D2(a) Reflective model Driscoll (1994)

What:

Knowing what I know now about patient communication consent and professionalism, I've been thinking about previous treatments I've had such as chiropractic, osteopathic and various massages.

So what:

Reflecting on the language and actions carried out without consent during my personal experiences, with over familiar practitioners has been something I have encountered which has made me feel uncomfortable enough not to return to them. This has ranged from them assuming I would be fine with a hand hold or treatment style, to even undoing my bra whilst I laid prone on the couch - without any word of explanation or consent. This certainly made my opinion, consent and views feel disregarded.

Now what:

Thinking back to these personal experiences, although I never complained, there are definitely learning experiences to take away from it. This has taught me what's good and not so good in a professional health care environment with patients. Simple errors of judgement can lead to bad feelings from patients, possible bad online reviews or even official complaints. Bearing this in mind, considering and recalling my own negative experiences; this can be avoided ensuring patients feel respected and informed throughout all encounters. This can be achieved by the following:

• Initial informed consent

• Checking the comfort of the patient with hand holds or positions and making sure they understand what I am verbalising and encouraging two way communications

• Avoiding making assumptions about what I 'think' may be ok with the patient

These simple steps can avoid overstepping boundaries as I have experienced.

B1(a) Reflective model Gibbs (1988)

Description:

During lectures, coming up with the answers to questions quickly, is something I'm working on.

Verbalising muscles/ligaments is something to practise. Lecture assistant, XXXX, highlighted this in a lecture this week.

At the time, I was uncomfortable with XXXX's manner; the way she spoke and how she expected immediate information verbally and on paper from me; I felt a bit silly. 

Feelings:

This frustrated me! I felt pressure, stressed and uncomfortable it took me back to being a child at school. I wasn't reactive, I just sat with how I felt and worked through the discomfort I felt. I really wanted to either cry or exit the room.

I must reiterate here, the discomfort was all mine, I created it not XXXX.

XXXX did help me massively during that session.

Evaluation:

I guess it's interesting how childhood memories flag up. I didn't enjoy school particularly, I wasn't academically smart; I blundered through it probably driving my tutors crazy. I'm not that child anymore and I've learned that I can take criticism and I can be thankful for the discomfort in breaking out of my comfort zone.

Analysis:

The following week in Soft Tissue class, I brought these feelings up in conversation with XXXX. I explained how stressed I became and how much I felt under pressure. XXXX was great and we discussed it, XXXX was unaware of my feelings at the time.

Conclusion:

Upon reflection, I am grateful for the experience as I feel it's the tough times that make me grow as a person and develop my resilience and skills. I definitely feel that I have sharpened my knowledge too as a result of the discomfort I felt.

Action plan:

I am sure this won't be an isolated incident of feeling uneasy under pressure, so managing my emotions moving forwards is most important for development. Knowing I dealt professionally and calmly with this experience will mean I can replicate it in future. I have attached a section of the year 1 OS416_CW2 which demonstrates my reflective input at the time of the event. I found the coursework and subsequent feedback really beneficial to explore how I can further evaluate situations, to form more of a working basis for improvement. This coursework was very challenging to write, even though I understood the requirements, there were areas which fell short which by developing, will help me reflect more in future to greater depths.

B1(b) Reflective model Driscoll (1994)

What:

An important self-reflection that I felt compelled to add to my Padlet, in view of my previous entry B1(a) and the unease I felt when feeling under pressure.

Considering how opinions affect, for better or for worse, the patient. 

Our own opinions can shape the way we treat a patient but taking on additional input and opinions can assist us to develop our thought processes as student osteopaths in clinic. Understanding how a student and a clinic tutor can work in harmony even when their ideas may appear differently initially. Likewise, this has been something I've seen when two tutors are discussing a patient's history and possible diagnosis.

So what:

Initially, this idea felt very awkward for me, having been self-employed where I had worked alone for many years, a difference of opinion would cause an inner conflict. Even though I wouldn't necessary voice my discomfort I was really aware of it. Being in clinic and observing how opinions from other students plus the opinions of tutors with other tutors, in clinic, who have mixed opinions which challenge development has been interesting and has helped me to appreciate that not everyone has the same ideas and thoughts. This has also enabled me to not take differences of opinion personally; as part of my learning process to enable me to be able to get the best out of my experiences by taking on the view from others whilst formulating my own ideas to build my knowledge.

Now what:

Ultimately, I need to be open-minded, to develop professionally, to gain the skills I need to safely and effectively treat my patients. This has really helped me psychologically and from a confidence perspective too. Knowing that my developed mindset will lead to accelerated learning and the desire to question myself or ask for help when I need it. 

D9. You must support colleagues and cooperate with them to enhance patient care.

D9(a) Reflective model Driscoll (1994)

What:

Meeting new people, students, patients and tutors is very interesting.  Different people, views, experiences, backgrounds and skill sets. This has made me really consider my input when communicating. What I mean by that is I always had a desire to be right! Even in my everyday life, I'd want not only the 'last word' but to heard at all cost if addressing a difference of opinion. This would make me feel quite unsettled if I was challenged, but really, I'd created the challenge by being unapologetically awkward! 

So what:

Looking at things differently, more openly and with care and thoughts towards others I feel more patient and understanding. I am more relaxed, less egotistic and I consider why people are the way they are, allowing for their character and opinions. This is aiding my interactions with peers as I am more able to support them where needed.

What now:

Feeling ok to be me and allowing others to be themselves too, challenge free. The more this shift continues the easier life becomes in general. I guess this has come as quite a surprise to me as I thought I had joined the ESO to learn about osteopathy, yet I am definitely getting more from it than I'd imagined. The attached research from Banerjee et al. (2016) regarding teamwork for medical students formed interesting reading around how curricular amendments in healthcare can aid development of practitioners (non-osteopathic specific). Obviously in medicine, teamwork failures and poor interpersonal communication has a safety risk for patients. With osteopaths these shortfalls might lead to lack of effective referral, poor patient management and lack of continuity in care. My experience so far, educationally at the ESO is that all our educational modules promote teamwork. We practise together, discuss cases and have presentation teamwork assessments. This has been really valuable for me to see how important it is which is one of the reasons I wish to always work within a clinic team environment at least 2 days per week, even when I am treating patients within my mobile clinic. I feel that this way I can remain in a position to discuss new research, patient cases and new techniques with colleagues to avoid stagnation in my osteopathic journey.

Banerjee, A., Slagle, J. M., Mercaldo, N. D., Booker, R., Miller, A., France, D. J., Rawn, L., & Weinger, M. B. (2016). A simulation-based curriculum to introduce key teamwork principles to entering medical students. BMC medical education, 16(1), 295. https://doi.org/10.1186/s12909-016-0808-9

During our Professional Skills lecture we discussed patient partnership, communication and professional understanding towards colleagues.

These were the words we put together during our Professional Skills lecture. This was interesting as there was such a wide variety of words, the largest being the most frequently selected. It helped me to see how others viewed things.

A4(a) Reflective model Driscoll (1994)

What?

Patient consent and the importance of initial consent compared with procedural consent.

Do not assume a patient is 'ok' with things until you clarify this in a non presumptuous way.

So What?

I write this following OSPE 2 today where I feel I rushed the consent element, although I'm sure my feedback will tell me!

Now What? 

Upon reflection I need to ensure I get consent before and during treatment. Including specific consent for certain techniques or body part contact, such as the pubis or sacrum.

UPDATED: FEB 2023 with consent feedback from OSPE 2 last month which I've attached.

To decipher the wording, it states:

'Spoke to patient well. Attention to patient. Honest - good - professional manner. Informing patient what (I'm) doing. Don't forget they need to understand too'

My mark was 10 out of 20 here, definitely suggesting room for improvements.

A5 Reflective model Kolb (1984)

Concrete Experience:

Female patient, aged 43. Presents with hyper-mobility and MRI confirmed degenerative changes to L4/5, which her Mother and Sister have too. No Radiation. Worse for bending forwards and standing too long. Better for NSAIDS and sitting. Patient has antalgic posture and loss of abdominal tone predisposing posterior pelvic positioning. This patient is Greek and although she speaks English well, there is a language barrier to over come.

Reflective Observation:

During the case history taking, I was conscious to watch for signs of lack of understanding, facial cues and pauses which suggested I needed to rephrase my explanations. Reading back notes to my patient and taking time to ensure she understood each stage. 

I encouraged my patient to stop me if I went too quickly, assuring her that I am happy to repeat myself. My patient felt comfortable to request further information and for me to reiterate what we were discussing. I utilised the poster on the wall to explain various MSK regions. I felt like I handled this situation well and it's given me confidence for future encounters where English language isn't the Mother-tongue. 

Abstract Conceptualism:

Whilst discussing treatment options, the patient disclosed that she feels her posture isn't helping her LSP. She requested some exercises to assist with this. The patient has taken her health seriously over recent years and has lost 20kg in weight. This reflection is based upon her first clinical encounter as a new patient at the ESO. The patient said she would be unable to return for a follow up as she's returning home to live. Following a mutual discussion with my tutor and the patient, due to the initial consultation time constraints; we wouldn't have time to treat and go through a detailed abdominal rehab discussion and practise the exercises given. The option of declining treatment at this time and going through the exercises for self help was offered. The patient felt that this would be more beneficial, particularly as she won't be able to return to the clinic. The patient practised the exercises shown and was given information to take away to enable exercise progression as strength improves.

The patient left the clinic pleased with the fact that she has something to work on herself. 

For me this was a situation whereby the patient was decisive in her manner and understood about her degeneration and postural weaknesses. Working with the patient with open and honest discussion to ensure they can help themselves positively.

Active Experimentation:

As a new 3rd year, new to clinic, I felt happy with this learning experience and it has inspired me to learn more about rehabilitation and exercises for patient self-help. I think I thought that patients wouldn't necessarily engage in exercises, but that pre-judgement is incorrect. Moving forwards I will remember this and avoid pre-judging. Patient partnership involves discussion of priorities, heath and treatment/exercise options and understanding a patients' thought processes; as well as the confidence to communicate my thoughts and the options for the patient in a way that they understand and can then decide what they feel will be best. The research by Kongsted et al. (2021) discusses the point I raise as above and self-management of lumbar pain can prove powerful and beneficial for the patient, as well as how manual therapists can empower them through salutogenic discussions surrounding health. By educating patients the fear of pain can be easier for them to manage too.

Kongsted, A. et al. (2021) ‘Self-management at the core of back pain care: 10 key points for clinicians’, Brazilian Journal of Physical Therapy, 25(4), pp. 396–406. doi:10.1016/j.bjpt.2021.05.002.

There is an element of  A, B & C within this encounter.  I am focusing on B2

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

B2(a) Reflective model Kolb's (1984)

Concrete Experience:

New patient encounter. Male. 73. 1 week ago fell, with ladder whilst trimming a tree branch. Landed on left side anteriorly positioned. Landed on concrete from approx 8 feet up.

Rib pain on left, patient said possibly fractured a rib. No hospital visit or Xrays.

Main complaint is LSP on right. QL spams 8/10 at time of trauma. Now very much settled down and minimal pain. Patient believes his lower back needs 'clicking back in to place'. 

DDX: QL hypercontracture following the trauma.

Treatment intention: Soft tissue LSP Mobs side lying, R QL inhibition, de-side bending and LSP decompression.

I explained to my patient that due to the fracture risk with his rib cage, I am unable to preform LSP HVTs. My patient was initially keen to express his desire for a HVT and said 'the rib is fine'. I further explained that whilst theres a fracture risk and the positioning for a HVT requires me adding weight to the area, it isn't safe or acceptable for such a risk to be taken. I explained that the muscles can be suitably worked upon and I can mobilise the joints safely without the need to HVT. My Patient understood our discussion and thanked me for explaining it to him. 

Restest showed improved LSP segmental movements in side bending and patient felt this too. Patient thanked me for his treatment and said he felt it had helped.

There are elements of:

A1 & A3. For communication, explaining my reasoning.

B2 for referral considerations.

Reflective Observation:

Upon reflection, I can see how easy it would be for a patient to think a certain treatment style would be necessary; especially when they felt it had worked previously for them to reduce symptoms. Making it important to educate through clear communication and layman's terms, sharing knowledge as well as understanding their desire for improvement in their discomfort. I feel that I did this.

Abstract Conceptualisation:

I would like to improve upon my own delivery of expectation management. To more confidently explain the risks, like in this case.  I was detailed and to the point, I also made it clear that a HVT was not to be performed today. Possibly I need more encounters like this to feel comfortable within my self to deliver information. 

n.b the decision to not HVT was made mutually between myself and my tutor, as was the decision to treat. The attached Red Flag Framework by Finucane et al. (2020) denotes spinal fractures as the largest number of serioous pathologies, particularly older patient and females, some of which are non-traumatic. Yet this patient, although male, being over 70 and have fallen from a ladder raised concerns.

Active Experimentation:

Additional notes: - Fri 31st Jan 2025 - 1 year since the initial evidence being written above.

At the time of the initial reflection I had been in clinic just a few weeks treating patients. Having experienced a year in clinic as I re-reflect, I am surprised that my tutor allowed me to treat. If this patient were to walk in again with the same age/traumatic onset and pain, I would be referring to rule out a spinal or rib fracture prior to treating. I have had the benefit of patient encounters or observations with similar traumas that have needed to get the green light from other health professionals prior to treatment. I was actually shocked to read these notes back in honesty, shocked that my tutor allowed me to proceed with treatment with no mention of referral or treatment withdrawal aside from HVTs. I only saw the patient once, so have no idea how his symptoms progressed.

Finucane, L.M. et al. (2020) ‘International Framework for red flags for potential serious spinal pathologies’, Journal of Orthopaedic & Sports Physical Therapy, 50(7), pp. 350–372. doi:10.2519/jospt.2020.9971.

C4. You must take action to keep patients from harm.

C4(a) Reflective model Driscoll (1994)

What:

Female patient attends clinic with CSP, upper traps pain.

Patient confides in my colleague concerning her stress levels and interrupted sleep with bruxism, disclosing that her 3 year old child had told her he'd been touched inappropriately. Patient has struggled with increasing stress and sleep deprivation since.

So what:

My colleague, was unsure how to address the situation in terms of questions to ask moving forwards concerning the events with the patients child. Our tutor advised her to ask if the patient feels the situation has been adequately dealt with - is she/the child now free from harm - have social services been informed.

The patient opened up and elaborated, explaining that the police have been involved, social services and that they were away from that situation, yet she was dealing with the guilt and upset from it, but she confirmed that they are now in a safe place.

My colleague was careful to record the conversations in detail and to tailor her examination and treatment to be conscious of building rapport with the patient without techniques which are too invasive. In time my colleague would like to assess the TMJ intra-orally, as suggested by our tutor; but that wasn't appropriate for the patients first visit to the clinic.

Now what:

Maybe not a situation I'll come across often, hopefully. Yet this was a valuable learning experience which made me consider how I may have responded if told something so upsetting from a patient. A reminder to expect the unexpected during a case history. Attached is further information regarding child protection and safeguarding, some are courses which could prove beneficial for CPD, yet there's still lots of free information to aid healthcare workers if they suspect issues may be arising within a family (Safeguarding children and child protection 2025).

Safeguarding children and child protection (2025) NSPCC Learning. Available at: https://learning.nspcc.org.uk/safeguarding-child-protection (Accessed: 30 January 2025).

This reflection covers many categories of the OPS - I have chosen to highlight the importance of A1

A1(a) Reflective model Driscoll (1994)

What?

Following today's lecture with Katie Barker I am reflecting on the OPS standards applicable and how I can best communicate with my patients. LGBQT+ individuals may not be initially forthcoming to disclose their habits in terms of genitalia/breast concealment or their surgical interventions that could be impacting on their health and MSK.

So What?

Remembering that anatomy doesn't determine gender - but understanding the sex of a patient at birth and the current anatomy is important as some individuals do not alter their anatomy at all.

In the event of a vaginoplasty, the pelvic floor is incised to create space, changing the tone of levator ani and pelvic floor.

Tucking can result in UTI's and altered gait, pelvic tilt and altered biomechanics.

Binding can affect drainage, thoracic mobility, costochondral damage, shoulder pain and cause bad posture.

Trans men - may have a uterus. Remember ovarian cancer, polyps, endometriosis.

To remain OPS compliant I must be inclusive and non-discriminative in my approach. Asking patients:

• What do you prefer to be called?

• Do you have a particular pronoun you would like me to use?

• Are there any anatomical areas that you'd like me to use specific language for?

• Any areas you'd like me NOT to examine?

  
  

Now What?

By giving patients the opportunity to express their preferences and for them to be reassured in a confidential setting is important for rapport, trust and treatment outcome. Research suggests that on average, 2/5 transgender people reported that healthcare staff had insufficient understanding of trans specific needs according to the trans Stonewall (2020) report. With understanding, empathy and an open mind; this can change. Remembering that communication operates both ways between me and the patient which incorporates effective and present listening skills, not just me talking.

Discussing sensitive cases with my tutor away from my clinic group, ensures patient confidentiality and trust, this also aids my tutor to build rapport by using patient preference terminology and pronouns.

LGBTQ+ Pride Flags (no date) HRC. Available at: https://www.hrc.org/resources/lgbtq-pride-flags (Accessed: 09 May 2025).

LGBT in Britain - trans report. 2020. Stonewall. Available at: https://www.stonewall.org.uk/lgbt-britain-trans-report

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.

Reflective cycle Gibbs (1988)

Description:

On the initial consult the patient reported right testicular varicocele which received surgical intervention.

Patient presents, appointment no. 6. Patient reported that his left hip was feeling stiff and uncomfortable. I was unable to reproduce symptoms through movements and testing.

In hindsight I could have referred back to the initial case history of the right testicular varicocele, as he had mentioned hip and groin pain with it; this would've triggered some questioning.

I could have asked:

How did the R hip feel with the varicocele?

Does the L hip feel the same as the R did?

Has the pt noticed any testicular changes?

During treatment the patient reported that he had an appointment the following day with oncology. I felt that I didn't ask suitable questions at this point. I did ask my patient to clarify who his appointment was with and he did repeat 'with oncology'.

I made the mistake of rebooking him for 5 weeks time. In hindsight this wasn't a good idea until we have the results of his investigations. I spoke with my tutor and we decided that the patient should be contacted to cancel his pre booked appointment, which was done.

Feelings:

I felt really upset following this encounter as I had lots of unanswered questions, and was concerned about what the diagnosis could mean for my patient. I felt helpless and like my knowledge wasn't as good as it should be, which diminished my confidence. My tutor was supportive and encouraging as he helped me to figure out what could have been done differently, he also praised how I had dealt with my own disappointments relating to my lack of knowledge. He also commented on how well I'd documented the discussion on the case notes, whilst advising me to take time to reflect and not be to hard on myself.

Evaluation:

I was pleased with how I'd explained hip and lower back associations; how I tested the hip to aim to reproduce symptoms and treated the patient with care.

Patient records are up to date and detailed including what pt reported towards the end of Tt with regards to oncology appointment - This is OPS Standards & Quality in practice, C2. I'm pleased I discussed this straight away with my tutor.

I was disappointed with my lack of questioning and not thinking on my feet, I didn't ask relevant questions at the time. I could have linked things much easier had I questioned the patient more effectively at the beginning of the case history. A reminder to always ask a returning patient if they have any new symptoms.

Analysis:

The learning aspect - what have I learned from this ?

It has reminded me to check the history if similar things present.

It has made me consider that other things can be the creator of pain, rather than simply mechanical pain.

I would've liked to have asked if the patient's L teste feels like the R teste did, pre op. Also, I would've liked to know if he was referred to oncology for the R teste too initially. My research suggests the varicocele would be a referral to urology.

Conclusion:

How might his help me in future situations ?

In future utilising the knowledge from the initial case history, I would be more likely to pick up on previous co-morbidities.

Following this encounter and what I have learned, I feel more confident in future to gently question my patient in terms of their upcoming appointment.

Knowing which departments deal with which complaints would help too - oncology/urology etc.

Had I known about my patient's appointment before I started treatment, I may have just done some LSP soft tissue work, as opposed to going through the hip testing etc. Which goes back to the initial case history - had I reminded myself of the R teste varicocele I would've considered that as a possibility for the L. And always asking the patient if they have any new symptoms since their last appointment as part of the case history catch up. The attached article by Venner (2007) provided beneficial reading for urology and oncology intervention in different cases which highlights specialities in each field, offering me further insight.

Action Plan:

Upon reflection over a period of weeks, it occurred to me that I assume the patient is always right and therefore I don't always question them appropriately to get to the bottom of things. This is something my tutor has highlighted too. Knowing this, I can ensure I question patients appropriately in a 'need to be nosey' kind of way, in their best interest. Sometimes I feel like the patient expects me to know everything and this makes me less likely to ask questions around meds or certain conditions, where I could be utilising a patients' experiences and symptoms to widen my knowledge.

The attached article by Venner (2007) suggest the close links between urology and oncology in certain cases but that the scope of practise for both must be acknowledged based upon experience and the task at hand. I found this useful to understand more about the roles of each specialist.

In future encounters I will adopt the following strategies:

• Habitually review patient notes ahead of treatments

• Ask 'any new symptoms since I last saw you?'

• Improve my understanding of referral pathways

• Understand that inquiring about a patient by asking questions is part of the process, I don't need to know everything!

• Reflections are important as is the support of tutors or colleagues, particularly when I feel I need emotional support

UPDATE: 8 weeks later the patient revisited clinic, I can confirm that his appointment was with UROLOGY not oncology and nothing abnormal was reported, which was a relief for all.

Venner, P. (2007) A medical oncologist is the most qualified specialist to provide systemic therapy for patients with advanced renal cell carcinoma, Canadian Urological Association journal = Journal de l’Association des urologues du Canada. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC2422954/#:~:text=Urology%20is%20a%20surgical%20specialty,is%20based%20on%20systemic%20therapy. (Accessed: 24 January 2025)

B3(a) Reflective model Driscoll (1994)

What:

EBP refers to everything that has been researched and scientifically evidenced and reported upon. This is utilised wherever possible to ensure patients are suitably informed and correctly informed. This gives patients confidence that what we practise isn't pseudoscience.

So what:

A practitioner must be able to refer to relevant literature to support rationale.

Likewise, understanding the mechanisms happening within the body, during the treatment, is imperative. Knowing how the tissues respond, how the nervous system and vascular system respond.

Now what:

GOsC and the OPS also advise the use of evidence informed practice. There is a lot of research when applying questions about osteopathy, utilising the path of tissue changes following mobilisation or soft tissue techniques and the outcomes. This knowledge helps to inform us and our patients based upon available evidence. Bordoni (2019) suggests that literature can guide in osteopathic evidence based techniques for treatment whilst providing osteopaths a constant stimulus, often in need of update. Such as with cranial techniques, where a practitioner's or patient's experience of a technique may prove beneficial in informing choices of treatment based upon these preferences. Regardless of evidence availability and that the key is transparency in patient situations enabling shared decision making.

Bordoni, B. (2019) The benefits and limitations of evidence-based practice in osteopathy, Cureus. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC6897345/ (Accessed: 12 May 2025).

D6. You must treat patients fairly and recognise diversity and individual values. You must comply with equality and anti-discrimination law.

D6 Reflection - applicable to standards B1,2,3,4 & D10

D6 Reflective model Kolb (1984)

Concrete experience:

Observing in children's clinic and a 7 Yr old male attends with his Mother.

The child articulately described paresthesia to toes with periods of numbness. Also his fingers tips. Both UEX and LEX symptoms can't be physically shaken off, like a peripheral entrapment. No pain anywhere. Patient reports his LEX sometimes feel weak.

His Mother is concerned about his symptoms and is an articulate and intelligent lady. His Mother understood the need to run some test to try and reproduce her son's symptoms.

I observed my colleague carry out a neuroscreen and muscle power tests. The patient reported some sensation changes to his legs before my colleague began.

Reflexes and muscle power was comparable left and right.

The patient is from a vegan family. My colleague concluded a possible vitamin deficiency causing the symptoms. B12 deficiency could be the cause.

My colleague referred the patient to the GP for blood tests to check for deficiencies. Once this was discussed, his Mother said she was concerned about a deficiency and disclosed that her Son was/is offered a very varied vegan diet but is a picky eater.

Reflective observation:

This was a really interesting case. Hearing first hand what the possible symptoms could be of B12 deficiency and seeing how this affected the patient, was a great learning experience as learning from a book never offers the same insight.

Abstract conceptualisation:

I subsequently referred to my pathophys notes from earlier in the year to solidify my learning, having seen B12 (suspected deficiency) first hand, with the potential neurological deficits. This reminded me of the importance of a detailed case history, plus not being afraid to ask additional questions not specific to the case history form.

A reminder of useful questions to ask patients/parents -

• Is the child a good eater?

• Has the child always been a picky eater?

• Vegan/vegetarian etc

What was really interesting to me was that my colleague has very strong views against veganism for multiple reasons, personal to himself. This came as a surprise to me as he was so professional in his communications with the patient and his Mother. My colleague was nothing but supportive of the patients' wishes regarding food choices and acted accordingly. This was excellent to see and really inspired me.

The recent research by Jensen (2023) was eye opening to me as I hadn't considered the impact upon the younger population with dietary shortfalls and B12 deficiency, something which needs more publicity as I wondered if possibly parents might consider veganism a good diet due to the reduction in saturated fat consumption and lowered associated risk of chronic diseases.

Active experimentation:

Expanding what we already know/ask to ensure nothing is missed but that the questions are asked where appropriate based upon the presentation of the patient. I have since utilised the B12 questions where a deficiency has been suspected with other patients during the case history.

Although I have no preconceived ideas or preferences regarding food choices, there may be other things that could form conflicting values which, unchecked, could lead to discrimination which would be non-compliant with ant-discrimination laws. To be mindful of this is paramount.

Jensen C. F. (2023). Vitamin B12 levels in children and adolescents on plant-based diets: a systematic review and meta-analysis. Nutrition reviews, 81(8), 951–966. https://doi.org/10.1093/nutrit/nuac096

D10 Reflective model Driscoll (1994)

What:

63 year old female patient. Presents at the clinic with lumbopelvic pain.

Patient had pars fractures 30+ years ago and suspected historic spondylolithesis.

My patient had no radiations or CE symptoms.

Upon examination it was clear that the patient had central obesity, no pitting oedema.

So what:

I explained to my patient that I would like to do a test for her abdomen to assess the fluid within. My patient gave consent. I tested for shifting dullness, this was positive. My tutor was happy for me to treat my patient and refer her for further investigations. My patient agreed and was happy that she'd visited the clinic as she said she never goes to the Drs normally, but she felt her tummy was bloated and would like to get some answers. My patient signed a consent form and I wrote a referral letter.

Now what:

The patient's GP organised an abdominal ultra sound and blood test to check for liver and kidney function. The patient was found to be pre-diabetic yet nothing else abnormal was reported. The patient was really pleased and relieved with this news as she knew she needed a blood test but had struggled to get an appointment prior to my letter, see attached. This was the first referral letter I'd written and it took a while for me to do, with practice, this will become a more streamlined process taking less time. Plus I now understand the importance of key points of inclusion within the letters to describe what is happening for the patient, which will make future letters easier to write.

D9. You must support colleagues and cooperate with them to enhance patient care.

D9(c) Reflective model Kolb's (1984)

Concrete experience:

During the 2nd year there were many discussions with my peers concerning clinic groups and who wanted to be with whom, and who wanted to avoid being in a group with whom too.

I knew early in to my studies that the clinic group needed to be a place where I would be challenged to improve whilst feeling like I could express my views and ask questions in a safe space.

Reflective observation:

Having observed the 3rd and 4th years I could see how different group dynamics were either inspiring people to learn and grow with support, or how they were having an adverse affect.

Abstract conceptualisation:

There are people who I connect with but that I knew I didn't want to be in a clinic group with because those individuals wont challenge me enough as our knowledge level is similar. I was keen to get a happy medium but I wanted to be challenged to be better, that was my priority.

Active experimentation:

I feel that being in clinic in my group has been a really positive experience. We are keen to progress and learn, wanting to be better, asking questions and developing.

We have different ideas and different strengths, this is very helpful as we can all support each other and respectfully assist or give each other space when needed. Our characters are all very different too and this inevitably brings variations in thought processing. I do feel that I have developed personally since being in my clinic group. I have developed more patience and understanding towards others and feel much less frustration than I had anticipated. We have become a team I enjoy supporting everyone in their journey of development and understanding.

A4(b) Reflective Model: Kolb (1984)

Concrete Experience:

Consent in practise is multi dimensional. Not only must the patient have the right to decline (examination, treatment etc) they also need to have the capacity to do so. Recording of conversations on the patient's file and reiterating the options available, including stopping the session. Reading a patient's body language to pick up on subtle cues or concerns.

Reflective Observation:

Reflecting back to Averille's Barefoot talk, she shared a paper on non verbal communication (NVC). Socially, NVC is common place within interactions, yet these have cultural differences. The NVC cues and facial expressions are imperative to practitioners, and why we would look out for cues suggesting confusion or discomfort.

Children, adults, males, females - all display different cues. Autistic children may have more neutral facial expressions and less outward reactions when stressed. The general conclusion being that there is much to learn about NVC and this in practice can help to guide us, but by no means takes the place of verbal spoken consent, see attached by Hall et al.(2019).

Abstract Conceptualism:

Lack of consent is a common complaint from patients to GoSC.

Following the same consent protocol with every patient, tailoring it where needed and providing the details on every patient's notes will help keep consistency within my practice and reduce the risk of issues arising.

Active Experimentation:

In a previous entry following year 2 OSPE (see A4a), I mentioned how I felt I'd offered minimal correct consent, and I did reflect upon it and it has made me think about how I can avoid lack of consent in future.

1. Fully explaining processes in layman's terms with my patient.

2. Sharing decision making.

3. Offering options - treatment/no treatment/alternatives.

4. Following NICE Guidelines where applicable.

5. Does the patient wish to have a chaperone?

6. Asking if a patient is happy to proceed.

7. Reading my patient's gestures (NVC).

   
   

   
   

   Hall, J.A., Horgan, T.G. and Murphy, N.A. (2019) ‘Nonverbal communication’, Annual Review of Psychology, 70(1), pp. 271–294. doi:10.1146/annurev-psych-010418-103145.

D2(b) Reflective model Driscoll (1994)

What:

18 months ago, we attended an online lecture with Steven Bettles from GoSC. Steven discussed the common complaints. A large number stem from practitioners being over familiar or 'over friendly' and this is something that must be considered.

I remember thinking about patient and practitioner working relationships at the time. We discussed various situations from money left to an osteopath in a will, to sexual relationships with patients.

So what:

Now I am in clinic I can see how important appropriate boundaries are with patients, and how easy it could be for situations to be misinterpreted I am a naturally friendly individual and sometimes have a habit of speaking without engaging brain. This is something I became very aware of early in my time at the ESO, and I made a conscious effort to address . With patients I avoid rushing to answer when I'm asked questions when, this gives me processing time before I speak. Enabling me to remain professional, approachable and responsive.

Now what:

Like many, I enjoy being liked, yet there are boundaries that need to remain in place.

I avoid over sharing my feelings, thoughts and any personal info. Being friendly, approachable and empathetic is important with patients but this must be done in a professional manner. Empathy and openness are quality I am pleased to posses as I see these as being paramount to clinical practice when utilised within professional boundaries.

The same goes for sharing political views or feelings on certain topics. Not everyone has the same thought processes and this could spark a debate which is unprofessional and unnecessary. Prioritising patient experiences, trust building and clinical relationships as a practitioner.

A1. You must listen to patients and respect their individuality, concerns and preferences. You must be polite and considerate with patients and treat them with dignity and courtesy.

A1(b) - Reflective model Driscoll (1994)

What?

Katie Barker gave us a lecture 5 months ago which is discussed in A1(a) evidence. That lecture proved to be exceptionally beneficial in terms of putting in to practise what I had learned.

It provided me much to consider and certainly educated me.

This week in clinic I had a patient who advised me they were born male and were hormonally reassigned female. They prefer they/them in pronouns.

I found this really interesting and they were open about their challenges. This was really helpful as it gave me a deeper understanding of what the patient comes up against in daily life. I appreciate that not everyone may be so forthcoming with information and I would need to read each situation as it presents to me.

Asking which pronoun people prefer and if there are certain parts of their body they would prefer me to avoid is very important. I was then able to advise my tutor of this so he was aware.

So What?

My patient wore a sports bra, with this in mind I would automatically avoid the chest area, in the same way I would a female. My patient was very masculine as their gender transition had started later in life.

Certainly I felt conscious not to say the wrong things and I know this will be easier in future. Above all being open and honest is key for me and if I feel I've made an error I would be happy to discuss it/apologise.

Now What?

I have attached an Italian study of Osteopaths and gender by Baldin et al. (2022) it appears there's tremendous room for improvement. Other countries may have different results from similar studies, this must be taken in to account. With communication playing a massive part in patient satisfaction and is one of the main areas for OPS complaints, hence the CPD requirements in this area being necessary.

I'm pleased to have experienced this during my time in the student clinic as I felt supported by tutors and colleagues which will help me to feel more confident to ask questions whilst understanding a patients' point of view. Communication with patients I have always felt confident with and yet this encounter did cause me to second guess myself a few times and then my communication felt a little 'staged', being aware of this for future encounters will make me feel less anxious through fear of saying the wrong thing.

Baldin, I. et al. (2022) A content analysis of osteopaths’ attitudes for a more inclusive clinical practice towards transgender people, Healthcare (Basel, Switzerland). Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC8953530/ (Accessed: 23 January 2025)

Reflective model Gibbs (1988)

Description:

Since the early weeks within year 1, myself and my peers rapidly got used to undressing to expose our body regions for practise sessions during lectures. Initially that feeling of embarrassment, soon subsided and undressing has become something we're all very familiar with and it would be easy to forget that patients may feel differently about body part exposure during treatments.

This week in clinic I had a situation with a new patient who wasn't comfortable to undress beyond leggings and a vest top. Her complaint was lower back pain with radiations to the glute, posterior thigh with paresthesia.

Feelings:

This made me feel really flustered and I wasn't able to confidently verbalise my reasonings for needing more skin exposure. Knowing that my tutor will press me regarding this outcome.

Evaluation:

I was able to reflex test effectively, myotomal test and PROM test her, which was good; yet my tutor was unhappy with the leggings for dermatomal testing. I did carry out a dermatomal test and the patient reported diminished sensation on the left side. I was only effectively able to test for dull sensation through her leggings. My tutor specified that if this were my CCA I would have just failed.

Analysis:

With this in mind, in the event of the same situation in future, I would ask my patient to remove her leggings and sit on the couch with blue couch roll over her lap for protection of modesty. This way I could effectively carry out more effective dermatomal testing, with patient modesty preserved, whilst being able to assess the skin for congestion/bruising and muscle tone/atrophy/scars. Once complete, the patient could the redress in their leggings.

Leaving the room for the dressing/undressing and being sure that the patient is happy and consenting to my requests following my explanation as to the reasoning behind my request. I would also be conscious to expose a patient for ONLY as long as is needed whilst particular tests are carried out.

Conclusion:

It has made me consider how important it is when a patient makes an appointment, that they're aware of what to wear, depending on their presenting complaint, region of the body and what they're comfortable with. This is a discussion which is valuable before a patient arrives for their first appointment. Ideally, stretchy shorts with a sports type bra or vest top is ideal. If the presenting complaint is the UEX then comfortable trousers would be fine on the LEX.

Action Plan:

The attached research by Johnson et al. (2016) suggests males are more comfortable to undress than females. Females are also more likely to consider the gender of the practitioner when needing to undress. Draping options for modesty to suit the patient plus clear communication as to why is of upmost importance. These are things I will consider in future as well as working towards effective, confident and clear communication of my requirements.

Johnson GM; Little R; Staufenberg A; McDonald A; Taylor KGM; (2016) How do they feel? patients’ perspectives on draping and dignity in a physiotherapy outpatient setting: A pilot study, Manual therapy. Available at: https://pubmed.ncbi.nlm.nih.gov/27716547/ (Accessed: 24 January 2025).

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

C3 Reflective model Kolb (1984)

Concrete experience:

In the student clinic, all notes are hand written. This has advantages and disadvantages. Multiple practitioners per patient over time, can result in hand overs which take longer to complete due to handwriting and legibility issues. It also takes space for storage and could be lost in the event of a fire. An electronic system could reduce the likelihood of boxes unticked, by flagging up unanswered questions discussed with the patient - such as consent.

Reflective observation:

New patient encounter following a 40 mph side collision RTA. Patient complaining of CSP and TSP pain, likely whiplash with head aches.

Abstract conceptualisation:

I knew straight away with this patient that there was a possibility of a compensation claim for a non-fault RTA, knowing that there are genuine and disingenuous claimants, I conversed this to my tutor in private - I was careful not to prejudge the patient. I was pleased that I considered both sides of a potential insurance claim and that I hadn't prejudged the patient. I was pleased with my examination and communication to the patient throughout and had decided in my mind that I would merely assess for TART to begin with.

Active experimentation:

My examination found trapezius myalgia with a rotation lesion in the upper Tsp with tenderness. I reported my findings to the patient and at this point I asked her if there was a personal injury claim going through, to which she replied yes. At this point I advised her that she could request a printed receipt for treatment from reception and that her notes would be stored with my detailed findings and treatment/prognosis should the insurance company or solicitors need them.

This was the first time I experienced how it might feel to have my notes scrutinised in a court of law. Upon further visits the TART resolved and I updated the patient's notes accordingly and discharged her. I referred to the Fitness to Practise (2010) article attached about notes and note keeping - although I know as a teaching clinic, this is taken care of for us; this wont always be the case when I work alone.

For my own patients I may consider Cliniko for record keeping and appointments. It costs a monthly subscription but is massively space saving and easy to operate.

Fitness to Practise (2010) FtP ebulletin September 2010 - General Osteopathic Council. Available at: https://www.osteopathy.org.uk/news-and-resources/document-library/fitness-to-practise/ftp-ebulletin-2010-september/#:~:text=You%20are%20responsible%20for%20the,birthday%20(see%20Clause%20117). (Accessed: 30 January 2025).

C5 Reflective model Driscoll (1994)

What:

During my second year I was observing in clinic. The student were discussing health & safety. The tutor mentioned to the 3rd year practitioner about first impressions. What a patient may feel, think and consider if they walk in to the appointment to see a scruffy practitioner (un-ironed tunic), dirt on the floor, full bin, blind open in view of others when undressing etc. I have attached the Health & Safety poster which is displayed in the waiting room for reception.

So what:

At the time I was observing, the 3rd year was really frustrated by the tutor's comments. He did talk to me about it and I could see the perspective from both sides. I could see that the room was messy, blind open in view of the outside world, scruffy tunic and shoes. There were two large dead flies on the floor in the treatment room too and the bin was over flowing. I did mention how first impressions do count and it was only later that I acknowledged the OPS and C5.

Now what:

Since practising in clinic myself, I have considered the tutor's words and I feel that it came from a good place and that she was right.

I therefore take pride in my room and will ensure that it is clean, reasonable temperature, without the bin overly full before I begin. Should there be a smell within the room, I open windows and pop a fan on to blow the air through.

I carry my equipment with me and I am covered by my tutor's insurance whilst I practise.

If I have a common cold and I am well enough to practise, I wear a mask to reduce the risk airborne spread and I wash my hands before and after each patient.

D1. You must act with honesty and integrity in your professional practice.

D1 Reflective model Driscoll (1994)

What:

Patient care needs to be a priority at all times. Working with the patients' best interests at the fore with communication and honesty. With regards to product selling from a clinic environment, this is something that can benefit a patient - for example pilates prickly balls or epsom salts etc. Yet there is a fine line between a suggestion to a patient and hard selling. Certainly to hard sell products on top of the treatment cost would be lacking integrity and is more for practitioner financial gains. Prolonging treatment revisits is also unprofessional and lacks integrity.

So what:

This is why I discuss treatment duration with my patients and I like to revisit the conversation if I feel positive changes have happened, earlier than I had anticipated; also if the progression is slower. Keeping communication channels open and documenting discussions in the patient's notes. By being open there is less likelihood of a patient feeling like they're simply being rebooked for treatment on a never ending weekly basis, as this might feel, to the patient, as if they're being taken advantage of for the practitioner's financial gain.

No what:

Writing my business plan I became aware of what GOsC and the Advertising Standards Agency are ok with, in terms of what an Osteopath can claim to be able to treat. Following these guidelines will ensure I remain compliant whilst building my business. Appreciating that open dialogue with patients and shared decision making as to treatment plans and durations is all part of this.

D3 Reflective model Gibbs (1988)

Description:

A 62 year old female patient attended clinic complaining of lumbopelvic pain. She had experienced back pain for around 30 years.

I treated her and thought no more of it. I saw her the following week and she explained that she was in a lot of pain post treatment on days 2,3 and 4 which had only slightly improved.

Feelings:

At this point in my clinical experience I was unaware of how over treating a patient can cause negative after effects, which is very much an individual process too as everyone reacts differently. On this patient's second visit, when she explained her discomfort, I felt bad for her. I felt like my aim was always to help her and not exacerbate the symptoms and I felt like I'd done something wrong.

Evaluation:

I looked at the amount of treatment I had given on the first visit on her notes, for her first every treatment and a 30 year chronic condition, it seemed a lot. Although her retest immediately after treatment showed increased blood supply to the area and increased ROM, this was short lived.

Analysis:

I discussed this with my tutor who said I'd likely over treated the patient. I was open and honest and explained that it's likely the treatment on her first visit was a little too much, in hindsight; and so I utilised more gentle techniques.

Conclusion:

My patient was concerned that the increase in her symptoms mean't that she was in a worse position than she thought, physically.

I took time to explain how the body can react and reassured her. I documented our conversation within her notes.

Action plan:

I have since reflected upon this and now appreciate that over treating patients is something I need to be mindful of to avoid unnecessary discomfort post treatment. Although this isn't always possible, to communicate honestly the possible discomfort risk to the patient is key.

Letting patients know that they can call up after treatment if they have any concerns too. This way they feel that their treatment is more than just the 40 minutes on the couch. Plus it can build patient confidence and reassure them. Monitoring of patients and encouraging them to communicate about any worries or discomfort during or after treatment is beneficial. I will also consider the benefit of starting out with a little less treatment and then monitoring patient responses to it, this will help me gauge what is working or what needs to be done differently as well as when to do more treatment.

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

D4(a) Reflective model Driscoll (1994)

What:

Last year we were given coursework to respond to a potential complaints letter from a patient. This complaint had been received in clinic as opposed to GOsC.

At the time I wrote the response, I felt I'd done a good job. My feedback suggested otherwise and raised some valuable points for reflection.

I feel that a complaint coming directly to the clinic as opposed to via GoSc gives a greater opportunity for potential resolve and suggests that the patient feels I am approachable and that I am likely to be able to resolve the matter for them. Whereas, if they didn't feel that was the case, a letter to GoSc could be more likely.

So what:

In my coursework letter I was trying to cover every eventuality, giving ALL the info and options for resolving the complaint, GOsC info for raising the complaint as well as explanations for the reasons why the patient felt the need to complain AND how I would be more mindful in future. It was a very busy bit of coursework to say the lest and in hindsight, it would've read as an erratic letter !

i think with it being a coursework piece I wanted to express my knowledge - but I definitely did too much.

In reality, a response to a complaint letter needs to remain focused on addressing THE COMPLAINT. With reflection on what can be done differently to avoid similar outcomes in future. Where can i improve? what went wrong?

Knowing that my handling of the complaint is imperative for future relations with the patient.

Encouraging a patient to express their views and advising them of the feedback service for compliments and complaints - opens the pathway for communication regarding the service they feel they're receiving. With the complaints procedure, patients need to be aware that they can refer it to GOsC.

Now what:

Should I need to respond to a letter of complaint in future, without the pressure of an assignment, in my clinical practise; I will be sure to take time to respond - I will seek advice as to how my response letter reads to ensure it is resolved asap. Whilst following the GOsC guidelines and using the information available to me (Fitness to practise complaints procedure: Draft guidance for osteopaths 2017). Certainly asking for opinions from colleagues or other healthcare professionals would be beneficial, assuming patient confidentiality is protected during such a process.

Fitness to practise complaints procedure: Draft guidance for osteopaths (2017) Complaints Procedure: Draft Guidance for Osteopaths - General Osteopathic Council. Available at: https://www.osteopathy.org.uk/news-and-resources/document-library/consultations/fitness-to-practise-complaints-procedure-draft-guidance-for/ (Accessed: 31 January 2025).

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

D5 Reflective model Driscoll (1994)

What:

During my clinic experience so far, I have been conscious to keep files close by me, not leave them unattended or left on a side in view of others. Likewise, should I remove a file from the filing cabinet, I ensure it's signed out and then replaced accordingly. There have been occasions where I've referred my patient and my patient has given consent for this and signed the relevant forms. This sharing of info, patient consent forms and discussion have been recorded in the patients' notes. I have not been aware of any breaches of confidentiality or sensitive data, so am unable to directly reflect; yet it has made me think of privacy issues in other, non-healthcare, settings.

So what:

In social circles, unrelated to health care, I have come across situations whereby people who are providing a professional service, disclose names and details of their clients. I cannot comment on the rules relating to their particular industry and information disclosure but it certainly makes me feel uncomfortable, I do not wish to hear these details and feel it's very unprofessional behaviour. Which makes me aware not to trust the person with too much info and I wouldn't utilise their services as I wouldn't want everyone knowing my business. This contrast in displays of professionalism with patients' confidential information, highlights my adherence to D5. I fully understand that data breaches can have serious implications.

Now what:

At the moment, clinic reception deal with customer files and archive them accordingly to ensure the 8 year timescales or 25 year of age (in the case of a child) are adhered to. This is something I need to be mindful of in my own practise. With this in mind, I will continue to reflect on data protection matters as they arise, as this is non-negotiable in practice.

Professionalism, trust, confidentiality and use of personal information is so important - treat others how you wish to be treated, this includes data privacy, whilst operating professionally within the OPS guidelines. The website for the Information Commissioner's Office (2023) is attached as GOsC recommend utilising their advice for safe use, storage and deletion of patient data in accordance with the 2018 Data Protection Act. This will be particularly useful post-grad when in my own clinic.

Information Commissioner’s Office (2023) Available at: https://ico.org.uk/ (Accessed: 15 May 2025).

D8. You must be honest and trustworthy in your professional and personal financial dealings.

D8 Reflective model Driscoll (1994)

What:

Writing my business plan, I took time to evaluate the pros, cons, similarities and differences between osteopaths, chiros and physios in my area. I assessed their individual websites, social media and performed google searches. Ensuring they were registered with the appropriate associations. I learned a lot about how to produce a slick, easy to use and informative website with clear pricing structure and patient information. Online booking options as well as contact details will be something I will employ as I feel this encourages people to book, rather than having to make a call to book.

So what:

I didn't observe any conflicts of interest or third party organisations where practitioners could financially gain from recommendation of patients; nor did I see any cross-selling or add on services, yet being mindful that this may not be openly publicised online is a possibility.

Most of the sites I visited were easy to navigate with contact details and pricing structure, but the website layout and professional look varied massively.

What was interesting is that not all the websites I visited had clear cancellation policies, this could be problematic from a patient perspective and a legal standpoint.

Now what:

The work I put in to creating a table with these points for my future benefit will help me to create a professional website that benefits my patient adhering to the OPS. I aim to produce a welcoming, user friendly website with online booking options, pricing structure and cancellation policy.

Upon graduation I will work on a self employed basis. I am already registered with HMRC as a sole trader (Service 2014). I will most likely use an accountant for my annual tax return, depending on the complexities.

I will do some hours within an established clinic and some hours stand alone.

My fees will be available for all to view, transparent and clear - including cancellation policy fees.

Remaining in line with GOsC guidelines.

Service, G.D. (2014) Working for yourself, GOV.UK. Available at: https://www.gov.uk/working-for-yourself (Accessed: 02 February 2025).

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.

D11 Reflective model Driscoll (1994)

What:

Recognising poor health within myself that could be contagious or risk factors for my patients and being comfortable to take advice from others regarding risk assessment.

So what:

Certainly it would be easy to think of the risks through covid, common colds or mental health and cognitive impairments. Yet blood borne infections didn't come to mind straight away. Hep B, C and HIV are risks with certain techniques and there is further guidance below:

https://webarchive.nationalarchives.gov.uk/ukgwa/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_074981.pdf

Now what:

Protecting others always springs to mind more than protecting myself, yet this is a dual process.

Following covid, wearing a mask if I have a cold has become common place and it is acceptable. I still offer the patient the choice of switching to another practitioner if they are still concerned about contagion through the mask. Likewise, I would prefer a patient to re arrange their appointment if they were too unwell to attend. Attached is the advise from GOsC regarding blood-borne infections (Blood-bourne infections advice 2019) which clearly states that osteopaths need to consider safeguarding their own health as well as that of others, reiterating that self reliance on decision making isn't ideal when risk assessing. There are many reasons why I want to work in a clinic environment for a few days a week, this being one of them as I will have other (more experienced) osteopaths to ask advice, particularly with risk assessment.

Blood-borne infections advice (2019) Blood-borne infections advice - General Osteopathic Council. Available at: https://www.osteopathy.org.uk/standards/guidance-for-osteopaths/blood-borne-infections-advice/ (Accessed: 02 February 2025).

D12. You must inform the GOsC as soon as is practicable of any significant information regarding your conduct and competence, cooperate with any requests for information or investigation and comply with all regulatory requirements.

D12(a) - No evidence

Reflective model Driscoll (1994)

What:

Information regarding conduct and competence would include:

1. being subject to regulatory proceedings by a professional body anywhere in the world

2. being charged with a criminal offence anywhere in the world

3. accepting a police caution

4. being suspended or placed under a practice restriction by your employer or a similar organisation because of concerns about your conduct or competence.

Student FTP professional behaviours and guidance (2017) is linked to this Padlet entry for information should I require it in future.

So what:

I have left the guidelines 1-4 above for D12 as something to bear in mind or review when needed. The above guidelines are understandably what GOsC needs us to be aware of to ensure the safety of patients in practice.

Thankfully this is something I am yet to reflect upon as I have no evidence of experience myself or via any of my peers.

Now what:

By maintaining and furthering my understanding of the requirements set by GOsC, beyond my fitness to practise as a student and into my career as an osteopath, I can subsequently avoid issues arising.

Student FTP professional behaviours and FTP guidance - draft (2017) Student FtP professional behaviours and FtP guidance - draft - General Osteopathic Council. Available at: https://www.osteopathy.org.uk/news-and-resources/document-library/fitness-to-practise/student-ftp-professional-behaviours-and-ftp-guidance-draft/ (Accessed: 02 February 2025).

What:

Since the OPS guidelines were introduced and reinforced, it has become easier to notice shortfalls within practice or patient encounters - this helps solidify my learning and OPS understanding.

So what:

At the current stage within my 3rd year, heading towards my 3rd term, I am in a position to appreciate the reasons why the professionalism categories are vital in a working clinical environment. However, some of the categories I don't have experience of and have not observed i.e OPS D12.

Now what:

I will continue to explore opportunities to link experiences or to link times when I have (or I have seen) how a potential OPS misconduct has taken place. This will further my knowledge through reflection.

D7(b) Reflective model Kolb's (1984)

Concrete experience:

After almost 3 incredible years of intense learning the Boxley site, it is being sold ahead of schedule. I have had a very challenging week accepting this news.

I am disappointed in the with holding of information from the senior management team, as we were promised transparency after a F2F meet with them where they said, on two occasions, that Boxley was safe until summer 2025 when we graduate. We were promised that our education would be unaffected. As of Sept 2024 we'll all be in Tonbridge Road. I have emailed my personal objection to these plans.

Reflective observation:

In relation to the OPS I am particularly relating to public trust and confidence and acting in a manner which is appropriate, honest and with integrity whilst having regard to my conduct in and out of patient contact; upholding the reputation of osteopathy - when the whole situation of mistruths has left me questioning the professionalism within the ESO itself, whilst keeping an outwardly positive and happy demeanour to my patients. Not discussing my own concerns or what is happening around me. This is particularly challenging with the few patients that have asked questions about the changes.

Abstract conceptualisation:

Behaving honestly in professional dealings is not something we, as students, are being shown from the ESO.

Unfortunately, there has been a significant disconnect between how we, as students, should operate and the Higher Management Teams' lack of honesty, poor transparency and decision making.

With held information about the Boxley closure, we only know these plans due to leaked information from a staff member. The lack of honesty we have been shown is disappointing to say the least. With all this going on in the background, I will not allow the disputes to impact upon my professional development and patient experience. Remaining neutral is the best policy.

Active experimentation:

Personal development, deep seated beliefs and core values are helping me to understand that I can only control myself and not what goes on around me, yet that doesn't make the situation any easier to come to terms with, it does mean that I can maintain my own focus towards my studies and personal growth.

I have learned valuable lessons in business conduct from this experience which will inevitably be carried with me in the formation of my own business. Over promising and under delivering leads to loss of trust and respect which cannot easily be over turned, this can dramatically impact upon professional conduct should careful consideration not be implemented.

I am proud of how I have over come my own disappointments without voicing anything detrimental to my patients. I have attached a study by Farahmand et al. (2022) about the benefits of lifelong professional, personal development and self-awareness which shows the differences among individuals when faced with various scenarios requiring resilience and coping strategies; stating that this comes initially from self-awareness. I need to be self-aware to make a transition for lifelong changes and positive development.

Farahmand S, Rad EM, Keshmiri F. Exploring the effective elements on the personal and professional development among health-care providers: A qualitative study. J Educ Health Promot. 2022 Aug 25;11:256. doi: 10.4103/jehp.jehp_1405_21. PMID: 36325227; PMCID: PMC9621364.

C1(a) Reflective model Gibbs (1988)

Description:

My recent CEX was with a take over patient and the patient's previous visit had involved a letter being written to the GP concerning a possible Dexa scan. This was met with some confusion from the patient, as although he'd consented to my colleague writing a letter, the patient was unsure if it was necessary.

Feelings:

The patient's concern regarding the reasoning behind the letter became clear which initially made me feel quite flustered, as I'd never experienced it before. I explained the justification regarding the letter and my colleagues' thought processes and the patient was reassured. I felt relieved that the patient pain was reproducible on testing during this CEX as this is something I struggle with at times.

Evaluation:

From my last CEX feedback, the things that improved were:

* Verbalising to my tutor the finer details, meaning absolutely no intervention from them this time.

* This pt was a take over and I took time to read the file, the history and understood what was happening.

* I picked up upon and verbalised note taking discrepancies.

I communicated well. 

I gained relevant informed consent.

I explained my reasoning. 

I tested and justified my treatment choices.

My patient relaxed throughout.

My patient showed retest improvements.

Analysis:

I could have assessed the following in a better way:

* Pt ilia/psis imbalanced. In future: assess feet together standing, what affect does that have on ilia?

* Then seated, reassess. Level now? = ascending lesion pattern 

* Scoloitic patterns. Consider writing apex of curves- I.e R curve apex L3 etc.

* Pt had foot extensor complaint. Ask pt to go up on tip toes to test metatarsal heads.

Conclusion:

My desire and commitment to improve, following my previous CEX feedback in term 2, has been implemented towards a clinically sound improvement, from 52% to this CEX at 86%. I felt confident throughout the process 

I am really happy with my result. The feedback is very useful and gives me things to consider for future patient encounters.

Action plan:

Learn relevant pathways when considering osteopenia. Dexa scan scores and what they mean, where the density is analysed etc, I need to refresh my memory for future encounters.

Remembering the risk factors for osteoporosis such as lifestyle, sex, medication history and age. This way I can be sure to offer my patients the right information to benefit them. Adding to this is that the decision to proceed with a referral is inevitably theirs and requires a signed consent form.

C1(b) Reflective model Driscoll (1994)

Carl Norris - Tutor feedback regarding examination and testing. A reflection worthy of sharing as it links to some previous concerns, allaying them.

What:

Orthopaedic tests are needed to rule out or justify DDX, yet a less acute patient, like today's; may result in a collection of negative findings and therefore me being unsure as to a WD.

With this in mind, I need to carry out the tests but also form a picture of the muscles/asymmetries in terms of TART. Basing my findings upon my palpation and observation skills.

So what:

This means that when don't have enough positive tests, I can begin to consider my osteopathic findings. These include SIJ restrictions, knee/hip OA anything that is justifiable in terms of potential compensation patterns and tissues contracting causing pain.

Now what:

It's worth remembering that a chronic condition with a lower pain score, is harder to reproduce the pt's pain - as opposed to an acute patient.

In my mind, the inability to reproduce the pain was a bad thing - as in raising flags that it may not be an MSK dysfunction; yet there was nothing in the pt's history to justify such concerns. I know that today's learning will help me moving forwards as I have been lacking confidence if I cannot reproduce a patients' pain. I recall in my CEX last month that I was relieved that I was able to test / reproduce the pain and felt reassured by that. Learning and understanding that the ortho tests vary in sensitivity & specificity too must be remembered, some are very weak tests and need combing with other tests including more osteopathic examinations. This has taught me to think outside the box and that not all complaints are as straightforward.

C6. You must be aware of your wider role as a healthcare professional to contribute to enhancing the health and wellbeing of your patients.

C6 Reflective model Driscoll (1994)

What:

You should be aware of public health issues and concerns, and be able to discuss these in a balanced way with patients, or guide them to resources or to other healthcare professionals to support their decision-making regarding these.

Evidence in terms of osteopathic practise can be limited in terms of availability, yet evidence informed practice is commonplace. For example a specific technique may not have it's own dedicated research but the method of a technique and the bodily responses, for example muscle relaxation, may have been researched. On a wider scale however, evidence based research is key for understanding gold standards of care for our patients. Knowing what may be beneficial for them to try, and what's not.

Consider this in another way, general public health concerns; maybe from the media are useful to understand to reassure patients or guide them to other professionals where necessary, using research.

I cannot directly reflect upon an observation or patient encounter surrounding C6 as I haven't had this opportunity as yet, but I can link my thoughts to that of the dissertation protocol learnings with research developments and confidence in the process.

So what:

In terms of my dissertation the research element and picking apart the details is helping me to locate bias or confounding evidence within RCTs. I am finding it easier to decipher what has been carried out.

Our recent Research Methods exam focused on best evidence in the form of a CAT table. This was so helpful. Moving forwards I will now add all of my evidence to a CAT to assess it when reviewing many RCTs. I can then easily pinpoint themes.

There are things to consider from the exam feedback:

• Fully list search terms and databases used

• Be clear with aims of the study

• Future research ideas are clear and well considered

• Consider statistical significance and the meaning with sample size variations

• Good points made towards future educational benefits

Now what:

The research required to complete my dissertation will help me guide patients through evidence based research and understanding. Yes, dissertation is one element of this degree but in relation to health care and learning the lessons to complete the research and highlight patient advice, guidance and referral pathways will aid future patient encounters.

The attached systematic review by Kumah et al. (2022), which sadly fell short as no studies were deemed eligible, does none the less make for thought provoking further reading around evidence based and evidence informed practise for under graduate students in health care. This I believe is very appropriate for osteopaths (students & post-grad) as it provides a fully holistic view of the available options which may be suitable for a patient beyond what we can offer, in this way communication and shared decision making can be thorough with patients in a non-biased and informative way, much more than just hands on therapy. Positively contributing to a patient's wellbeing and care.

Kumah, E.A. et al. (2022) Evidence-informed practice versus evidence-based practice educational interventions for improving knowledge, attitudes, understanding, and behavior toward the application of evidence into practice: A comprehensive systematic review of UG Student, Campbell systematic reviews. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC9013402/ (Accessed: 30 January 2025).

D4(b) Reflective model Driscoll (1994)

What:

Following a patient complaint about how they felt they had been treated and dismissed in the ESO clinic. I was asked by our Clinical Leader to take the patient on. Refer to the attached original email complaint from the patient. The hand written notes on the printed email are from our clinical leader.

The patient had felt that the mix of tutors and the effect that had on my colleague, was a factor in terms of his satisfaction diminishing as well as lateness of practitioner and np set treatment plan.

38 tr old male.

TMJ dysf

Bruxism

Stress / anxious nature.

Over thinker, by his own admission.

So what:

I treated him free of charge for the 1 hour take over, as agreed. I took time to build rapport and understand his needs. I was clear in my desire to work with him along with my desire to keep communication channels open so he could feel at ease with decisions hat he felt uncomfortable with.

The patient has responded well, I have seen him 3 times. he reports less TMJ discomfort and that his jaw feels more 'level'.

Upon his last treatment I explained to him that the body works as a whole is that it is possible that the TMJ is resolving and how it may be a good idea to work more globally - the patient understood and agreed.

I carried out a full global exam and GOT style TT with Lsp decompression and deside bend. I finished with some Csp traction, sub occ inhib and massetter ST.

The patient was happy and is rebooked for 4 weeks.

Now what:

I feel that the manner of the original complaint from this patient was genuine and SJ dealt with it rapidly and effectively, leading to a good working relationship between the ESO/myself and the patient. My patient felt he had been dealt with fairly and suitably. This situation has taught me about prompt complaint management, the benefits of accepting flaws in practice and how these difficulties can be overcome with correct handing of the complaint. Seeing the communications between SJ and the patient has been very useful to appreciate how to resolve patient issues.

C2(b) Reflective model Driscoll (1994)

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

What:

New patent encounter, with a Mother and her 2 month old baby.

Suffering some reflux, settling issues, latching complications with high pallet and mild tongue tie.

Baby was still jaundice, parents had sought professional opinion and told no light therapy needed.

Baby had only put on just over 2lb in weight in 2 months since birth.

Baby felt weak - according to my tutor, but reflexes/head lag were 'ok'.

So what:

I discussed the CHx and findings with my tutor - she spoke with a more senior tutor after the patient had left and they felt that there could be issues with the baby in terms of jaundice/feeding issues and lack of weight gain.

Now what:

I wasn't going to see the patient again due to my summer break. I therefore made sure the notes were fully up to date including the tutor(s) and my own reflections, making it clear that I hadn't discussed these thoughts with the parents as they were retrospective thought processes. I was also mindful to ensure everything within the notes were not only fully complete, but were legible for the next practitioner. This way whoever takes over the patient is fully informed regarding previous discussions and considerations.

Continuing to complete notes fully and in a timely manner can reduce future patient encounter complications or confusion. After the encounter I used the attached information from the NHS to further understand newborn jaundice and the implications if left untreated (Newborn Jaundice 2022).

Newborn Jaundice (2022) NHS choices. Available at: https://www.nhs.uk/conditions/jaundice-newborn/ (Accessed: 30 January 2025).

A4(c) Reflective model Driscoll (1994)

What?

Today a tutor demonstrated case history taking to the new 3rd years. Myself and some colleagues, as new 4th years; were allowed to observe.

This took place in room C with a genuine new patient.

I was impressed with the questioning from the tutor to the patient, rapidly narrowing down his DDx. However, provocative testing needed to be carried out and the patient wasn't informed of this and no consent was gained prior. The same happened before making contact with the patients' body, the tutor never asked permission.

What was interesting was that the tutor appeared flustered during the process too.

So what?

After the patient had left, I spoke 1 to 1 with the tutor and asked him why he hadn't asked for consent to test or make contact and he said he explained it 'afterwards' whilst walking the patient back to reception. I told him that retrospective consent doesn't count! He did thank me for pointing it out. I said to him that the 3rd years won't know what he did/didn't do if he didn't verbalise anything in the room in front of them.

Now what?

I took this as a reminder that we are only human and that anyone can make errors - yet I quietly questioned if the tutor ever asks for full consent as surely, if he did, it would be second nature and would happen automatically?

The largest complaints revolve around OPS A and communication/listening/disregard between 2013 & 2022 (NCOR concerns and complaints report 2022).

From this experience I can see how easily these statistics could be reduced just by asking for consent and communicating intentions. GOsC consent guidance is attached (Consent 2019).

The fact that I spotted the tutor's error and knew what should have been explained and where consent should have been gained during the encounter, proves my understanding of OPS A4. I was also pleased with my approach to the tutor as I questioned him in a non-confrontational way.

Consent (2019) Consent - General Osteopathic Council. Available at: https://www.osteopathy.org.uk/standards/guidance-for-osteopaths/consent/#:~:text=For%20the%20consent%20to%20be,the%20patient’s%20age%20or%20illness. (Accessed: 24 January 2025).

NCOR Concerns and Complaints Report 2013-2022 - General Osteopathic Council. Available at: https://www.osteopathy.org.uk/news-and-resources/document-library/complaints/ncor-concerns-and-complaints-report-2013-2022/ (Accessed: 24 January 2025).

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

B4(b) Reflective model Driscoll (1994)

What:

Until today, I hadn't considered audits... Taxes, insurances, registrations yes - audits no? I was a little unsure what it consisted of so the lecture with James was really beneficial.

So what:

After the lecture I now appreciate the need for auditing and how simply it can be implemented. Likewise with patient questionnaires, how these done anonymously, can bring things to light. The GS-PEQ questionnaire is validated for wider healthcare use (NHS/NICE).

Audits will enable practice reflection in a multi dimensional way to enable improvements to be made identifying strengths and weaknesses.

Now what:

I have saved the relevant documents from NCOR and the VLE materials on to my desktop for post grad reference and use. The NCOR handbook is attached here too (Clinical audit tools 2023). Combining this with ongoing personal development will aid patient encounters and practice standards.

NCOR Concerns and Complaints Report 2013-2022 - General Osteopathic Council. Available at: https://www.osteopathy.org.uk/news-and-resources/document-library/complaints/ncor-concerns-and-complaints-report-2013-2022/ (Accessed: 24 January 2025).

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

C2(a) Reflective model Driscoll (1994)

What:

During my time in the ESO clinic so far, I have taken over or covered many patients.

The handwriting of some of my colleagues is so bad. Many sections or phrases being illegible. This leaves me feeling uneasy that I may miss something which could be a vital piece of the puzzle. I also feel that I then take up vaualble patient time asking the same questions again to be sure I have eveything covered. Babalola et al. (2024) reports upon hospitals which includes the administration of medications which could lead to errors in type/dosages. It could be said that name misspelling is a minor indiscretion yet this could have implications within pharmacies for drug deliveries. In the osteopathic clinic, names spelled incorrectly may lead to calling the patient by the wrong name or wrong pronunciation, as well as incorrect filing. At worst it could lead to referral letters not being linked to patient notes through the NHS.

So what:

This makes understanding the patient's complaint and full history really difficult. It is also exceptionally time consuming and frustrating. This time concern then runs in to the actual consultation with the need to ask the patient questions, just to fill in the gaps.

Now what:

The obvious way round this would be to computerise all notes. Something which is very unlikely to happen at the ESO clinic as it would be exceptionally time consuming, but it's certainly going to be something I will be considering with my business

1) for clarity of notes

2) for space saving - no paper filing cabinets needed

3) Cliniko works well for this

In the meantime, whilst still studying I will do my best to produce legible notes for the benefit of others.

Babalola, A., Osundina, K. and Ajayeoba, T. (2024) Clinical Documentation Illegibility andQuality Health Care Delivery inSome Selected State Hospitals in Osun State, View of clinical documentation illegibility and quality health care delivery in some Selected State Hospitals in Osun State. Available at: https://aujs.adelekeuniversity.edu.ng/index.php/aujs/article/view/199/128 (Accessed: 12 May 2025).

D9(d) Reflective model Driscoll (1994)

What:

I have had a fantastic learning and developmental six weeks in headache clinic.

After the 6 weeks I emailed Helena Bridge (tutor) to say thank you to her.

This was part of her reply.

I thought I'd save it as I felt so happy receiving this feedback from her. It really reminded me what I'm striving for and how far I have come to this point.

So what:

Helena had complimented not just me, but our whole clinic team for our engagement and input. Stating how we work really well together in a supportive way, allowing each other time to process whilst being on hand to assist each other where needed. This really made me think about how lucky I have been! My clinic group are a fabulous bunch of people and we really get on so well, yet we are all such different characters too.

Now what:

I definitely feel lucky that I have been able to address things directly with my clinic group or oppose views without any bad residual feelings. This has helped me no end in terms of my development and confidence which has created a basis for future team work scenarios.

B4(a) Reflective Model: Driscoll (1994)

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

What:

Unsure which OPS standard to link this to as 'development' in line with the OPS is related to skills and professionalism, rather than personal development from an organic perspective, yet I do feel this change will positively impact upon my patients - hence choosing B4.

So what:

The changes in me during my degree have been overwhelmingly positive. I have always been someone who would look out for others and help people, but I haven't always done so with patience and understanding; which, in my opinion, made me sometimes unapproachable. Those who knew me well, knew my heart was in the right place and that my frosty exterior was harmless - yet those who didn't know me well, might avoid asking for my help through fear of my response. I never truly understood this before, but now I can see how this was the case. Over the past 4 years my social circle has changed massively too and this has been a positive change as I had the opportunity to reinvent myself and was able to wipe the slate clean, so to speak. I am no longer irritable or short tempered with people. I have more patience and time for helping others.

Friends have referred to me as 'approachable' 'genuinely caring' and 'understanding'. All qualities that were always within me yet now those qualities are offered more freely and not simply reserved for my nearest and dearest. I guess I hid my true emotion, never wanted to show any vulnerability, and I never wanted to show my feelings and being that way somewhat isolated me from building genuine contacts and friendships.

Now what:

This in turn has helped me build resilience and to feel connected to others and to build more meaningful relationships, the intention towards this shift has been the key - you cannot fake it. I feel that this will be conveyed to my patients in a positive way too.

Rao et al. (2024) discussed how The World Health Organisation defines mental health as a state of well being where a person is able to cope with stressors whilst learning well and contributing to their community. Showing resilience and decision making abilities with the benefit of relationship building all aids positive daily interactions, being adaptable in the face of adversity and demonstrating emotional intelligence. Worth remembering that this is merely my outlook - different people will respond differently to stressors for many reasons.

Rao, G.P. et al. (2024) Developing resilience and harnessing emotional intelligence, Indian journal of psychiatry. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC10911335/ (Accessed: 30 January 2025).

D7(a) Reflective model Driscoll (1994)

What:

After writing my business plan (attached) in year 3, I learned so much about how to market my business in a way to attract my 'ideal customer avatar'. It made me think about how I will spend my working week. Obviously initially, I will have more time on my hands than patients and it would be easy to allocate extra time on patients. I particularly feel this is a possibility when treating horses.

So what:

This may seem like not a big problem - but fast forward a few months/ a year and I will be busy and won't have the disposable time to spend with patients. In which case any patient (horse or human) that has had a lot of time previously, could then feel short changed. Even though the expectation of so much time is unrealistic, it's not the requirement of the patient to understand and acknowledge this.

"the patient may not remember what I say or do, but they will remember how I made them feel"

Now what:

With this in mind keeping to my timings is going to be important to avoid patients feeling short changed once I'm busy. I must start as I mean to carry on. No moving of the goal posts. If patients sense a shift in my demeanour, this could result in confusion or negative reviews through misunderstandings.

B3(b) Reflective model Driscoll (1994)

What:

Thinking back to my dissertation protocol assignment last year, I was very unsure and overwhelmed with the task ahead. Everything felt very strained and 'abnormal' with words and terms that were hard to digest. As time went on, with research, learning using YouTube/Scribbr and our own VLE slides and recordings, things began to make sense.

I definitely thought that dissertation was something that I would do and enjoy yet I couldn't really see how it would benefit me, well not to the degree that it has.

My initial plans were put in to place. I found the research. Tabulated and went through the motions. I then began writing, at this point I became so much more efficient at finding research and deciphering it. I was able to spot weaknesses or potential bias and the penny dropped at that point as to the benefit of dissertation!

I had a clear goal with my RQ. I knew I needed to answer the Q and I never thought it would be much more than that, but it was. It was far more infact. I then began looking at other implications of the research and how it can aid future research - now I don't mean on a basic level. I'm talking indepth. I could really feel the passion for the topic hitting home and broadening my view.

So what:

Obviously, I hope to have passed my diss! I have began working on the Viva assessment and I hope to be able to portray my enthusiasm and learning experiences through that too. There are things that I would do differently if I were to write another diss. I would increase the search terms for sure. I didn't realise it initially but I was quite reductive. This did mean I missed out a study that was good, recent and would've made my numbers level ( as I was comparing extremity outcomes; LEX & UEX ) I did report upon the research I missed out in my diss, it wouldn't have altered the overall results however I need to be mindful of this as I could've been researching something for a patient.

Now what:

The linked article from Licciardone (2008) supports the need for post grad osteopathic researchers to bridge the gaps and enable development of evidence based practices. Much of the available research for osteopathic specific techniques are through case reports, based upon specific dysfunctions. With the argument of 'every patient is unique and may respond differently to the exact same treatment' so the need for more robust RCTs focused on osteopathy and the desire for this from post grad enthusiasm, will be key to progression.

I have gained so much confidence in how and where to locate relevant research, this will help me no end in practice. In turn this will guide my patient care whilst enhancing the patient's experience and recovery, co-operating with the OPS guidelines.

Licciardone, J.C. (2008) Educating osteopaths to be researchers - what role should research methods and statistics have in an undergraduate curriculum?, International journal of osteopathic medicine : IJOM. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC2574521/ (Accessed: 12 May 2025).

B2(b) Reflective model Driscoll (1994)

What:

In term 2 we have Mr Tolson for Sports Clinic. I am looking forward to this as I have gaps in my knowledge in terms of exercise prescription and rehab timescales. Over the Christmas period I will be going over the 'sports injury course book'.

So what:

Refreshing my memory on tissue healing times, rehabilitation exercises and planning of rehab programmes. I'd definitely say that right now, my exercise prescribing has been basic. To work within the OPS 'B', I need to be clear of my shortfalls and prepare to refer to a physio for rehab in certain situations. This might be a sports enthusiast or athlete patient who has a fabulous knowledge of their own injury/sport/rehab etc. Possibly with a coach involved. I would not feel able or confident right now to to build a workable rehab regime.

Now what:

I am aiming to change this through the sports clinic. I feel that referring where necessary is imperative (OPS C6) yet simply referring due to failings in knowledge, is something I am in charge of. The limitations within my knowledge of sports injuries and exercise prescription I can over come to enhance patient care, knowing the pathways to refer to if needed. Mr Tolson has provided us copies of his workbook so we can go through the sections as part of our development, this is really beneficial as we discuss cases and build rehab plans. Having the work book brings to life what's being discussed and shown on slides, making it easier to apply to patients as well as recall the information taught. The more I understand about rehabilitation plans the better my decision making will become as to if I feel the patient can benefit from these, or if a referral to a specialist may be needed.

Knowing the best physios in my area and who specialise in which complaints, is good practise ahead of a referral of a sports rehab. Sports rehab being just one example - whereas the reality it that scope of practise and limitations in experience, training and competence will exist in other areas. Not being led by ego, but by the desire to aid patients is going to be key here.

D4(c) Reflective model Driscoll (1994)

What:

Following on from D4(b) - The patient I was asked to take over after the complaint email, had been visiting the ESO clinic every 3 or 4 weeks and last time I reflected about him, I was just beginning to treat more holistically. Whilst being clear in our treatment aims and communicating effectively and building rapport.

So what:

This patient has really gone from strength to strength and he is in the process of moving to Scotland this coming weekend. I saw him today for his final treatment in Kent and explained how he can locate an Osteopath in Scotland. He shook my hand when he left today and thanked me for helping him so much.

I'm so pleased he has had such benefit from his treatments.

Now what:

The way that this patient was dealt with in terms of his complaint towards my colleague and tutors' was diffused well enough to allow the patient to feel listened to and a solution was found to the patient's benefit. I learned a lot from reading through the written correspondence between our Clinical Leader and the patient to learn how to initiate the reply to a complaint, making the patient feel heard and being flexible enough to make changes and offer resolve.

A3. You must give patients the information they want or need to know in a way they can understand.

A3(a) Reflective model Driscoll (1994)

What?

Today in clinic I met an 8 week old baby and her mum.

The baby, I'll refer to as 'T', was born with Ankyloglossia aka tongue tie and struggled to feed. She had seen feeding specialists and had the tongue tie cut 2 weeks ago and was feeding better and mum was far more comfortable and now has no pain during feeding. Mum was advised to bring T to the ESO to assess any muscular restrictions. T suffers with hiccups, transient constipation and diarrhoea. Generally sleeps well, feeds well but still clicks and loses suction from time to time.

Upon examination I noted a large umbilical hernia (being monitored by GP), some abdo and diaphragmatic tension, with preferred L LSP side bend, suboccipital and anterior throat tension.

So what?

I explained my findings, in laymans terms, and thoughts in terms of treatment options to mum. I asked if mum had any questions and she said no - she said I had answered her questions through my explanations throughout. She then told me that T had briefly seen an osteopath somewhere else but that the osteopath hadn't explained anything about what he was doing or finding. This made mum question what he did, why he did it and even if he did anything at all. Leaving her feeling un-reassured about her baby's presentation and if she was doing the right thing in exploring osteopathy initially. During year 4, one of our assessments was a Case Study on a patient from one of the specialist clinics. I chose this encounter for my course work. A requirement of this was to ask for patient feedback to understand their perspective. That section from my coursework has been attached as evidence.

Now what?

This made me think about how complacency in practice can affect patient encounters. Just because I may repeat myself with certain descriptions, explanations or consent many times a day; this could be the first time the patient has ever heard it. Which makes it so important to explain what I am doing. I learned a lot from this as mum was honest about her concerns following T's appointment with the other osteopath.

Communicating effectively in a way that a patient can understand is so important to build trust and confidence in the practitioner, it's far more than just OPS compliance. To reflect upon this encounter is beneficial as a reminder of what I felt I did well and how I have developed as a practitioner. I feel that it is always important to communicate effectively but with a small baby and a concerned mum, this becomes more sensitive environment. Particularly if mum has been struggling with lack of sleep, upset baby and concerns surrounding baby's comfort or feeding. I am pleased that this all came quite naturally to me and I will carry this forward to future encounters.

A7(a) Reflective model Driscoll (1994)

What?

It's Christmas break season which is a great opportunity to cover for colleagues and see their patients, it makes for such a valuable learning time.

The patient I covered was late 50s and male. I had observed his initial appointment and follow up treatment. I remember him as he came across as anxious, a little arrogant and like he wanted to control the room.

I know my colleague had struggled with him and his obsessive need for flexibility and bodily concerns, without him really hearing what she was saying in terms of reassurance.

This week, covering him, I felt the same degree of difficulty. The patient has their beliefs and is quite set in his mindset, I wondered if he actually feels confident in the care we provide?

So what?

Possibly if I was treating him regularly this would need to be a conversation. Patient / practitioner compatibility issues can arise but can often be worked upon and requires professionalism. Yet it is different with this patient. Maybe because we are a teaching clinic he feels a sense of control? or lack of trust?

There are yellow flags raised for anxiety and body image/future health concerns with this patient, he carries a bag full of health related folders with him to appointments. He presents with NO PAIN or discomfort anywhere, with no co-morbidities or medications. The JOSPT article attached has a useful framework and suggests that revisiting flag screening questions often ( 2 weekly) with a patient can be beneficial (Stearns et al. 2021).

Now what?

This patient my colleague is happy to manage and continue treating, but it made me think about how I would feel if I were repeatedly undermined by a patient, he has a habit of raising his eye brows and muttering under his breath during treatments, he didn't do this with me; yet I have observed him doing it - which reinforces the lack of confidence he feels in 'us'. I would have to directly address this in honesty, if it happened during a treatment I was giving.

To aid my colleague, upon her return to the clinic, I discussed the patient and referred to the notes as I had tried to keep everything crystal clear to aid her future interactions with this patient to avoid unnecessary complications or misunderstandings, as this won't help the patient.

Certainly this interaction made me wonder why the patient is so keen to revisit? If I didn't have full trust and faith in a practitioner I'd find another to take over. Maybe the cost of a teaching clinic is most appealing? Either way it is a very interesting case and one I am keen to monitor, whilst supporting my colleague.

Stearns, Z.R. et al. (2021) ‘Screening for yellow flags in orthopaedic physical therapy: A clinical framework’, Journal of Orthopaedic & Sports Physical Therapy, 51(9), pp. 459–469. doi:10.2519/jospt.2021.10570.

C4(b) Reflective model Driscoll (1994)

C4. You must take action to keep patients from harm.

What:

In children's clinic I observed a 2 year old child who attended the clinic with new adoptive parents having been initially fostered, following a legal case with the maternal mother who was sentenced for abuse.

Although this case had a happy ending and the child hadn't presented at clinic during the abuse, it is a stark reminder that it does happen and we need to be aware of parental shortfalls.

So what:

In year 1 we were advised that sometimes children get brought to us to avoid the GP, in an attempt to 'help' the child's recovery from a care giver inflicted injury; with the hope that no one will notice or connect the dots. I found this an exceptionally distressing notion. I have often wondered how I would keep a cool head and not become angry. Then I remember that we need to be a safe place for the child and sharing my anger won't help the situation at all.

Maintaining the confidence of the caregiver/child is important to be able to gain as much info as possible before reporting the findings.

Now what:

The nspcc.org.uk website has CPD courses for healthcare practitioners to help with the complexities of such events.

The abuse doesn't stop at children, vulnerable adults are high on the list too. The nhs.uk website has information concerning abuse and neglects of adults at risk. It is worth noting the types of abuse vary massively from sexual and financial to neglect and psychological abuse.

As awful as it is to allow myself to consider that these things happen to other people, I must be prepared for it otherwise I will a) miss the signs or b) panic and risk worsening a situation when it presents.

In year one we were introduced to CPOMS (Working together to safeguard children 2023) which enables recording, tracking and centralised record keeping of concerns, to inevitably manage safeguarding concerns and aims to improve outcomes for children. Remembering this would prove beneficial in these circumstances with patients that I may encounter.

Working together to safeguard children 2023 update: How CPOMS can help  (2024) CPOMS. Available at: https://www.cpoms.co.uk/working-together-to-safeguard-children-2023-update-how-cpoms-can-help/#:~:text=The%20flexibility%20and%20customisation%20that,report%20via%20email%20or%20post. (Accessed: 30 January 2025).

C1(c) Reflective model Kolb (1984)

Concrete experience:

Today I had a cover patient as my colleague was off sick. Looking through the notes, the patient generally comes in for maintenance and has benefits from monthly visits in terms of reduction in fibromyalgia symptoms and muscular tightness, so at first glance I had prejudged an easy case.

The patient arrived with different symptoms which she hadn't experienced before, in the past this situation has made me feel panicked due to the returning patient time restraints and the need to acquaint myself with the patient and then examine based upon the discussion.

I decided to carry out a full neuro screen, check pulses (radial/femoral/dorsalis pedi) observe for peripheral oedema and question based upon poss B12 deficiency. All the tests I carried out were inconclusive or mixed results at best.

Reflective observation:

I was happy with my decision making in terms of deciding what examination to carry out and although everything was inconclusive, I safety netted the patient regarding worsening symptoms and explained about possible referral in the event of no symptom resolution. The patient is booked in next week to see her regular practitioner. The patient was fully informed regarding my thought processes and justification for the screening and I was pleased with this encounter. When covering for colleagues I am always aware of the implications with differences of opinions and how outcomes can vary when practitioner continuity is interrupted (Magel et al. 2018)

Abstract conceptualisation:

I felt a big shift during this encounter regarding my confidence, communication and this really helped my patient to feel confidence in me too. Had I not communicated as well, the patient may have felt confused as to why I was being so thorough. This is definitely a good reminder of how far my confidence, understanding and communication has developed along with my competence. There was a time, not so long ago, where a situation like this would have left me wondering what examination to do... if I needed to refer... asking for tutor support etc.

Active experimentation:

With this cover patient I worked 100% autonomously which has given me confidence in future to trust my instincts moving forwards, particularly towards CCA and graduation. Where I am required to decision make with confidence and to explain my thoughts with the patient in a way that they can understand, and be confident in my delivery of information. This will save any patient doubt in me, my experience and knowledge.

Magel, J., Kim, J., Thackeray, A., Hawley, C., Petersen, S., & Fritz, J. M. (2018). Associations Between Physical Therapy Continuity of Care and Health Care Utilization and Costs in Patients With Low Back Pain: A Retrospective Cohort Study. Physical therapy, 98(12), 990–999. https://doi.org/10.1093/ptj/pzy103

Original 1994 model: Driscoll, J. (1994). Reflective practice for practice. Senior Nurse, 14(1), 47-50.

ISBN-10: 0132952610 ISBN-13: 978-0132952613 APA Citation: Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs, N.J: Prentice-Hall.

Gibbs, G. (1988). Learning by doing: A guide to teaching and learning methods. Further Education Unit.

References:

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Mann, D. et al. (2000) Increasing osteopathic manipulative treatment skills and confidence through Mastery Learning, De Gruyter Brill. Available at: https://www.degruyterbrill.com/document/doi/10.7556/jaoa.2000.100.5.301/html (Accessed: 12 May 2025).

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B1(c) Reflective model Gibbs (1988)

Description:

A really tough day. Today's Wednesday and on Tuesdays I have a 12 hour day at the ESO, plus horse care, plus 3.5 hours of travel. I love Tuesdays as my tutors are brilliant and they push me. I learn a lot every week.

The downside is that the day is so long, yesterday I left the house at 0615 and returned at 2150. The alarm went at 0530 this am, so I can arrive at clinic on time. To say I'm exhausted today is an understatement and I really don't feel great.

Whilst in clinic today, I observed Lance he ultra sound scanned a knee. There was a knock on the door and a new patient had arrived who was booked in with a male colleague, but the patient requested a female practitioner so I stepped up to take it.

I have been working hard to really formulate DDx and my CHx questioning based upon my thoughts has really began to fall in to place along with my clinical reasoning. This has been thanks to additional lectures with Mr Fadil and Dan Brown.

Todays patient was relatively straightforward, but required a neuro screen plus SLUMP / SLR, PROM tests of LSP and hips. I was quick to narrow down my thinking and more so after examination.

Feelings:

I felt like I really had to concentrate to ensure I didn't miss anything due to tiredness. My tutor asked questions which I answered, whilst with my patient.

I treated the patient and rebooked them for 10 days time.

Upon discussion of the case with my tutor, I said that I don't feel 'on the ball' and he said he wouldn't have known that. He constructively critiqued my communication of the complaint to the patient, also how I tested the hip. This I found really helpful. He just advised me to have a clear speech for the patient based upon each DDx (in layman's terms). That made good sense to me.

My tutor said that for the next few months, I should aim to refine my approach to testing and treatment now, which I will constantly practise. He said that he doesn't feel I have too much to worry about heading towards CCA. He also said I need to have more confidence in myself.

Evaluation:

This makes me feel quite emotional as I've heard that twice this week from different tutors. I think I have been reluctant to trust myself and accept my ability exists, whereas I need to demonstrate the practitioner I've become and hold my own in a confident way and develop my posture as a practitioner.

Analysis:

I reflected upon a lecture early in year 1 when I felt really stressed, out of my depth and under pressure - Shown in evidence 'reflection B1(a)'. I have developed personally and professionally so much since that point and reading my Padlet entry from 3 years ago has been really useful today, as a reminder of my journey so far. Back then I would never have coped with being pressurised in front of a patient in the way I can now, I am proud of myself for overcoming this. I can feel the transition beginning from competent to {more} proficient which requires not only the skills I've been taught, but also the integration of those skills to know intuitively what to do and when to do it. I am happy that this is developing for me.

Conclusion:

I spoke to some of my colleagues about today's experience and felt pleased that even when exhausted I can still do a good job with patients, which has really helped my confidence. Equally they reassured me that I am capable. The attached article Mann et al (2000) discusses the importance of not only practising techniques to gain confidence, but in the mastery of such to enable unconscious competence over time with student practitioner growths in confidence. I would say that this is what benefitted my today, feeling tired - under pressure - un prepared for the patient and yet everything worked out just fine; I didn't feel it was an effort.

Action plan:

Moving forwards I need to direct my attention to different techniques that I don't use so frequently, refresh my derma/myoTs particularly the UEX still as this will make me feel less likely to need my notes to check things during patient encounters. Allowing just 30 mins per week to do this will sharpen my focus and make this a more automatic and slick process. Whilst showing the confidence I possess in the things I find easier to deal with.

I will be able to measure the improvements by the time it takes for me to complete a neuro screen, as well as how I can then immediately verbalise my findings. Currently this is taking a little too much time, which takes away time from a patients' treatment.

Mann, D. et al. (2000) Increasing osteopathic manipulative treatment skills and confidence through Mastery Learning, De Gruyter Brill. Available at: https://www.degruyterbrill.com/document/doi/10.7556/jaoa.2000.100.5.301/html (Accessed: 12 May 2025).

D12(c) Reflective model Gibbs (1988)

Description:

It's almost a year since my previous input about OPS D12 (see D12 a & b) and D12 remains a category which hasn't been experienced directly during my four years at the ESO, this made me consider how I can use this example to link and reflect upon in future scenarios.

With my Padlet entries for the OPS A - D in all sub-categories, I believe that ongoing development through experience is a must and with that in mind each of the explored reflection categories have been achieved and discussed; but only to my current level and current understanding.

Feelings:

I feel like it gives me future opportunities to link each of the OPS across many exposures and this feels far less reductionist, rather than a box ticking exercise for coursework completion. This is a positive process and will be a career long journey as my views, thoughts and exposures change.

Analysis:

During the portfolio coursework for the Padlet that I have nurtured for four years, it has very much come to life and the process of going over old notes and reflections has been truly powerful, far beyond my expectations.

Conclusion:

For my CPD I will continue to record, break down and reflect fully upon my learnings. Padlet is easy to use and the ability to add videos, research or photos is ideal; whilst keeping everything together in one place. The app on my phone makes input instant too.

Action plan:

Using Padlet combined with the OPS I also think I will benefit from multi reflections within the same section, this can be done when re reading notes from experiences. Forming an interesting way to see how my mindset, ability, thoughts and research has changed with time. Knowing how I felt reading over some of my early reflections from year 1 & 2, whilst completing the e-portfolio coursework, I can really see how this will benefit my development. I believe that personal and professional development are combined to enrich my osteopathic practice, this will involve learning from my mistakes and moving forward with an open heart and mind.

A3(b) Reflective model Driscoll (1994)

What?

This was my Children's clinic mini CEX. Feb 2025.

It was an interesting learning experience as Mum presented with a 2 month old baby and mentioned 'other mum' in our case Hx discussions. This prompted me to ask gently about the father, particularly in light of any hereditary health concerns. The baby was a sperm donor and although both Mum's were in contact with the Father, they knew little about him.

So What?

There would definitely have been a time early on in clinic where these conversations would have felt awkward or I would have avoided the questioning. The mother was very open and happy to discuss how everything came about and even how they are looking to use the donor again in future for 'other mum' to conceive.

Now What?

This encounter gave me confidence in my communication style and empathy. Asking genuine questions and engaging with my patient to understand her situation, whilst gaining her trust and building rapport.

I was really happy with the results of this CEX and I have attached the kind feedback from my tutor as evidence of this encounter.

A7(b) Reflective model Driscoll (1994)

What?

We're at the end of term 2 in year 4. This week in children's clinic, a couple brought in their 7 year old who had injured himself playing football. During the case history taking when I asked about previous injury/illnesses, they advised me that the child was involved in an accident which resulted in a loss of blood and yet they declined a blood transfusion. The family are Jehovah's Witnesses and blood is scared within their culture and not to be shared.

So What?

Although I understood their belief and that decision to decline the blood transfusion, I also felt alarmed that they would allow their Son to be in a near death situation and not be prepared to go ahead with the transfusion. Obviously, they were very lucky that he survived.

I think I found it so difficult to comprehend as I wouldn't hesitate to have/authorise a blood transfusion where necessary. I also give blood too, to help those in need.

Now What?

Moving forwards from this encounter, I have explored common religions and have a greater understanding for the reasons governing certain decisions. This will aid me in future not to be surprised or confused when medical or health related decisions are made that I might deem 'strange' 'different' or 'unnecessarily risky'. In subsequent visits from the family mentioned above, they opened up about their reasons for certain thought processes and this was really helpful. It helped allay my confusion and they were very open to my questions, this I thanked them for. Swihart (2023) highlights the concept of cultural competent care and shared decision making, not just with religion but spirituality too, so to understand the patient's perspective can enhance their care, trust and long term outcomes; as many will turn to their faith when stressed or pained for whatever reason. Swihart (2023) also lists religions and their beliefs on diet/health/death as well as Holy Tenets, which further informed me.

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https://doi.org/10.1093/ptj/pzy103

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