What?
The lecturing assistants filmed us performing side-lying scapulothoracic techniques and gave personalised feedback based on the video (file too large to upload).
My personalised feedback points were:
-  Take off watch for patient comfort
-  Make sure the couch is at the right height for my own comfort
- Make a wider base with feet so give me the most stable position
- Patients shoulder should be contacting my manubrium/sternum, not my opposite shoulder
- Try to achieve the biggest contact underneath the scapula as possible (as is comfortable for the patient) to get the best range of movement
- Make sure nails are super short so best contact is achieved (not worrying about hurting the patient)

Now What?
I am going to take these points forwards in my practical classes to optimise both my own and the patient's comfort. This will ensure I can apply the techniques as effectively as possible to have an optimal impact on the area being treated.

So What?
Receiving and implementing feedback like this is important at this point in the course as it ensures that we are performing techniques correctly and effectively, as patients will not always be clear if in discomfort. Taking critiques to implement moving forward is a key part of reflective work on practical skills.

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

What?
After recently having done a mock Clinical Integration exam, I have come to realise that this is the class that really sets us up for treating patients in clinic and into the future as an osteopath. The 5 stations in the exam will be:
1) listening to and taking notes on a case history
2) writing a summary of the case history and diagnosis
3) active, passive and special tests
4) treatment
5) writing a management plan
All of the elements of this exam will be applied to the individual case given, just as they would be applied to each different person in clinic.

So What?
Having observed in clinic for 27 hours so far this year, it is clear to see that this structure is almost identical to that which I have seen students follow in the clinic. Often 3rd and 4th year students have been encouraging, saying that the clinical integration course should set us up for clinic better than they felt they were without the course.

Now What?
Clinical integration is also important as it gives us a chance to consolidate knowledge and apply it in real-life situations provided to us. It reminds us that everything we learn in both practical and theory lectures needs to be mixed together in order to achieve the best possible and most appropriate patient outcomes.

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

What?
This picture shows a reflection sheet I filled in whilst watching a particularly interesting case at clinic, in terms of patient-practitioner interaction.  The patient was full of personality and consequently it was difficult to keep the appointment on track but also to keep the patient happy. Unfortunately there was no time for treatment but the patient seemed happy to return.

So What?
The  student practitioner dealt very well with the circumstances and guided her through the appointment with sensitivity and respect, which was really inspiring to watch. He adapted to her communication style and allowed her to express her needs, whilst also managing her expectations and the format of the appointment.

Now What?
This experience showed me that the hands-on parts of treatment are not always the most important, and that sometimes patients feel supported by being listened to. It also gave me some ideas on how to manage patient expectations, as it wasn't possible to treat her in this appointment due to the time taken gathering information in the case history.

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

What?

While treating a returning patient for upper thoracic and cervical spine pain, diagnosed as trapezius and thoracic erector spine myalgia, I received feedback that my treatment routine was lacking in osteopathic approach. Specifically, my tutor said that we don't study at the 'European School of Massage'! My treatment was composed of STW to the traps, rhombus, TES, long level TSp articulation, ST joint articulation, MET bilaterally to traps, and some GOT style CSp articulation.

So What?

Although I had included some osteopathic techniques, I did agree with the tutor that my treatment was not wholly osteopathic, since the emphasis was placed on the massage and soft tissue aspects. When I saw the patient again this week, I included the above techniques into a full supine GOT routine to better integrate the whole body back with the areas of concern.

Now What?

On reflection, I think I feel more confident using soft tissue and massage techniques due to my qualification in Sports Massage. I need to practice osteopathic techniques like further METs and HVT that could also be used to address the area, like an MET of SCM or a CD lift, in order to feel more confident in implementing them in the treatment room. I am going to continue to ask for feedback from my tutors for areas I could improve of each appointment and make sure to take forwards any summative feedback EG from CEX assessments.

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

What?
Part of our training to get ready to enter clinic has involved training in what to look out for in order to keep our patients safe from harm. This has included Female Genital Mutilation (FGM) risk recognition and Prevent duty training, as well as training on how to use the Child Protection Online Monitoring System (CPOMS).

So What?
This training is really important to recognise both explicit and implicit signs that someone may be vulnerable to abuse or being drawn towards terrorism. They may not always outright say the struggles they are going through but may give subtle signs through their conversation or actors. For example, a young girl whose parents pull her out of school to visit her family abroad for a long period of time may be at risk. Another example could be a teenager that starts to become isolated from their friends and family, and become secretive about their beliefs and internet use.

Now What?
It is important to keep refreshing these training resources to ensure I am alert to the signs that someone is at risk in the clinic; this could be a patient or another student. The current estimations are that 4.8 in every 1000 women and girls in the UK are living with the consequences with FGM (Dixon et al., 2018), and awareness is a top priority.

References:
Dixon, S., Agha, K., Ali, F., et al., 2018. Female genital mutilation in the UK- where are we, where do we go next? Involving communities in setting the research agenda. Res Involv Engagem, 4(29).

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

What?
I had a new patient in the clinic who presented with a temporal headache, associated with nystagmus, tenderness over the scalp and jaw, nausea, and other symptoms that meant I was unable to exclude temporal arteritis. We made the decision not to examine or treat, and refer her back to her GP with our concerns. She became very confrontational and the story of her symptoms began to change to try and convince me to treat her, as far as saying her GP had given us the all-clear to treat, when she had previously said she had not discussed it with them. I went to discuss her reaction with my tutor, who came with me to support and further explain the decision not to treat. She wanted to review the initial documentation signed at reception, as she believed she was entitled to treatment as she had paid a consultation fee; we immediately showed her the form which states that treatment is only given if deemed appropriate. Eventually, the patient agreed to the referral but requested a copy of the referral letter be sent to her as well as the GP.

So What?
I wrote the referral letter on the same day as her appointment and edited it alongside my tutor before handing it in for official printing. As we knew the patient had requested access, it highlighted how objective and impartial the letter needed to be; I was more conscious and considerate with the wording than I have been in previous referral letters. As soon as the letter was sent to the GP, I ensured it was also sent to the patient's personal email address.

Now What?
This experience brought attention to the way we discuss patients in communication with ourselves and other healthcare professionals. Although this was the first time so far that a patient has requested a copy of written materials related to their case, it doesn't mean that a patient in future won't request material retrospectively. Material concerning patients, including written notes and referral letters, should always be respectful and purely factual; we also must ensure it always reaches them in an appropriate and time-aware way.

References:
Ling, M.L., Yosar, J., Lee, B.W., Shah, S.A., Jiang, I.W., Finniss, A., et al., 2019. The diagnosis and management of temporal arteritis. Clinical and Experimental Optometry, 103(5), pp. 572-582.

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

What?
With the new coronavirus pandemic, going into clinic we will be required to wear PPE, increase the cleaning procedures in the rooms between each patient, and ask screening questions before any patients are allowed inside. This aims to reduce the risk to patients of contracting coronavirus from the ESO clinic and provide a safe environment for healthcare.

So What?
It is our responsibility to provide a hygienic, clean and safe environment, and GOsC has provided infection control guidance to help us achieve this. This is in addition to the Health and Safety Executive which aims to keep employees safe by ensuring PPE is provided, which will keep patients safe in turn.

Now What?
I will ensure to keep doing lateral flow tests at home as required to ensure I don't put patients at risk even if I am asymptomatic. I will also be aware of time management to ensure thorough cleaning can be done between appointments.

References for current updated guidance:
GOsC, 2022. Infection control guidance. Available at: https://www.osteopathy.org.uk/news-and-resources/document-library/about-the-gosc/interim-guidance-on-infection-control/. Accessed on: 3/5/2022

Health and Safety Executive, 2022. PPE guidance at work. Available at: https://www.hse.gov.uk/ppe/ppe-regulations-2022.htm#what-ppe-is. Accessed on: 3/5/2022.

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

What?
Today was the first time I had to refer a patient who wasn't safe to treat and then discuss this decision with them. She was aged 73 and came to the clinic presenting with a 6-month history of back pain from the lower Tsp down to the LS junction bilaterally- no axial movements could exaggerate the pain, although some palpation did. She had not discussed her back pain with any other healthcare providers. On questioning in the case history, she revealed that she was diagnosed with breast cancer earlier this year and had a lumpectomy a month ago, but refused lymph node removal and radiotherapy- the back pain started at the same time as the cancer diagnosis. She also refused imaging after surgery to confirm the complete removal of the cancer. These factors alongside her other symptoms such as constant pain, unremitting night pain, and weight loss, meant we could not rule out secondary metastases to the spine.


So What?
We made the decision to refer her back to both her oncology consultant and her GP to request further imaging. As a former nurse, the patient agreed that she had come across this thought herself but had dismissed it. Current research suggests that when a patient with a history of malignancy in the breast who presents with a new-onset of back pain, we should be highly suspicious of a secondary metastasis (Ju et al., 2014). This was further complicated by the patient's decisions made after surgery.

Now What?
It was a difficult conversation to approach but I explained my reasoning for not treating and requesting permission for referral, and she agreed to go ahead with that route. This experience highlighted to me the importance of knowing the red flags and pathophysiology of cancer as this patient was the first patient that I had seen that was not safe to treat. Going forward, I will research common metastasis locations of the common cancers I might come across in future, like lung and bowel cancer.

References:
Ju, D. G., Yurter, A., Gokaslan, Z. L., & Sciubba, D. M., 2014. Diagnosis and surgical management of breast cancer metastatic to the spine. World journal of clinical oncology, 5(3), pp. 263–271.

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

What?
I chose to participate in the specialist headache clinic at the ESO, and to accompany this work through a 3.5 hour workshop introduction to headaches. I was shocked at the huge range and number of headaches and the number of people affected by them. Previous to starting the headache clinic, I had only seen one patient with a new onset headache; it was associated with nystagmus, scalp tenderness, nausea and ultimately we decided that we were unable to exclude temporal arteritis from the differential process. The other differentials were BPPV, Meniere's disease and vestibular neuritis. Although I believe the outcome would have been the same after the headache course (referral to GP and no treatment), I feel my clinical reasoning lacked knowledge and justification at the time.

So What?
Working through the online course showed me exactly how much more I need to learn to be a competent practitioner dealing with headaches, especially with how prevalent they are in primary care in the UK. Recognising a pathological secondary headache is crucial to being a safe practitioner, which is complicated by the overlap in symptoms with non-pathological primary headaches.

Now What?
I recognise that the course I have undertaken is only a starting point for working with headaches, and that keeping up to date with knowledge and skills is a requirement of the OPS. I could achieve this by undertaking further courses and research, which would help me fulfil my CPD requirements, such as keeping up to date with NICE and the BASH guidelines and further courses supported by the OPHM and EdACHe group. A good starting point before this would be to go through this 3.5 hour course again, to refresh anything forgotten. I could also request to do some work shadowing, for example at the National Migraine Centre.

References:
NICE, 2021. CG150: Headaches in over 12s: diagnosis and management. Available at: https://www.nice.org.uk/guidance/cg150. Accessed on: 10/04/2022.
 British Association for the Study of Headache (BASH), 2019. Guidelines for the diagnosis and management of common headache disorders. Available at: https://www.bash.org.uk/guidelines/#. Accessed on: 10/4/2022.
Rolfe, G., Freshwater, D., Jasper, M. 2001. Critical reflection in nursing and the helping professions: a user’s guide. Basingstoke: Palgrave Macmillan.

What?
Reviewing my posts from previous years to complete the portfolio assignment, I reviewed the reflection sheet I filled out in first year. I noticed that the patient had effectively told the student that she consented to everything in advance to stop asking procedural consent, but the student was firm in saying that he needed to ask for her continued consent through the appointment.

So What?
The OPS makes it very clear that the consent is not valid unless it is informed; this means that the patient must be aware of the risks, benefits, aims, alternatives and the option of no treatment. The student was right to not implement this patient's particular request, as her consent would not be valid; if she decided to make a complaint, this could be a fitness to practice issue.

Now What?
Now that I am in clinic myself, I try to remember what it felt like to be at my first appointment and what my expectations were. I always make sure to inform the patients as much as possible, so that their consent is given voluntarily and is informed; I then record in their notes that consent was given, along with any concerns or questions they have.

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

What?
I had seen a patient in the clinic about 6 times when I was unable to attend one day as I was ill, and the appointment was covered by another student with a different tutor. The next time the patient visited, they weren't happy with the previous appointment and came with a written list of feedback and things they felt weren't dealt with safely and appropriately.

So What?
The patient decided they didn't want to go through the official complaints procedure, but requested not to see that student or tutor again. My tutor came to support me and we tried to explain the reasons why there may have been differences in examination and treatment; for example there being multiple ways to test the L5 myotome.

Now What?
Although I was unable to this time, in future I will make sure to provide a summary of a patient to anyone covering where possible in future. If this patient had decided to make a formal complaint, I am aware of the complaints procedure at the clinic; after graduation, I know that I should make patients aware of their ability to report to GOsC.

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

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

What?
As student observers, we need to sign a confidentiality form as shown above to confirm we understand the need to keep patients' health data protected, and if taking notes from cases to keep them anonymous. We also must respect patients' decisions when requesting to disclose their data for example if referring back to their GP. 

I have seen only one occasion where a patient declined to share their health data with their GP due to the implication it could have on their career. It was an 18-year-old male with low back pain and radiations following a high impact rugby tackle that had an axial impact; the tutor was concerned that due to the presentation of his symptoms and the nature of the injury, his back pain may have been caused by a traumatic spondylolisthesis. It was suggested that we refer him to his GP for imaging, but the patient declined as his life goal was to enlist in the army which he would finally be able to do as school finished a few months later, and this could stop his ability to enrol. The possible risks of improper management of spondylolisthesis were explained, and the patient agreed that possibly a private scan would be the answer as the results would stay off of his NHS record.

So What?
This experience showed me that although we want what is best for our patient's health, sometimes their health status can have a much wider impact than we first expect. We must respect our patients' wishes on their healthcare management, and provide them with as much information as possible to make an informed decision. Where information is disclosed without their consent, such as to protect the public, the information should be only what is necessary and should be recorded in their notes.

Now What?
Moving forward, I will place more emphasis on asking for the patient's goals, expectations, and concerns as this will create a clearer impact that health has on this patient as a whole. I feel this is a key element of the biopsychosocial model (Engel, 1981) and the holistic care we aim to provide, as it will help me to consider the consequences of my patient management.

References:

Engel, G., 1981. The Clinical Application of the Biopsychosocial Model, The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine, 6(2), pp.101–124.

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