this reflection has been carried out using Rolfe et al. (2001) reflective model.

Year 3, summer’s clinic.

Mrs X is a 72-year-old woman coming continuously for over 15 years to manage some low back pain due to lumbar spondyloarthropathy and associated bilateral hip OA. 

I covered the patient for another practitioner a total of 3 times when the other practitioner was on her summer break. 

During the initial conversation, Mrs X told me that she was very stressed, and as the stress load increases, the pain worsens. At the first treatment, I followed the same treatment plan that the previous practitioner did; however, during the second appointment, my tutor encouraged me to change the approach to a more functional/IVM type of treatment.

After explaining what I wanted to do and what I wanted to achieve, she gained consent and was happy to give it a go. Consequently, she told me she had some relief at the end of the treatment. 

The following week, she told me that the pain got worse a few days after our previous appointment. She deliberately asked me not to do any more functional/IVM type techniques, as she was convinced that was why the symptoms got exacerbated.

I then explained to her that the pain could have gotten worse for several reasons that were not involving my treatment approach. Moreover, I respected her wishes not to have any functional treatment and followed the same treatment plan previously used by her usual practitioner. 

 

I don’t use an IVM approach very often because I am still struggling to understand it myself. I feel something, I notice something happen, and I can presume that what I am feeling is what I should be expected to feel. I often struggle to do cranial osteopathy in the clinic because I don’t feel good enough.

I cannot know if Mrs X got worse because I was not good enough, and I’ll probably never know. Still, I am aware that I’m at the eso clinic to learn, experiment and play with osteopathy as long as you explain in the most appropriate way possible what you’re doing and why to your patient, checking for their understanding and gaining consent.

It is fundamental to continuously think that your ideal treatment approach could differ from what the patient wants. 

This story made me understand that even if the patient agreed to use a specific treatment approach during one session, I could not take for granted that it would happen the same during the following treatment. 

It is crucial to constantly check the patients' wishes and needs and try to accommodate them as much as possible without compromising the treatment outcomes.

 

Communication is fundamental for understanding the patient’s needs and wishes. Moreover, if a patient gives consent during a session, it must not be taken for granted that they will do the same during the following treatment. Consent is a continuous process made to help both patient and practitioner. I will always check after my treatment. 

REFERENCES:
Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

Year four, sports clinic.

I got a takeover patient from another practitioner. 

Mr x, 47 years old, suffering from recurrent episodes of discogenic pain since 2011.

I used as a treatment approach manual therapy accompanied by a rehabilitation program that my tutor and I created to address his needs. 

As the appointments progressed, Mr x started feeling better, and as he got better, he stopped coming, despite I suggested he keep progressing with the rehabilitation program. 

After two months, he came back to the clinic, telling me that he had one of the worst episodes of back pain that he had ever had. 

During that appointment, I spent more time understanding his beliefs, concerns, and expectations regarding his presenting complaint. 

When conversating, I noticed that his knowledge on the subject was limited and the patient was craving more information regarding his pain, as he didn’t understand why it was still present after so long. 

I took time out of the treatment to explain to him the nature of the pain and provide advice on self-care to manage the pain by himself as well. 

I made sure to offer him other treatment options, but he said he wanted to stick with osteopathy as he noticed that when he first came, he had improvements.

The treatments progressed in a good direction, and I thought that Mr. x was a good candidate to write about in my specialist’s clinic case study. Hence, I asked him if he could share some feedback, describing the motivations for seeking care, changes associated with the intervention and the impact of care on his quality of life. In the end, I didn’t use his case for my case study, however, here’s what he answered:

“I have suffered lower back pain and nerve discomfort for most of my adult life. I was diagnosed with two disc bulges and a tear in 2011. I sought treatment most recently to alleviate the pain and understand what issues were present.

The osteopath offered reassurance and listened to my long history. He always keeps me informed of my progress and provides sound explanations offering ideas to treat my condition. This has ranged from manipulation to rehabilitation exercises to strengthen my back whilst promoting good motion.

I am still suffering discomfort, but I am confident in the treatment I have been receiving. It has supported me to adopt new exercises and routines to promote a healthy back but also what to avoid in terms of aggravating my condition.

The osteopath's informative and personable approach has allowed me to have confidence in his treatment and given me the belief to continue and trust the process to hopefully maintain a healthier spine with less pain.

Kind regards,

Mr X”

This episode showed me how important it is to work in partnership with patients, and how much good communication with the patient leads to a trustworthy clinical relationship. 

Mr X made me realise how important it is to encourage the patient to ask questions and try to answer them in the most thorough way possible.

The feedback I received, proves how important it was for Mr X to have some answers to the questions he was having about his pain and how much understanding the nature of it changes the treatment outcomes. 

Moreover, I learned that, even if the patient already received osteopathic care from someone else and has been suffering from some type of pain, I cannot take for granted his understanding of the presenting complaint.

 

To improve my patient care, I always need to check the patients’ understanding of the nature of pain and not take anything for granted. Moreover, it is crucial to stimulate the patients’ curiosity and encourage them to ask as many questions as needed.

REFERENCES:
Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

You must give patients the information they want or need to know in a way they
can understand.

OPS A3.3: If you propose to examine or treat a patient who has difficulty communicating or
understanding, you should take all reasonable steps to assist them. For example,
make use of an appropriate interpreter if the patient communicates in a different
language to you. If you are unable to communicate sufficiently with the patient,
you should not treat them.

This reflection has been carried out using Rolfe et Al. (2001) reflective model.

During my first term in clinic, I got assigned a patient whose surname sounded like it was coming from the same country as mine. At the beginning of the consultation, noticing that the patient was slightly struggling to speak English fluently, I asked him where he was from, and he confirmed me he was from the same country as me. He told me he moved to the UK a couple of months prior to the appointment, and that he was still struggling to speak English fluently.

As much as I would have enjoyed having a patient that I could talk to in my native language, I explained to him that since the tutor was observing the consultation via the camera, we had to try to speak as much English as we could. Anytime there was a communication barrier, where he was not understanding or he didn’t know how to say something in English, we could have used the other language. 

The patient seemed happy with the proposed approach, and we continued the treatment by mixing the two languages when necessary.

 

This episode made me understand that in order to create a solid clinical relationship based on reciprocal trust, it is important to adapt the way of communicating with the patient depending on their needs.

Gladly, since we were sharing the same native language, gaining consent was relatively easy and did not take any additional time. Moreover, speaking the same language helped me to build a relationship of trust and respect between me and the patient.

I was confident throughout the consultation, and I felt satisfied with how I handled the situation.

I also noticed that I struggled more than expected in explaining some clinical findings in my native language as I never use it to practice osteopathy.

 

Being English my second language, I will always keep in mind how difficult it is sometimes to express yourself.  In the future, I will try to adapt my communication skills to suit the patient’s needs, whether it is a language barrier or some other communication barrier.

 
^{here's attached an interesting article on the value of communicating with patients in their first language.}


REFERENCES:
Ranjan, P., Kumari, A. and Arora, C., 2020. The value of communicating with patients in their first language. Expert Review of Pharmacoeconomics & Outcomes Research, 20(6), pp.559-561.

Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

In my first year, I was struggling to understand the importance of gaining consent. 

I come from a country where osteopathy is not regulated, and consequently, osteopaths don’t have any guidance and standards to follow. The process of gaining consent is not as developed as it is here in the UK, mainly because there is no “education” on it. 

I was used to go to the osteopath relatively often before starting to study here, and I never questioned what the osteopath was doing and why weren’t they asking me if it was alright for me to do things in a certain way or if I preferred another treatment approach. 

On the other hand, when I started this course, from day 0 they made pretty clear the importance of asking for consent and despite I wasn’t fully understanding its use of it I was trying to incorporate gaining consent into my examination and treatment routines.

 

Here’s for example what I wrote in an assessment I had to write in my first year: 

“The communication between practitioner and patient is necessary. In treatment, it is all about consent. Gaining consent is a crucial part of your practice and is both an ethical and legal requirement. in order to gain consent, the practitioner has to explain to the patient what is going to do and why during every step of the treatment adapting the explanation to the person that is interacting. This fundamental process, however, stops several times the practitioner, making him lose precious time that he could spend treating the patient or interacting with them.

At the moment, as a student osteopath, I am learning and practising presuming that the patient will agree with my treatment plan, however in reality patient can decline to give the consent leading to a different treatment”

 

Thinking back to when I was in my first year and reading this piece of assignment made me smile.

I am somehow embarrassed about how little I was understanding the topic before. 

 it seems like it was written by another person. 

In four years, my perspective and my opinions about osteopathy changed significantly. 

At that stage everything was new, everything was a challenge, and only now, looking back at it I can notice how reductive my opinion on gaining consent was. I was seeing it as a mere legal requirement, a waste of time, like a wall that was stopping me from creating connections with my patients.

Now, being in my second year of clinic, I don’t see gaining consent as a wall between my patients and me, I see it more as a safety net. It helps both me and the patient feel safe, it’s a way to understand each other and interact 

I am aware I’m still learning how to ask for consent appropriately and there are still many things I need to improve on, however, I am now aware of the absolute importance of it. 

  

Gaining consent is a fundamental part of our practice not only because it is a legal and ethical requirement but because it enables respect for the patient’s autonomy as it includes them in part of the decision-making process. As osteopaths, we must respect and support people’s right to accept or decline treatment and care. Asking for consent is giving a patient the ability to speak, the ability to express themselves. Asking for consent is giving the patients their freedom.

Sport’s clinic. February 2022.

The patient was a 17-year-old- female gymnast who complained of a UCL injury at the right elbow. The presenting complaint occurred after hyperextending the elbow whilst performing a back handspring at a competition. 

Radiographs were taken immediately after the onset and interpreted as normal. The patient was informed that the pain was due to soft tissue damage, but no specific structure was identified. The patient was managed with rest, avoidance of the offending activities and cocodamol, which was independently stopped two weeks after the onset.

She was feeling confused. They didn’t give her a diagnosis, they didn’t give her a prognosis, and they didn’t tell her when and how she could have gone back to practice gymnastics.

When you’re an athlete at a semi-professional level, your life turns around your sport: daily routine, friendship, goals, dreams, thoughts etc. now think, how would you feel if you would get injured doing what you love the most?

She was feeling very insecure, almost accepting that she might not be able to go back to do gymnastics at the same level.

My tutor and I took some time out of the initial consultation to listen to her, understand her concerns and reassure her. We tried to explain what she had, how we were thinking of managing it, and what we were expecting for her recovery. 

I asked my patient for some feedback for a case study, and here’s what she wrote: 

"I sustained an injury from gymnastics at a competition, I decided to seek treatment in hopes to get back to gymnastics as I was hoping to compete again, as well as gaining full function back in my arm.

During our first appointment, they assessed my injury and helped identify what was wrong with it. They spent time to understand my concerns and what recovery I was hoping for and gave me appropriate exercises that I was capable of to regain strength and full range of movement. They built upon these exercises over subsequent visits, and after three weeks, I can put a small amount of stress through my elbow without pain and restriction. 

This rehabilitation has had a massive positive impact on me. I now feel confident that I will be able to return to gymnastics at a competitive level."

As osteopaths sometimes we could wrongly think that everything that is not hands-on treatment is wasting our time and slowing the patient’s recovery time. 

This episode made me believe even more in the importance of taking time to listen to the patient. Sometimes people just need to feel listened to and understood. 

With this patient, I re-discovered the therapeutic beauty of listening. 

I could have (wrongly) just applied the biomechanical model only, without considering the biopsychosocial aspect of the complaint. However, I believe that listening to her, supporting, and empowering her, made a massive difference and fastened the recovery time. 

I understood that supporting the patient in caring for themselves is the key to empowering the patient and helping them and it’s the best long-term management that we can possibly aim for.

I believe that supporting patients in caring for themselves needs to be the most important aim of our management plan. A supported patient will have a positive mindset, and a positive mindset will help the recovery. I will always try to take some time to listen to the patient, encourage them, give them enough support to care for themselves and always aim to maintain or improve their health and wellbeing.

REFERENCES:
Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

I had a valuable experience during one of my first sessions of specialist children’s clinic. 

My patient was a 5-week-old child accompanied by both parents. The parents got referred to seek osteopathic care by a lactation consultant as their daughter was recently diagnosed with tongue-tie. Despite the baby recently undergoing surgery, breastfeeding was still an issue, especially when latching. 

During the case history taking, both parents were friendly and open to answering every question I was asking in the most detailed and helpful way. 

However, after discussing the case with my tutor, as soon as I knocked on the door to come back in, I noticed that the mother’s tone of voice changed.

She told me to come in in a very hesitant and embarrassing way, which made me start questioning what was going on.

As soon as I came in, the mother started rapidly covering herself and hiding behind her husband. Even not knowing what was going on made me start questioning myself and made me feel embarrassed.

I then realised that she was breastfeeding her daughter and, most likely she was not comfortable with having someone observing, however, she didn’t know how to address her discomfort to me. 

Once I acknowledged her discomfort, I asked if everything was alright and if she wanted to have some privacy until she was done with breastfeeding. 

As soon as I asked her that, her voice seemed already slightly relieved, and we agreed that they would have knocked at the door once they were ready to continue with the appointment. 

Furthermore, despite I discussed with my tutor the value of doing a breastfeeding observation, I decided that it wasn’t appropriate, so I had to rely only on a thorough examination of the infant.

Patients have different requirements for maintaining their dignity and modesty during a consultation. It is important to not underestimate needs and values in relation to gender, ethnicity, culture, religion, belief etc. and to not make assumptions about any patient’s ideas of modesty. 

I am quite conscious of gaining consent in clinic. Being English my second language, I am often doubting how much I am explaining myself correctly and if the patient is understanding completely what I want to tell them. That’s why I spend quite a lot of mental effort trying to be as concise and explicative as I can. As time goes by, I become more and more confident, and asking for consent it’s becoming easier than doing a case history. However, when “atypical” presentations occur, I start again having all the doubts I’ve had on my first day of clinic.

Am I respecting the patient or am I saying anything that might be misunderstood? Am I being clear enough? I honestly get quite stressed about it. But again, if you don’t make any assumption about any patient’s idea of modesty, you aim to empty your mind from any bias, and you want to accommodate the patient’s needs, you’re going in the right direction.

 

From that time on, during children’s clinic, before I go to discuss the case with my tutor, I also ask the mother if she needs to breastfeed when I’m away and make sure to ask if she wants some privacy until she is done with breastfeeding. 

REFERENCES:
Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

I had an interesting experience with an initial consultation during Christmas clinic in year 3. 

The patient was a 67-year-old male. As I first introduced myself to him and asked him if he could put the surgical mask on, I noticed he took a big breath out and mumbled something I did not catch. I tried to ignore it, we went to the treatment room and the case history taking went smoothly, the patient was explaining his presenting complaint and was pretty clear and talkative. After gaining consent, I started the examination with the tutor in the room and we finally diagnosed him with lumbar spine spondylosis. During the treatment time, as I usually do, I tried having a conversation with him, trying to establish and create some type of patient-practitioner relationship. The conversation was running pretty well since it was getting closer to Christmas, I asked him how he would have celebrated it, and he answered pretty politely again, and he asked me back. I told him that I was planning to go home the following week to spend some time with my family, however, due to covid restrictions I didn’t know if I would have actually managed to go back home. 

He then started talking about the covid situation, saying that everything that was happening was a big fraud, that the face masks were useless, that the government was controlling us and that covid was created to make the pharmaceutical companies richer. 

I probably wasn’t in the best mood to talk about it, and I noticed when he was talking that the conversation was touching a sore spot for me. A few weeks prior to that, my neighbour back home died of covid, I was very close to him, and I still didn’t fully recover from that episode at the time. 

I wanted to answer back, but I already knew that our discussion wouldn’t have led us to anything good, we would have started arguing and it wouldn’t have been pleasant for both of us. 

I took a big breath in, counted until ten and changed the topic, trying to ignore the conversation. We then changed the topic and smoothly continued the treatment. 

 

Dealing with patients that have different views in life from yours can be sometimes hard.

I usually see diversity as a point of discussion and growth, where an exchange of opinions can help you see a topic from another perspective. However, this time I got upset.

Sometimes I look back at this episode and think, “what would have happened if I would have argued back?”

However, I think that choosing peace and deciding not to argue back was the wisest choice I could have possibly made.

Although initially, it was hard not to be carried away by my emotions, I kept caring for my patient’s health, I kept trying to give him the best management I could have possibly provided him. 

The patient’s health comes always first. 

However, looking at it from another point of view, I should have addressed the topic objectively and from a medical point of view, providing information on the effect of the patient’s life choices, promoting his 

health and wellbeing.

 

I will always try to put my beliefs and values aside, appreciating and accepting everyone’s differences and beliefs. 

Despite I might have different ideas with my patients, I will always need to aim at being professional and giving the same quality of service to everyone, with no exclusions.

 

Reminder for the future: the patient’s health comes always first, no matter what. 

REFERENCES:
Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

As the fourth year is coming to an end, I am starting to revaluate my academic journey. 

Each year was characterised by new challenges, either in my academic or private life that influenced the way I dealt with my learning process. 

I arrived at ESO after a gap year. I was living by myself, in another country and my English skills were pretty basic. I must say, in the first months my biggest focus was to become fluent in English, unfortunately not prioritising the studying as much as I should have. 

I started learning how to deal with a patient, osteopathic principles, concepts and techniques, as well as creating the foundations of my knowledge by studying anatomy and pathophysiology.

I remember clearly the two weeks before my first pathophysiology exam, I crammed a bunch of information I wasn’t even understanding fully, studying day and night, and regretting I didn’t start earlier. I manage to pass the exam however, I promised myself I would have never procrastinated studying ever again but it didn’t go as planned. I failed, in fact, both anatomy exams. 

This had a massive impact on how I dealt with my learning attitude. If on one side I was doing pretty well on the osteopathic subject, I started feeling not worthy and capable of succeeding on the core knowledge exams. Over the summer I changed my mindset and approach to studying managing to successfully pass the anatomy exams. This represented a starting point for me. 

Despite all the problems, I knew that I chose the right path, I was loving what I was studying, and I was feeling for the first time I was in the right place doing the right thing.

 

year 2 was a transitory year. You know more than a first-year student, but you don’t know enough to go to clinic. This year revolved mainly around getting you ready for practising in clinic. I felt like it was more about learning how to apply our knowledge to a clinical environment. 

Academically it was going fine until the pandemic happened, and lockdown came alongside. Doing online lectures and exams had a massive impact on my attention and motivation, making me question if I actually wanted to study osteopathy. 

I felt like instead of progressing with my hands-on skills I was losing them, and instead of feeling ready and enthusiastic to start clinic I was just feeling lost. 

 

In year 3 I rediscovered osteopathy. All the doubts I had about this profession were gone after I started practising in the clinic. I felt that I rapidly increased my knowledge, filling some of the gaps I had developed over the first two years. 

My goal was to become the best practitioner I could have possibly become. Every time I was going to clinic, I asked tutors for something new, and I was practicing with my team.  As I always felt my core knowledge and my diagnostic reasoning were lacking this was my main area of focus during those sessions. 

If I was very happy with the stimuli I was receiving from clinic, unfortunately, I started feeling “bored” with what we were doing in Boxley: nothing was motivating me or thrilling me, and I was just studying to “tick boxes”.

 

In year four I discovered, and I am still discovering autonomous learning and problem-solving skills. I started understanding that what I was doing in Boxley was just supposed to be a guide for my independent research, to guide me and give me inspiration. I also started to rely less on the clinic tutors aiming to find my way to clinically thinking.

Term one was alienating, I worked day and night for my dissertation, and I was feeling like all the rest was unnecessary. I still went to all the lectures and clinic shifts; however, my mind wasn’t as focussed as it should have been. Despite that, working on the dissertation significantly increased my critical thinking skills, as well as it gave me more confidence in interpreting the currently available literature. 

During term two I finally started revising with my friends and colleagues the osteopathic techniques for the upcoming FOPE as well as improving examination routines in preparation for the CCA.

After my mock CCA, even though I passed it, I got confirmed what I already was aware of: I needed to improve my clinical reasoning. 

I started then creating a summary of all the most important information I needed for each area of the body and condition, including definition, demographics, key questions that separate this condition from others, examination features, prognosis, osteopathic and medical treatment and rehab exercises.

This is helping me revise and giving a sense to such a broad and immense topic, as well as highlighting my areas of strength and weakness.

 

I always tell myself I don’t know enough. I’m a very unsatisfied person and I believe that this unsatisfaction is one of the main reasons I managed to arrive in the fourth year. 

Only looking back at this four years journey, I actually notice that my knowledge is wider than I tell myself.

When reading the subsections of the OPS B1 none of the criteria seemed to be unfulfilled in my own practice. 

I still don’t feel I know enough, and I am happy about it.

As a soon to be graduate (hopefully) osteopath, my biggest fear is to accommodate what I already know. I want to keep feeling unsatisfied with how little I know because it’s the only way I will be able to progress in my career. 

 

Note for the future me: 

stay hungry for knowledge, keep questioning everything and revaluate yourself constantly.

REFERENCES:
Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

Year 3, reflecting on my first patient.

Today I had my first patient. I don't know how to describe how was I feeling. 

A part of me wanted to do it and the other just wanted to run away back home. It's weird. 

When I arrived at the clinic the patient wasn't assigned yet and I was pretty sure that I didn't want to have it. However, when I arrived in the team room with my group and my tutor I just felt that was the right thing to do. Another student wanted to have a patient as well so in order to decide we flipped a coin, not really professional but actually quite fair.  

10 minutes before the patient was supposed to arrive, I put the PPE on and I started realising that it was actually happening, after 2 years of uni I was having my first patient. The first one of many. 

I went then downstairs; everything was confusing. We had a first chat outside while I was asking him all the questions covid-related and then we moved upstairs to the treating room. 

The patient was complaining of low back pain in the right side that was radiating to the right pelvis and hip 

Case history went ok, except for the systemic enquiry questions, I didn't ask really useful and good questions, I should have been more specific and more confident. 

Straight after I went to my tutor to discuss my differential dignoses. 

As I did not have any experience with this process, and I was honestly confused by what was happening I asked my clinic tutor for support. It helped me a lot and gave me good guidance and advice.

The tutor also supported me throughout the examination process, guiding me and correcting me when I was doing something inappropriately. The examination routine performed was: observation, active lumbar spine testing, facet load, slump test, lower extremities neuro-screen, and passive lumbar spine testing.

I wasn’t very confident checking the reflexes, so my tutor, instead of judging me, showed me how to do it and asked me to have another try.

We diagnosed him with a facet joint irritation and, after 10 minutes of treatment the consultation was done. The patient was somehow feeling better, and I wasn't really believing it. 

Here’s a bit of context: 

I just got back to uni after 6 months of stop due to the pandemic, consequently, I wasn’t speaking English for a while, as well as not doing any hands-on practice. My communicative and osteopathic skills were a bit rusty.

I wasn’t feeling confident at all in treating patients, in my brain I was like an impostor, scamming the patients, convincing them that I could have helped them. 

Despite that, the entire consultation worked well. My tutor supported me, and I was grateful for the great learning experience I received. 

After this experience, I was more confident and less stressed, and I understood that, with practice and study, hopefully, I will be able to be a good osteopath one day.

 

It’s a long way to the top. 

I will need to improve a lot on the differential diagnosis and examination processes. 

In order to do it I will have to:

- Practice the orthopaedic examination routines

- Revise the diagnosis for each body region

- Revise in-depth the neurology

- Revise cardiovascular, respiratory and abdominal examinations

- Check the most common red flags

- Understand how to follow up with the systemic enquiry questions.

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

this reflection was carried out using Rolfe et Al (2002) reflective model.

Over the course of this degree, I understood the relevance and importance to apply updated evidence in my osteopathic practice. This degree’s curriculum teaches subjects such as critical thinking, reflective portfolios, research methods as well as doing a level seven research project. This was done to improve students’ knowledge and attitude towards research and evidence-based practice, as well as develop those skills necessary to develop competence and criticality in regard to the available evidence. 

Applying and adopting evidence-based practice skills into everyday clinical work is not without its challenges. And it appears that in contrast to other healthcare professions, evidence-based medicine (EBM) is not well accepted as in the osteopathic profession. 

Many tutors reinforce the need to constantly check for the most recent evidence, to make more sense of what we do and how we inform our patients. However, every time I asked them how they can keep up with research they just say that they read a lot around, leaving me without any guidance about the subject.

I often struggle to understand how to implement EBM in my clinical practice, furthermore, I struggle even more to understand how to “keep my knowledge up to date”.

As a health care professional, I am expected to keep up to date with research relevant to my clinical practice and to integrate this knowledge with my own experience and my patient’s values and preferences.

However, every time that I try to keep up to date with the research, I found myself lost.

With internet, we’ve got access to an infinite quantity of articles I often struggle to make a sense of them and decide if they are trustworthy and if they are applicable to clinical practice and to patient care.

I consequently found an article that tries to support osteopaths that are approaching EBM, aiming to empower them to judge research themselves, detect common fallacies in the conduct and reporting of different research designs and increase research accountability. 

They identified four M’s (points) to make sense of evidence, which are: 

-mistakes.

-misinterpretation.

-misrepresentation.

-misinformation.

 

You can find attached the full article here.

Applying EBM to osteopathy represents a challenge for me, however, It is my duty as a healthcare professional to keep my knowledge up to date in order to give my patients the best care I can provide.

I will try to implement the 4M’s in my future research, aiming to keep my knowledge up to date and solidify the foundation of my knowledge with trustworthy and qualitative evidence.

REFERENCES:
Rodi, J.D., Vaucher, P., Hohenschurz-Schmidt, D., Morin, C. and Thomson, O.P., 2022. 4 M's to make sense of evidence–Avoiding the propagation of mistakes, misinterpretation, misrepresentation and misinformation. International Journal of Osteopathic Medicine.

Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

Reflective writing is a fundamental component of developing professionally, it enables health professionals to question their selves, forcing you to take some time to revaluate and look from another perspective clinical situations that occurred. Making the portfolio during these four years made me start becoming a reflective practitioner. 

 

Sometimes analysing what you did and how you felt can be hard. You can feel embarrassed about how you acted, you might want to avoid the mistakes you’ve done, but only by analysing them and reflecting on what happened can help you become a better practitioner.

That’s what happens to me whilst I’m writing the padlet: I’m learning from my mistakes, understanding what are my weak and my strong points and what kind of osteopath I want to be and not to be.

Despite being a reflective practitioner presenting many benefits, there are several barriers that could stop me from reflecting appropriately and continuously. Factors such as time, motivation, and lack of organisation may in fact play a major role and affect my reflective writing time. Consequently, I will need to take into account this factor and try to anticipate any possible barrier I could possibly encounter

 

Although I know that being a reflective practitioner presents some disadvantages, over these four years I understood the importance of reflecting on my clinical and osteopathic experiences. I will continue to reflect and use this tool to grow, question myself and eventually reinvent myself, in order to become the best practitioner, I can possibly be.

REFERENCES:
Council, G.D., 2019. Benefits of becoming a reflective practitioner. A joint statement of support from Chief Executives of statutory regulators of health and care professionals. London: General Dental Council.

Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

I had an interesting experience during my first term of year four. 

It was a Monday morning, and I got assigned a new patient. Mrs x was a 77-year-old woman complaining of vertigo. It was her first time coming to see an osteopath for her and she didn’t know what to expect, she was kind of expecting an easy fix, one miraculous treatment that could make her complaint disappear. 

If on one hand there is a patient coming with unrealistic expectations, on the other hand, there was me, confused and frustrated, because my knowledge of vertigo was relatively low. 

The case history kept going and, despite my 
limited knowledge it seemed to me that the patient was presenting the common sign and symptoms of benign paroxysmal positional vertigo. 

The onset was sudden, following a rapid change in head position.  She was complaining of vertigo and loss of balance associated with light-headedness, dizziness, nausea and vomit. Moreover, symptoms were exacerbated by laying down, looking up and bending forward.

When I went to discuss my ddx with my tutor and after he heard me trying to find a possible diagnosis for the presenting complaint, he started questioning me: 

“How comfortable are you with a vertigo presentation?”

“Have you ever treated one?”

“Now honestly speaking, when was the last time you practised a Hallpike test or the Epley manoeuvre?”

I answered that my knowledge and competence were limited, however, if I would have been guided I could have at least performed the Hallpike test to see if I was able to reproduce any nystagmus.

As soon as I stopped talking, he then told me: 

“Do you like this patient? Now think she’s your grandma, would you like your grandma to have an okay-ish treatment or would you like her to receive the best management she can possibly have? Would you like her to receive a gold or a bronze standard management?”

I then answered with a doubtful and confused voice that I would have wanted my grandma to have gold standard management and then he said: 

“I am not judging your skills as an osteopath, but now, in this case, with this patient: can you give her the best management she could possibly have? You can either be a bronze standard or a gold standard practitioner, however, would you be ok being a bronze standard practitioner and giving relatively poor care to your patient?”

I said no, of course, but I still wanted to help her, I couldn’t tell the patient that I wasn’t able to treat her and then send her home, consequently, we did what my tutor usually does with these situations: we referred her to a vestibular rehabilitation therapist.

 

Honestly speaking, when I finished the appointment with this patient, I felt very unsatisfied and disappointed with myself. I didn’t treat a patient because I wasn’t good enough. I was feeling like I could have helped someone, but my limited knowledge stopped me. I was only thinking that if I only would have known more about the subject, if I only would have focused more in class and studied more for the exam I would have eventually been able to help her. I felt like that time I failed.

I told my tutor about it, as I, fortunately, have a good relationship with him and he told me that I was a student and my main area of study was musculoskeletal presentations, not vestibular ones.

Despite the wise words, he told me, I was still disappointed. I remember that my tutor also told me, this is a very good story to talk about in your padlet, think about it and reflect on it.

The days went by, and the days turned into months, and now, looking back at it with a clearer mind there was nothing to be ashamed of.

As a student, I am supposed not to know everything, and in case I don’t know something, I only need to recognise what my limits are.  The tutor, in this case, acted for me and helped me decide not to even examine the patient, and honestly, looking back at it he was right: I would have done a test I wasn’t capable of doing, in an inaccurate way that might have exacerbated the patient’s symptoms without benefitting her at all. This, however, does not mean that I need to be ok with not knowing something. The more you know the more you can help. 

This episode motivated me to revise BBPV and more in general, vertigo as a presentation. 

It also made me realise that I always must aim on delivering high quality and safe healthcare to patients. 

If I’m not able to conduct an appropriate evaluation and provide competent and appropriate osteopathic care, I need to put my ego aside and act with honesty with my patient and refer the patient to another osteopath or if required to another healthcare provider.

REFERENCES:
Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

this reflection has been carried out using Rolfe et Al. (2001) reflective mode.

During the summer break from the third to the fourth year, I had to go back to the UK five weeks prior to the beginning of the term to work at the ESO Clinic. It’s an interesting moment for students, you go to clinic every day, and you have many more patients than usual, and you start feeling how your life is going to be after you graduate. 

Since many students are on holiday during summer clinic, it happened multiple times that I had to cover some patients’ appointments whilst they were away.

This represented a very interesting and valuable learning experience: we had to treat patients that have been already diagnosed and manage the expectations they had with their previous practitioner, however, sometimes I noticed that it was very difficult to interpret some practitioners’ notes. 

Some patients’ notes were found to be incomplete, others weren’t signed by the tutor however, the most common thing I noticed was the difficulty in reading someone else’s handwriting.

 

I’ve always been aware of my handwriting. I write very small and very fast, and I know that often people struggle reading what I write, sometimes even I do struggle reading what I previously wrote.

It’s always been like that, even in elementary school I remembered that my English teacher made me rewrite a full notebook or homework because it was illegible. I tried changing my handwriting until a certain point when I just gave up and stopped caring.

Starting clinic, I had to force myself to be aware of how I write, and I had to make an effort to write in a more legible way, however, the majority of times I failed.

After the first week of summer’s clinic, I understood how much impact illegible handwriting does, consequently, I started making even a bigger effort to write more legibly. I personally still find it difficult, I must say, however, I know where my limits are and I know what I need to improve on.

As an osteopath, I must ensure that my records are comprehensive, accurate and legible, and in my case sometimes it does not happen. 

In the future, as soon as I will start working, I will most likely switch from handwriting my notes to typing them on a laptop. This will ensure that my records are legible for everyone and also will give me easier and tidier access to my patients' notes.

REFERENCES:
Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

 

On the 1^st of September 2021, I had my first initial consultation in headache clinic. Ms X presented in the clinic with unilateral excruciating headaches located on the left eye socket and temporal bone, with associated reddening and watering of the eye, blocked nostril, swollen eyelid, flushing and facial hyperhidrosis.

The pain started 25 years ago, with no particular onset. The frequency of the occurrence of pain gradually increased from sporadic episodes over a period of months, to daily episodes occurring twice daily, respectively around 02:00 pm and 11:00 pm, with episodes lasting around three hours. The patient was non-responsive to medication except partially to oral sumatriptan and pain was making her restless and almost wanting to hit her own head by way of relief.

With my tutor we recognised that the patient’s presentation was non-mechanical, hence we could not help her relieve the symptomatology with osteopathy. Specifically, my tutor and I suspected that the patient was suffering from cluster headaches. 

After receiving the patient’s consent, we consequently referred her to her GP, and she was also advised to contact the OUCH (organisation for the understanding of cluster headache) to seek help in concomitance of accessing help from her GP.

 

This was the first referral letter I’ve ever sent. I am glad I received the appropriate support and guidance from my clinic tutor. My tutor suggested to me how to format it as well as correcting it and checking whether something was missing or not. 

 

This episode gave me confidence and knowledge on how to write referral letters by myself. At the moment I am guided and supported by the tutors and the clinic staff, however, when I will be graduated it’s all going to be relying on me.

REFERENCES:
Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

Here’s attached the certificate for the Female genital mutilation safeguarding (FGM) training I attended. 

FGM is a significant global health concern and is becoming an increasingly important healthcare challenge in the UK. 

FGM is one of the most important human rights issues of our time because it goes hand-in-hand with other gender equality issues, including child, early, and forced marriage honour-based violence, and girls' education. 

The controversial and complex practice of female circumcision is one that carries important negative consequences for the quality of life of those who have undergone the procedure.

Osteopaths, as part of the health care professionals, have a mandatory duty to be trained on how to recognize this burden to keep patients from harm.

REFERENCES:
Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

 

Osteopathy is a manual therapy and as such practitioners as part of the diagnostic, treatment and management process skin-to-skin contact occurs with patients.

As an osteopathic education institution, the ESO has a vigorous infection control policy to minimise the risk of cross-infection between patients and practitioners.

The standard infection control precautions revolve on:

-patient placement

-hand hygiene

-Respiratory hygiene and cough etiquette

-Personal Protective Equipment (PPE)

-Management of care equipment

-Control of the environment

-safe management of linen

 

This can be thoroughly analysed and explained in the attached file, regarding in fact this policy.

As a practitioner, I always try to keep in mind the importance of minimising the risk of cross-infection, applying continuously the infection control policy of the clinic I’ll be working at.

REFERENCES:
Assets.publishing.service.gov.uk. 2022. [online] Available at: <https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/585584/RTI_infection_control_guidance.pdf> [Accessed 14 May 2022].

Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

 

I met Mr X, a 56-years-old man in my final term of year 3. Funny guy. He was always putting a smile on me; in every conversation, we were having he was able to look at the positive side and inspire me. 

I remember that during our initial consultation, he mentioned that he has been a smoker for over 37 years. I remember he told me that it was about 5 years that he was telling himself that he would have stopped on the next Monday, however, a few Mondays went by, and he was still smoking.

During the initial consultation, since there wasn’t a strong patient-practitioner relationship I only took note of what he told me, and I wrote a note for my future self to address this topic. 

A few sessions afterwards, me and Mr X, were getting along pretty well, it seemed he was trusting me, and I personally felt it was appropriate to address the topic. We then addressed the topic and he explained to me that he just didn’t know how to start, explaining that it was hard to imagine stopping something that you’ve been doing for your whole life. I then told encouraged him and told him that stopping smoking could have been one of the best things he would have ever done for his own health, and I asked him if he wanted some guidance on finding some helpful resources to understand how to stop smoking. He agreed, so we watched together the NHS quit smoking website, read it a bit together and conversated about it. He thanked me and told me that this time could have actually been the right time. The week after, however, he got covid so he didn’t come, and the week after that I went on holiday for my summer break. I never saw Mr X again, and I can’t know whether he tried to stop smoking or not, I can just hope so.

 

The negative health consequences of smoking tobacco are widely known. However, a considerable number of people continue to smoke.

This experience made me realise how much osteopaths can promote health to their patients.

The beauty of our profession is that we have time to talk to our patients, and we can manage to get to know them and establish a trustworthy relationship.

Having awareness of public health issues and concerns enables health care providers to empower the patient and make them proactive toward a healthier life.

 

I will always continue to get informed on the common public health issues in order to build some knowledge that enables me to discuss them appropriately with my patients, aiming to promote their health and wellbeing.

REFLECTION:
nhs.uk. 2022. Quit smoking - Better Heath. [online] Available at: <https://www.nhs.uk/better-health/quit-smoking/> [Accessed 16 May 2022].

Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

After graduation, and after several years of practice as an associate in various clinics in the UK, I am planning of going back to my hometown, away from England.

This will represent the chance to start the clinic I always dreamed about, which fully represents myself and the osteopath I want to be.

I wanted to start my clinic in a friendly and familiar environment, where I had a deep connection with people and strong local knowledge that could facilitate my business start, for these reasons, I decided to place my clinic in my hometown.

which is also, my hometown. 

Moving back to my country, however, represents a big challenge for me. Osteopathy in the UK is well established and regulated, however, in my native country, it is not. There is no such thing as Gosc and there is not much guidance on what osteopaths can or cannot do. 

If in the UK the advertising and promotional material must be in line with the advertising standards authority (ASA) and it needs to conform to current guidance, there’s no such clarity where I am coming from. 

Even though there is no regulation on what can or cannot be advertised in my country of provenience, I would never claim to treat a condition if there is no evidence of the effectiveness of such for a specific condition or if it doesn’t go in accordance with the ASA guidelines. 

My future clinic will give an English approach to osteopathy, following with attention and care the osteopathic practice standards, the concept of safety to treat, and shared decision making that is advanced here in the UK.

 

I want to be honest and clear with all my patients. 

Despite there is no regulation where I will be working I will still comply with the ASA guidelines and the evidence to advertise and understand my scope of practice. If patients will come with conditions that I cannot claim to treat I have the duty to inform them and eventually discuss the best alternative management options.

REFERENCES:
Practice, A., 2022. Health: Osteopathy. [online] Asa.org.uk. Available at: <https://www.asa.org.uk/advice-online/health-osteopathy.html> [Accessed 17 May 2022].

Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

 

Living in Maidstone, and in general, in a relatively small community has its pros and cons. I honestly like it, you go around, and you often see familiar faces which make you kind of feel like you part of a community. 

I live close to a pub, and, last year I and a few friends of mine were used to occasionally going there after clinic or during the weekend. It’s quite a small pub, mainly populated by 50 to 80 years old regular customers and young foreign students are quite rare. There is never a time when we go there, and we don’t talk to the locals. They know us as “the osteopaths from the college” and they always treat us very politely and respectfully. 

Multiple times I got requested to “sort” someone’s neck right there, at the pub, and of course, I always declined the offer, eventually advising them to come to the clinic to get a full consultation. 

It happened once that one of the locals booked an appointment with me and eventually a few days later we met again at the same pub. He started telling everyone that he had an osteopathic appointment and he started then asking me questions about what I did. As I didn’t want to abuse my professional standing, and I wanted to have appropriate professional boundaries with my patient I kindly tried to avoid the conversation and change the topic subtly. 

Sometimes it can be hard to establish and maintain clear professional boundaries with patients that you meet outside of the clinic. I am aware that in case I would address someone’s presenting complaint outside of the clinical and professional environment I would not give them the appropriate care they deserve, and it wouldn’t be as professional as I could. In this case, I think I acted promptly and correctly, not abusing my professional standing and not crossing professional boundaries with my patient. Despite the patient wanting to talk about the appointment, I personally felt it wasn’t the right time and space to have that type of discussion

 

Establishing and maintaining clear professional boundaries is fundamental to ensure that my clinical judgment is objective and that I can provide the treatment my patients need.

In order to give the same level of care to all my patients, I will always try to maintain clear professional boundaries with all my patients, whether I have been knowing them outside of the clinic or not.

 

As osteopaths it is our duty to be open and honest with our patients, explaining and providing enough information if something that we are going to do has the potential to cause harm or distress.

When I started clinic, I didn’t really know how to explain the risks of osteopathic treatment to my patients, especially in relation to the HVTs. Everything that I was saying was making the techniques sound the most dangerous thing on earth.

I was starting to feel insecure and confused, resulting in being unclear to my patients.  

I didn’t have a clear idea of what I needed to say and what was not appropriate to talk about and I also wasn’t understanding what was the method that I wanted to deliver this information to the patients.

More than once I chose not to perform an HVT to a patient because I didn’t know how to inform them properly about the potential risks of the technique. 

 

As soon as I noticed that this problem was affecting my patient’s care, I started asking for help from as many tutors as I could possibly ask.

I also found on the virtual learning zone a very useful pdf called “ESO communicating risk” that was giving evidence on the risk of osteopathic treatment as well as explained what to do and what to not do when communicating with the patient about the risk of a technique.

Here’s a list of what to do and not do when we are communicating the possible risks of a osteopathic treatment:

 

• Develop a trusting relationship as this is needed to communicate information

effectively.

• Communicate facts in numbers and words.

• Give figures in the Negative and the positive form.

• Compare risks of osteopathic treatment to risks associated with alternative

treatments for their condition,

• Remember that although a leaflet is helpful it is not sufficient on its own.

• Present a range of information in different formats to suit different people.

• Present statistics to patients in context with the patient’s individual presentation.

• Use visual aids with non-threatening colours, symbols and wording.

• Be honest about what we know and do not know – convey uncertainty.

• Explore patients’ understanding, reactions and opinions about the information.

•Compare risk of treatment with the risk of natural

disasters as patients have no control over these events,

• Compare risk with things that they enjoy doing, for

example sport.

• Use relative risk, such as A is 3 times riskier than B

 

I will always try to inform the patients in the best way possible if something has the potential to cause them harm or distress, offering an explanation and checking their understanding

REFERENCES:
Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

Fortunately, in my short osteopathic carrier I still didn’t receive any patient’s complaints, however, It is my duty to have a policy in place to manage any eventual complaints, responding quickly and appropriately to any that may arise. As I am practising now at the ESO clinic I need to have in mind the clinic’s patient complaints procedures. 

 

Here’s is in fact attached the ESO clinic patient complaints procedure

REFERENCES:
ESO - European School of Osteopathy. 2022. Patient Complaints Procedure - ESO - European School of Osteopathy. [online] Available at: <https://www.eso.ac.uk/eso-clinic/feedback/patients-complaints-procedure/> [Accessed 18 May 2022].

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

This reflection has been carried out using Rolfe et al. (2001) reflective model.

On my second year we’ve been assigned to write a response to a letter of complaint as part of our module.

I remember it pretty clearly, the submission date was relatively in concomitance with the anatomy and clinical methods exams and, as a procrastinator I am, I didn’t give as much importance as I should have given it to.

We were in our second term and, right before the anatomy and clinical methods exams, the pandemic started. Uni was closed, lockdown started and there weren’t any flights that were allowing me to go home. I was alone in Maidstone, and I was feeling so uncertain of the future. 

The complaint letter response still needed to be submitted. Despite all the difficulties I managed to submit it in time and eventually pass it, however with not the highest grade.

 

I don’t know if it was because of the pandemic and the overall uncertainty it led me to, but I actually struggled writing this complaint letter.

Even before the pandemic started, I was at a stage where I was discussing and revaluating my choice of studying osteopathy. I didn’t feel inspired anymore and I was starting to doubt if osteopathy was the right path for me.

Usually when I write an assignment I struggle at the beginning and then when I enter in the right mindset, I get obsessed until a point where I start finding fun what I’m doing. That time didn’t happen. I was constantly struggling, I didn’t have any inspiration, words weren’t flowing easily and the only thing I could think was how easy would it be if I would have had it to write in my native language.

Writing that complaint letter showed me how difficult it was for me to defend myself whilst sounding supportive and caring in regard to my patient’s needs.

Again, I don’t know if it was because of my mindset or it was actually difficult for me, however, it made me realise how much more effort I have to make to accomplish the same results as my native English speakers colleagues. 

 

Now what?
As I fortunately still didn’t receive any letter of complaint from my patients, I do not know how I will personally deal with it if it will ever happen, however, I am aware of my points of weakness and strength and I will try to use them in case I will have to.

REFERENCES:
Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

ESO students receive free treatment from our clinic. 

It is quite common, especially early in the year to have first years booking for a treatment just to have an overview of what the clinic looks like and what it is like to be in the final years. I don’t know why, but usually, it works this way: practitioners get bored because students don’t have much “wrong” and the students that are coming to get some treatments to remain disappointed. However, I always found the in-between students’ patient-practitioner relationship fascinating: especially when you’re treating a friend, you still need to establish and maintain clear professional boundaries, making sure that their privacy and confidentiality are safe.

During my second year of uni, one of my friends from the year above told me to book a consultation with her. She just started going to clinic and she wanted to practice how to do an initial consultation since I was having quite a severe elbow pain at the time. The treatment went very well, and in a few sessions, my presenting complaint’s symptoms decreased significantly, almost disappearing. 

Some time went by, and I met her in the canteen, we started having a general conversation, and then she started asking me how my elbow was feeling, the kitchen staff heard what we were talking about and joined the conversation, asking me what I was having. I was about to answer when my friend/osteopath decided to answer for me and explain what I was having and what she has done for it, instead of giving me the freedom to decide whether I wanted to explain it or not.

 

I honestly didn’t feel very disrespected, she acted spontaneously and without thinking of me as her patient, but only as a friend.

I genuinely didn’t mind it, however, I kept this episode in mind when I had an ESO student as a patient for the first time. Despite there might be a relationship that goes beyond being purely professional, it is important to ensure that the information disclosed during the appointment is kept confidential, to ensure the same level of care I would generally give to all patients.

 

It is important to give the same level of care to every patient regardless of the relationship they have with you. Patients need to feel that what they are going to tell you will remain confidential.

Sharing confidential information without consent can have a big impact on the patient’s life. I will always try not to disclose any information without my patients’ consent 

REFERENCES:
Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

I had a valuable experience during one of my first sessions in the children’s clinic. 

My patient was a 5-week-old child accompanied by both parents. 

The parents got referred to seek osteopathic care by a lactation consultant as their daughter was recently diagnosed with tongue-tie. Despite the baby recently undergoing surgery, breastfeeding was still an issue, especially when latching. 

When I asked what the parent’s occupation was, the father told me that he was a Muslim preacher.

During the case history taking, both parents were friendly and open to answering every question I was asking in the most detailed and helpful way. 

However, after discussing the case with my tutor, as soon as I knocked on the door to come back in, I noticed that the mother’s tone of voice changed.

She told me to come in in a very hesitant and embarrassing way, which made me start questioning what was going on.

As soon as I came in, the mother started rapidly covering herself and hiding behind her husband. Even not knowing what was going on made me start questioning myself and made me feel embarrassed.

I then realised that she was breastfeeding her daughter and, most likely she was not comfortable with having someone observing, however, she didn’t know how to address her discomfort to me. 

Once I acknowledged her discomfort, I asked if everything was alright and if she wanted to have some privacy until she was done with breastfeeding. 

As soon as I asked her that, her voice seemed already slightly relieved, and we agreed that they would have knocked at the door once they were ready to continue with the appointment. 

Furthermore, despite my tutor and I discussed the value of doing a breastfeeding examination, I decided that it wasn’t appropriate, so I had to rely only on a thorough examination of the infant.

I know that I couldn’t react very differently from what I’ve done, they didn’t mention that the baby needed to be fed, and I couldn’t know it, however, I should have acknowledged the cultural and spiritual differences that we had and adapted my approach in order to provide high-quality care.

I also noticed how little my knowledge of Islamic beliefs and how they were reflected in providing them care, consequently, before the following treatment I researched and found an article that helped me fill the gap I had. 

 

Delivering high-quality care to patients of the Muslim faith requires knowledge of the differences in cultural and spiritual values. Important differences include diet, ideas of modesty, privacy, touch restriction, and alcohol intake restriction The Islamic faith can influence decision-making, family dynamics, health practices, and risks, and the use of healthcare

Globally, Muslims represent substantial portions of society and remain the fastest-growing religion in the world. A healthcare professional will likely care for a Muslim patient during his or her career. The care of Muslim patients provides challenges for many non-Muslim healthcare providers. 

Delivering high-quality care to patients of the Muslim faith requires an understanding of the differences in cultural and spiritual values.

Understanding Islamic beliefs will assist healthcare professionals in delivering appropriate health care in a culturally sensitive manner.

REFERENCES:
Attum, B., Hafiz, S., Malik, A. and Shamoon, Z., 2018. Cultural competence in the care of Muslim patients and their families.

Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

 

“Being a student is about more than learning a subject. For many students, the university is also a time for personal experimentation and discovery. For younger students, it can involve the first experience of freedom from parental constraints. Social life can be hectic and demanding, at times coming into tension with crammed academic schedules.

A medical degree, however, is a preparation for a responsible and, at times, challenging profession and the General Medical Council makes it clear that along with the privileges of professional life come attendant responsibilities; and that these extend to medical students.

Among these responsibilities is the general requirement to avoid acting in ways that bring the profession into disrepute, thereby undermining the trust that patients have in their doctors. This requirement extends at times beyond the professional sphere to include some aspects of your personal and private life.”

 

“From great powers comes great responsibility”

 

As for a medical degree, the degree I am doing is a preparation for a responsible and challenging position I will do for the rest of my life. 

To be a good osteopath we need to internalise a set of values that will make us keep good conduct both professionally and personally. 

Any bad conduct can cause harm to others (like our patients), to our professional career, and to the reputation and future of our profession.

 

I will always have regard for my professional standing, even when I am not personally practising as an osteopath.

REFERENCES:
Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

The British Medical Association is the trade union and professional body for doctors in the UK. 2022. As a medical student, am I always on duty? - Ethics toolkit for medical students - BMA. [online] Available at: <https://www.bma.org.uk/advice-and-support/ethics/medical-students/ethics-toolkit-for-medical-students/am-i-always-on-duty> [Accessed 15 May 2022].

During the 3^rd year of this degree we had to write a business plan as part of our curriculum.

During the assignment, I had the opportunity to reflect on pricing. 

When I’ll open my own clinic, I will aim to responsibly choose the charging fees based on the market pricing and aiming to make osteopathy being accessible for everyone in need.

Here’s what I wrote on the business plan:

 

“The pricing has been decided on the current market pricing, clinic’s day to day expenses and estimated profit margin. The cost will be 55 euros for an initial consultation and 50 euros for the follow up appointments. Moreover, if patients cancel their appointments within 24 hours of their booked appointments, they will be charged 10 euros, and if they do not show up for their appointments, they will be charged 30% of the service.”

 

Back in my third year, thinking of opening a clinic was still a problem for the future me, I wasn’t thinking about it and I wasn’t really caring much about it, this assignment made me actually start reflecting on what kind of osteopath I want to be, where I want to be based, how I want to run my clinic etc.

I am very thankful for this assignment, because only when I started working on it I begun to question what my future is going to be like, leading me to some weeks were I was feeling thrilled and scared at the same time for what will come after graduation.

I also realised that being an osteopath and care about your patients cannot only be applied during the treatment session, however, it needs to be extended on the way you run your business and consequently, the way you charge them and communicate with them your professional and personal financial dealings.

 

In my future career, I will provide clear and visible information about my clinic's charging policies, respect my patients, and aim to keep osteopathy accessible for everyone who needs it.

REFERENCES:
Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

As my time in the ESO clinic is reaching an end, we need to start thinking about handing over our “maintenance” patients to the years below. 

Over these 2 years at the ESO clinic, I had the fortune to come across Mrs X, a 70 years old retired woman that comes for treatment every 4 weeks since 1999. 

I started treating her right at the beginning of my 3^rd year, and I really enjoy having a monthly appointment with her, as we created a very good patient-practitioner relationship.

She told me multiple times that I needed to find a talkative and dynamic person to substitute me, so I asked her if she was ok with meeting a possible candidate at the following appointment and she agreed.

On the following appointment, the chosen practitioner came to observe. After the treatment, when the observer left, I asked Mrs X if was happy with the candidate and she expressed positive thoughts.

I decided that I will still treat this patient until the end of the year, and then, once the course will be close to the end, I will hand it over to who we chose is going to be Mrs X’s new practitioner.

 

I still need to write the actual handover sheet that I will give to Mrs X’s future practitioner, however, I am happy with how I managed my patient’s expectations. Furthermore, my colleague was happy to meet the patient in advance, so she could know what she’ll be dealing with and how to interact with the patient.

I will also provide her with a patient summary I had to do for my mock CCA, so she can have a more accurate overview of the patient. 

I will continue to provide as much information as I can to all the patients I will have to hand over in the following month, to support my colleagues and provide the best quality of care possible to my patients.

REFERENCES:
Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

On the 1^st of September 2021, I had my first initial consultation in headache clinic. Ms X presented in the clinic with unilateral excruciating headaches located on the left eye socket and temporal bone, with associated reddening and watering of the eye, blocked nostril, swollen eyelid, flushing and facial hyperhidrosis.

The pain started 25 years ago, with no particular onset. The frequency of the occurrence of pain gradually increased from sporadic episodes over a period of months, to daily episodes occurring twice daily, respectively around 02:00 pm and 11:00 pm, with episodes lasting around three hours. The patient was non-responsive to medication except partially to oral sumatriptan and pain was making her restless and almost wanting to hit her own head by way of relief.

With my tutor we recognised that the patient’s presentation was non-mechanical, hence we could not help her relieve the symptomatology with osteopathy. Specifically, my tutor and I suspected that the patient was suffering from cluster headaches. 

After receiving the patient’s consent, we consequently referred her to her GP, and she was also advised to contact the OUCH (organisation for the understanding of cluster headache) to seek help in concomitance of accessing help from her GP.

 

This was the first referral letter I’ve ever sent. I am glad I received the appropriate support and guidance from my clinic tutor. 

As osteopaths, we need to work on our scope of practice and recognise our limits. With Ms x, we acted promptly to ensure her optimal care and enhance her health and wellbeing. 

Writing this referral letter made me initially feel insecure: I don’t know if it’s a common thing for osteopaths, but I think I have some sort of inferiority complex towards doctors. Despite I love my profession and everything that osteopathy involves, I almost feel I am not worthy to talk to them and I somehow feel judged. This can be attributed to some experiences I had in the past when interacting with medical students, that started attacking my profession and telling me that there wasn’t any good in osteopathy. 

Despite that, I had to put my patient’s health first place, acknowledging that the patient’s needs were beyond my limits and that Ms X’s management needed the contribution of other health and care professionals.

Thanks to this experience and the valuable help and guidance from my tutor, I overcame my inferiority complex and fully acknowledged the importance of a multidisciplinary approach.

 

I will continue to consider and promote a multidisciplinary approach every time it is appropriate.

Referring patients to other specialists is the optimal and absolute way to enhance their health.

^{Here is attached a referral letter I wrote with the support of my clinic tutor during the headache specialist clinic.}


REFERENCES:
Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

It was my fourth week of summer’s clinic; the weather was nice and going to the clinic every day was becoming a habit. I was actually enjoying and looking forward to and I started noticing how nice it was to go to clinic without having the pressure of attending lectures and studying for any exam. 

I remember it clearly: it was Tuesday the 7^th of September. I woke up that day feeling more tired than usual, however, I thought it was only because of lack of good quality sleep. Out of precaution, I took a test, and I noticed that there were two, however faint lines. I was positive from covid. At that moment I was still asymptomatic, however from the day after I had all the classic symptoms you could possibly have when you’re positive: fever, cough, shortness of breath, loss of change in the sense of taste and smell and headache. The first three days were pretty intense, however, from the fourth day on, all the symptoms subsided. 

 

Probably if there wasn't a pandemic, I would have not even questioned my tiredness, I would have gone to the clinic, struggled a bit more than usual and continued for the whole day. It was just a bit of tiredness, that’s it. However, since there was a pandemic, and I am also a healthcare professional now, I had to ensure that any possible problem with my health would not affect my patient’s wellbeing. As a carrier, I had to take all the necessary precautions to prevent transmitting covid to my patients. During those 10 days of isolation, I lost around 30 hours of clinic, which I had to recover over the following months, however, despite that, I know it was the right legal and ethical decision to make.

I will always continue to put the patient’s health first place. If I’ll believe again that my health could even possibly put my patient in any danger, I will take action to keep the patient far from any harm, not practising until I received the appropriate medical care.

REFERENCES:
Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.

 
this reflection has been carried out using Rolfe et al. (2001) reflective model.

what?
At the end of term 1 in year 3, I had a patient complaining of Bilateral hand stiffness,  right elbow pain and neck pain. She came to the clinic after unsatisfactory management received from an osteopath working in another clinic aiming to have a reduction of symptoms. During the case history, when I asked her what she thought was the cause of the pain she told me that the pain started following multiple episodes of domestic violence that occurred 5 years prior to the consultation.
I asked her if she was ok with giving me more details about that, to have a better understanding of what she was complaining about, and she calmly started giving me more details.
She explained to me she had a toxic relationship with her ex-husband. She was being beaten up every day for 2 years in a row. 2 years where bruises and black eyes were an everyday thing. She explained to me she had multiple concussions, and 4 ribs fractured. 2 years of hell, where she felt without voice and soul.
I sat there listening, giving her as much attention as I could, trying to show her empathy but without giving her the classic look you give to someone that suffers.
I admired her honesty and I think she needed to talk to someone about it. 
I didn't tell a word until she was done, partially because I was scared of saying anything wrong but mostly because I wanted to give her space.
I checked if everything was fine now at home and when she told me so, we continued with the case history.

so what?
At first, I honestly didn't know what to say. I was shocked by the brutality of things she was involved in.
But then I realised that I don't always have to say something. Sometimes the best thing to do is just listen.
The patient trusted me and felt like she could open up. Maybe it was the first time she actually said out loud that the pain she was having was caused by the violence she received. Or maybe not, who knows. We live in a time where we feel that we need to give our opinion about anything, and we forget the beauty of listening. Her story touched me a lot and made me aware of the therapeutic effect of being listened to without feeling judged.

now what?
Patients will come with different experiences, needs and values. I want to try to always give them full attention to express themselves without feeling judged.

REFERENCES:
Rolfe, G., Freshwater, D. and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions a User's Guide.