I followed the usual routine of coming out to speak to my tutor and going back in alone to take the blood pressure before my colleagues were due to join my again. Whilst taking the blood pressure ei again felt uneasy about how agitated she seemed so decided to try and delve a little deeper into what was going on.

She expressed to me that she was really worried about lots of people looking at her in the room as she was feeling anxious especially if she had to take her clothes off as she feels very self conscious about the way she looks and shes she is very overweight and ugly.

So i explained to her that this is a teaching clinic and my colleagues were purely in the room to learn. But we came to the agreement that there would be no further observation that session as i wanted her to feel as comfortable as possible.

So what?

On reflection i could have picked up on this earlier, however i know it would have been difficult for her to say something in front of the others. I felt bad for putting her in the situation where she felt uncomfortable however at the same time i did want her to understand the situation she was putting herself in and that she had signed the document (which explains observers) to say that she was happy for the consultation to go ahead. On the other hand, essentially, if she is not happy, there is no consent to move forward and therefore i would never push a patient back into a situation where they feel self conscious.

Now what?

I understood her point of view and I’m glad we could come to an agreement that suited us all. It meant that i could practice my presentation skills to my peers outside of the treatment room so the experience was still productive for everyone.

Moving forward, i will definitely be paying extra attention to these social cues from patients so if they are uncomfortable we can adapt the situation as soon as possible. This case also made me really reflect on how the biopsychosocial model incorporates itself within every consultation.

What? 

In my 3rd year as a practitioner at the ESO teaching clinic i took over a patient who had who had pain in her shoulder, lower back and knee. As it was a takeover i did virtually a repeat case history to make sure i had good understanding of her presenting complaints as well as her medical history and systemic health. She described all three pains as different as were due to their own separate onsets and each took it in turns to be more restrictive to her lifestyle. From there we continued with the examination and moved on to treatment. I felt quite a lot of pressure to make sure I was addressing all the areas that were causing her discomfort. I didn’t have much time to do this and felt rushed through to try and do techniques everywhere. I felt flustered but continued as I was trying I do what i thought was best for her. 

However, when the patient came back, she expressed that she had priorities in terms of what she needed treatment on that week as she felt like trying to do everything at the same time was too much for her and she had some anxieties in being completely undressed in front of others, especially if there are observers in the room as she was slightly overweight. 

Furthermore, I adapted my management plan for the patient so that it addressed what she communicated to me. I had to listen to her concerns about the environment for her treatment we agreed that the instances of observations would be minimised where ever possible, however it is a teaching clinic so this is the nature of the appointments here.

So what?

At first i felt embarrassed that my communication skills were not clearer when we originally met and that I hadn’t given her the opportunity to tell me her priorities for her pain but also her concerns regarding dignity. Seeing her in an emotionally vulnerable situation talking about her insecurities made me realise that i am not only doing this to help peoples pain but to create a safe environment for them to open up and express their feelings.

Now What?

This opened my eyes to the idea that i didn’t ask the right questions in the initial consultation. I reflected with the tutor on how i could have avoided this mis communication in the first instance. Therefore, moving forwards i will always be asking my patients clearing what they hope to gain from the treatment as well as what their priorities are if there is more than one point of pain and not moving on until we have worked together to create a clear management plan that we have been agreed on.

In the 1st term of 4th year as a practitioner at the ESO teaching clinic i have an initial consultation with a male in his mid 30’s. The first thing he said when i asked him how i could help was that he was autistic. This wasn’t his presenting complaint however it highlighted how prominent his diagnosis was in his life. 

I took this on board but didn’t draw too much attention to it as i didn’t feel that it was connected to his posture induced myalgia. When we moved to examination and treatment i realised that when i was palpating i had to be very clear and literal about the things i was saying. For example i would normally say “does this hurt?” The first time and then subsequently say “what about this?” Moving forward (purely out of habit). However he couldn’t make the relationship between all the different statements and was answering what do you mean quite a lot. 

I also found myself needing to explain the techniques i was using in further detail, for example a sternal recoil. Previously, when i have used this with patients i explained it as increasing pressure on the chest and then a quick release whilst working with their breathing. This is what i did with him, but he still seemed very taken aback (more so than i would expect) when the technique was performed.

So what?

I reflected that from prior knowledge i also knew that those with autism don’t react well when something happens that they weren’t expecting. Therefore, this wasn’t the correct technique to utilise for my patient.

I had to be very pedantic about explaining every detail of what i would like to do to gain proper consent from the patient and also explain where my hands where when he couldn’t see them and where i was going to place them so he didn’t jump.

Now what?

I know now that I wont be using these kind of techniques with him any more as if i did i wouldn’t be properly adapting to the needs of my patient and treating them on a individual case basis.

What?

At the end of 3rd year during one of our clinic sessions i had a patient come in who i had seen a few times before. Her working diagnosis was rib head dysfunction. I had previously used a supine HVT technique on her rib head to resolve the problem, the patient felt instant relief at the time but on return said although it had gotten a lot better there was still a little bit of residual pain in the area. After examination i decided that i felt another HVT was necessary for a restricted area through her thoracic spine. I explained that we were going to use the same technique as we did last week but on the vertebrae as opposed to the rib head itself to loosen off an area that wasn’t moving optimally. At that moment my tutor came in to observe the technique.

I asked the patient if they were okay to continue they said yes and so i started to cross their arms over their chest when my tutor asked me to stop and take a step back. He said to the patient, so what technique are you having done now and why? The patient struggled to answer his questions and thus the tutor said that i haven’t explained it properly.

So what? 

At first i felt quite upset as i was happy with my initial explanation and felt as though she should have been able to answer the tutors question easily. I felt that it made me look stupid and as though i was trying to cut corners in the tutors mind - which wasn’t the case at all. But with time i have realised that actually that some patients could feel pressure to have techniques done due to being in the professional environment and quick explanations that they don’t want to admit they don’t understand.

Now what? 

Therefore, i went over the consent process again and explained in more detail the aims of the technique as well as the side effects. Going forward i need to remember that patients don’t have the same training as us and have other things going on in their lives so they don’t always remember techniques that we did on them 1+ weeks ago.

I treated a patient at the ESO clinic at the end of my third year. I hadn’t used many cranial techniques up until this point as it was never something i had felt confident with - plus it’s difficult for some tutors to give you the freedom to explore those kinds of techniques. 

Nevertheless, the patient presented with non-specific lower back pain with a history of kidney stones 15 years ago. She also presented with headaches and expressed that she felt very stressed as she’d recently been going through a very stressful divorce. I decided to use cranial techniques, aiming to effect the HPA axis. 

The pituitary gland is located on the sphenoid so part of my examination was to assess the spheno-basilar synchondrosis (SBS), to understand whether there was a connection. I determined that the patient had a torsion of the SBS and so wanted to treat accordingly. 

I explained to the patient that i wanted to do a very subtle technique that works with some of the bones in the cranium and will affect a system that they wont be able to control or feel. They were open to the idea and i started my technique.

About 5 minutes in, the patient opened her eyes and and questioned me… “are you actually doing anything?”…

I was taken aback by this question as i felt so concentrated in what I was doing but i did my best to explain that like the vascular system, the reciprocal tension membrane wasn’t something that a person can consciously feel for themselves. I explained that even though my hands weren’t moving- i was working on an innate system and the bones in the skull. The patient looked bewildered but didn’t question me any further.

So what?

On reflection, i didn’t feel like i explained this process very well as i felt like i was taken off guard and didn’t prepare enough for justifications of my technique. I need to remember that because i’m surrounded by osteopathy and its principles in my everyday life, all of my friends understand this terminology like everyday language - but thats not the case for the general public. However, i do think my treatment was very osteopathic and a holistic way of managing their case - so that is a positive aspect to take forward.

Now what?

I need to move forward by gaining confidence around performing cranial techniques on patients and possibly even practicing on my peers who are unaware of the mechanism of cranial to improve justification and ensure the people’s i am explaining to will give honest feedback on their levels of understanding from what i’m saying.

What?

A 27 year old female patient attending the ESO teaching clinic presenting with right hip and lower abdominal pain with a sudden onset yesterday. After taking a case history and osteopathic examination i had a working hypothesis for her hip pain, however i was unable to be clear on her abdominal pain with such a sudden onset. With the assistance of my tutor we conducted a urine test to try and rule out infection and a visceral abdominal screening assessment. However, i could so identify the cause of the pain and felt she needed a second opinion to understand what was truly going on. After expressing these feeling toot my tutor be both decided that i would discuss with the patient an alternative approach to osteopathy (in the form of imaging) to rule out any red flags and have a better understanding of what is causing her pain.

So what?

I believe i made the right decision to refer this patient and acknowledge my limitations otherwise i might not have been acting in the best interests of the patient. Although i feel confident in the visceral screening skills i learnt at Boxley, i have only utilised them a few times and never when there was a possible pathological cause. I decided before i go any further and possibly cause her harm she needed to be referred to a specialist.

Now what?

This experience really made me appreciate how important it is that I keep my knowledge and skills up to date but also how important it is to be able to draw a line and admit that the judgement of another health care professional is more of value to the patient. The safest outcome for everyone is to act with honestly and give other options to provide the best patient care.

Recognising and respecting the limits of my training and competence is crucial in osteopathic practice. It involves having a clear understanding of my knowledge and skills while acknowledging their limitations. It also requires honesty with patients about what I can and cannot provide in terms of care, and referring them to specialists when needed. Continuous professional development and humility are important for expanding my expertise, learning from mistakes, and staying updated with advancements. By prioritising patient safety and well-being, I ensure ethical practice and maintain trust with my patients.

So what?

The practice exam really helped to boost my confidence and also my autonomy in the clinical decision making process but also the shared decision making process with my patients. It was odd to not have somebody question what i was doing and why it might be that diagnosis and not another. It made me realise how useful it is to bounce my ideas of someone else in a diagnosis discussion and whilst making the decision on whether to treat or not. On the other hand, i enjoyed having the responsibility and a snippet of what it will be like in clinic every day when i’m qualified.

Now what?

I will continue to maintain and expand my levels of knowledge, skills and professionalism to acquire the best results i can at the final CCA exam in June. I will make sure practically that i have practiced all of the testing routines to be prepared for presenting complaints in any regions of the body.

I had to ask another of our colleagues to contact them to give me an overview of the case and otherwise I felt it would have comprised the patients care.

Even then I felt like time was wasted in the appointment re asking questions because I could trust the notes in front of me- therefore there wasn’t so much time for TTT which was frustrating for both myself and the patient.

So what?

I was able to reflect upon how my notes are laid out and written so the most prevalent pieces of information are at the top so it would be easy for anyone to pick the patients case up and feel confident going into the appointment. This also made me think to the future as to what environment I would like to work in. To avoid this situation in the future I would definitely want to work in a place with electronic notes so handwriting is not a factor I have to worry about as at the moment I am a student and I know there are times I will feel out of my comfort zone/embarrassed in front of patients however I done not want to feel like that if I am helping out a colleague as it gives people a bad first impression.

Now what?

In terms of my time at the ESO I will ensure that if I need to take any time out of clinic I will make sure I have either organised my patients case with somebody prior to their consultation or i have written up a patient summary and put it at the front of the patients file so whoever picks it up has a clear idea of what is going on and how to move forward with the treatment and management plan.

When faced with such requests, I will prioritise professionalism and adhere to legal and ethical guidelines. This includes verifying the accuracy of the information, maintaining patient confidentiality, and providing clear and concise written material. I understand the importance of meeting deadlines and responding promptly to fulfill the needs of patients, colleagues, and other stakeholders.

By handling requests for written material and data effectively and appropriately, I will uphold the integrity of my profession and maintain the trust of those who rely on my services. This commitment ensures that information is shared responsibly, respecting privacy and confidentiality, and contributing to the overall quality of patient care.

On return she said that she was now feeling a pain in the left shoulder that radiated down the arm as well as a degree of chest pain and shortness of breath. I took her blood pressure and it was 180/90, I took it again, 176/86, i then asked my colleague to take it and check it and he got figures around the same levels. She then disclosed to me that she’d forgotten to tell me but 6 months ago she when the hospital for a work up on her heart and they discovered a narrowing artery around her heart which they gave her medication for, which she since has started opting not to take…

I was very alarmed that she had ‘forgotten’ to let me know this vital information…

We then did an emergency referral to her GP/A&E and told her to get seen right away. She seemed frustrated that we didn’t want to treat her but i explained the situation in detail and the importance of seeking immediate medical attention.

The next week i saw she had booked back in and i felt very apprehensive in the run up to the appointment. When she came in she said that she was very grateful that we made the decision for her to go and get seen - they checked her blood pressure and it was the same as our values so they were worried and then did an ECG, chest X-ray and blood tests. However, she said that they couldn’t find anything of note so they told her she would be fine. I asked specifically about this narrowing artery around the heart that had been mentioned previously but she said they didn’t say anything.

I was still sceptical about the situation as of course I wasn’t there to understand any of her results and i could only reply on her interpretation of what the doctors said and even with that she had two new hearing aids which she had previously explained have been troublesome!

Even still the tutor advised me that there was no more that we could do for her in terms of referrals if she has had all the tests done so we should treat her shoulder pain. Furthermore, i told her she definitely needed to speak to her GP to find a solution for not taking the medication she was prescribed for her heart.

So what?

I didn’t feel most comfortable moving forward but her shoulder symptoms did start to improve. I just felt uneasy that we didn’t have any answers and I know older people do naturally have higher blood pressures sometimes however hers was off the of anything that could have been excused. Even so I am glad we referred her and she got all the necessary tests done to ensure she was in reasonable health.

Now what?

At first I wasn’t sure what I could of exactly done differently moving forwards- but I think the most important point to take from this scenario would be to the taking of the case history and making sure I give her patient as many prompts as possible, (especially when they are older and have longer medical histories), to think about anything they have been through or had advice for previously. Secondly, I think I made the right decision to refer and I will now feel confident in future to go through this process and with the ongoing advice I gave her to do my duty as a healthcare practitioner in keeping her from harm.

This instance has stressed the importance of following through with questioning in the case history and on every return giving the patient the opportunity to present new information. In future i will be very vigilant with this.

Some of the clinic rooms have cracks in the wall or the paint is peeling off, they don’t have good ventilation and some of the material chairs have stains on them that I would feel sceptical about sitting on! 

When I observe my colleagues I notice things about their room set up which would make me feel uneasy as a patient for example the room being cluttered with chairs or the bin overflowing with couch roll.

So what?

I think that the clinic doesn’t give off the most professional environment and I understand that it is a teaching clinic that tries to break even more than make a profit but there are definitely things that us students can do to maximise the space we have. For example, make sure the patient is facing the most pleasant side of the room. If any chairs aren’t being used, remove them, make sure the couch is completely cleaned between every patient and neatly lay our couch role to create a more professional environment.

Now what?

I will continue to clean as much as possible for my individual patients and change chairs to make sure there’s no stains etc. if there is any feedback welcomed at the clinic I would also make a point of saying the a coat of white paint wouldn’t go a miss!

In future when going to work at a clinic I will make sure to gain an understanding of what is my responsibility in terms of cleaning and what is the clinic’s responsibility to I can ensure all of the hygiene standards are up to scratch for everyone who walks through the doors!

I recently have been treating a patient with polymyalgia rheumatica (PMR), and she has been doing very well. She has also been seeing other health professionals as she is currently trying to reduce her dose of steroids.

She has explained that she has recently ‘ballooned’ in size - but i can see that this is fluidly and not fatty and she knows that this is an associated symptom of trying to reduce her intake of her prescribed steroids (under the supervision of her rheumatologist. When she expressed these concerns to her consultant the advice given was to limit her consumption of carbohydrates and sugars and increase milk intake. 

From prior knowledge i know that milk is an inflammatory food and so I wasn’t sure what the consultant rheumatologist was trying to achieve with this advice. Also, my patient has quite an obsessive, disciplined personality and i didn’t want her to completely cut out sugars/carbs because in the long term they are needed for normal body function. I have made the decision that my knowledge is very limited on the topic of nutrition and so i referred my patient to a local nutritionist that i know from working in a local multidisciplinary practice a sports massage therapist. I felt that she would be able to give my patient more informed advice about how to go forward.

I felt this was a positive next step and i have done lots of work osteopathically with her and mechanically she is moving very well after our course of treatments together.

So what?

I felt very frustrated as i felt that she had been given counterproductive advice, however I couldn’t comment too much as i am aware my knowledge in nutrition is limited. Luckily i believe i made the right decision by using the resources around me to enhance my patients health by realising the limits of my own training.

Now what? 

Moving forward, for my own knowledge i am going to enrol in a course to expand my knowledge and be able to give my patients the best care i possibly can. However, until then i will be making sure i utilise other healthcare professionals around me to ensure a multidisciplinary approach as recommended by the NICE guidlines.

What?

A patient came to see me in my fourth at the ESO clinic for a post natal consultation. We diagnosed her with neurogenic TOS due to breastfeeding posture and compression patterns she was creating due to the way she was carrying her son. The patient was happy with the explanation and management plan and was excited about the prospects of her pain and discomfort being reduced.

The treatment plan was going well and with every treatment she found her pain to be less frequent and intense until its complete resolution. She is now continuing to come in as she has requested an alternative kind of treatment.

She came in and told me that her c-section scar was very painful on pressure and also felt numb at times. She has had one previous pregnancy and c-section before this and knows that it took a long time for the surrounding skin to feel normal again however she felt that after 6 months, this scar had not progressed the same way as before. The patient requested if i could do some work on the scar to help it heal/become less bumpy.

I instantly felt a bit worried as I hadn’t been asked anything like this before. However, i decided this wasn’t a moment that i should “fake it till i make it,” and i told the patient that I wasn’t personally very familiar with anything i could do for scars from any of my training but i will do some research and when she comes back next time i will happy to have a discussion about her options going forward whether the be osteopathic in nature or otherwise.

By the time she had come back to the clinic i had explored information provided by the internet and books as well as some of my tutors at Boxley.

One of my tutors specifically provides scar work in her clinic so she pointed me in the direction of some techniques based on the work of Sharon Wheeler.

I explained to my patient that i had done some research and i had practiced some techniques for scar work that may be beneficial to her however i do not claim to be a professional in this field and if she did want to see someone who has lots more experience then i would be happy to put them in touch. Our conversation also explored the progression on scars, especially c-section scars and other options for Keloid scarring like, steroid creams/injections or cryotherapy.

Following the conversation the patient explained to me that although she was aware that I wasn’t experienced in scar work that she trusted me as i had been honest with the limits of my training previously and would like to commence the treatment on an experimental basis.

So what?

I am very happy that i decided to tell the truth about not knowing about scar treatment and take the time to do research and if not this could have been detrimental to the patient. This gave me time to really educate myself about firstly whether or not this was something accessible to me as an osteopath but also how. It shows that even though we have a very broad curriculum at the ESO there is still lots that we haven’t been taught and that we can go on courses for in the future.

Due to the initiative i took, i have a well structured basis of shared decision making and informed consent with my patient. Every appointment we have had from this consultation i check in with the patient to she if she is happy with her progression and whether she wants to continue this type of treatment moving forward.

Now what?

Acting with honesty and integrity is a fundamental aspect of my professional practice as an osteopath. It requires providing transparent and accurate information to my patients, admitting my limitations, and seeking guidance when necessary. Upholding ethical principles, treating patients with respect and empathy, and maintaining confidentiality are integral to maintaining integrity. Regular reflection allows me to assess my actions and make improvements to ensure the trust and well-being of my patients. By embodying honesty and integrity, I contribute to a healing environment and uphold the highest standards of professionalism in osteopathy.

What? 

Over the years as an osteopathic student - every time one of your friends or family see you they always ask if you can have a look at their back, shoulder, knee, neck etc… or your opinion on their symptoms.

As a student or member of staff at the ESO you can get free treatments from the 3rd/4th year students therefore its common to sometimes be treating your friends who turn into your patients.

So what?

I have always found it difficult to create a professional front with my close family and friends as its difficult to maintain the objectivity that is required as an osteopathy.

I had this experience with my mother when i was practicing on her during the March 2020 lockdown. I was questioning her about her complaint to try and narrow down the DDx’s. It suddenly crossed my mind that there was a possibility that maybe i should be exploring systemic/pathological diagnosis but i had been previously blinded by this as i just assume my loved ones are in good health. However, i had not taken the time do carry out a proper case history with past medical history and systemic questioning because of these assumptions and the basis that it was an informal situation. 

As i know her so well i also felt that consent was very poor as there was too much comfort in our relationship.

I was very inappropriate and irresponsible of me to let my family member put their trust in me without doing a full case history which could have resulted in information that meant that OMT was contraindicated.

Now what?

Moving forward i have said that i will not treat family of friends without being in the correct setting and in the same format to with i would use with any other patient in clinic.

If i can avoid treating my family i probably will and i would send them in the direction of a trusted colleague so my relationships do not have any bias on the diagnosis.

In the first term of my 4th year at the ESO clinic I encountered a tutor that I had never met before. I had heard stories about him with made me a bit worried as I heard he was very strict and didn't hold back if he thought your ideas or what you were doing was wrong.

On introduction, I was pleasantly surprised that he had been made out to be a lot worse that he was in terms of strictness and confrontation however his personality was definitely very black or white and his answers were blunt and to the point… no messing around.

I appreciated his honesty and it was something I really respected about him as I want to always have productive feedback so I can improve and be the best osteopath I possible can be.

However, one day in clinic I had a patient in the clinic with L hip OA and Knee OA as well as degenerative changes in the spine due to previous surgery. I was happy with my examination and treatment/management plan with the patient which was based in shared decision making. My tutor entered the room when I was in the middle of my treatment to check on the patient progress and to see if I needed any assistance with patient management. He asked whether it was okay it he felt the range of motion through my patients hips to assess for himself. At first I felt a little offended as I felt he was doing this as he didn't trust my judgement however, I left him to it as I am obviously aware that I do not have anywhere as near as much experience as he does.

He then asked me to demonstrate the explanation of the diagnosis and management plan in front of the patient so he could give me feedback which I appreciated as that was what I wanted from the session. After I finish my explanation I asked the patient if they have any further questions but they didn't. My tutor then took over and, I felt, quite confrontationally said "you just need to be aware that osteoarthritis will never get any better to you need to accept that you will be in pain for the rest of your life."

I felt so angry that he had said this as I could tell this made the patient feel awful and defeated. There was no reason for him to 'rain on their parade' in such a way, when they were feeling so positive previously about how osteopathic treatment was helping their quality of life.

So what?

The thing that frustrated me more was that he wasn't lying. Obviously we know that once degenerative changes have occurred there is no way for them to be reversed - hence he was being open and honest. On the way hand, the criticism of this OPS is that, was it necessary to be that open and honest with the patient?

We know that research presents a placebo effect within osteopathic manipulative treatment, so who's to say that my patient will never be pain free ever again. What is the point in claiming to treat the symptoms of degenerative changes if my tutor uses his blatant honestly to crush any remaining hope my patient has left for their quality of life.

Now what?

I understand that being open and honest with patients, fulfilling the duty of candour, is crucial in healthcare. Adhering to the principles of candour not only promotes patient-centered care but also fosters a collaborative and supportive environment. It demonstrates our commitment to acting in the best interest of patients, ensuring that they are well-informed about their health, and that any adverse events or errors are promptly disclosed. Embracing the duty of candour serves as a reminder of the ethical obligation we have as healthcare professionals to prioritize honesty, integrity, and the well-being of those under our care. It demonstrates our commitment to acting in the best interest of patients, ensuring that they are well-informed about their health, and that any adverse events or errors can be promptly disclosed. However, I do believe there is a flaw in being closed minded and black and white about this topic. Its important to be realistic with the patient about prognosis although in my practice I don't believe it is right to act in the same manner as my tutor and compromise the biopsychosocial factors of the case.

What?

As a student practitioner at the ESO teaching clinic, i am aware that there is a patient complaint policy available at the clinic reception as well as on the clinic website. During my time in practice i have never received a complaint from a patient.

So what?

If i ever get one, i would make sure to gain full understanding as to why the complaint was made and put actions in places to either modify the next appointment or discussing with the patients the other options available to them.

Now what?

It would also be a learning opportunity for me to improve my patient management and apply it to future situations.

What?

In my 4th year at the ESO clinic I had a patient takeover for a women in her early 70's who struggled with OA in her hips and knees as well as carpal tunnel. Over the treatments I began to build up a rapport with the patient and she opened up to me about lots of things in her life, including about the life of her grand daughter. She explained to me how she was being bullied at school and was having a rough time with it, she refused to eat in front of the other girls and would cry most days about being picked on. As I didn't know her granddaughter very well I took a very passive position not he matter and listened however she did ask me how I thought I would feel and the support I would like as I was much closer to her in age. I kept my answers very brief, generalised and two sided and assured her that everyone is different and there is no right way to support someone, its on an individualised basis. Every time she would come in she would give me updates on what was happening and I think it was therapeutic for my patient to talk about it in an environment where nobody else knew anything so she could get her feelings out.

About six months later I was observing one of my colleagues in headaches clinic and she had a new patient coming in. The patient was a 16 year old female presenting with migraines amongst other headaches. The case history ran in the same fashion as usual and we began to uncover patterns to her headaches that coincided with the stress of attending school. Suddenly something clicked in my brain- the last name was the same, description the same, sporting background the same and her mother (my patients daughter) was a spitting image of my patient, just younger. So this was the granddaughter that I has been hearing about all this time.

I suddenly felt a split responsibility- felt that the information I knew about her background was a very important feature in the onset and maintenance of her [resenting complaint. However, I could speak up and break the confidentiality of the sessions I had with my patient. This made me feel really split and I didn't know what to do.

So what?

I thought about it for a good while until I decided what to do. When my colleague finished her case history she asked us observers whether we had any questions for the patient they we felt they had missed. I took this opportunity to ask her a little more about he daily patterns of the headaches and when she gave me clear indications it was related school I moved onto asking her about her support system at school and whether she had a good group of friends etc… her mother laughed instantly and then opened up a conversation about that she was having trouble with some of the girls there etc…

I was very happy that I was able to discreetly open this conversation so that I wasn't breaking anyones confidentiality or trust by claiming to know the information already. This was important as I didn't want to make my patients granddaughter feel uncomfortable either.

Now what?

Respecting patients' privacy and confidentiality, and effectively safeguarding their information, is crucial in healthcare. It builds trust, maintains relationships, and ensures data security. Patient information, including personal details, medical history, and treatment plans, must be handled with the utmost care and discretion. By upholding these principles, healthcare providers prioritise patient well-being and preserve their autonomy, contributing to a stable and ethical healthcare system.

I was wrong…

My patient presented to the clinic as a 48 year old women 7 months pregnant with twins through a rigorous IVF process. My patient expressed that it had been an incredible mission to get to this point but she was so excited to finally give birth to her babies.

She presented with bilateral neurogenic TOS and carpal tunnel. Her midwife and GP were aware of this but said they weren’t prepared to do anything about it whilst she was a high risk pregnancy.

An agreement was made with the patient that she would come in weekly for treatment to try and make the rest of her pregnancy as comfortable as possible. She had never had these symptoms before pregnancy and it was hopeful that they would disappear once she had given birth.

We were managing to keep her symptoms at bay following a couple of weeks of treatment and she was very happy but eager to get them out. 

Another aspect of my patients person was that she was a Muslim and she wore a head scarf. This in itself of course was no issue at all. However, because we were working around her shoulders and neck, she felt comfortable enough to remove her head scarf. My patient and myself had a chat about this and she said she was comfortable however there would have to be an assurance between us that no men would enter the room and see her and in her religion they must have their heads covered in front of any man apart from their husband. I then was not only in a professional position of trust but a personal trust that a male wouldn’t walk through the door unexpectedly.

So what?

This relationship with my patient made me reflect on the fact that even through there are adjustments that must take place to make her feel safe this couldn’t get in the way of the quality of treatment that i provided her with.

If i was ever in a group that had a male tutor i either communicated the situation with them and they didn’t enter the room whilst i was treating or i switched to a group with a female tutor if they weren’t comfortable with the situation.

This goes against many of my morals of gender and beliefs against the idea that a man is superior to a women so i had to separate my views on her religion and the way they view women in society to respect that she believes differently to myself and make sure i didn’t let that interfere with my treatment and management plan of the patient.

Now what?

If I’m have situations like this in future, as i’m sure i will, at the ESO clinic i would continue in the same way i have so far, but in clinic post graduate, i will ensure to my patient that no one else will be entering the room apart from the two of us and ensure my communication is clear as well as not asking my patient to remove any clothing especially religious unless absolutely necessary.

I believe it is important in our job to have an understanding of lots of different backgrounds so we can be empathetic to as many situations and lifestyles as possible.

What?

One of my class mates has social media accounts as many of us do, however her instagram in particular has a public setting meaning that anyone with the app can access her profile and see the pictures she posts. I feel that some of her pictures and posts are somewhat inappropriate and could give off the wrong idea if come across by patients, colleagues or even employers.

So what?

I think it to be unprofessional to share revealing photos of yourselves for your patients to see on social media as you are their healthcare provider.

Now what?

I wouldn’t ever have a public social media account just in case my patients ever tried to find me and felt offended by any of my posts. Observing this of my colleague has made me more conscious that not only are we representing ourselves but we are representing the profession of osteopathy as a whole.

I know this is important to have your clinic policies clearly available to all of your patients to minimise the chances of running into any problems.

During one of my clinic sessions, one of my colleagues observed me and prior to my new patient, asked me if i wanted to receive feedback from her on how i perform and some recommendations as to how i can improve my practice. I agreed to this as i wanted to improve wherever possible.

So what?

 

My colleague gave my a list of written feedback that took during my session that they noted down during my session including all different aspects of the appointment from case history taking to examination and patient management. It enabled me to explore and improve on things that i would not have reflected on prior to this experience.

No what?

Since the start of 3rd year I have always tried to observe my colleagues as much as possible especially during new patient consultations and give feedback for them to improve on. I do this because i really appreciate when others dot his for me as i find it a very useful learning tool to improve and refine my professional skills, therefore i want them to have the same opportunities. In future i will continue the process for my colleagues and ask others to do the same for me more regularly.

As her practitioner I had formed a great rapport with this patient and we got on very well, so I felt deeply saddened to hear this news as I also treat a few other of her family members. However, I knew that I was not trained professionally to help her deal with the emotions she was experiencing so I decided that she needed this treatment time to decompress her feeling but when I saw her next I would provide her with the information of different options of talking therapies so help her through this tricky time.

So what?

I felt deeply saddened by this experience but I went away and did some research into support groups as well as one-on-one in person or remote talking therapies to think about and have a look through.

The reason I felt this was important was that there are many links between that emotions of a person and the reflection of that on their pain intensity It is important that all WHO models are addressed in patients to optimise their health and healing time. I felt that if nothing way done, her back pain would get worse and then starts the cyclical pattern of her feeling helpless because everything feels like it is going wrong.

I presented her with the information in her next session and she was very grateful. She Agreed that she did need tot think about other aspects of her health as if she wasn't at her peak she couldn't be as helpful to others. She also wanted to seek some advice about diet management and nutrition for her daughter whilst she was undergoing chemotherapy. I explained to her that I don't have expertise in this are but could give her the contact details of someone I knew that did. 

Now what?

Recognising that healthcare is a team effort allows us to harness the collective expertise, skills, and perspectives of various professionals involved in a patient's care. Collaboration among healthcare professionals facilitates a holistic approach, ensuring that patients receive well-rounded, multidimensional care that addresses their diverse needs which is the very core of what osteopathy stands for. By valuing and incorporating the insights of others, we can tap into a wealth of knowledge and experiences, ultimately leading to better patient outcomes. Embracing a team-based approach not only enhances the quality of care but also promotes a supportive and harmonious working environment, fostering a culture of mutual respect and shared responsibility. By acknowledging and leveraging the contributions of our colleagues, we can collectively optimise patient care and work towards the common goal of improving overall health and well-being. This multimodal approach has been so important in the maintenance of any of the patients I see at the ESO clinic.

I started my 3rd year of the ESO whilst still in the midst of the COVID-19 pandemic. There was lots of PPE equipment around clinic and we had to be even more prepared to keep everything clean and sanitary for not only our patients but ourselves. I knew that if i contracted coronavirus i would not only put those around me at risk in my personal life but this would have a grave effect on someone of my patients - especially the elderly ones and those with serious conditions.

In November 2022, i started to fell flu like symptoms and generally just exhausted - at first i though it might have just been stress from the course and studying and exams and generally being spread thin however my boyfriend pushed me to test for COVID and it came back positive. I felt shocked as I had managed to stay away from all of it for the previous 2 years and now i had got it when everyone was a little less worried. 

As soon as i knew i rang the clinic and let them know what had happened and followed their protocol to not come in.

So what?

I felt split as i was very worried about missing out on clinic hours and experience and that i would fall behind. On the other hand there was no way i had the energy to treat and even if i do it would have been so irresponsible of my to put my patients, tutors and colleagues at risk.

I believe it is so important to be on peak form yourself before treating others who aren’t at optimal health - because otherwise you cant give them the full experience that one they are paying for but second they need.

No what?

Covid is not so much of an issue in our society at the moment as there has since been vaccinations circulating globally - however if you were to contract that or any other flus that you shouldn’t put your patients at risk as we must ‘do no harm’.

In my future as a student practitioner and a qualified practitioner i will make sure that if i am ill in any way, if i cant provide my patient with the care I would on a normal day then i should not be putting them at risk of picking up any illnesses (if they are contagious).

During my 4th year at the ESO, the GOsC came to the university on our careers day to give us a talk on the benefits and requirements for registering with the GOsC.

One of the steps is obtaining a DBS check so they can check any existing criminal history due to working with members of the public some one which are vulnerable people.

So what?

DBS check means that the GOsC will receive a copy of the disclosure if you have any convictions or cautions to your name. I instantly felt worries as i have had a speeding ticket and parking fine in the past and i didn’t know if these were shown on a DBS check and might have a negative impact on my application.

However, i did some further research and realised those things are not listed as an act of criminal offence and will not influence my registration process.

No what? 

By being aware of the paperwork required by the GOsC to move forward with an application added even more importance to the conduct of a person wishing to become an osteopath and the weight we carry as healthcare professionals. If at any point any of my paperwork is requested i will make sure to provide what is required as soon as possible and always cooperate with the requirements of the GOsC to ensure the process is carried out simple, smoothly and efficiently.

I had a patient coming in before christmas who i prescribed a course of exercises for. Further into the management plan it came to light that they weren’t engage with the exercises given and were completely relying on the treatment.

I generally try my best to create lifestyle changes that will slot easily into my patients daily routines so that they can quickly develop habits which will aid their recovery journey as well as making positive changes in the long run.

When i became suspicious that the patient wasn’t doing their exercises, I asked them to show me how they were doing them- this provided a bit of an awkward environment as they quite obviously couldn’t remember what i had given them even though they had paper copies of the exercises.

We then had a discussion about not being reliant on treatment and having to engage in some sort of activity outside the treat,ent room otherwise they cant expect to get any better.

So what?

I felt very disheartened by the situation at the time as i feel that i always put a lot of effort in to providing my patients with the best knowledge and tools for outside the treatment room. However on reflection, i cannot expect everyone to have the same outlook on their health as i do, and some patients have a lot more going on in their lives than i do and that could get it the way of any routine changes that might be difficult to implement if they are already busy.

Now what?

Moving forward i will still strive to provide the best and most ad hoc advice for my patients to overall help them make positive lifestyle changes.

In my second term of 4th year at the ESO clinic, i treated a 35 year old female presenting with bilateral hip pain and odd neurological symptoms down the leg. I began testing, working through the routines as i precisely would in other cases and the patient had removed her leggings in order for us to do some sensory testing through the dermatomes of the lower limb. Her underwear was not revealing but with the nature of hip circumduction i can understand it might feel a little odd for those who are not used to osteopathy. When i had finished all of my testing i still felt i didn’t have a good idea of what was going on and so i wanted to go and find my tutor t see if he was able to provoke any pain or retest the things that i had done.

I was about to leave and then i stopped myself and asked my patient is she would be happy to put her leggings back on. She had expressed that she felt comfortable dressed down with myself and my female colleague in the room, however i knew my tutor would want to conduct so supine general articulation through the hips and i wanted to ensure that neither of them felt like they were in an uncomfortable situation.

Then when my tutor came in the examination continued, i could see that she felt comfortable and he managed to illicit some pain so we could put together a diagnosis and management plan for treatment.

So what?

This has made me reflect a lot about whether it is necessary to remove clothing at all with testing and treatment. Patients will 9 times out of 10 feel more comfortable with their clothes on and maybe that would give us more accurate results from our testing. It is possible that we have always been taught to dress our patients down as much as possible to see more of the body and be more holistic for the purposes of our learning in the cognitive stage and not necessarily what we should always do going forward in practice.

Now what?

Moving forward i will only be asking my patient to remove especially necessarily items of clothing, with awareness as to how comfortable they are and also taking into consideration of which regions of the body we are working with and the genders of those who will be coming in and out of the room. Also, i will make it very clear to my patients that they can bring in shorts to wear for subsequent treatments if that would make them feel more comfortable.

I first treated her as a cover patient for one of my colleagues as they were ill, however the patient was very unhappy to have to explain her case again. At reception she complained about the arrangements here but we all explained calmly that this is a teaching clinic and the nature of the way things work here, if she doesn’t like it then it is her choice to seek treatment somewhere else.

Nevertheless, after the treatment, she specifically requested for me to be her practitioner and not to have anyone else.

In the weeks following that she kept returning and i came to learn more and more about her and she became comfortable with me. She started making what i felt was inappropriate comments regarding people’s ethnicity. I decided to ignore the subject completely, and move on with the conversation about her treatment. I decided if this was to arise again, i would gently tell her that i didn’t find the kind of language she was using appropriate and that if it happened again she would have to see somebody else for treatment.

So what?

The was already concerning for me as i felt that i had pressure to adapt my diary around her as opposed to her coming in when i can fit her in - but i still didn’t want that to affect her right to proper care. However, i felt very angry that she was making certain comments and that she felt that i wanted to hear them- i certainly didn’t!!! Although, on the other hand, i did feel sorry for her as i know comments like hers always stem from ignorance.

Now what?

After speaking with my tutor, it all felt a little lighter on my shoulders- however my tutor said “unfortunately, there are lots of people that still think this this in our world, we just have to deal with it,” and to be honest i don’t want to just have ‘to deal with it’. Moving forward, if this continues i have decided that i will make it clear that there is no place for those comments in my treatment room and if it does persist i will pass this on to people higher up in clinic management.

What?

At the end of my third year of studying at the ESO teaching clinic i had a session with a tutor who wanted to make a point and make us aware of some common instances of nomenclature in the world of medical diagnosis and treatment options that keep evolving based on new evidence.

This was because i had a takeover of a patient who had previously been diagnosed with Gilmores groin and i was unsure of what this was. I did my research and it turned out to be a condition that had been referred to in our lectures as sports hernia.

So what?

My lack of knowledge over this updated versions of the diagnosis caused me confusion. I also felt awkward and unprepared when I had to explain the diagnosis to the patient for a second time using an alternative name even though it meant the same thing. This made me realise how important it is to keep our knowledge up to date especially in osteopathy where we often have to collaborate with other healthcare professionals.

Now what?

I will make sure that with every diagnosis will not only be up to date which the range of possible treatment options and osteopathic techniques but also the variations of ways to say the same conditions and what is most widely used in recent research.

Each of the questions make reference to a different stage of the process. The reflection starts with asking yourself what happened in the situation, what was the problem/experience and what role did you take?

After this come self reflection regarding your actions and more personal thoughts towards the outcome. The last stage is is then to analyse the consequences of the prior steps and think about what you could do to improve/ alter your actions/process moving forward.

Personally i think this reflective model is the most appropriate one for me as i find it useful to be proactive in making quick and pragmatic improvements to my practice, preventing unnecessary overthinking and stress.

As healthcare professionals using reflective practice is equally important and useful on both personal and professional levels. It helps to consolidate all the information that comes from any one situation and helps us to clarify what is required of us. It aids the learning process by exploring the situation on a descriptive level, verbalising your thoughts and then finally analysing the outcome.

The following attachment is taken from an assignment i submitted - the personal information included is purely fictional and do not reveal/represent a real patient

What?

During my second year at the ESO, one of our assignments wad to write a response letter to a patient complaint after a treatment session. It was a letter from a x saying that they felt they have been deceived when we knew their son would be fine anyway without treatment.

So what?

When starting to engage with the assignment it seemed very easy and straightforward. However as i started Tod look further into the OPS i realised there were many points that needed to be covered with explanation as to why i (hypothetically) used techniques and backing them up with existing published literature.

Now what?

This assignment resulted very helpful and has given me a good structure to use in the future should i ever need it. I now feel comfortable with the steps i would need to take.

In my 3rd year as a student at the ESO, one of our assignments meant that we had to create a business plan for a prospective future clinic. This involved us creating a plan down to the core details about how we would go about starting up our own business-the finances we would need to start up and our yearly NET income.

I did enjoy the process as it was the first time i could take time to actually imagine how the i would run my own practice. Indirectly, it was provided me with good knowledge and consideration, maintaining a high standard of adherence to this OPS.

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