Throughout my osteopathy training, I’ve become much more confident in applying shared decision-making. I’ve improved in clearly explaining what I plan to do, why I’m doing it, what I can’t offer, and in listening carefully to my patient’s perspective. In my experience, this leads to more effective and successful treatment outcomes.

A systematic review and meta-synthesis by O’Keeffe et al. (2016) emphasized that patients benefit greatly from receiving clear explanations of their condition, supported by metaphors or analogies. This helps them not only understand their situation better but also explain it to others.

After studying both pain theory and psychology, I decided to write down a few analogies to clarify how I wanted to communicate with patients about why they experience pain. Two of those examples are included below. Doing this has made a real difference in my ability to confidently educate patients, something shown to be important in achieving good outcomes.

Going forward, whenever I find myself struggling to explain something, I plan to sit down and create analogies like these. While it takes some time, it’s been incredibly useful in practice and has long-term value, since I can reuse these explanations again and again.

1- Example:

"Pain works in such a way that all input coming into the body is sent to the brain. The brain then interprets this input and decides what you should feel and what you shouldn't. Based on memory, knowledge, and belief, the brain can turn the pain up or down.

For example, if you walk through tall grass, your brain receives input. It then communicates with various parts of itself and with your memory, things you've experienced before. If you've previously learned that tall grass isn't dangerous, you won't even notice it. But if you've heard or experienced that snakes can hide in tall grass, your brain might perceive it as a threat. This can trigger an alarm response that makes you tense up and quickly move away—and in some cases, your brain may even send out a pain signal."

2. Example

"Many factors can increase or decrease pain sensitivity and potentially trigger pain. Imagine your body as a cup. If you start filling that cup with things like lack of sleep, then add some long-term stress, followed by anxiety about your pain, and perhaps catastrophic thoughts like “what if my back gives out again?” Then, top it off with reduced physical activity, the cup starts to fill up. You might still not feel any pain. But then, one day, something small happens, and suddenly the cup overflows. That overflow can result in a lot of pain, even if the pain isn’t directly caused by a physical injury. The goal then becomes figuring out how to empty that cup again"

His symptoms included:

• Neuropathic pain described as burning and prickling

• Able to walk, but typically walked on his toes

• Disliked wearing shoes

• Constant numbness throughout his lower extremities

• No loss of muscle strength, but significant loss of balance

• Inability to identify which toe was being touched when someone touched them

• Still able to ride a bike

• Difficulty sensing the need for a bowel movement, which had led to occasional accidents

His symptoms began four years earlier. One evening while eating, he suddenly became extremely dizzy. After about 30 seconds, the dizziness subsided, and he felt a warm, floating sensation in his right leg. The next morning, he woke up with both legs numb.

He had seen several neurologists and undergone 6 MRI scans. The only notable findings were elevated protein levels in his cerebrospinal fluid and possibly some microembolisms. Based on these, the doctors suspected lumbosacral radiculitis.

Since it was a free screening session, I didn’t have much time for a full examination. However, my findings were:

• Endomorph body type

• Anterior posture type

• Tight calf muscles

• Right SI-joint irritation

  
  

As mentioned earlier, I had no prior experience with this type of condition. He came to me hoping that I could help. I was honest with him and explained that I hadn’t encountered a case like this before and would need to consult with some of my colleagues. Since he had only booked a free screening, I told him I would get back to him after I had gathered more information.

I discussed the case with my colleagues, and they advised me that what I could offer included helping him start a gentle exercise program to stimulate the nervous system, suggesting lifestyle changes, and possibly using some manual therapy to release some tension. They also reminded me to be clear about setting expectations, that I couldn’t promise results or perform miracles, and that ultimately, he would need to do most of the work himself.

In addition, I looked into some literature, which suggested that physiotherapy, when combined with a targeted strengthening program, might be beneficial.

I called him and shared all of this with him. He appreciated my honesty and said he would think about it. I haven’t heard back from him since, but I feel I handled the situation well by consulting with colleagues, reviewing the research, and being transparent with the patient. If I encounter a similar case in the future, I would take the same approach.

As a result, I didn’t put much focus on these topics.

Recently, I realized how much I’ve grown in this area. I’ve become much more confident when discussing lifestyle changes with my patients, because I now understand how significantly these factors can influence the healing process. I explain what the Danish Health Authority recommends, and how things like alcohol, nutrition, and smoking can affect the body’s ability to recover. Patients generally respond very positively, they appreciate the information and seem motivated to make changes.

After a few sessions with me, her reflux, heartburn, and back pain showed some improvement. We also discussed her stress levels and how they might relate to her heartburn. I encouraged her to begin strength training due to her osteoporosis. She started using weight machines but remained unsure about its safety and whether I truly had experience working with osteoporotic patients.

She had seen online videos from an osteoporosis expert from in Aarhus and contacted him for guidance. However, she was dissatisfied with the delayed response, which took several weeks. When he finally replied, he referred her to an osteopath he knew. A few weeks later, she visited that osteopath but was unhappy with the treatment, as it only involved dietary advice and no manual therapy. According to the osteopath’s notes, she claimed she hadn’t received much guidance from me, something I found frustrating, as I had indeed offered advice which she may not have taken seriously.

After several sessions without significant progress, I referred her to another colleague whom I believed would be a better fit. This colleague later told me that the patient had spoken positively about my treatment style and personality, though she felt there hadn’t been much improvement.

Reflection:
In this case, I dealt with a patient who openly criticized several of my colleagues. I found this frustrating and somewhat irritating, but I remained professional and did not let my emotions affect our interactions. I was particularly frustrated by her claim that I hadn’t provided any advice, which wasn’t true. It’s possible she didn’t fully absorb what I shared because I wasn’t perceived as an “osteoporosis specialist” or didn’t come across as confident enough.

Throughout my seven years as a physiotherapist, I’ve worked hard to avoid appearing uncertain, even when I have solid evidence backing my approach. In hindsight, perhaps I didn’t communicate my expertise convincingly enough. Ultimately, I referred her to another colleague—not because I couldn’t handle her critical attitude, but because I believed she might respond better and show greater compliance with someone else.

Action:
I will continue to maintain professionalism regardless of my personal feelings. This case has reminded me of the importance of sounding confident and clearly communicating that my advice is evidence-based.

In the last exam, this summer, we will be tested specifically on medical screening and the ability to identify red flags, an essential skill when treating patients.

Once I complete my training, I look forward to continuing my professional development through further courses. I enjoy learning, and it will be a great motivation to finally choose courses based on my own interests and clinical needs. To maintain and deepen my knowledge, I plan to set aside two hours per week after graduation to study areas where I feel less confident.

Experience:
I treated a patient who came to me with ongoing symptoms following a motorbike accident five months earlier. He was experiencing persistent headaches and was unable to return to full-time work. He had previously seen a physiotherapist, and although manual treatment had provided some relief, his headaches continued.

There were several issues I wanted to address. He was overweight, did not engage in any regular physical activity, and was under significant stress due to conflict with his employer. His boss insisted that he either return to full-time work or go on full sick leave, which added to his stress. He consumed alcohol only occasionally, a few times per week.

I did a full examination of him, including an eye test to rule out related issues, but the result was negative.

I explained to him the potential benefits of exercise, especially following a concussion, and provided some manual treatment. I also introduced other supportive strategies, such as stress management and healthy nutrition. In our conversations about increasing physical activity, he mentioned he enjoyed mountain biking or walking and was open to using a stationary bike at home.

It was my impression that he wasn’t truly engaging with my advice. His ongoing frustration with the headaches seemed to block progress.

I discussed the case with some of my fellow students. One suggested that I should identify what resources he had available so I could meet him at a level where he could manage the changes I was trying to implement. I tried this approach as well, but it didn’t lead to any breakthrough.

Eventually, I decided to involve a colleague, an osteopath at our clinic who is specialized in concussions. I asked the patient if he would be open to being seen by this colleague while I observed, and he agreed. My goal was to see if a different approach might be more effective. The osteopath confirmed my diagnosis and provided similar advice, but he delivered it with more authority and confidence, qualities that seemed to resonate with the patient.

Afterwards, the patient told me directly that I came across as somewhat insecure, probably because I was still a student.

Reflection:
The patient’s comment affected me, but it also provided valuable insight. This experience taught me that it’s essential to understand how each patient responds best to communication. In this case, the patient needed someone who projected more authority and confidence to feel reassured and to comply with treatment recommendations. It wasn’t that my knowledge was lacking, but rather the way I presented it.

Action:
Moving forward, I will focus on adjusting my communication style based on the individual in front of me. I will work on projecting more confidence and authority, even as a student, to improve my ability to engage patients and gain their trust.

For example, I once had a patient who came in for a free screening, not for treatment, but for case history taking and examination. Based on my assessment, I concluded that she would benefit from fascial drainage. Before her treatment session, I reviewed the lecture on fascial drainage from our GOT seminar, which we had recorded and practiced the technique several times on a family member. I also revised the relevant lymphatic anatomy. As a result, I felt more confident, and the treatment was successful.

I write this:

Hi ....

I hope you're doing well!

I'm reaching out to check in on how you're doing and to follow up on whether you need a new appointment after the recent cancellation.

Please feel free to let me know, and don't hesitate to reach out if you have any questions.

You can book a new appointment using the following link:

....

Best regards

Fortunately, most patients respond and explain that they have simply been too busy. Some do not reply, while others provide feedback or mention that they have chosen to try a different treatment approach.

For those who do not book a follow-up appointment, I take the time to review their case history and reflect on the treatment I provided, our communication, and what I could have done differently to improve their experience and outcome.

My case history taking has developed significantly during my time at ESO. I have become much more specific and detail-oriented in my approach. I also follow the guidelines set by the Danish Patient Safety Authority, which outline the essential elements that must be included in a case history and how to document them properly when working as an osteopath.

Experience:
I treated a 22-year-old female patient who presented with radiating pain in her left leg, specifically along the posterior side, extending all the way down to her foot. She also reported some pain in the groin area. The symptoms began suddenly while she was mopping the floor. Initially, the pain was present in both legs, and she was unable to move due to its intensity.

She did not report any loss of strength or sensory disturbances. The pain improved when she lay on her stomach and worsened with prolonged sitting. She described the pain as a constant, pulsing sensation that only subsided when lying in the prone position. Her pain intensity was rated at 7–8 on the Numeric Rating Scale (NRS) at onset and 6 upon arrival at the clinic.

She had previously consulted a medical doctor who prescribed paracetamol and ibuprofen, but these provided no relief.

The patient was a law student and worked in an office setting. She also reported having chronic headaches following a concussion sustained eight years ago.

Based on her symptoms—radiating posterior leg pain, worsening with sitting, and relief in the prone position—I suspected a possible lumbar disc herniation and conducted a thorough examination.

Active Range of Motion (ROM):

• Flexion: Reduced

• Extension: Reduced

• Side Bending: Reduced bilaterally

• Rotation: Within normal limits

Neurological Examination:

• Muscle Strength: Slightly reduced in the psoas, quadriceps femoris, hamstrings, and gluteus maximus

• Reflexes: Normal

• Sensibility: Reduced in the anterior thigh, shin, hamstring, and calf on the left side

Orthopedic/Neurodynamic Tests:

• SLUMP Test: Positive

• Straight Leg Raise (SLR): Positive on the left, though not worsened by neck flexion

• FABER Test: Positive on the left

• Ilium Compression & Separation Tests: Negative (no provocation)

• Thigh Thrust Test: Negative, but she had difficulty performing a pelvic lift, making it challenging to position my hand under the sacrum

Palpation & Soft Tissue Findings:

• Psoas and piriformis were tender and tight

• Unable to perform a reliable "rising thumb test" due to her limited ability to flex

Visceral Screening:

• Notable tension around the sigmoid colon

I saw the patient for three appointments. During these sessions, I focused on releasing muscular tension, addressing visceral restrictions, and improving overall mobility. I also introduced McKenzie exercises and provided guidance on healthy lifestyle habits to support healing, as well as strategies for pain management.

Since the patient was in the middle of an exam period and needed to sit for extended periods, I gave ergonomic advice tailored to her situation.

After three treatments, the only noticeable improvement was that she was able to sit cross-legged and reported minimal symptom relief. At the third session, I advised her to contact me after three days if there was no further improvement. When she did, and her symptoms persisted, I informed her that I would write to her doctor and explained what I intended to include in the referral.

Referral Letter to Doctor (Revised):

Dear [Doctor's Name],

I have treated ...... over the course of three appointments for low back pain with radiating symptoms in the left leg. Unfortunately, her symptoms have shown little improvement despite treatment.

Presenting Symptoms:

• Pulsating, radiating pain down the posterior left leg to the foot

• Limited response to paracetamol and ibuprofen

• Symptoms aggravated by coughing, sneezing, and prolonged sitting

• Pain relieved when lying on her stomach

• No reported loss of strength or sensation during daily activities

Clinical Findings:

• Active Flexion: Provokes radiating pain

• Extension: Slight improvement in symptoms

• SLUMP and Straight Leg Raise tests: Positive on the left side

• Muscle Strength: Reduced in the psoas, quadriceps, hamstrings, gluteus maximus and medius (left)

• Sensory Changes: Reduced sensation in the anterior thigh, shin, posterior thigh, and calf (left)

Treatment Provided:

• Manual therapy for muscle tension

• McKenzie-based exercises

• Pain education and ergonomic advice

Given the persistence of her symptoms, positive neurological signs, and lack of treatment response, I recommend further evaluation, including consideration of an MRI scan, to rule out a possible lumbar disc herniation.

Best regards,

When the patient visited her doctor, she was initially told to simply continue with the current treatment plan. However, the following day, she received a call from the same doctor, who had since discussed the case with a colleague who had also read my referral. Based on that conversation, the doctor agreed that an MRI was appropriate. Three weeks later, the MRI was performed and revealed a herniated disc at the L4/L5 and L5/S1 levels.

Reflection:
I was proud of how I managed this case. I initially focused on conservative treatment, but based on the patient's symptoms and lack of improvement, I strongly felt that further diagnostic clarification was necessary. I communicated this clearly and specifically in my referral to the doctor, which ultimately led to the correct diagnosis being made.

Earlier in my physiotherapy career, I worked in a clinic where my supervisor dedicated an hour each week to reviewing cases with me. She would go through my patient records and any letters to doctors. She had attended a course on professional correspondence and was highly detail-oriented when it came to writing to medical professionals. That experience helped shape my communication skills.

I have also been taught that physiotherapists should avoid directly requesting imaging, as it may raise unrealistic expectations in the patient and can be perceived as overstepping by the referring physician. In this case, I tried to be respectful while still making my clinical concerns clear.

Action:
After sending this referral, I revisited the Danish physiotherapy standards for communication with medical doctors. I learned that we should avoid using profession-specific terminology, such as "McKenzie" as it may not be familiar to doctors and could lead to miscommunication. This was a mistake I made in my letter. Going forward, I will be more mindful of using universally understood clinical language in interprofessional communication to ensure clarity and professionalism.

Being able to sanitize both the pillow and the treatment couch allows me to demonstrate to my patients that I take hygiene seriously and adhere to high cleanliness standards.

In private practice, patients often pay for their treatment themselves. This means they are typically very aware of the value they receive and expect treatment that is truly necessary, not more, not less. I don’t believe our patients are naïve; they can often sense if your intentions are not genuine. That’s why I always work with my patients’ best interests in mind. When they feel this sincerity, they are more likely to trust that everything I do is to support their health, not to fulfill my own agenda.

I’ve occasionally heard the suggestion that to maintain a busy schedule, you should see each patient at least five times. While I do agree that a longer course of treatment can sometimes provide a more holistic outcome, especially if it includes lifestyle guidance or long-term support, I don’t believe in a fixed minimum number of sessions. In many cases, I’ve seen patients significantly improve after just one or two sessions, especially when they’re motivated and responsive to advice. What matters most is that we identify and address the root cause of the problem and give patients the tools they need, however many sessions it takes.

During appointments, he would often show me pictures of his aquarium and invite me to come see it. After I casually mentioned once that I had been swimming, he asked if I wanted to go swim training with him. I politely declined, saying I preferred to swim alone, and repeatedly made excuses when he brought up the aquarium visits.

Reflection:
I always maintained a professional attitude and didn’t feel uncomfortable, just slightly irritated by the constant invitations. Since I had discussed the situation with my boss and knew the patient’s background, I understood that he was likely just lonely and looking for company. He never behaved inappropriately, but clearly wanted to spend time with me outside the clinic.

However, had I not been aware of his general behavior or had I felt uncomfortable in any way, I would have considered referring him to a colleague, perhaps mentioning that a colleague might be better suited to treat his specific issue. Alternatively, I could have made it clear that I don’t see patients outside of work, though that felt a little complicated since my boss regularly treated and socialized with others from the same club.

Action:
Throughout my time as a physiotherapist, I’ve been in a relationship , and it’s rare that a patient has given me inappropriate attention. I always aim to remain professional, but I recognize that I sometimes avoid direct confrontation and could become better at setting firmer boundaries when needed. If a similar situation arises in the future, I plan to politely redirect the patient to a colleague and emphasize the importance of them receiving the best care. Reflecting on this experience has helped me feel better prepared to handle such interactions in the future.

I did experience a situation once where a colleague, who was a newly qualified physiotherapist, had a patient who called our boss to complain. The patient had expected manual therapy but was only given exercises, which didn’t meet his expectations. To resolve the situation, our boss offered the patient a follow-up appointment with me, free of charge and covered by the clinic.

When I saw the patient, I made sure to clearly discuss his expectations before beginning the treatment. Fortunately, he was very pleased with the session and continued seeing me until his issue was resolved.

In situations like this, I think it’s important to remain neutral and professional. It’s essential to support your colleague by explaining their clinical reasoning while also actively listening to the patient and validating their concerns. Creating that balance helps maintain trust on both sides and fosters a respectful and solution-focused outcome. If it was me who got a complaint, this is how I would like my colleagueto act.

Our instructor, a colleague and osteopath who leads the course, advised that we should redact any information that is not directly relevant to the claim. For example, if a patient has a history of ADHD or anxiety, that information should be crossed out, as it could potentially be used by the insurance company to argue that the patient’s symptoms are not related to the concussion.

Initially, I was unsure about this approach. On one hand, patients are aware that much of what they share is documented, and they consent to us forwarding their records to the insurance company. I also felt that we should be able to trust that insurers will evaluate the case fairly. However, following this discussion, I now take a more cautious approach.

Whenever an insurance company requests a medical report, I carefully review the entire journal and redact details that are unrelated to the case, for example, issues concerning bowel function or hormonal imbalances. I now recognize that this protects the patient’s interests and ensures that only pertinent clinical information is shared.

At my job, we use a highly secure system that ensures patient records are stored properly. I am confident that it meets all GDPR requirements. In general, I take confidentiality very seriously and always ask for my patients’ consent if I need to discuss their case with a colleague for professional input.

When he shared his diagnosis, I felt a moment of internal worry. However, I recalled that well-medicated HIV-positive individuals have a very low risk of transmitting the virus. I was mindful not to make him feel discriminated against, so I chose not to wear gloves during the treatment.

Discreetly, while he wasn’t looking, I checked my hands thoroughly for any open wounds, there were none. I also carefully examined his skin during treatment to ensure there were no lesions or areas of concern. After the appointment, I looked up the transmission risk again to reassure myself, and what I found confirmed my understanding.

Reflection:
Although the session went smoothly, I felt a lingering sense of worry afterwards. I discussed the situation with a doctor in my family, who reassured me that there was no reason to be concerned. He asked why I didn’t simply wear gloves, pointing out that in hospital settings, it is standard for healthcare professionals to use gloves during patient examinations.

The reason I chose not to use gloves was because I was concerned the patient might feel singled out or discriminated against, and I didn’t want to risk damaging the therapeutic relationship. I also feared he might perceive me as judgmental or distant.

However, I realized that this internal conflict consumed mental energy during and after the session. In the future, I will prioritize my mental comfort and safety by wearing gloves in similar situations. I also plan to ask patients with HIV more specifically about their current health status and viral load, so I can be fully informed and confident in my approach. This example, reinforces my belief that I treat all patients equally and always do my best to ensure they feel comfortable and respected

As a general practitioner recently said, “You osteopaths are the last hope when people have tried everything else.”

I was raised to treat others with respect, and being part of a profession that commands such respect only motivates me more to do good work, work that I can be proud of.

In Denmark, healthcare professionals with authorisation are bound by regulations concerning how they conduct themselves in interactions with patients. Standard D7 in the Gosc specifically addresses how to preserve the integrity and reputation of the osteopathic profession. The answer lies in strictly following both the legal requirements set out for the profession and adhering to the moral standards expected of all healthcare professionals (the referrence).

Confidentiality, particularly regarding the information patients share during their case history, is a critical aspect of maintaining professional respect. As osteopaths, we depend on patients feeling safe and comfortable enough to share everything, so we can make an accurate diagnosis. Therefore, clear, respectful, and empathetic communication is essential in building and maintaining trust with patients.

Our journal system is secure, and I have full confidence in it.

A growing issue is that criminals are now using AI to get around security systems, which means we all need to stay updated on how these breaches can happen. But even simple things matter, like logging out when you step away from your computer and never sharing your password. It’s also crucial that all staff are aware of the risks of clicking on links in emails that may look harmless but can actually infect the system or open it up to misuse.

When writing emails to patients, I always ensure that no sensitive patient information is included. If such information is necessary, I use what we refer to as "secure email". Additionally, when patients send their insurance documents by email, I make sure to delete the message after reviewing it.

I haven’t experienced mental health issues, but I do notice that I become quite stressed during exam periods. Over the years, while training to become an osteopath, I’ve learned to reduce my working hours during these times. It’s important to me that I am not exhausted when seeing patients, so I can give them my full attention and energy. During our first-year exams, I didn’t take any days off and studied through the weekends, which I later regretted. Now, I allow myself more space when I need it, knowing it’s only for a limited period. This helps me protect my mental well-being and ensures I can stay fully present and professional in my work.

In Denmark, we have a system similar to the GOsC in the UK: The Danish Patient Safety Authority, which manages complaints or incidents of malpractice. If a practitioner becomes involved in such a case, there are clear rules on how to act and deadlines for responding. For example, it states that "You must report incidents you have been involved in yourself, as well as incidents involving other healthcare professionals that you become aware of," along with clear instructions on how to do so.

Overall, I do my best to follow all relevant regulations. If my physical or mental health were ever to compromise my ability to treat patients properly, I feel confident I would take a sick leave. So far, I’ve only taken time off to avoid passing on infections to patients.

Due to the high demand, some osteopaths set their prices quite high simply because they can. However, I believe we need to be careful not to raise fees so much that it becomes unaffordable for many. Everyone, regardless of their financial situation, should have a fair chance to receive help from an osteopath. According to the World Health Organization (WHO), financial barriers are a significant cause of health inequality, which highlights the importance of keeping osteopathic care accessible and affordable for all.

It’s important to make sure patients are fully aware of the cost of treatment before anything begins. At my clinic, we offer free screenings. This means the patient comes in, we have a conversation, and I do a quick examination to assess what we can and can’t help with.

I’ve heard from a couple of fellow students and colleagues who unfortunately, ended up in awkward situations, after doing a screening, they started treatment and maybe without being clear of the cost, and then sent an invoice. The patients thought it was all part of the free screening and ended up feeling misled.

Luckily, I’ve never had that issue. I think that’s because, right from the start of the screening, I explain that we’ll talk first, then I’ll do a short exam, and finally give them an idea of what I’ve found and whether I think treatment could help. At the end, if I have time for treatment the same day, I clearly say: “If you’d like to start treatment now, the cost is X otherwise, you’re welcome to go home and think about it.”

Most patients choose to start treatment right away, but by being upfront like this, everyone’s clear on the costs, and expectations are aligned.

As a physiotherapist, I have experience working in a sports clinic and have rehabilitated many young athletes. I’m experienced in using exercise-based strategies to support their return to sport. However, this conversation with my examiner encouraged me to shift my focus toward the specific contributions osteopathy can make in these cases.

Since then, I have paid more attention to aspects such as improving circulation, evaluating the patient’s available resources (both physical and emotional), understanding how they use their body in their specific sport, and identifying old habits and compensatory patterns. I also focus more on joint mobilization to help patients move more efficiently and optimally within their sport.