One thing I didn't understand today was when the practitioner didn’t give the patient exercises she could have done at home to help with her progression and response to treatments. The patient was a cover but he knew what the patient had been going through and what his management was so I was surprised he didn't take as much care. I think it would have been good to of given her a treatment plan.

Revisited:

I had a patient today that has been going to the ESO for longer than I've been alive. She also hasn't been offered the necessary help which I later discovered is because of her beliefs. I feel as if we've been conning her all these years. On assessing the previous practitioners' management I feel it was inadequate and I'm shocked someone hadn't changed the cycle prior to our appointments. 

I had a discussion with her about her options which were surgery, injections, or exercises to which she refused to do any of them. We agreed that I would give her updated options every 6 - 8 treatments to see if she would be in a better position to undertake the options that she has.

From this, I've gained the understanding that we must give options that promote the best for our patients whether or not they take it. Along with this that just because someone is not in the position now doesn't mean they'll be like this for the whole of the professional relationship.

I was impressed at how the practitioner is approaching the treatment and how he's talking to me about the tissues, what he feels, and how he approaches bettering this. He offered the patient chaperones and to stop if anything was concerning if they felt uncomfortable. He also involved the patient and went back and forth from laymen to medical to involve the practitioner.

I think I need to practice this skill as I can improve on how to make sure other students and tutors are informed and also that the patient doesn't feel uncomfortable.

Revisited;

I realised today that this is harder than it looks. I express these options to a mother of a 2-month-old patient in the appropriate manner as I have done multiple times but actually stopped to reiterate that they can have someone in the room. I wouldn't usually double-check but I felt as if I hadn't given the option because it was an actual option, but because I knew I had to protect myself. I came out of my sales-like pitch and changed my perception of what I was saying and actually offered these options again. This time meaning what I was saying, the patient asked for my tutor to come in and chaperone. 

When my tutor came in it actually gave the patient more trust for me to be handling her child. The tutor came and just stood in the room and answered any questions while I was assessing the baby and we discussed certain things and asked me for my input and thoughts. In all honesty, I thought if a patient would ask for a chaperone, I would feel as if it was something against me. However, it's actually because they need more support. It's nothing against me as a practitioner it's to make the patient feel as comfortable as possible and that's the main pull away from today.

Revisited:

I've noticed that when offering a chaperone to patients that are in by themselves, the majority choose not to have one. In contrast parents within the Children's Clinic prefer it. Their responsibility for someone else might influence the need for another, more experienced person in order to double-check that nothing is missed. I don't know always know how comfortable that makes the underage patient, babies don't care too much but preteens and 15-year-olds can feel slightly uncomfortable with multiple adults in the room.

I've found that it goes down to the full understanding of the patient, handling two coherent people is another world in itself. Double-checking with parent and child to check certain things is tiring but has to be done. Really now if I need to find, for instance, an ASIS on a teen I ask them to find them and assess from where their hands are. Hands-off is better in those instances and I think makes the child and the parent more comfortable.

The students today helped me learn some anatomy. I didn't realise there was a muscle in the neck that connected to the temples which produced headaches in the patient I was observing. I thought it was good that was explained that but by a student rather than a teacher. It encouraged me to do my own research and further my understanding.

Revisited:

Anatomy is a massive part of osteopathy. There has been a steep learning curve for me to understand. Alongside this, understanding what we can and can't help with takes high priority over thinking we can help everything.

Revisited:

I was covering for another student today and saw a male patient who had adductor pain. However, he was now getting an unremitting pain in his right testicle that he didn't submit by position as well as it not allowing him to sleep. He said he discussed this at the last appointment but the symptoms were much milder and could be reduced by position. This appointment ended in an immediate referral as this would signify a non-musculoskeletal pain. 

Simple things like understanding musculoskeletal pain vs. early signs of pathological pain are an important part of the appointments as anything out of the realm of mechanical pain, we cannot help with. 

I have begun to revise and keep lists of early signs and symptoms of pathological pain that can present as mechanical pain in order to help with my understanding if what I can help with and what patients need to be sent elsewhere.

Today was a hard one for me personally. I struggled with a few things. 

Firstly I was put with a really personable Tutor who was very calm and easy to get along with. However, I struggled with how the two practitioners I observed handled their patients.
 
The first practitioner had an elderly woman who had never been to an osteopath before. She came in with neck pain which the patient said needed, 'to be massaged out.' Through further questioning, the patient told us she lives alone now and has no family. She was in her 80's and really this issue was from 2 years ago. In my mind, I wondered if she had been recently widowed. This also made me think that possibly her late husband may have helped her with her neck pain when he was alive. It was only halfway through the treatment that it was established she was a widow from just over 2 years ago. I found it really hard to let it go and I think this is because it is our job to think of our patients as a whole, including what is happening in their lives that could have an impact on their pain. 

As a studying osteopath I'm finding out how much emotions and a patients mental state affects their treatment. It's such as important thing to take into consideration if we are going to look at the body as a whole this also includes the mind of the patient. 

The second thing that affected me to a really upsetting stage was the second patient coming in was experiencing back pain and she asked the practitioner if she could try for another baby. The practitioner replied, 'we'll have to check with you're GP'. There is nothing wrong with this response. Actually, it was a very safe thing to say as it could not be confirmed or denied at that moment. It was correct and formal, in a way to protect both the patient and the practitioner but I was so disheartened for the patient. I was so sad for her. I saw her face become deflated and her response was discouraged. It was almost as if there was no hope for her dream. It was promptly finished without any real direction to go. After that, I think that patient didn't have the compacity to express her concerns because of the stark answer towards her because every response afterward was 'yes that's fine'.

Revisited:

I've used this in my 2 years of practitionership to manage how I handle patients. Giving the correct advice in the right manner and working together to manage expectations while making appointments an open place to air out concerns and expressions of what's important to them allows for the patients' response, both towards myself and the management outlook to be greatly aided. I've tried really hard to put what the patient wants first rather than placing my wants for that patient on top. I'm there to support them in the way they need. 

I observed a patient today who has low functioning down syndrome resulting in him being nonverbal. He was accompanied by another patient from the ESO who the practitioner handling the case also treats. The carer, because of his previous experiences with treatment believed that this gentleman would benefit from a cranial approach treatment. 

As the case progressed the practitioner discussed him laying on the couch for assessment. The complacent patient started to become concerned and resisted the carer's encouragement to lay down. 

The practitioner decided to step outside for a moment and allow the patient to calm down. We talked in the tutor room while the tutor was with another student and she shared concerns over how to handle this patient. The main thing was that he wasn't forced into it. Despite being nonverbal it was clear the patient was not consenting to assessment or treatment. The practitioner raised concern about the pressure from the carer but he was clearly trying to keep the patient's best interests at heart. 

We went back in and the patient was in the corner of the room being consoled by the carer. The practitioner sat down and said she wouldn't be doing an assessment or treatment.

I'm so thankful that I have other students to discuss concerns with and learn from as well. 

On reflection, I think the practitioner did the right thing by stepping out, even for her own sake to ground herself again and to allow the patient some time to settle. Navigating between two people and keeping them on a good level of understanding is difficult but can be done. Moreover, if this was to happen to me out of the tutoring clinic I think I would find the principal or colleague to chaperone in order to have an objective bystander to give feedback as well someone who could comment if the situation was to turn negative.

Revisited:

I have been thinking about this event for a few weeks now and have been trying to approach it if I was in my own clinic with this patient and how I would respond to this situation. I think clear and concise notes taken would be the priority but also making sure there is enough room for these situations to happen. My physical presence should not be blocking any exits to allow the patient to feel as if they can't leave and possibly allow to soften the atmosphere. I also believe that conversation over the phone to the carer so that they fully understand what to expect and to try and explain that to the patient is important. 

As well as possibly also discussing the idea of allowing the first appointment to be almost a buffer, letting the patient meet me, and building rapport before treating. Along with this giving the patient the option of doing exercises at home because the management of a patient is important and has a great impact on a persons pain. 

Revisited:

I've started to look into how other clinics and other healthcare providers process child abuse, domestic abuse, and vulnerable adult procedures to take away points to take with me for when I go into practice. It was an interesting process and also a difficult one to go through, however, it is important. The main things I've taken away are hotlines and numbers to call if I find myself ever in that situation. I have looked into documents on the clearest process for the patient.

1. What? 
- This is a simple description of the events that transpired.
2. So what?
- At this stage, the events are broken down and analyzed in an attempt to interpret what happened and why.
3. Now what? 
- Taking in this interpretation of the events how will we move forward and what is the course of action.