their consequence--but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agenda--with state and local implications--for reducing medical errors and improving patient safety through the design of a safer health system.

This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes.

Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errors--which begs the question, "How can we learn from our mistakes?"

Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care.

To Err Is Human asserts that the problem is not bad people in health care--it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocates--as well as patients themselves.

First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

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collabauthor(name='institute of medicine (us) committee on quality of health care in america'

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national center for biotechnology information

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To Err is Human: Building a Safer Health System - PubMed

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Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDS--three causes that receive far more public attention. Indeed, more people die annually from medication errors th ...

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In this case, osteopathic treatment appeared to influence systemic responses, not only at the site of the patient’s symptoms but also distally. The patient initially presented with lower back pain, which was later identified to be associated with ischemia in the arteria iliaca communis. https://surgicalneurologyint.com/surgicalint-articles/differentiation-of-vascular-claudication-due-to-bilateral-common-iliac-artery-stenosis-versus-neurogenic-claudication-with-spinal-stenosis/ My therapeutic approach focused on promoting vascular circulation in the arteria iliaca and surrounding vessels. Following treatment, the patient reported a marked sense of wellbeing and a warming sensation in the lower extremities.

During the therapeutic process, the patient disclosed a longstanding history of poorly regulated hypertension, despite numerous medical interventions. Encouraged by the immediate improvements experienced after osteopathic treatment, the patient expressed a wish for me to assume responsibility for the management of his blood pressure. I made it explicitly clear that, due to my limited expertise in pharmacological hypertension management, I was not competent to oversee such care.

Nonetheless, I recognised and acknowledged his concerns, which centred on the perceived ineffectiveness of antihypertensive medication, fear of adverse effects, and general anxiety regarding long-term prognosis. As a clinician, it felt natural and ethically appropriate to engage with his concerns on a human level, while remaining focused on the ischemic back pain. Given his motivation and the symptomatic improvement—including reduced back pain and enhanced wellbeing in the lower limbs—we explored the potential association between vascular function and musculoskeletal symptoms.

Through open dialogue, the patient and I reached a shared understanding of the limitations of my role, while also acknowledging the therapeutic progress. It was agreed that his general practitioner (GP) should be involved. I therefore drafted a clinical letter to the GP, outlining my observations regarding ischemia-related back pain, the patient’s subjective improvements, and his concerns about ongoing medical management and prognosis.

The outcome was a collaborative care agreement, whereby the patient would self-monitor his blood pressure according to the GP’s instructions while continuing osteopathic sessions. The overarching goal was to stabilise his blood pressure and, if clinically appropriate, gradually reduce pharmacological dependency in favour of lifestyle and behavioural adaptations—contingent on his ongoing improvement.

This case exemplifies the transition from condition-focused treatment to a patient-centred approach. The involvement of the GP ensured I remained within my professional remit, while reinforcing safety, shared decision-making, and holistic care. The patient subsequently reported a renewed sense of self-efficacy and motivation to engage in his health management—outcomes that extended far beyond the original presenting complaint.

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Differentiation of vascular claudication due to bilateral common iliac artery stenosis versus neurogenic claudication with spinal stenosis - Surgical Neurology International

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

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

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I was not aware, that my HVT techniques to the thorax had altered during time, so they weren't aligned with what EsO recommended. The alteration was unfortunatley due to multiple introductions to HVT of thorax combined with habituel changes of my own preferrences. Thus my management of these techniques sowed dought of my spectificty as well as intensity in handling thorax HVT techniques. In this case I found my techniques not as specific as I desired and not of the required osteopathic standrds.

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Chiropractic Adjustment - Standing Thoracic

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I chose to consult with my fellow students in order to enhance segmental precision and refine my selection of vectors based on the specific thoracic lesion I intended to address. It became evident that my hand positioning was the primary limiting factor in the effective application of my techniques. As a secondary benefit, I became more comfortable with the management of thoracic group lesions and was able to fine-tune my lift technique.

A recurring challenge with manual techniques in everyday practice is that no two patients are alike. There is significant morphological variation among patients, which requires constant clinical adaptability. To address this, I have developed a structured approach in the form of an annual rotation plan that allocates time for revisiting and refining various techniques on a cyclical basis. Additionally, I have established an agreement with my colleagues to regularly dedicate time to reviewing clinical challenges, discussing manual techniques, and addressing other professional concerns arising in the clinic. This includes conducting random peer assessments to evaluate our osteopathic knowledge and practical skills.

The overall aim is to achieve the highest possible level of general professional competence while leveraging our diverse skill sets in a collaborative network. This serves to strengthen both patient safety and the overall quality of care we provide.

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

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

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

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

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Conducting osteopathic treatment within a predetermined time frame can be challenging, especially when the patient presents with time-consuming factors such as language barriers or mental and cognitive disorders. Additionally, the patient may resist parts of the assessment protocol due to differing expectations of the treatment.

It is important to maintain the integrity of your intervention without compromising patient safety, while simultaneously establishing a shared understanding of the treatment goals and what can be expected from the intervention. This is best achieved by obtaining a clear overview of the patient and their presenting complaint(s).

Be mindful to prioritise the patient's main concerns without neglecting clinically relevant issues that must also be addressed. Communicate your clinical reasoning clearly and ensure that the patient acknowledges your understanding of their situation. Collaboratively structure a treatment plan for the session, recognising the potential need for one or more follow-up sessions before a treatment prognosis can be reasonably established.

Keep in mind that patients are more likely to commit to a treatment plan that makes sense to them and feels worthwhile. Avoid rushing into diagnostic conclusions at the expense of developing rapport. Taking time to engage with and understand your patient is often essential for effective care. Pausing treatment to allow for reflection and deeper case understanding can be both educational and instrumental in ensuring patient safety.

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Neglecting the ability to conduct a thorough osteopathic patient evaluation and to deliver safe, competent, and appropriate osteopathic care can have significant consequences for patient outcomes and professional standards. Osteopathic Neuromusculoskeletal Medicine (ONMM) specialists emphasize the importance of integrating osteopathic principles into patient management, including the use of Osteopathic Manipulative Treatment (OMT) when clinically indicated. Failure to perform comprehensive evaluations may lead to missed diagnoses of somatic dysfunctions, potentially resulting in suboptimal treatment outcomes.

Moreover, inadequate assessment and management can compromise patient safety, particularly if contraindications to OMT are overlooked. Ensuring that osteopathic care is delivered competently requires continuous education and adherence to established clinical guidelines. Neglecting these responsibilities not only affects patient health but may also undermine the credibility and effectiveness of osteopathic practice as a whole.

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

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

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Maintaining high-quality clinical records can contribute significantly to positive treatment outcomes. Over the years, I have gained valuable insights by reading my colleagues’ patient journals and comparing them with the patients’ reported success.

The vast majority of successful cases are associated with patients whose records are well-structured and thoroughly documented. Discussions with colleagues about what constitutes a comprehensive journal often highlight the importance of clear communication, mutual respect, and a shared motivation to collaborate. My colleagues frequently express that they felt they truly understood their patients—and, most importantly, that they had established a strong and constructive therapeutic relationship.

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Health professionals’ routine practice documentation and its associated factors in a resource-limited setting: a cross-sectional study

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Documenting routine practice is significant for better diagnosis, treatment, continuity of care and medicolegal issues. However, health professionals’ routine practice documentation is poorly practised. Therefore, this study aimed to assess health…

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Through my clinical practice, I discovered that the clearer and more comprehensible my patient records were, the greater the success I achieved in treatment progression. This led me to recognise a direct relationship between the quality of my documentation and the effectiveness of the care I provided.

The main challenge was maintaining consistency in producing records that were accurate, clearly articulated, and completed in a timely manner. Delays often arose when treatment sessions were interrupted or when time was limited. I also became aware that a lack of understanding on my part regarding the patient’s presentation or clinical dilemma could lead to fragmented and vague documentation.

This insight prompted me to introduce structure both in clinical assessment and in the way I documented findings. A structured approach supported a systematic method for data collection and helped establish a rational examination plan. This in turn created an overview of the patient’s condition and clinical dilemma, forming the basis of an effective treatment plan.

I found that structured treatment sessions helped to manage time more effectively and reduce the risk of important elements being overlooked. It also became apparent that the patient’s core presentation and concerns were not always fully revealed during the first session. However, there were always elements that could be meaningfully addressed from the outset. In such cases, it became essential to maintain well-organised notes from the initial consultation that could be revisited in future sessions.

I found the self-audit model particularly useful in ensuring that at least a minimum standard of data was consistently captured—allowing for later revision if necessary. The SOAP model also proved valuable, as it helped integrate the patient’s own perspectives, concerns, and expectations into my clinical reasoning alongside objective clinical findings. This approach had the added benefit of enhancing the quality of referral documentation and supported professional discussions with colleagues regarding patient cases.

Example of a Model Patient Note (SOAP Format)

Patient ID: 0413-22M
Date: 13 May 2025
Clinician: Jane Doe, M.Ost

S – Subjective:
Patient reports insidious onset of mid-thoracic discomfort, worse on deep inspiration and during seated work. Denies trauma. No red flags. Pain rated 5/10.

O – Objective:
Posture: mild kyphosis. Palpation: T4-T6 hypomobility. Muscle tone increased paraspinally. Respiratory excursion reduced. No neurological deficit.

A – Assessment:
Mechanical thoracic dysfunction with associated myofascial restriction. No contraindications to OMT.

P – Plan:
Applied soft tissue release and articulation to T4-T6. Instructed on thoracic mobility exercises. Plan to review in one week. Patient tolerated treatment well.

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

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

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It’s important to be aware that general practitioners and medical specialists—my main professional collaborators—often receive over 80 electronic messages per day. Therefore, communication must be concise and precise, with a clear indication of the intended action. The clinical rationale for the request should be well-founded and explicitly stated in the documentation.

Obtaining relevant data presents its own challenges. In Denmark, clinicians can access test results, imaging, and biochemical data via the national digital health platform, provided the patient consents. However, access to patients’ medication lists is limited, and many patients do not know the names of their medications. Information regarding medications or hospitalisations can usually be obtained from the patient’s GP.

A third challenge in handling written material arises when the patient’s reason for consultation involves insurance or public benefits. In such cases, it is crucial to maintain a critical perspective from the outset. Gathering documentation, case histories, and factual information about the patient’s condition and circumstances can be helpful—but must be done with care.

Written communication may also touch on areas the patient finds private or sensitive. Therefore, it is essential to be transparent about what information you are responding on or requesting, from a third part and, and why. This supports obtaining informed consent and demonstrates respect for the patient. Always inform the patient that the data will be used only within a specified timeframe and reassure them that all information will be treated with strict confidentiality.

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10 Tips for Responding to a Records Request: Risk Adjustment Audits

By Barbara Griswold, LMFT (last updated March 6, 2025)

Many of us have practiced for decades without having a health plan ask that we send a copy of a client's chart. But in the last few years, providers are having the new experience of receiving records requests from third party companies hired by health plans, including Blue Cross, HealthNet, MHN, Medicare, OPTUM/United, and Aetna.

You may have read my articles about 90837 CPT code provider profiles which sometimes included a threat of records review (if you missed those articles, click here). And there are many other reasons why your records might be requested by a health plan, including pre-payment claim audits, retrospective (post-payment) claim audits, and chart reviews.

However, this article focuses on "risk adjustment" record requests from third party companies including Inovalon/ComplexCare Solutions, Datavant (formerly Ciox Health), Virtex, Change Healthcare, Coativity, Datafied, Episource, Alliant and Reveleer. While these companies are hired by health plans to do a variety of projects, the latest project is carrying out risk adjustment audits under the Affordable Care Act (ACA).

What's a risk adjustment audit? In a risk adjustment audit, information from health provider records is used by the plan to determine the severity of illnesses of plan members. After these assessments, health plans that have a greater number of "healthier" members are required to transfer funds to plans that have a greater number of "sicker" members. Think of this audit as a way for the health plan to get a snapshot of the health of their plan members so they can forecast future expenses for their members as a whole, and to recoup money from other health plans who may have spent less.

The good news for providers and clients? In my mind, these are the least threatening of all the types of records requests. Not a wink of sleep should be lost when thinking about them. Risk adjustment requests are not for the purpose of determining the medical necessity of treatment. The plan is not looking at whether or not to approve future sessions. They are not reviewing your care. It is not a documentation review aimed at critiquing the state of your notes (so don't panic if you have lousy notes). It will not negatively affect the member's coverage, premium, or your provider agreement. Best of all, the goal is not recouping money from the therapist or client. So while annoying, they shouldn't be a cause for concern.

Note: While these requests may be intimidating, you may find the requesting agencies are quite disorganized. They may call for information (to verify your fax or address) several times, even if you already responded. They may call to say they never received records even when you already sent them. So just expect this.

So if you get a records request, what should you do? There is no correct answer here. But here are some tips when considering your response:

1) Confirm it is a Risk Adjustment Audit. Carefully search the letter you received for the words "risk adjustment." It's usually mentioned on the page from the health plan itself. If you don't see this, the rest of the advice I give here may not apply.

2) Don't panic about the deadline on the letter. Call the requesting agency and/or the health plan and ask for an extension, if you'd like more time. Most seem very willing to give more time.

3) Prepare to be shocked: Ask them what they REALLY need. In most cases, DESPITE WHAT IT SAYS ON THE REQUEST, you probably don't need to send your notes at all! If you were to contact the requesting agency, chances are they would tell you a treatment summary would suffice. [One important exception to this may be Reveleer, who told one therapist they would not accept a treatment summary, but it's still a good idea to call to be sure.]

Remember to document your call, who you spoke to, and what they said. The summary generally should include a VERY BRIEF summary of client name, date of birth, diagnosis, dates of service during the time period on the request, general reason for treatment, basic description of client symptoms, treatment plan goals, session modality/frequency (average), length of sessions, progress, and prognosis. A few sentences for each of these areas is fine, and the treatment summary should be no more than one page. Better still, I have a sample Risk Adjustment Treatment summary you can purchase and use as a template to make it super-easy - it is available in my online store ( click here).

4) Note carefully the time frame of sessions requested on the release. It is usually a one year time period. Any information you release should be restricted to service provided during that time period.

5) If you are a network provider, you shouldn't need to notify your client, or get a client release. When your client started therapy with you, you likely had them sign a release authorizing the exchange of information with their health plan. And complying with administrative requests like these are part of what you agreed to when you joined the plan. Furthermore, HIPAA doesn't require client notification. This might be a good time to beef up the release you have clients sign at the start of treatment.

6) If you are an out-of-network therapist, confirm with the requesting agency that the request was not sent to you in error. If you do release information, you will need to get a release from your client. However, according to the California Medical Association, "non-contracted physicians are under no obligation to comply with the requests"(see their article - click here)

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10 Tips for Responding to a Record Request: Risk Adjustment - Navigating the Insurance Maze

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10 Tips for Responding to a Records Request: Risk Adjustment Audits By Barbara Griswold, LMFT (last updated March 6, 2025) Many of us have practiced for decades without having a health plan ask that we send a copy of a client’s chart. But in the last few years, providers are having the new experience […]

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Briefly I apply these principles concerning sharing, responding on requests and gathering written information:

Informed Consent
Before sharing patient information, it's essential to obtain explicit, informed consent. Patients should be made aware of what information will be shared, with whom, and for what purpose. This transparency upholds patient autonomy and trust.

Minimum Necessary Disclosure
Only the information necessary for the intended purpose should be shared. This principle minimizes potential breaches of privacy and aligns with data protection regulations.

Need-to-Know Basis
Access to patient information should be limited to individuals directly involved in the patient's care. This approach ensures that sensitive information isn't unnecessarily disseminated.

Secure Communication Channels
When transmitting patient information, use secure and encrypted methods to prevent unauthorized access. This includes secure email systems, encrypted messaging platforms, and protected electronic health record systems.

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NHS England » Data and clinical record sharing

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Version 1.3, 13 March 2025 This guidance is part of the Data sharing and interoperability section of the Good practice guidelines for GP electronic patient records.

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

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

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UTH

Patientsikkerhedstyrelsen

Patientklagenævnet

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Patient Safety Incident Response Framework

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When a patient seeks your help, it is a declaration of trust—an act of humility, as they place their confidence in someone they may have no prior knowledge of. This trust warrants nothing less than a courteous, welcoming, and compassionate reception from the practitioner.

The patient requires a safe and supportive environment, and such an atmosphere also enables openness and honesty, which are essential for establishing an effective therapeutic relationship. One key area of attention should be to avoid exposing the patient to danger, discomfort, inconvenience, or harm. The practitioner’s focus must remain on the patient’s wellbeing, ensuring that care is delivered within safe and respectful boundaries.

The practitioner should continuously inform the patient to ensure they are sufficiently well-informed to engage in open dialogue and respond rationally to the intended plan for assessment and treatment. In addition, the practitioner must remain observant of non-verbal signs—such as facial redness or unusual perspiration—that may indicate patient distress during the session.

Finally, it is essential for the practitioner to regularly check in with the patient regarding their comfort and wellbeing throughout the course of care. This open dialogue not only fosters safety and trust but also helps to verify whether the patient has understood the treatment intentions and plan, thereby ensuring that informed consent is genuine and ongoing.

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Situations may arise in which the patient experiences discomfort or feels overwhelmed during treatment, despite the practitioner’s best efforts to prevent this. In such cases, it is essential to address the issue as soon as it is recognised in order to clarify the nature of the problem and find a resolution that is satisfactory to the patient.

Occasionally, an adverse event may occur unintentionally, without necessarily leading to conflict, yet the patient may still have been exposed to potential harm or, in the worst-case scenario, sustained an injury. In Denmark, there is a national authority where such incidents—referred to as utilsigtede hændelser (unintended events)—can be reported by the patient, their relatives, the healthcare provider, or others involved.

The purpose of reporting unintended events is to support learning and prevent recurrence. Reports are submitted digitally, and practitioners are encouraged to initiate the report where appropriate. Alternatively, patients may be guided to do so themselves if they feel more comfortable taking the initiative.

To ensure transparency in our clinic, we have made information about unintended events accessible to our patients on our website:

For both myself and my clinic, it is a source of continuous learning to engage in open and constructive dialogue about unintended events. Such conversations contribute not only to safer care, but also to trust and professional development.

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Vi har altid stor fokus på sikkerhed. Men skulle du opleve, at noget går galt i din behandling eller opleve en utilsigtet hændelse, hvor behandlingen hos os har været til skade, uventet og unødig smerte eller ulempe, vil vi meget gerne, at du tager kontakt til en af vores medarbejdere.

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

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

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akkreditering

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My patients are treated in a clinical environment that receives more than 60 individuals per day. The majority of our clientele are aged 40 and above, and many already present with compromised health status. Additionally, we are responsible for managing patients diagnosed with Multi-Drug Resistant Staphylococcus aureus (MDRSA), and it is essential that this group is treated without stigma or discrimination.

The central challenge lies in protecting our wider patient population from potential infection risks—both during individual treatment sessions and in group-based rehabilitation programmes. Hygiene therefore plays a substantial role in my daily clinical practice and requires a high degree of vigilance from both myself and my colleagues.

The worst-case scenario would be to become a source of infection, which would not only pose a direct risk to patients but also reflect a negligent attitude toward the responsibility we hold for the health and safety of others.

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The clinic has been accredited for its hygiene standards, among other parameters related to safety and treatment quality. In addition to meeting the requirements of accreditation, there are numerous factors that require continuous attention in order to maintain a robust infection prevention protocol. These include:

·       Ensuring that both patients and practitioners have access to hand sanitiser immediately upon entering the clinic.

·       Displaying signage throughout the clinic reminding patients and staff to disinfect equipment and hands after contact.

·       Facilitating dynamic entry and exit procedures to avoid patient congestion and minimise the risk of airborne transmission.

·       Conducting screening prior to treatment for symptoms of influenza, cold, or gastrointestinal illness. If a patient appears unwell, further questioning may result in postponement of treatment until full recovery. Masks are available for both practitioner and patient where deemed necessary for infection control.

·       Group sessions are held with a minimum of one metre between participants, and patients are directed immediately to the exercise studio upon arrival to avoid crowding in the waiting area.

·       A cleaning and ventilation routine is implemented after each treatment, group session, or patient encounter.

·       For patients diagnosed with Multi-Drug Resistant Staphylococcus aureus (MDRSA), appointments are scheduled at the end of the day. An extended hygiene protocol is followed, including disinfection of the waiting area and universal cleaning of treatment spaces before the next patient enters.

·       Hygiene performance is reviewed monthly through spot checks, alongside ongoing reporting of any deviations that could impact infection control or compliance with accreditation standards.

·       Dedicated bathroom and shower facilities are provided for staff, along with separate areas for storing personal belongings not used during treatment. Practitioners are mindful of not bringing potential contaminants into the workplace. Gloves, face shields, and masks are readily available in the clinic to protect both patients and staff.

References:

·       Statens Serum Institut. (2023). National Infection Control Guidelines – General Precautions (NIR). Available at: https://hygiejne.ssi.dk/NIRgenerelle [Accessed 15 May 2025].

·       Danish Institute for Quality and Accreditation in Healthcare (IKAS). (2022). Accreditation Standards for Primary Healthcare Clinics. Available at: https://ikas.dk [Accessed 15 May 2025].

·       World Health Organization. (2020). Infection Prevention and Control During Health Care When COVID-19 is Suspected. Geneva: WHO.

·       European Centre for Disease Prevention and Control (ECDC). (2018). Guidelines for the Prevention and Control of MDR Organisms. Stockholm: ECDC.

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Den største del er ofte skjult under overfladen...
Hvis et tryksår ikke bliver behandlet i tide, kan det have meget alvorlige konsekvenser for patienten. Men med den rigtige forebyggelse kan 95% af alle tryksår forebygges - få inspiration til hvordan. Kampagnen udspringer af de mere end 3.600 rapporterede utilsigtede hændelser om tryksår, som styrelsen har modtaget i løbet af 2022 og 2023.
Forebyg tryksår

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Vi autoriserer sundhedspersoner, fører tilsyn på sundhedsområdet, rådgiver myndigheder og arbejder med læring på tværs af sundhedsvæsenet.

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

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

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

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

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At times, I find myself in situations where I feel uncertain during a course of treatment or encounter something unfamiliar in a treatment session. This uncertainty can lead to anxiety about whether the patient might feel unsafe or uneasy. I have experienced that I sometimes unintentionally try to conceal my uncertainty, even though it may be obvious to the patient that I am not fully in control of the situation.

I often reflect on whether this stems from a tendency toward routine-based practice, which may lead to a lack of critical thinking about my clinical approach—and, as a result, limit my ability to absorb new knowledge and deliver safe, high-quality care. In addition to compromising the quality of treatment, there is a risk that the patient's confidence in the intervention and their trust in me may be affected. Both outcomes are detrimental to the therapeutic relationship as well as to the safety and quality of care provided.

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I have made a conscious effort to engage in real-time reflection and to express openly to the patient when I do not fully understand the nature of their problem or how best to approach it. This practice aligns with the principles of honesty and integrity in professional conduct. Such transparency can be delivered constructively by actively involving the patient in my clinical observations and diagnostic reasoning. In doing so, the patient becomes an informed participant and is able to respond on a well-founded basis, supported by the openness and sincerity demonstrated from the outset.

It is essential that the roles within the clinical interaction are clearly delineated—specifically, that I maintain the role of healthcare professional, while the patient serves as the primary source of subjective information. Patients may feel unsettled if they sense that I am unable to respond or act as expected within the scope of professional competence. This is particularly relevant when clinical scenarios extend beyond my current expertise.

In such situations, it is critical to end the session in a respectful and appropriate manner, while informing the patient that I will either return with a well-considered management plan or facilitate a referral to another qualified healthcare provider with the necessary expertise. In doing so, I aim to safeguard the patient from undue distress and simultaneously uphold a standard of professional responsibility and ethical care.

I have found that encounters like these strengthen the therapeutic alliance. Patients are more likely to take shared responsibility in their care journey, and the process evolves into a collaborative project rather than a one-sided treatment plan. This encourages a more balanced and equal relationship between clinician and patient. An open dialogue, coupled with a sincere invitation to co-create the therapeutic direction, nurtures trust, respect, honesty, and dignity—elements that underpin a constructive and potentially more effective course of treatment.

references:

https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-019-0347-3

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Trust and respect in the patient-clinician relationship: preliminary development of a new scale - BMC Psychology

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Background Trust and respect may be an important component of client-provider relationships. This study aimed to develop and report preliminary psychometric analyses of a new brief measure to evaluate a patient’s level of trust and respect for their clinician. The scale was designed to be applicable in multiple healthcare contexts, with a particular focus on mental healthcare. Methods Adult patients completed the study survey in an academic outpatient psychiatric clinic waiting room. Classical and Item Response Theory (IRT) analyses were utilized to examine the adequacy of scale items. Validity was examined in relation to the patient-therapist alliance and to willingness to share private information (social media content) with one’s clinician. Results Beginning with 10 items, a final 8-item version of the measure was created with an internal consistency reliability of .91. Principal components analysis indicated that the scale was best viewed as capturing one overall dimension. A Graded Response Model IRT model indicated that all items contributed information on the latent dimension, and all item curves were not flat at any region. The correlation of the trust/respect total score with the alliance was .53 when respect-related items were deleted from the alliance score. The trust/respect scale was significantly associated with patient willingness to share social media posts with their clinician but the alliance was not. Conclusions The brief measure of patient trust and respect towards their clinician was unidimensional, showed good internal consistency, and was not redundant with existing measures of the alliance. The scale has the potential to be used in a wide variety of healthcare settings.

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

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

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(Upload feedback neurologisk eksamen)

To my astonishment, I received negative feedback on my patient interaction during my neurology examination in year two.

It was perceived that I had not demonstrated politeness, care, or consideration according to good clinical standards. This surprised me, as I have always taken great pride in these values throughout my clinical practice.

Admittedly, I felt challenged and under pressure during the exam, especially because I didn’t feel I delivered a sufficiently strong academic performance. I was genuinely embarrassed by the feedback and felt uncomfortable being perceived as inconsiderate or lacking in empathy.

For me, the foundation of any successful course of treatment lies in demonstrating politeness, compassion, humility, and dignity in how one interacts with the patient. The patient deserves nothing less when they place their trust in you by seeking your help. Maintaining dignity—even under pressure—is, in my view, the most important principle of all.

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The article by Lampe, Hitching et al. (2023), https://journals.sagepub.com/doi/full/10.1177/10398562231191662, raised my awareness of a possible underlying burnout that I had not previously recognised. This realisation was particularly significant considering that I am over the age of 60 and have been in clinical practice for more than 34 years. The possibility that I might be experiencing burnout had not occurred to me before reading this work.

In response to this perspective, I chose to undergo supervision both professionally and in my personal life. The aim was to gather observations and feedback regarding potential signs of burnout, stress, depression, or similar reactions that might pose a risk to patient safety, affect their sense of well-being during treatment, or compromise the quality of my clinical practice.

The process is ongoing. So far, stress assessments have been positive, with the explanation being that I currently have a high level of engagement across several domains—running a clinic, working as a consultant, pursuing studies, and maintaining an ambition to continue long-distance running. Overall, the goal is to improve my ability to prioritise time and tasks, particularly by focusing on those aspects that are most important for sustaining personal health and well-being.

In the clinic, my efforts are directed toward ensuring that patients feel comfortable, safe, and genuinely cared for—not only in regard to their health concerns but also as individuals. Being received with courtesy, respect, dignity, and an empathetic approach contributes greatly to a positive treatment experience.

Younger colleagues have also played a valuable role by introducing me to contemporary concepts such as the notion of being "woke" and other evolving social issues that I may not have previously been attuned to.

References:

https://www.decent.com/blog/effective-strategies-for-setting-boundaries-in-healthcare

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Introduction

Imagine a world where every nurse knows exactly where to draw the line with patients. That's the goal of professional boundaries in healthcare. These boundaries are vital for creating a safe and ethical environment. Organizations like the American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN) set the standards to help healthcare workers navigate these boundaries. Whether it's avoiding sharing personal information or ensuring a hug remains professional, these guidelines help protect both patients and nurses from crossing into inappropriate behavior. Let's explore why these boundaries matter and how to set them effectively.

Understanding Professional Boundaries

Defining Professional Boundaries

Professional boundaries are the lines that separate the nurse's professional role from personal relationships with patients. These boundaries ensure ethical conduct and maintain trust in nurse-patient interactions. They help prevent issues like sexual misconduct and inappropriate behavior, protecting both parties.

The Role of the Code of Ethics

The Code of Ethics for Nurses, provided by the American Nurses Association (ANA), and guidelines from the National Council of State Boards of Nursing (NCSBN) are essential. They help nurses understand how to set boundaries and why it's crucial. These codes guide professional nurses in maintaining therapeutic relationships without crossing the line into dual relationships or personal interactions.

Importance of Ethical Standards

Adhering to these ethical standards is vital. They help establish a safe environment where patients feel respected and cared for. By following these guidelines, health professionals can avoid boundary violations and maintain professional behavior, ensuring the integrity of their patient relationships.

The Nurse-Patient Relationship

Dynamics of the Nurse-Patient Relationship

The nurse-patient relationship is built on trust, respect, and empathy. It's crucial for providing effective care. Nurses must be aware of their professional boundaries to avoid inappropriate behavior. Sharing too much personal information or forming a personal relationship can cross the line.

Maintaining a Therapeutic Relationship

A therapeutic relationship is key to patient care. It involves setting boundaries to ensure interactions remain professional. Following the Code of Ethics for Nurses helps maintain this balance, preventing issues like sexual misconduct or emotional over-involvement. The NCSBN and ANA provides guidelines to help nurses navigate these challenges, ensuring ethical and effective care.

Common Boundary Issues

Over-involvement and Inappropriate Behavior

Healthcare workers often face boundary issues like over-involvement or inappropriate behavior. It's essential to recognize and avoid these situations. For instance, sharing too much personal information can cross the line, blurring the professional boundary between nurse and patient.

Examples and Consequences

Boundary crossings might include accepting gifts or spending extra time with a patient. While these actions may seem harmless, they can lead to more severe violations. A boundary violation could be developing a romantic relationship with a patient, which is unethical and could result in disciplinary action from the state board or even the nurse's license being revoked.

Implications of Sexual Misconduct

Sexual misconduct is a serious boundary violation. It involves any inappropriate sexual contact or behavior, such as forming a sexual relationship with a patient. This not only breaches professional ethics but also the Code of Ethics for Nurses. The NCSBN outlines strict guidelines to prevent such behavior, emphasizing the need to maintain a professional and therapeutic relationship.

Understanding these common issues and their consequences helps nurses set boundaries effectively, ensuring ethical and professional behavior in all interactions.

Setting and Maintaining Boundaries

Strategies for Setting Boundaries

To set boundaries, start by being clear about your role and limitations with patients. This helps establish a professional boundary from the beginning. Avoid sharing personal information or engaging in any behavior that could be seen as inappropriate or crossing the line.

Importance of Self-Awareness

Self-awareness is key. Recognize the warning signs of boundary issues, like feeling too emotionally involved or considering a dual relationship. Understanding these signs can prevent problems before they escalate.

Practical Tips

Keep conversations focused on patient care.

Avoid physical contact beyond what is necessary for care.

Seek guidance from a supervisor or colleague if unsure.

Follow the NCSBN and state board guidelines to maintain professionalism and respect in nurse-patient interactions.

Maintaining boundaries ensures ethical behavior and protects both the nurse and patient.

The Role of Nurse Leaders

Promoting Boundary Policies

Nurse leaders have a critical responsibility to promote and enforce professional boundary policies. They ensure that the ethic for nurses is upheld, protecting the nurse-patient relationship from any boundary violations.

Supporting Through Training

Leaders can support their staff by providing clear guidelines and regular training. This helps nurses understand the NCSBN standards and the Nurse Practice Act. Training should cover recognizing inappropriate behavior and preventing emotional or romantic relationships with patients.

Nurse leaders play a vital role in establishing a culture of professionalism and ethical practice in healthcare settings.

Legal and Ethical Considerations

Legal Ramifications

Violating professional boundaries can lead to serious legal consequences. Actions like sexual misconduct can result in disciplinary action by the state board, including the loss of a nursing license. The NCSBN provides clear guidelines to help prevent such violations.

Ethical Considerations

Maintaining boundaries is essential for patient safety and professional integrity. Following the ethic for nurses, including the Code of Ethics, ensures that the nurse-patient relationship remains therapeutic and respectful. Ethical behavior protects both the client relationship and the healthcare worker's professionalism.

By adhering to these standards, nurses can establish a safe and ethical environment for their patients.

Boundaries in Direct Primary Care

Maintaining Professional Boundaries in DPC

In Direct Primary Care(DPC), maintaining professional boundaries is crucial due to the close and continuous nature of nurse-patient relationships. Nurses must adhere to the ethic for nurses and the guidelines from the NCSBN to prevent boundary issues.

Unique Challenges and Strategies

DPC settings pose unique challenges as relationships with patients can become more personal over time. To avoid crossing boundaries, healthcare workers should:

Clearly communicate roles and limitations

Avoid sharing personal information or engaging in inappropriate behaviors

Importance of Clear Communication

Clear communication and adherence to professional standards are essential in DPC. This ensures that all interactions remain therapeutic and respectful, protecting both the nurse and patient from potential issues.

Conclusion

Setting and maintaining professional boundaries in healthcare is essential for ensuring ethical conduct and protecting both patients and nurses. These boundaries prevent issues like sexual misconduct and inappropriate behavior, fostering a therapeutic and respectful nurse-patient relationship. Organizations like the ANA and NCSBN provide critical guidelines to help nurses adhere to these standards. By following the Ethics for Nurses and the Nurse Practice Act, healthcare workers can avoid boundary violations and maintain professionalism. This commitment to ethical practice safeguards the integrity of the client relationship and the well-being of all involved.

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Effective Strategies for Setting Boundaries in Healthcare | Decent

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Learn effective strategies to set and maintain professional boundaries in healthcare, ensuring ethical conduct and patient safety with guidance from ANA and NCSBN.

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

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

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Read more

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As an osteopath, the primary intention of practice is to help others. In order to achieve this, one must meet the patient with openness, empathy, sensitivity, and a genuine interest in identifying and understanding the issue that burdens them. This includes assuming responsibility when accepting the task of safeguarding the patient’s health and well-being, while also acknowledging the patient’s expectation that you are trustworthy and committed to providing safe, high-quality care.

When a patient seeks your help—often without any prior knowledge of you—it is an act of trust that should be reciprocated only with sincerity and honesty. This is especially vital, as the success of any treatment process is contingent upon the trust established between the patient and the practitioner.

In clinical practice, unforeseen events or situations may occur, leading to inconvenience or, in the worst cases, harm to the patient. These incidents can be procedural in nature, such as unintended events arising during the patient’s use of clinical equipment, either independently or under supervision, as well as during manual treatment or patient handling in the context of group sessions.

Procedural errors may include referral based on an incorrect diagnosis, incomplete or missing prerequisite clinical information, or failure to identify relevant comorbidities that are crucial for determining the appropriate intervention. Unintended incidents related to the use of clinic equipment or movement within the clinical environment can also pose risks or cause inconvenience to the patient.

Furthermore, misunderstandings between the patient and the clinician, or mishandling of the patient and the techniques applied, may result in physical or emotional harm, be perceived as overly invasive, or generate a sense of insecurity—and in the worst case, cause injury.

The practitioner must always remain observant and attuned to the patient, particularly with regard to any burdens they may be carrying or any potential risks to their safety and well-being.

reference:

https://www.surgeryjournal.co.uk/article/S0263-9319(20)30175-7/fulltext

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In aviation, there is a shallow authority gradient and culture such that a junior first officer can question the most senior captain without fear of retribution. The same culture needs to be implemented across healthcare.

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Reflection on Patient Communication Using Gibbs’ Reflective Cycle

1. Description – What happened?
A patient was referred by a rheumatologist due to pain in both Achilles tendons and had been diagnosed with tendinopathy based on an ultrasound scan. Upon conducting my own clinical assessment, I found that the symptoms were more likely related to lumbar spinal stenosis. Following the first consultation, I attempted to contact the rheumatologist both electronically and by phone but was unsuccessful.

At the second consultation, I informed the patient that I had not received a response. The patient accepted my assessment and agreed to pursue the lumbar stenosis hypothesis. However, he later expressed concern that this approach might put him at odds with the referring rheumatologist, who was also managing his psoriatic arthritis treatment. The patient feared that challenging the rheumatologist’s diagnosis might provoke a negative response and jeopardize his ongoing care.

Although the treatment I provided was effective, it further added to the patient’s concern about conflicting care plans. The main challenge was to create reassurance and address the uncertainty without undermining the rheumatologist’s authority. Ideally, this could have been resolved through dialogue between myself and the rheumatologist. As this did not occur, I decided to contact the regional quality centre, an institution responsible for handling adverse events with the aim of system improvement and learning. In this case, my concern was rooted in protecting the patient’s well-being, as I did not find it acceptable for the patient to be left feeling insecure.

2. Feelings – What were you thinking and feeling?
I felt professionally confident in my clinical reasoning but was uncertain about how best to navigate a disagreement in findings. I felt responsible for the patient’s comfort and progress, yet also concerned about being perceived as disloyal to a fellow clinician. I hoped to encourage interdisciplinary dialogue but was unsure whether my outreach would be received openly.

3. Evaluation – What was good and bad?
Positively, the patient experienced symptom relief and felt heard and understood, which strengthened our therapeutic alliance. However, it was problematic that the patient was caught in an informational crossfire between two healthcare professionals. This created insecurity that could have undermined trust in the treatment process. I considered involving the rheumatologist essential to developing a shared care plan, but unfortunately, that dialogue did not materialize.

4. Analysis – Why did it happen, and what was the learning?
This situation underscored the importance of clear and open communication with both patients and colleagues. It illustrated that patients can experience loyalty conflicts when faced with differing professional opinions, leading to confusion and anxiety. Clinically, I learned the value of thorough documentation and respectful communication with other healthcare professionals, even in the presence of disagreement. I also came to better appreciate that a patient’s need for safety and confidence is often more about trust and shared understanding than about any single "correct" diagnosis.

5. Conclusion – What could I have done differently?
I could have contacted the rheumatologist earlier, presenting my clinical findings in a professional and collegial manner. This might have reduced the patient’s sense of being caught between two providers and enabled a shared explanation that included both imaging and clinical findings. Additionally, I could have spent more time exploring the patient’s concerns and clarifying how different diagnoses can sometimes coexist.

6. Action Plan – What will I do next time?
In the future, I will take a more proactive approach to contacting referring physicians when diagnostic discrepancies arise. I aim to strengthen interdisciplinary communication while ensuring that patients feel informed and safe. I also intend to use written summaries for both patients and colleagues to clarify clinical reasoning and treatment plans.

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

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

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It is the clinic’s duty to safeguard the interests of the patient, and to respond immediately to unforeseen incidents, complaints, and any resulting accidents or potential harm to patients. A patient must never leave the clinic with an unresolved issue. As a minimum, measures must be taken to ensure proper follow-up on reported cases or any matters that may compromise patient safety and the quality of care and service.

We acknowledge that patients may not always feel comfortable addressing concerns directly with us. Therefore, our website provides information on how to file a formal complaint with the relevant authorities if a patient feels they have been treated improperly and wishes to pursue compensation or legal action against the clinic, https://www.stpk.dk/

Our website also offers guidance on how to report adverse events, https://aarslevfysioterapi.dk/utilsigtede-haendelser/.

All clinic staff are required to inform the management immediately of any cases involving disagreement, adverse events, or complaints from patients or external collaborators.

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Når du rapporterer UTH, er du med til at forbedre patientsikkerheden.

Formålet med at rapportere UTH er nemlig at forebygge, at en lignende hændelse sker igen. Når I rapporterer UTH på din arbejdsplads, bliver det synligt, hvor der er risiko for patientsikkerheden, og hvor I kan arbejde med at lære af og forbedre det, der ikke gik, som det skulle.

Utilsigtede hændelser kan derfor være et værktøj til fx at se, hvor man skal sætte ind og ændre arbejdsgange og bestemte måder at gøre noget på.

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Når noget går galt i forbindelse med sundhedsfaglige opgaver, kalder man det en utilsigtet hændelse (UTH). Det er en hændelse, som har eller kunne have haft konsekvenser for patienten i forskellig grad. Man kalder det utilsigtet, fordi det ikke var meningen, at det skulle ske.

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

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

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As healthcare professionals in Denmark, we are obligated to comply with the following legal frameworks and regulatory standards. Beyond the technical legal requirements, it is our responsibility as clinicians to ensure that the information we hold on patients receiving treatment in our clinic is accurate, up-to-date, and sufficient.

Accessible, well-organised, and precise patient records are an invaluable resource in managing clinical care. Conversely, negligent handling of patient records or sensitive personal information demonstrates a lack of respect and dignity towards our patients and may constitute a breach of privacy and criminal offence if such data falls into the hands of unauthorised third parties.

Key Legal Frameworks That Must Be Observed

1. The Danish Health Act (Sundhedsloven)

Chapter 9: Patient Records

Requires all authorised healthcare professionals to maintain and store patient records.

Records must be kept concurrently with, or as soon as possible after, patient consultations.

Patient records must be retained for a minimum of 10 years after the last entry.

Relevant Sections: §§ 15–21.

The Health Act on retsinformation.dk

2. The Authorisation Act (Autorisationsloven)

Obligates authorised healthcare professionals to keep records in accordance with good clinical practice.

Failure to maintain or properly manage records may result in disciplinary sanctions.

The Authorisation Act

3. The General Data Protection Regulation (GDPR) and the Danish Data Protection Act

Sensitive personal data (including health data) must be securely stored.

Includes requirements for:

Clear information to patients about how their data is processed.

Consent in certain cases (e.g., for marketing or data sharing).

Data processing agreements when using external IT providers.

The right to access, correct, and delete data (where applicable).

The Danish Data Protection Agency – Health Data & GDPR

4. Executive Order on Patient Records for Authorised Healthcare Professionals

(Executive Order No. 1225 of 24/10/2007)

Provides specific guidance on how records should be created, what they must include, and how they must be stored.

Covers both paper-based and electronic record keeping.

Journal Executive Order

Practical Requirements for Record Keeping

Requirement

Legal Basis

Record retention for a minimum of 10 years

Health Act § 21

Protection against unauthorised access

GDPR, Data Protection Act

Clear data processing agreement

GDPR Article 28

Right to access and file complaints

GDPR Articles 15 and 77

Records must be easily legible

Journal Executive Order § 4

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What is the GDPR? Europe's new data privacy and security law includes hundreds of pages' worth of new requirements for organizations around the world. This GDPR overview will help you understand the law and determine what parts of it apply to you.
The General Data Protection Regulation (GDPR) is the toughest privacy and security law in the world. Though it was drafted and passed by the European Union (EU), it imposes obligations onto organizations anywhere, so long as they target or collect data related to people in the EU. The regulation was put into effect on May 25, 2018. The GDPR will levy harsh fines against those who violate its privacy and security standards, with penalties reaching into the tens of millions of euros.

With the GDPR, Europe is signaling its firm stance on data privacy and security at a time when more people are entrusting their personal data with cloud services and breaches are a daily occurrence. The regulation itself is large, far-reaching, and fairly light on specifics, making GDPR compliance a daunting prospect, particularly for small and medium-sized enterprises (SMEs).

We created this website to serve as a resource for SME owners and managers to address specific challenges they may face. While it is not a substitute for legal advice, it may help you to understand where to focus your GDPR compliance efforts. We also offer tips on privacy tools and how to mitigate risks. As the GDPR continues to be interpreted, we'll keep you up to date on evolving best practices.

If you've found this page - "what is the GDPR?" - chances are you're looking for a crash course. Maybe you haven't even found the document itself yet (tip: here's the full regulation). Maybe you don't have time to read the whole thing. This page is for you. In this article, we try to demystify the GDPR and, we hope, make it less overwhelming for SMEs concerned about GDPR compliance.

History of the GDPR

The right to privacy is part of the 1950 European Convention on Human Rights, which states, "Everyone has the right to respect for his private and family life, his home and his correspondence." From this basis, the European Union has sought to ensure the protection of this right through legislation.

As technology progressed and the Internet was invented, the EU recognized the need for modern protections. So in 1995 it passed the European Data Protection Directive, establishing minimum data privacy and security standards, upon which each member state based its own implementing law. But already the Internet was morphing into the data Hoover it is today. In 1994, the first banner ad appeared online. In 2000, a majority of financial institutions offered online banking. In 2006, Facebook opened to the public. In 2011, a Google user sued the company for scanning her emails. Two months after that, Europe's data protection authority declared the EU needed "a comprehensive approach on personal data protection" and work began to update the 1995 directive.

The GDPR entered into force in 2016 after passing European Parliament, and as of May 25, 2018, all organizations were required to be compliant.

Scope, penalties, and key definitions

First, if you process the personal data of EU citizens or residents, or you offer goods or services to such people, then the GDPR applies to you even if you're not in the EU. We talk more about this in another article.

Second, the fines for violating the GDPR are very high. There are two tiers of penalties, which max out at €20 million or 4% of global revenue (whichever is higher), plus data subjects have the right to seek compensation for damages. We also talk more about GDPR fines.

The GDPR defines an array of legal terms at length. Below are some of the most important ones that we refer to in this article:

Personal data - Personal data is any information that relates to an individual who can be directly or indirectly identified. Names and email addresses are obviously personal data. Location information, ethnicity, gender, biometric data, religious beliefs, web cookies, and political opinions can also be personal data. Pseudonymous data can also fall under the definition if it's relatively easy to ID someone from it.

Data processing - Any action performed on data, whether automated or manual. The examples cited in the text include collecting, recording, organizing, structuring, storing, using, erasing... so basically anything.

Data subject - The person whose data is processed. These are your customers or site visitors.

Data controller - The person who decides why and how personal data will be processed. If you're an owner or employee in your organization who handles data, this is you.

Data processor - A third party that processes personal data on behalf of a data controller. The GDPR has special rules for these individuals and organizations. They could include cloud servers like Tresorit or email service providers like Proton Mail.

What the GDPR says about...

For the rest of this article, we will briefly explain all the key regulatory points of the GDPR.

Data protection principles

If you process data, you have to do so according to seven protection and accountability principles outlined in Article 5.1-2:

1. Lawfulness, fairness and transparency - Processing must be lawful, fair, and transparent to the data subject.

2. Purpose limitation - You must process data for the legitimate purposes specified explicitly to the data subject when you collected it.

3. Data minimization - You should collect and process only as much data as absolutely necessary for the purposes specified.

4. Accuracy - You must keep personal data accurate and up to date.

5. Storage limitation - You may only store personally identifying data for as long as necessary for the specified purpose.

6. Integrity and confidentiality - Processing must be done in such a way as to ensure appropriate security, integrity, and confidentiality (e.g. by using encryption).

7. Accountability - The data controller is responsible for being able to demonstrate GDPR compliance with all of these principles.

Accountability

The GDPR says data controllers have to be able to demonstrate they are GDPR compliant. And this isn't something you can do after the fact: If you think you are compliant with the GDPR but can't show how, then you're not GDPR compliant. Among the ways you can do this:

Designate data protection responsibilities to your team.

Maintain detailed documentation of the data you're collecting, how it's used, where it's stored, which employee is responsible for it, etc.

Train your staff and implement technical and organizational security measures.

Have Data Processing Agreement contracts in place with third parties you contract to process data for you.

Appoint a Data Protection Officer (though not all organizations need one - more on that in this article).

Data security

You're required to handle data securely by implementing " appropriate technical and organizational measures."

Technical measures mean anything from requiring your employees to use two-factor authentication on accounts where personal data are stored to contracting with cloud providers that use end-to-end encryption.

Organizational measures are things like staff trainings, adding a data privacy policy to your employee handbook, or limiting access to personal data to only those employees in your organization who need it.

If you have a data breach, you have 72 hours to tell the data subjects or face penalties. (This notification requirement may be waived if you use technological safeguards, such as encryption, to render data useless to an attacker.)

Data protection by design and by default

From now on, everything you do in your organization must, "by design and by default," consider data protection. Practically speaking, this means you must consider the data protection principles in the design of any new product or activity. The GDPR covers this principle in Article 25.

Suppose, for example, you're launching a new app for your company. You have to think about what personal data the app could possibly collect from users, then consider ways to minimize the amount of data and how you will secure it with the latest technology.

When you're allowed to process data

Article 6 lists the instances in which it's legal to process person data. Don't even think about touching somebody's personal data - don't collect it, don't store it, don't sell it to advertisers - unless you can justify it with one of the following:

1. The data subject gave you specific, unambiguous consent to process the data. (e.g. They've opted in to your marketing email list.)

2. Processing is necessary to execute or to prepare to enter into a contract to which the data subject is a party. (e.g. You need to do a background check before leasing property to a prospective tenant.)

3. You need to process it to comply with a legal obligation of yours. (e.g. You receive an order from the court in your jurisdiction.)

4. You need to process the data to save somebody's life. (e.g. Well, you'll probably know when this one applies.)

5. Processing is necessary to perform a task in the public interest or to carry out some official function. (e.g. You're a private garbage collection company.)

6. You have a legitimate interest to process someone's personal data. This is the most flexible lawful basis, though the "fundamental rights and freedoms of the data subject" always override your interests, especially if it's a child's data. (It's difficult to give an example here because there are a variety of factors you'll need to consider for your case. The UK Information Commissioner's Office provides helpful guidance here.)

Once you've determined the lawful basis for your data processing, you need to document this basis and notify the data subject (transparency!). And if you decide later to change your justification, you need to have a good reason, document this reason, and notify the data subject.

Consent

There are strict new rules about what constitutes consent from a data subject to process their information.

Consent must be "freely given, specific, informed and unambiguous."

Requests for consent must be "clearly distinguishable from the other matters" and presented in "clear and plain language."

Data subjects can withdraw previously given consent whenever they want, and you have to honor their decision. You can't simply change the legal basis of the processing to one of the other justifications.

Children under 13 can only give consent with permission from their parent.

You need to keep documentary evidence of consent.

Data Protection Officers

Contrary to popular belief, not every data controller or processor needs to appoint a Data Protection Officer (DPO). There are three conditions under which you are required to appoint a DPO:

1. You are a public authority other than a court acting in a judicial capacity.

2. Your core activities require you to monitor people systematically and regularly on a large scale. (e.g. You're Google.)

3. Your core activities are large-scale processing of special categories of data listed under Article 9 of the GDPR or data relating to criminal convictions and offenses mentioned in Article 10. (e.g. You're a medical office.)

You could also choose to designate a DPO even if you aren't required to. There are benefits to having someone in this role. Their basic tasks involve understanding the GDPR and how it applies to the organization, advising people in the organization about their responsibilities, conducting data protection trainings, conducting audits and monitoring GDPR compliance, and serving as a liaison with regulators.

We go in depth about the DPO role in another article.

People's privacy rights

You are a data controller and/or a data processor. But as a person who uses the Internet, you're also a data subject. The GDPR recognizes a litany of new privacy rights for data subjects, which aim to give individuals more control over the data they loan to organizations. As an organization, it's important to understand these rights to ensure you are GDPR compliant.

Below is a rundown of data subjects' privacy rights:

1. The right to be informed

2. The right of access

3. The right to rectification

4. The right to erasure

5. The right to restrict processing

6. The right to data portability

7. The right to object

8. Rights in relation to automated decision making and profiling.

Conclusion

We've just covered all the major points of the GDPR in a little over 2,000 words. The regulation itself (not including the accompanying directives) is 88 pages. If you're affected by the GDPR, we strongly recommend that someone in your organization reads it and that you consult an attorney to ensure you are GDPR compliant.

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What is GDPR, the EU's new data protection law? - GDPR.eu

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What is the GDPR? Europe's new data privacy and security law includes hundreds of pages' worth of new requirements for organizations around the world. This GDPR overview will help...

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To meet the necessary precautions, all paper-based materials containing sensitive personal information are stored securely under lock and key. The clinic strives to digitise paper records, which are then shredded before disposal. All digital records are stored in a secure cloud environment with two-factor authentication. Sensitive correspondence is encrypted. The distribution of documents containing personal information occurs only directly to the patient or via post, and only with prior consent from the patient or their legal guardian.

Any breach of these protocols would not only constitute a serious violation of patient trust but also be subject to:

• Supervision and sanctions by:

The Danish Patient Safety Authority (for breaches of record-keeping obligations)

The Danish Data Protection Agency (for data protection violations)

• Potential consequences:

Official orders or injunctions

Police reporting

Fines

Revocation of professional authorisation (in severe cases)

References: Danish standards for digital kommunication: https://medcom.dk/

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Mest for børn

Datatilsynet har lanceret et digitalt spil om databeskyttelse, der både er sjovt og lærerigt! Det indgår i en undervisningspakke, som er målrettet 10-12 årige børn - men alle kan være med. Kan du vinde den store guldpokal? Så kast dig ud i Datadysten nu!

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Datatilsynet er den centrale uafhængige myndighed, der fører tilsyn med, at reglerne om databeskyttelse bliver overholdt. Vi rådgiver og vejleder, behandler klager og gennemfører tilsyn hos myndigheder og virksomheder.

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

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

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It is indecent, offensive, and fundamentally wrong not to demonstrate respect and dignity toward fellow human beings. Healthcare professionals must not indulge in prejudice or discriminatory behaviour. Such conduct only contributes to division, insecurity, broken trust, and, in the worst cases, emotional harm to those subjected to it.

Key Legal Frameworks Against Discrimination in Healthcare

1. The Danish Health Act

Section 2(2): The healthcare system must "… provide the population with easy and equal access to healthcare services."

Equality in access to healthcare is a core principle: Discrimination based on ethnicity, gender, age, religion, disability, sexual orientation, etc., is prohibited.

Health Act – retsinformation.dk

2. Executive Order on the Duties of Authorised Healthcare Professionals (Ethical Rules)

Requires healthcare professionals to show respect and uphold patient dignity in all interactions.

They must not act in conflict with the patient’s rights or integrity, including actions based on prejudice.

Executive Order No. 1240 of 27/10/2008

3. Equal Treatment and Anti-Discrimination Legislation

The Act on Ethnic Equal Treatment and the Act on Prohibition of Discrimination in the Labour Market also apply within the healthcare sector.

These laws prohibit discrimination on the basis of race, skin colour, national or ethnic origin, gender, religion, disability, age, sexual orientation, and more.

Act on Ethnic Equal Treatment – retsinformation.dk

4. The European Convention on Human Rights & the Danish Constitution

Denmark is bound by the European Convention on Human Rights, which prohibits discrimination (Article 14).

Section 70 of the Danish Constitution guarantees freedom from discrimination on the basis of religion and belief.

Ethical Guidelines from Professional Bodies

• Ethical Guidelines for Physicians (Danish Medical Association)

"The physician must show respect for the patient’s integrity and dignity and must not be influenced by prejudice."

• Danish Physiotherapists: Code of Ethics

"The physiotherapist acts loyally and fairly and respects the patient’s cultural, religious, and personal values."

Code of Ethics – Danish Physiotherapists

Examples of Prohibited Forms of Discrimination

Category

Example

Race or ethnicity

Refusing treatment to individuals based on skin colour

Religion or belief

Avoiding treatment of patients wearing religious head coverings

Sexual orientation

Making derogatory remarks to LGBTQ+ individuals

Disability

Failing to accommodate physical or cognitive disabilities

Language/nationality

Denying treatment to non-Danish speakers without offering interpreter support

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Policy statement: Ethical principles and responsibilities of physiotherapists and member organisations

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This policy statement holds ethical principles and explains the ethical responsibilities of physiotherapists and member organisations addressing all aspects of professional conduct.

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I am both the owner of a clinic with employees and a practising clinician myself. It is in my best interest to ensure a polite, respectful, and consistently welcoming tone between practitioners and patients. This reflects not only my personal ethical stance against prejudice and discrimination, but also the fact that such behaviour would be harmful to the clinic’s business model and reputation. Discrimination based on religion, culture, race, gender, or other personal characteristics has no place in a healthy clinical environment.

According to both Danish healthcare legislation and ethical guidelines, clinic owners and managers have a duty to intervene if colleagues behave in a discriminatory manner—failure to act can also be deemed unethical.

Who can sanction healthcare professionals?

1. The Danish Patient Safety Authority (STPS)

Role: Supervisory authority for authorised healthcare professionals.
Powers:

·       Investigates misconduct and breaches of the Authorisation Act, including:

o   Unprofessional behaviour

o   Unethical or discriminatory treatment

·       May issue decisions such as:

o   Formal reprimands

o   Orders for professional or ethical remediation

o   Temporary or permanent revocation of authorisation
https://stps.dk

2. The Danish Agency for Patient Complaints (STPK)

Role: Handles complaints from patients concerning the conduct or treatment by healthcare professionals.
Sanctions:

·       Criticism of the healthcare provider

·       Referral to STPS in serious cases

·       Does not impose direct disciplinary sanctions but plays a key role in case development
https://stpk.dk

3. The Equal Treatment Board (Ligebehandlingsnævnet)

Role: Reviews cases of discrimination, including those based on race, religion, disability, age, gender, and sexual orientation.
Sanctions:

·       Compensation or damages awarded to the patient

·       Publication of decisions with named individuals in certain cases
https://naevneneshus.dk

4. The Danish Data Protection Agency (Datatilsynet)

Role: Sanctions unlawful or degrading handling of sensitive personal data, which may also constitute discriminatory behaviour.

Types of Sanctions

Sanction Type

Authority

Description

Professional criticism

Danish Agency for Patient Complaints

Formal statement declaring the behaviour unacceptable

Official orders/remediation

Danish Patient Safety Authority

E.g. supervision, continuing education, or mandatory changes in practice

Temporary revocation of authorisation

Danish Patient Safety Authority

In cases of severe or repeated unethical conduct

Permanent revocation of authorisation

Danish Patient Safety Authority

For gross incompetence or posing danger to patient safety

Compensation/damages

Equal Treatment Board

Typically in cases of proven discrimination

Criminal charges and court proceedings

Police and courts

In serious cases (e.g. hate crimes, assault, or severe discriminatory conduct)

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Nævnenes Hus sekretariatsbetjener en række uafhængige domstolslignende nævn.
Det betyder, at vi behandler sager og forbereder afgørelsesudkast til nævnene, så de kan træffe korrekte afgørelser til tiden.

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

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

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This guidance highlights the critical importance of professional integrity, not only during clinical practice but in all aspects of an osteopath’s life. Reflecting on this as a healthcare professional involves acknowledging your dual role as both a clinician and a representative of a regulated profession.

In my case, I live near my clinic, and the majority of my patients encounter me in the local community or see me during my runs. Furthermore, my social interactions often include people who are currently in treatment or who know someone receiving care at the clinic. I am more exposed to public scrutiny than colleagues who live several kilometres away from their practice.

This exposure, both professionally and personally, places an additional responsibility on me to avoid creating any adverse perceptions. This applies not only to the reputation of my clinic but also to the standing of the osteopathic profession as a whole. My focus is on proactively identifying and mitigating factors that could discredit either.

Unfortunately, discredit and rumours may arise from misunderstandings, which is why it is essential to be attentive to how patients perceive and experience care provided by myself and my clinical staff. The more proactive we are in addressing concerns that may affect reputation, the better positioned we are to manage and resolve potential issues.

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Gibbs’ Reflective Cycle helped improve a structured approach to problem-solving.
In this particular case, it related to leadership and organisation within the clinic.
The model is also a valuable tool when reflecting on patient cases where one feels they have fallen short.

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

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

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My clinic relies on paying patients, which is why it is important for us to attract a clientele that is willing to invest in our services in order to address their health concerns.
The downside of a fee-for-service model is that individuals without sufficient financial means—such as single mothers, low-income individuals, and students—may not have access to our services. This issue has become more pronounced in recent years. In addition to this, we receive an increasing number of patients referred through insurance coverage. Unfortunately, this also contributes to greater inequality in access to healthcare. Moreover, insurance companies often attempt to impose their own views on how a patient care pathway should be conducted—even before the patient has been clinically assessed.
Below, the advantages and disadvantages of out-of-pocket payment for healthcare services are outlined.

Advantages of Patient Payment

Cost-effectiveness:
A systematic review from the United States showed that patients with back pain who received chiropractic care generally had lower healthcare expenses compared to those treated by other healthcare professionals. In 92% of the studies reviewed, the costs were lower for patients who were treated by chiropractors.
(Source: BioMed Central)

Reduction in opioid use and surgery:
Several studies indicate that patients who initially consult chiropractors or physiotherapists are less likely to be prescribed opioids or referred for surgery. This can lead to both lower costs and better patient outcomes.

High patient satisfaction:
Patients often report high satisfaction with treatments provided by chiropractors and physiotherapists, especially for musculoskeletal disorders such as low back pain. This may be attributed to a more holistic approach and longer consultation times.

Disadvantages of Patient Payment

Increased financial burden for patients:
User fees can place a financial strain on patients, particularly those with low income, potentially resulting in delayed or avoided treatment. This may worsen health outcomes and lead to higher long-term costs.

Inequality in access to care:
Studies have shown that higher patient fees can lead to disparities in access to care, with patients of higher socioeconomic status more likely to access necessary health services compared to those with lower income.

Potential overuse of services:
In some cases, direct payment may result in the overuse of healthcare services, where patients request or are offered unnecessary treatments. This can increase overall healthcare costs without corresponding improvements in patient outcomes.

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Research

Open access

Published:

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Chiropractic & Manual Therapies 22, Article number: 3 (2014) Cite this article

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Abstract

Background

Chiropractors, physiotherapists, and osteopaths receive training in the diagnosis and management of musculoskeletal conditions. As a result there is considerable overlap in the types of conditions that are encountered clinically by these practitioners. In Australia, the majority of benefits paid for these services come from the private sector. The purpose of this article is to quantify and describe the development in service utilization and the cost of benefits paid to users of these healthcare services by private health insurers. An exploration of the factors that may have influenced the observed trends is also presented.

Methods

A review of data from the Australian Bureau of Statistics, Australian Health Practitioner Regulation Agency, and the Australian Government Private Health Insurance Administration Council was conducted. An analysis of chiropractic, physiotherapy and osteopathic service utilisation and cost of service utilisation trend was performed along with the level of benefits and services over time.

Results

In 2012, the number of physiotherapists working in the private sector was 2.9 times larger than that of chiropractic, and 7.8 times that of the osteopathic profession. The total number of services provided by chiropractors, physiotherapists, and osteopaths increased steadily over the past 15 years. For the majority of this period, chiropractors provided more services than the other two professions. The average number of services provided by chiropractors was approximately two and a half times that of physiotherapists and four and a half times that of osteopaths.

Conclusions

This study highlights a clear disparity in the average number of services provided by chiropractors, physiotherapists, and osteopaths in the private sector in Australia over the last 15 years. Further research is required to explain these observed differences and to determine whether a similar trend exists in patients who do not have private health insurance cover.

Introduction

In Australia health care costs are covered by the private and public sectors. In 2009-2010 the private health insurance sector provided $13.5 billion towards the total cost of the Australian health care system. This represented about 12% of total health funding[ 1]. These funds came from two sources: insurance premium payments by members ($9.2 billion) and premium rebates from the Australian Government ($4.3 billion). Of the $9.2 billion paid by members, 5.3% went to payment for non-hospital, non-medical treatment such as chiropractic, physiotherapy and osteopathic services.

Australian chiropractors, physiotherapists and osteopaths are all trained to diagnose and treat musculoskeletal (MSK) conditions[ 2- 4]. It is therefore reasonable to assume a degree of overlap in the types of conditions treated by each of these professions. A recent cross-sectional study of chiropractors from Victoria, Australia reported that MSK conditions were the most common reason for patients seeking chiropractic care. Chiropractors who participated in the study stated that MSK conditions were the main reason for the practitioner-patient encounter in 60 per 100 encounters (95% CI, 54-67 per 100 encounters)[ 5]. The Australian Physiotherapy Association's 'Scope of Practice' states that physiotherapy involves the prevention, diagnosis, and management of movement disorders that involve the MSK system[ 6]. In addition, physiotherapists also provide other services including, but not limited to, post-fracture, post-surgery and pre- and post-natal care. It is a similar scenario for osteopaths with nine of the twelve conditions listed under 'Treatment' by the Australian Osteopathic Association being MSK in nature[ 3].

Musculoskeletal conditions such as back and neck pain cause significant disability and loss of productivity and represent a considerable portion of healthcare expenditure in Australia. The Global Burden of Disease study 2010 ranks low back pain and neck pain first and third respectively in Australasia as the cause of years lived with disability[ 7]. The prevalence of these conditions increases up to the age of 60[ 8] and the demand for health care services associated with managing them is likely to increase significantly over the next three decades. It is therefore important to quantify and describe current trends in service utilisation in order to assist future planning of healthcare service provision and expenditure.

In Australia, the provision of chiropractic, physiotherapy and osteopathic services is driven by a number of factors that can be classified as internal or external. Internal factors encompass graduate capabilities, code of conduct and self-regulated professional behaviour and practice, while external factors include government legislation, private health insurance policies, individual/community preference, population demographics, economic circumstances such as the level of household disposable income and the health status of the population[ 9]. These factors operate in a state of dynamic equilibrium, whereby change in one factor produces an alteration in one or more of the others. Understanding the dynamics of these changes is not always straightforward. The aims of this article are to A) quantify and describe developments in service utilisation and total cost of service benefits for chiropractic, physiotherapy and osteopathic services in the Australian private health sector, and B) to discuss factors that may account for any observable trends in the development.

Methods

Data sources

Data were obtained retrospectively from the Australian Bureau of Statistics (ABS)[ 10], Australian Health Practitioner Regulation Agency (AHPRA)[ 11- 13], and the Australian Government Private Health Insurance Administration Council (PHIAC)[ 14, 15] with a review period of 15 years (1998-2012) chosen for convenience. The PHIAC is the regulatory body for the private health insurance industry in Australia. It protects the consumer by ensuring a safe, efficient, compliant, and competitive health insurance industry. The PHIAC collects key information and monitors activity from all health insurers in Australia on a quarterly basis.

In this study data was gathered from PHIAC pertaining to total cost of services, ancillary benefits, and number of services provided to all Australians with private health insurance by chiropractors, physiotherapists and osteopaths. The total 'cost of service' represents the sum total of the fees charged at the time of consultation (fee for service) to individuals with private health insurance. An 'ancillary benefit' relates to the portion of the total fee for service that is reimbursed by the health insurer. A 'service' represents one visit to a healthcare provider. The number of general treatment policies held during the review period was also retrieved from the PHIAC databases. A 'general treatment policy' represents insurance for treatment that is intended to manage or prevent a disease, injury or condition, and is separate to hospital treatment cover.

Total numbers of registered, practising practitioners in 1998 and 2012 were collated using data from the ABS and AHPRA. Data regarding the total number of hours worked by registered physiotherapists, in both the public and the private sector, were obtained from the ABS and from three Australian state government agencies (New South Wales 2009, Queensland 2005, and Victoria 2006)[ 16- 19]. The ABS data described the percentage of hours worked by physiotherapists in the private sector in 1998.

Quarterly data relating to the majority of these key variables was available for the review period for the chiropractic, physiotherapy and osteopathic professions. In this study, quarterly services, cost of services, and ancillary benefits data were summated to give yearly statistics for that period. No other transformations were required.

Data analyses

Each discipline's service utilisation and cost of service utilisation trend was plotted showing the level of services and benefits over time. The percentage change from one year to the next for both total service cost and number of services was calculated for chiropractic, physiotherapy and osteopathy. The percentage change in practitioner numbers between 1998 and 2012 was also calculated. As chiropractors and osteopaths work exclusively in the private sector, an estimate of the number physiotherapists working in the private sector was required. The estimate for the total number of physiotherapists working in the private sector in 2012 was based on data from the three state government agencies. The proportion of 53.5% was calculated by taking the average number of hours worked by physiotherapists in the private sector across these three states and applying it to the total number of registered, practising physiotherapists in 2012. The average yearly number of services delivered was calculated for each profession by dividing the total number of services by the total number of registered, practising practitioners in the private sector for each profession. The percentage change from the previous yearly figures was calculated for all the key variables.

Results

Number of practitioners

Table 1 shows the number of chiropractors, physiotherapists and osteopaths in Australia in 1998 and 2012 working in private practice and the proportional change over time[ 11- 13, 19- 21]. As the number of physiotherapists working in the private sector in 2012 was not directly available we used the estimate referred to previously for the analysis. There were just under three times (2.9) as many physiotherapists as chiropractors in 2012 and 2.6 times as many chiropractors as osteopaths. The osteopathic profession experienced a four-fold increase in practitioner numbers during the review period which was considerably larger than the increases in the number of chiropractors and physiotherapists. It is however important to note that despite this large increase in the practitioner numbers during the review period, the overall number of osteopaths is much smaller when compared to the number of chiropractors and physiotherapists working in the private sector.

Table 1 Total number of registered, practising practitioners in the private sector by profession in 1998 and 2012

Level of services

Figure 1 reports the total number of chiropractic, physiotherapy and osteopathic services provided to individuals with private health insurance between 1998 and 2012[ 22]. Profession service figures have been provided in Additional file 1[ 15]. Figure 2 illustrates the total private health insurance expenditure for chiropractic, physiotherapy and osteopathic services between 1998 and 2012. A detailed breakdown of this data is provided in Additional file 2[ 22]. There was an overall trend towards increasing expenditure for all three providers during the review period. While the total number and dollar value of osteopathic services was less compared to chiropractic and physiotherapy services the percentage change in osteopathic services exceeded chiropractic and physiotherapy for the majority of the review period. The expenditure on osteopathic services must be interpreted with the knowledge that the overall level of services for the osteopathic profession represents a small percentage of the total expenditure for services rendered by the three services providers.

Total number of services provided to individuals with private health insurance by profession: 1998 - 2012. Source: PHIAC[ 15].

Private health insurance rebates by profession: 1998-2012. Source: PHIAC[ 15].

Average number of services per practitioner

In 1998 the average number of services per practitioner provided to individuals with private health insurance per practitioner was 1,901 for chiropractors, 691 for physiotherapists and 141 for osteopaths. Using the estimated figure for the number of physiotherapists working in the private sector, the average number of services per registered, practising practitioner in 2012 was 2,252 for chiropractors, 796 for physiotherapists and 483 for osteopaths[ 11- 13]. The average number of services provided by chiropractors was more than two and a half times that of physiotherapists and four and a half times that of osteopaths working in the private sector in 1998 and 2012.

Discussion

The purpose of this study was to quantify and describe developments in service utilisation and total cost of service benefits for chiropractic, physiotherapy and osteopathic services in the private healthcare sector in Australia between 1998 and 2012. There has been a substantial increase in the number of chiropractors, physiotherapists and osteopaths in the last 15 years, with physiotherapy being the largest of the three providers in terms of practitioner numbers in the private sector. This growth in practitioner numbers has been accompanied by a steady increase in the utilisation of these services, a scenario that has been most pronounced for osteopathic services. Chiropractors have delivered more services to individuals with private health insurance compared to physiotherapists and osteopaths for the majority of the review period. Chiropractors deliver, on average, a higher number of services each year in the private sector compared to physiotherapists and osteopaths. With respect to expenditure, there has been a trend towards an increasing cost of chiropractic, physiotherapy and osteopathic services, as well as an increase in the benefits paid for these services by private health insurers. Both the total cost and the benefits paid for osteopathic services have accelerated dramatically over the review period when viewed alongside the data for the other two service providers.

The secondary aim of this study was to discuss the factors that may account for the development in the figures relating to total cost of services, benefits paid by private health insurers, and utilisation rates for chiropractic, physiotherapy and osteopathic services. While it is not possible, based on the data, to provide definitive explanations for the observed trends a discussion of the factors that may have contributed to changes in these areas is presented below.

With respect to service utilisation, the increases observed during the review period cannot be fully explained by the increase in practitioner numbers. Between 2005 and 2010, the total number of workers across all health occupations in Australia increased by 26%. During the same period, the number of chiropractors and osteopaths increased by 17% while the number of physiotherapists increased by 42%[ 23].

The number of chiropractic services provided to patients with private health insurance was higher than for physiotherapy for the majority of the review period (1998-2011). If the two professions were compared on size alone it would make sense that the profession with the largest private sector presence (physiotherapy) would have also provided the most number of services. However, this was not the case for the majority of the review period. Data from 2012 highlights a change to this trend with the total number of services provided by physiotherapists exceeding those provided by chiropractors. It is yet to be seen whether this increase will continue into the future.

Factors that could explain the disparity in the number of services provided by chiropractors and physiotherapists during the review period include internal factors such as code of conduct and self-regulated professional behaviour and practice, and/or external factors such as government legislation, changes in private health insurance policy or economic factors.

Code of conduct and self-regulated professional behaviour and practice includes elements such as fees charged for services, and the location of practices. With respect to the fees charged for chiropractic services, the average fee declined in real terms between 2007 and 2012[ 9]. The opposite situation occurred regarding fees for physiotherapy services with average fee in real terms increasing between 2007 and 2012[ 24]. However, the benefit paid by private health insurers declined by approximately 1% in the same period for both chiropractic and physiotherapy services[ 9, 24]. The size of the difference in both fee for service, and benefits paid by insurers over this period is therefore unlikely to account for the disparity between the average number of chiropractic and physiotherapy services.

While there is a general consensus regarding the types of conditions that fall within the scope of practice for each profession, the precise case-mix for each profession is not well-described in the literature. It could be argued that physiotherapists, through their involvement in areas such as post-surgical rehabilitation, may see patients who justifiably require more frequent and intensive care. This could have created a scenario where there is considerable heterogeneity in case-mix between the three professions. This scenario could also potentially alter the length of time required to treat each patient, with patients seeing a physiotherapist experiencing greater disability requiring more care and attention equating to longer 'service' duration.

The data presented in this study describe a higher average number of services provided per chiropractic practitioner compared to physiotherapists and osteopaths. This finding does not necessarily mean that chiropractors delivered more services per patient. Instead, it may be that chiropractors see more new patients or a greater proportion of their existing client base more often. Recent industry estimates suggest that Australian chiropractors see approximately 300,000 patients per week[ 9]. Using this estimate, each chiropractor (4402 in June 2013) would be seeing on average 68.1 patients per week. Based on a 48 week working year these estimates are higher than the estimates detailed in this study. More accurate point prevalence data on service utilization for each of these professions is required before any meaningful predictions can be made about the level of chiropractic, physiotherapy and osteopathic services in the future.

Results from a 2005 Australian survey of 1,067 adults over the age of 18 found that 16.1% reported using chiropractic services during the previous 12 months[ 25]. The most common reasons given for seeking chiropractic and osteopathic treatment were back and/or neck pain, non-specific musculoskeletal problems and enhancement of general health and well-being[ 25]. While the response rate for each of these categories did differ between the two professions the size of the differences are not enough to explain the disparity in the average number of services for each profession.

A recent survey of 1,427 Australian women showed high utilisation of chiropractors in non-urban compared to urban settings[ 26]. It may be the case that there is a different pattern in the utilisation of chiropractic, physiotherapy and osteopathic services in rural areas. It is important to note that there has not been any research into the utilisation of these services by males in non-urban regions. However, we do not believe that a preference for chiropractic in non-urban settings would be sufficient to explain the magnitude of the disparity in average servicing as the number of chiropractors practising in rural and remote regions of Australia (30%) is substantially less than the number of chiropractors practising in urban regions (70%)[ 27].

With respect to the previously identified external factors that could explain the utilisation disparity between the three disciplines, the Australian Federal Government does not regulate the level of chiropractic, physiotherapy or osteopathic services provided in the private sector. As for private health insurance coverage, the increased uptake in general treatment cover over the review period does not match the increase in service provision by the three professions. There have not been any changes in private health insurance policies during the review period that favoured one discipline over the other or any economic factors that may have influenced the Australian economy in a way that would have impacted on the three disciplines differently.

An absence of practice guidelines for the chiropractic profession could account for a high average number of services provided per practitioner. This absence may have unwittingly led to the acceptance of a wide variation in the level of servicing among chiropractors in Australia. However, the problem is not unique to the chiropractic profession, and would therefore exist to some extent in both the physiotherapy and osteopathic professions. This is an area in which further research is required. While our analysis cannot identify whether the average number of services per chiropractor can be uniformly applied across the profession, it is possible that a section of the profession practices in a manner so different to the rest that the average for the entire profession becomes distorted. Anecdotally, there are large differences between chiropractors in the average number of services provided per patient. It must be acknowledged that the same scenario could also exist within the physiotherapy and osteopathic professions. However, if this were the case for chiropractic, it would be of interest to the private health insurance sector as they provide the majority of benefits for chiropractic services. In the current economic climate, it is hard to imagine insurers continuing to support such high levels of utilisation without evidence to support the premise that a higher level of servicing delivers increased benefit to their members. This point is especially pertinent to insurance companies as there has been a steady increase in the number of Australians with general treatment insurance over the review period[ 15]. It must be noted however that while an individual may have had general treatment cover, this does not mean that they have coverage for chiropractic, physiotherapy, or osteopathic treatment within that general treatment cover.

The differences observed between the three service providers with respect to service utilisation, and average number of services provided per practitioner cannot be adequately explained by the data presented here. It is possible that factors that were not measured in this research such as working hours, full-time equivalent working status, capacity of a profession to treat patients, patient demographics, and treatment type/content may be salient. Further research that includes these metrics is required to more accurately account for the observed trends.

Limitations

There are several limitations to this study. Firstly, the estimate for the number of physiotherapists working in the private sector was based on figures from only three states at different time periods. It is unknown how these estimates relate to full-time practitioners as there are no current reports that detail the full-time equivalent status of practitioners working in these three professions. Secondly, PHIAC collects data on the cost of benefits for services and the number of services received by individuals with private health insurance. However, if a patient had exceeded their yearly benefit limit for a particular service, any additional services provided by a treating practitioner after that point would not have been recorded. Furthermore, not all Australians have private health insurance. In fact, only 54.6% of Australians had general treatment policies in December 2012[ 28]. Of the patients with private health insurance, not all had a level of cover that included ancillary services such chiropractic, physiotherapy or osteopathy. Currently, chiropractic, physiotherapy, and osteopathy services are bundled together in the majority of ancillary health cover packages. Patients are therefore not given the option to select health insurance coverage for an individual profession, despite any preference they may have. The reasons for seeking chiropractic treatment are quite diverse and readers are directed to a recent review paper by Hurwitz[ 29] for a more detailed discussion on the topic. It must be acknowledged that the data presented in this paper does not fully reflect the various reasons for why patients choose a particular modality and that this may be a salient factor in the observed trends in service utilization. Further research, including an analysis of the social and cultural reasons that drive care seeking behaviour, is required to accurately profile/explain the trends in utilisation across the three professions.

The data presented in this study do not include data from the Chronic Disease Management arm of the Enhanced Primary Care Program. Under this program, patients with a chronic medical condition, e.g. chronic musculoskeletal condition, who would benefit from multidisciplinary care, are eligible to receive five allied health services in conjunction with standard GP care. These services are rendered under a GP management plan and are covered publicly under the Medical Benefits Schedule in Australia[ 30]. Services provided under this program are not included in the data from PHIAC. It is possible that a proportion of patients that would ordinarily be recorded in the private system have not been identified in this study due to their involvement in this program. This may have influenced the figures relating to total cost of services, level of services and the number of average services provided per practitioner. It is however important to note that chiropractors, physiotherapists and osteopaths are involved in this program.

The estimate for the point prevalence of chiropractic service utilisation obtained in this study is lower than the utilisation figures obtained from a recent industry report[ 9]. This finding highlights a need for accurate data regarding point prevalence of chiropractic service utilisation. There is also a paucity of data pertaining to point prevalence of service utilisation for physiotherapy and osteopathy services. Targeted research into service utilisation rates amongst those with and without private health insurance is required to accurately explain the observed trends in service utilisation for these three professions.

Conclusion

This article describes the development in the utilisation of chiropractic, physiotherapy and osteopathic services in Australia over the past 15 years. While there is a paucity of data to inform the drivers of this change the authors have provided some hypotheses for the identified disparity in service provision and identified areas where further research is warranted. While this study highlights a clear disparity in service utilisation in the Australian private sector, further research is required to determine if a similar trend exists in patients who do not have private health insurance cover. De-identified individual patient data and de-identified individual clinician data regarding variability in frequency of services per patient are required to better explain the observed trends.

Abbreviations

ABS:

Australian Bureau of Statistics

AHPRA:

Australian Health Practitioner Regulation Agency

PHIAC:

Private Health Insurance Administration Council

MSK:

Musculoskeletal.

References

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Acknowledgements

Thank you to Petra Graham for her help and advice with the statistical analyses.

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Authors and Affiliations

Department of Chiropractic, Macquarie University, Balaclava Rd, North Ryde, 2109, Australia

Roger M Engel, Benjamin T Brown, Michael S Swain & Reidar P Lystad

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Correspondence to Roger M Engel.

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All authors contributed equally to the design, analysis, writing, and review of the final manuscript.

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Engel, R.M., Brown, B.T., Swain, M.S. et al. The provision of chiropractic, physiotherapy and osteopathic services within the Australian private health-care system: a report of recent trends. Chiropr Man Therap 22, 3 (2014). https://doi.org/10.1186/2045-709X-22-3
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# data[].attributes.attachment_link.title
The provision of chiropractic, physiotherapy and osteopathic services within the Australian private health-care system: a report of recent trends - Chiropractic & Manual Therapies

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Background Chiropractors, physiotherapists, and osteopaths receive training in the diagnosis and management of musculoskeletal conditions. As a result there is considerable overlap in the types of conditions that are encountered clinically by these practitioners. In Australia, the majority of benefits paid for these services come from the private sector.

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

# data[].attributes.subject
D9. You must support colleagues and cooperate with them to enhance patient care.

# data[].attributes.body
It is frustrating to receive a patient from another practitioner without adequate information. Not only is it inconvenient for the patient to have to repeat details they have already shared with the previous clinician, but the absence of critical information may also compromise patient safety and the quality of care. Conversely, I have experienced the greatest success in patient care when I receive comprehensive records that are contextually relevant to the patient's current situation and presenting complaint.

Unfortunately, I occasionally receive extensive information lacking clinical reasoning from the referring provider. Simply listing findings and observations is insufficient unless a clear clinical perspective has been established.

The literature highlights the following consequences of poor patient handovers:

1. Increased Risk of Medical Errors
Miscommunication during care transitions is a leading cause of adverse events in hospitals and primary care. A systematic review by Starmer et al. (2014) found that implementing standardized handoff procedures reduced medical errors by 23% and preventable adverse events by 30% (Starmer et al., New England Journal of Medicine, 2014).

2. Delayed or Inappropriate Treatment
When essential clinical information is not effectively communicated, patients may receive incorrect or delayed treatment, especially during provider handovers or interprofessional transitions.

3. Patient Dissatisfaction and Readmission
Poor communication leads to fragmented care, contributing to increased patient dissatisfaction and higher rates of unplanned readmissions (Kripalani et al., JAMA, 2007).

4. Compromised Patient Safety
The World Health Organization (WHO) identifies communication failures as one of the top root causes of sentinel events worldwide. Effective handovers are essential for ensuring patient safety and continuity of care.

Suggested References:

Starmer AJ, et al. (2014). Changes in medical errors after implementation of a handoff program. New England Journal of Medicine, 371(19), 1803–1812. https://doi.org/10.1056/NEJMsa1405556

World Health Organization (2007). Communication during patient hand-overs: WHO High 5s Project.

The Joint Commission (2017). Sentinel Event Data – Root Causes by Event Type.

Arora V. & Johnson J. (2006). A model for building a standardized hand-off protocol. Quality and Safety in Health Care, 15(6), 401–406.

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Reflection on Effective Patient Handover Practice

One of the most helpful guiding principles in my clinical practice has been to envision how I myself would prefer to receive a patient from a colleague. Patient records that focus clearly on the main complaint and include reasoned arguments with a coherent narrative across the case history, physical findings, and treatment response provide an ideal starting point for the receiving clinician.

When referring a patient whose condition remains unresolved, it is valuable to include the referring clinician’s clinical reasoning based on their observations, tests, and attempted interventions. This helps the next provider avoid repeating ineffective approaches and enables a more targeted and timely continuation of care. For the patient, such a handover supports continuity, avoids redundant procedures, and strengthens trust in a multidisciplinary care approach.

Moreover, clinicians often prefer handover notes and discharge letters that are concise, structured, and clinically meaningful. Avoiding unnecessary filler text and instead emphasizing clear reasoning ensures that critical information is not lost. The primary objective must always be to safeguard the patient’s well-being, which sometimes requires striking a balance between brevity and the inclusion of essential clinical details. In my experience, the better I understand a patient, the easier it is to be succinct and precise.

Scientific References Supporting the Importance of Effective Handover:

1. World Health Organization (2007)
Poor communication during handovers is a major risk factor for patient safety. WHO recommends standardized tools such as SBAR (Situation, Background, Assessment, Recommendation) to reduce errors and miscommunication.
World Health Organization. (2007). Communication during patient hand-overs. Patient Safety Solutions.

2. Starmer et al., NEJM (2014)
A multicentre study found that the implementation of a structured handoff program led to a 23% reduction in medical errors and a 30% reduction in serious medication-related errors.
Starmer AJ et al. Changes in Medical Errors after Implementation of a Handoff Program. New England Journal of Medicine, 2014. DOI: 10.1056/NEJMsa1405556

3. Holly & Poletick, Journal of Clinical Nursing (2014)
This systematic review concluded that effective handovers are essential for care continuity and result in better patient outcomes and satisfaction.
Holly C, Poletick E. A systematic review on the transfer of patient care from one caregiver to another. J Clin Nurs. 2014. DOI: 10.1111/jocn.12362

4. The Joint Commission (2017)
Inadequate handoff communication remains one of the leading causes of serious adverse events. The Commission emphasizes the need for formal, standardized communication protocols as part of safe clinical practice.
Joint Commission. Sentinel Event Alert, Issue 58.

5. Greenstein & Arora, Academic Medicine (2009)
Highlights the importance of structured handoff training during medical education to reduce errors and foster interprofessional collaboration.
Greenstein EA, Arora VM. Improving patient handoffs through standardized training. Acad Med. 2009.

Why it Matters

Patient Safety: Incomplete handovers are associated with medication errors, misdiagnoses, and treatment delays.

Improved Clinical Continuity: Structured handovers facilitate a clearer understanding of the patient's journey.

Better Collaboration: Standardized procedures enhance mutual trust and communication across disciplines.

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

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

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During my time as a healthcare professional, I have engaged in a wide range of collaborative efforts with other healthcare providers.
Challenges in such collaborations may include the allocation of responsibilities, maintaining a respectful working relationship, and, at times, conflicts of interest stemming from business or financial considerations. Some practitioners may attempt to retain full responsibility for a patient's care to maximise income, even when they may lack the specific competence required for effective management. This can compromise the quality of care and is ultimately not in the best interest of the patient.

It is inappropriate for clinical quality to be sacrificed for financial gain, and the situation is further exacerbated when practitioners speak negatively about one another. Such behaviour undermines patient trust—both in the practitioner and in the intervention being offered.
Finally, the patient's safety and quality of care may be jeopardised if their condition is not addressed promptly and in accordance with established clinical guidelines.

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Abstract

Background

In a period of change in the organization of primary care, Interprofessional Collaboration (IPC) is presented as one of the solutions to health issues. Although the number of inter-professional interventions grounded in primary care increases in all developed countries, evidence on the effects of these collaborations on patient-centred outcomes is patchy. The objective of our study was to assess the effects of IPC grounded in the primary care setting on patient-centred outcomes.

Methods

We conducted a systematic literature review using the PubMed, Embase, PsycINFO and CINAHL databases from 01/01/1995 to 01/03/2021, according to the PRISMA guidelines. Studies reporting the effects of IPC in primary care on patient health outcomes were included. The quality of the studies was assessed using the revised Downs and Black checklist.

Results

Sixty-five articles concerning 61 interventions were analysed. A total of 43 studies were prospective and randomized. Studies were classified into 3 main categories as follows: 1) studies with patients at cardiovascular risk (28 studies)-including diabetes (18 studies) and arterial hypertension (5 studies); 2) studies including elderly and/or polypathological patients (18 studies); and 3) patients with symptoms of mental or physical disorders (15 studies). The number of included patients varied greatly (from 50 to 312,377). The proportion of studies that reported a positive effect of IPC on patient-centred outcomes was as follows: 23 out of the 28 studies including patients at cardiovascular risk, 8 out of the 18 studies of elderly or polypathological patients, and 11 out of the 12 studies of patients with mental or physical disorders.

Conclusions

Evidence suggests that IPC is effective in the management of patients at cardiovascular risk. In elderly or polypathological patients and in patients with mental or physical disorders, the number of studies remains very limited, and the results are heterogeneous. Researchers should be encouraged to perform studies based on comparative designs: it would increase evidence on the positive effect and benefits of IPC on patient variables.

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Introduction

The development of primary care, defined as a model of care that supports first-contact, accessible, continuous, comprehensive and coordinated person-focused care, is a global priority [ 1]. Studies have already shown that most patients are treated in a primary care setting [ 2, 3]. Most patients suffering from common diseases such as hypertension, diabetes, chronic obstructive pulmonary disease and asthma only consult a primary care provider [ 4]. The ageing of populations, the growing importance of chronic pathologies, the international shortage in the health care workforce [ 5], and the growing complexity of care pathways call for development of new modalities of practice in primary care.

Functioning in a primary care team, based on Interprofessional Collaboration (IPC), is widely supported by the health authorities in France [ 6], similar to existing models in several countries [ 7]. IPC is defined as several health workers from different professional backgrounds providing comprehensive services by working with patients, their families, and other caregivers [ 8]. This definition can be supplemented by the need for contact, negotiation and interaction among health care professionals. As this concept is recent and vast, several terms have been used, but the term IPC is the most currently used [ 9]. Part of these IPC teams regroup professionals in the same practice. Many practices work as a team of GP's, nurses (including Advanced Nurse Practitioners), paramedics (including Advanced Clinical Practitioners), clinical pharmacists, physiotherapists, physician associates and others. In this model, an integrated and collaborative approach to patient care has been developed. The literature on this subject shows a recent emulation with numerous articles in many journals [ 1, 7, 8, 9, 10, 11]. Several authors have reported that working as a team is a source of satisfaction among professionals [ 7, 10]. A 2018 literature review reported how primary care teams were formed [ 11], but it did not report any information on the effect of these organizations on patient-centred outcomes.

Some authors have focused on the team-based approach for specific pathologies for which collaborations largely mobilize specialists and hospital professionals, but these investigations concern secondary rather than primary care services [ 12, 13, 14]. While a recent literature review [ 15] investigated the effect of IPC in a primary care setting on adults with diabetes and/or hypertension, we wanted to further investigate which areas of treatment and primary care team organization had an effect on patient-centred outcomes.

A better understanding and better characterization the composition of IPC teams and the health fields in which this collaboration would be relevant and effective for patients is important for decision-makers and professionals who wish to engage in the evolution of their practice. Which professionals are involved in IPC? For which treatments and illnesses have results been obtained? For which treatments and diseases have we not obtained convincing results?

The objective of this study was to assess the effects of IPC grounded in primary care setting on patients-centred outcomes.

Methods

This systematic review was conducted according to the PRISMA guidelines [ 16]. We searched for studies published between January 1st, 1995 and March 1st, 2021. To ensure that we found all research articles published by the various health professionals, we chose to increase the number of search engines normally used. The following databases were searched: PubMed, Embase, PsycINFO and CINAHL. Additional articles that were found by hand searching the references were also reviewed. The following research algorithms were used 1) PubMed: ("Intersectoral Collaboration"[Mesh] OR "Cooperative Behavior"[Mesh] OR "Patient Care Team"[Mesh:NoExp]) AND ("Primary Health Care"[Mesh]) AND ("Outcome and Process Assessment, Health Care"[Mesh]); and 2) Embase, PsycINFO and CINAHL: " intersectoral collaboration", " cooperative behaviour", " patient care team" AND " primary health care" AND " outcome and process assessment, health care". First, the titles were reviewed, and then the abstracts and full texts of the selected articles were reviewed independently by two reviewers with the Abstrackr tool [ 17]. Any disagreements were resolved by consensus; MJ, MA, and JFH resolved any remaining disagreements.

After reading the full texts, we included the following studies in this analysis:

studies reporting on IPC

studies conducted in the primary care setting, involving primary care providers exclusively

studies involving at least 2 different primary care providers, regardless of the type and level of collaboration (from a simple phone call to a multidisciplinary medical appointment).

The exclusion criteria were as follows:

interventions involving multidisciplinary teams working between primary and secondary care

the absence of a primary endpoint centred on patient health (studies focusing on economic outcomes, manuscripts reporting practices for declarative data only)

the absence of a comparative design with a control group and statistical analysis (studies based on a before-after design involving the follow-up of only one cohort of patients were excluded)

abstracts not respecting the IMRAD structure

manuscripts not accessible in English.

One reviewer (MA) independently extracted data using a prepiloted form and was supervised by a second reviewer (CB), and the following data were collected: study country, pathology(ies) studied, intervention, the number of patients included, design, study duration, main outcome measures, and patient outcomes (selected on the basis of frequency of reporting and clinical relevance). For consistency and clarify of presentation, the results centred on patient outcomes are grouped within 3 categories in the remainder of the manuscript: 1- patients at cardiovascular risk, 2-polypathological and elderly patients, and 3- patients with mental health problems, chronic pain and unexplained complaints.

The quality of the studies was then assessed using the revised Downs and Black Checklist [ 18]. The checklist includes 27 items on reporting (10 items), external validity (3 items), internal validity (13 items), and power (1 item). Similar to others studies, the power item was modified regarding whether a power analysis was described (0 = not reported, 1 = reported). The maximum possible score is 28 for randomized studies and 25 for nonrandomized studies. Quality was categorized by using the following Downs and Black score ranges: strong (21-28), moderate (14-20), limited (7-13), and poor (≤ 7) [ 19].

Results

Selection and general description of the studies

A large majority of the included studies were from North America (40) or Europe (13). The other studies were from Asia (5), Australia (2), and South America (1). Forty-three studies were prospective and randomized. Four studies were carried out over a period of more than 24 months [ 32, 34, 36, 64].

Depending on the studies, the number of patients included varied between 50 and 312,377: 5 studies included more than 5,000 patients, 37 studies included between 200 and 5,000 patients, and 19 studies included fewer than 200 patients.

Constitution of the teams (Table 1)

Pathologies

All the studies evaluating the effect of IPC on patients with chronic diseases: patients at cardiovascular risk (28 studies), elderly and/or polypathological patients (18 studies), or patients with mental health problems (12 studies). One study addressed chronic pain related to musculoskeletal disorders [ 78], and 2 other studies included patients with medically unexplained complaints [ 77, 82]. We chose to include these studies in the same paragraph and in the same table as patients with mental health difficulties. One study included in the polypathology group evaluated criteria for monitoring comorbidities (warfarin testing compliance, eye care compliance for diabetes, etc.) and cancer screening in the general population (mammograms and occult blood screenings) [ 67].

Effect on patient variables

Patients at cardiovascular risk (Tables 2 and 3)

The 28 studies addressing cardiovascular risk focused particularly on diabetes (18 studies), hypertension (5 studies), overall cardiovascular risk (4 studies), or dyslipidaemia (1 study). The most common primary endpoints were glycated haemoglobin levels (14 studies), blood pressure (14 studies) and LDL-c or total cholesterol levels (9 studies). Three studies had a real morbidity criterion (cardiovascular events) as the primary endpoint, and 3 other studies assessed the number of visits to the emergency department. Fifteen studies described IPC with pharmacists, and 15 described IPC with nurses.

Interventions around cardiovascular pathologies were mainly based on team-based patient education or doctor/pharmacist collaboration (medication review, blood pressure monitoring, frequent contact about treatment by phone, through the patient's file or concertation meetings).

Of the 28 studies focusing on cardiovascular risk, five reported no significant results for their main endpoints. Benedict's study [ 22] which included 1960 patients, showed effects on the secondary endpoints, particularly in the short term.

The Heisler [ 34] cluster randomized trial focused on physician/pharmacist collaboration. It included 4100 patients but failed to show positive effects on blood pressure at 6 months, and only short-term secondary results showed a 2.4 mmHg improvement in blood pressure related to the intervention. Both groups (control and intervention) showed improvement during the study. The nonrandomized study by Manns [ 38] including 150,000 diabetic patients was able to show the effectiveness of the management of diabetic patients in the primary care network, with a reduction in the number of hospital and emergency department visits. Secondary analyses also showed an improvement in ophthalmological follow-up and glycaemic control. Jiao [ 36, 37] also showed an improvement in HbA1c levels and in the occurrence of cardiovascular events (from 2.89% to 1.21%) for the group participating in a diabetes monitoring program. These 2 studies offered network support that included many diabetes professionals: podiatrists, nurses, and dietitians.

Among the 9 studies analysing an effect on cholesterol levels, 6 reported positive results while 3 concluded that there was no effect [ 21, 41, 49].

Elderly and/or polypathological patients (Tables 4 and 5)

The results of studies on the effect of IPC on the care of elderly or polypathological patients are inconsistent. Of the 18 studies included, 10 reported significant positive results, of which 8 were randomized controlled trials. Fifteen of these studies included doctors and nurses, after which pharmacists were the professionals most involved in care. The retrospective study by Riverin [ 64] associated nurses with doctors and was based on a population of 312,377 patients. The study did not demonstrate any improvement in the primary outcome measure: hospitalization 3 months after hospital discharge. It showed only a short-term decrease in the number of emergency room visits and deaths (fewer than 4 deaths per 1000 treated) in the group receiving the IPC intervention.

Eight studies did not show the effectiveness of their intervention on their primary outcome measure or variable. Eight randomized trials had documented effects. Three randomized trials [ 52, 55, 69] showed that the quality of care received by elderly patients was perceived as better when care was provided within the framework of a formalized collaboration among health professionals. The measurement tool in these 3 trials was the Patient Assessment of Chronic Illness Care (PACIC). The same type of result was observed in a study using the Quality of Care for Chronic Disease Management score [ 59].

With regard to functional abilities and patient symptoms, the randomized trial by Burns [ 57] showed beneficial effects of collaborative outpatient practices on patient variables relating to addiction (IADL, MMSE, maintenance of social activity) or mental health (CES-depression, general well-being, life satisfaction). The effect of IPC on hospital readmissions varied greatly among studies. Sommers et al. [ 66] reported a significant decrease in the number of admissions to the hospital or intensive care unit. Riverin et al. reported a decrease in the use of emergency rooms and a decrease in mortality (secondary outcome measure of the study) [ 64]. Conversely, some randomized trials concluded that there was no impact on their primary outcome measure [ 51, 53, 57, 60].

The only study focusing on cancer screening by mammograms and occult blood screenings in the general population showed better follow-up for patients followed by a health care team [ 67].

Patients with symptoms of mental or physical distress (Tables 6 and 7)

Among the 12 studies addressing mental health, the outcome measures sometimes included depression (10 studies), anxiety (1 study), or posttraumatic stress (1 study). Eleven studies were prospective and randomized, and 2 randomized trials included more than 1200 patients [ 72, 83]. Only one study did not show a significant result on the primary outcome measure [ 83], which was the clinical depression score at 2 years.

A positive effect of the IPC intervention on patients with psychological disorders was reported in 10 studies, at least in the short term (6 months). There were no significantly positive results for 2 studies [ 83, 84], including that of Sherbourne, which was the only study to assess depression at 2 years. Chan's study [ 73] showed an improvement in the HAD score at 6 months in the intervention group, but this effect was no longer statistically significant at 12 months.

Arean et al., Engel et al. and Aragonès et al. reported an improvement in the SCL-20 score [ 71, 72, 74]. Four articles reported the effect of collaboration on medication compliance in depressed patients [ 70, 72, 75, 76], while Petersen concluded that there was no effect on compliance with these treatments [ 80].

Two studies were only interested in medically unexplained symptoms: that of Kolk [ 77] did not report a positive effect, and that of Shaefert [ 82] only reported an improvement in the "mental health" component of the quality of life score (SF-36) but no improvement in physical symptoms or care utilization at 12 months.

A study on musculoskeletal disorders showed that multiprofessional management involving general practitioners, occupational therapists, physiotherapists and rheumatologists significantly reduced the number of days off work: 63.8 days in the intervention group versus 92.8 days in the control group [ 78].

Assessment of study quality

The studies had an average quality score of 17 points (out of 28 points) using the revised Down's and Black Checklist [min = 9, max = 21]. Eight studies had a high-quality score, 41 had a moderate-quality score, 12 had a limited-quality score (between 9 to 14 points), and no studies had a poor-quality score (< 9).

Discussion

The studies that assessed the effect of IPC on patient outcomes could be grouped into 3 categories, depending on whether the patients 1) were at cardiovascular risk, 2) were elderly and/or had polypathology, or 3) had mental or physical disorders. One study also aimed to improve prevention care. Our review of the literature did not find any studies that evaluated the effect of IPC on patient outcomes in the following fields: orthopaedics and the musculoskeletal system, cancer care, paediatrics, current infectious diseases, and patient health monitoring. Only one study analysed cancer screening in addition to monitoring comorbidities. The positive effect of IPC on patient outcomes has been widely described in patients at vascular risk. Of 28 studies, only 5 reported no significant effect on their primary outcome measures. For the 2 other categories (elderly and/or polypathological patients, patients with physical or mental disorders), the reported effects varied from one study to another. Among 18 studies that assessed the effect of IPC on the outcomes of elderly or polypathological patients, only 10 studies reported positive effects on the primary outcome measure, and 11 out of 12 reported positive effects in the category of patients with mental disorders. In this last category, 10 studies focused on patients with depressive syndrome. The majority of studies reported clinical improvement in patients. The majority of the proposed interventions relied on 3 main health professionals: general practitioners, pharmacists and nurses. Other professions were less frequently included in the studies.

The clinical impact of the effects observed can also be questioned. For example, the study by Heisler [ 34], a large randomized study (4100 patients), showed a reduction of 2.4 mmHg in blood pressure thanks to the help of the pharmacist, which is clinically limited. With regard to depression, one can wonder about the benefit of a 3.6-point reduction in the Hamilton score for patients, even if the result is statistically significant [ 81].

As in other studies, we found that GPs, nurses and pharmacists were the most represented professionals in the IPC teams in the primary care setting [ 11, 85].

Several authors have shown that IPC would increases patient use and costs of care [ 86]. These indicators of the use and costs of the health care system are important from the perspective of the decision-maker, but they must be interpreted with caution. On the one hand, less use of to the health care system can testify to better individual health with lower morbidity (a reduction in the number of visits to the emergency room for example, or a reduction in the number of hospitalizations) [ 38, 66, 87]. On the other hand, these indicators can also attest to a positive effect with regard to issues of compliance and improvement of patient health: in many patients with chronic diseases monitored in primary care, the recommendations emphasize the prevention of serious events through the implementation of reinforced medical monitoring, resulting in an increase in the use of health care system by patients. Thus, the increase in the number of consultations with a health care professional may be appropriate during a period of antihypertensive treatment dosage adjustment to allow the achievement of the objectives [ 29].

Strengths and limitations

This literature review has several strengths. First, it is the first to identify in a transversal way in which fields the effect of IPC has been analysed and in which fields this effect has been demonstrated. In 2020, Pascucci carried out a literature review and a meta-analysis on the subject, but without restricting its research equation to the primary care setting and only focusing on patients with chronic pathologies [ 88]. It concluded that IPC would improve the 3 following cardiovascular outcomes: BP, HbA1c levels, and the number of days of hospitalization in patients undergoing the IPC intervention. Second, our systematic review was based on the PRISMA quality guidelines; the research was carried out in 4 databases. Third, we assume that the focus on studies conducted in a primary care setting, involving primary care providers exclusively, might be a strength, while previous authors focused on the collaborations between primary and secondary care professionals.

This review also has limitations. The formalization of the search equation leading to the selection of studies required tedious work since there is no published search filter to search for articles addressing IPCs. It might be the main limitation of this review. Future work should consist of a specific and sensitive search filter developed by researchers in the field.

It was not possible to perform a bias analysis with the iCROMs [ 89] tool because the designs of the studies were too disparate. The quality of the studies was therefore assessed using the revised Downs and Black Checklist [ 18].

Effective studies are probably overrepresented compared to ineffective studies due to publication bias [ 90]. Similarly, many studies presented significant results but were based on post hoc or subgroup analyses.

The low level of evidence of clinical efficacy may be linked to the low level of internal validity of these studies, which are mainly pragmatic clinical trials [ 91, 92]. These trials are complex and therefore give positive results with greater difficulty.

In our review, the analysis of the differences between the control group and the multiprofessional intervention groups may have been biased by the fact that the primary care teams studied set up collaborative actions based on different concepts, e.g., the use of information technology, the training of health professionals or the therapeutic education of patients. Therefore, it is sometimes impossible to differentiate for these interventions whether the demonstrated effect is linked to the action implemented by a tool or solely by the IPC.

The concrete typology and level of collaboration among professionals differs greatly from one team to another, and this aspect was not the focus of our research. We therefore chose to describe IPC from the perspective of the most common definition and real life practice [ 8] without detailing the interactions involved in collaboration or its level. The type and level of interaction within the IPC teams depends on local contexts, dependent on national support for primary care and IPC [ 8, 9]. Reviews have already confirmed that, in this context and in the absence of new work on the subject, it is difficult to find a consensual definition of the typology of IPC [ 9, 11].

Perspective

Primary care research within the framework of IPC must be able to invest in the field of primary prevention and screenings; currently, IPC is underrepresented in the fields of chronic diseases, cancers, vaccination, addictions, etc., as well as some fields mentioned above (locomotor, oncology) that have not benefited or in which little research with a high level of evidence exists. These areas have already been explored and described in the literature, but not with a comparative trial evaluation in the specific field of IPC in primary care. Our focus was quite narrow and doesn't give a wide picture of the IPC in primary care.

The interventions offered to patients are often well described in the articles, but the description of the type of professionals and their levels of collaboration is often limited. For example, a patient will be able to benefit from an exchange regarding his pathology and treatment with a pharmacist, who will make recommendations that will be discussed with the doctor, but exchanges between health professionals are insufficiently described in terms of the methods, duration, and frequencies of interactions [ 43].

Further work should focus on the intensity of IPC and the elements needed to achieve effective IPC. The following organizational elements are necessary: health policies structuring primary care and funding the time needed to work together, networks with local governance, secure and shared IT systems for working together on patient records, trainings for primary care teams to learn how to work together in confidence without losing sight of the patient's objectives [ 93].

Some studies, such as that of Benedict in 2018, showed an improvement in the primary outcome measure in the short term (3 or 6 months) without long-term maintenance [ 22]. As multiprofessional primary care teams have to deal with an increasing number of patients with chronic pathologies, it would therefore be logical to hope for a long-term effect of these interventions: studies with longer period of follow-up would be needed in this context.

Conclusion

Many studies have shown that IPC can improve the management of patients at cardiovascular risk. Other studies have investigated the effect of IPC in polypathological elderly patients and in patients with mental or physical disorders. For these pathologies, the number of studies remains limited, and the results are heterogeneous. Researchers should be encouraged to perform studies based on comparative designs: it would increase evidence on the positive effect and benefits of IPC on patient variables.

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

Adj:

Adjusted

C:

Control group

CI:

Confidence interval

DBP:

Diastolic Blood Pression

HSCL score:

Hopkins Symptom Checklist score

HADS:

Hospital Anxiety and Depression Scale

I:

Intervention Group

IPC:

Interprofessional Collaboration

LDL-c:

Low Density Lipoprotein cholesterol

OR:

Odds-Ratio

MPR:

Medication Possession Ratio

MSDs:

Musculoskeletal Disorders

NRd:

Not Randomized

NS:

Not Significant

P:

Prospective

PACIC:

Patient Assessment of Chronic Illness Care

PTSD:

Post traumatic stress disorder

R:

Retrospective

Rd:

Randomised

Rd C:

Randomised in Cluster

SBP:

Systolic Blood Pression

SCL:

Symptom Checklist-core depression

References

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Acknowledgements

We thank Solène Girard, Adam Mouhib, Antoine Nogueira, and Louise Rouxel for their help during the data collection. This article is supported by the French network of University Hospitals HUGO ('Hôpitaux Universitaires du Grand Ouest').

Funding

The study was funded by the French Ministry of Health. The research team members were independent from the Ministry. The funders had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; and the preparation, review, or approval of the manuscript.

Author information

Authors and Affiliations

1. Department of General Practice, Faculty of Medicine, University of Nantes, 1, Rue Gaston Veil, 44035, Nantes, France

Céline Bouton, Manon Journeaux, Maud Jourdain & Cédric Rat

2. Primary Care Federative Department, Faculty of Medicine, University of Nantes, Nantes, France

Céline Bouton, Maud Jourdain, Morgane Angibaud, Jean-François Huon & Cédric Rat

3. Faculty of Pharmacy, University of Nantes, Nantes, France

Jean-François Huon

Contributions

CB and CR were responsible for conducting the systematic review, including the interpretation of the results and the drafting of the full report of the systematic review. MJn, MA, JFH conducted the search and data extraction. MJx contributed to the data analysis and helped to draft the manuscript. All authors read and approved the final manuscript prior submission.

Corresponding author

Correspondence to Céline Bouton.

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The authors declare no competing interests.

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Supplementary Information

Assessment of studies quality.

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Bouton, C., Journeaux, M., Jourdain, M. et al. Interprofessional collaboration in primary care: what effect on patient health? A systematic literature review. BMC Prim. Care 24, 253 (2023). https://doi.org/10.1186/s12875-023-02189-0
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DOI: https://doi.org/10.1186/s12875-023-02189-0

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# data[].attributes.attachment_link.title
Interprofessional collaboration in primary care: what effect on patient health? A systematic literature review - BMC Primary Care

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Background In a period of change in the organization of primary care, Interprofessional Collaboration (IPC) is presented as one of the solutions to health issues. Although the number of inter-professional interventions grounded in primary care increases in all developed countries, evidence on the effects of these collaborations on patient-centred outcomes is patchy.

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Evidence Supporting Interprofessional Collaboration in Primary Care

Research highlights the substantial benefits of Interprofessional Collaboration (IPC) in primary care. In particular, it enhances patient safety, treatment outcomes, and patient-reported satisfaction. Furthermore, studies show that patients appreciate the expansion of the healthcare team when it leads to coordinated efforts across disciplines. Additional evidence suggests that IPC fosters a more holistic approach to care and contributes to greater professional satisfaction among practitioners.

It is evident that no single clinician possesses the full competence or knowledge to manage every condition presented in clinical practice. I find it essential to acknowledge this limitation and remain vigilant in identifying when the involvement of other professionals is necessary in a patient’s care journey.

Models Supporting Collaborative Practice

I find both Tuckman’s team development model and Elwyn et al.’s shared decision-making model (BMJ, 2012) to be excellent tools for fostering healthy and effective collaboration. While each can be applied independently, their combination is particularly powerful. Elwyn’s model stands out by introducing structured and accountable interactions between professionals, including scheduling and shared responsibilities. This contrasts with Tuckman’s model, which, although foundational in team dynamics, lacks a structured approach to ongoing collaboration. Moreover, shared decision-making facilitates documentation sharing, enhancing mutual learning among professionals.

Tuckman’s Team Development Model
(Tuckman, B. W., 1965)
Purpose: To understand and navigate the stages of health team development.

Forming: Establishing introductions and setting expectations

Storming: Managing conflict and clarifying roles

Norming: Developing shared frameworks and operational standards

Performing: Engaging in effective, synergistic collaboration

Shared Decision-Making and Care Pathway Mapping
(Elwyn et al., 2012, BMJ)
Purpose: To establish collaborative treatment strategies with the patient at the centre.

Key Elements:

Defining professional roles and responsibilities

Sharing documentation and ensuring follow-up

Clarifying communication pathways (e.g., secure IT systems, discharge summaries, and teleconferencing)

Scientific References Supporting IPC:

1. Systematic Review – BMC Primary Care (2023)
A review of 65 studies revealed:

82% of cardiovascular patient studies reported better clinical outcomes (e.g., blood pressure and glucose control).

92% of studies involving patients with mental or physical conditions demonstrated positive effects.

Mixed results were noted in elderly and multimorbid populations.
Source

2. Overview of Systematic Reviews – IJIC (2021)
An umbrella review of 34 systematic reviews concluded:

IPC enhances care delivery and patient satisfaction.

Impact on clinical outcomes and healthcare usage varies by implementation.
Source

3. Patient Experiences – BMC Primary Care (2022)
An integrative review of 48 studies (>3,800 patients) found:

Generally positive patient experiences, especially in chronic care.

Patients appreciated coordinated efforts and expanded care teams.
Source

4. Professional Benefits – Journal of Interprofessional Care (2015)

IPC reduces medication errors and improves outcomes.

It enhances job satisfaction among healthcare professionals.
Source

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

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

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The global incidence of infections and communicable diseases is increasing.
This rise is due to a combination of factors, including climate change, declining vaccination rates, and increased contact between humans and animals.

Global Trends in Communicable Diseases

Rising disease outbreaks: The number of infectious disease outbreaks has increased significantly since 1980. An analysis of more than 12,000 outbreaks from 1980 to 2013 showed that both the number of outbreaks and the variety of diseases have grown markedly. Although outbreaks are on the rise, data suggest that the incidence per capita is decreasing, which indicates that global improvements in prevention, early detection, control, and treatment are becoming more effective in reducing the number of infections.
Source: The Journalist’s Ressource: https://journalistsresource.org/economics/global-rise-human-infectious-disease-outbreaks

Impact of climate change: Climate change contributes to the spread of vector-borne diseases such as dengue and malaria into new areas, including parts of Europe. Warmer temperatures and altered precipitation patterns create favourable conditions for disease-carrying insects, increasing the risk of outbreaks in previously unaffected regions.
Sources: Financial Times, The Guardian: https://www.ft.com/content/599c87da-7920-4832-87de-98934cb5cbc4

Declining vaccination rates: One of the most concerning trends is the reduction in vaccination rates, which has led to the resurgence of previously controlled diseases such as measles. In 2025, a significant rise in measles cases has been reported in the USA and Canada, primarily due to falling vaccination coverage.
Source: The Times of India: https://timesofindia.indiatimes.com/life-style/health-fitness/health-news/not-just-covid-these-5-diseases-are-spreading-fast-globally-in-2025/articleshow/121193953.cms?utm_source=chatgpt.com

Zoonotic Diseases and Human Behaviour

Increased human–animal interaction: Human encroachment into wildlife habitats and intensive farming increases the risk of zoonotic diseases, where pathogens are transmitted from animals to humans. This has been a major factor in previous pandemics such as COVID-19 and continues to pose a global health threat.
Source: Financial Times: https://www.ft.com/content/a7148663-dd17-4334-b423-b92204ed56cd?utm_source=chatgpt.com

Antimicrobial resistance (AMR): AMR is a growing concern, with bacteria and other microorganisms becoming resistant to existing treatments. This makes infections harder to treat and raises the risk of spreading resistant strains.
Sources: CDC, The Guardian, World Health Organization: https://wwwnc.cdc.gov/eid/

Conclusion

The increasing global incidence of infections and communicable diseases is a complex issue that requires a multidisciplinary approach. Prevention, early detection, and control measures are essential to address this challenge. It is vital to strengthen vaccination programmes, monitor the impact of climate change on disease transmission, and reduce high-risk human behaviour that increases contact with potential zoonotic sources.

Professional Reflection (Acupuncture and Infection Control)

In my clinical practice, I provide acupuncture either as a standalone treatment or in combination with osteopathy. Our clientele consists primarily of individuals aged 40 and above, many of whom present with comorbidities and a health profile that renders them particularly vulnerable to infection. Therefore, in addition to maintaining high hygiene standards in the clinic, I must be vigilant regarding my own potential to pose a risk of infection to patients.

One challenge is the tendency to attend work while mildly unwell, in an effort not to disrupt the patient’s treatment progression. This seems contradictory when we advise patients to cancel appointments if they are ill. Consequently, I question whether we consistently follow the same sick leave standards that we expect from our patients.

Acupuncture requires heightened attention to hygiene due to the obvious tissue penetration involved. The key challenge lies in maintaining the same level of awareness toward potentially harmful factors that are less invasive—technically speaking—than acupuncture, yet equally capable of transmitting infection.

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Infection Control and Practitioner Well-being in a Busy Clinic Setting

The concentration of individuals in one place—up to more than 60 per day in our clinic—constitutes an infection risk in itself. In light of this, we are obliged to implement measures that mitigate the risk of transmission. We aim to achieve this by ensuring that patients spend as little time as possible in the waiting area to avoid crowding. Appointment schedules are arranged to reduce wait times, and clinicians escort patients in and out of the clinic to minimise unnecessary contact with others.

Treatment rooms are ventilated and disinfected after each session—whether individual or group-based. Multiple hand sanitiser stations and paper towel dispensers are available for patients using clinic equipment independently or participating in group sessions. Clinicians have access to changing facilities, separate bathrooms, and hand hygiene products. Additionally, gloves, masks, and face shields are available as protective equipment to prevent cross-infection between practitioner and patient.

Patients presenting with symptoms of fever, flu, or gastrointestinal illness are not to be seen. If there is any uncertainty, the patient is advised to cancel their appointment. Beyond hygiene, there are also psychological and physical conditions that can compromise the ability to deliver safe and responsible treatment.

Mental health conditions such as depression or anxiety may impair a clinician’s ability to maintain adequate focus on the patient and their situation. In such cases, the clinician may be unable to process patient data effectively or respond to patient needs cognitively or emotionally, potentially resulting in unintended incidents.

Similarly, physical impairments—such as fractures or sprains—can hinder the clinician’s ability to react swiftly in emergencies (e.g., supporting a fainting patient) or to execute manual techniques accurately and safely, increasing the risk of patient discomfort or harm.

In Denmark, provisions exist to arrange occupational accommodations with both employers and public authorities. These accommodations allow for a gradual return to work for those on long-term sick leave, enabling a progressive increase in working hours. This supports a balance between recovery and continued workforce participation.

Crucially, such arrangements ensure that patient safety and care quality are maintained while allowing clinicians the time and support they need to recover fully.

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Climate change increases chances of zoonotic disease ‘spillover’

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Habitat encroachment means more opportunities for animal-to-human infection

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

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

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Gender Bias in Health Research and Its Clinical Implications

There is increasing awareness that women's health is underrepresented in medical research, which may lead to disparities in diagnosis and treatment. While there has been progress towards more balanced gender representation in clinical trials, key gaps persist.

An analysis by the Danish Medicines Agency and the Danish Health Authority found that, overall, gender representation in clinical research is well-balanced. However, women remain underrepresented in specific areas, such as cardiovascular diseases and certain cancers. This may result in women receiving less effective treatment, as sex-specific physiological differences are often not adequately addressed in the research design (Lægemiddelstyrelsen, 2025).
Source: https://laegemiddelstyrelsen.dk/da/nyheder/2025/ny-analyse-generelt-god-balance-i-baade-kvinders-og-maends-repraesentation-i-klinisk-forskning

A report discussed in Dagens Medicin noted that although the findings are not dramatic, they are significant and highlight a need for more equity in representation:
Source: https://dagensmedicin.dk/rapport-undersoeger-koensrepraesentation-det-er-ikke-et-dramatisk-fund-men-det-er-et-ret-vigtigt-fund

Feminist scholars have criticised research design for being influenced by "neurosexism"—the tendency to exaggerate or misinterpret gender differences—leading to stereotypical assumptions and exclusion of women in trial designs and data analysis. A more inclusive research model that accounts for both biological and social differences is needed.
Source: kvinderogsundhed.dk

A 2019 study by Harvard Medical School found that women comprised only around 40% of participants in clinical trials related to cancer, cardiovascular disease, and psychiatric conditions—despite making up 51% of the general population (AAMC, 2020).
Source: https://www.aamc.org/news/why-we-know-so-little-about-women-s-health

In early-phase industry-sponsored clinical trials, women made up less than 30% of participants, often due to concerns about hormonal fluctuations and pregnancy.
Reference: Singh, K., & Swarup, R. (2025). Women are poorly represented in clinical trials. That’s problematic. Nature India. https://doi.org/10.1038/d44151-025-00036-y

Furthermore, when women are included, data are often not analysed separately by sex, potentially obscuring important differences in disease manifestation and treatment effectiveness.

Consequences of Underrepresentation:

Misdiagnosis and delayed treatment: Women often present with different symptoms than men—particularly in cardiovascular disease—and may be misdiagnosed or diagnosed too late.

Increased risk of side effects: Medication dosages are frequently based on male physiology, which can lead to more severe or frequent side effects in women.
Source: Adelaide Now – Article on Overmedication in Women

Insufficient treatment for female-specific conditions: Conditions such as endometriosis and menopause remain under-researched, resulting in limited clinical knowledge and fewer treatment options.

Health outcome inequality: The lack of female inclusion in trials contributes to broader gender-based disparities in health outcomes.

Clinical Perspective:

The national clinical guidelines we follow in my clinic do not take gender differences into account. This may appear negligent, especially when research from the U.S. has shown that cardiovascular conditions in women were often detected too late because screening models were based on male populations. This delay in diagnosis hindered timely intervention.
Reference:
Sun, T. Y., Walk IV, O. J., Chen, J. L., Nieva, H. R., & Elhadad, N. (2020). Exploring Gender Disparities in Time to Diagnosis. ArXiv. https://arxiv.org/abs/2011.06100

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Clinical Perspective:

In my clinical practice, the guidelines used for managing low back pain are not sex-specific. The assumption that all patients can be treated the same way can lead to suboptimal outcomes and inappropriate care for some individuals. For instance, research from the U.S. has shown that cardiovascular conditions in women were often detected too late because screening models were based on male populations. This delay in diagnosis hindered timely intervention.
Reference:
Sun, T. Y., Walk IV, O. J., Chen, J. L., Nieva, H. R., & Elhadad, N. (2020). Exploring Gender Disparities in Time to Diagnosis. ArXiv. https://arxiv.org/abs/2011.06100

Evidence and Gender-Based Differences in Pain Perception

In everyday clinical practice, it is essential to be aware that symptoms of the same disease may present differently in men and women. This awareness enables timely recognition of potentially dangerous comorbidities and competing conditions.

Biological Differences in Pain

Hormonal influences: Women’s experience of pain is significantly affected by hormonal fluctuations, particularly oestrogen and progesterone. These hormones can increase pain sensitivity and influence the body’s production of endogenous opioids such as endorphins.

Reference: LiveScience (2022). Oestrogen may spur the body to make opioids after injury. Available at: https://www.livescience.com/health/neuroscience/estrogen-may-spur-the-body-to-make-opioids-after-injury

Nociceptor activation: Research indicates that certain compounds activate pain receptors differently in men and women. For example, prolactin sensitises pain receptors in women, while orexin B has a similar effect in men.

Reference: Fysio.dk (2011). Hvorfor har kvinder flere smerter end mænd. Available at: https://www.fysio.dk/fysioterapeuten/arkiv/nr.-1-2011/Hvorfor-har-kvinder-flere-smerter-end-mand

Psychosocial Factors

Pain perception and reporting: Women tend to report higher pain intensity and have lower pain thresholds than men. This is influenced by both biological and societal norms, which may make it more socially acceptable for women to express pain.

Reference: International Association for the Study of Pain. Fact Sheet on Gender Differences in Pain. Available at: https://www.iasp-pain.org/resources/fact-sheets/156455

Bias and stereotyping: Women's pain is more likely to be dismissed or attributed to psychosomatic causes by healthcare professionals, often resulting in suboptimal treatment.

Reference: Fysio.dk (2011). Hvorfor har kvinder flere smerter end mænd

Clinical Implications

Under-treatment: Women are more frequently prescribed sedatives rather than analgesics compared to men, even when reporting similar levels of pain.

Delayed diagnosis: Women often experience longer diagnostic delays for several conditions, which can result in symptom worsening and chronic pain development.

Reference: Sun, T. Y., Walk IV, O. J., Chen, J. L., Nieva, H. R., & Elhadad, N. (2020). Exploring Gender Disparities in Time to Diagnosis. arXiv. Available at: https://arxiv.org/abs/2011.06100

Summary Table: Gender Differences in Pain

Aspect

Women

Pain threshold = Lower

Reported pain intensity = Higher

Prevalance of Chronic Pain = Higher

Common Treatment approach = Sedatives

Common Time to diagnosis = Longer

Men

Pain threshold = Higher

Reported pain intensity = Lower

Prevalance of Chronic Pain = Lower

Common Treatment approach = Analgesics

Common Time to diagnosis = Shorter

These differences underscore the importance of gender-specific considerations in pain research and management to ensure fair and effective treatment for all patients.

Reference: Mosca, L. et al. (1999). Guide to Preventive Cardiology for Women. Circulation, 99(18), 2480. https://doi.org/10.1161/01.cir.99.18.2480

Clinical Reflections

In my clinical practice, pain is the most common complaint among patients. Understanding sex-related differences in pain physiology is vital for tailoring treatment strategies appropriately. Even when patients present with similar symptoms, consideration must be given to the biological, physiological, and biopsychosocial differences between the sexes.

For instance, when managing back pain, I adapt my choice of techniques, treatment intensity and frequency, and even consider whether individual or group therapy is more appropriate. Broadly, I observe that women are more receptive to theoretical explanations and educational input, while men often prefer manual interventions and respond well to technical modalities such as TENS or acupuncture.

In group settings, women tend to value shared discussions and mutual support, whereas men often focus on "fixing" the problem and prefer physically intensive approaches.

Despite these trends, individualised treatment remains essential. Recognising gender-related differences aids not only in symptom interpretation but also in guiding clinical decision-making.

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Long term treatment in clinical practice

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Long term treatment in clinical practice

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My clinic collects statistical data both from our internal records and from public authorities regarding our clinical output, particularly in relation to the volume and composition of treatments delivered. The latter includes data categorised by diagnostic group and the types of interventions patients have received, mapped according to diagnosis. In addition, we maintain an overview of our patient demographics, including gender and age distribution, as well as the frequency of consultations per patient.

We also collect cost-related data from both public authorities and internal financial records, allowing us to evaluate treatment costs per patient. On the quality side, we independently assess patient-perceived treatment quality through anonymised patient surveys. The anonymised data is analysed with the aim of identifying areas for improvement and promoting learning among clinicians, particularly with regard to self-reflection on clinical practice.

Furthermore, patients were asked to evaluate practical aspects of the clinic such as parking availability, ease of contact, the facilities, and hygiene standards. Overall, patients expressed high satisfaction with the clinic's service, the physical environment, and the care they received. The majority of respondents indicated they would recommend the clinic to others, which we consider the strongest possible endorsement.

Additionally, the clinic participates in a collaborative quality improvement network, based on data-driven benchmarking. This includes the comparison of anonymised treatment data with that of other clinics to support collective learning and ongoing clinical development.

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EVALUATION OF YOUR VISIT TO ÅRSLEV PHYSIOTHERAPY

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It can be challenging to be confronted with patients’ opinions and attitudes—especially when you have not invited or expressed interest in hearing views that directly conflict with your own sense of what is right and wrong. Such situations can arise because the practitioner, by default, is welcoming, kind, and genuinely interested in the patient. This approach is intended to create a strong foundation for engagement and cooperation throughout the treatment process.

Unfortunately, some patients interpret this openness, empathy, and concern for their well-being as an invitation to involve the practitioner in their personal opinions and views about life or society. This is rarely ill-intentioned, but rather a reflection of the fact that the patient feels they are in a safe environment. A sense of safety is, in fact, desirable from a therapeutic standpoint, and it is therefore important that the practitioner fosters a safe space that supports dialogue related to the patient's presenting issue.

The challenge for the practitioner is to avoid being drawn into discussions that could disrupt this therapeutic environment and potentially jeopardize the course of treatment. Emotional or sensitive topics are often the ones that trigger confrontation or cause the practitioner to inadvertently become involved in a debate that leads nowhere constructive.

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Religion, Conscience, and Controversial Clinical Practices

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We are committed to deepening our understanding of the treatment of chronic low back pain. My colleagues and I are currently developing a diaphragm-inspired approach, based on the recognition that the evidence base for managing chronic low back pain remains relatively limited.

Our starting point is the existing literature, which indicates promising outcomes when diaphragm-focused breathing techniques are integrated into low back pain treatment. As a result, we have implemented both patient education initiatives and group-based sessions that incorporate breathing exercises. In addition, we offer manual treatment of the diaphragm and aim to integrate its function into both lumbar stabilisation and mobilisation strategies.

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Incorporating learning in clinical practice

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I have always been fascinated by the connections and underlying causes of the problems my patients present to me. I am particularly intrigued by situations where patients exhibit similar symptoms and behaviour, yet respond differently to treatment—despite an apparently “identical presentation” of their symptom profile.

This was also one of the reasons I chose to pursue training in osteopathy. I came to realise that, even with many years of clinical experience and a wide range of postgraduate education and courses, I am not always able to achieve the desired outcome in treatment.

Continuing Education & Courses:

Acupuncture

McKenzie Method – Lumbar Spine Therapy

Cervical and Thoracic Spine Manipulation

Advanced Assessment of the Lumbar Spine

Exercise on Prescription

Medical Exercise Therapy (MET)

Management of Chronic Pain

Specialist Training in Foot Injuries

Differential Diagnosis and Red Flags

The Motivational Back School

Multiple Sclerosis – Clinical Course

The Complex Back Patient – A Communicative and Cognitive Approach

Rehabilitation after Acquired Brain Injury

Analysis and Treatment of Shoulder Dysfunction

Medical Exercise Therapy (MET)

Post-Mastectomy Rehabilitation – Kirsten Tørsleff’s Method

https://journals.lww.com/ijsoncology/fulltext/2017/07000/how_to_study_effectively.10.aspx

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In regard to avoiding unpleasant and distructive confrontations with patients I have learned to adknowlede, that the patient as well as me are individuals with beliefs, thougths, cultrual backgrounds and behavioural indifferences, that not necessary match and in the worse case create disturbing confrontations if we try to enfoce our thoughts and ideas on one and the others. An inpartial conduction af a treatment does not ensure an appropriate assesment and treatment. In the worst case your focus will be disturbed and patient safty as well af treatment quality is in risk of getting geopardised. Jeg har derfor tillærte mig at adressere det forhold, som patienten henvender sig til mig med, fordi det er et naturlig udgangspunkt for at opbygge et forhold til patienten. Dette betyder ikke at jeg underligge mig patientens velbefindende, men indgyde patienten til at være med i dialogen ved at vise interesse og omtanke for det problem patienten søger hjælp til. På den måde blive min rolle som professionel behandler manifesteret

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I have found particular value in using clinically relevant screening tools prior to the first consultation or during initial patient contact. These tools provide important information regarding the patient’s clinical status and often serve as a natural foundation for initiating the therapeutic process. https://pmc.ncbi.nlm.nih.gov/articles/PMC4089835/ I have observed that patients perceive these questionnaires as a sign of genuine interest in their condition, and the ensuing dialogue about their responses can be used as a form of patient education.

Such conversations frequently allow for the exploration of patients’ beliefs and expectations regarding treatment and prognosis—especially when addressing misconceptions or treatment-related myths. Commonly used patient questionnaires in my clinical practice include:

STarT Back Screening Tool – for identifying the risk of chronicity in patients with low back pain.
https://startback.hfac.keele.ac.uk

SF-36 Health Survey and EQ-5D (EuroQol-5 Dimension) – for assessing general health and quality of life.

SF-36: https://www.rand.org/health-care/surveys_tools/mos/36-item-short-form.html

EQ-5D: https://euroqol.org/eq-5d-instruments/

PROMs such as the:

Roland-Morris Disability Questionnaire (RMDQ): https://www.rmdq.org

Oswestry Disability Index (ODI): https://www.physio-pedia.com/Oswestry_Disability_Index

Functional Rating Index (FRI) or other condition-specific functional status forms.

These tools assist not only in clinical assessment but also in building patient rapport, tailoring communication, and supporting shared decision-making processes.

Over the years, I have learned to be attentive to encouraging patient reflection. More specifically, this involves not only gaining insight into the patient's overall well-being from session to session, but also actively inquiring about their experiences with specific techniques, exercises, and daily life challenges.

These reflections often take place during treatment sessions—for example, I may ask the patient whether a particular technique feels appropriate, helpful, or comfortable for them. I also learn from unexpected patient reactions, such as discomfort during techniques like IVM or BLT, which can provide valuable clinical insight. A dynamic and open dialogue with the patient contributes to a deeper understanding of their reactions and perceptions—both of the treatment itself and of the underlying rationale for receiving it. The patient’s beliefs and myths, particularly in relation to conditions such as low back pain, influence how treatment is structured and delivered. Ultimately, my ability to understand the patient is essential for fostering a strong therapeutic relationship, which in turn has a significant impact on the outcome of the treatment.

The systematic review by Morton, de Bruin et al. (2018), https://pmc.ncbi.nlm.nih.gov/articles/PMC6492285/, found that beliefs about the negative consequences of back pain are widespread across countries and populations. In contrast, fear-avoidance beliefs are less commonly held among most groups.

Importantly, belief in the negative consequences of back pain is associated with higher levels of pain intensity and diminished functional capacity. These beliefs are particularly prevalent among older individuals and those with poorer self-rated health.

However, the review also highlights a notable gap in the literature: few studies have explored how such beliefs influence long-term pain management behaviours and outcomes.

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Patient-Reported Outcomes (PROs) and Patient-Reported Outcome Measures (PROMs)

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In recent years, there has been an increased focus on placing patients at the center of health care research and evaluating clinical care in order to improve their experience and ensure that research is both robust and of maximum value for the use…

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Prophylactic Measures

Patient management includes preventive efforts aimed at avoiding relapse, as well as measures to anticipate and address potential recurrences.

Health Promotion

The patient is actively considered within the broader context of health promotion.

Patient Education

Patient education is a crucial part of treatment, enabling the patient to understand their condition and the underlying causes of the complaint for which they are seeking care. In a clinical setting, it is important to assess the patient’s level of knowledge regarding their condition, including their understanding of potential causes and contributing factors.

In addition, patients often hold their own beliefs, assumptions, and myths about their symptoms. It is important that the practitioner is aware of these perspectives in order to engage the patient in the appropriate context. This requires curiosity, openness, and reflective dialogue from the clinician. This can pose a pedagogical challenge for the practitioner.

Creating an environment where the patient feels heard and understood—through the practitioner’s empathy and responsiveness—can promote mutual learning and enhance the patient’s receptiveness to educational input.

Patient Information

Providing patients with information serves as a foundation for the clinical process by helping them feel secure and guided through their course of care. Information about what the process involves—including examinations and treatment planning—gives patients a well-informed basis for giving consent to treatment and participation in the course of care.

It is essential that the practitioner ensures the patient has truly understood the information. This is achieved by cross-checking the patient’s responses and confirmations. In some cases, patients may consent to an intervention without fully understanding what they have agreed to. The practitioner must therefore be attentive to the patient’s behavior and reactions during treatment, and must clearly explain what will happen, how it will be carried out, and the purpose of the intervention.

This applies both to individual components of treatment and to the overall structuring and conclusion of a treatment session. The latter is important for establishing a baseline for the next session or concluding the course of care.

An informed patient will understand—and have consented to—what the treatment involves, how the process is structured in relation to that, what the prognosis is, and what the goals of the intervention are, including how progress will be monitored to ensure alignment with agreed outcomes.

This information can serve as a form of contract between practitioner and patient, supporting active patient participation and fostering a therapeutic partnership. In this way, the patient becomes a co-owner of the process.

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The challenge of working with preventive measures, health promotion, and patient well-being lies in identifying the patient’s own resources and motivating them to activate these resources in pursuit of a healthier and more fulfilling life—based on their own goals and values. In this context, I have found that empathy plays a vital role, along with meeting the patient at eye level to establish an equal and respectful relationship.

Such a relationship creates the foundation for open dialogue and mutual commitment toward achieving shared objectives. Gail Sowden from the University of Leeds has contributed to a deeper understanding of the value of truly understanding one's patients.

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Executive Order on the Authorisation of Osteopaths, Executive Order No. 981 of 28/06/2018, sets out the regulations for practicing as an osteopath in Denmark. In addition to holding at least a Bachelor's degree in osteopathy obtained abroad and providing a clean criminal record, the education must meet specific requirements regarding the distribution of ECTS credits across both academic content and patient safety-related competencies.

For osteopaths educated outside the EU/EEA, recognition is generally based on Executive Order No. 478 of 10/05/2013 on the authorisation of certain healthcare professionals who are citizens of and/or trained in countries outside the EU/EEA.

Application must be submitted to the Danish Patient Safety Authority (Styrelsen for Patientsikkerhed) together with the following documentation:

Proof of completed education in osteopathy (diploma and curriculum)

CV outlining relevant professional experience

Copy of any other relevant health professional authorisations (e.g. physiotherapist, chiropractor)

Certificate of good standing from the health authorities in the country of education

Criminal record certificate

Proof of language proficiency (typically Danish at B2 level if the education was completed abroad)

Reference:

https://stps.dk/sundhedsfaglig/autorisation/soeg-autorisation/osteopat

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BEK nr 981 af 28/06/2018, Indenrigs- og Sundhedsministeriet

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Retsinformation.dk er indgangen til det fælles statslige retsinformationssystem, der giver adgang til alle gældende love, bekendtgørelser og cirkulærer m.v. Der er også adgang til Folketingets dokumenter og beretninger fra Folketingets Ombudsmand.

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Rights and Obligations upon Authorization

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Duty of Action for Healthcare Professionals in Denmark

As a healthcare professional, you have an active duty to take appropriate action if your health or personal circumstances pose a potential risk to patient safety, professional competence, or public trust. Doubt should always lead to reflection and ideally consultation—not to inaction.

In Denmark, healthcare professionals—including doctors, osteopaths, physiotherapists, and others—have both a legal and ethical responsibility to act if their ability to deliver safe and competent patient care is compromised. This applies in cases of health-related issues as well as legal proceedings, criminal convictions, or any event that may raise concerns about professional suitability.

1. In Cases of Health-Related Limitations

Duty of Self-Evaluation and Action

According to the Health Act and most professional authorisation laws (e.g., for physiotherapists and physicians), healthcare professionals are obligated to:

Refrain from working if their condition poses a risk to patient safety

Seek relevant medical treatment and support

Consider informing their employer, supervisory authority (e.g., the Danish Patient Safety Authority), or clinical partners, if deemed necessary

National Health Authority Guidance:

“Healthcare professionals must not continue working under conditions where illness or functional impairment makes them unfit to provide safe and appropriate patient care.”
(Source: Danish Health Authority – Guidance on Duties and Responsibilities)

Relevant legislation: Authorisation Act (Autorisationsloven)

2. In Cases of Legal Proceedings or Criminal Conviction

Duty to Notify the Danish Patient Safety Authority (STPS)

You are required to report to STPS if:

You are convicted of an offence that may affect your trustworthiness, ethics, or professional suitability (e.g., violence, fraud, sexual offences, gross negligence)

Your professional judgment is likely to be compromised due to ongoing legal proceedings—even without a conviction

STPS will assess whether further actions are needed, such as:

Supervision

Temporary suspension

Restriction of professional activities

Revocation of authorisation (in severe cases)

Legislative source: Authorisation Act – danskelove.dk

Examples of Appropriate Actions

Situation

Recommended Action

You suffer from a physical or mental illness that affects clinical judgment

Step back temporarily, seek treatment, and notify your employer if appropriate

You are under criminal charge or conviction for an issue affecting patient safety or ethics

Notify the Danish Patient Safety Authority

You are unsure whether you can still deliver safe and competent care

Consult a peer, professional association, or STPS

Guidance and Support

Professional associations (e.g., Danish Physiotherapists, medical unions) offer legal advice and counselling

STPS provides guidance in cases of fitness to practise and disciplinary matters
Read more at stps.dk

Work environment support and psychological counselling may be relevant, especially in cases involving stress or burnout
Mental Health for Healthcare Professionals – patientsikkerhed.dk

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Reflections on Infant Treatment and Professional Development

The osteopathic training has greatly inspired me to work with infants. Until now, I have refrained from doing so in my clinical practice, as I have not felt competent in handling children who cannot communicate verbally. In short, I worry about unintentionally causing harm due to an inability to detect signs of overload or distress during treatment. Mr. Kok Weng Lim was an extraordinary example of how treatment can be delivered without words, relying instead on brief communication with the parents. It was remarkable to observe how Mr. Lim created calm around the infant, allowing him to manage and treat with precision. His mastery of non-verbal communication, and the harmony between him and the infant, formed a compelling unity.

My impression of Mr. Lim's approach was that he led not by assertiveness, but with distance and curiosity, asking insightful questions about the child’s daily behaviour and wellbeing, and observing with careful, non-invasive attention. Palpation was gentle and unhurried, and the treatment followed naturally from the findings. At the end of the session, the infant appeared peacefully tired in a healthy and balanced way. The only thing I missed was feedback from the parents on how the infant fared after the session.

As uplifting as it was to witness Mr. Lim in action, it was equally humbling to realise how much I still need to learn to treat infants with such professionalism and safety. I left the seminar with a sense of awe, questioning whether I could ever develop the same level of expertise.

Scientific Perspective on Communication with Infants and Families

Research highlights several essential findings for effective communication between healthcare professionals, infants/young children, and their caregivers:

1. NICE Guideline 204 – "Communication by Healthcare Staff" (2021)
This comprehensive UK guideline from the National Institute for Health and Care Excellence (NICE) outlines how healthcare staff should interact with infants, children, and young people, including their parents or guardians. Recommendations include:

Using the child’s name and creating a personal connection

Adapting communication to the child’s developmental level

Active listening and acknowledging the child’s emotions

Using visual aids and playful methods to aid understanding

Involving parents as partners in the process These approaches aim to establish a safe and supportive environment that fosters the child’s wellbeing and cooperation during treatment.

2. "Paediatric Patient Perceptions of Healthcare Professionals" (2024)
This study explored perspectives from children aged 3–18, identifying what they value in communication with healthcare staff. Children preferred:

Friendly and patient professionals who show genuine interest

Clear and age-appropriate information

Being involved in discussions and decisions

The use of play and visual tools to explain complex topics The findings emphasise tailoring communication to the child's developmental needs to enhance their healthcare experience.

3. "Communication Between Mothers and Health Workers in Neonatal Units" (2019)
A qualitative South African study highlighted how effective communication with mothers of newborns enhances neonatal care quality. Key findings include:

Good communication builds trust and maternal engagement

Poor communication leads to misunderstandings and lower care quality

Involving mothers in decision-making improves infant health outcomes Training healthcare professionals in communication techniques that promote parental collaboration and understanding is recommended.

Practical Recommendations for Health Professionals:

Early engagement: Initiate communication with both the child and parents early to build trust

Age-appropriate communication: Adapt language and explanations to suit the child’s developmental level

Use of playful and visual methods: Incorporate images, toys or roleplay to explain procedures

Parental involvement: Treat parents as partners and involve them actively in decision-making

Empathic listening: Pay attention to the concerns of both child and parent and respond with understanding

References:

https://pubmed.ncbi.nlm.nih.gov/39663230/

https://healthmanagement.org/c/hospital/Health/nice-published-positive-experience-guidelines-for-baby-child-and-adolescent-healthcare

Wreesmann, W. W., Lorié, E. S., Van Veenendaal, N. R., Van Kempen, A. A., Ket, J. C., & Labrie, N. H. (2021). The functions of adequate communication in the neonatal care unit: A systematic review and meta-synthesis of qualitative research. Patient Education and Counseling, 104(7), 1505-1517. https://doi.org/10.1016/j.pec.2020.11.029

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Clinical Intention and Next Steps

Inspired by Mr. Lim’s teaching, I have become acutely aware of the importance of non-invasive care and the need to avoid forcing hypotheses during treatment. Instead, I strive to approach each child with openness and curiosity. While I have not yet treated infants in my clinic, I have applied this mindful approach when treating older children and adolescents.

In addition to Mr. Lim’s teachings, the NICE guidelines have also been valuable, even though I have yet to begin my osteopathic work with infants. Moving forward, my intention is to become more confident and competent in this field. My clinical framework will be based on the following principles:

1. A holistic view of the child:

Assess the child as a whole, including birth history, nutrition, sleep, breathing, and motor development

Observe the interaction between cranium, spine, pelvis, connective tissue, nervous system, and organ function

2. Gentle manual techniques:

Use non-manipulative and non-invasive techniques suited to the infant's delicate tissue

Develop skills in craniosacral and functional techniques (e.g., indirect techniques) to support intrinsic motion and release restrictions

3. Focus on birth trauma and biomechanics:

Learn techniques for infants born via C-section, assisted delivery (forceps/vacuum), or traumatic labour

Apply cranial and cervical techniques targeting, for example, the vagus nerve to support digestion, sleep, and crying

4. Common infant conditions to address:

Colic and digestive issues

Asymmetry (e.g., head flattening, preference for one side)

Sleep disturbances

Excessive crying

Breastfeeding difficulties due to jaw, neck, or tongue restrictions

Motor restlessness or developmental delay

5. Collaboration and safety:

Collaborate with health visitors, midwives, physicians, and physiotherapists

All treatment will be based on the infant's response and only proceed in the absence of contraindications

Scientific Evidence While the evidence base for osteopathic treatment of infants is limited, it is growing:

Hayden et al. (2019) found osteopathy may reduce colic symptoms in some cases, though evidence remains weak

Posadzki et al. (2010) highlighted the need for larger, controlled trials

Guillaud et al. (2016) conducted a systematic review suggesting osteopathy shows promise for functional disorders, though study quality varies: https://doi.org/10.1186/s12887-016-0670-4

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Reflections:

·      Avoid having prejudices to e.g. obesity and be open minded when discussing issues concerning health and well-being.

·      Keeping adequate attention and making notes of key information.

·      Make sure to keep your questioning open

·      Challenge your hypothesis through patient reaction and treatment outcome

·      Understand connectivity between structure and function

·      Patients are motivated as long as they feel you listen to them, understand them and their issues.

·      Assessments can be preferred from treatment if necessary and as long as the patient can see the point of it and believes the aim of assessing is constructive.

·      IVM can benefit from being introduced through demonstration/ patient experiencing it  prior an oral explanation.

References:

•​​(Still, n.d.)​

•Sports:​(EVIDENCE-INFORMED PRIMARY CARE MANAGEMENT OF LOW BACK PAIN Clinical Practice Guideline |, 2015; Geneen et al., 2017; Hackney & Walz, 2013; Raya-González et al., 2020)​​(Raya-González et al., 2020)​​(Tori Stone, 2021)​

•​​(Effects of the Central Tendon Osteopathic Treatment on the Cardiorespiratory Function in Healthy Subjects · Osteopathic Research Web · Osteopathic Research Web, n.d.; Geneen et al., 2017)​

•Digestive/ Endokrine:

•​​(Hackney & Walz, 2013; Tennant, 2013)​​(Itriyeva, 2022)​

•Menstrual-Related Headache:

•​​(Dysmenorrhea: Menstrual Cramps, Causes & Treatments, n.d.; Itriyeva, 2022; Moy & Gupta, 2022; Wallner et al., 2006)​

•Neurological​(Basbaum et al., 2009; Fitzcharles et al., 2021; Lorimer Mosely, n.d.; Tennant, 2013; Wallner et al., 2006)​:

•

•​​Basbaum, A. I., Bautista, D. M., Scherrer, G., & Julius, D. (2009). Cellular and Molecular Mechanisms of Pain. Cell, 139(2), 267. https://doi.org/10.1016/J.CELL.2009.09.028

•​Dysmenorrhea: Menstrual Cramps, Causes & Treatments. (n.d.). Retrieved August 6, 2024, from https://my.clevelandclinic.org/health/diseases/4148-dysmenorrhea

•​Effects of the central tendon osteopathic treatment on the cardiorespiratory function in healthy subjects · Osteopathic Research Web · Osteopathic Research Web. (n.d.). Retrieved July 31, 2024, from https://www.osteopathic-research.com/s/orw/item/2390

•​EVIDENCE-INFORMED PRIMARY CARE MANAGEMENT OF LOW BACK PAIN Clinical Practice Guideline |. (2015).

•​Fitzcharles, M.-A., Cohen, S. P., Clauw, D. J., Littlejohn, G., Usui, C., & Häuser, W. (2021). Nociplastic pain: towards an understanding of prevalent pain conditions. The Lancet, 397(10289), 2098–2110. https://doi.org/10.1016/S0140-6736(21)00392-5

•​Geneen, L. J., Moore, R. A., Clarke, C., Martin, D., Colvin, L. A., & Smith, B. H. (2017). Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. In L. J. Geneen (Ed.), Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd. https://doi.org/10.1002/14651858.CD011279.pub2

•​Hackney, A. C., & Walz, E. A. (2013). Hormonal adaptation and the stress of exercise training: the role of glucocorticoids. Trends in Sport Sciences, 20(4), 165–171.

•​Itriyeva, K. (2022). The effects of obesity on the menstrual cycle. Current Problems in Pediatric and Adolescent Health Care, 52(8), 101241. https://doi.org/10.1016/j.cppeds.2022.101241

•​Lorimer Mosely. (n.d.). Explain Pain, second edition.

•​Moy, G., & Gupta, V. (2022). Menstrual-Related Headache. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK557451/

•​Raya-González, J., Clemente, F. M., Beato, M., & Castillo, D. (2020). Injury Profile of Male and Female Senior and Youth Handball Players: A Systematic Review. International Journal of Environmental Research and Public Health, 17(11), 3925. https://doi.org/10.3390/ijerph17113925

•​Still, A. T. (n.d.). PHILOSOPHY OF OSTEOPATHY. http://www.osteopathie-france.net/Information/livresapprof_philo.htm

•​Tennant, F. (2013). The Physiologic Effects of Pain on the Endocrine System. Pain and Therapy, 2(2), 75. https://doi.org/10.1007/S40122-013-0015-X

•​Tori Stone, P. L. D. P. M. and N. S. S. PhD. (2021). Exercise Treatment of Obesity. National Libary of Medicine.

•​Wallner, C., Maas, C. P., Dabhoiwala, N. F., Lamers, W. H., & DeRuiter, M. C. (2006). Innervation of the pelvic floor muscles: A reappraisal for the levator ani nerve. Obstetrics and Gynecology, 108(3), 529–534. https://doi.org/10.1097/01.AOG.0000228510.08019.77

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·      Gain more expertise in retrieving bio-psychological aspects from the patient

·      Avoid autonomy in your clinical performance by evaluating journals and be critical in not approaching patients in the same way even though they express same symptoms and beliefs to their problem

·      Enhance working with structure in praxis

·      Take time in sessions to make immediate reflection from the treatment.

·      Enhance patients to give feedback on experience from former treatment to reap information that could be beneficial for the treatment and avoid  composing assessments and treatments the patient hasn’t found favourable.

References:

•​​(Still, n.d.)​

•Sports:​(EVIDENCE-INFORMED PRIMARY CARE MANAGEMENT OF LOW BACK PAIN Clinical Practice Guideline |, 2015; Geneen et al., 2017; Hackney & Walz, 2013; Raya-González et al., 2020)​​(Raya-González et al., 2020)​​(Tori Stone, 2021)​

•​​(Effects of the Central Tendon Osteopathic Treatment on the Cardiorespiratory Function in Healthy Subjects · Osteopathic Research Web · Osteopathic Research Web, n.d.; Geneen et al., 2017)​

•Digestive/ Endokrine:

•​​(Hackney & Walz, 2013; Tennant, 2013)​​(Itriyeva, 2022)​

•Menstrual-Related Headache:

•​​(Dysmenorrhea: Menstrual Cramps, Causes & Treatments, n.d.; Itriyeva, 2022; Moy & Gupta, 2022; Wallner et al., 2006)​

•Neurological​(Basbaum et al., 2009; Fitzcharles et al., 2021; Lorimer Mosely, n.d.; Tennant, 2013; Wallner et al., 2006)​:

•

•​​Basbaum, A. I., Bautista, D. M., Scherrer, G., & Julius, D. (2009). Cellular and Molecular Mechanisms of Pain. Cell, 139(2), 267. https://doi.org/10.1016/J.CELL.2009.09.028

•​Dysmenorrhea: Menstrual Cramps, Causes & Treatments. (n.d.). Retrieved August 6, 2024, from https://my.clevelandclinic.org/health/diseases/4148-dysmenorrhea

•​Effects of the central tendon osteopathic treatment on the cardiorespiratory function in healthy subjects · Osteopathic Research Web · Osteopathic Research Web. (n.d.). Retrieved July 31, 2024, from https://www.osteopathic-research.com/s/orw/item/2390

•​EVIDENCE-INFORMED PRIMARY CARE MANAGEMENT OF LOW BACK PAIN Clinical Practice Guideline |. (2015).

•​Fitzcharles, M.-A., Cohen, S. P., Clauw, D. J., Littlejohn, G., Usui, C., & Häuser, W. (2021). Nociplastic pain: towards an understanding of prevalent pain conditions. The Lancet, 397(10289), 2098–2110. https://doi.org/10.1016/S0140-6736(21)00392-5

•​Geneen, L. J., Moore, R. A., Clarke, C., Martin, D., Colvin, L. A., & Smith, B. H. (2017). Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. In L. J. Geneen (Ed.), Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd. https://doi.org/10.1002/14651858.CD011279.pub2

•​Hackney, A. C., & Walz, E. A. (2013). Hormonal adaptation and the stress of exercise training: the role of glucocorticoids. Trends in Sport Sciences, 20(4), 165–171.

•​Itriyeva, K. (2022). The effects of obesity on the menstrual cycle. Current Problems in Pediatric and Adolescent Health Care, 52(8), 101241. https://doi.org/10.1016/j.cppeds.2022.101241

•​Lorimer Mosely. (n.d.). Explain Pain, second edition.

•​Moy, G., & Gupta, V. (2022). Menstrual-Related Headache. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK557451/

•​Raya-González, J., Clemente, F. M., Beato, M., & Castillo, D. (2020). Injury Profile of Male and Female Senior and Youth Handball Players: A Systematic Review. International Journal of Environmental Research and Public Health, 17(11), 3925. https://doi.org/10.3390/ijerph17113925

•​Still, A. T. (n.d.). PHILOSOPHY OF OSTEOPATHY. http://www.osteopathie-france.net/Information/livresapprof_philo.htm

•​Tennant, F. (2013). The Physiologic Effects of Pain on the Endocrine System. Pain and Therapy, 2(2), 75. https://doi.org/10.1007/S40122-013-0015-X

•​Tori Stone, P. L. D. P. M. and N. S. S. PhD. (2021). Exercise Treatment of Obesity. National Libary of Medicine.

•​Wallner, C., Maas, C. P., Dabhoiwala, N. F., Lamers, W. H., & DeRuiter, M. C. (2006). Innervation of the pelvic floor muscles: A reappraisal for the levator ani nerve. Obstetrics and Gynecology, 108(3), 529–534. https://doi.org/10.1097/01.AOG.0000228510.08019.77

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When I began working as a clinician, I believed chronic low back pain (CLBP) was something that could be treated in all cases. Over the years, I observed a pattern: no matter how intensively we treated the spine, a large portion of patients with low back pain would experience spontaneous relapses. I also noticed that patients presenting with nearly identical symptoms could react very differently to the same treatment. Patient A might respond positively, while Patient B experienced no benefit—or even worsening—despite being of the same age, gender, job situation, and activity level. Literature supports this: a significant share of patients experience relapses regardless of treatment .(Back Pain Medication: What Medicines Help Lower Back Pain?, n.d.; Fatoye et al., 2023; Menezes Costa et al., 2012)

In Denmark, this observation is recognised by acknowledging recurrent low back pain as a potentially chronic condition. Long-term use of medical, manual, or surgical interventions is discouraged, as there is no conclusive evidence that any one treatment approach is superior for managing CLBP. Imaging diagnostics are no longer routine but are instead reserved for cases where surgery is being considered or where red flags suggest conditions like fractures, malignancy, or rheumatological disease. The WHO supports this approach.(Who Guidelines on Chronic Low Back Pain, n.d.)

My osteopathic training has opened my eyes to the complexity of low back pain and its relationship to bodily function, psychosocial context, and patient behaviour. My education and clinical experience have primarily focused on musculoskeletal, neurological, and psychosomatic perspectives. I have also explored acupuncture, particularly the meridian concept, which to the uninitiated may resemble Integrated Visceral Manipulation (IVM) in osteopathy. I never fully connected with the meridian concept, even though it closely mirrors major nerve pathways. In contrast, osteopathy has offered a much more grounded and structured understanding of bodily interconnections.

This shift in perspective made me realise that my earlier approach to treating spinal and musculoskeletal conditions was too simplistic. I became increasingly intrigued by the interaction between bodily systems and how that influences CLBP. This led to my decision to write a dissertation exploring whether breathing techniques could be an effective addition to the treatment of patients with chronic low back pain.

Back Pain Medication: What Medicines Help Lower Back Pain? (n.d.). Retrieved June 3, 2024, from https://www.webmd.com/back-pain/what-medicines-help-with-low-back-pain

Fatoye, F., Gebrye, T., Mbada, C. E., & Useh, U. (2023). Clinical and economic burden of low back pain in low-and middle-income countries: a systematic review. BMJ Open, 13, 64119. https://doi.org/10.1136/bmjopen-2022-064119

Kolář, P., Šulc, J., Kynčl, M., Šanda, J., Čakrt, O., Andel, R., Kumagai, K., & Kobesová, A. (2012). Postural function of the diaphragm in persons with and without chronic low back pain. The Journal of Orthopaedic and Sports Physical Therapy, 42(4), 352–362. https://doi.org/10.2519/JOSPT.2012.3830

Menezes Costa, L. D. C., Maher, C. G., Hancock, M. J., McAuley, J. H., Herbert, R. D., & Costa, L. O. P. (2012). The prognosis of acute and persistent low-back pain: A meta-analysis. CMAJ. Canadian Medical Association Journal, 184(11). https://doi.org/10.1503/CMAJ.111271

Who guidelines on Chronic Low Back Pain. (n.d.). Https://Www.Who.Int/News/Item/07-12-2023-Who-Releases-Guidelines-on-Chronic-Low-Back-Pain.

Wideman, J., & Winchester, B. (2013). Literature Review: Core Stabilization From The Inside Out: The Role Of The Diaphragm And Intra-Abdominal Pressure.