Following 6 weeks of children clinic with a tutor they gave me some written feedback:
"What I have observed that went well:

CVS screen-cold hands and feet can be asked as well as colouring ie. blueness or mottled."

This feedback is from taking a new patient case history of a 6 week old. I felt like I listened well, gathered data well and enabled the mother the opportunity and the time to say everything she wanted to say. I also feel it is important that when treating babies that I make sure the mother knows that she is in control, should the baby get upset or she would like to stop the consultation, or wants to feed or change her baby that she can.

This reflects the OPS A1, whereby I have given my patient the time to say everything she needs to, taken the time to listen and have accommodated for the need of the patient e.g. by treating while feeding.

I could have however enquired about the ideas, concerns and expectations separately, giving the patient the opportunity to express all of these. As it is important to address and to accommodate all of these which can all be equally important. This reflects the OPS A1.3.


3. Case reflection 05/05/21

Today I had a patient present in women's health clinic. She was 35 weeks pregnant and had neck pain. Within in the initial discussion she reported having being diagnosed with general anxiety disorder, this had effected her within the last year with specific concerns regarding her health. One year prior to her presentation, she had become concerned about having a neurological disorder to the extent that she had seen a neurologist privately. All tests came back negative.
She was now very concerned about her neck pain and she believed that something serious was going on. Her midwife had her attend hospital for a psychological assessment regarding her anxiety over her pain.
She had also attended a physiotherapist that told her her pain should be better within a week, when it didn't this heightened my patients anxiety.

On examination, I found that there was a musculoskeletal cause of the pain meaning the patient was safe to treat.

Given the patients anxiety, I allowed her time to express her concerns.  Following examination, it was important to spend time explaining her symptoms, making sure she understood the differential diagnosis, so that it didn't heighten her anxiety. It was also important that I managed her expectation, meaning that if she wasn't completely better in a weeks time that this wouldn't cause her further distress.

I enjoyed this case as my patient visibly relaxed after my explanation of her pain and during the treatment. It was good for me to adapt to her mental health throughout the consultation and allow her additional time to listen to her concerns and address any questions she may have. (OPS A1).

What I would have liked to improve on in this scenario is my time management, I would have liked to address my patients concerns without having over run. I also found that I allowed the emotional distress of my patient to stay with me for too long. Whereby I continued worry about the case, how she was effected and what more I could have done for her for too long. (OPS B1.11).

During practise I have found that I am more in tune to what I am feeling and can therefore focus a technique on what it is supposed to be doing. For example, every technique we practise is the same as when practising a HVT, our goal of the HVT is to hear the audible 'pop'. When practising, even on each other, we should aim to have a focused and effective technique.

As I am gaining a better understanding of how the body moves and feels while I am using my hands, I find I have a greater drive to be effective in practise.

OPS B1.7: well-developed palpatory skills

4.Entering clinic for the first time post lockdown 17/08/20

On returning to the ESO for summer clinic following over 4 months off, I was very aware of the fact that I was unable to treat a patient for all this time. Although we had had plenty of time to focus on improving our knowledge, I felt like I had lost a lot of the practicality that I had gained during my time in clinic in third year: case history taking, clinical reasoning and the application of our knowledge in a real life situation.  

I was concerned that I wouldn’t be able to gain what I had lost and progress to the required level by the end of 4th year. 

 I was also scared that I had lost a lot of my practical skills. 

Following my first week I am feeling more confident, I feel that with each patient I gain more confidence in my ability. I am still aware that I need to put a lot of work in to improve my practical skills. I need to improve the fluency and accuracy of my examination. 

In general I am pleased with myself, in general my patients have seemed happy with my treatments .

In the will make sure that I use the spare time that I have at clinic to practise and improve my practical skills. 

I had a patient who presented with anterior shoulder pain when chest pressing. During the exam I was able to run through the orthopaedic tests but with no positive tests to suggest the pain causing structure, I was stuck.

My tutor at the time wasn't giving me any suggestions prior to treatment as to how I could help this patient and was short tempered when I found myself stuck on what to do. I found this frustrating and was holding back tears following the encounter with the tutor. I treated the patient and left clinic that evening feeling deflated and unsure of myself as an osteopath.

Following this scenario I have decided to tackle my lack of knowledge when treating shoulders. I have considered how they are complex structures and knowing the source of the pain extremely difficult without imaging. I have looked into the different models of classifying shoulder pain including the shoulder symptoms modifications model and the movement system model. Which considers looking at thoracic posture, scapular posture etc.

When I look back at the situation it now seems obvious to me that I should have considered these things. However, considering this was the first shoulder that I was treating in 6 months I resent the tutor for not giving me a gentle nudge in the right direction.

I am aware that by July next year I will be on my own treating patients and that I should start finding independence while in clinic now to prepare myself. Despite being disappointed in my performance that day, I feel I have  since then responded in the correct way, by focusing my study in this area so that the next time I get a patient with shoulder pain who doesn't fit an orthopaedic diagnosis, I won't freeze.

OPS B1.2:  knowledge of human structure and function sufficient to inform appropriate care
B1.10: problem-solving and thinking skills in order to inform and guide the interpretation of clinical and other data and to justify clinical reasoning and decision-making


6.Clinic reflection 16/09/20

Today I had my first baby in clinic, she was 12 weeks old and presented with torticollis. 
The tutor encouraged me to take the lead with the case history, but she remained in the room. I found that after a few questions during the case history I froze and didn’t know what to ask, so the tutor had to take over. I think as I am unfamiliar with the norms of  pregnancy, birth and looking after a baby it was difficult for me to have a relaxed conversation with the mother. Prior to children’s clinic I had taken the time to study what could go wrong and how to do the examination, but I hadn’t thought to look over what is involved in the normal processes. I think especially when you are talking to a mother who is the ‘expert’ through her experience, it is easy to find myself caught out and uncomfortable during these discussions. 
I will now spend some time looking over what a mother experiences when pregnant and through birth and cover what the normal birth processes are. I think being able to discuss this with mothers is something which will also take time and some experience, which I will hopefully gain throughout children clinic, as it is such a different experience to normal clinic and treating musculoskeletal disorders. 

In children’s clinic today I had a continuing appointment with a 4 week old baby I had seen the week prior. The parents brought her into clinic for silent reflux which was causing her discomfort and led to her being unsettled. I was guided by my tutor throughout and felt the examination and treatment went ok.

I noticed that there was a generally tense atmosphere with the parents; the way they described their babies presenting complaint used extreme language which suggested they were very anxious and concerned. They asked many questions with the general theme of ‘is my baby normal?’ The baby seemed healthy and I was able to assure them that, for example, the fontanelle was normal. Despite having no reason for concern and with my tutor beside me, it felt like a lot of responsibility to be advising parents on the health of their baby. There is so much to learn when treating children and babies, and for me to feel confident in giving any advise I will need to improve my knowledge, so I am confident to pick up when something is wrong.

I felt these parents needed a great deal of reassurance. It was also important that we thought about the language we used when discussing our findings, to make sure that they weren’t taken out of context and considered as a serious health risk. I took the time to explain that the words we were using such as ‘compression’ may sound scary, but they were only descriptors of what we were feeling, and not a sign of a serious problem. This patient definitely tested my communication skills and made me conscious of the way I was using my words, and how they could be perceived. This was challenging and somewhat overwhelming but felt it went ok. However, at the end the mother asked “if she doesn’t have treatment, what would be wrong with her in later life?”. This told me that there was still some miscommunication. In the future I will need to regard patients individually and assess which points I may need to emphasise or where further explanation is required, so that they can make informed decisions about the care they receive.

OPS: A2


3. Patient reflection 23/09/20

During children’s clinic today I had an 8 year old child present with hyper-mobility, which was giving her difficulty when walking and writing at school.
I was really happy with how this went, the tutor took me to the side after and told how well I had done with my communication and interaction with the child. I think I had done well to include the child in the discussion, during the case history and during the explanation of what hyper-mobility was. I was proud of how I had dealt with the child when she had gotten upset because of how the condition was effecting her life. 
Overall this was a positive experience for me, when in a completely new situation as I don’t have any experience with children, I felt I adapted to the situation well.
OPS A2.3 You should be sensitive to the specific needs of patients and be able to select and utilise effective forms of communication, which take these into account.

Today I had a patient present to clinic with a complex case history. She was 30 years old, had been experience LBP since she was 20, and now had a wedge fracture of T7. Her medical history also included:

I felt ok to take the case history, and was happy with how I managed to do it while having everything clear to present. We decided that we would be ok to continue with examination. The tutor agreed that we would be able to treat her as she was currently under investigation with her GP. Although we would not be able to fit it in to this session.
However, I was required to have a frank disscussion with the patient, as she had a chronic and complex history it was important for her to know that we aren't going to be able to 'cure' her. It was important that we informed her of her options and let her know that we would be able to treat her and give her exercises to help with the mechanical problems we had found which could offer her some relief and give her more control to meet her goal of being more active, but there was clearly something more systemic going on that she would likely need medical help with. 

I think I handled this situation ok, I believe that being able to smoothly and clearly discus these things the way that I would like to be able to will come with experience. I was comfortable to speak with my patient in this way, which is something I would not been comfortable to do a few months ago.  However, I would like to improve my professional manner so that I can be more reassuring to patients.
OPS A2.4: You should share accurate and relevant information with patients, and encourage them to ask questions and to take an active part in decisions about their treatment and care.

Today I had patient who was suffered with wide spread chronic pain following an accident in 2008. I found the presentation quite daunting especially since the patient appeared generally exhausted and forlorn. She had recently stopped working and had been very stressed, she was unable to sleep for very long each night. 
I felt overwhelmed and like I wouldn’t be able to help her as much as I would’ve liked to. 
I was able to give her a global treatment and diaphragmatic breathing to go home and do, as she was very tensed and rigid from holding in her stress and from not moving due to pain. - this was the first time I had seen the extent of which stress could have on someone, she really struggled at the beginning with breathing into her stomach. 

I will look into how I can help my patient deal with stress, as I have seen the impact of psychosocial factors on her pain. 

(OPS A5)

3. Patient reflection 7/12/20
Today I had a continuing patient, this patient had been coming to the clinic for years, he has osteoarthritis effecting the mobility of his ribs, so seeks treatment in order to improve his breathing. I had a discussion with the patient that he may also have COPD given his history of repertory infections and shortness of breath, therefore I would like him to see his GP. The patient was adamant that he did not want to see his GP, he had experienced anxiety and panic attacks with hospitals in the past and was happy with the treatment he was receiving in the clinic and felt like it significantly improved his breathing.

I had to respect my patients feelings and decision, despite disagreeing with this. We had to come up with a compromise, in that we agreed to measure his blood saturation and chest expansion at every appointment. The patient agreed that if these every dropped below normal levels that he would go to his GP, but in the mean time he would be able to get osteopathic treatment.

It is hard when you want to help your patient as much as possible, but they don't agree with how this can be done. I had followed the OPS in encouraging him to seek healthcare from others, and when I accepted his decision regarding this. However, it is important to consider in the future when the boundary of him refusing medical treatment becomes unsafe to treat osteopathically.


4. Patient reflection 14/04/21
Today I had a patient you presented to the clinic with mid-thoracic pain, with the working diagnosis of muscle fatigue. Within the case history she noted that she had gained a bit of weight over lockdown and asked if this could have contributed to the pain and if she should lose weight.

I explained to my patient that I can not be sure that losing weight will decrease her pain, but it is important to eat a healthy varied diet and to exercise regularly. I explained that increased weight can create increased strain to muscles and ligaments.

Discussing lifestyle changes with patient is not normally something that I feel comfortable with. In this case it was made easier by the patient bringing up her weight, however, I do not think I would be comfortable to start this conversation. I feel that people tend to be aware if they are over weight, so it would feel potentially rude and condescending to bring this up, on the other hand, it is important to educate people on how this may be effecting their body and how they can live a healthy lifestyle.

I remember a tutor in the past suggesting that if you have an over-weight patient who you think you could benefit from losing some weight, you could try simply asking them "is their anything that you can think of that you could do to help with your pain?" - suggesting that some patients may know that losing weight can help, and you can develop the conversation from there. This made me think back to a tutorial on motivational interviewing: https://www.aafp.org/fpm/2016/0900/p32.html 

This uses a goal-orientated communication style. So you guide the conversation, in a understanding and empathetic way, getting the patient to highlight what has worked for them in the past, what might have gone wrong and ultimately guide them towards a plan.  This could be a useful tool when supporting patient in caring for themselves.

In this case I could have been more empathetic to my patient, considering that the lockdown was a hard time. I could have help the patient consider how she could go about losing weight in a way that works for her, whether this meant finding an exercise that she likes, joining a weightless group or even discussing this with her GP. 

In the future I will consider this approach when discussing a lifestyle change like weight change, I will appreciate the fact that they may have struggled with this in the past, and work with my patients to find a way that they feel they will work with them to lose weight. 

Today I had a 67 year old male, grounds worker, present to the clinic with groin and anterior thigh pain. The patient had a previous working diagnosis of hip OA. For the examination we decided to use a neurological exam to be certain the pain wasn't coming from his back. This led to the findings of:

This suggested to us that he likely had a myelopathy, and needed referral for further investigation.

He did, however, also have pain on FADIR at the effected hip, with associated myalgia of the quads. 

For this patient we had decided that he needed a referral to his GP as soon as possible. Upon discussion the patient reported the gait changes for 5 years, suggesting there is a slow progression of his symptoms. In addition, we noted that there was a clear musculoskeletal cause for his hip pain. Which has improved from osteopathic treatment in the past.  We discussed the referral with the patient and agreed that we would also be able to conservatively treat his hip.  

With this case, I was glad to have identified the neurological findings - I could have taken the previous diagnosis, and missed identifying the serious pathology. In the future I will make sure I will always thoroughly test my patients, despite the diagnosis they may have been given. 

It was also interesting to discuss whether it was safe to treat this patient. We had identified that he had both an upper motor neurone lesion, and osteoarthritis in his hip. As he had been experiencing these symptoms for 5 years we could deduce that this was not an acute myelopathy. We could have referred the patient and justified not treating them, however, as an osteopath I could gently treat the patient, and give him pain relief by focusing on his hip and Lex, without treating his spine, where the cause of the myelopathy could lie. In the future I will consider where I can help someone as an osteopath, when I need to refer them and if the two can be used in adjunction to each other, meeting all of the patients needs.

I attended a barefoot talk which ran over a number of techniques.
It was really helpful and I learnt a lot of new techniques.
Most importantly for me, I learnt the importance of using your body while treating. Firstly it allows you to relax your hands, so that you can palpate better, and it is far more comfortable for the patient. Secondly, it is way more efficient for your body, looking after yourself in the long run when you'll have to be treating lots of patents within a day.

2. Reflection 03/06/20

Over the course of the lockdown I have found that I have had additional time to study things of my interest. I have regularly watched online seminars including discussions with orthopaedic surgeons, specialists on shoulder pain and osteopaths with special interest in a number of different areas. This has has made me realise that there is so much that I am excited to continue learning about after university finishes.

I know that we are obliged to take part in regular CPD when qualified as osteopaths. I see that this is so important as there is so much for us to know as osteopaths in order to provide the best care. I look forward using this time to study things that I feel passionate about in order to provide the best possible care for my patients. 

3. Discussion with tutor 19/01/21

Today during an online tutorial our tutor challenged us to explain the management of a number of different DD's, in terms of what are the surgical options, what are the conservative options and which has the best prognosis. My knowledge on this was a bit rusty, and I struggled to know which medical options were best. 

It is important that we stay up to date on the available research so that we can advise our patients on all the available approaches to their care and what will have the best outcome. 

In the future ongoing research is required to stay up to date with the options available for my patients. I will continue to study throughout my career, giving myself time to develop my knowledge. 

I have seen a patient for the third time today, each time he starts the consulatation saying how he has seen improvement in the pain, however it was shortly followed by a new associated pain. From extensor hallicus longus tendinopathy, to plantar fasciitis to a subacute gastrostocs strain. 
Due to the ongoing changes with his injury, we decided to take a step back from the acute injury and try a more global approach as there is clearly a greater mechanical promblem occuring. 
I have found this frustrating, where by my treatment seemed to be effective however it was not tackling the primary problem, so there was not any long term relief.

I will aim to improve my knowledge of the anatomy and the biomechanics of the foot to try and get a better understanding of what's going on. I think in the future I will also try to take a more global approach from the start, especially in patients with acute pain, as you don't want to aggravate the acute pain causing structure, but may be able to offload strain to that area.  

During summer clinic a member of my team had a 89 year old patient with LBP. There was no known onset and he had been experiencing dizziness, which he hadn't been to see his GP about. He also had a history of prostate cancer.

During the discussion prior to examination, we had discussed the screening questions for dizziness, and  the possibility of metastasis from the prostate to the spine.

During the examination it was observed that he had a pulsating mass in his abdomen and was referred to the GP to be seen urgently with a suspected AAA.

We were later called and told that he had a large AAA, and that he had metastases all over his body.

This was the first time that I had witnessed a patient being referred for something life threatening and it had got me thinking about how I would have handled this scenario. Would I have noticed his AAA? Would I have referred for possible metastasis?

It's hard to guess how I would have handled it, but it has really made me aware of the possibility of patients walking in with something more sinister. I really need to be thinking about the possibility of this with every patient that walks through the door.

When discussing this with a tutor they said that they refer any patient with a history of cancer and back pain which has no known cause. That also said that they screen for AAA with every older male with LBP. I had never heard of taking these precautions before, but I will definitely take this on board for the future.

I have also revised my screening questions for AAA, dizziness and other possible cardiovascular problems.

3. Patient Reflection 19/11/20

Last week I had a patient attend clinic presenting with a LBP with radicular pain into their R leg. The case history suggested this was due to a disc herniation. Upon examination I found that in addition to the radicular signs in the R leg, the patient also had significant weakness and diminished reflexes in the L leg. This was suggestive of a central disc herniation. 

I informed the patient of the DD, and informed them of the symptoms associated with cauda equina syndrome so that they can head straight to a&e if these were to develop. My tutor and I decided that it was ok to do some gentle treatment, if the patient was happy with this.

This week the patient returned, I was with a different tutor and he had not seen any improvement. With my tutor we discussed the risks associated with bilateral symptoms, and we decided that it was best that we refer the patient for imaging, to better know what we were working with.

This highlighted to me the different clinical opinions on what is safe to treat and what isn't. The patient needs to be made aware of the risks. When there is uncertainty it is sensible to refer.

In the future, I will make sure the patient is fully aware of any risk of treatment. I will research the cause and risks associated with bilateral symptoms in the lower extremity.

OPS C1.3:  formulate an appropriate working diagnosis or rationale for care and explain this clearly to the patient.
C1.6: evaluate post-treatment response and justify the decision to continue, modify or cease osteopathic treatment as appropriate
C1.10: where appropriate, refer the patient to another healthcare professional, following appropriate referral procedures.


4.Takeover patient 12/04/21

Today I had a 67 year old male, grounds worker, present to the clinic with groin and anterior thigh pain. The patient had a previous working diagnosis of hip OA. For the examination we decided to use a neurological exam to be certain the pain wasn't coming from his back. This led to the findings of:

This suggested to us that he likely had a myelopathy, and needed referral for further investigation.

He did, however, also have pain on FADIR at the effected hip, with associated myalgia of the quads.

For this patient we had decided that he needed a referral to his GP as soon as possible. Upon discussion the patient reported the gait changes for 5 years, suggesting there is a slow progression of his symptoms. In addition, we noted that there was a clear musculoskeletal cause for his hip pain. Which has improved from osteopathic treatment in the past.  We discussed the referral with the patient and agreed that we would also be able to conservatively treat his hip. 

With this case, I was glad to have identified the neurological findings - I could have taken the previous diagnosis, and missed identifying the serious pathology. In the future I will make sure I will always thoroughly test my patients, despite the diagnosis they may have been given.

It was also interesting to discuss whether it was safe to treat this patient. We had identified that he had both an upper motor neurone lesion, and osteoarthritis in his hip. As he had been experiencing these symptoms for 5 years we could deduce that this was not an acute myelopathy. As an osteopath I could gently treat the patient, a give him pain relief by focusing on his hip and Lex, without treating his spine, where the cause of the myelopathy could lie. In the future I will consider where I can help someone as an osteopath and when I need to refer them.

C1: You must be able to conduct an osteopathic evaluation to deliver safe, competent and appropriate osteopathic care to your patients.

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

Today I had a 67 year old male, grounds worker, present to the clinic with groin and anterior thigh pain. The patient had a previous working diagnosis of hip OA. For the examination we decided to use a neurological exam to be certain the pain wasn't coming from his back. This led to the findings of:

This suggested to us that he likely had a myelopathy, and needed referral for further investigation.

He did, however, also have pain on FADIR at the effected hip, with associated myalgia of the quads. 

For this patient we had decided that he needed a referral to his GP as soon as possible. Upon discussion the patient reported the gait changes for 5 years, suggesting there is a slow progression of his symptoms. In addition, we noted that there was a clear musculoskeletal cause for his hip pain. Which has improved from osteopathic treatment in the past.  We discussed the referral with the patient and agreed that we would also be able to conservatively treat his hip.  

It was important that we produced the letter as promised in good time and sent it to his GP. Firstly, as it is our duty to get the patient the care that is needed as quickly as possible, and secondly it shows good professionalism and reliability. In the future I will always perform task like this as quickly as possible, I would hate to feel undependable when a patient is in need of help.

The patient also asked for a copy of the letter, I provided this straight away, but I felt it was important that I took the time explain the letter as it included words like 'ataxic' and 'myelopathy'. It is our duty to provide the patients any notes or letter written about them on request. In this case I was happy to do so, but I was wary of language that may be triggering and provoke fear and concern in my patient.

While in children's clinic today, our tutor brought up the topic of child abuse and what to do as a practitioner if we suspect something. This is such an important topic for us to discuss, and if I were to find myself in a scenario where I suspected the abuse of a child, I would be terrified and not know what to do. 

Together as a group we were able to pick up on a few signs of abuse such as bruising, burns, being withdrawn and a child that may flinch with sudden movement or with a fear being touched.  

However, when asked what we would do in this scenario, we didn't know. Call the police? Social services? 

What to do if we only have a small suspicion? 

It is hard to now how to act in these scenarios, but with a small bit of research I have found so many resources offering advise, what signs to look for and who to contact. In addition to this, there are a number of charities which offer support and advise to those who have experienced some kind of abuse. I have attached a booklet from the gov website with advise for practitioners.

I have fortunately not seen a child or adult in this scenario. As scary or saddening the situation might be, I would like to be able to act fast and know who to contact. In the future, I will make myself aware of the local social services where I will be practising. I will be perceptive to any signs of abusive in any of my patients.

A colleague of mine came into clinic today following an accident which required his arm to be in a sling. They had a continuing patient which they wanted to see still, stating they can treat them with one hand and that it can be an exercise based appointment. The tutor argued that this is potentially wrong for a couple of reasons, the first being that they should look after themselves and allow themselves to rest and heal, secondly that they will not be able to offer the patient the same quality of care which they normally receive. They agreed to ring the patient and give them the choice. They opted to delay the appointment until they could receive a proper treatment.

While in the student clinic, this scenario is frustrating but does not have the same consequences getting injured while in practise will. When unwell in the future I can imagine that it would be tempting to push through, treat your patients and be able to continue earning. However, this puts your patients at risk if you are ill with a communicable disease, or it means that you are unable to offer them the treatment they need. It can also be considered dangerous for the patient, if you are unwell and exhausted you may find that you are unable to perform as well, potentially missing something important. 

It is important to put your own health first, in the case of my colleague they could have hurt their arm further, or slowed the healing process, meaning they couldn't work for even longer. It is also important to consider that there is only so much you can put yourself through until you put yourself at risk of burnout. 

In the future, I will consider my own health. This is an important consideration for both me and my patients, making sure I can both maintain my well-being and also ensuring my standard of care does not falter.