During the second term of my first year in clinic I had a new patient who presented with acute low back pain. This was the first time that I had encountered someone with an acute problem with recent onset, however I confidently proceeded with the case history, examination and before proceeding with the treatment I thoroughly explained to him what his potential diagnosis was as well as the prognosis. At the end of the session my patient was lying on his right side and I told him that he could get changed before walking to the reception to book another appointment. He explained to me that standing up from that position would be very difficult, so I offered my help to sit him down on the couch first, before getting him to stand up. I had not learnt a particular method to do this with acute patients, but I decided to improvise. As I pushed the patient to sit up, he screamed in pain. While we were walking outside towards the reception he was shaking and complaining of the excruciating pain he was feeling. When he was unable to walk any further, I helped him to sit down on a step and left him to tell my tutor what had happened. My tutor was dismissive and not of any help and commented: “Marco, what have you done to him!” in a mocking way, causing my colleagues to laugh. Therefore, without any guidance or support from my tutor, I was left to handle the situation by myself. I returned to my patient, helped him get up and walked him to reception where we both sat down, and he asked me to explain to him in more detail what was wrong with his back. I made a drawing of his spine and spent some time talking to him, which was enough for him to get out of that unbearable pain before leaving the clinic. I felt responsible for the exacerbation of the patient’s symptoms after helping him to sit up and felt guilty that perhaps his increased pain was the result of the technique used. When he was shaking and unable to walk, I panicked as I thought he may blame me for causing his pain. I felt that he might not have hurt himself if I had asked my tutor for assistance in seating the patient more appropriately, rather than attempting to manage this myself, due to my lack of experience. However, I managed to control my emotions and maintain a calm exterior. I felt very embarrassed speaking to my tutor, especially when my colleagues started laughing at his comment; as this made me feel judged and uncomfortable. On the other hand, I demonstrated confidence and professionalism in the way I handled the situation which made me feel proud of myself. 

This was an important learning experience which taught me a great deal about safety and patient care. My decision to help the patient sit up without being confident of the safest way to do this may have demonstrated a lack of competence in my osteopathic care of the patient.  I found my tutor’s reaction to the situation unhelpful, as he could have avoided making a sarcastic comment. I would have preferred him to constructively guide me in what to do next in that situation, though I was unable to address this with him directly.  A positive outcome of this was that my patient came back to see me and was pleased with the improvements he had made after my treatment, which boosted my confidence and self-esteem. It also taught me something about how acute patients may present and react to different stimuli, such as treatment methods and little accidents which can exacerbate their symptoms.             Although I could have managed this situation better, this was a very important learning experience for my career. After the patient sat on the step, I should not have left him alone there, but my company and reassurance may have been needed and helpful in that circumstance. The fact that I managed to keep calm and reassured him later on though, was an excellent demonstration of how I can adapt to new situations.

NOW WHAT

Following this patient contact, I learned how to help acute low back pain patients in the most efficient and effective way; and going forward I will endeavour to learn different methods of supporting them, in order to adapt to the range of cases I expect to encounter in the future. I will avoid improvising if I find myself in a situation where I am not sure about the appropriateness of my technique or lack confidence, and I will seek help from a tutor, senior colleague or another health care professional. 

C2. You must ensure that your patient records are comprehensive, accurate, legible and completed promptly.

WHAT:

Completing my patient's records has proved to be one of the most stressful and time consuming aspects of being in clinic since the beginning of third year. Because of my tendency of being a perfectionist, I have always struggled to promptly complete my notes while I am with the patients in the treating room. From the moment that the patient's forms have changed completely, I still have not got used to the new format, therefore I always forget about certain steps that I am supposed to adhere to.
The thought of having to complete the new patient form after the session  makes me very anxious, as I Know that I will have to be very thorough and really concentrate on things that I am not sure of.
I find it very tiring and stressful, especially when having multiple patients in the same clinic session.

SO WHAT:

Although I am quite slow at completing  patients' records and it is a process that gives me stress and anxiety, I found that most tutors are satisfied with the way I present the notes to them  and very rarely someone has complained about them.
Moreover, I always ensure to write in a very legible and precise way, which makes it much easier and enjoyable for both tutors and fellow students.
 Reflecting on this matter, realised that I have never asked help from someone with more experience than me. As soon as I realised that completing my patients' notes was accompanied with the previously mentioned emotions, I could have pursued some guidance from other students, especially from the year above mine or from tutors that would have been willing to help.
 
NOW WHAT:

My aim regarding this situation is to change the feelings that have developed around writing notes. I could start by explaining to patients that I would keep writing notes throughout the consultation, that would allow me to spend less time writing once the patient has left. Moreover, I will go through the patient form before each patient arrives, in order to have in mind what I will have to write while I am dealing with the patient, that will fill all the blanks beforehand, diminishing my anxiety when actually writing information down. 

C3. You must respond effectively and appropriately to requests for the production of written material and data.

WHAT:

A patient complaining of chronic low back pain whom I treated for almost a year, asked me one day to provide him a letter to be brought to a specialized doctor, in order to get an ergonomic chair for his workplace. I arranged with him that the letter would have been ready for him to collect it on a Monday evening. After he left I procrastinated writing the letter until I forgot about it, therefore when he came to collect it on Monday the letter was not there and he had to wait another week to receive that.
I felt terribly sorry for the patient because I guaranteed him that he would find what he needed exactly on that day. Because it was the first time for me to produce that kind of work, the thought of having to do that was making me feel very anxious and that is the reason why I procrastinated. The patient in the end was very relaxed about it and made me feel comfortable with the fact that I had forgotten to write his letter.

SO WHAT:

My organization and professionalism were at my lowest standard in that occasion. I should have not underestimated the situation in that manner, showing my patient that I did not take his request seriously. The positive side of it is that I learned a great deal about a new process and I also changed the way I now approach this kind of matters.
I could have definitely asked some guidance to someone more experienced than on me  the same day that my patient asked me for that evidence for his doctor. However this has turned out to be a really important learning experience for me,  in terms of organization skills, patient's satisfaction management knowledge about writing letters and legal boundaries when writing to another health care professional.

NOW WHAT:

Every time action is required in terms of writing letters for special patients' needs, I will ensure that I organize myself straight away and in the most efficient way possible. Instead of procrastinating I will endeavour to take action as soon as possible and in the eventuality that I have to defer my duty I will set multiple reminders that will guarantee my patient's satisfaction.
 
C5. You must ensure that your practice is safe, clean and hygienic, and complies with health and safety legislation.

WHAT:

After the Corona Virus (Covid-19) outbreak, in our teaching clinic we had to thoroughly follow strict hygienic procedures in order to keep us, the patients and our clinic staff safe. It was of paramount importance that we washed and sanitised our hands often as well as wiping the treatment couch before and after each treatment. Normal pillows, couch covers and blankets were not allowed to be used. All of us diligently followed these rules until the clinic was closed on the 23rd of March 2020. Although the hygiene standards are normally very high in our clinic, this particular situation demonstrated an excellent endeavour from the institution.
The promptness with which the ESO changed the hygiene protocol made me feel relaxed in a very stressful situation like the recent Corona Virus outbreak. It felt as though everyone was compliant with the new rules and also patients seemed to understand and accept the new guidelines.

SO WHAT:

This situation only has positive aspects to consider as every possible precaution to minimise the possibility of spreading  the virus was applied. The government guidelines were also properly followed, therefore the clinic was closed promptly as soon as that became inevitable.
Me and my colleagues  followed all the instructions from the clinic management team, keeping the environment clean and as safe as possible for our patients. nobody struggled with this sudden change in habits and our patients appreciated our efforts.
 
NOW WHAT:

This particular event and the response of our clinic taught me a lesson that I will take on board in the future. After graduation I will ensure that my private practice is safe, clean and hygienic at all times and I will be ready to take different measures if an emergency situation like the one we experienced may arise.

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.

WHAT:

One of my clinic group colleagues one day decided to observe me during a continuing appointment with a young female patient complaining of lower back pain. After finishing the session my colleague gave me a very constructive and comprehensive written feedback. She pointed out that it was good that although my patient was very shy I managed to make her so comfortable that she could actually open up about deep emotional matters with me. However, she noticed that the patient's attitude would get  flirty at times during the consultation and I would encourage that by "subtly flirting back" with her. She suggested that I stopped that behaviour because on her opinion I was breaking professional boundaries with my patient and that is against the Osteopathic Practice Standards.
 At the beginning I was shocked by my classmate's comment about my behaviour with the patient because I was genuinely not aware of that and I disagreed with her. However, while reflecting upon the matter and Iooking at it from a different perspective, I realised that I was actually responding to my patient's flirtatious conduct in the exact way my colleague pointed out. This made me feel embarrassed both with myself and with my clinic mate, because we are obviously not expected to have that kind of interaction with our patients. This made me feel nervous about meeting my patient again and self conscious about my behaviour with patients in general. When I met that patient  after receiving the feedback I felt very uncomfortable when I recognized that she was flirting with me but I managed to keep calm and just carry on with my treatment in both a respectful and professional way.

SO WHAT:

My behaviour was obviously not professional and unacceptable for a clinical environment. My colleagues eagerness to observe a continuing appointment, which is very unusual among students of our University, and her professional honesty made this experience a positive one, because it allowed me to look at my own behavior from a completely different perspective. Also it made me not only appreciate more honest feedback, but also it made me begin to encourage other colleagues to come observe me during continuing appointments and give me constructive comments.
Although I should have noticed by myself what was happening in terms of my interaction with my patient, my attitude towards it was very positive.
I accepted the comment and promptly acted upon it, which demonstrated my open minded attitude and an ability to self reflect.

NOW WHAT:

I will reflect and ponder during and after each of my appointments about the way I interact with my patients. I will also set clear boundaries and I will make sure to discuss with the patient if a similar situation arose again. Asking for regular feedback will be key to keep progressing as a professional.

D4. You must have a policy in place to manage patient complaints, and respond quickly and appropriately to any that arise.

WHAT:

I had to deal with a patient's complaint during the first term of fourth year. At the start of the initial consultation the patient had let me know that he had to leave five minutes early as he had to do something important after our appointment. I informed the patient that my priority for the session was to complete a thorough case history and examination, in order to come up with a specific diagnosis. I explained that due to the time this may take and his need to end the session early, I could not guarantee that there would be time for treatment. In the end there was no time to treat the patient following assessment, and despite my earlier explanation the patient was not happy about this and complained that I “should have made sure to allow some time for treatment rather than spending more than 20 minutes outside the room chatting to my tutor". I apologised and reassured him that during the next appointment I would only need to take a brief case history and examination, which would allow half an hour for treatment. I explained to him the reasons behind me spending all that time discussing his case with my tutor and reminded him of our discussion at the beginning of the session. Although the patient acknowledged this, he still expressed dissatisfaction with the outcome of the session.                                          At the time I felt very stressed and anxious due to the way my patient’s behaviour towards me changed once he realized that he would leave the Clinic without receiving treatment. His reaction made me feel as though I had intentionally prevented him from receiving treatment and had not been clear to begin with. My tutor however was on my side and endorsed my actions on that occasion, which made me feel supported and gave me confidence that I had done the right thing. This helped to alleviate my anxiety, and I realised that I had no reason to feel stressed.  

I dealt with this situation verbally with the patient during the session, showing sensitivity to the patient’s feelings and reassuring him that he would receive treatment during our next appointment. If the patient had not been satisfied with this and wished to make a formal complaint, I would have taken the appropriate actions in line with the Teaching Clinic’s formal complaints procedure, which at the time I was not familiar with. While I felt nervous at that time of the interaction, I maintained my professionalism throughout, without allowing my emotions to affect my response. The patient accepted my explanation and apology and decided to book a continuing appointment. After only one treatment, his symptoms had completely subsided, and the patient was very pleased with me as a practitioner, explicitly pointing out to my tutor that my "manual skills are really impressive".               
I consider this as an overall positive experience, especially as when the patient started complaining about the situation, I thought he would not have come back in the future. The fact that he did return, and he actually gave me verbal feedback stating how impressed he was with my performance. This made me realize how important it was to handle situations with patience and professionalism.

NOW WHAT:

The key point to note based on this experience is to familiarize myself with the complaint policy of the ESO Teaching Clinic and of any future clinic that I will work in. This will allow me to be prepared for any situation where a patient might raise a formal complaint. This experience has reinforced the need to manage patient expectations and be explicit at the start of each session with regards to its aims. For example, the main purpose of an initial consultation is to come up with a clear diagnosis and inform patients that this might not include treatment. 

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

WHAT:

Whenever we are required to carry out an assessment which involves taking one of our patients as a real life case, it is necessary to photocopy the patient's notes in order to complete the assessment. It is essential and paramount that patient's confidentiality and privacy is protected, therefore it is our duty as students and professionals to make sure that no names, addresses and dates of birth are still present on the sheet that we photocopy and take outside of the teaching clinic.
During these assessments, although I always make sure to cut out my patients' private information, I realised that in multiple occasions I forgot to ask the patient whether they are happy with me using their case for an assessment.
 Anonymising personal data felt enough for me at the time of the assessments for me to carry on without any ethical issue.
 However, reflecting upon it makes me feel guilty about not actually gaining proper consent from the chosen patients. I now feel like in a way I have not respected those people entirely, and they deserved to know that I was using their information, even though they were thoroughly anonymised.
 
SO WHAT:

My preciseness in cutting out all personal data from the patients' sheet was a good demonstration of professionalism, it shows how seriously I take confidentiality issues. On the other hand, not letting the patient be aware of the fact that their cases were being used demonstrates at the same time a lack of professionalism and integrity.
What was described above is not something that is absolutely unacceptable but it is good practice to make sure to avoid that in the future, both at the teaching clinic and in  private practice.

NOW WHAT:

Next time I will have to use one of my patients' case to carry out an assessment I will definitely make sure to ask the patient for consent, letting them know that all personal information would be protected and not brought outside the teaching clinic. This will be done before photocopying the patient's file and before even deciding with certainty which patient is suitable for the task.
 
D9. You must support colleagues and cooperate with them to enhance patient care.

WHAT:

In multiple occasions my colleagues needed support during their patient's appointments, and I volunteered to help them whenever I had no patients booked in. For instance during children clinic a female patient brought along her 4 year old daughter and her newborn son along with her to clinic. Because her newborn son obviously needed continuous attention it would have been impossible for my colleague to treat his patient without someone else's help.                My presence in the room was key to carry out his treatment, which really helped his patient who was in a lot of pain. Another example of cooperation with colleagues to enhance patient care is when for example I give advice to my fellow students with regards to rehabilitation plans for patients with conditions that I dealt with before. Sitting down with them to come up with the best management plan for their patients is also  very important for me to challenge my beliefs and strengthen my existing knowledge. Although I very often offer help to my colleagues, I don't tend to ask for help, especially when it comes to deal with my own patients management.
Helping others always makes me feel fulfilled and I don't mind giving up my activities if someone else really needs my help. That is true especially if I can use my knowledge and skills to support someone else's work. On the other hand, whenever I am in need I always don't feel comfortable asking my colleagues for help as it feels to me as though I could be wasting their time. Sometimes that makes me feel very frustrated as I could get some information that I cannot find online and someone offering help could also turn into a dialogue rather than a simple favour.

SO WHAT:

It is great to support each other during our time in clinic, that makes us feel like a team and encourages us to work for each other to enhance patient satisfaction. However, not asking for help for fear of wasting someone else's time is not a behaviour that can work in a team and should be avoided for everyone's benefit.
I could have used those situations where I helped my colleagues to ask for some sort of help myself, so that I wouldn't feel asking too much if it seems like an exchange.

NOW WHAT:

In the future I will aim to create positive interactions with my colleagues where I ask for help and immediately offer my support in any areas that I feel most confident, such as rehabilitation plans. That will allow me not to feel afraid of asking for help and at the same time to create a healthy learning environment.

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

WHAT:

I had a new patient during the second term of my fourth year that complained of elbow and forearm pain. After taking a thorough and comprehensive case history I went to discuss
the case with my tutor. I was honest with him and I admitted that I was not sure what the issue with that patient was as I had not encountered anything
similar before. My tutor was very helpful at the time and guided me through both the diagnostic process and the  physical evaluation. This made me feel supported and comfortable during the patient's appointment. I felt particularly calm because I was expecting to be judged by my clinic tutor for my lack of knowledge around this, however, he turned out to be extremely empathetic. At the end of the examination I was prompted to write a letter to my patient's GP that required imaging of the patient's elbow. A fracture of the radial head was suspected and treatment was a potential contraindication in
this case. This is a clear example where the contribution of other health care professionals was crucial in order to deliver a safe intervention for the patient.

SO WHAT:

This experience has highlighted the importance for me as a student of receiving guidance from an experienced professional figure. It also taught me that it is crucial not to
have gaps in my clinical preparations, such as in my knowledge of issues with
the upper extremities.  It also reinforced the importance of a structured assessment process when dealing with a new patient. This allows me not to leave any considerations uncovered and it requires critical and reflective thinking.
I now see the situation from an additional perspective, and the learning points that I take away are essential in my academic and professional development. My tutor's approach of taking a step back and considering the help of other health care professionals was a great educational experience, because it demonstrated how important it is to work only within your professional scope to ensure safety in practice, and consider the support of other health care professionals as part of optimising patient care.

NOW  WHAT:

My action plan is to create a habit of including in my everyday study routine a space exclusively dedicated to strengthening concepts which I am not confident with, such as the differential diagnostic process of issues with the elbow, forearm and wrist, as
well as the ankle and foot. This will allow me to confidently deal with a wider range of patients and be prepared in situations that are outside of my comfort
zone (or immediate specialism). Furthermore, I will ensure that I remain self-critical and aware of instances where I am not sure whether my intervention is the most appropriate or safest option, and always consider the
support of other professionals (in osteopathy and multidisciplinary) for advice, collaboration and/ or onward referral.


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

WHAT:

During the beginning of third year I was in a children clinic session and I happened to have a strong cold. There was new patient assigned to me that morning and he was 3 weeks old. I was not sure if my state of health was suitable for such a young baby so instead of relying on my own assessment of my health in relation to the potential risk of my contact with the patient, I decided to consult my clinic tutor. She suggested that not only I shouldn't have treated that patient, but also that I should be in the same room with him during the consultation. Therefore I accepted her opinion and one of my colleagues volunteered to take that new patient. However, during that same week I took for granted that my state of health was not a threat for adult patients and instead of consulting my clinic tutors I just went ahead treating my patient as usual.
Not participating to that newborn first consultation felt as the right thing to do and it was relieving to ask my tutor's guidance as it meant that I was not taking a responsibility that was too big to handle by myself. On the other hand, I did not feel like sabotaging all my other appointments and that is why I decided not to ask any advice with regard to me healthy enough to treat my adult patients. Looking back at it, it does now feel like a mistake, especially with elderly patients, because what I was experienced it as a simple cold might really affected someone much older than me in a much more violent way.

SO WHAT:

It was great to both ask my tutor for advice and promptly find one of my colleagues to replace me for that patient's new consultation. However, treating all my other patients as normal without asking for any second thoughts by more experienced and competent clinicians was poor conduct and it goes against the OPS D11.
In that occasion I could have simply asked my tutors' opinion on the matter, which could have been as well in accordance with my actions.

NOW WHAT:

I plan to continue making sure that I am safe to treat children but to also guarantee my adult patients' safety. In the future I will ring clinic in advance letting them know about my health and share it also with my tutors in clinic. That will avoid the risk of putting my patients in danger, as well my colleagues and all members of staff.

The patient kept coming for about three months, so although he was catching me unprepared on multiple occasions and on numerous subjects, he really appreciated my manual skills and my attitude. We still managed to build a solid rapport and he was impressed by the improvements that he had on his body during the time I was seeing him, finally managing to get out of pain after years of chronic discomfort.
 This particular situation was very challenging for me, especially because it was making dread going to clinic. I could have made and effort to  predict what kind of questions my patient would have asked me in future appointments making to revise certain subjects but I have never done so, showing a lack of engagement and organization.
 
NOW WHAT

The most important point that I will focus on after this experience is to write down anything that I lack in terms of knowledge during my clinic time and make sure I will look up everything before the next session. I will also make sure to find interesting ways to learn and couple the theoretical knowledge with the practical aspect of it.

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

WHAT:

One of my first patients at the beginning of third year was a mother of four in her early forties who complained of pain on the left buttock with radiations down the thigh and leg. Out of all the patients I had during that year she was the one who I developed the strongest rapport with, however after the initial improvements she seemed to have reached a plateau. Although she was pleased that she had achieved in quitting all her medications while maintaining a relatively low level of pain, I started considering that I may not be the most competent person to manage her particular case, due to limitations in my level of expertise. I liaised with my tutor who supported me and agreed that I may not be able to progress this patient further and that it was appropriate to discuss alternatives with her. Therefore, on the 15th treatment I spoke to the patient about this and suggested that she seek help from a qualified Osteopath with the skills and experience better suited to her case, for a better chance of overcoming her pain. She responded that she would have been happy to carry on seeing me as her Osteopath, however she appreciated my professional honesty and asked if I had someone in mind to recommend that she could receive treatment from. I gave her the name of an experienced Osteopath and I discharged her from the clinic wishing her the best of luck.                              The rapport established with the patient over a long course of treatment initially made it a difficult decision to discharge her not having fully met her expectations. Not only did I feel as if my intervention was incomplete, I also felt ambivalent about the decision of discharging her. I wanted to try my very best to help my patient reach her goals before ending treatment, though I had to accept that this may not always be possible and therefore my clinical judgement to suggest ceasing therapy was appropriate on this occasion. Unfortunately I felt that my tutor lacked empathy when handling the situation of this patient, as the patient expressed her frustration to me and commented on feeling uncomfortable with the way that my tutor discussed her limited improvement in relation to the amount of treatments and the amount of money she had spent. Although it was not possible to directly address this, I feel glad that my patient felt comfortable to express this to me, as this helped her.

In addition to this being an invaluable learning experience, it also helped in improving my confidence and self-esteem. In fact, after a month without seeing the patient following her being discharged, she presented again to clinic admitting that she preferred to continue her treatment with me, as she trusted me as a practitioner and she wanted to try again to address her pain. Eventually, after a few sessions her leg pain slowly started disappearing until only the pain on the left buttock was left. After a few more treatments the patient reported the presence of only intermittent pain until she finally became pain-free.                        Reflecting on this experience made me realise that I could have handled the situation in a different way. First of all, I could have discussed the possibility of receiving help from another practitioner with the patient earlier on, before the 15^th appointment. That would have given the patient and I more time to process this option, rather than having to make a decision quickly, due to the pressure received by my tutor. Another important thing that I could have done is presenting the case to a different tutor and after discussing my concerns we could have come up with a completely different management plan to treat my patient. That could have given me another perspective on the case and might have made a difference in outcomes, in terms of pain reduction and the general well-being of the patient. 

If a similar situation arose again, I would be ready to deal with the circumstances in a more organised and effective way. Acknowledging with the patient the possibility that my treatment may not be effective is essential in order to manage the patient’s expectations from the offset. I also plan to continually review my patients’ expectations against their progress as an essential part of treatment. This will be undertaken in practice at appropriate intervals based on individual cases. As discussed above I will suggest the possibility of seeking help from someone else at the right time if needed; and finally, to consider trying with a different approach when there is no longer improvement in the patient’s condition (plateau).

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

WHAT:

On several occasions, my clinic tutors have pointed out that I should update my knowledge, especially regarding physiological and pathological processes. This matter would usually arise during discussions about my patients' initial consultations, where I discuss the differential diagnosis and  potential contraindications to treatment due to a pathological process. According to the tutors, limiting myself to learning from an outdated textbook is a poor effort to become a successful practitioner. This reinforced the fact that it is essential for me to continually access recent and reliable sources that present updated information and recent theories and keep up to date with the evidence base.
I often felt frustrated when confronted with the reality of our profession. Studying in detail complex physiological notions is hard enough, let alone "going the extra mile" in making sure that certain concepts have not changed with the advancements of technology and research. I found this extremely time consuming and tiring, especially considering how demanding the course is, and because of my lack of experience of intensive study.

SO WHAT:

Looking at the situation from the perspective of my tutors, I can appreciate their effort to encourage me to challenge myself to become a better practitioner.
The positive aspect of this experience is that it taught me how important it is not to settle within the boundaries of my comfort zone and develop a critical type of thinking. Moreover, this will encourage me to practice my research skills, which are a fundamental aspect of my continuing professional development.

NOW WHAT:

I need to start practicing regular research to update my existing knowledge and to also use this as an opportunity to learn about less familiar aspects of the profession, discover new areas of practice and confront controversial matters via different material. I plan to subscribe to the newsletters of reliable peer-reviewed journals, that will potentially update me with emails regarding my subjects of interest, allowing me to have access to the most recent articles and motivate me to carry out my own research. Furthermore, I could create virtual learning groups with my current osteopathic colleagues, in order to share interesting material and keep each other updated with advancements in the medical and osteopathic field.

B4. You must be able to analyse and reflect upon information related to your practice in order to enhance patient care.

WHAT:

During the beginning of my fourth year I spent quite a lot of time writing down reflections on my clinic book. At the end of each day at the clinic I would take some time to reflect about my practice with patients, thinking how to improve myself in order to enhance patient care. However, I only took on board a few things of those action plans. An example is the way I ask for consent with my patients. After one of my tutors repeatedly gave me the same feedback regarding consent, I made an effort to change my habit by practicing a new way of verbalizing that.
Spending so much time reflecting and writing down my thoughts without actually taking any action is frustrating. It demonstrates my tendency not to take to the end something that I have started when it comes to academic matters. Obviously, the amount of work, stress and distractions present during this course do not make it easy for me to keep track of everything, especially something that does not feel as necessary as studying for an imminent exam, for instance. On the other hand, taking my tutor's feedback into action and noticing the difference in my performance brought along by my effort to change a habit felt very satisfying and in a way it gave me the motivation to keep up with that.

SO WHAT:

Recognising the fact that I haven't taken action for most of my constructive reflections reported on my book is actually an essential step forward in my development path. It allows me to take a positive look at the matter, especially considering the fact that I managed to make a real difference with my patients when I actually worked on improving an aspect of my practice as a result of a constructive feedback and reflection.
One the ways I could have approached this matter is that I could have picked 1 learning point from my book at the beginning of each week and put it into action in clinic with my patients during each session. That would have allowed me not to feel overwhelmed by the amount of aspects of my practice that I should be focusing on improving.

NOW WHAT:

My plan to put into action what I have been reflecting about during my time in clinic involves me going through my reflection book and writing up a list of key points which I need to work on in the next months of clinic. This list is going to be organised in order of importance, to prioritise what needs to be worked on first and leave the rest for later.
As mentioned above, it would be a clever idea to then pick one key point per week and only work on that before moving to the next one.

During summer clinic, after the end of third year, I had a takeover patient who was seen for the first time one week earlier by a student from the International Department. This was a female student who had reported in the patient’s notes examples of inappropriate behaviour, particularly towards females, which led to the clinic assigning him to me- a male practitioner. For our first session I was part of Clinic Group 3, therefore the room that I prepared before going to collect the patient was situated upstairs. After greeting him and introducing myself at the reception I told him where the session would take place. As he stood up with his stick he rudely answered: "You gotta be kidding me!", while emphasizing the fact that he needed a stick to walk, which I hadn’t seen yet. I apologized and politely asked him to sit back down, reassuring him that I would promptly set up a different room on the ground floor.                                          This was my first experience since starting clinic where someone was rude to me and it felt as if I was being attacked, because of the patient’s aggressive tone of voice, facial expression and body language. I felt that the patient had misjudged the situation and perceived me as being insensitive and not empathic towards him. This made me feel uncomfortable and rejected as a practitioner, especially because I was not aware that the patient had mobility issues and used a walking aid. These feelings of judgement returned at the start of future follow-up appointments with the patient, because of the negative impact of the initial interaction with him. This was particularly true because my patient was not an easy person to have a conversation with, which made it impossible for me to address the inconvenience of our initial encounter. 

I feel that I handled the situation very professionally without showing the patient that I did not like his reaction and I actually apologised to him. Although I did not feel this was my fault and disliked the patient’s impolite reaction, I managed my emotions well, kept them to myself and accepted the fact that he had the right to feel angry at me (OPS A7). What was good about this experience is that although initially I thought that the person I was treating was rude, over time I was able to experience his personality more fully and surprisingly we got on quite well. He also often complimented me in front of my tutors, claiming that "the way I use my hands to treat is absolutely formidable".                I am glad I had an experience which I initially perceived as negative because it taught me a great deal in the long run. It showed me I am able to manage difficult situations without them affecting my clinical performance, whilst still providing an optimal therapeutic experience for the patient. I also realized that as a result of my conscious effort to remain grounded and maintain a positive and friendly demeanour I was able to gain his trust, evidenced by his returning for future appointments.

NOW WHAT

One thing that I realized I did not do and could have done in order to avoid a repeat of this type of situation was to notify the reception and request that they leave a special note on the system that would be added for future patients with mobility difficulties who might struggle to walk up and down the stairs. Also, I will make sure to report in my notes any specific requirements or adjustments needed for patients with particular needs (OPS C2).

A2. You must work in partnership with patients, adapting your communication approach to take into account their particular needs and supporting patients in expressing to you what is important to them.

WHAT:

I found myself in a situation where my patient was really struggling to communicate effectively with me, both due to a language barrier, as she has recently moved to the UK and also for the fact that she is a very shy and emotional person.
 In that circumstance, I really had to adapt my way of engaging with patients in order to properly understand her, meet her particular needs and ensure to manage her case in the most effective and specific way possible.
The patient was in very acute pain and the fact that we were struggling to communicate effectively made me feel pity for her, I could perceive her frustration through her words. I felt also slightly nervous because the case history took very long, the thought of my colleagues observing were getting bored was also making me uncomfortable.

SO WHAT:

The positive aspect of this experience, as highlighted by my tutor on the day, is that I really made an effort to adapt my way of communicating and listened patiently with the intention of meeting the patient's expectations. The negative part of it is that the way I felt was quite intense at the end of the case history and the consultation left me very tired once the patient left.
 I probably should have kept communicating extensively with the patient during the treatment, which I failed to do as I was feeling overloaded with the amount of "extra-thinking" needed during the case history and examination.
Overall this was a great learning experience as I got to perform in a way that was different from ordinary.
 
NOW WHAT:

It would be important for to practice verbalizing the explanation for my diagnosis, examination and treatment in the simplest and straightforward way as possible, in order to address the needs of the broadest range of patients. 

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

WHAT:
Throughout my clinical experience since the beginning of third year, the feedback that I have been receiving most often from both fellow students and tutors regards the fact that I do not ask enough patients' consent, equally during examination and treatment.
I agree with the fact that I often fail to gain consent as I take for granted that my patients are comfortable with me carrying out any examination or treatment maneuvers. I feel that continuously asking patients if they are comfortable with me proceeding with the process is both forced from my side and excessive from the patient's point of view. It is very frustrating to keep hearing this comment because I truly do not believe it is necessary to repeat myself so often when patients  already agreed that I could proceed with examination and treatment.

SO WHAT:

I have improved at gaining consent from patients, both in frequency and in the way I construct the actual question for the patients. I always make sure to ask patients if they are happy for me to perform anything that might feel uncomfortable or that involves the palpation of intimate areas. However, when I carry out normal maneuvers which I don't perceive as invasive or potentially uncomfortable for the patient I avoid repeating myself.
I should have accepted and worked upon the feedback that I received since the beginning of third year, so that I could have got into the habit of gaining consent earlier on during my clinical journey. Although I improved that aspect of my interaction with patients I still must work on it and make sure to always record it appropriately.

NOW WHAT:

I will start to include the process of gaining consent in my routine practice with my university colleagues. I will then integrate what I practice in the sessions with my patients, in order to create a habit that will last for my whole professional career. Furthermore I will pursue the guidance of different tutors, to find the style the better suits me.

A5. You must support patients in caring for themselves to improve and maintain their own health and wellbeing.


WHAT:

At the beginning of my clinical experience, more precisely after the Christmas break of my third year I was confident enough to give advices and to motivate my patients to improve and maintain their own health and wellbeing. These recommendations ranged from breathing exercises  to core stability work to mindfulness to general "day-to-day life" advices. I used to be so eager to make changes in my patient's lives that they would give me very good feedback about my encouraging behaviour. However, all that eagerness to help my patients dissipated during my fourth year, until I got to a point where I did not even think about my patient's home care and I restricted my intervention to merely treating them without even giving them a rehabilitation program. 
The reason why I stopped being so proactive with my patients is multi-factorial. First of all as soon as the end of third year approached I felt overwhelmed with the amount of extra-clinical work that I had to go through. My time in clinic ended up being in the background and my motivation and self esteem dropped. This led me to not being as grounded and confident with my patients and tutors, which affected my overall performance. Moreover, the thought of having to justify to my tutors why I came up with certain advices for my patients was too stressful and made me prefer to only stick to my treatment. This was obviously made worse by my lack of confidence at the time which made me doubt that anything I thought could be helpful for my patients was only the result of my biased belief system that I developed through my personal experience of chronic low back pain.
As a consequence of that, my time in clinic became stressful and demotivating, making me feel like I was wasting time that I could have spent studying for my exams and also it made me doubt about my desire of becoming an osteopath. Although things have changed since the end of third year, I still feel in a similar way whenever I have to prepare for non-clinical assessments.

SO WHAT:

I am very proud about the eagerness and passion about supporting my patients in caring for themselves that I demonstrated during the first part of my clinical experience. Not only seeing my patients improving their condition and listening to my advices was a very rewarding experience but it also encouraged me to get better, to keep learning and updating my knowledge, in order to deliver an ever improving service for my patients. The fact that I stopped with that behaviour was both frustrating and demotivating, as my eagerness to help and improve myself reached it lowest level.
 Before reaching the point where my final year exams were very close, I could have started preparing for them in advance, so that the whole process wouldn't have become so overwhelming. If I organized myself by doing my exam preparation along with my clinic revision every day, I would have definitely got to the end of the year more relaxed and I probably would have been able to remain in the same flow with patients.

NOW WHAT:

My aim for the future is to always plan in advance without getting surprised by the overwhelming amount of work that I have to carry out at the last minute.
Therefore, I will focus on keeping track of all my assessments throughout the year, working on them weekly so that when the exam date gets closer I can keep my focus with my patients in clinic whilst getting ready for the assessment.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

For 6 weeks during the first term of our fourth year, we had a slot in clinic which was exclusively dedicated to headache patients. This happens as part of a rotation, so that each of our group can experience this specific clinic modality by the end of fourth year. Every headache clinic session would start with a short tutorial on headaches by one of our clinic tutors. When I am not familiar with a topic I really struggle to listen and pay attention to the lecturer, and at times my mind wanders to completely unrelated subjects. This was the case with the previously mentioned tutorials, and the reason I decided to take very comprehensive notes; as it helps me to keep my attention on the lecturer because  I am driven by the need to complete a task, that is writing down as much information as possible. Whilst this task helps to keep my mind focused, it is often the case that I struggle to take information in during the lecture as I am so focused on writing down the words being said. This does not work in the long run as I neither remember any of the content of the lecture, nor look at the notes ever again.
 This is what happened with regards to headache clinic, I did not retain any relevant information apart from the really basic terminology and this not only made meeting and treating headache patients really stressful, but it also did not make me progress in my understanding of headache patients during those six weeks.
 It is very frustrating not being able to concentrate on something that you are required to, especially if you will need to demonstrate that knowledge with real patients or in exam situations.
 However, I did have the opportunity to treat several patients complaining of headaches, which was both interesting and challenging and motivated me within my self-directed study . Despite not always being confident with my patients’ situation, I still managed to improve my practical skills with those type of patients. The more I improved in my skills and knowledge, the more interested I became in those types of complaints, which led me towards the end of the term to do research directly related to this patient group.

SO WHAT:

This experience with the headache clinic taught me that although I may lack knowledge around a subject, I can still improve my practical skills with real patients. Most importantly, I learnt that in order for me to become interested in a topic and pay attention to someone else talking about it I need to feel motivated and have a tangible goal that drives the interest. In the example mentioned above, finding  myself in a  situation where  improving my knowledge and understanding of a topic would increase my ability to help someone was a good motivation to study.
If I always prepared myself before meeting my patients by properly following the tutorials and doing my own research at home, my learning experience during the six weeks of the rotation would have been richer, more fulfilling and overall less stressful. I could have achieved that for instance by speaking to friends or relatives who suffer from headaches prior to commencing the six week headache clinic, and this may have allowed me to attend the tutorials with a completely different mindset, eager to find out about my friends and /or relatives conditions and how to potentially help them.
 
NOW WHAT:

In the future I plan to prepare myself before attending lectures, tutorials or workshops, and will keep in mind the important learning points from my headache clinic reflection.
I learnt that if I lack the foundation knowledge for what I am going to listen to (e.g., a lecture), I will not be able to concentrate and may not be able to take anything in or learn anything new. I know that I must be able to relate to a topic, or identify an area where I can improve, in order to find it interesting, and this will require me to spend time in familiarising myself with the topic to begin with. Additional things that can help me achieve this include going through the material of the lecture when possible, study the basic concepts that will come up and find real life experiences which motivate me to keep focused on the lecture I am attending. This will help me enormously to avoid feeling frustrated and help me to use my time more effectively, for example to be able to pay attention at and engage more during tutorials, and this will enhance my knowledge, competency and self-confidence.

Children's & Maternity Clinic

WHAT:

Children’s & Maternity Clinic is a challenging part of our clinical experience as we start dealing with patients that are structurally completely different from the ones that we were used to treating in third year (adults). Our University provided numerous tutorials, lectures and extensive material to prepare us for this different type of experience. Despite this, I never felt that I was doing enough research or work because of the amount of time that it took me to prepare for assessments in addition to attending lectures and regular clinic. Moreover,  my unfulfilled wish to fully concentrate on my physical and mental care further prevented me to spend time focusing on subjects that were not necessarily important to pass exams.
Fourth year posed a particular challenge for me with regards to both clinical and academic responsibilities and I had to juggle several demands at once with additional personal commitments, including part-time working and preoccupations with being due to become a father. A specific challenge was to learn how to carry out a full examination routine on children. This involves a series of special testing aimed at assessing the neuromotor state of the baby that we were shown during the summer clinic just before starting fourth year. I procrastinated from properly learning and practicing that routine because until that point I had always carried out the osteopathic type of examination and was confident when carrying out this method of assessment, although it is limited to palpation and listening to the involuntary mechanism (IVM). For this reason, I often felt anxious when presented with a new clinic patient as I worried that my tutor may have required me to do the full examination routine, though I actually had not learn it. This is frustrating because I am aware that learning this assessment would have taken me no more than half an hour to fully absorb and probably three further practices of five minutes to keep it my memory, which would have allowed me to carry it out with patients confidently. 

This teaches me that it does not take much effort to learn a simple routine, but most importantly that practicing something that I am required to be able to demonstrate would avoid feeling stressed in numerous situations and it would give myself motivation to work more and more intensely. In this particular situation I could have simply organised myself with one of my colleagues and arrive 10 minutes earlier to clinic and to school every day for two weeks and master that routine. That would not have changed my routine at all, as 10 minutes are a very manageable amount of time two find only for two weeks, and at the same time it would have made a huge difference because I would have learned something essential for clinic.

I plan to prioritise what I have to learn in my clinical and professional environment, so that I can find a short time every day for a certain period of time only to complete one task at a time, in order to avoid anxiety and at the same time improve my confidence and expand my knowledge.

Sports clinic.

WHAT: 

My experience with Sports clinic during third year was overall a very positive one. This included Sports Osteopathy lectures mainly focused on rehabilitation plans and clinic sessions dedicated to amateur and professional sportspeople, both of which were mentored by the same clinic tutor. I really enjoyed the lectures because they included a theory part which was interesting and stimulating, and a practical part, that gave the opportunity to all of us to practice the rehabilitation exercises that we are supposed to advise our patients to perform at home. I found this approach perfect for its purpose and it was also a variation to the routine that we developed at the ESO. Because of my previous interest in sport and rehabilitation I did not feel as the lecturer was introducing to me something completely new, but it was an addition to my existing knowledge on the matter. This made me keen and focused during the lessons, where I participated actively and enthusiastically, asking and answering questions, presenting new ideas and taking part to the physical exercises. Being an active participant of the lecture without feeling nervous about interacting in front of the whole class was both unusual and exciting. Throughout the course I got used to feeling anxious and scared of judgment when I found myself in situations where my interlocutors where multiple people at the same time.
The clinical sessions were both interesting and rewarding. I personally had an extremely positive experience with a sportsman who had a knee injuring and had to stop both his sport and his job temporarily because of his pain. Through the sessions I could appreciate measurable improvements until the patient reported being pain free and was able to return to work first and finally take up his sport again. This empowered me because looking at the bigger picture I achieved what I had not managed to during all my years in education: I went through a process of receiving, elaborating and putting information into practice in a consistent manner, a method that was both relaxed and enjoyable.

This demonstrates that despite my experience in my education history where I always struggled to be involved in a particular course from beginning to finish as well as taking the content outside the lecture and working on it by myself, I managed to do so in Sports clinic with excellent results. Possessing the basics foundations around a subject is key for me to develop a proactive and reflective type of approach, which allows me progress in an efficient manner. Moreover, having a basic understanding of the subject gives me the confidence to interact without fear during the lecture, allowing myself to demonstrate my academic skills and creativity.
I learnt that repetition is key to fixate concepts in my mind. The sooner I revise a lecture and incorporate some extra knowledge to it, the more I’m able to retain information and the more motivation this gives me. Throughout the lectures and clinic sessions I kept my interest and focus by discussing with my colleagues outside the university or clinic hours, looking at different sources of information and asking advice to my tutor. Having an interesting patient case was also a key factor to enhance my drive to learn more and improve myself, both in the academic and practical aspect. 
Reflecting on it I could have made the process more interactive by asking my colleagues to come and observe the sessions with my patients as well as participating to my colleague’s sessions as an observer, when I had some spare time. This would have allowed me and my fellow students to exchange feedback about our approach and our practical skills, which could have permitted us to improve in different aspects of our practice and to give us some new ideas and enhance our creativity.

I plan to take this experience as an example from which I can learn and act on other situations in a similar way. I also will prioritise the clinical interaction with my colleagues in form of observation with feedback, practice sessions and tutorials.