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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. (GoSC 2018, p.6)

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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. (GoSC 2018, p.6)

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2. You should be alert to patients’ unspoken signals; for example, when a patient’s body language or tone of voice indicates that they may be uneasy, experiencing discomfort, or anxious and vulnerable.

This reflection has been carried out using Gibbs’ (1988) reflective model.

Description:
In the beginning of 3rd year, 2 of my peers and I were discussing a situation on what our reactions would include when a patient becomes emotional during a consultation. We discussed that there are many different reasons as to why someone may cry and our actions would depend on the cause of why somebody may feel like that.

Feelings:
I am usually interactive, sharing my ideas and opinions, however, I felt that I was unable to confidently share responses which I would tell my patient. The fact I did not entirely know what I would do when a situation like this would occur to me, made me feel quite uncomfortable and worrisome.

Evaluation:
It made me realize I had a flaw in my communication skills, as moments like these are crucial for a development of a well-established patient-practitioner relationship.

Analysis:
The reason I may have felt this inadequacy, is because I did not have a previous experience with an emotional patient before. I wanted to learn more about certain strategies, as it is very likely it will happen to us as osteopathic practitioners, due to the increased allocated time we have, compared to other healthcare practitioners.

Action plan:
I then asked various clinical tutors who, in my opinion, are highly skilled in communication on their opinion regarding such situation. From these various opinions, I have made my own strategy in dealing with an emotional patient.

Two months later, during an initial case history, a patient was explaining her presenting complaint being low back pain, however, I picked up some unusual non-verbal communication: her body-language was slouched, she was mostly looking down, did not sustain eye-contact for a long period of time and the tone of her voice gave me some indications for a psychological aspect which may arise along the case history. Later through the consultation, she mentioned her husband suffers from severe Parkinson’s disease and dementia and she solely needs to take care of him. The regulations of COVID-19 decreased her supporting environment, which may have contributed to her physiological musculoskeletal pain and her pain perception, as she needs to lift him quite regularly and the care she needed to provide implied to be continuously throughout the day and night.
Along the course of her explanation - she started to tear up and became emotional.  She verbally opened up to me, explaining her feelings and emotions - she felt guilty for receiving osteopathic treatment, which resulted in her not being able to provide care for her husband at that moment in time. We discussed the points she raised further, and the patient went on to mention this is the first time she has been able to share her feelings with anyone yet, due to the fear of judgment. I was fortunate to have made her feel comfortable, taking an empathic listening role, the tutors I spoke to have advised me to do.
We commonly decided that the patient needed a listening ear that day, rather than an examination focused on provocative testing, aiming to form a working diagnosis. It resulted in me not examining or treating the patient, but having a therapeutic conversation, keeping professional boundaries at all times. Although I felt that I did not have that much input in the conversation, the patient thanked me extensively afterwards, for my listening role.
In this conversation, we have worked in partnership into explaining what the most appropriate treatment for her may involve. I asked what her ideas were regarding referral to psychotherapy, alongside or without osteopathic treatment. The patient agreed as to this being a valuable option to her for the future, yet did not decide to seek psychological assistance at that point in time.

Analysis:
From this case, I have drawn numerous conclusions:
Firstly, I am grateful I reflected previously, so I was able to prepare for a situation like this. It taught me how important verbal discussions are between colleagues and peers, as this may give rise to certain strengths or weaknesses in our practice life which we can choose to further elaborate on.
Secondly, the reason I may have been alert is because of my psychology background I have had in secondary school, next to the psychology lectures we have received from the European School of Osteopathy, where we covered body language in people who suffer from depression. This highlighted to importance of being alert to non-verbal communication for me as a practitioner, yet also outside of osteopathy.

Action plans:
I was eager to learn more about ways to support someone who is grieving, hence I researched more about this topic - one article has described several different ways which suits me (Harvard Health Publishing 2019). This elaborated my communication skills, around the topic in dealing with patient who may carry emotional baggage.

References:
Harvard Health Publishing, 2019. Ways to support someone who is grieving, Available At: https://www.health.harvard.edu/mind-and-mood/ways-to-support-someone-who-is-grieving
[Accessed April, 26, 2021].

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Ways to support someone who is grieving - Harvard Health

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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. (GoSC 2018, p.6)

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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. (GoSC 2018, p.6)

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4. You should share accurate and relevant information with patients, and encourage them to ask questions and to take an active part in decisions about their treatment and care.

This reflection has been carried out using Gibbs’ (1988) reflective model.

Description:
In the beginning of my clinical experience, I experienced continuing patients returning to see me and they mentioned they have not performed the exercises I provided them with. This occurred on multiple occasions.

Feelings:
This was frustrating for me at points, as some patients were not getting better and was afraid they might blame me for that. Therefore, at times, I felt the need of letting the patient know that it is their fault we are not meeting their expectations for improvement.

Analysis:
Therefore, I evaluated the situation and analyzed this may be due to 3 things: firstly, the patient may not have enough time or motivation. Secondly, because I did not emphasize the benefit the patient may experience from performing an exercise or not sufficiently instructing the patient, for them to confidently, autonomously perform them well.  Thirdly, the patient could also feel discomfort or pain while doing them.

Conclusion:
I realized I cannot change their time or motivation, without invading personal space: I wanted to remain respectful towards my patients regarding their choices of how they want to spend their time in the day.

Action plan:
Hence, I focused on shared decision making with the patient: before educating the patient about the exercises I wanted to be reassured they will have the time to do them by asking: “Would you be interested in doing some exercises, at home?”, followed by: “Do you think you will have time/manage to do these?”, and many more outlined below.
I started to ask these questions as I did not see a point in prescribing exercises to a patient, if they cannot manage to find time or motivation to complete them. Furthermore, when they respond positively to this question, this may also be a positive note for them, resulting in potentially higher compliance of performing exercises.
Next to this, I decided to perform research as this is a significant, reoccurring problem in health care. Physiopedia provided an article which addressed this issue (Internet1 2014), with evidence-based advice of only prescribing 2 exercises at a time.
All of these, resulted in an observed increased adherence from my patients to home exercises. This resulted in me not feeling frustrated anymore, as well as working in partnership with patients, so they are able to take an active part in decision-making about their treatment, working in partnership with the patient. By provided advice in self-care, my management plan will be tailored to those individuals who can manage this, resulting in an overall improved care.

References:
Internet 1, 2014. Adherence to Home Exercise Programs, Available At: https://www.physio-pedia.com/Adherence_to_Home_Exercise_Programs [Accessed June, 2, 2021].

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Adherence to home exercises (HEP) in rehabilitation is a significant problem, and the reasons for this are multifactorial, covering both psychological and situational factors that vary between each individual, and that need to be considered by clinicians in the design of personalized exercise programs.

Providing a home exercise program (HEP) to patients is one of the most fundamental and important aspects of physiotherapy.

Patients who adhere to their prescribed exercises are significantly better at achieving their goals and demonstrate a greater increase in physical function.

Patients adhere poorly to their prescribed home program, with varying estimations from research. Non-adherence to a home exercise program has been shown to be as high as 50-65% for general MSK conditions. In the low back pain patient population, non-adherence to home exercise has been shown to be as high as 50-70%.

Nonadherence of a HEP increases the risk of recurrent injury or flare-ups with less positive outcomes long term and can result in the physiotherapist believing that their current treatment is not effective.

Overall, there is a need for good quality evidence to identify potential barriers to patient adherence and the strategies that are effective at combating those barriers.

When setting a HEP remember that the long list you may put together may be all inclusive but research shows

Subjects who were prescribed 2 exercises performed better than subjects who were prescribed 8 exercises, another report finding those prescribed 4 or more exercises had a lower rate of compliance than those prescribed 2 or fewer[10]

Subjects who are prescribed 2 exercises will perform better than subjects who are prescribed 8 exercises

Subjects who are prescribed 2 exercises will comply on their self-report exercise log more than subjects who are prescribed 8 exercises

Compliance with behavioral treatments (eg, an exercise program) is similar to drug compliance; as complexity increases, compliance decrease (confused man R).

Perceived Barriers - eg forgetting to exercise, not having the time, not fitting into the daily routine, work schedules[1](See image, busy multi tasking at home).

Self-Efficacy ie an individual's belief in their own capability to achieve a task that will produce a targeted result.

Threat and Beliefs ie The beliefs a patient holds regarding their condition and the decisions made by patients are based on their own beliefs, personal experiences, and the information they receive.

Locus of Control - patients with an external locus of control demonstrate a lesser degree of adherence with HEP.

Pain - Pain levels during exercise in musculoskeletal patients presented strong evidence as a barrier to adherence in a systematic review.[1]

Physical Activity - Studies suggest that those who are physically active at baseline demonstrate significantly better adherence to home exercise programs.

Psychological Symptoms - Depression as a barrier to adherence has strong supporting evidence.[1]

Social Support - The social support network of the patient has also been suggested as a possible factor in adherence eg friends and family members, as well as support from the therapist.

This is a good video (10 minutes) on barriers to exercise, or perceived barriers, to exercise and ways to overcome them.

Health technologies, such as the use of mobile devices, including mobile phones and tablets, as well as software apps, provide us with the opportunity to better support the patient and clinician, with a data-driven approach that incorporates features designed to increase adherence to exercise such as coaching, self-monitoring and education, as well as remotely monitor adherence rates more objectively.

Software apps exist on the market and may well change the way of many home exercise plans in clinics. The promise to do such things as " make it easy to build a home exercise program in seconds, with beautifully designed instructional videos. The built-in efficiencies will reduce your workload. Plus, our software motivates your patients and improves outcomes, with tracking tools and insightful analytics." Research is yet to confirm this but many clients like the idea of visualisation and direct feedback

Combining the popularity of mobile devices with the on-going search for fitness, thousands of fitness applications (apps) are available for free or low cost. Apps allow users to set fitness goals, track activity, gather workout ideas, and share progress on social media. Physiotherapists should stay abreast with recent research and follow the guideline as they emerge.

Those who utilized the apps were more likely to have a positive attitude about the apps.

Usefulness and perceived difficulties in particular should be considered with future app development.

App usefulness and ease of use may be facilitated by using health behavior theories to guide development.

One systematic review identified strong evidence for computerized technology not being more effective at improving HEP adherence compared to other strategies.

Patient Education

Educating patients on pain versus harm by explaining the nature of pain and nociception and suspending the belief that pain is an indicator of further tissue damage

Reinforcing messages which reduce fear or anxiety about pain

Emphasizing the idea that exercise will lead to less pain, anxiety, and depression

Countering maladaptive coping strategies

Employing motivational techniques and Motivational interviewing to set personal treatment goals

Managing expectations by educating patients the importance of their own HEP.

Minimizing pain during a HEP eg heat, ice or TENS pre or post session.

Use a graduated HEP - to reduce anxiety and fear avoidance, progress slowly and gradually to increase patients' confidence in their own physical abilities

Providing clear HEP, both printed and verbal instructions, when introducing a new exercise program, check patient's ability to recall.

Encouraging patients to keep exercise logs, diaries, logs to track their progress, symptoms, etc

Reviewing exercise and symptom logs at every treatment

Personalized Approach

Tailoring exercise program demands to the patient. Patients should be introduced to regular exercise in small steps that they feel confident they can manage

Participating in Telerehabilitation and Smartphone Apps in Physiotherapy in the form of email support or telephone support

Providing patients with pictures and videos of themselves performing the prescribed exercises

Establishing a personalized HEP negotiated and agreed upon with the patient

Include social network, for encouragement and involvement, and to boost their confidence

These videos below (total 6 minutes) give insight to HEP and adherence.

Diaries. Limitations - poor completion rates, inaccurate recall and self-presentation bias.

Computer programs, phone applications and wearable technology (e.g. pedometers)

See also Physical Activity and Outcome Measure

The following are samples of tools available to estimate patient adherence

1. Sports Injury Rehabilitation Adherence Scale (SIRAS)- 3-item scale completed by the therapist

2. Hopkins Rehabilitation Engagement Rating Scale (HREPS)- 5-item questionnaire completed by the health professional in an acute inpatient setting.

3. Adherence to Exercise Scale for Older Patients (AESOP)- patient completed 43-item questionnaire

4. The Modified Rehabilitation Adherence Questionnaire (RAQ-M)- 25-item scale to evaluate potential barriers to patient adherence

Level of Evidence

Pain - worsening pain during a treatment session is associated with a barrier to a home exercise program

Low levels of physical activity at baseline - patients who are not used to following a regular fitness program are less likely to incorporate a physiotherapy exercise program into their schedule

Low self-efficacy

Anxiety or stress at baseline - strong predictor of poorer outcomes at long term follow-ups

Depression - lower levels of depression are correlated to a greater motivation to exercising

High degree of helplessness

Lack of social support - the absence of a strong support network can lead to lower levels of adherence to a HEP

Perceiving barriers to exercise eg transportation problems, child care needs, work schedules, lack of time, family dependents, financial constraints, convenience and forgetting

High levels of neuroticism

2. Moderate

Internal locus of control the belief that individuals are responsible for their own outcomes (adhere better to home exercise programs)

3. Limited Level of Evidence

Higher disability level - those with higher disability level were more likely to adhere to a HEP

Lower motivation - research shows no clear relationship between motivation level and adherence to HEP

4. Conflicting Evidence

Greater pain at baseline - unclear whether greater pain at baseline serves as a motivating factor or a barrier to exercise adherence

Age - currently there is evidence on whether older patients vs younger clients adhere more or less to their HEP

Low levels of optimism - although low levels of optimism are associated with withdrawal from goal pursuits there is no clear evidence that it results in decreased adherence

This article by Bollen et al (2014) cites 58 studies reporting on 61 measures of self-reported adherence, thus the measures can be determined through using the reference list.

1. Argent R, Daly A, Caulfield B. Patient involvement with home-based exercise programs: can connected health interventions influence adherence?. JMIR mHealth and uHealth. 2018;6(3):e47.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5856927/ (last accessed 19.5.2020)

2. Di Fabio RP, Mackey G, Holte JB. Disability and functional status in patients with low back pain receiving workers' compensation: a descriptive study with implications for the efficacy of physical therapy. Physical Therapy. 1995 Mar 1;75(3):180-93.

3. Pinto BM, Rabin C, Dunsiger S. Home‐based exercise among cancer survivors: adherence and its predictors. Psycho‐Oncology: Journal of the Psychological, Social and Behavioral Dimensions of Cancer. 2009 Apr;18(4):369-76

4. Karnad P, McLean S. Physiotherapists' perceptions of patient adherence to home exercises in chronic musculoskeletal rehabilitation. International Journal of Physiotherapy. 2011 Jun;1(2):14-29

5. Beinart NA, Goodchild CE, Weinman JA, Ayis S, Godfrey EL. Individual and intervention-related factors associated with adherence to home exercise in chronic low back pain: a systematic review. The Spine Journal, 2013, 13:1940-195

6. Bassett SF. The assessment of patient adherence to physiotherapy rehabilitation. NZ J Physiother, 2003, 31: 60-66

7. Wright BJ, Galtieri NJ, Fell M. Non-adherence to prescribed home rehabilitation exercises for musculoskeletal injuries: the role of the patient- practitioner relationship. J Rehabil Med, 2014, 46: 153-158

8. Miss Massey. Barriers To Exercise Adherence. Available from: http://www.youtube.com/watch?v=PeqaRuDS0ko [last accessed 30/08/2016]

9. Gaikwada SB, Mukherjee T, Shahb PV, Ambodeb OI, Johnson EG, Dahera NS. Home exercise program adherence strategies in vestibular rehabilitation: a systematic review. Phys Ther Rehabil Sci, 2016, 5(2), 53-62

10. McLean SM, Burton M, Bradley L, Littlewood C. Interventions for enhancing adherence with physiotherapy: A systematic review. Manual Therapy, 2010 15: 514-521

11. TED Talks. Cosmin Mihaiu: Physical therapy is boring - play a game instead. Available from: http://www.youtube.com/watch?v=3_AZ5R2SC88 [last accessed 30/08/2016]

12. ELLICSR: Health, Wellness and Cancer Survivorship Centre. Dr. Paul Ritvo on How Cancer Survivors Adhere to an Exercise Program and Why: WE-Can Program. Available from: http://www.youtube.com/watch?v=ib-nL77WYTs [last accessed 30/08/2016]

13. McLean S, Holden M, Haywood K, Potia T, Gee M, Mallett R, Bhanbhro S. Recommendations for exercise adherence measures in musculoskeletal settings: a systematic review and consensus meeting. Project Report. Chartered Society of Physiotherapy. 2014. (Submitted)

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Adherence to home exercises (HEP) in rehabilitation is a significant problem, and the reasons for this are multifactorial, covering both psychological and situational factors that vary between each individual, and that need to be considered by clinicians in the design of personalized exercise programs. Providing a home exercise program (HEP) to patients is one of the most fundamental and important aspects of physiotherapy.

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A3. You must give patients the information they want or need to know in a way they can understand (GoSC 2018, p. 7)

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A3. You must give patients the information they want or need to know in a way they can understand (GoSC 2018, p. 7)

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3. If you propose to examine or treat a patient who has difficulty communicating or understanding, you should take all reasonable steps to assist them. For example, make use of an appropriate interpreter if the patient communicates in a different language to you. If you are unable to communicate sufficiently with the patient, you should not treat them.

This reflection has been carried out using Gibbs’ (1988) reflective model.
Description:
My first ever patient in the European School of Osteopathy clinic, was a 56-year old female, who natively spoke Italian. As I went to greet her at the reception, she reacted very surprised that I was not Italian, because I covered her from an Italian colleague who was ill that day. She emphasized that she needed someone who spoke fluent Italian. Coincidentally, there was an Italian colleague of mine who recently joined the school. The patient agreed to the option of me taking the case history, with the colleague being in the room for assistance, and if needed, to act as an appropriate interpreter. The patient her English was not bad at all, except for the medical history which needed assistance from my colleague. I appropriately adapted my communication in order for her to understand me as much as possible: this involved me speaking slowly, clearly, using a lot of intonation and speech articulation. The presenting complaint was quite straight-forward, mechanical based in origin and the patient was systemically well. The tutor and I decided she was safe to treat, despite their being some significances in her medical history, which we clarified further with our interpreter. We were able to conduct examination, a working diagnosis and a short and long term management plan and conducted some conservative treatment that same session. Afterwards, she wondered if it was possible for her to have a practioner who speaks Italian, because she would like to be able to communicate about her daily life as well, which we were unable to do with the language barrier. We commonly decided it that also in order for the optimal quality of care, e.g. for her to express her concerns or expectations, it may be more beneficial for her to have a practitioner who speaks Italian.

Feelings:
Overall, I felt like it was an overall fun process, I had a truly rare case as my first patient and I feel like I handled it well and professionally.
Although I felt a bit disappointed for her to ask for a different practitioner afterwards, given the effort I have put in to try and let us understand each other. Also, because she was my first patient, I was looking forward to a long-lasting relationship with her.

Analysis:
The reason why I may have seen it as such fun process, may be because I was very excited and looking forward for having my 1st patient, from the moment I started learning about osteopathy. I have often wondered how my 1st patient experience will be like - and it was extremely educative as I did not have a similar scenario ever since.
I often wonder if I would have enjoyed the same experience as much, if this was not my 1st patient.

Conclusion:
This was a scenario that went overall quite well, however, this was because I was very lucky for my colleague to be present that day. I concluded that understandable, unambiguous communication is crucial for all aspects throughout the consultation, especially the case history and informed consent.  Furthermore, the medical history is crucial for determining whether or not the patient is safe to treat.

Action plan:
I decided to challenge myself to imagining as to what I would do in the future, if I did not have a colleague usable as interpreter. I concluded that my actions will all depend on the level of English the patient speaks, prioritizing my safety in practice:

If the patients level of English is very low to absent, I will be unable to communicate anything to him/her and will fail to comply with the osteopathic practice standards for obtaining a complete case history, and receive valid informed consent. Therefore I will be unable to treat the patient.

If the patients level of English is low to moderate, it will depend on if I will be able to maintain my safety in practice. This means, that if she is unable to answer crucial questions for me to clinically judge whether or not the patient is safe to treat, I will be unable to treat.

If the patient is safe to treat, however, my clinical judgement leads to deciding that the patient is unable to understand my informed consent, then I will be unable to treat.

One solution for all of the above, may include advising the patient for bringing an appropriate interpreter in next time. If the interpreter is able to communicate this to him/her, then I will be able to continue to treat, with valid ongoing consent.

Next to this, we have received a tutorial by a clinic tutor who highlighted aspects, which I often missed, in regards to communication, introduction to the patient, and most importantly non-verbal communication (therapeutic touch). This gave me further insights of the importance of effective communication skills, not only to follow protocol (e.g. safe to treat, informed consent), yet also on how to improve the relationship between the patient and me, potentially leading to better results.

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D1. You must act with honesty and integrity in your professional practice. (GoSC 2018, p. 20)

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D1. You must act with honesty and integrity in your professional practice. (GoSC 2018, p. 20)

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2.1 Your advertising and promotional material, including website content, is legal, decent, honest and truthful as defined by the advertising standards authority (ASA) and conforms to current guidance, such as the UK Code of Non-broadcast Advertising and Direct and Promotional Marketing (the CAP code).

This reflection has been carried out using Gibbs’ (1988) reflective model.
Description:
The first occasion I came across to the Committee of
Advertising Practice (CAP) guidelines in association with the Advertising Standards Authority (ASA) was at the end of 3rd year (Advertising Standards Authority 2016), due to an assignment where we needed to complete a Business Plan. Until this point, I was unaware of such advertising guidelines for osteopathy. Initially, I would have appreciated to have discovered this list sooner. Also, I felt quite surprised when I saw the short list as I expected there to be many more conditions on the list.

High importance is laid upon this list, within the osteopathic profession, with many osteopaths displaying this list on their website as an informative guideline for treatable conditions by osteopathy.
When analyzing the list, I can understand the advantages such list provides: a recognized, approved list for osteopaths to share with patients, and it mainly eliminates explicit or implied treatment claims for specific conditions which go beyond that of the evidence based spectrum.
Meaning, it acts as a restriction for osteopaths in how they can advertise themselves, which is in my opinion ethical towards the patient and preventative for patient complaints towards osteopathic care.

Feelings:
Yet, because of its natural restrictions it encompasses, I actually feel this undersells what osteopaths are able to treat. During the course, when learning techniques, teachers would include conditions which may benefit from the discussed technique, with these conditions being absent on the ASA list.

Analysis:
Although the main goal from the list is to provide concise, indisputable guidance, I reasoned there are components which are quite ambiguous, containing subjective terms such as “minor”, “uncomplicated”.
Secondly, there is ambiguity between question and answers, as this answers the question “Which medical conditions can osteopaths claim to treat?” - however there are various terms used, which are not classified as conditions, but symptoms: “joint pain”; “digestion problems”; “tension”. There is clear inconsistency in the appraisal as there are both conditions (e.g. migraine) and symptoms in the list.
Furthermore, there are symptoms which are not condition-specific, as there is no differentiation made from systemic causes e.g. infectious, neoplastic, metabolic, which are untreatable by osteopathy, needing necessary urgent referral. All of which may lead to misinterpretation of the spectrum of conditions treatable by osteopathy and misguidance to the patient.

Action plan:
I decided to speak to my personal tutor about this matter of course, where he agreed with me, which led to an enlightening discussion. He provided me with insights on how to remain ethical in claiming what we can treat and what we cannot. He shared his ideas about the differences between informed consent with shared decision making, compared to imposing unrealistic expectations to a patient, especially, in conditions which are not found in the list. He described his statements with the following example: he shared with me a scenario when a patient came into his practice, with a 20-year old history of urinary incontinence (which is not found on the list). The patient mentioned she had unsuccessfully tried every evidence-based approach such as lifestyle, pharmaceutical and exertional interventions, with osteopathy being her last option. The incontinence had a severe impact on her quality of life, stigma, embarrassment and sexual health, especially in the last years. He mentioned to her that there is no evidence to support osteopathy for her presenting complaint, and there is a likelihood of adverse events, supporting an informed consent approach. There was a shared-decision making present in regards to the techniques chosen, and after a couple of treatments, the symptoms fully subsided.

I concluded that the APA guidelines are extremely useful for the aforementioned reasons. However, when a presenting complaint presents itself, not found on the list, it is necessary for the patient to be aware of this. The patient needs to acknowledge this is not an evidence-based approach and as practitioners we can not impose lies or ideas to the patient, especially not on our website. Thus, I will continue to cohort to this osteopathic practice standard, by not exceeding estimations of the effects of osteopathy in my advertising or by imposing untruthful ideas towards patients.

References:
Advertising Standards Authority, 2016. Which Medical Conditions Can Osteopaths Claim to Treat? Available At: https://www.asa.org.uk/advice-online/health-osteopathy.html [Accessed May, 14, 2021].

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Note: This advice is given by the CAP Executive about non-broadcast advertising. It does not constitute legal advice. It does not bind CAP, CAP advisory panels or the Advertising Standards Authority.

Osteopaths are trained in therapeutic approaches that are suitable for a broad range of individuals, including pregnant women, children and babies. Osteopathic care is delivered through a range of interventions which may include onward referral, health management advice, manual therapy, exercise therapy and others. Osteopaths adapt their therapeutic approach depending on the individual needs of the patient and their presenting complaint. Manual therapy techniques employed may include articulation and manipulation of joints and soft tissues.

Osteopaths have been regulated by statute since 1993 by the General Osteopathic Council (GOsC) and may refer to conditions for which medical supervision should be sought if they hold convincing evidence of the efficacy of their treatments.

Which medical conditions can osteopaths claim to treat?

Based on evidence submitted to CAP prior to November 2016, the ASA and CAP accept that Osteopaths can claim to treat the following:

Arthritic pain
Circulatory problems
Cramp
Digestion problems
Fibromyalgia
Frozen shoulder/ shoulder and elbow pain/ tennis elbow (lateral epicondylitis) arising from associated musculoskeletal conditions of the back and neck, but not isolated occurrences
Headache arising from the neck (cervicogenic)
Joint pains
Joint pains including hip and knee pain from osteoarthritis as an adjunct to core OA treatments and exercise
General, acute & chronic backache, back pain (not arising from injury or accident)
Generalised aches and pains
Lumbago
Migraine prevention
Minor sports injuries
Muscle spasms
Neuralgia
Tension and inability to relax
Rheumatic pain
Sciatica
Uncomplicated mechanical neck pain (as opposed to neck pain following injury i.e. whiplash)

If marketers use different medical terms to describe one of the above conditions, they may be asked to provide evidence to demonstrate that this description is generally agreed to have the same meaning as that approved condition.

Which medical conditions can osteopaths not claim to treat?

Any conditions that are not reflected above are likely to be problematic unless the marketer holds robust clinical evidence to support their claims.

Are claims to treat babies, children and pregnant women acceptable?

As regulated health professionals, osteopaths may refer to treating specific population groups such as pregnant women, children and babies. However, at present there is a limited or negative evidence base for the effectiveness of osteopathy in treating conditions specific to those groups, such as colic or morning sickness.

Consequently, references to treatment for symptoms and conditions that are likely to be understood to be specific to babies, children or pregnant women are unlikely to be acceptable unless the marketer holds a robust body of evidence.

Where an adequate evidence base has been established for the efficacy of osteopathic treatment for particular conditions in the general population, claims that do not materially depart from those already deemed acceptable by CAP and which describe interventions that are consistent with osteopathic practice, are likely to be acceptable.

The ASA has recently carried out a review of advertising claims in relation to the treatment of babies, children and pregnant women using osteopathy which explains in more detail the types of claims (including phraseology) that are likely to be acceptable and those that are not. Osteopathy: ASA review and guidance for marketing claims for pregnant women, children and babies.

Can I call myself a "Doctor"?

Claims such as "Dr" and "Doctor" are likely to be understood to mean that the Osteopath holds a general medical qualification. As such, Osteopaths not holding such a qualification should avoid references to "Dr" or claims that are likely to have the same meaning.

Updated on 2 December 2016.

More on

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Advertising Standards Authority | Committee of Advertising Practice

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Note: This advice is given by the CAP Executive about non-broadcast advertising. It does not constitute legal advice. It does not bind CAP, CAP advisory panels or the Advertising Standards Authority. Osteopaths are trained in therapeutic approaches that are suitable for a broad range of individuals, including pregnant women, children and babies.

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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  (GoSC 2018, p.16)

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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  (GoSC 2018, p.16)

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1.3 formulate an appropriate working diagnosis or rationale for care and explain this clearly to the patient

This reflection has been carried out using Gibbs’ (1988) reflective model.
Description:
Along the course of year 3 and 4, I experienced a lot of controversial advice from clinic tutors in diagnostic reasoning and its wording. Some tutors do not accept certain diagnoses, including somatic dysfunction, sacroiliitis, piriformis syndrome, an osteopathic lesion of the viscera and many more. Until 2nd year, this was never challenged to us as students.

Feelings:
This has left me in doubt numerous times as this was a reoccurring issue, I could not find a solution to.

Analysis:
When looking at the bigger picture, I saw that I was battling between finding my own identity as a practitioner, to where I sit in the evidence-based versus the osteopathic spectrum. What I mean by that is, how subjective or objective am I influenced as a practitioner? What do I prioritize, what are my beliefs? Do I believe in “miracles” or do I solely believe in what the evidence says is true?
At first when I realized this, I saw it as a complete weakness. I felt that, as a 3rd year, I needed a unique selling point, that I could not sit between the two. I could not assess/treat some patients structurally, with a pure evidence-based approach, and some pure osteopathically, with a cranial/visceral approach.

Conclusion:
As a 4th year, however, I became less frustrated as I saw this as my biggest strength: I am able to explore different opinions, visions and approaches, without closing any doors. I feel like I could learn something from every tutor present in the ESO clinic.
This is what true Osteopathy meant to me - not any type of approach, not only treating a patient with HVT, MET, visceral, cranial, BLT, BMT,... but being able to treat whoever comes through the door. Whether this is someone who needs an HVT or pure cranial work, I chose to set a long-term goal for being able to treat as many people as possible with my toolbox of osteopathic modalities.

Action plan:
This motivated me to revisit where my initial doubts came from: am I  able to use somatic dysfunction as a diagnosis? I decided to ask a peer of mine if I could read her dissertation as her topic was: “What are the attitudes and beliefs of osteopaths on somatic dysfunction as a clinical diagnosis?”. This has enlightened me in the argumentation osteopaths use whether to use it as a clinical diagnosis or not. It also reassured me to observe that it is not uncommon for there to be a diversity in opinions, outside of my teaching environment. I decided to continue the path I think is right: to graduate with an open mind, to be able to explore as much modalities as possible. Despite this, I strongly feel that the curriculum has prepared me to be able to formulate an appropriate working diagnosis relative to the presenting complaint. Lastly, I will rationalize an osteopathic treatment plan that is sensible to me and the patient, unrelated to what the wider opinion of this treatment holds, as long as compliance is shown to the OPS.

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A4. You must receive valid consent for all aspects of examination and treatment and record this as appropriate. (GoSC 2018, p. 7-9)

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A4. You must receive valid consent for all aspects of examination and treatment and record this as appropriate. (GoSC 2018, p. 7-9)

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1. Gaining consent is a fundamental part of your practice and is both an ethical and a legal requirement. If you examine or treat a patient without consent, you may face criminal, civil or GOsC proceedings.

This reflection has been carried out using Gibbs’ (1988) reflective model.
Description:
Along the course of Year 1, I experienced particular challenges in the reasoning and understanding the importance of gaining consent. To give an example, in a practical lecture in Osteopathic Concepts, when practicing observation skills, I often received feedback about my consent needing to improve, despite my observation routine being fully complete. This occurred in multiple other occasions in the practical classes.

Feelings:
I felt like the tutors emphasized more on gaining consent, rather than improving our osteopathic skills and knowledge. I often felt frustrated by this as I was unable to comprehend on why obtaining consent was such crucial aspect in Osteopathy. I could understand the relevance when addressing intimate areas, yet not for the most common areas treated such as the spine or shoulder. My reasoning for this confusion involved: “If someone goes to an osteopath, they know that we need to have hands-on contact, for both examination and treatment?".

Analysis:
These emotions might have occurred because of my lifetime experiences with my osteopath, in Belgium, who hardly ever obtained consent. As I received treatment from my osteopath since I was a newborn, up until now, I soon realized he didn’t obtain consent because of the numbers of years I have been visiting him already, in contrast to the fact he would go through the same process of gaining consent for new patients. Yet, this brought a huge bias to my preconceptions of obtaining consent, and looking back, my osteopath did not comply with the criteria for ‘ongoing consent’.

Conclusion:
After I have observed the repeated relevance of obtaining consent in clinical observations and obtaining different opinions by several tutors and in combination with English not being my native language, I soon realized communication was a weakness of mine and I was eager to make it a strength.

Action plan:
Therefore, I have made my own, individual, structured expressions, which made sure that my explanation will be more fluent, structured and clear for my patient. This allowed me to further expand my vocabulary in English as well. I then began to realize that communication towards the patient is most likely to be the most important aspect in osteopathy. I developed a particular interest in developing effective, kind communication skills, and I have added anything in regards to this into 1 document which I called “communication”. It addresses all parts of a clinical setting from introducing yourself to the patient, to discharging them. It also encompasses expressions used in English and common scenarios which may occur to me (like shown in A1).  Communication became a passion of mine and never stopped being curious in improving ever since.

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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. (GoSC 2018, p.20-22)

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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. (GoSC 2018, p.20-22)

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2. Appropriate professional boundaries are essential for trust and an effective therapeutic relationship between osteopath and patient. Professional boundaries may include physical boundaries, emotional boundaries and sexual boundaries. Failure to establish and maintain sexual boundaries may, in particular, have a profoundly damaging effect on the patient, is likely to bring the profession into disrepute and could lead to your removal from the GOsC Register.

This reflection has been carried out using Gibbs’ (1988) reflective model.
Description & Feelings:
I have been handed over a female 30-year old patient who was very talkative and enjoyed having conversations. She was not married, nor had any kids. In every consultation there was hardly any moment of silence, which as a practitioner, I really enjoy. One of the reasons I decided to study osteopathy is because of the clear social side it brings by learning about others people’s lives, every day.
We developed quite a sustainable patient-practitioner relationship, increasing after every consultation. At some points she felt guilty for talking about her life so much and started to show more and more interest in my life as a student. She started by asking generic questions, which developed to be more specific tailored to my feelings. Although I answered these quite shortly/bluntly, I initially saw no harm in her asking these personal questions. In the opposite, it was the first time I experienced a feeling of a patient seeing me as her equal, rather than “her practitioner”. There was a moment of proudness for me, as I had some insecurities before about whether it was possible for me to have a well-established professional relationship between my patients and me. However, in the following treatments, her questions went on to develop more into my personal life, which I answered quite bluntly, again. Surprisingly, she insisted by asking specific questions about me, including if I had a relationship, or a history.
At that point in time, I had to take a step back. I was quite flustered in the treatment room. I had no idea how to handle this or how to communicate to her that I cannot satisfy her curiosity. I went on and respectfully mentioned I am unable to answer that question as I need to keep a professional barrier, to which the patient understood and apologized in return. Afterwards, there was a big silence as I continued to treat her.

Analysis:
After the consultation, I asked my tutor who supervised this case, for a private discussion. I explained what happened and asked for advice.
By seeking advice from a tutor, I managed to analyze as to why this emerged this way, with a combination of my reflection and his input.
We concluded that firstly, I handled it quite well and this was not mainly my fault as she decided to insist, despite my brief, concealed answers.  However, for preventative measures, we still came up with some errors which could have been improved. Firstly, although I withdrew information from her, since the start, I could have answered even more briefly. An option for this would be answering with a ‘Yes’ or ‘No’, even with generic questions about my student life. This may have prevented her to show further interest into my personal life. Secondly, my reaction in the treatment room could have been more explanatory, with a preventative aim, because a rebooking was planned for the following week.

Action plan:
The tutor and I discussed my best options forward: before the examination, inform the patient about the necessary professional boundaries which need to be kept, with a potential referral to a colleague, that would need to be made if the patient would not be able to understand or change. In this week, I prepared for this conversation, however, the patient did not return after that.

This event has made me explore other strategies for keeping professional boundaries in an osteopathic setting. The video underneath, explains ways to accomplish this (Internet3 2019). It made me realize that I have found this challenging in the beginning, as I am passionate about what I am doing, but I I have to remember to keep it professional and not personal.

References:
Internet 3, 2019. 3 Firm Ways To Set Therapy Boundaries, Available At: https://youtu.be/HHdXCHnZo3c [Accessed May, 14, 2021].

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C2. You must ensure that your patient records are comprehensive, accurate, legible and completed promptly  (GoSC 2018, p.16-17)

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C2. You must ensure that your patient records are comprehensive, accurate, legible and completed promptly  (GoSC 2018, p.16-17)

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1. Records help you to provide good-quality care to your patients and should include:

1. date of the consultation

2. patient’s personal details

3. any problems, symptoms, concerns and priorities discussed with your patient

4. relevant medical, family and social history

5. your clinical findings

6. the information and advice you provide, including a record of how this is communicated to your patient

7. a working diagnosis and treatment plan

8. records of consent

9. any treatment you undertake

10. any communication with, about or from the patient

11. copies of any correspondence, reports, test results, etc relating to the patient

12. clinical response to treatment and treatment outcomes

13. the location of your visit if outside your usual consulting rooms

14. whether any other person was present and their status

15. where an observer is present (for example, a chaperone, peer observer, osteopathic student, or potential student) as well as their status and identity, you should record the patient’s consent to their presence.

This reflection has been carried out using Gibbs’ (1988) reflective model.
Description:
The ESO clinic provides a templated case history form, including all the necessary contents mentioned in the list above.

Feelings, Analysis and Conclusion:
In the beginning of 3rd year, I felt that the template made case history taking much easier, enabling me to focus on what the patient was expressing, rather than thinking about the next question I had to ask. This enhanced active listening for me and thus, improved clinical patient care. As I progressed more and more towards 4th year, tutors slowly made it clear as to why these criteria are fundamental to ask. I became curious because often I did not see the relevance in asking certain points.

Action plan:
When I became to understand the reasoning behind it, it prompted me to dive into asking further details and interpreting this data. To use an example: a positive family history of cardiovascular disease: what consequences does this piece of information contain? Can it change my diagnosis? How does this shape the safety and quality in my practice? How does this change my patients management? These are crucial questions I asked myself, not just for the sole purpose of completion, yet for improving quality care in practice.

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A4. You must receive valid consent for all aspects of examination and treatment and record this as appropriate (GoSC 2018, p.7-9)

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A4. You must receive valid consent for all aspects of examination and treatment and record this as appropriate (GoSC 2018, p.7-9)

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6. The patient needs to understand the nature, purpose, benefits and material or significant risks to them of the examination or treatment proposed. The patient must then be free to either accept or refuse the proposed examination or treatment. Some patients may need time to reflect on what you have proposed before they give their consent to it.

The following link (Internet2 2012) has provided me with well-explained instructions as to how we can communicate benefits and risks effectively to patients. It made me improve my informed consent structure by introducing me to the BRAN-model: Benefits, Risk, Alternatives, Nothing. I went on to adopt this model every day in clinical practice with every patient, which made me match my goals I was aspired to achieve: a fluent, structured, clear communication process. I will continue to comply with this structured approach as I observed it educated my patients during their decision-making process, enhances the patient-practitioner relationship and follows a consistent, structured model, which aids to our credibility.

References:
Internet 2, 2012. Communicating benefits and risks effectively to patients, Available At: https://youtu.be/I3-Y4wd1y2Q [Accessed May, 14, 2021].

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Communicating benefits and risks effectively to patients - Pippa Bark

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Pippa Bark, Principal Research Fellow at University College London discusses how best to communicate benefit and risks effectively to patients, including how to integrate risk information into practice, ensuring common sense prevails. The presentation was given at the GOsC Regional Conference held in Borehamwood, London on 16 July 2012.

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D3. You must be open and honest with patients, fulfilling your duty of candour. (GoSC 2018, p.22)

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D3. You must be open and honest with patients, fulfilling your duty of candour. (GoSC 2018, p.22)

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1. If something goes wrong with a patient’s care which causes, or has the potential to cause, harm or distress, you must tell the patient, offer an explanation as to what has happened and the effects of this, together with an apology, if appropriate, and a suitable remedy or support.

This reflection has been carried out using Gibbs’ (1988) reflective model.
Description:
I was providing osteopathic care to a 22-year old female patient, for 9 continuous weeks. When preparing for the consultation at week 6, I was unable to find her clinical notes from the week before. I started to search everywhere, yet I was unable to find it.
I have let my tutor know beforehand, in which she put huge emphasis on taking care of patients notes and made me realize I made a big mistake. I am usually quite organized, so I completely understood the importance of this. The tutor has let me feel I have made a terrible mistake and I felt a lot of guilt. I immediately addressed this to the patient and I repeatedly apologized to her. I offered her the option to discuss this with the tutor, clinical manager or discontinue treatment with me. The patient accepted my apology and was completely okay with it, which was quite a relief for me.

Analysis:
On reflection, I would not even put this down as a mistake of mine, yet more as an accident as I felt like this could happen to anyone. The paper may have just fallen out of the file when I handed it to the reception or while walking. Because the tutor really wanted to get her point across, she occasionally used some personal attacks which were unrelated to the event. Losing a patients notes has never happened to me before, and never happened since. For these reasons, I felt that I was unfairly treated by the tutor.
Next to this, the way the patient reacted towards me may have been because I approached her carefully, truthfully, admitting a mistake has been made, while including an apology.

Action plan:
In the course of the week, my feelings of being mistreated gradually increased. I decided to openly, carefully discuss this with my tutor.
The tutor accepted my opinion and went on to apologize. She shared with me that she had a bad day and felt sorry for crossing the line with me. Although this didn’t change anything to the fact the patients notes were missing, this made me feel much better as I felt like I handled this situation well. Because I am planning to work as an employee in the future, I thought this was an extremely helpful discussion. Before this point, I genuinely thought you could not question hierarchy or share your feelings with them - just deal with it. When working for an employer, there will be moments I will experience altered feelings which I may need to express to him/her. This taught me that open discussions are possible, especially if done in a respectful, open, careful manner.
Secondly, it has also taught me that patient notes are extremely valuable and should be well taken care of as these are parts of evidence. I will continue to recognize this importance by making sure my handwriting is neat, my notes are understandable, in chronological order and closely monitored.

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A5. You must support patients in caring for themselves to improve and maintain their own health and wellbeing. (GoSC 2018, p. 10)

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A5. You must support patients in caring for themselves to improve and maintain their own health and wellbeing. (GoSC 2018, p. 10)

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1. Supporting patients in caring for themselves may include:
1.1 providing information on the effects of their life choices and lifestyle on their
health and wellbeing

This reflection has been carried out using Gibbs’ (1988) reflective model.
Description:
In year 2, I observed a 60-year old continuing female patient, with osteoarthritis of the right hip joint, in the ESO student clinic. The patient was overweight, with a BMI of 31 and denied any improvement of her symptomatology after receiving continuous care for weeks/months. Previously to the consultation, the student practitioner and tutor privately discussed her BMI as the main predisposing and maintaining factor for her degeneration, with a plan of providing her information to lose weight. The tutor decided to let the student perform this discussion autonomously, while the student mentioned she felt incompetent to do so. Later in the room, the student practitioner privately discussed with the patient that losing weight will be the only option for her to improve, reasoning this is an evidenced-based approach. In turn, the patient reacted what seemed to be, disappointed. She mentioned she realized she was overweight, yet there was not much she could do about it. The student did not explore this response further and did not provide information for any other alternatives. The situation resulted in the patient being discharged and the student practitioner did not provide further information about any other alternatives, not even surgery.

Feelings:
While reflecting on this approach, I had a lot of compassion with this patient, due to the fact I could observe she was upset. Next to this, I noticed I was quite judgmental about the practitioner afterwards, for her not being as sympathetic as I expected her to be. The student also did not provide any alternatives, leaving the patient going away without hopes of getting better. I felt that there was an extremely large amount for improvement.

Analysis:
Despite the patient was upset, it is good to consider that this may not have been due to the direct approach this student decided to take, but solely due to the news of her weight interfering with her lifestyle, once again. It may well be that the patient has tried various ways of losing weight in the past, without success.
Nevertheless, although losing weight is an evidence based approach for osteoarthritis in the hip, osteopathic practitioners need to consider this can be an extremely sensitive topic for the patient to be addressed.

Conclusion:
It made me comprehend that we are very unaware of our patient personal history: this patient may have had a history of bullying due to her weight, a history of continuous failure when opting for losing weight, or an inadequate support environment for her to make such big step etc,... These are all crucial aspects in the success rate of the management of this patient, which need to be accounted for.
Furthermore, it made me recognize that learning communication skills for these type of scenarios may be challenging for a student practitioner who has hardly any experience in this field, compared to a clinical tutor. In this occasion, it made it even more challenging for the practitioner to improve her communication skills, as the tutor was not present in the room at that time and was unable to provide any feedback.

Action plan:
This moment challenged myself to think what could have been improved upon, potentially leading to an improved patient-practitioner support environment and an improved clinical patient care.
Firstly, I decided to research the NICE-guidelines for osteoarthritis. NICE-guidelines suggest to firstly advice, local muscle strengthening and general aerobic fitness, before advising lifestyle changes.
Furthermore, it provides recommendations for obesity in a separate section, exploring criteria ranging from identification, to assessment and management (NICE 2014). It covers all necessary points, which were largely missed from the student practitioner - such as: explore belief systems about obesity, weight loss and lifestyle, eating patterns, physical activity, previous attempts on losing weight, motivation and time. It goes on to provide classified management options such as behavioral interventions, physical activity, dietary, pharmacological and surgical interventions. This research has aided me for optimal clinical patient care when a similar scenario occurs.

Secondly, it also encouraged me to ask clinical tutors to come into the room with me when discussing diagnosis, examination and management plans with my patients. This made sure I was able to request informative feedback regarding my communication, afterwards. I then drew conclusions from my feedback I received and proceeded to enhance my communication skills.

References:
NICE, 2014. Obesity: identification, assessment and management, Available At: https://www.nice.org.uk/guidance/cg189/chapter/1-Recommendations [Accessed May, 14, 2021].

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A6. You must respect your patients’ dignity and modesty (GoSC 2018, p. 10-11)

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A6. You must respect your patients’ dignity and modesty (GoSC 2018, p. 10-11)

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2.4 giving patients the option of covering areas of their body that do not need to be exposed for examination or treatment. This can be achieved by providing a suitable gown or cover, asking that they only remove such items of clothing as are necessary for the proposed examination or treatment, or providing the opportunity to get dressed again in full or part as appropriate. If you feel it is necessary for the examination or treatment that the patient
is undressed to their underwear, you should explain this to the patient, and seek their consent.

This reflection has been carried out using Gibbs’ (1988) reflective model.
Description:
An initial experience of a practitioner fully respecting the patients’ dignity and modesty occurred to me as an observer in 2nd year.
The student-practitioner had a continuing patient coming in, where he warned me before that she can be quite reluctant on observers being present for examination and treatment. The patient mentioned to the practitioner I was able to observe. At the point the examination was about to start, the practitioner has previously received informed consent for her to get undressed, yet still provided her with a gown to cover herself. During the examination, the practitioner noted the patient was not feeling at ease, while I did not notice this. He prompted her numerous times to be completely honest with him, regarding me as an observer to be present in the room. After numerous approvals from the patient, the practitioner finally decided to ask me to leave the room.
Afterwards, when he finished treatment, he apologized for asking me to leave the room, even though the patient did not tell me to do so. He went on to tell me that the patient thanked him for asking me to leave the room, as she did feel brave enough to tell us and she did not want me to feel insulted or for me to miss a learning-opportunity.

Feelings:
I was surprised at the time the practitioner asked me to step out of the room, as I took it a bit personal. Afterwards, I was even more surprised when he shared the patients’ response with me. Especially because I did not notice it.

Analysis:
The reason why I was so surprised when the practitioner asked me to step out of the room, may probably be because I assumed that the patient was going to be okay with it, as she was wearing a gown. This was the first time I have seen a patient been offered a gown, which is why I thought there was no further possibility for her to feel uncomfortable.

Conclusion:
The practitioner has done a miraculous job respecting the patients modesty, by providing a gown and being attentive to her non-verbal communication. If the practitioner did not identify the discomfort the patient was in, this may have had other outcomes in terms of patient-practitioner relationship and effectiveness of the treatment, potentially leading to the patient not coming back.

Action plan:
In the beginning of my career as a student practioner, I was pre-occupied with focusing on my examination routine, my findings, handholds for techniques and many more aspects of my provided care, hence I focused less on how comfortable my patient felt in terms of exposure. When I became more confident and fluent in my routines, I started to be more sensible in providing options for respecting patients modesty and dignity, as observed in the aforementioned case. In order for patients to be advised of their rights of full modesty, I started to explain they can be offered a vest top, shorts, a gown, or a blanket. If denied or approved, I recorded this in my notes. I also told my patients it was okay to not fully undress down to underwear, if I judged it would not interfere with my treatment plan. Furthermore, I started to advise the possibility of having a chaperone present: they are welcome to bring a friend or family member or a fellow student or member of the practice can be used as a chaperone as well. Besides, it is important to be aware that the ESO student clinic introduces each patient to the standard guidance for modesty in the consent form, which is found below. I familiarized myself regarding the consent form, in the ESO clinic but also in the future practice I will be working at.
Furthermore, I started to see a direct relation between the patients who are more comfortable and the tissues being more accessible when palpating. As a result, I found that my techniques became more effective and I met the patient expectations better in terms of improvement. Complying with this standard will act as a benefit to both the patient and me.

The ESO teaching clinic provides a consent form for new patients, including information about the possibilities discussed, as found below. Nevertheless, it is necessary for practitioners to remind their patients about their options for keeping their dignity and modesty.

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A7. You must make sure your beliefs and values do not prejudice your patients’ care (GoSc 2018, p.11)

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A7. You must make sure your beliefs and values do not prejudice your patients’ care (GoSc 2018, p.11)

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3. You are not obliged to accept any individual as a patient (subject to the points raised in paragraph 1 above), but if having done so you feel you cannot continue to give them the good-quality care to which they are entitled, you may decline to continue treating them. In that case, you should try to refer them to another osteopath or healthcare professional where appropriate. Reasons for not accepting someone as a patient or declining to continue their care might arise where: 3.1 they are or become aggressive

This reflection has been carried out using Gibbs’ (1988) reflective model.

Description:
As I was preparing for an initial case history, the tutor mentioned to me that the patient is quite known in the clinic for her schritzophrenic behaviours, including verbal aggressiveness towards the receptionists team and the practitioners involved. The tutor and I had a 15-20 minute conversation that I am able to deny to provide care, if she acts aggressive towards me. The tutor shared with me that in the beginning of his career, he would treat such patients, however he now chose not to do this anymore for various reasons and he reassured me that he will support me in whatever decision I make. However, another thing he mentioned is that those patients become the best word of mouth!
As I went to the reception to pick the patient, I noted that 3 reception members of staff, a clinical manager and head of department were all waiting at the reception, for this patient to come in. This was very unusual and it made me feel scared, as I had no idea what was coming my way. From the moment I let the patient in, I saw that she was observably upset. She even started cussing about how hot she was feeling, when answering the COVID-19 questioning for a high temperature.
I calmly guided the patient into the room, she threw her mouth mask on the couch, opened the window while shouting to me that she couldn’t breath, because she’s got asthma. Immediately afterwards, she shouted the following words: “Low back pain, pins and needles down my leg, fix me”, while pointing her hand down towards her left foot. This startled me and I soon realized I had to be extremely specific with my questioning for making a working diagnosis, in comparison to other patients. Following the introduction about what the consultation might contain, my tutor came into the room. I started my generic “SOCRATES’ routine, by asking the coherent questions. The patient was very withdrawn in giving us information, and there was a lot of ambiguity in her answers. After the 3rd/4th question, the tutor stepped in by making her aware that we are only asking these questions for her to benefit from, and if she would not want to share information we are trying to elicit from her, we could not provide her any treatment. The tutor did this with a strong, firm voice, being very composed but at the same time remaining respectful.
At that moment in time, the patient decreased her tone of voice, put her mouth mask back on and kept standing next to the window. The input from the tutor has allowed me to then perform a careful case history screening. There were moments where the patient, explicitly wanted to share her distress with me, by increasing the magnitude of her voice and taking an imposing/intimidating body language.  One example included me asking about her previous history of complaint, by which she was extremely dissatisfied by provided care in the ESO clinic. Apparently, she has submitted a complaint previously, towards one of her previous practitioners. This was because the practitioner has performed an HVT, which dramatically aggravated her symptoms. There was another point I felt distressed, when I asked her about her relieving factors for her pain, where to she replied “Drugs”. This word made me very attentive, by which I replied: “Did you take any today?”. She mentioned she took some in the morning. I then asked: “What is the name of those drugs?”. She answered “cocodomal”. I furtherly questioned whether she takes any recreational drugs, which she denied using. After this, the patient decided to sit on the chair I placed in front of me. Throughout the consultation, I remained overall quite calm and composed and at times more passive than others. When she would express her distress, I reacted with certain expressions like: “I can see why you’re upset.”, or: “I understand why you were concerned”.
These have been taught to us in a lecture of case history taking in 2nd year.

During the whole consultation, there was a mixture of feelings:

Predominantly I was scared and anxious: for any physical aggressiveness towards me, due to the magnitude of the patients voice. However, the tutor mentioned I managed this well by not showing this to the patient.

Insecure initially: from the start I predicted that I will have to make many efforts for her to share with me as much information to make an appropriate working diagnosis. I also realized she may not like this.

Doubtful: if I should follow my tutors decision in choosing not to treat her, because the patient had mentioned that she put in a complaint towards a previous practitioner for performing an HVT which aggravated her symptoms dramatically.

Controversially, I knew I was handling this patient well with my communication, so I felt also very confident at times.

Assured: I knew the tutor was observing everything through live feed cameras and he would come in and support me when needed.

After such a horrific/traumatic case history, I had differential diagnosis and decided that the patient was safe to treat. I started examining her and concluded a working diagnosis of left piriformis syndrome. Throughout the whole examination and treatment, I made sure my consent was extremely detailed without any ambiguity. I treated her accordingly that day, with conservative treatment and MET of the piriformis. Interestingly, after the treatment, the patient approached me completely differently: she was less in pain and acted less upset/aggressive.

Following the next treatments, she has managed to gradually build her trust in me and wanted nobody else as a practitioner. I have treated her for a period of a year, with a total of 26 treatments. It resulted in the best established patient-practitioner relationship out of all my patients. The patient became the best word-of-mouth, advising all her friends about me as a practitioner and we had many great conversations between the two of us. This was undoubtedly the patient from who I have learnt the most from. If there would be one thing out of all things that this experience taught me is the biopsychosocial overlap with the patients pain perception: her pain, stress levels and behaviour were all significantly linked. Whenever one would increase, the other one would increase as well. One specific example included at treatment number 12, where she came in with the same severity of pain compared to when we started. This because, her beloved dog, which she incredibly cares about has gotten bitten by another dog on a Sunday walk. She took the dog to the vet and as she expressed her frustrating emotions about her dog being hurt, she kicked a door with her left leg. This was the same leg that had the working diagnosis we have been treating her for.
I have been treating this patient with many different aims and objectives, each time she came in. This included structural work on the agreed working diagnosis, yet also craniosacral treatment. One other time, she came in with beginning symptoms of polymyalgia rheumatica where I referred her to her GP. It was indeed PMR and the patient has been put on prednisolone. This resulted in her feeling extremely bloated and lethargic, in which she experienced benefits from visceral treatment.
We commonly decided that she was able to be discharged around the end of May and at the last treatment she had given me a letter acting as a future reference, with a “Thank-you” card and a Belgium flag.

Reflection:

What did I do well?

I kept my composure, acting as a listening practitioner, wanting to show her support, not here to make her feel judged or attacked by.

I built an extremely strong relationship with her by doing this, as she felt benefit from expressing her emotions to me, yet I kept professional distance at all times.

What could I have improved?

Replace the role of the tutor in the case history when he felt the need of stepping in: mentioning that we ask these questions for her to benefit from. Reassure her that we are not here to annoy her.

She sometimes came late, (max 5minutes), and I mostly mentioned that it was “fine” for me. I often found myself lucky for not having a patient afterwards, but in the future, I would do this differently by mentioning to her first that she needs to come on time. Perhaps, if this wouldn’t change, by still finishing on time, which results in her having a diminished amount of treatment time, provoking her to come on time.

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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. (GoSC 2018, p.22-23)

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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. (GoSC 2018, p.22-23)

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1. A complaint is an opportunity to reflect on the communication and standard
of care that was given, and it may highlight areas of your practice that could be improved. A complaint which is handled well can also result in a stronger bond of trust between you and your patient, leading to improved patient care.

This reflection has been carried out using Gibbs’ (1988) reflective model.
Description
In second year, we had to complete a response to a letter of complaint. During the completion, I found myself struggling quite significantly, in comparison to my peers, which is unusual. I observed the older peers in my year, to deal with the assignment much smoother than the younger ones, the group which I belonged with. When I received my results back, these were indeed low and my amount of feedback was large.

Feelings:
This caused a period of uncertainty for me: I started to severely question whether studying osteopathy at such young age, was still the right path. During my course, I often dealt with comments about my young age - as I joined at 17 years old and will become the youngest ESO graduate in history, at 21 years old. Before this assignment, I saw this as a huge strength, while then, I saw it as a flaw for my problem-solving skills, which needed wisdom and experience in life. I became even more doubtful, when I heard that the assignment was not as problematic to some other young peers as well.

Analysis
The reason of having such doubts may be closely related to the fact I have had numerous jokes from peers, about me not being able to be independent. It was a large insecurity of mine, because it is correct to say that it was challenging for me to adapt to full independency, in a different country, learning a different language. However, I also related this to my young age, reason being, I developed an insecurity about my age and studying osteopathy abroad. Was this the right thing to do? Should I have waited longer to study osteopathy? I know I want to become an osteopath as fast as possible, however, could I have studied something before this? I started to analyze my process of studying osteopathy, although I knew wanted nothing else than that.

Conclusion:
This led to reasoning for being too young, whenever I would struggle.
My mental aims from then on, involved primarily acceptance, yet ignorance at the same time: yes, I am very young for this curriculum and profession, however, I will not use this as an excuse for any obstructions I may face in the future.

Action plan:
Going forward, by not wanting to make excuses, I decided to demand for further feedback on my assignment, in a face-to-face discussion with the modulator. This resulted in seeing my significant flaws, and being able to learn from them in the future. The assessor mentioned to me it was a very wise decision for me to speak to her for further feedback, as we all will face letters of complaints in the future at one point. I took her advice on board and feel confident in responding to a letter of complaint, if necessary.

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PPD II 21804817_OS526 A response to a letter of complaint

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D5. You must respect your patients’ rights to privacy and confidentiality, and maintain and protect patient information effectively. (GoSC 2018, p. 23-24)

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D5. You must respect your patients’ rights to privacy and confidentiality, and maintain and protect patient information effectively. (GoSC 2018, p. 23-24)

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1. Maintaining patient confidentiality includes:
1.1 keeping confidential your patients’ identities and other personal
information, and any opinions you form about them in the course of
your work

This reflection has been carried out using Gibbs’ (1988) reflective model.
Description:
In year 3, I lived with a colleague of mine which was extremely informative as he and I often discussed our patient cases with one another. We learnt each other things we have learnt ourselves in clinic, not withholding any information because we both knew we wanted to become great osteopaths.
In the 2nd month after the start of year 3, my clinic group and his clinic group were in the same building, and one day I saw him with one of his patients. That same evening, he talked about his challenges he experienced with a case he had that day. He went on to explain the case history, examination findings and the feedback the tutor gave him. He was unsure about whether or not he could help this patient due to the long history of lumbar degeneration the patient came in with. He felt quite pressured as osteopathy is the last option before she considers surgery. He mentioned her degeneration is so severe that she cannot walk without the support of her 2 crutches. Afterwards, I mentioned I had seem him with that patient and I asked him if I was correct. To my surprise, he answered: “I couldn’t possibly comment” - I did not understand his response at first, by which he explained he will uphold the confidentiality of the patient.

Feelings:
My initial feelings were that he did not trust me, that this was something personal towards me. However, on a second thought, he massively impressed me by his response: we both knew the patient discussed was the patient I saw, using the 2 crutches, yet he chose not to please my curiosity.

Analysis:
It made me reflect on myself, whether or not I have maintained my duty of confidentiality in the past. In honesty, it made me realize I have unconsciously not met the confidentiality at times.

Conclusion:
This event massively increased my awareness when discussing cases with peers or teachers. The strategy he took is correct and goes along my morals. His answer was careful and respectful, not indicating any personal distrust towards me.

Action plan:
I have used and will continue to use this composure for whenever I suspect someone would show an extensive amount of interest in my patients or if I get close to breaching the patients confidentiality. I have also familiarized myself with the confidentiality code of practice from other health care institutions, such as the NHS (Department of Health 2003).

References:
Department of Health, 2003. Confidentiality, NHS Code Of Practice, Available At: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/200146/Confidentiality_-_NHS_Code_of_Practice.pdf
[Accessed April, 26, 2021].

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D6. You must treat patients fairly and recognize diversity and individual values. You must comply with equality and anti-discrimination law. (GoSC 2018, p. 25)

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D6. You must treat patients fairly and recognize diversity and individual values. You must comply with equality and anti-discrimination law. (GoSC 2018, p. 25)

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1. You should be familiar with the requirements that apply to you under equality law.

This reflection has been carried out using Gibbs’ (1988) reflective model.
Description:
Along the last 2 years, one peer of mine was increasingly expressing his political opinions towards me and closer colleagues. Firstly, he was sharing quotes and images in one shared group chat we had. He continued in the next months by wearing clothes supporting his political party. This specific party, advocated discrimination towards specific groups of populations. This got progressively worse and resulted in us expressing our disapproval towards him imposing his ideas and political opinions on us. He could not understand he had to be careful discussing such sensitive topics, especially in an environment like ours which aims to be professional with no tolerance for discrimination. One colleague and me, in particular, have made many unsuccessful efforts for him to try to understand.

Feelings:
It made us feel extremely disturbed as we considered him to be a friend, meaning people may associate us with him. I noted it affected me much more in comparison to other colleagues.

Analysis:
As a person and practitioner, I stand for equality and anti-discrimination. This person also knew about this, but was not considerate in respecting my values.

Conclusion
After the world-spoken event of George Floyd, we decided to withdraw from him as a friend. This is because his statements related to this event, were unjustifiable. Being part of a widely-diverse community, as an osteopath I will be meeting people with different characteristics and from all different backgrounds. I will never not treat a patient based on these factors, and I refused to associate myself of someone who potentially would.

Action plan:
Many complications followed after, as the Student Welfare Officer got involved because of this. It resulted in us coming to an agreement of having no further communication with each other. I am relieved and proud of being brave enough to take my professional identity in my own hands, due to the fact his behavior went against my individual values and the corresponding osteopathic practice standards. Therefore respecting the equality law is crucial not only as a practitioner, yet also as a human-being (AgeUK 2020).

References:
AgeUK, 2020. Equality, discrimination and the Public Sector Equality Duty, Available At:
https://www.ageuk.org.uk/globalassets/age-uk/documents/factsheets/fs79_equality_discrimination_and_the_public_sector_equality_duty_fcs.pdf  [Accessed April, 26, 2021].

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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. (GoSC 2018, p. 25)

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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. (GoSC 2018, p. 25)

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1. The public’s trust and confidence in the profession (and the reputation of the profession generally) can be undermined by an osteopath’s professional or personal conduct. You should have regard to your professional standing, even when you are not acting as an osteopath.

This reflection has been carried out using Gibbs’ (1988) reflective model.
Description:
This standard has been a challenge to me as a student from the moment I joined the course. Additionally, on numerous occasions, peers and tutors have often questioned me/provided feedback on my lack of upholding my professionalism outside of the workplace.

Feelings:
It made me feel insecure - as if I could not be who I wanted to be. I felt overly judged in regards to this criteria and started to overthink about whether or not I should care what other people think of me, whether osteopathy was the profession I would like to continue in, if I am unable to be myself, or if I should start changing this behaviour as soon as possible.

Analysis:
The reason of why I was having such trouble to accept this osteopathic practice standards, may be because of several reasons.
Firsty, it may be because of the young age I joined the school. Despite age is not considered to be associated with professionalism, it did in my case. I felt more and more professional when I was turning older, coming towards adulthood.
Secondly, taking my philosophy of life into account, is it very important for me to consider that this has shaped me to who I am today. Early in my life, I had dealt with many losses due to death in my family. This, in combination with my enraisement, has shaped my take on life by realizing every day could be your last day, so you should make the most of it. A day without experiencing true happiness, was a lost day for me. Since I had this mentality, I was looking out for ways of creating happiness - one of them being less professional than I should be. I am often described as extraverted, outgoing, action-oriented and the life at the party.  This involves me often taking this role, without a second thought for “having regard to my professional standing, even when I am not acting as an osteopath.” Furthermore, results from a personality test (found below), describes me with exactly the same characteristics.

Conclusion & Action plan:
In order to comply with this standard I had to majorly develop as a person and as a professional. By doing so, I have asked my closest peers to provide feedback on occasions where I would lose track of upholding my professionalism. I started to seek colleagues who felt the same way, and who were willing to change this. I began to increasingly reflect on who I was, which parts were unchangeable and which were crucial to be dismissed. After lots of hard work, dedication and a lot of emotional discussions, I feel I have developed into ensuring a professional profile at all times, including when not acting as an osteopath. I will continue to analyze whether or not my overall presence will be representative of the standing of the profession.

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D8. You must be honest and trustworthy in your professional and personal financial dealings. (GoSC 2018, p. 25-26)

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D8. You must be honest and trustworthy in your professional and personal financial dealings. (GoSC 2018, p. 25-26)

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4. You may recommend products or services to patients only if, in your professional judgement, they will benefit the patient.

This reflection has been carried out using Gibbs’ (1988) reflective model.
Description:
A post-natal patient came to see me with 3 presenting complaints: low back pain, shoulder pain and coccydenia. I managed to get rid of the shoulder pain and coccydenia after 2 treatments, yet the low back pain remained. I have provided her with 9 continuous treatments, without having any effect on the severity of her low back pain. My possible options were slowly decreasing, as I confidently tried every different osteopathic modality, in combination with and without exercises. Along the course of the treatment plans, we addressed all possible areas of the body which may have come into play, without success. This prompted me to do autonomous research about post-natal low back pain and management plan. I came across the option of a “Serola Belt” - a stabilizing belt applicable around the pelvis for pregnant and post-natal women, aiming to maintain pelvic stability. I decided to advise this belt to her, after discussing this with my tutor who agreed, despite there being no robust effectiveness. I shared with her my reasoning, what benefits it may bring, the relative high cost (£33) in comparison to products I usually advise such as resistance bands (£10).
The following treatment, she came in with the belt, in need of further instructions of how to apply the belt. Because I have never come into contact with the belt, I felt extremely incompetent and irresponsible, as I had no idea on how to answer this inquiry. I decided to honestly share this with her, as to which she responded quite understandable, however, I realized this scenario makes me lose credibility as a practitioner. Afterwards, she came back the following 2 weeks mentioning that her pain has decreased, which made me relieved.

Analysis:
Despite a happy ending, I realized it could have resulted in completely the opposite way. I was found lucky because of the patient being so understanding, because I am still a student. Furthermore, I am relieved the belt has helped with her symptomology.
On reflection, I have found it completely unethical for me to advise something to my patients, which I have not tried out myself. On the other hand, because I am familiar with the product now, I am more confident in advising the belt to post-natal patients.

Action plan:
I researched the area more and discovered that about the Active Straight Leg Raise Test (ASLR), accounting for a functional pelvic test, assessing pelvic instability (Vleeming et al. 2008). If positive, this determines an increased likelihood of benefit a sacroiliac stability belt may bring to the patient. In the future, I will encorporate this test in my examination routine for post-natal patients, solely advising the belt to a patient when the test returns positive. Any product I am considering to advise to my patients will be purchased by me beforehand. This will eliminate similar scenarios and result in improved patient care, as I will be hopefully able to answer enquiries from the patients regarding the product. By doing so, I act as an ethical, honest practitioner, solely advising the product which may act as a benefit to the patient, from objective findings in my examination.

References:
Vleeming, A., Albert, H. B., Östgaard, H. C., Sturesson, B., Stuge, B., 2008. European guidelines for the diagnosis and treatment of pelvic girdle pain. European Spine Journal, 17(6), pp. 794–819.

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D9. You must support colleagues and cooperate with them to enhance patient care.  (GoSC 2018, p. 26)

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D9. You must support colleagues and cooperate with them to enhance patient care.  (GoSC 2018, p. 26)

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3. If you are responsible for an associate or assistant, you should provide professional support and adequate resources for them so that they are able to offer appropriate care to their patients. You should not put them under undue pressure, or expect them to work excessive hours. You should not expect them to provide treatment beyond their competence.

This reflection has been carried out using Gibbs’ (1988) reflective model.

Description:
In year 4, a colleague in my clinic group had some troubles with a case of hers. Her approach is quite evidenced-based and does not tend to use BLT, fascial unwinding or craniosacral therapy. A patient came in with a presenting complaint who warranted a very osteopathic approach. It was hard for her to identify the tissue-causing symptoms and form a diagnosis. During her clinical reasoning process she had asked me for my opinion, I shared with her more the osteopathic side of thinking when considering this patients’ presenting complaint, including the 5 osteopathic models. She mentioned she has rarely heard such good explanation and it made a lot of sense to her. She felt confident going into examination and treatment again and came back to me after the consultation. She wanted to practice more with me and exchange each other’s ideologies/experiences/concepts/hypotheses etc. as she felt she could learn a lot from me.

Feelings:
This made me feel quite proud as one of my aims is to learn as much about osteopathy as possible during these 4 years. It made me feel like I wanted share my experience in regards to osteopathic findings more with my peers and it prompted me to inspire others. There is an extreme quantity of knowledge that can be gained in osteopathy and this knowledge is massively interchanged by face -to-face teaching settings or discussions, adopted by those who are eager to learn more. This goes in line with the fact it isn’t an education program that is available in regular universities because of its nature in regards to teaching, with a need of personal supervision.

Analysis:
The reason I felt such satisfaction is because I always felt I want to inspire people, I want to become exceptional in my craft and being able to share that with others. One of my idols in life, Kobe Bryant, has always put the emphasis on inspiring the younger generations: transpiring knowledge and theories to those who want it enough, otherwise, what is the point? I felt like I have managed this well, due to the fact my colleague, who initially is evidence-based driven, was open to learning from my osteopathic ethos. This meant a lot to me.

Action plan:
Since then, it has boosted my confidence in discussing my theories with tutors, peers from my year and those in the years below. In year 4 I have lived with 3 second years and initially it started of slow. I taught them a few things occasionally, but this started to grow massively after the aforementioned event with my colleague. Currently, I keep sharing new aspects I have learnt with them, aiming to increase their interest and ambition regarding osteopathy. They are extremely grateful for my willingness to share answers on their questions and I am extremely grateful for them to show interest for me to share my passion.
This has caused me to have shared my interest with the European School of Osteopathy in becoming an assistant, for next year. I aim to continue to expand my knowledge as much as possible, and in turn, to share this knowledge with those who are curious and keen to be educated.

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D10. You must consider the contributions of other health and care professionals, to optimise patient care. (GoSC 2018, p.26-27)

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D10. You must consider the contributions of other health and care professionals, to optimise patient care. (GoSC 2018, p.26-27)

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1.4 work collaboratively with other healthcare providers to optimise patient care, where such approaches are appropriate and available.

This reflection has been carried out using Gibbs’ (1988) reflective model.
Description:
One of the first times I have truly worked collaboratively with another health care provider was in the specialist headache clinic. The tutor was extremely knowledgeable and over the course of 6 weeks, had put a lot of emphasis on collaborative work for optimizing our results with migraine patients. One example includes her offering lifestyle modifications to her patients, based on the mnemonic SEEDS (sleep, exercise, eat, diary, and stress). I had one patient who suffered from chronic migraines. I have completed the “Case Report”-assignment in 4th year discussing this case, which can be found below. In this case I have showed a clear collaboration between osteopathy and her present dietician who she was seeing regularly, for there to be an optimal holistic approach. This contained an educational handout to the dietician in regards to limiting types of food which have been shown to be common triggers for migraine sufferers.

Feelings:
In my opinion, this tutor is one of the only tutors in the ESO clinic who has shown it is completely possible to work along other healthcare professionals, while applying osteopathic treatment.
I felt that in osteopathy there is often an ego of osteopathy being the solution for everything, including myself.

Analysis:
The reason why I may have felt this way, is because of the fact I have never been inspired by any tutor that clearly showed a collaboration between an osteopath and another health care professional may work.

Conclusion:
I needed to be able to dismiss my ego of osteopathy being the sole solution for the majority of conditions out there. I realized this is, and cannot be the case. We all need to rely on other specialists in their fields, when aiming for an optimal patient-centered care.

Action plan:
This encouraged me to explore further options available outside of osteopathy when dealing with a presenting complaint, such as migraine, which is shown to benefit from an overall/holistic approach. This will enable the patient to feel that the most appropriate care is aimed to be provided for them and feel appreciated that someone is looking after them appropriately.

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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. (GoSC 2018, p. 27)

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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. (GoSC 2018, p. 27)

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2. If you are exposed to a serious communicable disease, and you believe that you may be a carrier, you should not practise until you have received appropriate medical advice, and you should follow any advice you are given about suspending or modifying your practice. You should take all necessary precautions to prevent transmission of the condition to patients.

This reflection has been carried out using Gibbs’ (1988) reflective model.
Description:
There are scenarios which may occur in osteopathic care, where a patient comes in with a highly transmittable condition, endangering the osteopath and the following patients. Examples are shingles, conjunctivitis, impetigo, tuberculosis and many more. In such instances, the osteopath is unable to treat the patient, due to the risk of transmission.
However, a much more recent virus, named COVID-19, took undisputedly priority above all: a global pandemic broke out at march in year 3, which regulated all physical/social contact.
In the pandemic, when the clinic reopened in July, there was an extreme emphasis being put on for forbid people to come in if any symptoms of COVID-19 were present, for both patients and staff. Practitioners had to perform a careful screening with each patient, for the detection of the COVID-19 virus, by asking the following questions:

Any continuous cough?

Loss of/or change in taste/smell?

Any members of the household who experienced symptoms of COVID-19 or who has been tested positive?

Next to this, many other guidelines have gotten induced one of them being that practitioners were forced to wear a mouth mask, aperone and gloves. The Institute of Osteopathy (iO) has informed osteopaths with updated guidelines, from Public Health England (The Institute of Osteopathy 2021). It includes sections such as adapting your practice, frequently asked questions and many more. Next to this, the European School of Osteopathy provided guidance for students, when returning to clinic after the pandemic, which is found below.
Practitioners had to disinfect the treatment room, were unable to use couch covers and were advised to regularly receive a COVID-19 test at the school premises. Although these guidelines may compromise optimal osteopathic care, this was irrelevant as the virus carries life-threatening and disabling effects.

Feelings:
Often, teachers, colleagues and including myself, used to repeatedly complain about these regulations, especially the gloves and aperone. I did not enjoy following these guidelines at all, because I felt it was a burden and an overuse of plastic, which goes against my morals as I tend to not enjoy using plastic at all. Furthermore, I felt that because I was in the medical health sector, my social life had been massively impacted, for me not to get contaminated. This was progressively worse over time in year 4 and although I followed all the rules, I sincerely was getting annoyed by them, due to the prolonged period.
However, on reflection, I cannot believe how selfish I was acting like, when people are losing their loved ones because of this virus. All I could think about is the lost time and memories accounted for, the relationships that diminished through the separation of quarantine and that it had forced me to become a different version of myself, a version I did not like.

Analysis:
There are many reasons as to why I may have felt that way, yet one of the main reasons was because majority of people around me were having the same mentality, because we were all making the same sacrifices. Nevertheless, I became disappointed in myself that it took me so long to realize that the complaints I was making were inappropriate: I had a roof above my head, foot on the table, and most importantly, I did not lose any of my loved ones to the virus.

Action plan:
Although I was in the health sector, sacrificing my personal, social time, in the period of September-December, I have become much more appreciative due to the fact our university/clinic was able to continue its schedule, in comparison to many other universities who remained closed. I started to look at the bigger picture, the future: to become a great osteopath. At last, that is the reason I am here for, miles away from home. I started to focus a lot on my own development as an osteopath. In the period of January till May in particular, where I realized I cannot withdraw joy from the usual things I loved doing (social events being one of them). So I taught myself on withdrawing joy from working, studying, researching, completing notes, being organized and becoming an overall better practitioner. I wanted to keep my mind busy, and I chose osteopathy to do that. In return, this improved my relationships again and the time I invested had its extreme benefits when I compared myself to my colleagues, before everything happened. I have made a massive jump in terms of knowledge and skills, curiosity and motivation, which were increasingly lacking with most of my peers. I am very grateful for the adaptations I was able to make and for such a big passion to be present in my life. As far as my knowledge, I did not have COVID-19,  this is because all of my tests (6) were negative and I did not contain any antibodies. I am very proud of this, as I made many sacrifices for putting my patients on the first place. I feel like I have clearly demonstrated to be able/motivated enough to comply with the osteopathic practice standards, solely by looking at this criteria. Moving forward, I will continue to put my patients health at the first place, for instance to get vaccinated and to not attend shifts when I am symptomatic or experience a high temperature. I will also aim to remain hygienic, washing my hands after every treatment. In case I will not be able to make the right assessment about my own conditions, an external party (eg. GP) may help determining the right decision.

References:
The Institute of Osteopathy, 2021. COVID-19, Available At: https://www.iosteopathy.org/covid-19/[Accessed May, 14, 2021].

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RETURN TO CLINIC 13th JULY - STUDENTS _final_PDF

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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. (GoSC 2018, p. 27)

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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. (GoSC 2018, p. 27)

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C3.You must respond effectively and appropriately to requests for the production of written material and data. (GoSC 2018, p. 17)

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C3.You must respond effectively and appropriately to requests for the production of written material and data. (GoSC 2018, p. 17)

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1.1 produce reports and referrals, and present information in an appropriate
format to support patient care and effective practice management

This reflection has been carried out using Gibbs’ (1988) reflective model.
Description:

When performing an initial case history, in march 2020, a patient came in with a history of a road traffic accident (RTA), 1 month prior to the consultation. When I finished the case history, I needed to present my case to the tutor, as usual protocol dictates. I was aware of the following follow-up questions I had to ask, in order to be complete with my data gathering:

Going through litigation?

Mechanism of RTA?

Speed of vehicle?

Whiplash/concussion presence?

The tutor mentioned I needed to elicit much more information about the RTA, for getting the whole picture with regards to osteopathic management, yet also for litigation purposes.
The patient was indeed going through litigation, where the tutor mentioned that this is incredibly important to be as detailed as possible, because the likelihood for a request for producing the written material of that case increases majorly. Especially if the patient is in pain, which they probably are, because they came to see us.

Feeling:
This made me feel motivated of learning more about follow-up questions in case history, especially if my notes are likely to be required for legal purposes.

Analysis:

Because this area was covered multiple times before in previous lectures, I thought I was very complete with my follow-up questioning on this subject, however the reason why I felt so motivated afterwards, is because it showed me once again that learning never stops. Osteopathy is a profession that requires continuous professional development, one of the reasons it became such passion of mine.

Conclusion:
It made me recognize the relevance of full completion of clinical notes, not only for appropriate diagnostic reasoning and patient management, yet for legal purposes as well. In patients going through litigation, the details have to be huge and the diagnosis needs to be accurate and well-supported by data gathering and objective findings. This, because our clinical notes can be used as evidence and may be requested for legal purposes. I would want them to be as accurate as possible in order for me to be safe, backed-up by my notes.

Action plan:
I asked the tutor for advice on how to improve my follow-up questioning and therefore completion of notes. On his turn, he gave me advice and a list of questions he would like to ask (found below). I started to learn these, for completion of my data gathering in the future and recognized the significance of getting the whole picture in any situation, not just following an RTA.

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C4. You must take action to keep patients from harm. (GoSC 2018, p. 17-18)

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C4. You must take action to keep patients from harm. (GoSC 2018, p. 17-18)

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2. You should have an awareness of, and keep up to date with, current safeguarding procedures, including those relevant to your local area, and follow these if you suspect a child or vulnerable adult is at risk.

This reflection has been carried out using Gibbs’ (1988) reflective model.

Description:
In year 2, I attended a lecture about the Osteopathic Practice Standards, involving this criteria. Personally, I had a definite interest when this point got addressed, as I thought it is likely for us to deal with such circumstance. The reason why I think this is because we have more time with the patient to communicate, on top of the fact we can observe bodymarks due to potential self-harm or harm by others, as they get undressed. When our teacher explained this point, he has used an example of when he had to break patients’ confidentiality: the patient had always felt comfortable for expressing their emotions with him. At one point the teacher clearly saw the patient was having one of the most difficult times of his life, going through many different emotional events. The patient mentioned he was losing motivation and hope and was seeing the end of the tunnel. At that point the teacher shared his actions with us: he continued the treatment, yet as the patient walked out of the room, he phoned up the patients’ GP and making the GP aware of what just happened. Afterwards, he saw the patient a couple of months later and the patient excessively expressed their gratefulness to the teacher. He mentioned he went through the darkest period of his life, but this period has gotten to an end. This was because of the psychological support he received that his GP had spoken to him about.

Feelings:
I was extremely attentive to this story,  because I felt that if the right actions are taken, a life can be saved.

Analysis:
We have been competently educated for identifying life-threatening medical conditions, yet psychological life-threatening dangers can be often missed. This is as important as we are trying to identify someone’s life is at risk.
The reason I may have perceived this story with such great significance/value is because I have lost my father due to suicide. This has had a marked impact on my life, who I am today and what I want from life. It had lead to the way I conduct myself as a practitioner, prioritizing certain aspects more than others, in osteopathic care.

Action plan:
It had grown my interest even more in psychology, recognition of mental disorders and their management. I went on to complete a safeguarding training, which was compulsory for joining the ESO teaching clinic in 3rd year. This training helped me for recognition and actions which need to be undertaken.

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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. (GoSC 2018, p. 13) 

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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. (GoSC 2018, p. 13) 

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Description:
Over the last 4 years, this criteria was easier to reflect on compared to others. This may be because when I did not know something, this became very apparent, especially in the ESO teaching clinic, where tutors would identify an area of weakness when needing to justify clinical reasoning based upon the knowledge that I have. Found below, are all the grades I have received from year 1 till year 3.

I will address each year into further detail.

Year 1:
In year 1, I had particular trouble in the beginning of the course to keep up with the new knowledge we were being taught, in comparison to colleagues. This, because I arrived late in November: I initially started studying osteopathy in Belgium, but the university I was in decided to stop the full-time osteopathic education, so I chose the ESO to continue my education for the same year. This resulted in me falling behind on the course modalities pathophysiology, anatomy and all the practical lectures. It forced me to study a lot in the beginning of my transfer, yet still permitted me to score 80% on my first exam, 1 month after I joined.
I knew for a fact osteopathy is what I wanted to be passionate about, for the rest of my life. Which is why I had certain goals in mind since the beginning of my career as a student. Some of these goals were more generic such as “Become a great osteopath, not just average”, or were more specific such as “Graduate with a First Class Honours”.  In year 1, I developed crucial knowledge regarding anatomy, pathophysiological processes and osteopathic philosophy and concepts, which were all incredibly exciting to be educated about.

Year 2:
In year 2, I felt that it was more about learning how to apply the knowledge I have learnt in year 1, rather than learning a lot more new aspects, especially practically based knowledge: application of anatomical landmarks, origin, insertion, innervation, and function of muscles became a lot more smoother for me. We have been introduced to many principles of clinical reasoning and biomechanics in 2nd year, which shaped my osteopathic skills tremendously.

Year 3:
In year 3, in the beginning of the year, I have found my knowledge to have increased drastically after my clinical hours, with or without patients. My goal included for every time I went into clinic, to learn something new, each time. The majority of times in clinic, I have focused mainly on improving my diagnostic reasoning, by data gathering from in the case history.
In combination of clinic and assignments of professionalism, I have been appropriately introduced in to how to critically evaluate scientific information and data to inform osteopathic care. Furthermore, our psychology lectures gave me a further understanding of the psychological and social influences on patients and expanded my knowledge in this aspects as well.

Year 4:
In year 4, I developed a more autonomous problem-solving and thinking skills. I started to rely less on clinical tutors for their opinion regarding clinical reasoning in forming a correct working diagnosis and whether or not the patient is safe to treat. This, by understanding the characteristics of the normal and abnormal functioning of different body tissues and systems to inform the interpretation of clinical findings and the ability to determine changes in health and function by the appropriate use of observation, palpation, motion and clinical evaluation.
Because this became a strength of mine, I started to focus mainly on improving my short and long term management plans. However, after my mock CCA, I identified that I was lacking examination routine and practice because of several reasons: firstly, the pandemic has made my number of patients decrease. Secondly, I was focusing for a long period on theory because I could see some peers of mine, which I normally compared myself to, getting more knowledgeable than me. I am competitively driven for a majority of things in life, especially in my osteopathic education, hence I did not want let that gap increase. Thirdly, I was preparing for my mock CCA and became more insecure about whether or not my theoretical knowledge is sufficient or not, hence I focused dominantly on theory once more.
I started to observe a clear connection between those same colleagues of mine who were more knowledgeable, and their practical skills being not as skillful as mine. Although this is subjective, they mentioned they lacked confidence, palpatory and technical skills in practical settings. This has given me more confidence, as I reflected that both my theory and practical were equally qualitative in practice.

Action plan:
The aforementioned goals from 1st year became more and more realistic over the length of the course. I have ensured that, as a practitioner, I have been continuously reflective by identifying weaknesses and making them my strengths. I have adopted this philosophy by a great professional athlete, named Kobe Bryant, who has inspired me in becoming exceptional in my craft. It has also taught me that setting goals in life, will definitely aid to my self-discipline, aiming for improvement.
I have and will always continue in showing major interest for receiving feedback from patients, colleagues and tutors and as part of my CPD, being self-reflective by discussing challenging and non-challenging case analyses with colleagues or superiors, because all of these have accounted for the majority of my development in knowledge, skills and performance.

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C5. You must ensure that your practice is safe, clean and hygienic, and complies with health and safety legislation. (GoSC 2018, p. 18)

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C5. You must ensure that your practice is safe, clean and hygienic, and complies with health and safety legislation. (GoSC 2018, p. 18)

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1. Your practice premises must be clean, safe, hygienic, comfortable and appropriately equipped.

This reflection has been carried out using Gibbs’ (1988) reflective model.
Description:
In the course of year 3 and 4, I have always aimed for my treatment room to be as presentable as possible. I often judged colleagues for not putting in effort for small details I greatly valued. Examples are: positioning the couch roll perfectly on the bench with the right length, or arranging the pillow decently so it is separately wrapped in a piece of couch roll.

Feelings:
I feel like like this shows the patient that I am willing to make that extra effort for them, to make them feel important. A controversial impression would be given to the patient if my treatment room was unorganized or presenting as unhygienic. On the picture attached to this criteria, it aimed to demonstrate how clean and hygienic I want my practice room to be like.

Analysis:
The reason I am highlighting cleanliness, may be because of the fact I have been visiting my osteopath since I was born and he gave me the exact same impressions. Not once did I observe a lack of hygiene or tidiness.

Conclusion:
It is a continuous impression we give to the patient about our personality - showing I am organised, will boost my credibility. This, in combination with a professional outfit, by looking very presentable. I strongly feel that the identity of the treatment room should go hand in hand with the way the practitioner is dressed, and with the personality of that practitioner. By doing so, it will enhance the impression patients may receive of the ‘overall cleanliness’, if the practitioner also looks very presentable and hygienic him-/herself.
To my surprise, there are no guidelines in the osteopathic practice standard in regards to outfit/clothes/shoes. However, such guidelines may not be present due to the nature sport osteopaths may manage their patients with: executing exercises correctly in front of the patient may need a sports outfit, including shorts and trainers.

Action plan:
In the long term, I am very excited for arranging my own clinic space, wearing my own chosen outfit, personalized to the clinic. I am aiming to increase the value I put into details in the clinic, with regards to hygiene, attractiveness and safety.
In the short term, I will continue keeping a high reputation of the clinic I will be working for, making sure my treatment room fulfills these criteria at all times.

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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. (GoSC 2018, p.18)

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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. (GoSC 2018, p.18)

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1. You should be aware of public health issues and concerns, and be able to discuss these in a balanced way with patients, or guide them to resources or to other healthcare professionals to support their decision-making regarding these.

This reflection has been carried out using Gibbs’ (1988) reflective model.
Description:

Approaching the final months of 4th year, a clinical tutor decided to test our knowledge in management of degeneration of the hip, outside of osteopathy. He wanted to see if we could sufficiently guide a patient to other healthcare professionals, even with a commonly seen, treatable musculoskeletal complaint. It resulted in him identifying a big weakness amongst all of us, including me, because we could not offer patients their full rights in our consent process, by providing them the options and guidance in their decision-making.
Identifying conditions which need medical support, is something that has been focused on majorly during the course. However, knowing how to sustain a multimodal approach in the conditions we commonly seen, was lacking.

Feelings:
I became very aware that my knowledge for external treatment modalities outside of osteopathy was incomplete.

Analysis:
This may have been because of the fact I praised osteopathy higher than other health care professions. This has originated from one of the reasons I joined osteopathy: its holistic, effective approach, in comparison to medicine, acupuncture, massage, chiropractic care etc. I strongly feel osteopathy includes all systems/structures of the body, aiming for true improvement caused by the body’s own self-healing mechanism. I may have lost myself in appraising osteopathy, by believing in it too much.

Conclusions:
I needed to reconsider what I understand by a true patient-centered approach includes for me, as a practitioner. What if it includes the patient warranting another form of medical health care or a multimodal approach?

Action plan:
I reconsidered my ethos about a patient-centered approach and how I can ensure the delivery of a patient-centered approach as an osteopath.
Furthermore, the tutor has strongly adviced us into looking for management protocols of commonly seen musculoskeletal complaints in osteopathy, such as hip osteoarthritis, subacromial impingment syndrome, disc prolapse, and many more (NICE 2014). Next to this, he offered a group discussion about surgical referral, including its referral and operative procedures, prognosis, risks and benefits. More importantly, he demonstrated how he would communicate this to the patient, including reassurance of his support for their decision-making process.
Since then, I have aimed to be familiarized with the current NICE-guidelines as to when and whether it be deemed suitable for multimodal referrals including electrotherapy, podiatrists, imaging and surgery.

References:
NICE, 2014. Osteoarthritis: care and management, Available At: https://www.nice.org.uk/guidance/cg177/chapter/1-Recommendations [Accessed May, 14, 2021].

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B2. You must recognize and work within the limits of your training and competence.(GoSC 2018, p. 14)

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B2. You must recognize and work within the limits of your training and competence.(GoSC 2018, p. 14)

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2. If not, you should consider:
2.1 seeking advice or assistance from an appropriate source to support your
care for the patient
2.2 working with other osteopaths and healthcare professionals to secure the
most appropriate care for your patient
2.3 referring the patient to another osteopath or appropriately qualified
healthcare professional.

This reflection has been carried out using Gibbs’ (1988) reflective model.

Description:
In the 2 years I have been a student practioner, I have decided to refer 6 patients for the following hypotheses:

1. Traumatic spondylolisthesis (A&E)

2. Migraine (dietician)

3. Cholesystisis (GP + A&E)

4. Polymyalgia rheumatica (GP)

5. Cervical myelopathy (+cauda equina) (A&E)

6. History of TIA/stroke (GP)

Feelings, Analysis & Conclusion:
Whenever I refer patients to other healthcare professionals to secure the most appropriate care for my patient, there was a development of feelings in the first times compared to the last times.
In the beginning (examples 1-3), I relied predominantly on my tutors’ support for appropriate decision making. Although I have elicited the information well in the first 3 cases, I felt unconfident in autonomously making the decision as to whether and where we would refer them. The reason I may have felt this way is because of the lack of experience I had and because I was not aware of the management protocols of the conditions, meaning I was lacking knowledge.
In the later stages (4-6), I have made the decision myself, without guidance of the supervised tutor. I felt confident in referring these as the signs and symptoms of the patient and the objective findings retrieved from examination were less ambiguous in comparison to the first 3. I gained knowledge in regards to management protocols and I felt that these last 3 were more ‘obvious’ for a need of referral. I would like to mention that although these were my decisions, the tutors agreed in all scenarios.

Action plan:
I chose to ask advice to one specific clinic tutor, who is excellent in follow-up questions for identification of medical conditions. Next to this, I chose to improve my differential diagnosis reasoning by fully reading a book specifying in this field (Goodman, 2018). Because I was discovering such quantity of information, I had to structurally store this into a document, which I named “systemics” (found below). Extra pieces of information would get added into this document whenever I learned something new about a diagnosis which needs referral.
All of these reasons may explain why I became more confident in my screening for referral and following decision-making. I continue to expand my knowledge about medical conditions which need referral and will add information to this document. This, because as a medical health practitioner, it is my responsibility for providing optimal safety in practice. It is impossible for me to comply with this if my knowledge is incomplete in this area.

References:
Goodman, C.C., Heick, J., Lazaro, R.T., 2018. Differential Diagnosis for Physical Therapists: Screening for referral 6th ed., Missouri: Elsevier.

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B3. You must keep your professional knowledge and skills up to date. (GoSC 2018, p.14)

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B3. You must keep your professional knowledge and skills up to date. (GoSC 2018, p.14)

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1.1. be professionally engaged, undertaking professional development activities and complying with GOsC requirements regarding continuing professional development

This reflection has been carried out using Gibbs’ (1988) reflective model.

Description:
As a student in year 3, I have already attended an undergraduate Continuing Professional Development (CPD) event. This because I identified a weakness in my knowledge, skills and performance regarding osteopathically approaching the Temperomandibular joint (TMJ).

Feelings:
I felt I was lacking osteopathic reasoning in regards to assessing the TMJ for dysfunction, needed clarity on predisposing factors to TMJ dysfunction, and I was curious for holistic osteopathic treatment possibilities.

Analysis:
The reason I may have felt this way is because we have only briefly covered TMJ assessment in clinical methods, observing any deviation, basic palpating and seeing intra-oral inhibitory techniques on the pterygoid muscles. Next to this, TMJ was included in our MET curriculum at the end of year 3 and in osteopathic techniques curriculum at the end of year 4. Lastly, I have always had bias towards my interest of the TMJ, as my sister suffered from a long history of jaw claudication. It was often discussed at the dinner table, with no clear solution for many years.

Action plan:
The 8-hour course exceeded my expectations and provided me with further insights in how to treat more holistically. The course leader demonstrated a live treatment, with a very holistic approach, working form the feet upwards. This, because the stomatognathic system is highly proprioceptive, and sensitive to any changes happening elsewhere in the body. Along the whole day, we covered each seperate technique he demonstrated and see which kind of effect this has on the range of motion, quality of motion and potential present deviation of the jaw. It inspired me in scoping to be even more holistic, in every treatment I perform, especially when the patient comes in complaining of a dysfunction in highly proprioceptive structures such as the stomatognathic system or suboccipitals, accounting for neck pain or headaches.

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B3. You must keep your professional knowledge and skills up to date. (GoSC 2018, p.14)

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B3. You must keep your professional knowledge and skills up to date. (GoSC 2018, p.14)

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Furthermore, I have attended numerous barefoot club events in order for me to expand my knowledge I feel less secure about/eager to learn more about. Summaries from my eventbrite tickets can be found below.

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B4. You must be able to analyze and reflect upon information related to your practice in order to enhance patient care (GoSC 2018, p.14)

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B4. You must be able to analyze and reflect upon information related to your practice in order to enhance patient care (GoSC 2018, p.14)

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1. To achieve this you will need to have sufficient knowledge and ability to collect and analyse information and evidence about your practice to support both patient care and your own professional development.

Along the end of year 3 we had to begin the process of making our dissertation: a piece of work causing a what-seemed-to-be never ending rollercoaster of emotions. It was by far one of the hardest times in my life. By completing a literature review, I mainly demonstrated independence in gathering data for pre-determined, Masters Level analysis as per protocol, by answering my individualized research question: “What is the proportion of studies reporting the effect sizes of alternative exercise regimens as a treatment for women with stress urinary incontinence and what is their effectiveness on Quality of Life, Pelvic Floor Muscle Strength and Urinary Leakage?”

I completed my dissertation over the course of 8 months, however, I started to prioritize on it in the last 4 months. Underneath, I chose 4 questions which aim to reflect on my performance and where I critically discuss the process I underwent through for completion.

What did the dissertation taught me?
The dissertation has taught me the following points:

To be able to select and apply an appropriate methodology in answering a focused research question. This had taught me on how to utilize databases sufficiently, in order to retrieve studies relevant to the research question.

To be able to produce original and innovative research in a clinically relevant area, if I was to chose to perform research in my career pathway at some point.

To be able to analyze and objectively be critical on retrieved sources, relevant to a topic being explored for continuing my professional development.

To be familiarized with research terminology and draw conclusions from retrieved sources.

Practice-related, it has most certainly expanded my knowledge about a topic I was curious about for further exploration, in this case stress urinary incontinence. Performing such expanded research into 1 subject, resulted in me becoming more knowledgeable in this topic. It has taught me about the mechanism, the prevalence in affected population, risk factors to look out for in patients, the marked impact on quality of life, the large under-reportion of stress urinary incontinence towards health care professionals due to its associated embarrassment, its current management and an observed gap in the knowledge that needed to be addressed.

What were my limitations? (Reflection)
In combination with retrieving my feedback on my dissertation, there were numerous limitations identified.

Accessing all Bucks University provided databases, as I did not utilize science direct. On reflection, there was a high potential to an increased amount of retrieved studies when performing a strategic search on this database.

When I am unable to retrieve full-text articles I wish to access, I will explore the option of contacting library services and authors of studies for full-text retrieval.

I could have scoped to be more critical, in particular in the discussion section. In this section, I observed there was also a lack of comparison to the wider literature. However, I demonstrated critical reflection, by addressing the present limitations in my dissertation well.

I could have started with a more concise research question, which hopefully would have resulted in less inconsistency between the question, abstract and discussion. This would then hopefully result in a decreased chance of leading to confusion for the reader by bringing in answers to the research question sooner and clearer.

Am I satisfied with myself in regards to being able to comply with this osteopathic practice standard, because of the dissertation? (Feelings & Evaluation)
The dissertation has undoubtedly aided to structurally collect and analyze information and to scope for criticality as an osteopath, however it was not solely the dissertation which gave me these skills and insights. When looking back, I feel like all assignments in the previous years for the module of professionalism & identity, prepared me as much as possible to complete our dissertation sufficiently. It increasingly taught me these skills with every assignment, scoping for more and more autonomously and criticality.

What would I do differently, if I was to do it again? (Action plan)
Next to the limitations I appraised earlier, I would do the following differently, if I was to do it again:

As mentioned before, this was an extremely emotional roller coaster for me. It had massive psychological complications as I was in a continuously stressed state of mind. I have observed that my interpersonal relationships have severely suffered in this period and socially, I became much less interactive. I was lacking energy, felt lethargic and worked many hours till late in the night. One thing I would certainly do different is respect my mind and body more by allowing me to take more breaks and start the entire process earlier.

A supervisor was there to support me, to assist me through the process with their advice and knowledge and answer any relevant questions I may have had. Although I have used my supervisor sufficiently, I would perhaps worry less about judgment from his behalf. This would allow myself to be more open for asking questions which I am unsure about, which may lead to me feeling less insecure and potentially get a better result.

Discuss more with peers about how they are doing, which obstacles they might have faced and how they have overcome these. This might have helped me with similar issues I experienced and let me realize I am not the only student facing challenges. As a result, I might have learnt from their strategies and may have decided to adopt these in regards to similar issues I faced.

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B4. You must be able to analyze and reflect upon information related to your practice in order to enhance patient care (GoSC 2018, p.14)

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B4. You must be able to analyze and reflect upon information related to your practice in order to enhance patient care (GoSC 2018, p.14)

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Furthermore, each learning outcome for the dissertation is in accordance with osteopathic practice standard B4, as seen in the picture below.
I have also demonstrated my accomplishment of 62% in regards to my dissertation, showing compliance with B4.

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References:
Advertising Standards Authority, 2016. Which Medical Conditions Can Osteopaths Claim to Treat? Available At: https://www.asa.org.uk/advice-online/health-osteopathy.html [Accessed May, 14, 2021].

AgeUK, 2020. Equality, discrimination and the Public Sector Equality Duty, Available At:
https://www.ageuk.org.uk/globalassets/age-uk/documents/factsheets/fs79_equality_discrimination_and_the_public_sector_equality_duty_fcs.pdf  [Accessed April, 26, 2021].

Department of Health, 2003. Confidentiality, NHS Code Of Practice, Available At: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/200146/Confidentiality_-_NHS_Code_of_Practice.pdf
[Accessed April, 26, 2021].

Gibbs G., 1988. Learning by Doing: A Guide to Teaching and Learning Methods. Oxford: Oxford Polytechnic.

GOsC, 2018. Standards Of Practice | General Osteopathic Council, Available At: https://www.osteopathy.org.uk/news-and-resources/document-library/osteopathic-practice-standards/updated-osteopathic-practice-standards/ [Accessed April, 26, 2021].

Harvard Health Publishing, 2019. Ways to support someone who is grieving, Available At: https://www.health.harvard.edu/mind-and-mood/ways-to-support-someone-who-is-grieving
[Accessed April, 26, 2021].

Internet 1, 2014. Adherence to Home Exercise Programs, Available At: https://www.physio-pedia.com/Adherence_to_Home_Exercise_Programs [Accessed June, 2, 2021].

Internet 2, 2012. Communicating benefits and risks effectively to patients, Available At: https://youtu.be/I3-Y4wd1y2Q [Accessed May, 14, 2021].

Internet 3, 2019. 3 Firm Ways To Set Therapy Boundaries, Available At: https://youtu.be/HHdXCHnZo3c [Accessed May, 14, 2021].

National Institute for Health and Care Excellence, 2014. Obesity: identification, assessment and management, Available At: https://www.nice.org.uk/guidance/cg189/chapter/1-Recommendations [Accessed May, 14, 2021].

National Institute for Health and Care Excellence, 2014. Osteoarthritis: care and management, Available At: https://www.nice.org.uk/guidance/cg177/chapter/1-Recommendations [Accessed May, 14, 2021].

The Institute of Osteopathy, 2021. COVID-19, Available At: https://www.iosteopathy.org/covid-19/[Accessed May, 14, 2021].

Vleeming, A., Albert, H. B., Östgaard, H. C., Sturesson, B., Stuge, B., 2008. European guidelines for the diagnosis and treatment of pelvic girdle pain. European Spine Journal, 17(6), pp. 794–819.