Using the Rolfe et al model (Rolfe 2001)

February 2019

What?

Today in my clinic observation I thought about how easy it is to learn from observation. The 4th year student practitioner was extremely competent and professional in her patient handling and I learnt a lot from observing her.

On the observation sheet I noted what I thought she did well and not so well. This practitioner's patient rapport was very good and her knowledge base around osteoarthritis was excellent and I found her explanations easy to follow and helpful. However, she sometimes forgot to obtain ongoing consent. I can see that when the patient is happy and relaxed with you it is difficult to remember to do this. 

So what?

Even when working with returning patients I need to obtain informed consent to treatment, which entails ensuring that they understand the risks, alternatives and possible benefits of any treatment they receive. This is an important of patient partnership and shared decision making as even treatments that are meant to help a patient come with risks, and it is essential for patients to accept those risks when getting care.

Now what?

I understand that this is very important in clinic and I need to ensure that I am practicing the skills now on other students so that it is embedded in my practice before I have real patients.  Going forward I will try to remember to practice verbalizing asking for informed consent.

References:

NICE, Overview | Osteoarthritis: Care And Management | Guidance | NICE. Available at: https://www.nice.org.uk/Guidance/CG177 [Accessed March 12, 2022a].

Rolfe, G., Freshwater, D., Jasper, M. 2001. Critical reflection in nursing and the helping professions: a user’s guide. Basingstoke: Palgrave Macmillan. 

Roache, R., 2014. Why Is Informed Consent Important? Journal Of Medical Ethics, 40(7), pp.435–436.

D6 GOSC Practice Standards 2019
D6: You must treat patients fairly and recognise diversity and individual values. You must comply with equality and anti-discrimination law

“The real purpose of scientific method is to make sure nature hasn’t misled you into thinking you know something that you actually don’t know” – Robert Pirsig, Zen and the Art of Motorcycle Maintenance

What?

This week in clinical integration we had a session on unconscious bias and how this can impact our interactions with patients as we unconsciously categorise and assess them in some way without really thinking about why we are doing that. It affects everyone but will also lead to different judgments as how a person thinks depends on their life experience.  It can inadvertently lead to beliefs and views about a person that are not right or reasonable. As an example, I have caught myself thinking that an overweight patient's problems were due to this, rather than the injury they had sustained which led to the weight gain.

It made me reflect on the book I read last summer – Thinking Fast and Slow by the Nobel prize winner Daniel Kahneman.  In it he explains the brain thinks in two different ways: the System 1 part is fast, automatic, with little or no effort and involuntary.  System 2 is slow, deductive, effortful, deliberate and can take a lot of time.  System 1 does most of the work of the brain (necessarily), whereas we tend to think we rely on system 2, so we think we may be deliberating when we are not, and these heuristics, or mental shortcuts, can lead us to make errors of judgement without us even realising it. 

So what?

Unconscious bias is a product of system 1 as it is a bias that is automatic, we are unaware of consciously making it and it is outside of our control.  It is triggered by our brain making quick judgments and assessments of people and situations, influenced by our background, cultural environment and personal experiences.  As you can know you have cognitive illusions, but still believe them, for me, the key point is that being aware that everyone has bias does not mean you overcome the bias – for that you have to take rational steps to switch on system 2.  This requires conscious effort and probably putting in place a system to ensure system 2 is being used.  I would hope that the taking of a full patient history, which requires following a set format, and thinking about the best outcome for the patient in front of you will help overcome some of the limitations of system 1 thinking and encourage deliberation before reaching a diagnosis.  

Now what?

Overcoming unconscious bias can be overcome by taking a taking a patient-centered approach and relying on data gathered in the case history and examination to guide my treatment plan.

I need to keep in mind the swimmers at my local pool.  I like to swim laps in the fast lane and when a new swimmer enters the lane I automatically assess them to see how I will have to alter my stroke – will they be faster, or slower than me?  I’ve learnt that actually my unconscious biases are often completely wrong – fit looking young men who I assess as fast sharks in the pool who will steam past me, often have poor technique and splash along slowing me down as I catch them up, whereas frequently larger, older ladies who I consider may have picked the wrong lane are super sleek swimmers in the pool and fly past.

References:

Interview with Daniel Kahneman on Thinking fast and slow:
Daniel Kahneman: Thinking Fast vs. Thinking Slow | Inc. Magazine - YouTube

NHS: https://www.bfwh.nhs.uk/onehr/recruitment/recruitment-process/unconscious-bias/


Marcelin JR, Siraj DS, Victor R, Kotadia S, Maldonado YA. The Impact of Unconscious Bias in Healthcare: How to Recognize and Mitigate It. J Infect Dis. 2019 Aug 20;220(220 Suppl 2):S62-S73. doi: 10.1093/infdis/jiz214. PMID: 31430386.

I am reading Ben Goldacre’s book Bad Science, which has an entire chapter on the placebo effect.  I’ve come to osteopathy from a prior career based on rational, evidence based thinking which makes me inclined to be quite cynical about some of the claims some advocates of osteopathy make.  It’s been fascinating to read about the power of the placebo effect and made me wonder about it in the context of osteopathy.  I’ve seen for myself that a white coat and a professional manner can go a long way and studies have shown that pain, in particular, can be reduced by the placebo effect.  So would it matter if osteopathy was to some extent a placebo?  It’s easy to think of a placebo as a sham because it is somehow not real, but if the effect is real is that sufficient?  Interestingly, even when patients know they are taking a sugar pill they still often feel better.   From reading some press articles on the placebo effect I think at the moment the best view is that put forward by the GMC who apparently say “We do not require doctors to use only evidence-based treatments, in any form of medical care, but we do expect doctors to do their best to ensure that any treatment they offer is in the patient's best interests. This will generally mean that any known risks of the treatment are outweighed by the potential benefits to the patient."  This is an area I look forward to learning more about as it throws up interesting ethical quandaries and conflicts.  It may be that the more interesting reality is just that we don’t yet understand how osteopathy works. My challenge on this course is to learn how it works so that I can put forward credible evidence-based explanations to patients, or honestly acknowledge where that evidence is not yet available, but at all times to only act in a manner that is in the patient's best interests. 

References:

Ben Goldacre, What’s Wrong With The Placebo Effect? | Science | The Guardian. Available at: https://www.theguardian.com/science/2004/apr/15/badscience.science [Accessed March 13, 2022].

Bishop, F.L., Aizlewood, L. & Adams, A.E.M., 2014. When And Why Placebo-Prescribing Is Acceptable And Unacceptable: A Focus Group Study Of Patients’ Views. PLoS ONE, 9(7).

Goldacre, B., 2008. Bad Science. , p.338.

Rossettini, G., Carlino, E. & Testa, M., 2018. Clinical Relevance Of Contextual Factors As Triggers Of Placebo And Nocebo Effects In Musculoskeletal Pain. BMC Musculoskeletal Disorders, 19(1).

January 2019

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

B 1.2 a knowledge of human structure and function sufficient to inform appropriate care

Prosection was booked for the first Monday back after Christmas and before the break the tutor had told some funny, but rather alarming stories about his time dissecting as a medical student.  I really wanted to attend and understood how useful it would be for my understanding of anatomy, but had no experience of being face to face with a human body and whilst I thought I could “handle it” I had an element of uncertainty in my mind over the whole thing.   

The night before the visit I was checking the Kings College website to find out where to go and came across the section for body donation.  In the past I’d thought this was a bit ghoulish and could think of nothing worse than medical students poring over a body, but looking at the page made me view the whole thing very differently.  A service of thanksgiving is held each year at St George’s cathedral with ushers and readers provided by a teaching institution served by the London Anatomy Office on a rotational basis.  There was also a testimonials page praising the compassion and kindness of the London Anatomy Office and how they had helped to honour the deceased’s wishes.  It made me feel honoured to be able to attend the prosection and actually on the day it was an amazing experience.  Once over the initial thought of “Ohh it’s a human body” it was incredible to be able to look at, touch and think about the intricacy of the structures in the body.  The whole year group was engaged and respectful.    The staff were really helpful in sharing their knowledge.  

Seeing, touching and examining a body is a very different experience to studying anatomy from a book or slides. The bodies were so much denser and the structures so much closer packed than I had envisaged. It was fascinating to see how tendons and ligaments blended onto bones and muscles. 

I came away feeling I had learnt so much anatomy and that I wanted to return as soon as possible which really surprised me.   I’ve been recommending it to those who did not go.  

 

February 2019 

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

B. 1.7 - well-developed palpatory skills 

B. 1. 9 - the ability to determine changes in health and function by the appropriate use of observation, palpation, motion and clinical evaluation 

“Touch is not just a sentimental human indulgence – but a biological necessity” - Professor Francis McGlone

I’ve been learning about slow nerve fibres called C-tactile (CT) afferents from reading The Stress Solution by Dr Rangan Chaterjee (Chatterjee 2019).  He talks about the research carried out by Professor Francis McGlone, which has changed the landscape on how science understands touch in humans. In short, CT fibres carry the touch signal from the skin to the limbic system in the brain.  The interesting bit is that Professor McGlone’s research has shown that humans respond to a specific kind of light, stroking touch at a speed of roughly 5 centimetres per second (McGlone et al. 2014).  Only at this speed are the CT afferents firing an impulse.  He has shown that this is the speed that people automatically adopt when stroking another human and that this is also the speed which people most like to be stroked at. CT afferents connect to the hypothalamic-pituitary-adrenal (HPA) axis, which acts as a stress broadcast system and ultimately triggers the release of the hormone, cortisol ready for fight or flight. Stroking at this speed calms the HPA axis and reduces cortisol levels. It also increases the tone of the parasympathetic nervous system and releases serotonin and oxytocin.

Reading this made me reflect on the importance of touch as an osteopath and the need not only to develop palpation skills, but to monitor how touch makes a patient feel and that performed correctly it can be a very real antidote to stress.  Feedback from my practical exam suggested I could improve my monitoring of patient comfort.  Understanding a little more about the science of touch has made me reflect on the importance of not just performing a technique, but how that technique feels to the patient and the response it triggers in them.  Slowing down and tuning into these CT afferent fibres in some techniques is very important and something I will try and bear in mind going forward when touching patients. 

References:

Chatterjee, R., 2019. The Stress Solution : The 4 Steps To Reset Your Body, Mind, Relationships & Purpose. , p.271.

McGlone, F., Wessberg, J. & Olausson, H., 2014. Discriminative And Affective Touch: Sensing And Feeling. Neuron, 82(4), pp.737–755.

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

B2.1. You should use your professional judgement to assess whether you have the training, skills and competence to treat a patient, seeking advice where necessary.

In January I took my first practical exam. I thought I had prepared thoroughly and had spent quite some time practising with my study group. However, on the day I was surprisingly nervous (first time taking this style of exam) and found switching between answering questions from the examiner and considering the patient tricky and that my dealings with the patient were rather perfunctory. I was also very aware of my own lack of knowledge compared to that of my examiners which made me sound very hesitant when answering questions.

When I got the results, I was initially quite dismayed and upset by what I saw as my poor performance. It made me really question whether the course was the right one for me. I sought more feedback from all the examiners and during those discussions I realised that actually my performance was good for the stage I am at and that they thought the exam had gone well. I decided not to try and address all the comments, but to try and improve by focussing on improving two key issues for the next exam. These are new skills I am learning and I need to be a little easier on myself and not expect to be perfect from day one.

I am at the start of my osteopathic career. Over the course I will build the skills I need in order to be able to treat patients in a professional manner and this will take time and perseverance. I need to trust in the process.

My 2 key takeaways to work on are:

1. Appear more confident. Confidence is important when dealing with patients. Since January my anatomy knowledge has improved and this will help with my confidence. From some further reading I also understand that confidence will ebb and flow not only whilst I am a student but also post graduation ( (Subramaniam et al. 2015). l will try not to let the examiner distract me from providing good patient care.

2. Engage with the patient more. I am going to develop more of a script to explain what I am doing in more detail that I can rehearse so I appear less phased in an exam setting. I will try to ensure that I communicate effectively to the patient what I am doing, what I am looking for, how I am going to do it and seek consent for these actions at every stage (Leach et al. 2013).

Finally, Charles Darwin wrote that ignorance often generates greater confidence than does knowledge – I have taken it slightly out of context but it is a thought I am going to hold on to.

References:

Leach, C.J., Mandy, A., Hankins, M., Bottomley, L.M., Cross, V., Fawkes, C.A., Fiske, A. & Moore, A.P., 2013. Patients’ Expectations Of Private Osteopathic Care In The UK: A National Survey Of Patients. BMC Complementary And Alternative Medicine, 13(1), p.122.

Subramaniam, P., Eaton, S.-A., Cranfield, J., Mulcahy, J., McLaughlin, P., Morrison, T. & Vaughan, B., 2015. Osteopathic Graduates Perceptions Of Stress And Competence – A Longitudinal Study. International Journal Of Osteopathic Medicine, 18(1), pp.40–49.

 

Shocking feet!
April 2019
Using the Rolfe et al. reflective model (2001)

In clinic I sat in on a new patient consultation.  The patient was a 70 year old retired truck driver with lower back pain which had started 5-6 weeks ago with no apparent trigger.  He said he was otherwise fit and well but as the case history went on it became apparent that he had a number of different health issues.  He was a heavy smoker until 3 months ago, suffered from emphysema and was on blood pressure tablets.  He still drank 14 pints a week and had a very red nose suggesting excessive alcohol consumption.  In the last few months he had experienced dramatic weight loss.  On undressing he had scaly grey skin covering his back and feet.  His left big toe was white, swollen, as were his ankles, his foot appeared ulcerated and he reported numbness in his feet, both suggestive of diabetes.    His arm movements were restricted and he had poor muscle tone generally.  His general posture can best be described as if he were still driving his HGV, that is, rounded shoulders and very slouched posture.  Despite all this he managed to perform the active tests that the practitioner set and there was no pain on palpating his back.

The practitioner was very professional but did not spend any time asking why he had not visited his doctor, or seeking to understand his attitudes to his own health.  

I’ve thought quite a lot about this patient as it made me realise that as an osteopath I will see all types of people and I will need to deal with patients who may have very different values to me in terms of hygiene and health.  To be honest I found this man’s back and feet quite repellent and was shocked he was not seeking treatment with his GP for these.  It also made me sad that whilst fairly elderly he did not seem to value his health very highly even though it was having a very direct impact on his lifestyle by restricting him to the house. 

Secondly, it made me reflect on what is the meaning of health.  This patient clearly did not regard himself as being in ill health and was only seeking treatment in relation to the back pain despite having a number of other untreated issues which he had not discussed with his GP.   Rather than being unaware of his symptoms, he may have made a conscious decision not to seek treatment, which during the taking of the case history was not explored by the practitioner.

Whilst I hold my own personal values, I understand that I cannot seek to impose these on patients. In some circumstances this may be difficult but I need to be able to treat all patients with the same compassion and kindness, without necessarily seeking to judge their values.  However, patients also need to be encouraged to seek appropriate medical care.

 

B.1.2 a knowledge of human structure and function sufficient to inform appropriate care

March 2019

What?
For a long time I was in denial about the need to learn
anatomy and busily boring anybody who would listen that it was akin to having to learn every road name in Rochester without ever having been there and then every road name in Maidstone etc. etc. 
 
 By Christmas I totally understood why I needed to do it (a
lightbulb moment in itself) but still had not really got to grips with it. By January the first anatomy exam was looming and after a lot of effort I'm really pleased with my exam result.
 
 So what?
Anatomy enables us to understand our patient's body and where it may be in dysfunction. Without the guiding map that anatomy provides osteopaths cannot work. 
 
 Now what?
I know that this will be an ongoing project that fundamentally underlays all my other osteopathic skills and is therefore essential to my practice. I am experimenting with different ways of learning from videos, podcasts, books and flashcards to help me get to grips with what is a huge area to learn but only one aspect of the course.  

I’ve just had a second lecture on reflective writing.  This, like almost everything on the course, is completely new to me and I felt really uncertain on how to approach it or what was involved.  Is it a diary full of small reminisces?  Amusing stories? I’m finding it easier to identify what it is not - it’s not creative writing, it’s not a straightforward account, it’s not a diatribe moaning about my frustrations, it’s not an academic essay, nor a piece of critical writing.  

I recall hearing about radio programmes on how it has been used extensively by NHS surgeons and airline pilots to reduce human error in their work, which in both cases can lead to catastrophic consequences, so clearly a very good thing!

Despite starting a new career I still regard myself as a lawyer .  I can’t honestly say that self-reflection features highly as a skill prized in City law firms, although it probably should!  A lot of lawyers are pretty arrogant and since there’s always the next deal to be done reflecting on how things might have been handled differently (except in the face of a negligence claim) does not come easily.   Whilst I don’t think I fall into that category it’s a new skill for me to master and as a result having set up my Padlet I studiously ignored it for the first term.  But I can’t ignore it any longer…..

The lecturer advised I look at some books and I just had not appreciated that there is an academic discipline around this subject.  I’ve read about the different models and I am starting to write up items that interest me in a more reflective way.  Already I’m actually enjoying the process and it is making me reflect on what I am thinking about in a different way (and oh it is also an outlet for frustrations if I frame it properly)……I think the main benefit for me is to reflect on what I’m learning and think more deeply about what it means from an osteopathic perspective. I think there might actually be something to this!

Making mistakes is human. The important element is to recognise and acknowledge the error and learn from my mistakes and grow as a professional health practitioner. Self-reflection on my actions makes me more self-aware of the circumstances that I face and allows me to think around difficulties I encounter. Reflective practice is a very healthy habit to cultivate.

Whilst very useful now as a student to reinforce my academic learning, I can see that it also prevents complacency arising once qualified as it forces me to challenge my assumptions and continually self-assess and seek to improve my performance and patient care and hence the patient experience.  For this to be successful the process needs to be carried out in a critical and focussed way, that is questioning, evaluating and tying the reflection back to an evidence-based approach that supports the resulting change proposed.  This also acts to ensure that the practitioner stays up to date with current thinking.  

I am going to use Rolfe’s model (Rolfe et al. 2001), which has the benefit of being simple and straightforward for someone new to reflection.  It can be summarised as follows:

                What?                                          So what?                                                      Now what?

What? – Describe the event

·         What happened?

·         What did I see/do?

·         What was I trying to achieve?

·         What actions did I take?

·         What is the issue? 

So what? – Analysis 

·         What is the issue?

·         How did I feel at the time?

·         What were the effects of what I did (or didn’t do)? What does the literature suggest I did well / should do differently next time? What does the literature say about why it is important? What may be the possible consequence of this?

·         So what could/should I have done to make it better? 

·         What is my new understanding of the situation?  

Now What? Proposed actions following the activity

·         What are the implications of what I have described or analysed?

·         How can I change my practice?

·         What can I learn or develop to move forwards?

·         What is my action plan? What tools will I use to help me do this?

 References:

Learning Through Reflection | Models Of Reflection Training. Available at: http://www.ventureteambuilding.co.uk/learning-through-reflection/ [Accessed May 4, 2019a].

 Reflective Commentaries. Available at: https://cedar.exeter.ac.uk/media/universityofexeter/schoolofpsychology/cedar/documents/pwp/Supporting_reflective_practice_and_writing_reflective_commentaries.pdf [Accessed May 4, 2019b].

Kolb, D.A., 1984. Experiential Learning : Experience As The Source Of Learning And Development, Prentice-Hall.

Rolfe, G., Freshwater, D. & Jasper, M., 2001. Critical Reflection For Nursing And The Helping Professions A User’s Guide.

https://intranet.exeter.ac.uk/insess/PCMD%20materials/refwrtngwrkshp.pdf

·         use of wall charts to explain his findings 

·         explaining how the appointment would run

·         acting out what he wanted the patient do 

·         using his hands to model when explaining his findings 

·         switching between French and English to ensure the patient’s understanding 

·         providing a guiding hand to the patient to assist her in making movements and getting up and down from the plinth 

·         a welcoming and happy demeanour and active listening to what she was saying – hearing her as a person

·         a happy, confident and professional manner 

So what?

It was clear that the practitioner had developed a lovely rapport with the patient and that she felt very listened to and engaged in the consultation.

Now what?

In terms of developing the way I explain things to a patient I could bear in mind the following:

·         this is what I think is the matter …

·         this is what I think about why this may have happened to you ….

·         this is the treatment I can offer ….

·         this is why I think the treatment will help you ….

·         you may notice these side effects ….

·         and these benefits …..

·         this is what you can do to help yourself ….. 

·         come back to see me when or if …..

·         is there anything more you would like to check with me?

This will help the patient feel a sense of participation in the appointment and also give them a sense of control
(Mitchell & Cormack 1998).

References

Mitchell, A. & Cormack, M.A., 1998. The Therapeutic Relationship In Complementary Health Care, Churchill Livingstone.

So what?

The course was really helpful and very well taught. Exercise prescription forms a very limited part of my course and I felt that I lacked skills and knowledge in this area, especially as a number of NICE guidelines suggest that it is an essential part of patient treatment. For example, the NICE guidelines on back pain suggest that manual therapy should only be given in conjunction with an exercise programme therefore developing skills in this area is important. The course was based on current thinking and evidence which supported my learning needs. (NICE 2013; NICE 2014; Internet 1 NICE; Internet 2 NICE)

Now what?

I am planning on using the skills I have learnt to help with rehabilitating my patients in clinic.

References:

Internet 1: NICE, Assessment | Diagnosis | Neck Pain - Cervical Radiculopathy | CKS. Available at: https://cks.nice.org.uk/topics/neck-pain-cervical-radiculopathy/diagnosis/assessment/ [Accessed February 12, 2022a].

NICE, 2014. Behaviour Change: Individual Approaches Public Health Guidance [PH49]. NICE.

Internet 2: NICE, Management | Back Pain - Low (Without Radiculopathy) | CKS. Available at: https://cks.nice.org.uk/topics/back-pain-low-without-radiculopathy/management/ [Accessed December 28, 2020b].

NICE, 2013. Physical Activity: Brief Advice For Adults In Primary Care. Available at: https://pathways.nice.org.uk/pathways/physical-activity#path=view%3A/pathways/physical-activity/encouraging-people-to-be-physically-active.xml&content=view-node%3Anodes-brief-advice-for-adults-in-primary-care [Accessed November 2, 2021].

A2.1 You should be sensitive to the specific needs of patients and be able to select and utilise effective forms of communication, which take these into account.

Using the Rolfe et al model  (Rolfe et al. 2001)

A new patient in clinic divulged to me that their breast cancer had returned, and that the prognosis was not good and likely to be terminal in the mid-term, although they were continuing to have treatment.  I was caught off guard when the patient said this as I was not expecting this. It left me at a loss for words and feeling embarrassed but also wanting to show compassion. I ended up saying how sorry I was to hear this and moving on. 

 

 

As a result of this awkward situation, I’ve been pondering how to respond to patients who disclose major life-threatening, pre-existing diagnoses.  I found the following advice in Breaking and Mending by Joanna Cannon – A junior doctor’s stories of compassion and burnout very thought provoking (Cannon 2019).  Like me with my patient, the author’s experience as a medical student was to offer empathy and compassion by saying how sorry they were.  In fact, the consultant instructed Joanna “you would say thank you for telling me that information”.  She explains that saying sorry is a value judgement and that “Those are heavy words, and you might be giving him a weight he is unable to carry”.  Joanna Cannon acknowledges “He was right”.
 
 

 

I’ve reflected long and hard on why this maybe the correct response as it felt very counter-intuitive as I have always felt it is important to show empathy with a patient.  Being empathetic has also been advocated by tutors. However, I acknowledge that words are never, ever just words but carry a whole weight of meaning with them.  As an osteopath I need to pick my words carefully – especially around long-term back problems, degeneration, pain and outcomes.  It is important not to label in a way that gives a patient an extra weight to carry.  Going forward, I will consider carefully how I pick words but I want to also be empathetic. 

 

(Cannon 2019)

By Giles Yeo (2018)

What?

I had a patient with a very high BMI who told me that she was trapped in a cycle of weight gain and loss that was impacting her life.  I wanted to encourage her to lose weight because of the pressure it was putting on her joints.

So what?
In our society there is a lot of stigma attached to being obese and yet it is very much on the rise.  It can feel a very sensitive issue to raise with patients. 

This book, written by a geneticist specialising in obesity, made me think differently about obesity.  Several times I have been asked by patients if losing weight will help their condition, which has often led on to conversations where they have told me that they are trapped in a cycle of diets and weight gain. 

I’ve been pondering how to discuss this difficult issue with patients and reading this book has made me far more empathetic to the difficulties that they face in losing weight. I will be taking these ideas into clinic with me and I love the way that science is now taking some of the stigma surrounding weight gain away. 

Genes have an influence on weight in a variety of ways. Yeo sets out that having too much food, coupled with not moving around enough, is a contemporary problem, and would not have been a “selection pressure” during evolution.  With the rapid changes in the last 50 years, accumulated genetic changes, which would have varied across the population and had a neutral effect where there was not enough food, were suddenly unmasked in our modern food and living environment,  So while the average weight of the population has increased because everyone is exposed to more food and moving around less, some people, because of their spread of genes, have become more obese than others in this environment. 

He discusses the strongly held belief held in many quarters that we are in full control of our own eating behaviour, that the environment is responsible for our shape and size, and that our genes have minimal, if any, effect.  He emphasises that it is important to remember that the drive to eat is one of the most primitive of instincts to promote survival.  It has been shaped by millions of years of evolution and has provided living creatures with powerful and redundant mechanisms to adapt to and respond to times of nutrient scarcity.    Genes have played a role in our response to this new nutrient rich environment. 

Obesity and other diet related illnesses are perceived to be simple problems of eating less and moving more; they are considered to be diseases of choice.  In reality, the complex interactions between our genes and the environment mean that we all behave differently towards food, and hence there are no easy one size fits all solutions.   

The book also debunks several current popular diet ideas. He points out that removing gluten form your diet is not a good idea unless you are coeliac as whole grains are a great source of fibre which most of us do not eat enough of.   Similarly, if you have the genetic adaptation for digesting lactose consuming diary is not going to be bad for you.

First studies show the genetic heritability of bodyweight and shape in twins is around 70 per cent.  

He finishes with 6 simple rules for weight management:

1.       It ain’t supposed to be easy

2.       Eat a little less of everything – don’t demonise food but too much of anything is also bad

3.       Food that takes longer to digest generally makes you feel fuller

4.       Don’t blindly count calories – calories counting without taking into account calorific availability is meaningless.  All calories are equal but some are more equal than others. 

5.       Eat more unsaturated fats

6.       Don’t fear food.

 

Now what?

It has been really useful for me to reflect on the fact that obese people are not lazy or weak. They are fighting their genes and struggling against their biology.  Understanding this removes the stigma and may go some way to helping fix the problem. Framing the conversation in terms of the latest science on the topic also makes it less personal and easier to raise with a patient.

Reference

Yeo, G., 2018. Gene Eating, Pegasus Books.

September 2020

B2. You should use your professional judgement to assess whether you have the training, skills and competence to treat a patient, seeking advice where necessary.

B1.1  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

So a big week this week – the first week in clinic and a lot of nervous anticipation. And today was my day to get a new patient - a 74 year-old with lower back pain. I enjoyed taking his case history and coming up with a diagnosis, but I also made some mistakes along the way and was very glad that my tutor was on hand to help me.  

The biggest error was not following up on the fact that the patient had had prostate cancer a few years ago and had his prostate removed. He was no longer under the care of a consultant, but I failed to ask follow-up questions and did not consider that the cancer may have returned as a metastasis at a different site. I had assumed that since he had treatment for it he was safe for me to treat. In fact, the commonest place prostate cancer will metastasis to is bone including the spine, followed by ribs and pelvic bones (Kakhki et al. 2013; Gandaglia et al. 2014; La Manna et al. 2019). 

Identifying potential red flags is a key skill to master.  The patient may need referring to a doctor for follow up and potentially further cancer treatment.  In addition, I need to also establish that they are safe to treat with osteopathy before I proceed. 

I have done some further reading around prostate cancer (NICE 2019) and feel I have a better understanding of treatment plans and follow-up.  

My big takeaways from today were:

·          Make sure I follow up on asking enough questions around subsidiary issues – in this case, his knee and hip, specifically how long for and where?

·          Don’t forget red flags – in this case prostate removal – the patient had the risk of metastasis to bone in the spine

·          Work on thoracic lumbar testing and improve smoothness

·          Work on converting testing routines as learnt into standing, sitting, side-lying routines.

Gandaglia, G., Abdollah, F., Schiffmann, J., Trudeau, V., Shariat, S.F., Kim, S.P., et al., 2014. Distribution Of Metastatic Sites In Patients With Prostate Cancer: A Population-Based Analysis. The Prostate, 74(2), pp.210–216.

Kakhki, V.R.D., Anvari, K., Sadeghi, R., Mahmoudian, A.S. & Torabian-Kakhki, M., 2013. Pattern And Distribution Of Bone Metastases In Common Malignant Tumors. Nuclear Medicine Review. Central & Eastern Europe, 16(2), pp.66–69.

La Manna, F., Karkampouna, S., Zoni, E., De Menna, M., Hensel, J., Thalmann, G.N., et al., 2019. Metastases In Prostate Cancer. Cold Spring Harbor Perspectives In Medicine, 9(3).

NICE, Recommendations | Prostate Cancer: Diagnosis And Management | Guidance | NICE. Available at: https://www.nice.org.uk/guidance/ng131/chapter/Recommendations#assessment-and-diagnosis [Accessed March 12, 2022].

July 2020

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

To achieve this, you should: 

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

At the end of the second year just before I started in clinic, I took this 12 hour course on managing back pain. I recognise that I will see a lot of patients with chronic back pain in clinic and the more skills I have at my disposal the better for me and my patients. 

The course was designed for healthcare professionals with a role or interest in managing patients with low back pain and is approved by the British Psychological Society for the CPD purposes for healthcare professionals. 

The course gave me an understanding of how a cognitive behavioural approach can be used to manage ongoing low back pain.

It utilises the Back Skills Training (BeST) programme developed by the University of Oxford to focus on ‘undoing’ beliefs about low back pain, and provides skills to become more active, despite pain. The programme was developed by experts in psychology, physiotherapy, cognitive-behavioural therapy (CBT), and people with long-standing low back pain. 

The course explored the BeST programme, examining the causes of persistent low back pain, and the cognitive behavioural approach.  Topics covered included: 

·         The nature and cause of persistent low back pain.

·         The cognitive behavioural approach.

·         Exercise and activity for low back pain.

·         How thoughts and feelings can influence pain.

·         Pain management skills.

By the end of the course I had learnt how to:

·         Apply a CBT approach to effectively help people better manage persistent low back pain.

·         Reflect on how to implement these techniques in clinical practice.

·         Gained knowledge on how to lead a group back skills training (BeST) programme in a clinical setting.

·         Demonstrate understanding of a CBT approach to managing persistent low back pain.

As an osteopath I do not want to be didactic and tell people what to do.  This course made me realise how important it is to get participants onto a self-discovery journey and work with their back pain and to involve them in the decision-making around how to manage their pain. The course gave me useful skills to use in clinic and made me think about how people with chronic pain perceive that pain and how it can limit their life. I will use these skills going forward with patients.

Link to the BEST course: CBT to Manage Low Back Pain - Online Healthcare Course (futurelearn.com)

July 2021

The weekend after my exams I attended a Barefoot Club day long workshop to improve my GOT skills.  The day was a mix of 3rd and fourth years with an experienced, dynamic lecturer and a good atmosphere as everybody had finished their exams and was ready to let their hair down and relax on a nice summer’s day after a stressful term.  I really enjoyed the day and was looking forward to trying out new techniques in the clinic the following week.  Unfortunately, on the Monday I was told there was a case of Covid in the group and the whole group needed to isolate for 10 days – meaning no clinic until the end of term for me. 

I felt really angry because, to be honest, the group as a whole was not very compliant with the Covid requirements and I felt there was some encouragement from the leader to disregard the rules, which resulted in people mixing very closely. Clearly, in retrospect, there should have been more compliance with the rules around mask-wearing and social distancing.  

Despite the frustration, I recognised that the decision to isolate even though I did not have any symptoms and did not test positive was the correct one as it would be terrible to carry Covid into clinic and potentially pass it to patients who are vulnerable to catching the virus and being seriously ill.

I also realised that the pandemic has been going on for a long time now and everybody at the workshop was tired after a busy term.  On reflection, as a group we should have been more aware that Covid is still around and especially as healthcare practitioners we cannot afford to relax our guard as we have a duty to our patients to protect their health.  

I also felt frustrated as we have all worked so hard to keep Covid out of the ESO and generally levels of compliance have been high. In retrospect, I am cross with myself for not standing my ground for a more compliant approach. I feel I should have spoken out against the overall atmosphere and tried to move the group dynamic to obey the rules. Although I took actions to protect myself I could have done more to lead the group dynamic in the right direction, rather than letting popular opinion hold sway. 

In future, I will be more confident in taking the lead to express unpopular opinions and stand my ground more. 

This experience has reinforced with me the need to continue the measures we have been taking in the foreseeable future with mask-wearing, room cleaning, ventilating etc. in clinic.  

Reference:

D3 - Reflective writing – responding to a complaint

August 2021

Whilst I have been fortunate enough not to have received any complaints from patients to date, I understand that this can happen quite easily and is usually due to a lack of communication (NCOR 2019). Many complaints also concern lack of consent (NCOR 2019). 

Both the ESO and GOsC have formal processes for dealing with complaints by patients, but ideally the situation should be resolved without the need for formal intervention. 

Receiving a complaint, especially as a student or new graduate is very daunting and I think there can be a temptation to either deflect criticism by becoming defensive and arguing with the complainant or being in denial and ignoring it in the hope that the problem goes away. For the practitioner there is a lot at stake as it can end in litigation or professional misconduct proceedings, which can lead to being struck off the GOsC register and being unable to practice.  

In fact, a complaint should be seen as an opportunity to listen and learn.  Reflecting on the communication and standard of care that was given may highlight areas of practice that could be improved. Handled well, it may also result in a stronger bond of trust between the practitioner and the patient, leading to improved patient care.

Rather than hiding my head in the sand in the event of a complaint, I should be upfront and confident of resolving it at an early stage.  This requires acting constructively and allowing patients the opportunity to express their dissatisfaction and provide sensitive explanations of what has happened and why.

I had an opportunity to practice this skill in one of our assessments where we had to write a letter in response to a complaint concerning cranial treatment of a baby.  For me, the key points are to actively listen to the patient and respond to the issues they raise, encourage communication to check their understanding at all stages of the visit to the osteopath, explain what you are doing, particularly where there is a possibility of adverse events.  In the event of a complaint, avoid becoming defensive and explain what has been done and why, empathise and acknowledge the patient’s feelings, but don’t necessarily apologise if you feel, on reflection that your processes were correct.  

I found the slides in the attachment helpful.

References:

Trends in complaints and claims against osteopaths – NCOR Slide 1 (ncor.org.uk)

Types of concerns and complaints raised about osteopaths and osteopathic services in 2013 to 2019. NCOR.  Link on GOsC website at NCOR Concerns and Complaints Report 2013-19 - General Osteopathic Council (osteopathy.org.uk).

 

 

In the last week of clinic before Christmas, I was surprised and excited to find that I had an evening in the headache clinic.  I had not prioritised it as a choice out of the specialist clinics but my interest in the area is growing and I was pleased that I would be able to get a chance to see it and work with the very renowned tutor. However, I also approached the evening with some trepidation as I had not had a chance to fully complete the e-learning headache course.  On the evening I was the only student in the headache clinic so had a one on one session with the tutor, who was also being observed by the clinic manager. 

I took the patient’s case history and went on to exam her.  She had been experiencing an increasing frequency of headaches in the last few weeks, a stiff neck and one episode of visual changes. When I took her blood pressure, I was alarmed that a 38 year old, seemingly healthy patient had a blood pressure of 180/120.  I was so surprised that I took it again before going out to the team room to inform the tutor. She was also surprised and I asked that she check it as I almost did not trust my own reading.  The clinic manager took a reading from the patient’s left arm and found that it was higher at 200/125 and she may have been at risk of having a stroke.  We knew we needed to refer urgently and luckily her husband was waiting in the car park and could drive her to the hospital.  (The clinic manager also had a brief discussion with a former GP who is now a student to confirm the best course of action).

We de-briefed afterwards as the incident left us all a bit surprised and taken aback.  As yet the patient has not been in touch to update us on what was found at the hospital. I lost a bit of sleep thinking about this appointment (although the BP may have been high due to white coat syndrome), but the following points came out of it:

On the positive side I stayed calm, I recognised that the patient was not safe to treat and needed urgent medical investigation for the cause of hypertension. I am grateful that in a recent tutor group discussion we had discussed at what level BP it is no longer safe to treat a patient.  Going forward I will be confident in my own abilities to take a BP reading as initially, I doubted that I had done it correctly as the reading was so much higher than I had thought the patient was likely to present with. I was grateful to have colleagues to confer with. 

On the negative side, I was uncertain whether the patient would have been safe to take herself to A and E.  I also realised that I am not clear on the secondary causes of hypertension and that I need to spend time looking at this. I have now done some further reading and made notes on this so I feel better prepared going forward.  Ensuring that I screen for cardiac and kidney problems may help identify problems, but equally hypertensive patients may present with no symptoms. I have also asked various tutors when to refer an older patient to their GP for high blood pressure as the guidance I had seen is not clear on this – the view seems to be that one needs to assess the whole person and build up an overall picture of their health before referring.

So what?

It is critically important to be able to identify red flags and refer patients where necessary.

Now what?

It is really important to refer patients where necessary and not treat them where it may be dangerous to do so.  Not all cases may be as clear cut like this one but it is important to ask myself in every patient encounter if this patient safe to treat before proceeding.

References and futher learning I have looked at:

White coat syndrome - Blood Pressure UK

Secondary hypertension - Secondary hypertension in adults (nih.gov)

Clinic in the holiday periods, whilst not always welcome (Christmas Eve!) does give a very good opportunity to practice skills.

Being able to assess and treat a cover patient and determine if I agree with the diagnosis is good preparation for the CCA.  Now I have been in clinic for a while it is also a good opportunity to see how other practitioners take their notes.  I am very aware that as a left handed writer I do not have the neatest handwriting, I can also get so engrossed in listening to the patient’s story and maintaining eye contact that I forget to record their responses at the same time, especially in relation to negative responses, or do so in a way that when I look back is messy and I run out of room to write responses.  

I know that negative responses are just as important as positive responses and that it is important that notes are thorough - especially if someone else has to look at them in the future.  Practice Standard C2 sets out clear guidelines on this requirement and states that patient records are comprehensive, accurate, legible and completed promptly. I feel I could improve in this area ahead.  

I have been impressed by some of my colleagues’ notes (and equally disappointed by others which have given me inadequate information) and will adopt some of their practices.  In particular, the use of a chart to record neuroscreen results is very helpful and clear and easy to refer to at the next appointment.   Going forward I am going to try and draw up a chart before I go back into the room to conduct the examination, which will make it easier to fill in the results in clear and legible manner. 

At the end of the autumn term of my fourth year, I saw a female patient in her 30's who presented with shoulder and clavicle pain. She had longstanding back pain, which had got worse during lockdown whilst working from home; a whiplash injury from an RTA; and a fall on an outstretched hand 2 months ago following which the pain had again got worse.

 After taking a careful case history and examining the patient I determined that the patient was safe to treat and did not have an underlying pathology. I diagnosed right-sided myalgia of trapezius, levator scapulae and teres minor and major, together with subacromial impingement and various restrictions in her thoracic spine.   The patient asked me if I thought she should obtain imaging of the shoulder to understand if there was “damage to the joint”. She had already obtained an x-ray which had ruled out a fracture.
 
 So what? 

In cases like this, where I do not suspect an underlying pathology, questions around imaging can be difficult to manage with a patient.  I find they test my communication skills, on the role of imaging in diagnosis and treatment.  Patients can have a belief that imaging is necessary for diagnosis and management of a shoulder problem, and it is important to handle these questions appropriately so that the patient feels their question has been listened to and their expectations met. I am aware that a wide range of factors can influence a patient’s beliefs about the cause of their shoulder pain but that the strongest influence is the information that they receive from healthcare professionals and careful use of language is necessary (Cuff and Littlewood 2017). 

The Nice Clinical Knowledge Summary (CKS) on management of rotator cuff injuries states that ultrasound or MRI should not usually be requested by primary care (NICE 2017). The CKS explains that this recommendation is based on research which “indicates that partial tears are a common report finding, however, these can be asymptomatic or a false positive examination finding. Hence if a tear is found on ultrasound, it does not always correlate with the person's symptoms or mean surgery will definitely be needed. The BESS/BOA guideline recommends ultrasound findings should be interpreted by orthopaedic surgeons and considered along with the person's symptoms and previous management.”

Knowledge of the CKS provides me with confidence that I am acting with integrity if I do not suggest imaging and that I can frame a conversation that explains the appropriate use of imaging in this scenario. 

Currently, I do not work within an environment where I am under pressure to sell my services or cross-sell any other services that a clinic may offer but I recognise that it is important to always act with the patient’s interests at heart not those of the clinic’s, which may not be aligned with that of the patient where there is a revenue-generating opportunity, for example, if the clinic offers in-house ultrasounds or would benefit by treating the patient over a long period without progression.   

I have discussed suitable treatments to use with my tutor and made a note on the file to review the patient’s progression over the next 6 weeks. If the patient is not progressing, I will refer to the patient’s GP at that stage suggesting that imaging may be necessary. I have also used the Rehabmypatient app to review suitable exercises to use with the patient and suitable progressions for them.   

This would be acting with integrity in line with the OPS requirements set out in D1 as I would initially avoid subjecting the patient to an investigation or treatment that is unnecessary or not in their best interests, but at the appropriate time recognising that I may need to refer for imaging if I am not obtaining suitable progress.

Cuff A, Littlewood C. Subacromial Impingement Syndrome - What does this mean to and for the Patient? A Qualitative Study. Musculoskeletal Science and Practice. Elsevier Ltd; 2017 Oct 17,1–14.

National Institute of Healthcare Excellence (NICE) 2017. Scenario: management of Rotator cuff injuries https://cks.nice.org.uk/topics/shoulder-pain/management/rotator-cuff-disorders/ [Accessed 9 January 2022]

 

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

D9.1 - where the care of patients is shared between professionals, you should consider the effectiveness of your handover procedures. Effective handovers can be done verbally, but it is good practise to make a note of handover in the patient’s osteopathic records.

The European School of Osteopathy has a clear procedure for referrals to the local A&E department, which involves handwriting a form for the patient to take to A&E with them which outlines the nature of the concern, the tests conducted and any other pertinent information.  The process is straightforward and importantly quick to undertake in what is an emergency situation. 

Attached is a copy of a form which I completed for a patient who four hours prior to her appointment had falling down some stairs and presented at clinic with an extremely swollen ankle. On testing I was concerned that the Ottawa ankle rule criteria were fulfilled, which establish if a patient should be referred for an x-ray following an acute ankle injury. 

I was pleased that I could make a professional referral to an external healthcare professional and wanted this to reflect well on the ESO. 

However, whilst I had some familiarity with the Ottawa rules and could recall them in the moment, the experience threw up some practical questions on their application and this situation gave me an opportunity to study them in more detail and I now feel I have an enhanced understanding of the rules.  It is very useful to have a set of predefined criteria in these situations and in order to ensure that I remain abreast of the best evidence-based practise I will continue to look out for other examples of such criteria that I can use in my clinical practise.

References:

Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, et al. Implementation of the Ottawa ankle rules. JAMA 1994; 271: 827-83

Plint AC, Bulloch B, Osmond MH, et al. Validation of the Ottawa Ankle Rules in children with ankle injuries. Acad Emerg Med. 1999 Oct;6(10):1005

 Ottawa Rules - "EM in 5". Available from: http://www.youtube.com/watch?=1&v=UEnacnxh804[last accessed 07/12/17]

(Using Rolfe et al. reflective model 2001)

What?

Since I have been in clinic, we have always had Covid hygiene protocols in place, meaning that when I see a patient, I have triaged them at the front door for COVID symptoms, we both wear masks and I have been wearing a plastic apron and gloves throughout the session. The room has also been cleaned and ventilated throughout the consultation. This was in line with the clinic policy, which in turn, was based on GOsC recommendations for a COVID safe environment in clinic.

However, on 6 January the guidance has changed.  Going forward masks remain mandatory, but the use of apron and gloves is based on personal risk, in particular likely exposure to blood or bodily fluids, broken skin or mucous membranes.  

So what?

To date I have been asking my patient’s whether they would like me to continue wearing PPE and everybody so far has said they are happy if I do not wear full PPE. I have chosen to wear PPE when treating a baby with a very runny nose and chesty cough, as I did not know whether the baby had COVID, but I explained my rationale to his mother who understood my concern.

Generally, this has led to more skin to skin contact which I feel is beneficial to my palpatory skills.  It has felt very different, almost sensory overload, contacting a patient’s skin directly and I can certainly feel more in the tissues without gloves. However, the downside for me as an eczema sufferer is far more hand washing and drying which is not so good for my skin, as we need to sanitise or wash our hands every time we step out of the treatment room.  

Now what?

As risk assessment becomes based on personal choices and beliefs the position for an individual becomes more difficult to navigate. On 23^rd December I was asked to treat a patient who was mask exempt and I was told that the tutor was willing to see the patient.  Even though it felt difficult to decline to take the patient when the tutor was willing to proceed, I said I was not willing to treat him. I felt my risk exposure to COVID was much higher than the tutor’s as I would spend much longer in the room with the patient. It was also just before Christmas and the first time my immediate family would have been all together in six months and I was not willing to jeopardise that opportunity by risking greater exposure to the virus. In the event another student was willing to treat the patient.  As the pandemic progresses, these decisions are becoming more political and potentially more difficult, but it is important to be able to stick to my personal values and safety assessment. I understand that everybody’s risk assessment will be different and different individuals’ views are just as valid as my own.  

Action plan

There have been times during the pandemic when I have felt quite anxious about going into clinic as I feel I am relying heavily on everyone complying with the rules, in order to avoid exposure to the virus.  One way to manage my anxiety about this aspect of clinic is to determine what personal risks I am willing to run.  Going forward I will not be willing to see patients without a mask, but I will ditch the apron and gloves if the risk of fluid exchange is low. 

References

COVID-19: personal protective equipment use for non-aerosol generating procedures.  Guidance on the use of personal protective equipment (PPE) for non-aerosol generating procedures (APGs) - COVID-19: personal protective equipment use for non-aerosol generating procedures - GOV.UK (www.gov.uk)

Link to GOsC guidance: Interim guidance on infection control in osteopathy during COVID-19 pandemic - General Osteopathic Council

Link to Institute of Osteopathy guidance: COVID-19 | Institute of Osteopathy (iosteopathy.org)

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

D5.1 Maintaining patient confidentiality includes:

What?

I sometimes feel that the clinic environment is not conducive to maintaining confidentiality in relation to patient details. Examples of occasions when confidentiality may be breached include: intentionally discussing very intimate details of a patient's trauma in front of a group, thin clinic room walls so that patients can overhear conversations in another treatment room or the tutor room, difficulty leaving a group in a team room to discuss potentially confidential issues (I experienced this in relation to a patient who was also a student which I found very awkward), gossiping about patients among students, referring to patients in reception or discussing patients with tutors in corridors.

So what?

Keeping patients' details confidential is important to build patient trust and a positive therapeutic relationship.  If a patient thinks that confidentiality is being breached, they are unlikely to be open and honest about their symptoms during a consultation and may be discouraged from seeking treatment at all. The imperative to keep the information confidential reflects not just on the individual practitioner, but on the practice and more broadly upholds the reputation of osteopathy.

UK data protection law, the GDPR, also requires that patients’ personal data is kept confidential and secure and only processed in accordance with the law.

Now what?

I endeavor to ensure that I will maintain confidentiality by maintaining an awareness of where and with whom I will discuss patients. I will be more assertive with my group and tutors to ensure that patient confidentiality is maintained, particularly, when the patient is also a student at the ESO. 

The resources below provide very useful advice on how to maintain confidentiality and can be used to create a safety net for correct proceudres and to stay the right side of the law. 

References

Institute of Osteopathy resources on GDPR: GDPR for Osteopaths | Institute of Osteopathy (iosteopathy.org)

GOsC resources on GDPR: Data protection - General Osteopathic Council (osteopathy.org.uk)

Institute of Osteopathy resources on maintain confidentiality: Keeping out of trouble | Institute of Osteopathy (iosteopathy.org)

NHS - A Guide to Confidentiality in Health and Social Care - NHS Digital

I have attached the ESO clinic complaints procedure that patients can use if they are unhappy and dissatisfied with the treatment that they have received. Luckily to date I have not received any complaints but if this occurs, in order to react professionally at the time, it is useful to be aware of the clinic procedure. All osteopaths must have a policy in place to manage complaints and respond to them. I am also aware that when patients complete the new patient paperwork prior to their first consultation they are informed that they can also make a complaint to the clinic and, ultimately to GOsC.  Details are provided on how to go about this.

On graduation I will ensure that I maintain awareness of the complaints policy/procedure in any clinic that I work in.

Reference
GOsC: How to make a complaint: Making a complaint about the GOsC - General Osteopathic Council (osteopathy.org.uk)

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.

D2.4 - You should be aware of the risks to patients and to yourself of engaging in or developing social or commercial relationships with patients, and the challenges which this might present for the therapeutic relationship and to the expectations of both patient and professional. You should also be aware of the risk of patients developing an inappropriate dependency upon you, and be able to manage these situations appropriately, seeking advice from a colleague or professional body as necessary.

During the first lockdown I had a longstanding patient of a similar age to myself with chronic thoracic pain issues which would resolve for a few days and then return. I would see her fortnightly over a period of around nine months. During lockdown I became aware that I was I only social outlet as she was isolating with her husband and elderly parents.  Whilst I was happy with my management plan for the patient’s chronic issues I became concerned that the patient was becoming dependent on me and raised the issue with my tutor as a potential issue.

I understand from my reading that factors such as a patient’s attitude, motivation and anxiety level can influence their perception of pain and disability. These factors can lead to pain behaviours (PB) that can persist and become maladaptive, which can further increase the risk of chronicity or persistence of symptoms and disability. Healthcare providers should be able to recognise maladaptive PB in a clinical context and be prepared to refer the patient if you feel that they need further help beyond the bounds of our skills and knowledge.  Chronic pain patients may need treatment, but we also need to make sure that we address their psychological needs if they are to progress. 

I was glad that the tutor did not dismiss my concerns and complimented me on being aware of the potential issue.  

Following discussion with the tutor we agreed that when we got to summer clinic I would pass the patient to a colleague who would treat her over the summer and break the link with me. In the event the patient chose not to receive treatment over the summer and as far as I am aware has not returned to clinic. I am hoping that with the easing of restrictions and a return to a more active life she was self-managing her long term chronic issues and had more social engagement with others. 

The discussions with my tutor and my reading around the subject it made me more aware of this issue, which was not covered in our psychology module.  I also recognise that the lockdowns were a unique time, which presented many people with difficult challenges. However, recognising that there is an asymmetry in the clinical relationship between practitioner and patient is important and care needs to be taken to avoid adopting a paternalistic attitude. 
(Adams et al. 1994; Huprich et al. 2013; Cary & Gyurcsik 2020; Naye et al. 2021; Salmon & Young 2009)

Adams, N., Ravey, J. & Bell, J., 1994. Investigation Of Personality Characteristics In Chronic Low Back Pain Patients Attending Physiotherapy Out-Patient Departments. Physiotherapy, 80(8), pp.514–519.

Cary, M.A. & Gyurcsik, N.C., 2020. Differences In Adaptive And Maladaptive Psychosocial Responses To Chronic Pain Among Adults With Varying Physical Activity Levels: Https://Doi.Org/10.1177/2049463720942535, 15(3), pp.259–269.

Huprich, S.K., Hoban, P., Boys, A. & Rosen, A., 2013. Healthy And Maladaptive Dependency And Its Relationship To Pain Management And Perceptions In Physical Therapy Patients. Journal Of Clinical Psychology In Medical Settings, 20(4), pp.508–514.

Naye, F., Cachinho, C., Tremblay, A.-P., Saint-Germain Lavoie, M., Lepage, G., Larochelle, E., et al., 2021. How To Objectively Assess And Observe Maladaptive Pain Behaviors In Clinical Rehabilitation: A Systematic Search And Review. Archives Of Physiotherapy 2021 11:1, 11(1), pp.1–14.

Salmon, P. & Young, B., 2009. Dependence And Caring In Clinical Communication: The Relevance Of Attachment And Other Theories. Patient Education And Counseling, 74(3), p.331.

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 courtesy

A1.5 - Your patients should have your full attention and you should allow sufficient time to deal properly with their needs. 

In January 2022 we had our CCA exam.  My new patient was an acute 84 year old man who had suffered a fall the day before he was clearly shaken up by this and in a lot of pain.  He took a long time to describe what had happened, his signs and symptoms and prior medical history.  He was struggling to stand and undress.  It had been impressed upon us that we needed to run to time and would lose marks for overrunning. I was panicking that I would never be able to finish the consultation on time, but also wanted to give him the time to explain fully what had happened.

So what?

I found this guidance on a nursing website which is emphasises why it is important to allow someone time to tell their story: " Listening can be frustrating when patients are slow or hesitant in their answers, unclear, confused or contradictory – whether as a result of nervousness, their condition, or their natural disposition. Resist the temptation to finish a sentence or make their point for them: you do not know what they are planning to say. Avoid jumping in with conclusions or solutions before you have heard their account, as interruptions may give the impression that you do not have time to listen, or that you do not value their contribution. This will inhibit what or how much they share with you; if you need clarification, wait for a natural pause before seeking further explanation."

I have learnt that whilst it very important to be able to run a smooth and professional consultation, it is also important to listen to the patient’s story. Failing to obtain all the relevant information could result in making the wrong decision on whether the patient is safe to treat, the patient feeling unheard, or missing clues about the level of pain that they are in.  

It is difficult to know when to offer to assist a patient with their clothes as I do not want to undermine their autonomy. I have been in this situation a couple of times and find it quite awkward and continue to seek the best way to approach this with compassion and empathy.  

I am glad that I took the time to listen sensitively to this patient and pleased that this was reflected positively in my exam feedback.  I realised during the consultation that it was more important to give this patient a complete and appropriate examination rather than trying to rush to meet the exam timetable, even if it meant running a few minutes late. I'm glad I was able to make this decision in the heat of the moment, but on reflection I still feel that it was the appropriate course of action with a patient who was clearly in a great deal of pain, unable to move speedily and who, because of his advanced age, took time to describe what had happened and his signs and symptoms. At the end of the day appropriate patient care is more important than running absolutely to time. I was gratified that I did manage to finish on time with a short period of treatment. 

In my previous career I was also under an obligation to uphold trust and confidence in a profession and to conduct myself in a professional manner at all times.  I understand that this obligation extends outside the clinic to all aspects of my life and so encompasses not just professional competence but professional conduct as well. I am very aware of how important and all-encompassing this is and that it need not be a high degree of moral opprobrium.  As a result of this I have always been wary of posting on social media. I strive to maintain a professional digital footprint. 

I have looked at the GOsC reports on Fitness to Practice Investigations and published decisions of the Professional Conduct Committee and Health Committee which has given me a good feel for the range of behaviours for which osteopaths are disciplined and understand that this can result in removal of the right to practice. 

GOsC Annual Fitness to Practise report 2020-21: fitness-to-practise-report-2020-21.pdf

Link to case report on what constitutes unacceptable professional conduct in GoOsC bulletin: ftp-bulletin-april-2016.pdf

Shaw v General Osteopathic Council [2015] EWHC 2721 (Admin)

Link to case report of Shaw V GOsC: Case update: High Court confirms ‘moral opprobrium’ is part of test for determining unacceptable professional conduct as Osteopath’s appeal is dismissed and admonishment sanction stands | Regulatory Blog | Kingsley Napley 

During the third year we were required to prepare a business plan for a future osteopathic practice.  The assessment required me to consider how much I would charge for my services that would enable me to cover my outgoings and how I would maintain financial records for my practice.  I also looked at what was required to register the business with HMRC for payment of tax and National Insurance. Self-employed and small businesses often find themselves in difficulty as they do not anticipate how much tax has to be paid. Maintaining clarity on fees and having in place an effective system, such as Cliniko, for maintaining records and compliance with bill schedules should help me to stay organised. I have attached the feedback for this section of the assessment.

Money can be a difficult issue to discuss, but when setting charges I should feel confident in my skills and self-worth. Giving clear and visible information about fees at the time of booking is one method of avoiding disputes about charges. 

Many osteopaths are self-employed and their reputation is at the heart of their business and consequently maintaining a good reputation is important as it goes to the heart of the brand you are trying to build business around. 

Trust is at the heart of any professional relationship and given the importance of money in society trustworthiness is often measured by how straightforward and honest a person is around financial affairs. I understand that dishonesty, or even disorganisation, in money matters can easily bring both myself and the profession into disrepute. To date I've always managed my financial affairs responsibly and I have no personal experience of financial difficulties. 

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

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

Using the Rolfe et al. model (2001)

What?

The Covid 19 pandemic has meant that strict cleaning and hygiene protocols have been introduced in clinic to help control the spread of the virus. I have understood the importance of complying with these policies.

In addition, vaccinations have done a great deal to ease the strain on healthcare resources caused by the Covid pandemic. I recognise that getting vaccinated is a very personal decision and that potentially a number of different factors are involved in making that decision, ranging from an individual’s personal health concerns to deeply held principles and views on individual rights. 

For me it was an easy decision to decide to get a vaccination as I remember the early days of the pandemic when there was real fear around catching Covid and the terrible toll laid out in the daily news, which vaccinations have rescued us from.

I also feel that I work with a lot of elderly and health compromised patients and that it is my duty to ensure that I act in the best way to protect their health. I have found it difficult in clinic not to lose my temper with colleagues who have chosen not to get vaccinated and must remind myself that this is a personal decision, although I continue to engage in debate over the issue. 

Most of my patients, who have disclosed their vaccination status, are vaccinated, but on occasion I have encountered one who is not. I need to remember to stay respectful, polite and evidence-based when discussing Covid 19 vaccination with patients. This can be tricky when a patient is basing their views on something they read on social media!

The OPS can be used as guidance on how to approach this issue. 

GOsC guidance (C5.5 of the OPS) states that osteopaths should ‘take all necessary steps to control the spread of communicable diseases’ and D11 of the OPS states that osteopaths must ensure that any problems with their health ‘do not affect their patients’.

I am continuing to carry out lateral flow tests before going to clinic which helps ensure compliance with D11 OPS. 

I have also chosen to get vaccinated and am grateful that I am in the position to have the choice to make. For me the benefits of the vaccine as set out on the NHS website outweighed the risks: 

‘Research has shown that the vaccines help:

·           reduce your risk of getting seriously ill or dying from COVID-19

·           reduce your risk of catching or spreading COVID-19

·           protect against COVID-19 variants.’

The Institute of Osteopathy and GOsC have clear guidance to help practitioners in this area and I will continue to maintain and uphold patient safety using stringent infection control procedures and vaccination. 

I need to ensure that discussions with patients about vaccines are based upon credible and legitimate sources of public health information such as the NHS website or the MHRA website.

I will continue to accept Covid boosters that are offered to me and ensure that I stay up to date with the latest thinking on vaccination from reliable resources such as the Institute of Osteopathy, the NHS and GOsC so that I can engage with patients on the topic in a meaningful and evidence based way.

Other relevant standards relating to COVID-19 vaccines, include:

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

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

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

References:
Link to letter from the Chief Professions Officers for England explaining why healthcare professionals should get vaccinated. - file:///C:/Users/lenovo/Downloads/2letter-on-professional-responsibility-to-reduce-risk-of-covid-19-infection-to-patients.pdf.  

C4: You must take action to keep patients from harm

C4.6: You must comply with any mandatory reporting requirements, for example, those related to female genital mutilation (FGM) in England and Wales.

Using the Rolfe et al reflective model (2001)

During the course I have undertaken various types of safeguarding training, including in relation to spotting and preventing female genital mutilation (“FGM”), which has helped me recognise the issues involved and how to take action to report a suspected case.  FGM is illegal in the UK (Female Genital Mutialtion Act 2003), but unfortunately there are still girls who are subjected to it or live with the effects. From looking online I have learnt that 80 NHS trust and 16 GP practises sent reports of a patient with FGM attending their clinic and 665 new cases were recorded in this period, which is a shocking figure (NHS).

Over the course I have learnt that I have a role to play in protecting vulnerable adults and children who are most at risk from harm and abuse.  These are people who are not able to protect themselves, so the responsibility to protect them falls on others who are in some way responsible for their care, including healthcare practitioners. 

This responsible includes complying with mandatory reporting requirements, such as those in relation to FGM in England and Wales, which is also referred to in C4.6 OPS. I need to know how to spot the signs of FGM and the reporting procedures.

Safeguarding imposes legal obligations which it is important to comply with and I therefore need to understand the procedures to follow and ensure that I am properly trained to spot safeguarding issues. 

Once I graduate I will ensure that I maintain my awareness of, and keep up to date with, current safeguarding procedures, including those in my local area, so I know what to do if I suspect a child or vulnerable adult is at risk.  Starting at a new practice will require me to understand their policies and procedures. 

Female Genital Mutilation Act 2003. Available at: https://www.legislation.gov.uk/ukpga/2003/31/contents [Accessed March 4, 2022].

NHS, Female Genital Mutilation - July 2021 To September 2021 - NHS Digital. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/female-genital-mutilation/july-2021-to-september-2021 [Accessed March 4, 2022].

Rolfe, G., Freshwater, D. & Jasper, M., 2001. Critical Reflection For Nursing And The Helping Professions: A User’s Guide. Basingstoke: Palgrave Macmillan. Journal Of Research In Nursing, 7(5), pp.392–392.

Using the Rolfe et al model (2001)

During year 3 I had a patient who had recently been in a car accident and was potentially going to make an insurance claim for whiplash injury. The tutor warned me that I would need to be very clear in my note recording as it was possible that at some point in the future my notes might be required by the insurance company or solicitors.  We discussed exactly what information I should record, which included more information than I would normally ask.  This included whether she banged her head or experienced loss of consciousness, was she wearing a seatbelt, could she get out of the car, her pain levels at the time and subsequently and the exact details of how the accident happened. 

Since starting in the clinic I have learnt how to maintain good patient records and ensure client confidentiality in accordance with the clinic’s procedures.  Clear, well maintained patient records means that if called upon I can produce accurate, detailed information as required.  Over the two year period, my records have improved in quality and clarity. 

Good record-keeping aids clear communication between professionals and demonstrates that best practice has been followed.  It forms an important component of professional standards. 

Complete, contemporaneous and well-organised medical records are essential for good practice and continuity of care. They are also necessary in case of a clinical negligence claim or complaint against me and can be seen to reflect the quality of care provided and provide an insight into the clinical judgment being exercised at the time. 

 Now what?

I have researched the different elements that make up good patient records (Abdelrahman and  Abdelmageed 2014) and put together the following learning points which I try to keep in mind:

1.       Always date and sign notes. They may not be changed – any changes or inaccuracies should be clearly marked up, dated and initialled. 

2.       Making good notes is a skill that I need to make routine.  I need to record as much detail as possible about the discussions I have with patients, including evidence that valid consent has been obtained. I also need to include details of a patient’s treatment needs where appropriate, in case another practitioner needs to treat them.

3.       Notes must be clear, legible, accurate, and able to be readily understood by others.

4.       The notes need to document all decisions made, any discussions with the patient, information given, relevant history, clinical findings, patient progress, investigations, results, consent and referrals.

5.       The records include a range of material, such as handwritten notes, computerised records, correspondence between health professionals and imaging records.

6.       Offensive or gratuitous comments – eg, racist, sexist or ageist remarks are inappropriate, and the notes should only include things that are relevant to the health record.

7.       They need to be written in a way that I would be happy to show a patient as they have a right to access their own medical records.

It is also important to maintain patient confidentiality and follow current law on retaining, storing and disposing of patient records (Data Protection Act 1998).

Once I have graduated, I will take care to ensure that I take these skills with me and maintain records to a high standard.  

Legislation.gov.uk. 2015. Data Protection Act 1998. [online] Available at: http://www.legislation.gov.uk/ukpga/1998/29/contents [Accessed 9 March 2022]

Abdelrahman W, Abdelmageed A. Medical record keeping: clarity, accuracy, and timeliness are essential BMJ 2014; 348 :f7716 doi:10.1136/bmj.f7716 [ Accessed 10 March 2022]

March 2022

This should include the ability to: 

1.1 take and record the patient’s case history, adapting your communication style to take account of the patient’s individual needs and sensitivities 

1.2 select and undertake appropriate clinical assessment of your patient, taking into account the nature of their presentation and their case history 

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

1.4 develop and apply an appropriate plan of treatment and care

I have just had my mock CCA exam and I have attached the feedback from it. It has been interesting to compare it with the feedback from my exam at the end of year 3.  

I feel my ability to conduct an osteopathic evaluation has really improved this year and I have a better understanding of why we ask some of the questions we do in relation to the systemic questions and how to sort and rationalise the information that the patient gives me. 

However, I am also aware that there are areas where I still need to do some work.  I feel that I am not yet consistent in gaining consent in the later part of the examination, that is explaining the treatment plan, prognosis, and providing different treatment options, including the risks and benefits of each.  This was an area that was generally highlighted in the feedback from the exams. I know consent is a vital part of shared decision making and important to the patient so I need to improve my communication in this area. 

I have written a script that I can use with both new and returning patients to cover these points.  I am also going to highlight it on my case history form to remind myself to cover the point. After every patient I will review if I remembered to cover this.  If this does not work I will continue to find a way to improve on this area. 

June 2021

This should include the ability to: 

1.1 take and record the patient’s case history, adapting your communication style to take account of the patient’s individual needs and sensitivities 

1.2 select and undertake appropriate clinical assessment of your patient, taking into account the nature of their presentation and their case history 

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

1.4 develop and apply an appropriate plan of treatment and care

Reflection using Rolfe et al’s model (Rolfe et al. 2001) 

I have attached a copy of the feedback that I received from my end of year exam in year 3 which involved taking a case history online with 2 examiners and formulating an examination and treatment plan.  I was thrilled with this mark as during year 3 it has been a challenge to convert what I learnt in theory last year into a useful process that I can replicate with patients and adapt to the information that they are giving me during the case history. There was one area for improvement relating to time management. 

I have understood that I need a good case history to formulate a working diagnosis and from that determine a treatment plan and that I need to be able to adapt my questioning to the patient’s symptoms.  On occasion in clinic I have not always known what follow-up questions to ask or indeed what the answer is telling me in order to shut down a particular line of inquiry. In this exam I took a long time with the case history so that I had gathered as much information as possible to reach the most accurate working diagnosis.   I am hoping that in time I will have built up more of a library to call upon to make this process quicker but generally in clinic I manage my time efficiently and run to time.  Greater confidence in my diagnosis will also help speed up the questioning.    

I am trying to speed up this learning process by listening to medical podcasts and read widely around the presentation of different symptoms in order to build on and cement my knowledge.  

Rolfe, G., Freshwater, D. & Jasper, M., 2001. Critical Reflection For Nursing And The Helping Prefessions: A User’s Guide. Basingstoke: Palgrave Macmillan. Journal Of Research In Nursing, 7(5), pp.392–392.

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

I have not had to contact GOsC regarding my conduct or competence to date, but I have looked at the GOsC website and I am aware that there is a contact number to call to discuss any concerns that I have regarding compliance with this section. Throughout my professional career, I have been subject to similar obligations and understand how wide-reaching they can be, including being triggered if I am subject to a police caution, or charged with a criminal offence. This requires contact with GOsC at an early stage well before any possible conviction. In my previous career as a solicitor, I knew someone who was convicted of drunk driving as a student and was subject to additional procedures before she could be admitted to the profession. At the time I was really surprised by this, but I now understand that professional values need to be upheld in all aspects of one’s life.

As a healthcare professional my actions in my private life are as important as those in my professional life. I understand that it is important to uphold the reputation of the entire osteopathic profession through my conduct so as not to bring the reputation of the profession into disrepute and that it is important for GOsc to ensure that the standards of professional behaviour are complied with. I have spent time on the GOsC website looking at the reports of the hearings on fitness to practice and feel that I have a good understanding of what type of behaviour is considered unacceptable. As a healthcare professional we will see many vulnerable patients and they must be able to trust us and have every expectation that we will be trustworthy and honest. In all cases patients expect healthcare professionals to treat them properly and behave ethically as they are dependent on us.

References:

GOsC information on fitness to practice: Concerns - General Osteopathic Council (osteopathy.org.uk)

 

D 10.1 To achieve this, you should:

1.       treat other health and care professionals with respect, acknowledging the role that they may have in the care of your patients; any comments that you make about other healthcare professionals should be honest, valid and accurate

2.       understand the contribution of osteopathy within the context of healthcare as a whole

3.       follow appropriate referral procedures when referring a patient, or when one has been referred to you

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

February 2022
Using the Rolfe et al reflective model (2001)

What?
I have attached the feedback from a presentation I gave on thoracic outlet syndrome ("TOS") for a recent assessment.  The examiner asked me what I thought the most important OPS was when planning treatment for TOS.  I replied that from my research it was the provision of multi-modal care. The treatment plan recommended by the NHS recommends multi-modal care and I identified that imaging specialists, GP, surgeon, occupational therapists, and yoga teachers might be involved in the patient’s care.  I was pleased to receive the attached feedback from the assessment, which noted that I had a good awareness of referral pathways and the role of osteopathy within a multi-disciplinary framework.   

So what?

Osteopathy is only one form of healthcare treatment for a patient.  Some complex or chronic cases require multi-modal treatment where other health professionals are involved in a patient’s care to provide a complete treatment plan.  Or perhaps at some point in the treatment I may realise that the patient needs to see a different style of practitioner as they are not responding to osteopathy in the manner that I had envisaged. 

Now what?

When I am qualified, I think it will be important to get to know and understand what other local health and wellbeing practitioners in the area can offer as working collaboratively can enhance everybody’s practice.  This requires that I take the time to educate myself to understand what other practitioners can offer to patients, understand how they practice and the evidence to support what they do.  It is an important part of being a professional to speak respectively about other healthcare providers and acknowledge the role they may play in looking after my patients, or that they may be better placed to care for them. 

D1: A lack of integrity in your practice can adversely affect patient care. Some examples are:

Using the Rolfe et al. reflective model (2001)

What?
At the end of the autumn term of my fourth year I saw a male patient in his 40's who presented with shoulder pain. He worked as a carpenter and engaged in frequent awkward overhead movements together with longstanding back pain.  After examining the patient, I diagnosed right-sided rotator cuff injury (supraspinatus tendinopathy) with associated myalgia of trapezius, levator scapulae and teres minor and major. The patient asked me if I thought he should obtain imaging of the shoulder. I was uncertain how to answer this question at the time and said I would respond to him at the next appointment. Views on when to obtain imaging for shoulder cases are divided between the tutors but I wanted to reach my own view following research. 
 
 So what? 

We can provide imaging at the clinic (which would be of benefit to the clinic), or refer to a local private hospital if this is appropriate. However, according to the NICE guidelines ultrasound and MRI should not be requested by primary care.  Xray should only be requested in the following circumstances:

·         there is a history of trauma; 

·         there is little improvement with at least 6 weeks of conservative treatment; 

·         symptoms last more than four weeks, there is severe pain or restriction of movement, suspected arthritis or any red flags are present.

Research and NICE guidance emphasise taking a thorough case history, using physical examination tests to examine ROM, stability, and strength, and using specialized tests to help determine early prognostic indicators (Brown et al. 2015; NICE n.d.). Rotator cuff injuries should be managed in the initial stage with:

·         Rest (in the acute phase).

·         Exercise/ physiotherapy.

·         Corticosteroid injection.

·         Referral to intermediate or secondary care after a course of conservative treatment has failed

It is important to reach my own evidence-based knowledge base of when it is appropriate in a patient's mangement to obtain imaging and to be able to explain this to patients to manage their expectations.  It feels good to know that I am acting with my patient’s best interests at the centre of what I do by having evidence behind me to back up my decision and which I can put in my notes. 

References:

Brown, G., Park, K. & Bicknell, R.T., 2015. Musculoskeletal Disorders And Treatment Management Of Occupational Shoulder Injuries In Primary Care. J Musculoskelet Disord Treat, 1, p.1.

NICE, Clinical Knowledge Summary summarising best practice for shoulder pain: Rotator Cuff Disorders | Management | Shoulder Pain | CKS | NICE. Available at: https://cks.nice.org.uk/topics/shoulder-pain/management/rotator-cuff-disorders/ [Accessed April 1, 2022].

 

 

B3 - you must keep your professional knowledge and skills up to date

B 3.1 To achieve this, you should keep up to date with factors relevant to your practice, including…..research and other relevant developments in healthcare.

Using the Rolfe et al model (Rolfe et al. 2001)

My lockdown project was to improve my knowledge of nutrition so that I am better able to support patients' needs. 

Weight loss can benefit people with arthritis by taking load from the joint and I have been asked by patients if losing weight will help their condition (NHS). Obtaining a qualification in this area has given me more confidence to discuss what can be a difficult issue with patients as weight and diet are very personal matters where patients can easily take offence.  Being able to discuss the latest research on diets and obesity take the edge off this and keeps it impersonal (Holden et al. 2019). 

Nutrition and diet is a subject that is very close to my heart. This course broadened my knowledge base. I will continue to pursue my reading in this area and consider its clinical application to my practice.

Holden, M.A., Waterfield, J., Whittle, R., Bennell, K., Quicke, J.G., Chesterton, L., et al., 2019. How Do UK Physiotherapists Address Weight Loss Among Individuals With Hip Osteoarthritis? A Mixed-Methods Study. Musculoskeletal Care, 17(1), pp.133–144.

NHS, Arthritis - Living With Arthritis. Available at: https://www.nhs.uk/conditions/arthritis/living-with/ [Accessed April 1, 2022].

Rolfe, G., Freshwater, D. & Jasper, M., 2001. Critical Reflection For Nursing And The Helping Prefessions: A User’s Guide. Basingstoke: Palgrave Macmillan. Journal Of Research In Nursing, 7(5), pp.392–392.

March 2022

A 2.1

1.       Trust is an essential part of a clinical relationship and requires effective communication between osteopath and patient.

2.       You must care for your patients and do your best to understand their symptoms and support their health.

3.       You should be sensitive to the specific needs of patients and be able to select and utilise effective forms of communication, which take these into account.

Using the Rolfe et al reflective model (Rolfe et al. 2001)

This week I saw a new patient in clinic. he had consented to two observers in the room but seemed very anxious and ill at ease. He had come in extensively about back and hip pain which he attributed to lifelong scoliosis. I took an extensive case history and did my best to make him feel at ease. During the course of the case history, he said that he suffered from health anxiety, and had taken antidepressants in the past and his main concern was to understand what was causing the pain and reduce it.  

I took his blood pressure which I realised was high (160/100) and without mentioning it to the patient I examined him and then said casually this blood pressure was on the high side and I was going to retake it to check it. On the second occasion, it had in fact gone up a little.  I then went to see my tutor and we agreed the patient was not safe to treat.  He also said I should have not examined him as the blood pressure was too high to do this. He left me to tell the patient. I went back and explained to the patient that we could not treat him until his blood pressure had been checked out by his GP.  I also took the time to tell him that my examination had not shown any major concerns in his back and I thought the pain was coming from his scoliosis.  He was visibly relieved and then told me he had been extremely anxious about his back pain and concerned that it was something major causing the problem. It was also his first time visiting an osteopath and he had been really unsure about what to expect. We had a good chat about not catastrophising about his blood pressure until he had seen his GP and he left very happy even though he had not received treatment saying that he would be back once he had his check-up with the GP. Even though I did not treat his back he left saying it felt better.

Being an osteopath is so much more than just physical treatment.  On reflection, I think this patient was primarily seeking reassurance that there was nothing major wrong with their back and on learning that felt reassured, and their pain decreased, even though they potentially were suffering from hypertension. 

This patient made me think about the biopsychosocial model, which aims to evaluate the patient in a holistic way.  The model as illustrated by the diagram below claims that the overall health and well-being of a person depends on three different elements: biological factors, psychological factors, and social factors (Engel 1977; Frazier 2020). All three factors are valued equally, and biological factors cannot be held solely and completely responsible for the health and well-being of an individual.  (Query – how well does the course give us a toolkit for this aspect of treating patients?)

Tutors have already stressed the importance of asking a patient their expectations of the visit.  I had sort of considered this pretty obvious – that is, to feel better.  I now see it is a valid question but that actually the real purpose of the visit may only become apparent from detailed observation of the patient’s demeanour and skilful extensive questioning by the practitioner to elicit where their real concerns may lie (Acquati et al 2019).  This may need careful exploration in a very sensitive way not just an off-pat question. 

Acquati, A., Uberti, S., Aquino, A., Cerasetti, E., Castagna, C., Rovere-Querini, P. & Pisa, V., 2019. Do Empathic Osteopaths Achieve Better Clinical Results? An Observational Feasibility Study. International Journal Of Osteopathic Medicine.

Engel, G.L., 1977. The Need For A New Medical Model: A Challenge For Biomedicine. Science, 196(4286), pp.129–136.

Frazier, L.D., 2020. The Past, Present, And Future Of The Biopsychosocial Model: A Review Of The Biopsychosocial Model Of Health And Disease: New Philosophical And Scientific Developments By Derek Bolton And Grant Gillett. New Ideas In Psychology, 57, p.100755.

Rolfe, G., Freshwater, D. & Jasper, M., 2001. Critical Reflection For Nursing And The Helping Professions: A User’s Guide. Basingstoke: Palgrave Macmillan. Journal Of Research In Nursing, 7(5), pp.392–392.

A4.2 - Gaining consent is an ongoing process. You must ensure that patients are able to make decisions at all stages of their treatment and care and continue to give consent.

Using the Rolfe et al. reflective model (2001).

October 2018

I had never been to an osteopath before visiting the clinic as a patient last summer and had no idea what to expect.  I was surprised to be asked to bring shorts with me when I made the appointment.  

During the appointment itself I was also amazed that such a detailed case history was taken, which did not seem to relate directly to my complaint.  I did not think this would be necessary for diagnosis and it seemed a very slow process.  I had thought it would be much more technique-based and more akin to an appointment with a physiotherapist.  The practitioner did however take the time to explain the process to me and also asked if she could touch me.  

I felt quite exposed and vulnerable bending over in front of the practitioner.  I knew she was only looking at my back, but at this stage she did not explain her findings.  I was left wondering what was going on.  Once she had consulted with her tutor, a diagnosis was given and treatment suggested involving a manipulation.  The practitioner gave a limited explanation of what this involved.  As this was the first time I'd experienced treatment, again, I had no clear idea what to expect and in retrospect, I realise she could have given me a much more detailed explanation of the techniques she was going to use.   Nor did she explain how close she would be to me during the manipulation (she was bent right over me).  It felt very intimate and had she explained the process in more detail I would have understood this better and not been surprised.

However, the practitioner did tell me that I might react treatment and to call the clinic if I experienced discomfort.

As an addendum to this, since starting as a student, a couple of other students have mentioned negative clinic experiences to me.  These have both involved pelvic or gynaecological issues. In both cases, the practitioner gave a limited explanation of the proposed treatment to which the student in each case agreed.  However, they had not sufficiently explained where treatment would take place, or how intimate it would be.   In one case written consent was obtained but not in the other.  In each case, the student was left quite shaken by the experience and in one case felt violated by it.   This is despite the students being osteopathic students and who therefore have an appreciation of both anatomy and osteopathy. 

This raises a number of key points which are important for me to remember when dealing with patients:

1.       Explaining the process involved in attending the clinic is very important for new patients in order to put them at ease.  This may need adapting depending on the patient’s desire for information.  Checking for feedback is important to understand their comprehension.

2.       Use the tools and aids in the clinic room to assist the patient’s understanding, for example,  models, wall charts, and modelling yourself.  

3.       Consent needs to be informed - particularly when treating intimate areas when a full, clear and detailed explanation is even more important.  Consent cannot be given if it is not informed, that is, the patient does not fully understand what they are consenting to.  This is also critical when working with adults, the elderly, or mentally impaired patients.  

4.       Patients will not have the same level of understanding of anatomy that I do.  Using everyday language is important.

5.       Explain at the beginning where you are going to touch and why before you do so.  If you then need to touch another area seek fresh consent before doing so. 

(Cocanour 2017)

Hopefully using these ground rules will help me.

As a student osteopath it can be tricky to remember everything we need to cover in a clinic session but gaining valid informed consent is a very important part of the process to keep both us and our patients safe. 

Cocanour, C.S., 2017. Informed Consent-It’s More Than A Signature On A Piece Of Paper. American Journal Of Surgery, 214(6), pp.993–997.

Rolfe, G., Freshwater, D. & Jasper, M., 2001. Critical Reflection For Nursing And The Helping Prefessions: A User’s Guide. Basingstoke: Palgrave Macmillan. Journal Of Research In Nursing, 7(5), pp.392–392.

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

A4.3: For consent to be valid, it must be given:

Using the Rolfe et al. reflective model (2001).

March 2022

Last week I had a new patient in clinic who was 15 years and ten months old.  She was escorted by her grandmother who was her legal guardian as she had been removed from her parents at 4 months old due to severe abuse. I find working with teenagers one of the most challenging types of patient as it is essential to win their trust very early in the first appointment.  I also feel that, on occasion, teenagers would not come to clinic of their own accord but are obliged to attend by their parents. With this patient, because of her background and age, I felt particularly anxious as I was not sure what mental state she would be in and wanted to do everything absolutely by the book.  

In the initial appointment I took a long time to explain how the appointment would work and was very careful to engage both the make a guardian and the patient in conversations around consent. I made sure that before placing my hands on any part of her I had explained where I would like to place my hands and what I would be doing.  I could sense that she was uncomfortable in just her bra and negotiated before looking at her spine that she would remove her vest for a short period of time to enable me to you look at her spine as a whole and could then replace it. 

The appointment took longer than usual, but I discussed this with my tutor and we agreed that it was better to take a lot of time with this patient to ensure that she was at ease. I felt that I established a good rapport with her and by the end of the session she was I happy to return the following week for treatment. I was thrilled when her grandmother told me as they were leaving that her granddaughter had really warmed to me which she did not often do on a first meeting. 

Before the appointment I had looked at the test for Gillick competence (Hickey 2007; Griffith 2016).  This was less relevant in this case as case the guardian and patient shared the same point of view, but this may not always be the case. Medical professionals need to consider Gillick competency if a young person under the age of 16 wishes to receive treatment without their parents' or carers' consent or, in some cases, knowledge.

If the young person has informed their parents of the treatment they wish to receive but their parents do not agree with their decision, treatment can still proceed if the child has been assessed as Gillick competent.  The following is taken from the NSPCC website:

“There is no set of defined questions to assess Gillick competency. Professionals need to consider several things when assessing a child's capacity to consent, including:

·         the child's age, maturity and mental capacity

·         their understanding of the issue and what it involves - including advantages, disadvantages and potential long-term impact

·         their understanding of the risks, implications and consequences that may arise from their decision

·         how well they understand any advice or information they have been given

·         their understanding of any alternative options, if available

·         their ability to explain a rationale around their reasoning and decision making.

Remember that consent is not valid if a young person is being pressured or influenced by someone else.

Children's capacity to consent may be affected by different factors, for example stress, mental health conditions and the complexities of the decision they are making. The same child may be considered Gillick competent to make one decision but not competent to make a different decision.

If you don't think a child is Gillick competent or there are inconsistencies in their understanding, you should seek consent from their parents or carers before proceeding.”

(NSPCC)

It was a useful exercise to consider Gillick competency with this patient even if it was not needed.   Whilst I feel well practiced in the day to day gaining of patient consent there are also occasion when the issue of consent will require more thought, for example with patients who are minors or elderly and the ability to consent should never be assumed.

References:

Griffith, R., 2016. What Is Gillick Competence? Human Vaccines & Immunotherapeutics, 12(1), pp.244–247.

Hickey, K., 2007. Minors’ Rights In Medical Decision Making. JONA’S Healthcare Law, Ethics And Regulation, 9(3), pp.100–104.

NSPCC, Gillick Competence And Fraser Guidelines | NSPCC Learning. Available at: https://learning.nspcc.org.uk/child-protection-system/gillick-competence-fraser-guidelines#heading-top [Accessed April 3, 2022].

Rolfe, G., Freshwater, D. & Jasper, M., 2001. Critical Reflection For Nursing And The Helping Prefessions: A User’s Guide. Basingstoke: Palgrave Macmillan. Journal Of Research In Nursing, 7(5), pp.392–392.

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

A3.1 - Before examining or treating a patient you should ensure that they understand:

Using the Rolfe et al. reflective model (2001).

January 2022

At the end of Christmas clinic, I had a patient in her late 30s with thoracic pain.  On examination, I found her thoracic spine was hypo-kyphotic and she had a somatic dysfunction at T6-9.  Following a discussion with the tutor, I decided to articulate the area, treat the area with soft tissue and then adjust the area with a thoracic manipulation.  I explained the diagnosis and treatment plan to the patient and asked if she had questions but also hurried on with my explanations.  I also remembered to explain that the area may or may not “pop” and that she might experience soreness in the area afterwards for up to 48 hours.  The tutor came to supervise the manipulation.  

On the second attempt, I managed to put through the manipulation and there was a loud pop. At the same time, the patient let out a loud cry of surprise. I felt really awkward and was concerned that she was in pain. In fact, she was fine but had not been expecting the pressure through her thorax or loud crack.

I think having the pressure of the tutor watching my manipulation made me give more of a speech around the consent for the manipulation than should have been the case.  I did not sufficiently check in on the patient’s understanding and take the time to engage in a meaningful dialogue with her. The process of obtaining consent was too hurried. On reflection, I should have ensured that the patient really had understood what was going to happen and whilst the patient consented, I am not sure on this occasion it was informed consent and that the patient was involved in the decision-making process (Evans 2002; GOsC).  

The Guidance in Montgomery vs. Lanarkshire Health Board, which is the leading case on consent, makes clear that ‘the doctor’s advisory role involves dialogue, the aim of which is to ensure that the patient understands’ (Supreme Court 2015). The judgment goes on to say that the duty to provide information is not fulfilled ‘by bombarding the patient with technical information which [they] cannot reasonably be expected to grasp’. By having a discussion, the osteopath can check that the patient understands the risks and benefits of treatment.

This incident shook me out of any complacency around treating patients. In future, I will go into more detail about the risks and benefits of the treatment and give a fuller explanation of how the technique is performed before asking for consent and proceeding. I will also explain the nature of the pop. I will also make sure that I have considered if an HVT is the best approach for the patient and if I have any doubts I will choose a different technique. A good approach is to explain the nature of an HVT at one treatment but not put the patient under any pressure to proceed with it at that time but tell them they can choose to have it done at the next appointment. 

Informed Consent: Montgomery V Lanarkshire Health Board | Hong Kong Lawyer. Available at: http://hk-lawyer.org/content/informed-consent-montgomery-v-lanarkshire-health-board [Accessed November 5, 2019].

Evans, D.W., 2002. Mechanisms And Effects Of Spinal High-Velocity, Low-Amplitude Thrust Manipulation: Previous Theories. Journal Of Manipulative And Physiological Therapeutics, 25(4), pp.251–262.

GOsC, Obtaining Consent Patients’ Capacity To Give Consent: Guidance For Osteopaths Practising In England And Wales - Yahoo Search Results. Available at: https://www.osteopathy.org.uk/standards/guidance-for-osteopaths/consent/ [Accessed March 14, 2020].

Rolfe, G., Freshwater, D. & Jasper, M., 2001. Critical Reflection For Nursing And The Helping Professions: A User’s Guide. Basingstoke: Palgrave Macmillan. Journal Of Research In Nursing, 7(5), pp.392–392.

Supreme Court, T., 2015. Montgomery (Appellant) V Lanarkshire Health Board (Respondent),

Using the Rolfe et al. reflective model (2001).

November 2021

This week I observed a colleague with a new patient in clinic. The patient was a young Muslim girl who had come in regarding long standing backache that was becoming progressively worse as she was studying hard for exams and spending a lot of time sedentary.  She was wearing a hijab. My colleague explained that we generally asked patients to wear shorts for the examination and treatment stages of the appointment. The patient explained that she was not willing to undress or change into shorts. I thought my colleague handled the position well by explaining that it is easier to see what is going on if the patient is undressed, but that she would work around it. In the end, she took a detailed case history and palpated the patient’s spine through her t-shirt.  Treatment proceeded with the patient wearing her t-shirt. 

The OPS guidance explicitly provides that an osteopath can give 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. 

I found the attached article an interesting read on this topic, which is written by an Indian doctor (Mahmood 2018). 

An examination needs to be conducted in an atmosphere where the patient's cultural and religious beliefs are respected. The privacy and modesty of the patient should be respected and preserved, and this can be achieved by discussing the issue early in the appointment to manage expectations on both sides early on, which avoids any later embarrassment. 

The OPS guidance on this topic is very clear, that is, that patients have a right to their modesty and should not be denied treatment as a result.  I understand that cultural sensitivity engenders trust and improves the healthcare experience for these patients by understanding and attempting to accommodate their values as much as possible.

Moving into practice once I graduate, I will endeavour to make sure that I am aware of cultural differences that may affect how I work with patients. 

Mahmood, S.E., 2018. Is Patient Modesty Being Honored Or Outraged In Clinical Practice? High Time To Introspect. Indian Journal Of Health Sciences And Biomedical Research (KLEU), 11(2), p.105.

Rolfe, G., Freshwater, D. & Jasper, M., 2001. Critical Reflection For Nursing And The Helping Prefessions: A User’s Guide. Basingstoke: Palgrave Macmillan. Journal Of Research In Nursing, 7(5), pp.392–392.

A7.1 The same quality of service and care should be provided to all patients. It is illegal to refuse a service to someone on the grounds of their age, disability, gender reassignment, marriage or civil partnership, pregnancy or maternity, race, religion or belief, sex or sexual orientation.

A7.2 You should maintain a professional manner at all times, even where a personal incompatibility arises with a patient.

Using the Rolfe et al. reflective model (2001).

November 2020

 I was observing in clinic this week and one of the fourth years had a new patient, which I sat in to observe. When the patient arrived, he was in his late 20s (a couple of years older than the female practitioner). He was also very anxious, on edge and slightly aggressive towards the student osteopath. He also made some slightly inappropriate comments. The student took the case history and then, as is normal, we left the room to discuss the case with the tutor. Once in the team room she raised with the tutor that the patient was making her feel very uncomfortable and "creeping her out". She wondered whether he had taken drugs prior to the appointment as his behaviour seemed slightly erratic and on edge. I agreed with her assessment of the position and together with the tutor we discussed the best way to proceed. It was agreed that I would stay in the room throughout the duration of the appointment to support the student osteopath and to sound the alarm if anything untoward took place. In fact, as the appointment progressed the patient became more relaxed, and by the end of the appointment was very appreciative of the practitioner for helping his pain. When we discussed the case afterwards, we concluded that maybe anxiety prior to the appointment was making him seem more aggressive than he actually was.

I have reflected on this case as, once qualified, it would be quite common to be alone in a practice without other people nearby. In that eventuality, it would be important to have procedures in place when treating patients to keep myself safe.

I've also thought about how pain and anxiety can affect people differently and can sometimes make them lash out at people who are trying to help them. Maintaining a calm professional demeanour diffused a potentially difficult situation and allowed the appointment to proceed. Equally the student practitioner knew that she was being supported by her tutor and my prescence in the room. She did not allow her true feelings to show and was very professional throughout. 

Acting professionally can sometimes take us out of our comfort zone but also gives us a facade that we can use to disguise our feelings towards a patient and allow treatment to proceed. It takes skill to handle difficult patients and not letting your feelings show is a good method to disassociate from your personal opinions of a patient. 

Going forwards I will make sure I maintain a professional attitude at all times with patients.

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

In clinic I sat in on a new patient consultation.  The patient was a 70 year old retired truck driver with lower back pain, which had started 5-6 weeks ago with no apparent trigger.  He said he was otherwise fit and well but as the case history went on it became apparent that he had a number of different health issues.  He was a heavy smoker until 3 months ago, suffered from emphysema and was on blood pressure tablets.  He still drank 14 pints a week and had a very red nose suggesting excessive alcohol consumption.  In the last few months he had experienced dramatic weight loss.  On undressing he had scaly grey skin covering his back and feet.  His left big toe was white, swollen, as were his ankles, his foot appeared ulcerated and he reported numbness in his feet.    His arm movements were restricted and he had poor muscle tone generally.  His general posture can best be described as if he were still driving his HGV, that is, rounded shoulders and very slouched posture.  Despite all this he managed to perform the active tests that the practitioner set and there was no pain on palpating his back.

From some research on diabetes mellitus I now understand that symptoms of diabetes mellitus include:

·         Diffuse, painful neuropathy in the feet, shin and anterior thighs

·         Diabetic amyotrophy (painful wasting of the quadriceps muscles usually seen in older men with diabetes).

·         Diabetic feet with foot ulcers with ischemia, infection and neuropathy leading to tissue necrosis.

(Kumar & Clark)

 

The patient was displaying all of these signs and symptoms, but the student practitioner could not diagnose this as a blood test would be required.  Rather an osteopath’s role must be to encourage the patient to visit his GP and seek treatment for the signs and symptoms.   If helpful for the patient, this may mean writing a letter of referral to the GP.  Since I can’t be certain of a diagnosis, care must be taken not to cause the patient more worry or anxiety whilst still emphasizing the importance of seeking further medical guidance. I also wonder if he was suffering from depression and needed help to gain perspective on his situation.  

 

Seeing this patient has made me realise how difficult it may be to walk a tightrope between encouraging a patient to look after their health and not revealing my own fears about the severity of what may be wrong with them.  Sometimes, much as I may want to, I may not be able to provide the solution but will need instead to work with the patient to build trust and encourage better self care using a multi-modal approach.

 

Kumar, P.J. & Clark, M.L., Kumar & Clark’s Clinical Medicine

February 2022

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

Using the Rolfe et al. model (2001)

Vaccinations have done a great deal to ease the strain on healthcare resources caused by the Covid pandemic. I recognise that getting vaccinated is a very personal decision and that potentially a number of different factors are involved in making that decision, ranging from an individual’s personal health concerns to deeply held principles and views on individual rights. 

I have had a few patients who have told me that they have not taken up the opportunity to get a Covid vaccination. A couple have said that they have based this decision on something that they have seen on a social media platform, usually relating to unlikely adverse side effects 

The OPS can be used as guidance on how to approach this issue. C6 requires me to be aware of my wider role as a healthcare professional to contribute to enhancing the health and wellbeing of my patients.  This requires that I consider public health issues and concerns and am 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.

The guidance in C6 OPS is clear and I will ensure that discussions with patients about vaccines are based upon credible and legitimate sources of public health information such as the NHS website or the MHRA website.  I need to remember to stay respectful, polite and evidence-based when communicating with patients about Covid 19 vaccination. 

I will ensure that I stay up to date with the latest thinking on vaccination from reliable resources such as the Institute of Osteopathy, the NHSH and GOsC so that I can engage with patients on the topic in a meaningful and evidence-based way.

Other relevant standards relating to COVID-19 vaccines, include:

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

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

May 2022

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

6.1 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.

Reflection using the Rolfe et al. model (Rolfe et al. 2001)

I have a slightly overweight patient who suffers from chronic neck pain and who I see every 3 weeks for maintenance treatment.  I have reinforced with her the importance of keeping mobile and improving the flexibility of her spine to help support her neck. She has been enjoying a yoga class which has really helped with her symptoms. At her last appointment she came in with a new complaint - her left knee was swollen and painful. I diagnosed osteoarthritis.  She told me that due to the pain she had stopped going to yoga and walking her dog. 

I had recently spotted draft Nice guidance on the importance of exercise for people with osteoarthritis, which when combined with weight loss (if needed) can significantly reduce joint pain (Nice 2022).  Armed with these facts I could discuss the importance of maintaining exercise with her and discuss how to manage this appropriately during a flare up.  I felt confident having this discussion with the patient as I knew the latest advice and could refer her to it in a professional manner.

Staying on top of the latest health guidance is very important to allow me to educate and reassure my patients.  Regularly checking the Nice press releases is a good way to be alerted to the latest news and advice. 

NICE, 2022. National Institute For Health And Care Excellence Osteoarthritis: Assessment And Management (Update) NICE Guideline Draft for consultation 

Rolfe, G., Freshwater, D. & Jasper, M., 2001. Critical Reflection For Nursing And The Helping Prefessions: A User’s Guide. Basingstoke: Palgrave Macmillan. Journal Of Research In Nursing, 7(5), pp.392–392.

 

 

1.2 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.

Using the Rolfe et al. reflective model (Rolfe et al. 2001)

I have been treating a 15 year old patient.  In the initial appointment I sensed that she was not comfortable removing her vest top to stand in just her bra.  I explained why it was helpful to see her spine in relation to her complaint and we agreed that she would remove her vest for a short period of time to enable me to you look at her spine as a whole and could then replace it. She was happy with that solution and it allowed me to make a good assessment of her body. 

Reading the patient’s body language allowed me to foresee that the having to stand exposed in the room was making this young girl going through puberty feel uncomfortable and enabled me to deal with the issue before the patient felt awkward or embarrassed in front of strangers.  

Reading a patient’s non-verbal language requires me to be self-aware of the signals I am receiving from the patient and not to become so focussed on what I am doing that I ignore them.  Interpreting and responding to non-verbal signals is an important part of the patient/practitioner dialogue and has been shown to lead to increased levels of patient satisfaction (Roter et al. 2006). 

Rolfe, G., Freshwater, D. & Jasper, M., 2001. Critical Reflection For Nursing And The Helping Prefessions: A User’s Guide. Basingstoke: Palgrave Macmillan. Journal Of Research In Nursing, 7(5), pp.392–392.

Roter, D.L., Frankel, R.M., Hall, J.A. & Sluyter, D., 2006. The Expression Of Emotion Through Nonverbal Behavior In Medical Visits: Mechanisms And Outcomes. Journal Of General Internal Medicine, 21(Suppl 1), p.S28.

Poor communication is at the root of most patient complaints. Effective communication is a two-way exchange, which involves not just talking but also listening with care

Using the Rolfe et al. reflective model (Rolfe et al. 2001)

May 2022

I have attached the feedback sheet from my recent summative mini clinical exam. My patient was a 57-year-old man suffering from back pain, with a complex medical history. The clinic tutor was in the treatment room to observe the case history, physical examination and explanation of the diagnosis to the patient. 

My feedback reflects that I allowed the patient to tell their story and that my case history taking was clear and flowing but I failed to ask sufficient questions around the medications he was taking.  

The systemic questions and medications that a patient takes form an important part of the overall story that the patient may not attach much weight to, but enable me to gain a complete picture of the patient. Therefore I need to give them as much attention as the other areas. 

I am going to continue with my current method of case history taking as it seems to be working well and enables me to build good rapport with my patients.  Going forward I will also make sure that I really follow through on the systemic questions and questions around medications.  This will allow me to take better account of them in reaching my diagnosis and treatment plan. It is fine to lookup unfamiliar medications to understand the impact that they may be having on the patient.

This reflection has been conducted using the reflective model previously described by Rolfe et al. (2001).
 
 What?
I have attached the mark sheet containing the results and feedback regarding the osteopathic technique station of the second year osteopathic practical exam.  My scores were not very good and the examiner commented that my palpation looked poky.

So what?
Technical skills is an area that I lack confidence with and need to practice, particularly when under pressure in an exam.   

 Now what?

I will check anatomical landmarks and continue to improve my anatomical knowledge to localize specific muscles. I will continue to practice my palpation skills in class.  When I am practicing with my study group I will ask for feedback on how they are feeling when I work on them to ensure that I accurately identify areas of dysfunction and differentiate between acute and chronic tissue texture changes.
 
  REFERENCES

Rolfe, G., Freshwater, D., Jasper, M. 2001. Critical reflection in nursing and the helping professions: a user’s guide. Basingstoke: Palgrave Macmillan. 

May 2022

 

Using the Rolfe et al. reflective model (Rolfe et al. 2001)


 What?

I have attached the handover sheet that I filled in when I needed to hand my existing patient to a colleague.

 On the form I have tried to be give accurate and useful information on the care so far, including the primary and secondary presenting complaint, working diagnosis, treatment and medical history in order to support my colleague in the osteopathic management of this patient.
 
 
 So what?

 Providing a handover sheet is good practice and helps ensure a seamless handover of the patient which is essential for providing high-quality care, promoting teamwork and cooperation between colleagues and allows them to be aware of any issues or concerns that need to be addressed. I hope that it will help the new practitioner build a good rapport with the patient. 

 
 Now what?

 I will continue to write handover notes to aid and support colleagues to give our patients high-quality care for patients.
 
 

Rolfe, G., Freshwater, D. & Jasper, M., 2001. Critical Reflection For Nursing And The Helping Prefessions: A User’s Guide. Basingstoke: Palgrave Macmillan. Journal Of Research In Nursing, 7(5), pp.392–392.

Using the Rolfe et al reflective model (Rolfe et al. 2001)

In Year 1 I had to submit a reflective essay on my perspective on osteopathy and how tradition, regulation, evidence and practitioner and patient values may influence that personal viewpoint over the duration of the course. I have attached my feedback sheet which show that I had understood the concept of reflection but needed to develop clear action plan to go forward.

Having started by being unclear and uncertain what reflection was and how to use it to support my practice I have done quite a bit of reading around the topic and have a clearer understanding of what it is trying to achieve (Bolton & Delderfield 2018; Williams et al. 2012)

Reflection in now a habitual part of my practice.  I may not always write it down but I try and reflect on my experiences in clinic and have often engaged my tutors in discussions around particular difficulties and contradictions in views or evidence that I have encountered, which has been very helpful. Over the course I have come to realise how beneficial and helpful it is and I will integrate it in my practice going forward.

Bolton, G. & Delderfield, R., 2018. Reflective Practice : Writing And Professional Development 4th ed., Sage.

Rolfe, G., Freshwater, D. & Jasper, M., 2001. Critical Reflection For Nursing And The Helping Prefessions: A User’s Guide. Basingstoke: Palgrave Macmillan. Journal Of Research In Nursing, 7(5), pp.392–392.

Williams, K., Woolliams, M. & Spiro, J., 2012. Reflective Writing, Palgrave Macmillan.

B 3.1 To achieve this, you should……keep up to date with factors relevant to your practice, including: ….research and other relevant developments in healthcare.

Using the Rolfe et al reflective model (Rolfe et al. 2001)

This year we have been treating babies in clinic which has been very rewarding and interesting.  It has really benefited my cranial techniques as this is the principal treatment method. I treated one baby for reflux, thorax tension and bronchiolitis.  I noticed on the notes from the previous practitioner that the baby was diagnosed in utero with an aberrant right subclavian artery (ARSA) but that this did not seem to feature in the notes after that.  I had not come across this condition before and it led me to research it, understand the impact on the baby and consider how osteopathy might help.

The treatment was successful and I had some lovely feedback from the baby’s mother. I used the case for an assessment, which went well.  I am glad that I investigated this condition as I believe that it led to a better understanding of what was going on with the patient and how treatment might be able to help.  Understanding the ARSA, which is quite a rare condition, allowed me to formulate a better treatment plan. 

Stay curious! There will be lots of conditions that are new to me going forward – I need to make sure I take the time to research them and consider how osteopathy can help using the 5 osteopathic models that we have been taught to formulate the aims and objectives of a treatment plan.
When the five models were first introduced in clinical concepts I did not understand their relevance. Even in year 3 I did not understand how to integrate the models into a treatment. It is only with a little more experience that I see how they can be used to help formulate treatment plans that takes account of the patient's needs. As I graduate and face the challenge of managing patients without a tutor on hand to ask planning treatment based on the models will be a great help.

D3: You must be open and honest with patients, to fulfill your duty of candour

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

May 2022

Using the Rolfe et al reflective model (Rolfe et al. 2001)

This evening in clinic I had a cover patient whose symptoms included vertigo and tinnitus.  My diagnoses included BPPV but also possible cervical arterial dissection.  Testing in clinic does not enable me to rule out the latter although on the basis of the case history it was unlikely (Rushton et al. 2014). The tutor and I discussed getting informed consent from the patient and discussed that as I have a duty of candour to the patient that before I executed the Hallpike test to test for BPPV I needed to inform her of the risk that it might bring on symptoms, but also that it might induce a stroke if a cervical arterial dissection was in progress. However, I should also explain why this was unlikely.

Whilst I was aware I needed to inform the patient of the risks around the test bringing on the symptoms of vertigo I had not considered that I also needed to explain the risks of bringing on a stroke because I had assessed the risk of a cervical arterial dissection as low.  However, I understand that however unlikely the risk was till present.  The patient looked surprised when I mentioned the risk of stroke in performing the test and I also offered her alternatives to testing and treatment, but she agreed to proceed with the test. 

Whilst I had assessed the risk of cervical arterial dissection as low and agreed this with my tutor, I still should have remembered to raise this with the patient in order to obtain both informed consent to the testing and to fulfil my duty of candour.

Placing the decision to go ahead with the test protects me as the patient has been appraised of all the risks and consented to them but also ensures that I am engaging in shared decision-making with the patient.

This was a really useful reminder of the importance of standing back and assessing all the factors in a case before proceeding to testing. This incident has brought the interplay between D3 and A4 OPS much more to the forefront of my considerations when I obtain consent from a patient and I realise that I need to take both fully into consideration. Being candid is an important part of obtaining informed consent even if the conversation is tricky or takes time, but ultimately is an important part of building trust and a relationship with the patient. 

Rolfe, G., Freshwater, D. & Jasper, M., 2001. Critical Reflection For Nursing And The Helping Prefessions: A User’s Guide. Basingstoke: Palgrave Macmillan. Journal Of Research In Nursing, 7(5), pp.392–392.

Rushton, A., Rivett, D., Carlesso, L., Flynn, T., Hing, W. & Kerry, R., 2014. International Framework For Examination Of The Cervical Region For Potential Of Cervical Arterial Dysfunction Prior To Orthopaedic Manual Therapy Intervention. Manual Therapy, 19, pp.222–228.

May 2022

Using the Rolfe et al reflective model (Rolfe et al. 2001)

2.1 You should use your professional judgement to assess whether you have the training, skills and competence to treat a patient, seeking advice where necessary.

2.2 If not, you should consider:

·         seeking advice or assistance from an appropriate source to support your care for the patient

·         working with other osteopaths and healthcare professionals to secure the most appropriate care for your patient

·         referring the patient to another osteopath or appropriately qualified healthcare professional.

May 2020

Using the Rolfe et al. reflective model (Rolfe et al. 2001)

In 2020 I had a patient with knee osteoarthritis. During one appointment he mentioned to me that he had had a long-standing cough that he could not shift. At the following appointment, I detected a slight change in his voice that concerned me. I mentioned it to my tutor and together we proceeded to examine his throat.   We found he had raised lymph glands and a palpable lump on the side of his neck. We advised him to visit his GP to get it checked up. 

This week the patient returned to clinic and told me that following our advice he had seen his GP and sinus cancer was diagnosed for which he has now received successful treatment. He was very grateful for our advice without which he would not have called his GP.

Knowing how to identify and refer a patient for a serious health issue is a very important skill, even when it does not relate to the main complaint that a patient comes in with.  Picking up small clues can help form an overall picture of the patient’s health.

Looking back at my other reflections in this section which all date from earlier in the course I realise how much I have learnt and how far I have come in my journey as a healthcare professional.  I feel proud that I have developed the skills to identify potentially serious health issues and know when to refer a patient for urgent medical attention. Even though I did not have the full picture I acted on the information available to me at that time and recommended that he saw his doctor.

I also recognise that I am at the start of this journey and need to keep building on my skills and really listen to a patient's case history to ensure that I piece all the details together. 

Rolfe, G., Freshwater, D. & Jasper, M., 2001. Critical Reflection For Nursing And The Helping Prefessions: A User’s Guide. Basingstoke: Palgrave Macmillan. Journal Of Research In Nursing, 7(5), pp.392–392.