Pathophysiology revisited

I finally finished a task that I started early in the Autumn term which ended up shelved because of the dissertation - At a glance notes for my clinic file, copied from this succinct book of lists! Better late than never. Revision on the go...

A book of lists - Perfect!

Patho summary sheets I made for my clinic file (1)

Patho summary sheets I made for my clinic file (2)

Clinic week / Elective reflection

Well, clinic for 4 days really and only two new patients between them. Clinic is quiet and I am not very focused. I wake up and realise I can spend the time practising technique and suddenly everything is ok again. I really used the empty slots well and practised like mad! Feedback from friends is positive, my soft tissue is much better and my HVTs are more specific, but I still need to be quicker with the impulse!

We have had some time to discuss and demo techniques we learned in electives. Everyone seems to agree it is a real shame we can't try them all. Functional was the only one I didn't want to push for this year and unexpectedly we were taught some in the obstetrics elective. It was only this exposure that made me consider exploring it in future, as I definitely wasn't interested based on the two hours we got in second year. I also attended one S-CS class last term, but then I was off sick and didn't go back. Again, I would consider exploring this in future.

Technique LH Course & OSPE Feedback

Certificate of attendance LH Technique Course

16th & 17th April
Oh the excitement - two days with the legend that is Laurie Hartman! Yes it was good, but I felt so tired and I found it all quite difficult. Clinic starts on Monday and I have spent the last 2 weeks "Easter holiday" running around trying to de-stress, but failing! I felt I couldn't give it my all, but still found it inspirational. Good job I brought the painkillers though - having had no manipulations for two weeks, my poor skeleton was lulled into a false sense of security. I was in agony by the afternoon of day one! I can't believe we are fourth years and will soon be hoping to earn a living out of this. I would pay NOT to be meddled with by one of us! Seriously, how can we be so bad at this?

I can't copy my OSPE feedback into this post and I don't know why. B Low is good enough for me right now, but in a way I am strangely disappointed, as I know I could have actually done better for once! It would have been really nice to do very well at something, it's been a while! The feedback is fair and I am glad I passed as I really wasn't sure how I had fared. I am so glad I didn't do badly. I really needed a bit of a pick me up after the CCAs and this has actually made me feel a bit better.

Visceral & IMS Electives

IMS slides and  list (hurrah!) of techniques completed with positive feedback

IMS - what a pleasant surprise. I chose this elective unwillingly, being under the influence of peer pressure, continually reminding me that employers usually want you to have an interest in IMS.

a) I did the course so I never have to work for anyone again (depressingly, this appears to be most unlikely).

b) I just didn't get it in second year and couldn't imagine how we could pick it up again in fourth year having had no further experience of it for a whole year.

Thankfully I was wrong on the second count anyway. Suddenly I found I could feel it - my palpation had improved - JOY! We were in a small group, which always makes a huge difference to me and putting anatomy, theory of the techniques and practical application together in the class also really worked for me. Absolutely nothing beats one to one tuition! We are not allowed to use it in clinic though, so the learning ends here for now.

Visceral Elective Slides - Including list of techniques  - Hurrah! One less list for me to make!

Sadly I missed quite a few visceral classes due to illness (and ASM), but it appears that if I can just get my hands on the right Jean-Pierre Barral video / DVDs I can most likely catch up and learn at my leisure. That suits me just fine, being a visual type and all. Whilst I am a great admirer of the tutor leading this elective, the class was so large that I got no real benefit from going most of the time. Sadly, this elective was the one I found the least useful because of this, although I will definitely be trying to teach myself the techniques in due course (hopefully from JPB DVDs). The techniques were well worth finding out about. I just really need the attention when it comes to mastering technique though!

Clinic reflection

A patient presented this week with a proper lymphoedematous leg. Hurrah! She had inguinal lymph nodes removed following skin cancer in the leg five years ago. This has confirmed that I really want to learn the specialist manual lymphatic drainage techniques for oedematous conditions (as well as the osteopathic lymphatic pumping techniques which are focused more on immunity). The LEX was heavy and becoming debilitating - she could barely bend it at the knee. There were several other problems, but I was most frustrated by the limb and knowing that there is so much more I want to be able to do for her. I did manage to apply two of the soft tissue techniques I learned in the weekend course in November (VF) though.

I also heard from a colleague who saw a new patient of mine from a couple of weeks ago. Both he and his tutor felt that a completely different diagnosis was more appropriate than the one I came up with (which was actually decided mainly by my tutor, as I genuinely wasn't sure what was going on). They thought that early degeneration of the hip at 51yo in a personal trainer was most unlikely. My tutor had discussed with me that this was the most probable cause of the symptoms at the time. I find situations such as this extremely frustrating and this is exactly what makes me have my doubts about the whole thing!

I dread the 4.40 or 11.40 new patient slot, as I feel there is even less time than usual to discuss ideas and the diagnosis with tutor afterwards. This wouldn't happen at AECC! I did really like the way they booked time with their senior tutors to discuss new patient management plans and get questioned about their diagnoses etc before the patient returned to commence the plan. I had a complex acute patient this week and was not happy at all with the diagnosis I ended up getting signed off at 6.05, but I had no choice and amended it accordingly.

I was also blasted during a returning patient presentation recently, for no real reason other than the sound of my voice I think. It suppose it is just about getting used to tutors again, now we have swapped days, but I felt like a mouse being tossed in the air by a menacing cat. This is something I can laugh off now, but sadly, I realise with hindsight, that actively trying to avoid this sort of encounter in the past has possibly meant I missed out on learning opportunities - even if they did come with this sort of price!

Visit to AECC

This was a real eye opener and a great day out! I wanted to study chiropractic originally, but there wasn't a course in London. I think if I had actually gone to an open day there in the first place, I might have just moved to Bournemouth! The facilities were amazing and they are at a huge advantage being able to learn about and treat children as undergraduates, as well as having a high tech rehabilitation centre run by a physiotherapist, with some seriously state of the art equipment. Students took x rays and wrote their own reports which were marked and corrected by a specialist. This was also enviable. I have little experience of reading imaging. They are even taught how to use ultrasound for diagnostic and treatment purposes. They must save a fortune, given the amount of postgraduate courses they don't need to do!

I thought the way they had 2 hour slots for new patients and performed all dcp exams on everyone was of great benefit, although I did not agree with the lack of treatment at the first visit. All patients were provided with gowns and shorts which I thought was an excellent idea and I would like to do this in future. Their case files were extremely detailed with several standard forms in use and they were organised with dividers, which I felt made them much easier to follow. One of the forms covered consent and all patients had to sign this. I definitely plan on doing this in the future. The students do not mention consent again during the course of treatment, once this form has been signed!

I felt that the time they got to spend with senior tutors (by making appointments with them) discussing cases, diagnoses, clinical reasoning and management plans, was invaluable and something I have missed out on and could really have benefited from if we had such a system here. They had laboratories in their teaching building and I was told that their anatomy lecturer was one of the editors of Gray's Anatomy! They did not go into clinic until fourth year, but I felt this disadvantage was probably outweighed by how advantageous it was to get their dissertations out of the way in third year.

At the moment I really wish I had gone there - but I am aware that the grass is often always greener and I am just exhausted and miserable right now! I am thinking about looking into studying there though, but I imagine fee increases will put a stop to that. It not a realistic idea anyway. They really made us feel welcome and were happy to show us around. Sadly I heard that they were treated badly when they came to BSO and clinic reception were not expecting them!

Interestingly, the students I spoke to did not have any preconceptions about osteopathy and were curious to discuss similarities and differences. My own chiropractor also has this attitude and thinks of the professions as similar. I wonder why osteopaths have such negative views about chiropractors. It is all I hear in clinic from tutors and students alike. I don't understand it! 

I am going to investigate Gonstead technique - some of the moves they had were great.

Balanced ligamentous tension course / TMJ

BLT Course attendance certificate

This course was unexpectedly brilliant! I only went because a colleague kept telling me how amazing it would be and I was scared to miss it, but I wasn't really convinced. UNTIL NOW! It was along similar lines to the balanced membranous tension techniques we had been discussing in IMS recently. I could really feel structures unwinding as both practitioner and patient. Sadly, I was absolutely shattered (two days after the OSPE / end of the manic spring term) and faded fast after lunch, but managed to hang on half heartedly until the end. I definitely want to learn more of this. It is  very gentle way to work and would be lovely for the pregnant ladies and the old folks! For anyone in fact. I had happy hands again.


We were given a manual about TMJ in technique and I can't describe how much this pleases me, so here it is; a prime example of what I have spent all of this time trying to create for every area of the body. This is going to save me lots of time and I might even become quite adept at treating the TMJ as a result, as I've got something to work from straight away when practising! For the second time this year, I pleaded with a tutor to be given any written information at all for technique, but there is nothing available yet. I keep hearing how I am meant to be able to work it out for myself at this level. Fair enough, but what level I wonder - I'm certainly not on it yet! Below it is an example of my hastily scribbled notes from fourth year technique class, that I struggle to decipher afterwards and this year am finding particularly difficult to split into the individual techniques / modifications (as I try to work it all out for myself)!

A manual - just what I need!

                 Notes from technique class

Clinic report & CCA feedback

Clinic reports:

Monday - C High
Thursday -  C Med
Again, positive feedback about patient care.
Need to work on differentials, improving knowledge base, direction of treatment & longer term management.

I think I am already tackling these problems the best I can, although I really do need to improve my management plans and somehow teach myself more about stretches and rehab exercises.

CCA  - D low
Of course I am grateful to pass, but in addition to my D in the mock, this has destroyed my confidence! I am dreading next time. Usually, I think feedback is fair, but there are a few things I disagree with this time round. I can appreciate that maybe as a reaction to my feedback last time, I was over enthusiastic about referring this patient early on in the encounter. I was obsessed with safety issues and not leaving anything to chance!

However, the external examiner seemed to query my assessment that my patient was an unreliable witness and I firmly stand by this belief. She also mentioned in the notes that I "struggled a bit with the patients' accent" - what an understatement, we could barely understand each other!! Given that my marks have suffered, as I did, "not want to take responsibility for the patient" and the examiner was concerned whether I would have "continued with the process without so much guidance and prompting," I am somewhat uncomfortable that I do still stand by what I did and there is no way I would consider taking this patient on in real life!

It appears in the notes that I was trying to refer because of the fact she had Parkinsons' disease, whereas I was quite clear that it was because of her confusion, night sweats, unexplained weight loss and the lack of mechanical aggravating and relieving factors. The notes state that there is no need to refer as she sees a neurologist every three months - I feel this goes against everything we have been taught about "never to assume." I couldn't have justified not suggesting a referral, on the basis that I assumed the neurologist would know about the above symptoms and would have investigated them independently of treating her Parkinsons.'

I am amused that I am praised for being "honest" about my lack of knowledge about Parkinsons' when all I did was ask to look up the drug (Madopor), which we had been encouraged to do if medications were unfamiliar! I admit though, that my knowledge is limited.

The RP went ok, and it appears that I just really didn't shine in my second NP which was straightforward.

Anyway, better luck next time is what I need and a good helping of hard work in the meantime. I just hope I do not get another situation where I have to decide whether or not to refer after my last two experiences!

CCA Feedback