WHAT?

A 52-year-old female patient presented with chronic neck and shoulder tension exacerbated by prolonged computer use and high stress levels. During the case history I asked whether she had previously seen anyone for this issue, as I do with all patients. The patient replied that she had seen many people previously including physiotherapists on the NHS, privately and seen several manual therapists. She expressed significant anxiety around manual treatment due to previous negative healthcare experiences, where she felt rushed, unheard and the fact that she was unaware of what was being done and when it was. I then made sure to make a note of this in the concerns box of the case history form.

After listening carefully to her concerns, I reassured the patient that everything would be done with her full consent and if she did not understand anything or had any questions to stop me and we would go through it again. I also made sure I reiterated the layout of the consultation so that she had an idea of what would come next. Before treatment, after I had explained the patient’s diagnosis, I presented the patient with a range of treatment options with some including more gentle treatment options of which I discussed with her in depth of their mechanisms and their risks/benefits. During the treatment, I regularly asked if the pressure was comfortable and reassured her that we could adjust anything to suit her needs. She then became a lot happier and more confident about the treatment and expressed her gratitude to myself and my tutor of how we made her feel heard and took her anxieties/concerns into consideration.

SO WHAT?

This experience highlighted the importance of truly listening to patients not just gathering clinical data but also creating safety in the appointment for patients to express their emotions and concerns. Her anxiety was rooted in a past breakdown of trust from manual therapists so it was crucial for me to validate her feelings, slow the session down allowing for her to understand the process, offer gentle treatment options and reassure the patient that everything would be done only with her full consent. After I had this patient, I reflected that respecting patient preferences is not only an ethical responsibility and part of the OPS but also essential for effective care and building trust in a patient-practitioner relationship (Kwame & Petrucka 2021). This appointment reinforced how empathy is a key factor for therapeutic rapport and patient comfort.

NOW WHAT?

Moving forward, I will continue to listen to patient concerns and anxieties and be more conscious of the emotional aspect that patients bring to their appointments. I will keep reminding patients that they can always ask me to stop at any point or ask questions if they are unsure of anything. I will always make sure that my patients feel comfortable during the appointment, and I will try to address any concerns they may have. I will also continue to document patients concerns, preferences for techniques and feedback into their records which will ensure that if another student were to cover for me or take over their care that they will honour their preferences and individuality.

DESCRIPTION:

A 78-year-old male presented with left hip and knee pain that had an onset of 2 months. The patient had a history of a stroke 2 years ago which left him with speech difficulties. He could use short phrases, gestures and a communication board. The patient was accompanied by his daughter who aided him for the communication aspect of the consultation.

Due to his speech difficulties, the initial consultation required adaptation. I made sure I used clear and simple language. I noticed that open-ended questions led him to confusion and frustration as he could not give a detailed answer. Therefore, I changed to closed questions. I also encouraged him to use the communication board, visual aids and his daughter to help clarify key points without her speaking for him.

Despite this, I was able to gather that the pain had worsened, was aggravated by walking and stairs, and was generally quite stiff. I ensured that the patient had time to communicate throughout the consultation and gathered that his main goal was to remain independent and mobile enough to continue his daily short walks that he enjoyed doing with his grandchildren.  

FEELINGS:

Initially I did not feel confident as I did not have much experience working with post-stroke patients with communication difficulties. I was worried that I may not have been able to fully understand his symptoms or goals. I was also worried about the time that it would have taken me to complete the consultation. However, I soon felt comfortable as my tutor reassured me that time was not an issue. Due to this, I adapted my approach and I felt so much more confident as I could see the patient becoming more engaged and also confident in himself throughout the session. I felt quite a strong urge of responsibility to ensure that he felt that he was fully heard. I was conscious of not making assumptions or relying on his daughter for information. I felt empathetic towards the challenges he has faced which created a strong urge to make sure his goals could be met.

EVALUATION:

Overall, the appointment went a lot better than I first anticipated. I believe that I was able to adapt my communication style which enabled me to engage with the patient whilst still gathering accurate clinical information. The presence of his daughter also helped me to understand some aspects of his condition but did this without overstepping too much. However, I could have benefitted from more training on supported communication techniques for patients with neurological conditions.

ANALYSIS:

This experience highlighted the importance of adapting communication to each individual patient’s needs. According to Bright & Reeves 2020 adapting appointments to best suit communication abilities improves understanding, trust and compliance. Research also shows that patients with post-stroke speech difficulties often feel left out of healthcare decisions due to the lack of communication strategies available (Carragher et al 2024). And by giving this patient time and space to express his goals in the appointment, I I could ensure that the treatment plan was centred on his priorities, specifically that he wanted to maintain his daily walks which aligned with patient-centred approach.

CONCLUSION:

I have learned that working in partnership with patients requires more than just clinical knowledge. It requires flexibility in situations, patience, the ability to adapt and to have creative communication. Even when verbal communication is restricted, patients can still be included in their care when supported appropriately.

ACTION PLAN:

Going forward I will seek further training or CPD on communication approaches for patients with speech or cognitive impairments. I will use communication boards, visual aids and alternative methods of communication when verbal speech is impaired. If I was to be in this situation again, I would allow for extra time in these appointments to ensure patients can express themselves fully.

WHAT?

A 62-year-old male retired gardener presented with neck pain for which he had previously seen his GP for and was sent for imaging. The recent x-ray report showed “mild degenerative changes” and “minor disc space narrowing”. He was very worried as to what this meant as no medical professional had explained what this meant and what to do going forward.

Therefore, the appointment involved me explaining the findings simply in layman’s terms. Mr X explained that he is more of a visual learner, so I used a spine model that we have stored in the library to clarify the anatomical location mentioned in the report and what the changes might look like. I made sure to check his understanding frequently. I also explained that osteopathy may also be beneficial to help manage some of his symptoms, after which he consented to a physical examination.

SO WHAT?

This appointment highlighted how medical jargon can cause confusion and anxiety for patients like in Mr X case as supported by this study (Gotlieb et al 2022). Mr X’s visible relief after the X-ray findings were explained to him and what they meant for him going forward demonstrated the importance of giving information to patients in a way that matches their understanding. From this case, I have realised how important it is to limit the use of medical jargon as it could increase patient anxiety and can lead to fear and/or misinterpretation about the cause of their symptoms. Ensuring patients understand their diagnosis helps manage expectations, reduce anxiety and support shared decision making (NHS 2023 a). Thus, adapting language to suit individual patients is crucial.

NOW WHAT?

In future appointments I will routinely ask patients if they have had any imaging reports and whether the results have been explained to them and if they understand. If they do not, I will go through this with them to make sure they understand. In my osteopathic appointments, I will consistently use layman’s terms to avoid using any medical terminology. I will also regularly check patients’ understanding throughout the appointment. My aim is to make sure that information is accessible and to reduce unnecessary worry caused by unclear communication.

EXPERIENCE:

During a clinic session, I saw a 45-year-old female patient presenting with right shoulder pain aggravated by overhead movements. After taking the case history, I explained that I would like to perform a physical examination to help rule out diagnoses to help find the cause of her symptoms. I explained that this might provoke some of her symptoms and potentially aggravate her pain. The patient seemed quite anxious so I took additional time to explain each stage of the examination, including what it would involve (active range of motion, passive range of motion, special tests, palpation) and that she was in control of the session at all times thus she could stop at any time.

Before proceeding, I explicitly asked for her consent for each part of the examination. She understood and gave her consent, which I documented in the case notes. Later in the session, I proposed a treatment plan using a combination of soft tissue techniques, MET techniques and mobilisations. I again explained the nature, purpose and risks/benefits of this. I also gave her alternative treatment options and the option of no treatment. The patient was happy to go ahead with the proposed treatment but did ask some questions about whether it will hurt and this is when I reiterated some of the risks that she may have post-treatment soreness for up to 72 hours, which is common but usually short-lived, and that she should start to see some improvements. I also reassured her that she could stop me at any point during the treatment as she could throughout the appointment previously. She felt more confident, and I received her consent to go ahead and recorded it in her notes.

In a follow-up session the patient mentioned that the soft tissue techniques provided some soreness and did not want to carry on with that technique. She reported that she was quite anxious to report that back to me as she did not want to hinder the treatment plan. I responded and reassured her that I would not perform any techniques she did not consent to. I reminded her that patients are in control of their treatment and that would be respected and met at all times.

REFLECTION:

This case made me realise how important it is to gain consent in a clear, continuous and respectful way. While I already had been taught about the importance of consent for the patients notes and to be able to proceed into examination/treatment, this was the first time I felt the patient truly engage with the process by asking questions to gain further knowledge before she consented. It reinforced that consent is not a signature or a simple ‘yes’ regarding a technique for example but it is a conversation.

Reflecting back onto the follow-up appointment, it also reminded me that consent is not a one-time thing. It is long term and should be gained throughout every session. It also made me realise that just because the patient has had a treatment approach done before, that a patient may not always want it or may choose an alternative. It should never be assumed that they will have it done again due to previous treatments.

ACTION:

I am confident that I addressed all my patient’s questions and gained informed consent for all aspects of examination and treatment. Moving forward I will continue to always clearly explain what I am doing and why before performing any examination or treatment whilst always gaining consent to do so. I will continue to encourage patients to ask questions. In future appointments, I will aim to make sure that I observe for any verbal and non-verbal cues for hesitation and confusion. If I ever sense hesitation or misunderstanding, I will pause and address the discussion to re-establish informed consent. I will further continue to document consent explicitly in case notes for examination and treatment at every appointment.

DESCRIPTION:

Mr X is a 50-year old male who works with heavy machinery and has attended the clinic for many years previously with low back pain. This particular appointment, Mr X presented with aching and occasional sharp pain in the left calcaneus, especially during weight bearing, with increased pain the morning and tenderness in the left gastrocnemius. After a thorough examination and excluding other diagnoses, achilles tendinopathy was diagnosed.

I provided education on the condition and discussed a range of conservative management options. I explained that a lot of his improvement would come from him doing exercises and self-management. I also offered alternative therapies that may be effective for Mr X to be aware of as well.

The patient had a total of 5 follow-up sessions and Mr X consistently reported that he had not completed any of the exercises given. He expressed increasing frustration and described the pain as “life-destroying”. Following this, I reiterated how important it was for him to do his exercises and then he would see improvement. Despite this, there was no change in his behaviour.

FEELINGS:

·      I felt rather angry and frustrated towards this patient when he said he had not done his exercises for the 5^th time. I felt that he was placing the blame on me for his lack of progress, even though I had clearly explained from the beginning that the key to his improvement would depend on him doing his exercises.

·      I was concerned that my frustration might have negatively impacted the therapeutic relationship and potentially hindered his recovery.

·      I was worried that I might have come across as dismissive or patronising by repeating the same advice.

·      Upon later reflection, I began to feel empathetic and guilty, realising that perhaps I had not done enough to explore why he did not engage with his exercises and that I may have missed an opportunity to better support him.

EVALUATION:

Looking back, I recognise that although my initial approach was informative, it was not effective in motivating Mr X to engage in his exercises. While I explained the importance of doing the exercises to him, I did not explore his beliefs, concerns or barriers to adherence. I had just assumed that he was unwilling, rather than considering that he might be unable or unsure.

I realise that repeating the same advice was not helpful and could have contributed to him continuing to not complete his exercises. I should have been more patient and explored why he was not doing them. If this patient chose to not do the exercises based on his beliefs, I should have respected that even if I disagreed. I also recognise that I allowed my frustration to show, which may have caused him to feel judged which may have reduced his motivation to follow my recommendations of self-management as well.  

ANALYSIS:

This case taught me the value of honouring and enabling patients’ decisions in self-care, particularly when they present with a diagnosis which responds effectively to self-management. It has made me realise that self-management support must be patient-centred, collaborative and adaptive to personal barriers. According to NICE 2020 and recent evidence from Pabon & Navqi 2023, exercise and load management are first-line treatments for managing achilles tendinopathy, and there is poor evidence to use manual therapy alone (Physiopedia 2025). This is why I kept recommending self-care since I wanted the patient to be pain-free by having the most up-to-date evidence-based practice.

CONCLUSION:

From this case I have learned that supporting patients in self-management requires more than just giving advice based on what we know as practitioners and what we have researched. It requires collaboration. In the future, I need work with them to undertsand why they do not want to do their exercises and address their concerns instead of telling patients what to do. I also need to make sure that I still encourage patients with their self-care even if I do not agree with the patient’s way of wanting to manage their condition. Additionally, I need to be more mindful of my own emotional responses so I can maintain an open, respectful and therapeutic relationship – even if patients do not follow the plan that I believe is best.

ACTION PLAN:

In future situations when patients are not willing to adhere to self-management recommendations, I will explore the patient’s perspective as to why they do not want to. Furthermore, I will work with patients to help them identify specific barriers and will try to help them cope with them if the patient wants to do this. I will provide ongoing support and encouragement to patients with maintaining their health and well-being. However, if patients do not want to do their exercises, I must also respect their decisions even if I disagree with them. Finally, I will regularly reflect on my communication and manage my own emotional responses to ensure that I remain profession, understanding and non-judgemental.

WHAT?

During a clinic session, I saw a 21-year-old female patient presenting with muscular tension in the cervical, thoracic and shoulders that had been exacerbated by exam stress as a university student. After the case history, I explained that I would like to perform a physical examination which would involve her removing her top so I could observe her back and shoulders, only if she felt comfortable doing so.

She looked like she felt uncomfortable and hesitated. I immediately offered the option of a gown explaining that she will be able to change in private and that she would remain covered during the examination except for the area being assessed. I also offered a chaperone and reassured her that we could modify the examination if she preferred not to remove anything clothing.

She chose to wear the gown and asked for a female chaperone. I left the room while she got changed and made sure to knock before re-entering. Throughout the examination, I ensured that the gown remained properly draped and that only the area being examined was exposed as explained to the patient. At the end of the session, she expressed her appreciation for how comfortable, respected and not judged she felt especially when having a male tutor present for the appointment.

SO WHAT?
This experience reminded me how it is important to protect patients’ dignity and modesty especially when they may feel vulnerable. The patient’s initial reaction reminded me that even something as routine as removing a top for examination can feel deeply personal. My actions by offering privacy, draping, explanations of each step and the availability of a chaperone seemed to ease her anxiety.

It made me reflect that patients may worry about being judged regarding their body, especially younger patients or those from different backgrounds. It is estimated that almost 31% of teenagers felt embarrassed about their bodies (Mental health foundation 2019) and roughly 60% of adults also experience negative thoughts regarding the way they look (Mental health UK). These high statistics further highlight how osteopaths play a huge role in providing a safe, non-judgemental spaces where patients can feel secure in undressing if needed.

My patient thanked me for helping her feel comfortable during the appointment with a male tutor present. This made me reflect that in our clinic, there is a much higher proportion of male tutors compared to female. This makes it very difficult to be able to book patients in with certain tutors based on gender which does not give patients much availability or choice. This issue could impact patient comfort. Therefore, this could be something that should be brought to the attention of clinic thus enhancing patients experience and allowing them to have choice.

NOW WHAT?

In future appointments I will always explain clearly and respectfully as to why as osteopaths we may ask people to undress for examination if necessary whilst acknowledging any potential anxiety that this may display. I will continue to make sure that patients know that they are in control of their appointment and at any point they feel uncomfortable that it will be addressed straight away. I will always offer privacy, a chaperone and choice of draping options (in the clinic - gowns and potentially outside of clinic towels as well). I will make sure that I check in with the patient throughout the examination to ensure they feel comfortable. In addition, I will continue to reflect on wider clinical issues like gender dynamics and explore how we might improve patient choice and comfort within the clinic at university.

EXPERIENCE:

A 55-year-old male presented with chronic low back pain. In the case history, the patient mentioned that he had seen homeopaths for this issue and is a strong believer in natural healing methods like energy healing. He continued to say that he preferred to avoid scans and trips to the doctors/hospital unless absolutely necessary.

At first, I felt a bit concerned and slightly conflicted about how to proceed. Personally, I value evidence-based approaches and rely on current clinical guidelines such as NICE guidelines to support my decision-making. I worried that his beliefs might limit my ability to create an effective plan and I thought of whether to hand him over to another student who also valued these beliefs.

Instead of handing him over, I took time to understand his beliefs without judgement. Therefore, when it came to explaining the treatment, I adapted my communication to align with his perspective that he believes in. I incorporated the use of the osteopathic principles and concepts explaining that osteopathy is a whole-body approach which encourages and supports the body’s natural ability to self-heal.

REFLECTION:

This made me aware of how easily personal beliefs can unintentionally affect clinical attitudes and potentially lead to bias. My initial reaction was influenced by my preferences for evidence-based practice. However, I did recognise in the appointment that if I had dismissed or challenged the patient’s views, it could have damaged the patient-practitioner relationship. This could have reduced the effectiveness of the treatment or caused the patient to book in with another practitioner. As I was able to remain open-minded, I was able to build trust and deliver care that was both respectful to his values and was still clinically appropriate.

It also reminded me that respecting a patient’s beliefs does not mean that I have to abandon clinical reasoning but means presenting it in a way that aligns with their belief system. I did this in order to better understand his beliefs and to show him that I had listened and wanted him to feel heard.

ACTION:

Moving forward, I will:

·      Continue to reflect how my own beliefs may influence how I respond to patients

·      Remain open-minded and respectful with patients who may hold alternative health beliefs

·      Seek opportunities for further CPD in alternate therapies which can improve my ability to work with diverse perspectives

WHAT?

Above is attached part of a mark sheet from year 4 CEX, containing feedback from a tutor on a continuing patient appointment.

The patient came in complaining of a new episode of low back pain and right hip pain. He had previous imaging performed prior which showed moderate osteoarthritis of the right hip and mild degenerative changes in the left hip and left sacroiliac joint.

In this assessment, I was evaluated across several clinical competencies including case history taking, clinical reasoning, examination, diagnosis and treatment/management. The feedback highlighted that I demonstrated good rapport and communication with my patient. That I was effective in my examination and provided clear explanations of findings and had a well-considered management plan. And finally, that my treatment looked effective including good use of posture and body during techniques most of the time.

My tutor advised that I should improve on developing more effective leverage techniques when working with larger patients and to reduce the time spent on repeated examining elements as they had already been previously performed.

SO WHAT?

This feedback has reassured me that I am progressing well in my ability to apply osteopathic knowledge in clinical scenarios. I was very pleased with my mark and feedback.

Based on my areas for improvement, I spent a lot of time examining my patient as my tutor had not seen this patient before. As it was for an assessment, I wanted to cover that aspect of the assessment to gain marks. But looking back, spending excessive time did not add clinical value to my process and took valuable time away from other aspects of the appointment. The feedback that I need to develop more effective leverage was a gap in my technical abilities that I lacked. I feel as though this was due to confidence as I was more comfortable showing the tutor techniques that I preferred rather than those best suited to the patient. After my tutor discussed this with me I recognised that as a result of this, I could have compromised my own physical safety.

NOW WHAT?

After the CEX and my provided areas for improvement, I reviewed different techniques that I could use for larger patients to be able to make my techniques more beneficial for them as well as protecting myself from any harm in doing so. I am now much more comfortable when it comes to treating patients who are of a larger build. After the feedback, I spent time going through each case to assess whether each part of the examination was necessary and if it added value to my clinical knowledge and reasoning. This has helped me to minimise time during follow-up appointments to make my examination more targeted and effective. I now make sure that regardless of if it is in an exam situation for myself, that the patient’s examination and treatment are based on patients’ needs and not what I believe ‘looks good’ to get marked on.

WHAT?

During my mock CCA, I had a 73-year-old female patient that presented with acute low back and right hip pain. She reported that pain had followed when she had swung a heavy load of rubbish into a dustbin 3-4 days ago. She described the pain as sharp, deep and persistent with the pain worsening progressively. She struggled to weight bear and had to use her husband’s cane. She reported that it was 10/10 and reported paracetamol had only provided little relief.

In her medical history, the patient mentioned a long history of smoking, previous history of fractures, a history of malnutrition, no history of taking HRT and no prior DEXA scan.

I performed percussion and vibration tests with informed consent. These tests provided unremarkable findings and therefore I went on with a cautious physical examination guided by her pain tolerance. No neurological deficits were found, but based on her age, post-menopausal status with no HRT, sudden onset of pain, previous history of fracture, history of malnutrition and long history of smoking I became increasingly concerned about the possibility that the patient may have an undiagnosed fragility fracture.

I felt quite unsure about the diagnosis as it could have been mechanical due to unremarkable findings in the examination. However, I thought that continuing with treatment could potentially worsen an underlying fracture. I discussed the case with my examiner and I made the decision that the patient required urgent referral to A&E for further imaging to rule out a fracture and also further assessments as to why if it was fractured – questioned osteoporosis. I explained the concern and reasoning to the patient, who was very understanding and agreed to seek further care that day.

After I had completed my examination and got my feedback, my examiner confirmed that they would have taken the same management approach.

SO WHAT?

This experience highlighted how important it is to recognise red flags and clinical presentations outside my scope of training. As osteopaths, while patients come in expecting treatment, we must recognise when it is out of our limits, inappropriate or unsafe to proceed.

In this case it could have been potentially unsafe to continue with treatment without ruling out serious pathology. I followed the NICE guidelines that recommends urgent referral of patients presenting with acute back or hip pain even after minor trauma if there is a potential spinal fracture due to risks of osteoporosis (NICE 2024).

By acknowledging my limits and seeking help for other healthcare professionals, I prioritised this patient’s safety and acted responsibly in accordance with the OPS.

NOW WHAT?

This experience has helped me to strengthen my understanding of when to recognise my limits of my training and thus refer to another healthcare professional to provide them with the appropriate care. For all future appointments, I will remain vigilant for red flag signs and symptoms.

WHAT?

These are my certificates from a continual professional development course that I attended halfway through my 3^rd year.

I attended a sports taping workshop which ran over a weekend and included both theoretical and practical elements. We covered assessment and taping techniques for a range of conditions including shoulder instability, knee pain, plantar fasciitis and low back pain etc. We practiced hands-on taping techniques on peers, received feedback from a lecturer and discussed the clinical reasoning behind different taping approaches depending on the patient’s condition.

SO WHAT?

This workshop enhanced my understanding of how adjunctive techniques like taping can complement osteopathic care. Prior to this session, I had no understanding of how or when to use tape confidently in clinical practice.

In the workshop I gained practical experience and confidence in applying techniques correctly. It also helped me to improve my clinical reasoning for choosing specific tape types, placement and duration based on the patient’s condition and activity level. I have applied what I have learnt from there in clinic as well which has strengthened my clinical reasoning overall.

By doing this course before I had graduated, it has taught me the importance of why osteopaths do CPD learning. While, It is a requirement for being a safe and effective practitioner, it also allows practitioners and graduates to learn things beyond the university curriculum to deliver high-quality care for patients if necessary.

NOW WHAT?

Following the workshop, I began integrating sports taping into clinical practice where appropriate. In children’s clinic, we had a young male who was very active playing football. I used kinesiology tape for his lower extremity complaint and received positive symptom relief during activity. Moving forward I will continue to seek external CPD opportunities to further my skills and confidence across a wider range of techniques. When I graduate, I will continue to keep my knowledge and skills up to date by going to worships for techniques etc to maintain and enhance my knowledge from my studies at university.

WHAT?

I had a 35-year-old female present with acute right sided neck pain and stiffness which followed a car accident 2 weeks ago. She had been diagnosed with whiplash associated disorder (WAD) by the GP. She came in for treatment as her discomfort levels were still quite high and she wanted to try to reduce her symptoms.

I took a full case history and assessed for any red flags as she reported having headaches since the accident. I therefore used the SNNOOP-10 criteria and also the 5D’s, 3N’s and 1A to screen for cervical arterial dissection or vertebral artery insufficiency (Myers et al. 2020) which I had learnt from my sessions in headache clinic. Thankfully she did not report any of these symptoms but I still safety netted her on these symptoms.

I performed an examination of active and passive range of motion, palpation, an upper and lower neurological examination and a cranial nerve screen which were all normal. Palpation showed muscular tightness in the suboccipital and cervical areas with reduce mobility in the upper cervical spine and C5/C6.

SO WHAT?

By using my anatomical, physiological and biomechanical knowledge regarding whiplash I was able to create a working diagnosis of post-traumatic muscular tightness/myalgia secondary to WAD. Based on this and shared decision making, the patient and I created a treatment plan which included gentle soft tissue techniques, MET’s and indirect articulations all supported by breathing exercises.

By ensuring I had sufficient knowledge with red flags I was able to rule out serious pathology confidently. This allowed me to provide appropriate and safe treatment confidently as well.

The patients’ physical symptoms were manageable however she had severe anxiety about the movements in the neck. Due to my knowledge behind the mechanism of a whiplash injury I was able to take time to explain to her why this was occurring and what she should expect to see with pain and improvements. My ability to address both her musculoskeletal presentation and her psychosocial context was essential to providing effective care as it built a level of trust.

NOW WHAT?

Following this case, I took time to review the current research on WAD particularly surround the education for managing persistent symptoms. For all future appointments, I will continue to use my knowledge and skills to be able to support myself as an osteopath to be able to provide patients safe and effective care. If in a case I have not come across something in particular, I will seek resources and literature to be able to provide that I have sufficient knowledge in that area as well.

I have attached my marksheet from a 4^th year practical exam.

EXPERIENCE:  

In a recent practical exam, we had to formulate an appropriate working diagnosis based off a case history that had already been taken prior to the exam. We had to explain our clinical reasoning clearly, using medical language to the examiners and layman’s terms when explaining to the patient/model as that would be appropriate for a real patient in a clinical setting. Based on our working diagnosis we had to develop and demonstrate an appropriate plan of treatment in front of our examiners, justifying our choice of techniques and adapting them to individuals. Before showing my techniques I also explained to my model the potential risks from treatment including the possibility that they may experience post treatment soreness for up to 72 hours. I obtained informed consent before proceeding.

REFLECTION:

After my exam, I felt very anxious, worrying that I had not demonstrated my skills effectively as I felt that I should have shown a broader range of techniques. However, when I received my feedback, I was surprised to see that I had in fact met the marking criteria which aligned with the OPS C1. On reflection, I believe that the anxiety was largely due to the exam setting rather than a lack of clinical ability.

What made this exam difficult is that our models do not match the made-up case history patient. Therefore, the models may be of a different body type or respond better to other treatment approaches that I have not clarified as we have to focus on the patient in the provided case history. However, in my exam there was a technique that I mentioned that I would do for the patient in the case, but I had to adapt it for my model as I noticed the model visibly was discomforted by the technique and thus, I changed my handhold and opted for another technique that suited him. This was noted in my feedback as “good consideration of the patient/modal duality.”

This experience showed the importance of being prepared to adapt treatments based on feedback from patients in clinic.

ACTION:

To continue building what I had been successful in showing, I will continue to adapt techniques based on patient’s feedback, their preferences and their morphology. While my feedback was positive, I will further continue to refine my palpatory skills and my techniques to be able to make them more effective for patients. I will do this by doing regular peer practice and asking my tutors for their feedback. This will be an ongoing process of reflection to make sure I continue to deliver safe, competent and appropriate evaluation and treatment. Based on my reflection, I also aim to become more confident in trusting my clinical judgement, even under pressure.

WHAT?

Every time I have a new or continuing patient in clinic, I am required to fill out the form provided in clinic. For initial consultations, the patients record form includes areas to document the presenting complaint, occupation and hobbies, past medical history, systemic screening, differential diagnoses and examination led by our differential diagnoses includes both osteopathic and orthopaedic findings. There are also sections for modesty and consent, patient preferences or special precautions (which are important for other practitioners to know if they take over the patients care), working diagnosis, agreed treatment and management plan, prognosis and relevant guidelines used in the case. The continuing form is shorter but still includes sections for symptom updates, examination, working diagnosis, treatment and post-treatment responses ro additional notes.

After each appointment, my notes must be reviewed and signed by a tutor before being handed to reception to be filed. They read through the notes thoroughly to ensure they are accurate and legible. If they are incomplete or do not meet this standard, I am expected to correct them accordingly.

In 3^rd year I would usually wait until after the appointment to fill in the examination section for the findings. However, in 4^th year I am managing a fully booked clinic schedule. I have found that after I have had 4 patients continuously, I have had some instances where I have forgotten some of my findings. This can lead to missing or incorrect details which affected the accuracy of my notes.

SO WHAT?

This has made me realise the importance of completing my notes within the session to deliver safe and professional care. When I delay writing my notes, I am at a risk of forgetting any key information which may affect patient management or even legal accountability.

I have also realised that poor record keeping does not just affect me but could impact future practitioners treating this patient and possibly affect patient safety. This has influenced me to document these findings during the session rather than after.

NOW WHAT?

As a result, I am currently working on writing my notes during the session, so they are accurate and complete. I have found recently that I have been doing better with this however I am still aware that I struggle to always finish my notes in the session, and this is something I would like to improve on. I have also recently asked my clinic tutors to make sure I have the notes written during the session so therefore I cannot slack off.  

WHAT?

In one of my appointments for children’s clinic I was asked to provide a written summary of a young boy’s osteopathic assessment and management. The request came from the child’s father, who had accompanied him to all appointments. The child’s mother, who had only been present at the initial consultation, was allegedly taking the father to court on allegations of child abuse. Hence why he requested a copy of the child’s folder to support his defence. The parents of the child were divorced, and it was very apparent in the initial consultation that they had conflicting views about the child’s healthcare. The father strongly believed in holistic treatments while the mother preferred medical management and had expressed interest in surgical options.  

As a student and being put in this position for the first time, I did not know how to proceed. Immediately I informed my clinic tutor and discussed the situation with her. I also had to consult the receptionists to find out if there was a procedure that needed to be followed for this. As this involved a minor and had legal implications, the clinic’s formal data protection and consent protocols were followed. During the first visit for patients, they must sign a consent form and for minors this will be done by their parents/guardians. As a result of shared custody of the 4-year-old, both parents had to sign this consent form. On this form they both had ticked the box to be able for us to use his information in letters etc. With this in place, a summary was created under the guidance of my tutor and was saved to the patient’s electronic database, as well as printed and filed in the child’s physical folder. These records were stored and handled in accordance with GDPR and the clinic’s data protection policies.

SO WHAT?

This experience was an important learning point in terms of how sensitive written data requests can be, particularly in the case of minors and legal proceedings. All my previous referral letters have been to GP’s, and this situation took me by surprise as I never thought I would be put in this situation. When the father mentioned that the documents would be used in court, I started to panic. Thoughts started to go round my head like “will I be involved in the trial and could I be asked to testify?” My tutor very quickly deescalated these thoughts and reassured me that it will just to be presented in court that he is receiving effective care as the child is improving without the need for surgical intervention.  

This case has also made me learn that documentation should always be neutral and factual as it could always be used in court or shared with third parties. Therefore, this summary did take me a little while to write with the help of my tutor to make sure I did not show any biases.

NOW WHAT?

This experience has significantly improved my understanding of my responsibilities around written data requests. When I have graduated, I will continue to get documentation of consent for osteopathic treatment for minors by both parents in the case of shared custody. I will aim to remain objective and factual in any written reports particularly when there is a possibility of legal use. I will also reflect more widely on the role of osteopaths in legal contexts ensuring that my actions always prioritise the patient’s welfare and legal protections.

DESCRIPTION:

Before coming to the clinic and treating patients, I was required to complete both a safeguarding course and first aid training. These courses covered a range of topics including how to recognise signs of abuse or neglect and how to respond to these based on local safeguarding procedures. The first aid training included responding to emergencies such as fainting, seizures or cardiac arrests which are scenarios that I could encounter in clinical settings. The training included both theoretical and practical skills creating scenarios to help me prepare for real-life situations in clinic.

FEELINGS:

I have previously completed many first aid courses and felt very confident in my ability to respond to emergencies. But I was still happy to keep my knowledge up to date as since COVID a few things had changed especially around the use of mouth to mouth. Regarding the safeguarding, I felt a bit overwhelmed by the amount of responsibility that comes with this. I questioned if I would know how to act appropriately in the moment if I was faced with a real scenario. However, by the end of the training I felt more confidence. Since the course I talk about this in clinic with my tutors which has further validated my knowledge.

EVALUATION:

What I thought the most valuable part of the experience was recognising the physical signs of abuse and how to escalate any concerns that I may have. I also found it very important to learn that abuse is not just physical but also mental and can be done by adults and children. What I found difficult in this course was when they took us through real-life cases involving children and abuse. It was emotionally challenging but necessary to understand the complexity of safeguarding in practice.

It is always good to keep my knowledge up to date regarding first aid as if I had to respond to a situation, I would be able to do so calmly and effectively due to the course which could potentially prevent harm or save a life.

ANALYSIS:

Completing this training has helped me realise how important it is to keep up to date in both safeguarding and first aid training. Anything could happen in the consultation room, and I believe that from the training I would now feel confident to be able to act appropriately. To protect patients from harm does not just mean recognising when something is wrong and how to respond but it also means that we should create an environment where patients feel safe and supported.

CONCLUSION:

While the first aid training had not changed much since my last course, I have realised the importance of regularly refreshing my knowledge as some of the information had changed and updated, which I wouldn’t have known without retraining. I need to make sure I stay up to date with policies and procedures for safeguarding as part of my professional responsibility so that I can act more confidently and appropriately if needed.

ACTION PLAN:

Going forward I will:

·      Regularly review safeguarding and first aid procedures both through CPD and in discussion with other healthcare professionals.

·      If I move away when I graduate, I will make sure I know the policies and produces in that local area for safeguarding

·      Stay alert for signs of distress or harm in patients and be prepared to escalate concerns via the right pathway

·      If I work in a multidisciplinary clinic, I will also learn if there are any safeguarding leads, so I know where to turn if I need support with patients

I make sure I follow the OPS C5 by:

Maintaining a clean and hygienic environment:

o   I do this by always ensuring that treatment areas are cleaned before and after each appointment. This includes wiping down the couch and replacing the couch roll.

o   I make sure to always wash and sanitise my hands before and after any patient contact to minimise the risk of contamination.

Compliance with Health and Safety Procedures:

o   I regularly perform risk assessments in my treatment room by removing trip hazards like patients’ shoes or bags and adjusting the couch height when patients are getting on and off.

o   If there was an emergency, I am aware of where to find the first aid kits and also am aware of what staff to alert to situations.

o   Based on the procedures, I am also fully aware of the clinic’s fire safety procedures, including the location of fire extinguishers, fire exits and designated points to meet.

Responding to infection/disease/illness risks:

o   During COVID-19, I adhered to protocols for PPE, sanitising regularly and using masks to reduce the risk of transmission.

o   If a patient presents with symptoms of an infectious illness, I will screen them appropriately and would possibly reschedule if appropriate. I have had a few cases where patients have had diarrhoea and vomiting - I did not treat them, I rescheduled their appointment, aired out the treatment room and made sure it was deep cleaned.

By doing so I contribute to a safe and professional environment that supports high-quality patient care and meets the osteopathic standards.

EXPERIENCE:

A 50-year-old male presented with chronic low back pain. He worked remotely from home spending long hours seated at a desk. On my 5^th treatment with this patient, I had a different tutor who had never seen the patient before. The tutor mentioned to me that I needed to consider discussing the patient’s weight as part of my wider role in supporting his health and possibly to help with his musculoskeletal complaint.

At first, I was very nervous as I did not want to offend or make my patient feel uncomfortable. However, when it was brought up in conversation, my patient showed concerns about his sedentary lifestyle and weight but he was unsure about how to start making changes. This then moved into a conversation regarding the implications of prolonged sitting and physical inactivity. I suggested that the patient should try to take regular exercise breaks during his workday and to start with short daily walks to gradually start to increase his activity levels.

My patient had taken this advice for a few sessions and had felt better in himself. After these appointments I researched if there was anything else I could do for this patient as he was motivated. From my research, I found resources on the NHS website such as “Get Active” and “Healthy Weight” websites which offer guidance on physical activity and weight management (NHS 2023 b). I also recommended that he consult his GP for further support including potential referrals to nutritionists.

REFLECTION:

From what I have learned through the university course, I already had an understanding that it is part of our responsibility as osteopaths to encourage health and well-being for patients. From this case, I feel so much more confident in talking to people about managing their weight in a sensitive manner and what resources are available out there for them to also help support them. By doing so, I fulfilled OPS C6 by promoting health and empowering my patient to take steps forward to improve his wellbeing.

ACTION:

Therefore, I will aim to continue to promote health and wellbeing in all patients. I will also continue to seek further resources, that are accessible for patients, to make sure I stay updated with relevant online guidance that provide patients with additional support. In addition, I will keep working on my communication skills to be able to continue addressing sensitive topics with confidence and compassion.

WHAT?

I treated a 60-year-old male patient who presented with mild neck stiffness with diagnosed cervical spondylosis. This patient was my 3^rd ever in clinic. After 3 treatment sessions, over the space of a month, he reported full resolution of his symptoms. He said he felt “back to normal”. In his last follow-up appointment, he said that he was symptom-free but asked whether he should still come in weekly or fortnightly to “stay on top of things”. I asked why this was and he said that is what his previous osteopath had done before and was encouraging maintenance treatments even if the patient had no symptoms.

I did not know what to say at first, but I considered that another session might be helpful from a preventative aspect or alternatively for my own learning as I did not have many patients. But there was no justification for my patient to have further treatment. I then discussed this with my tutor and asked for their advice in which they confirmed that treatment was no longer indicated.

I explained this to the patient and was honest that due to him having no symptoms, ongoing regular treatment was not necessary. I then gave him advice and exercises for self-management. I also encouraged him to come back if symptoms returned or if he suffered with any other symptoms. I documented this in the case notes.

SO WHAT?

This has improved my understanding of my ethical responsibilities as a future osteopath. Even though an additional appointment might have helped me develop my skills, continuing treatment with a patient who had no clinical need would have put my own interests above theirs. If I had treated this patient, it could have possibly led to harm by causing new symptoms.

My tutor discussed with me that if I had chosen to keep on treating this patient again for no reason, it would have been seen as prolonging treatment unnecessarily which is a sign of lack of integrity. By being honest and prioritising the patient’s wellbeing, I demonstrated the OPS, C1.

NOW WHAT?

In all appointments I will evaluate whether treatment is clinically necessary and in the patients best interests and not my own. I will avoid prolonging care unnecessarily for my own benefit especially as a student wanting to improve my skillset and experience. I will be honest with patients when treatment is no longer required and what to do for self-managing their symptoms.

WHAT?

I was treating a 37-year-old male for chronic shoulder pain and had seen him over 4 appointments and had built a good rapport with him. At the end of the 4^th session, he made a comment that he was wanting to buy me a gift to say thank you for helping reduce his pain. I thanked him but explained that I was unable to accept gifts as an osteopath as this would not be professionally appropriate and goes against our guidelines that we have to abide by.

At his next appointment, after the treatment had finished, he asked if I would be open to going out for a drink with him once I graduated. Even though it was said casually, I felt very uncomfortable and recognised that a professional boundary had been crossed. I responded politely but firmly stating that as a healthcare professional I could not engage in a personal or social relationship with any patients during or after their course of treatment. I emphasised that this interaction must remain professional. I made sure to document this interaction in my notes and discussed with my tutor what I should do. We agreed that if further comments were made, it would be appropriate to put this patient with another student.

SO WHAT?

I reflected quite heavily in this situation as I was panicking that I had led this patient on unintentionally. My tutor reassured me that I had not and handled the situation very professionally. It made me aware that the boundary that was crossed was initially very subtle however it needed to be addressed early and respectfully.

This has taught me the importance of maintaining clearly defined professional boundaries, especially once patients begin crossing the lines between therapeutic and personal relationships. Even though the comments may have seemed harmless, the comments made me feel very uncomfortable and it compromised the professional relationship we had built.

This has reminded me that I am in a position of trust and responsibility, and I must not allow this to be misinterpreted.  Upon my reflection after this patient, it has made me realise that when asked about my personal life, I should lead the conversation onto another topic as this may have resulted with oversharing my personal life.

NOW WHAT?

In future situations I will:

- Remain alert to early signs of inappropriate behaviours that cross boundaries in clinic and when I graduate.

- I will respond to these situations professionally and respectfully ensuring patients fully understand the professional limits of the therapeutic relationship.

- I will always document any concerns clearly in patient’s notes.

- I will seek tutors’ advice if I feel unsure about how to manage similar scenarios. If I am graduated and this situation were to happen again, I would consult the principal osteopath or a mentor.

- I will stay vigilant to not overshare about my personal life and if a patient asks questions I will direct the conversation into a new topic.

EXPERIENCE:

A 42-year-old female presented with upper thoracic dysfunction. As part of my treatment plan, I used a high velocity thrust (HVT) technique to the thoracic spine. I had previously been supervised with this technique and felt confident to perform it to this patient.

During the setup, before the thrust, my hand position slipped slightly which altered the direction for the thrust. After the manipulation, the patient reported increased discomfort in the area. I reassessed the patient and found increased local tenderness but no signs of red flags or neurological involvement. The patient was visibly in pain, and I recognised that due to my slip in the setup, it had contributed to her pain.

I reassured the patient that nothing serious had occurred. I gave a complete honest explanation that while the HVT technique is generally safe, my hand slipped during the setup and this likely caused unintentional irritation or muscular strain. I offered a sincere apology and chose not to provide any further treatment that day. I provided advice for breathing exercises and offered to get the patient some ice. I also informed her that I would call from the clinic to follow up with her the next day.

I reported this to my tutor and documented the details thoroughly in my notes.

REFLECTION:

At the time I felt very anxious and concerned that I had caused unnecessary discomfort, especially since the patient had started to see improvements for her initial complaint. I worried that I had lost my patients trust. But I tried to remain calm and I took responsibility for what had happened and explained the situation honestly. My patient appreciated my honesty and she was very understanding.

I feel as though if I was not a student and this had happened in a private clinic, that a patient would not have the same point of view as my patient due to the financial costs of a private clinic and that they expect us to be able to do it without making a mistake. However, I spoke to tutors about this feeling and they discussed that we do make mistakes and cannot be perfect all the time, but it is the way we respond to such incidents that matters just as much as the technical skills themselves.

This experience has taught me that if I make a mistake, I will always be open and honest to take responsibility by acting professional.

ACTION:
I will continue to respond to adverse effects of techniques with honesty if it was due to my technique. I have been more attentive to my setups for any techniques, particularly so in a HVT, to reduce risk of errors like in this patient. I will also document any incidents and seek supervision where needed so that my tutors can criticise my techniques to make them more effective and accurate. I will also start to view mistakes as learning opportunities and will reflect on them every time to strengthen my technical ability and ethical practice for patients.

EXPERIENCE:

Even though I have not had any complaints made about me by a patient at the ESO clinic, I am aware that complaints can happen. To prepare for this, I have taken time to familiarise myself with the university’s patient complaints procedure as attached above. This outlines the steps for patients to make a complaint and how to acknowledge, record and respond to these concerns.

As part of our clinical induction week, we were introduced to the ESO’s complaint policy and how important it is to respond to them professionally and quickly. In this lecture, tutors shared with us examples that they have encountered and how they dealt with them. Many of them were similar where miscommunication regarding treatments or expectations led to dissatisfaction.

In year 2, as a part of our module we had to respond to a patient’s complaint letter. This also gave me good skills and experience to be able to respond to patients’ complaints. At the time I did not see the reason why we had to complete this however being in clinic it has taught me the relevancy behind this assessment.

REFLECTION:

Although I have not directly experienced a patient complaint, reflecting on this standard has made me realise how important it is to have a clear policy in place to follow. It is also reassuring for patients to know that there is a fair and transparent procedure that will take place if they have any concerns or something to complain about.

I have learnt through my tutors’ examples that avoiding complaints is not about being perfect but by maintaining open and clear communication, managing patients expectations, having thorough informed consent and responding promptly if a patient is dissatisfied. This is also supported by research which found that most concerns raised by patients are based on poor communication and a lack in gaining informed consent (Browne et al. 2019; Carnes, 2016).

I have learnt that a small issue left unacknowledged can escalate if it is not addressed correctly and quickly.  The university’s policy makes sure that complaints are reviewed, responded to and documented in appropriate timeframes.

ACTION:

Therefore, to uphold this standard I will make sure that if a patient complains that I will follow the ESO’s policy. If this was to happen in private practice, I will make sure I am aware of that clinics procedure to make sure that the complaint is dealt in a professional manner. I will communicate clearly and honestly with patients about their care ensuring they know what to expect in each session to minimise the risk of having a complaint be made. I will check in with patients about their comfort and any concerns they have so I can address these early. If a patient was to make a complaint, I would direct them to the ESO’s complaints procedure and make sure they know how to pursue a complaint further, for example by informing them of their right to report the issue to the GOsC. I will aim to reflect on all patient feedback, both positive and negative, to be able to improve my clinical practice and learn for future situations.

WHAT?

A 29-year-old female patient presented to the clinic with chronic pelvic pain. During the case history she disclosed that she had recently experienced a miscarriage and was really struggling emotionally which she was actively seeking counselling for. She requested that this information was to not be shared with her partner who I also treated regularly at the clinic.

Following her request, I made sure to note this detail discreetly and clearly in the patients notes, flagging it so only ESO clinic staff and students involved in her care could see it.

I then treated her husband a week later. He was asking how she was doing and displayed some concerns and wanted to see what was going on. I politely explained that due to patient confidentiality, I could not disclose or discuss any aspect of her appointments without her consent. I informed my clinic tutor of this situation and documented this into my notes as well.

SO WHAT?

While I felt a bit awkward not answering the partner’s questions especially as he expressed concern, I recognised my duty to the patient and her expressed wishes and that she did not provide me with consent.

If I was to discuss any details with the partner, I would have completely lost trust from the patient and also would not know the repercussions of telling the partner this sensitive information.

This experience has increased my confidence in setting boundaries and reinforced the importance of safeguarding patients trust.

NOW WHAT?

I will never discuss my patients’ details with another person without their consent regardless of their relationship. I will always document any specific requests about privacy or withheld information which is also important if another student were to take over this patient.  I will ensure that all written and verbal information is handled with discretion and stored securely.

EXPERIENCE:

I treated a 30-year-old patient who identified as transgender and was looking to have gender-affirming surgery in the next few months. The patient presented with mechanical low back pain.

Before the appointment, the patient had called the reception to ask if the student who was treating them could use their chosen name and pronouns. When greeting the patient in the waiting room, I made sure I used their chosen name and pronouns to make sure I created a welcoming environment for them. In the case history, the patient expressed some of their anxieties about previous negative health interactions which were based on their gender identity.

I reassured the patient that as osteopaths we respect patients’ preferences. As usual, I asked if the patient would like to have a chaperone present during the appointment, which they declined. They mentioned that they were so grateful for being treated so respectfully, inclusively and non-judgementally. The patient said that was the best experience they have had and would recommend their friends to go to the clinic as they would feel safe and comfortable to be themselves.

REFLECTION:

I was very mindful to make sure that the patient felt comfortable and respected. It was very distressing to hear that just because of their gender identity, they had previous negative experiences. This is why osteopaths must abide by the Equality Act 2010 which legally protects people at work and other places from discrimination and disadvantage (Equality Act 2010). The Act includes protected characteristics like age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation.

By recognising and respecting diversity, I created a therapeutic environment where my patient felt valued and supported. This was also reinforced by a lecture that we had in 3^rd year, from a previous student that covered the importance on LGBTQ+ inclusion in healthcare. This was a real eye-opening lecture and made me feel responsibility to make sure I do better in clinic.

ACTION:

To uphold the standard C6 I will:

• Engage in ongoing learning focussed on diversity, equality and inclusion to better understand the needs of these patients.

• I will consistently use inclusive language, ask for and respect patients preferred names and pronouns.

• I will reflect on patient interactions that I have had/will have to identify areas for improvement in providing inclusive care.

WHAT?

During a party that only included osteopathic students, I experienced a situation that challenged my personal boundaries and professional values. A student, who was drunk, began to make inappropriate comments to myself and another student. Their behaviour made us both feel very uncomfortable and unsafe as it was clear that their actions were gradually getting worse.

Although this was a non-clinical setting, we were still representing the profession and that behaviour was unacceptable. I stayed calm and removed myself and the other student out of the area and immediately told the staff supervisor at the event of what had happened. After the supervisor heard about our account and his behaviour, the student was removed from the party.

SO WHAT?

That experience made me think about how professionalism extends far beyond the clinic environment with patients. As students and future healthcare professionals, our conduct in public settings directly impacts how others perceive our profession. The student’s behaviour not only violated our personal boundaries but risked losing the public’s trust in osteopaths if this behaviour was witnessed publicly.

By taking appropriate action and involving a responsible authority figure, I believe that I upheld the standard D7. I acted in a way that protected myself and another student and also ensured that the problem was resolved without causing unnecessary tension.

It has made me realise that safety and professionalism is not just for the patients but also between colleagues and peers. It has made me more aware that we should hold each other accountable even in social environments but in an appropriate way.

NOW WHAT?

Going forward I will continue to hold myself and others to a high standard of professional conduct regardless of the setting we are in. If I witness inappropriate behaviour I will act accordingly to ensure that it does not occur again. This personal experience has empowered me to be more confident in speaking up against behaviour that threatens safety or the reputation of osteopathy. I now have a deep understanding that professionalism is not limited to treatment rooms but is a constant expectation that extends to how we act, interact and represent osteopathy in all aspects of our lives.  By doing this, I will continue to demonstrate adherence to D7 ensuring my behaviour reflects professionalism both inside and outside of the clinic/workplace.

WHAT?

At the ESO clinic, there are fixed prices which are clearly stated on the website (as attached above) and as well as in the waiting room in the reception. Compared to other osteopathic prices in the Maidstone area, I believe that the ESO prices are very reasonable as treatments are provided by students that are still currently learning. I had one patient who asked if they could get a discount as they thought the prices were too high for the whole appointment to be provided by a supervised student. I explained that I had no authority to alter these prices and that all clinic fees are fixed and managed by the administrative team. I took the patient to the reception, where they asked again, in which the reception replied with the same answer.

SO WHAT?

As a student, it is not in my role to alter the pricing of treatments, it is based on the university and the team there. If I had given the impression that prices were flexible, it would have been very misleading and unprofessional. It also made me reflect that had that patient been given a discount, other patients would have expected the same, which undermines the value of student-led care. Therefore, by having consistency in financial communication will help avoid disputes about fees and supports fairness.

NOW WHAT?

At university, I will continue to direct patients to the reception or clinic website if they have concerns about the cost of treatment. If I am in a situation again, I will clearly communicate that pricing fees are set by the clinic and apply equally to all patients.

WHAT?

As I am coming to the end of my 4^th year at the ESO clinic, I am beginning to hand over some of my patients to 3^rd year students. To support both my patients and my colleagues in the year below, I have invited the 3^rdyears to become familiar with the patient’s case, understand the treatment approach so far and observe how myself and the patient interacts and communicates. This also gives the patient a chance to meet their new practitioner in a supported environment, helping to build trust in the 3^rd year before they take over.

If a 3^rd year cannot observe, I must fill in a handover form which includes a patients name, date of birth, presenting complaint, secondary complaint, working diagnosis, treatment so far, medical history and any other additional comments. This supports the student doing a take-over by providing all relevant information on one sheet in a clear layout.

SO WHAT?

By encouraging the 3^rd year students to come and observe these patients, I have hopefully set them up for a more successful journey with that particular patient. For the 3^rd year students, it also offers a smoother introduction to the case and give them an opportunity to ask questions. For the patients, this also gives them preparation and knowledge of who will be taking over their case which will aim to decrease any anxieties or concerns when I hand them over, so it instils trust in the new practitioner.

This experience has highlighted that patient care does not stop when my studies and as it is my responsibility to ensure that my handovers are done with care, good communication and respect. Failing to do this could create confusion and disrupt therapeutic progress.

NOW WHAT?

As I complete my last term, I will continue to handover patients in a structured and supportive way. I will encourage 3^rd years to observe sessions with patients they will be taking over, so it builds their confidence. I will clearly communicate case details, important information and patient preferences during take-over, using the handover form if necessary. I will reassure my patients that their care will remain consistent and that I trust the colleague that I will be handing over, to start encouraging the process of a new patient-practitioner relationship.

WHAT?

A 22-year-old female presented to the ESO clinic with ongoing tension type headaches (TTH) that was diagnosed by a GP and chronic upper thoracic tension and dysfunction. In the case history she mentioned a long-standing history of anxiety, low mood and difficulties when sleeping. Even through her issue was musculoskeletal, it seemed as though her symptoms were closely linked and maintained by psychological stress.

Osteopathic treatment helped to relieve some of her physical tension, but her symptoms returned when she would have increased levels of stress. After discussing this with my tutor, we agreed that the patient may benefit from additional psychological support. In the next sessions, I sensitively and respectfully suggested the idea of working alongside a counsellor with the treatment she was receiving. The patient was very much happy to do this, so I wrote to her GP who then referred her to a local counselling service.

SO WHAT?

A few appointments later the patient reported significant improvements in her physical symptoms and also in her emotional wellbeing. Her TTH had also reduced in frequency. She said that having a safe space where she could talk about her worries made her feel more in control, less stressed and less tense.

This highlighted by working collaboratively with a mental health professional, I could optimise the patients care. This is due to the other healthcare professional addressing the biopsychosocial contributors to her pain. Osteopathic care alone could not fully address the underlying emotional distress but in combination with counselling her overall outcomes improved. This is further supported by literature which suggests that multimodal approaches are more effective for managing chronic pain for example, manual therapy should be used in combination with psychological approaches (Cohen et al. 2021).

NOW WHAT?

For all patients I will consider the need to refer or collaborate with other healthcare professionals when it is in the patient’s best interest which could optimise their care. I will continue to develop my understanding of alternate professions which could be of benefit to patients to work alongside with osteopathic care. I will also continue to extend my knowledge of local and national services that I can direct patients to when appropriate.

WHAT?

In November, I fractured my finger following an accident at home. I thought I would be able to manage patients by modifying my techniques and using my non-dominant hand. When attempting to treat a patient following that accident, I experienced pain and a loss of strength in that hand. For this patient it limited the range of techniques I could provide effectively and safely. This is when it became clear that my injury impacted my ability to deliver optimal care.

SO WHAT?

I realised that continuing to treat patients in this condition could compromise the quality of care I provide and potentially pose a risk to patients. Instead of relying on my judgement alone I went to the head of clinic about the injury. After an assessment and a discussion, it was agreed that I should temporarily step back from hands-on practice. This meant that my scheduled patients were covered by other students, in which I made sure there was a smooth handover of case notes.

I was able to recognise my limitations due to my own physical health. It has highlighted that decisions about my fitness to practice should not be based solely on my own judgement. This is due to me underestimating the level of impairment that I had. Instead, it is essential and follows the standard of D11 to seek appropriate medical guidance and assessment to ensure that patient safety is not compromised.

NOW WHAT?

Moving forward, I will continue to acknowledge how my own health may affect my clinical practice. From this experience, I understand that self-assessment alone is not sufficient enough and that should I gain a medical professional opinion to base whether I can continue practicing or not. If I am unwell or physically impaired, I will prioritise patient safety above all and ensure that if these patients are covered by another student/osteopath, that this is managed professionally and smoothly.

WHAT?

Even though I have not encountered this situation as a student, I considered how I would respond if I were ever involved in an incident that may raise questions about my conduct or competence. For example, if I were to be issued a police caution for a non-clinical matter, I understand that this is a significant matter which could affect public trust in me as a healthcare professional. Even if it is unrelated to patient care, any event would still fall within the standard of D12.

SO WHAT?

This standard requires that I inform the General Osteopathic Council (GOsC) as soon as possible if I am subject to a police caution, criminal charge or face regulatory or disciplinary action. This is to maintain professional standards and protect the public or other practitioners. If I failed to provide such information, it could be seen as dishonest or negligent, which potentially could cause a greater concern than the incident itself.

In this scenario, I would seek advice from a clinic tutor and the head of clinic. If I were in private practice, I would also seek advice from the principal osteopath or a mentor. I would then write to the GOsC, explain the situation clearly and provide relevant and necessary documentation. Then I would cooperate with any investigations or requests for information to demonstrate accountability and integrity.

NOW WHAT?

Even though I have not yet faced a situation that would reflect this standard, I understand the importance of informing the GOsC if it were to ever happen. I will make sure that I stay familiar with the types of incidents that must be reported under D12 and will act accordingly if a situation arises. I will also continue to uphold the values of professional conduct, again highlighting that my responsibilities extend beyond the clinic setting.

Browne, F., Bettles, S., Clift, S. & Walker, T., 2019. Connecting patients, practitioners, and regulators in supporting positive experiences and processes of shared decision making: A progress report. The Journal of Evaluation in Clinical Practice, 25(6), pp. 1030-1040.

Carnes, D., 2016. What can osteopaths learn from concerns and complaints raise against them? A review of insurance and regulator reports. International Journal of Osteopathic Medicine, 22, pp. 3-10.

Carragher, M., Steel, G., O’Halloran, R., Lamborn, E., Torabi, T., Johnson, H., et al., 2024. Aphasia disrupts usual care: “I’m not mad, I’m not deaf” – the experiences of individuals with aphasia and family members in hospital. Disability and Rehabilitation, 46(25), pp. 6122-6133.

Cohen, S., Vase, L. & Hooten, W., 2021. Chronic pain: an update on burden, best practices, and new advances. Lancet, 397(10289), pp. 2082-2097.

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