This standard is, among others, reflected in a case treating a patient with shoulder pain through my written exam paper in Osteopathic Clinical Consultations in year 2. Furthermore, before gaining consent to perform the treatment technique, I never did any High Velocity Thrust-techniques.

Attached is a part of the anonymized medical journal.

In this case, I was treating a patient who was an elite sports athlete runner who recently became a father. He came to me with hip pain during running and neck pain. Treatment consisted, among others, of load management, strengthening exercises and optimisation of recovery/the body's self-healing ability through tools to manage stress and sleep.

•Manual joint mobilization techniques: Consider manual joint mobilization techniques for patients with tension-type headaches in addition to usual care (very low evidence).

•Supervised physical activity: Consider supervised physical activity for patients with tension-type headaches in addition to usual care (very low evidence).

•Psychological treatment: Consider psychological treatment in addition to standard treatment for patients who experience tension headaches that significantly limit their quality of life (very low evidence).

•Acupuncture: Consider acupuncture for patients with tension headaches in addition to usual treatment (low evidence).

•Patient education: It is good practice to consider patient education for patients with tension headaches (based on consensus - no evidence). 

Despite having an improvement by applying most of the clinical guideline recommendations, which of the interventions led to the improvement remains unknown. In my opinion, the guidelines lack recommendations on interventions targeting the potential aetiology and modifiable risk factors of tension-type headache, e.g., stress, lack of sleep, general health and ergonomics.

Lastly, my aim to respect my patient's dignity and modesty is reflected in my grades from year 2 examinations in the MSK-station. I achieved a 90 % mark in "act and interact with a professional and respectful demeanor".

Attached is an anonymized section from the medical journal.

Nevertheless, recently, I've started to be more authentic with more eye contact and conversation/subjective examination at the cost of less rigorous medical journaling. However, I think implementing both and achieving a very positive patient experience is achievable. My next step is to take more time conducting the medical journal.

Following the consultation, I called my patient to follow up and hear how he was doing and whether he had a scan or not, but he didn't answer, unfortunately.

In hindsight, I think I did the right thing by referring, even though just a small amount of doubt was present: "when you're in doubt, you're not in doubt".

Until today, I've always used it in case my patients have symptoms which could be related to high blood pressure. However, I agree with these practice standards, and I probably should measure blood pressure for general health issues in most of my patients as it is a "silent killer" because patients often have asymptomatic presentations. From today on, I will do it.

We started a treatment course and saw minor improvements during the initial follow-ups, however, more and more consultations were made, and pain was very fluctuating. Some follow-ups she felt a bit better, some follow-ups she felt worse, and some she felt no difference. Despite no clinically meaningful improvements and even some new reoccurrences of painful musculoskeletal conditions during the treatment course, she kept asking for a new appointment. After a vast amount of treatments, I told her that if no noteworthy improvement has been experienced until the upcoming appointment, I'd recommend her having a second opinion from my colleague. Nevertheless, the symptoms always seemed to always in the following consultation.

We talked about her stress levels and managed them throughout the treatment course. Last time I talked to her, she told me a lot was "going on", and she consulted with her psychologist. I haven't spoken to her since, despite trying to reach out for her via e-mail.

Looking back, I think she felt comfortable in my company and was probably too comfortable, in the way she was not comfortable seeing other therapists, maybe because she felt ashamed of her body weight.

About a week later, I received a message through the contact form on our webpage, saying she needed to talk to me about the treatment because she felt sick after the treatment. Straight away, I was worried, but at the time, I only did manual therapy of the shoulder and the neck of a mild level of intensity, so it was very doubtful that my treatment could have harmed her. Nonetheless, I recognized it could have been a possibility, and I messaged her back, letting her know that I was very sorry if in any way I did any harm to her and asked her to please let me know if I could help in any way. She e-mailed me back and told me that it wasn't my fault she has been to the psychologist since the last appointment and most likely experienced an untreated mental trauma in the form of her husband passing away two years ago.

A week later, I received the e-mail as attached. She cancelled the follow-up and told me she felt cheated because she had a free screening, she did not know when the screening ended, and she said she declined to do any exercises and receive any information about the treatment price. She ended the mail by telling me she wanted a refund. I did not doubt at all that I informed her about the price, and she agreed to start treatment, including exercises. I got a feeling of confusion, irritation, and injustice and found myself ruminating for many hours regarding what I should do about it, and I wanted to avoid a bad review anywhere online (and in public). In the end, I found myself spending a lot of time ruminating about this issue but also not deciding the issue. Based on this and the benefit of the doubt - she did ask for the price as she walked out - I chose to give her a refund and a polite apology for the possible misunderstanding.

When reflecting, I think this is a unique situation in every case; however, if the same thing happened again, I would choose the same option.

Furthermore, I always ask my patients for psychosocial factors through questions like: "Do you like your work?", "How's everything at home?", "How's your relationship with your partner?", "How are your kids doing?". If my patient is emotionally loaded, I let them know I am no psychologist nor psychotherapist; however, often, it may help to get some frustrations off their chest by letting someone know. If they are interested and feel comfortable doing so, they are more than welcome to talk to me about their issues, and I inform them about my duty of confidentiality.

I feel I dealt with this properly and didn't start discussing any beliefs or politics, but kept focus on the issue itself without forgetting treating the person as a whole. This may, to some degree, be supported by the fact that he returned half a year later to me with another complaint.

In the future, I think this will be the right approach. However, I am not bothered to any degree about which sexual preferences my clients have nor which gender they prefer to be. So if they open up a discussion, I think I might optimize treatment and relation to the patient while keeping a professional distance by asking questions regarding their social situation and trying to put myself in their situation.

Furthermore, during my osteopathic education, I've experienced a lot of likely and less likely hypotheses coming from colleagues regarding patient examination and treatment, which sometimes frustrates me. It is possible to see both bad and skillful osteopaths, but this is possible in any industry. Over time, I have acknowledged that there are different opinions on this topic. When speaking to people outside the osteopathic environment, I am always very mindful of speaking positively about osteopathy.

My reflections on my handover are that despite not being completely confident in what next step was or should be for my client, I was completely honest in the way I provided him with possibilities, and I included shared decision-making in the process. I think honesty and authenticity are more important than the delivery itself. If this approach is applied, I think delivery will improve with experience and time - the opposite will probably not be the case. So, in the future, I will focus on maintaining honesty and authenticity.

Furthermore, I have taken out an insurance policy (attached) that offers sick pay. When reflecting on it, this is beneficial to decrease any inclination to go to work despite being sick to any degree, because to be honest, earlier in my career, I have attended work despite being a bit sick with a cold now and then.

Then, we proceeded to examine her lower hip pain and found a working diagnosis of gluteal tendinopathy. We managed load, and I gave her a strengthening exercise with a certain dosage and advised her to take iron supplements as advised by the Danish Health Authorities and make sure to follow the remaining recommendations by them. Furthermore, I advised her to see her doctor an extra time to ensure safety.

Crossfit: Every day: 1 time per day; 1-2 hours per session. Soccer: 2 x per week. Weightlifting 2 x per week. Calisthenics 1 x per week with son.

Competes 3-4 times per year in elite level CrossFit.

Thus, my recommendation was to decrease the amount of exercise, especially exercises in the bar, pull ups, muscle ups, rowing, etc. - exercises which loaded the biceps brachii and rotator cuff the most. After a month we gained considerable improvement in her pain levels.