To blog or not to blog....

The LPA deadline has passed and therefore I no longer need to blog. It is early days, but I have no idea if it is of any benefit to continue! I didn't enjoy it at first, but I've got used to it now. Life feels different without having it to worry about....

If I blog again in the next 2 weeks it is a sure sign of procrastination. I should be revising for the next CCA. Why am I even here now?

Future plans...

It is with great trepidation that I face the next CCA. Although I know I have made a big leap from last year and I can't possibly have got worse over the course of this year, my CCA grades so far suggest the opposite to be true. From D high to D low is a damning verdict! Apart from clearly being on the rubbish side, at least there are some obvious reasons for this - my failure to initiate writing a doctors' letter the first time around and then in response to this, an over zealous instant referral the second time around. (However, I still maintain that the patient in question was an unreliable witness and had red flags that may not have been addressed elsewhere, but never mind). I would love to improve on my OSPE grades to boost my confidence (B low/C mid formative; B Low summative), but at this stage a pass will do! However, I will be concentrating on devising treatment routines for specific conditions, as we have been advised that this will be the format of the next exam. I also need to find out more about our first aid requirements - we did something earlier in the year, but it seemed quite basic - I'm just hoping I don't have to pay to do anything else!

In the longer term, it is all about technique for me. In my experience this (and trust/rapport) is the main factor which makes me return to a practitioner and this is where my focus will lie. Feedback suggests I'm good to go on the rapport front! I expect my palpation to improve in time and I generally hope to speed up the whole patient encounter straight away. I have managed to widen the variety of techniques I use in clinic this year, but it is a constant effort not to use the old favourites. I think it is really damaging to stick to a few trusted/most easily achieved techniques at this stage and I am always consciously trying to avoid doing this!

In terms of LPA criteria not quite satisfied, to be investigated more later (when time constraints and health allow) I would like to explore the evidence base for manual techniques further and have a few high quality papers at my fingertips to which I can refer people to. It is my experience in the last couple of years that often evidence is conflicting, as I have found recently regarding subjects such as stretching and using ice/heat etc. I aim to at least stay informed about the latest research both "for and against" ideas, so I can at least discuss it and direct people to it, in order that they can make informed decisions. I think I am coming to the conclusion that the "informed decision" is what it's all about and I will be satisfied that I am being professional enough if I can confidently say that there is no evidence that the treatment or advice causes any harm and if there is an absence of acceptable evidence of significantly good results, it is performed/advised on the basis of anecdotal or experiential success and it is then the patients' choice whether to proceed or not.

I also hoped to read up about harmonics, but this will have to wait. Sadly, an external course I did not take, but an approach I see taken by many students and enjoyed by patients. I am also loathe to admit the supine C/T thrust still evades me at this point, but I hope that I achieve it before I leave (whenever that is)! I also have not achieved the O/A thrust since we were told not to do the only version I ever found success with! I hope I can get over this. My other nightmare is the sidelying, posterior SI thrust - success comes and goes as it pleases!

I anticipate practising mainly structurally at first. I would feel like a fraud if I offered cranial treatment right now. Finances permitting, I will take the cranial course, maybe in January. I am definitely interested, but don't think I'll manage September sadly.

I want to learn all the osteopathic lymphatic (pumping) techniques / protocols! The closest I came to them was on the Classical one day  course. The classical guys love them. Sadly, my dissertation left me none the wiser! The nature of the exercise and the papers included for review meant that although the results of various lymphatic protocols were discussed, the techniques and their implementation were mentioned only in the methods sections and were not instructive in their description (hence no enlightening tutorial from me on such techniques)! I also want to learn the specialist manual lymphatic drainage techniques for oedemas / lymphoedemas.

There were various areas I did not include in my learning contract that came up over and over again and will be part of my future quest to fill the gaps. Core muscle strengthening, rehab (especially re shoulder, knee and ankle) and strapping, to name just a few. I also need to brush up on my neurology, keep red flag information at the forefront of my mind and become really familiar with NICE guidelines. It is the information related to the less frequent presentations that is easiest to forget and I think it will require an ongoing reasonable effort to keep it familiar. I have little knowledge about sports injuries, but more about pregnancy which I definitely hope to take further.

There are other areas I would also like to explore in the future. I have always been interested in nutrition and I have recently developed an interest in Alexander Technique. I am quite interested in a few of the post graduate courses at the AECC such as diagnostic and treatment use of ultrasound and I would also like to be able to work with animals. I still find myself drawn to traditional Chinese Acupuncture, an original study consideration of mine. However, fee increases certainly rule out another degree for me!

Finally, I am hoping a couple of practice visits I am arranging locally and up North may lead to even a few hours a week employment and I have also made enquiries about room hire nearby.

Although I have had my ups and downs on the course, I still hope to find that this is a rewarding career and I already see it as an opportunity for lifelong learning!

Support Clinic

And out of the blue I found myself in support clinic! Having begged to be included last term and then being firmly rebuffed, I am suddenly included without even asking. My grade has dropped I suppose. Should I be even more worried than I already am? I've only managed two weeks out of the three as I was absent once. This is quite useful, but would have been so much better for me last term.

I have been told by one tutor that I am better than I think I am and that I just need to improve my confidence. My confidence was ok though before I started getting Ds! I really feel that there is nothing to feel confident about.

The best thing about this experience is that another tutor has taken me under her wing and seems willing to spend a bit of time with me each week. She has somehow uncovered some real concerns I have about the profession and wants to help me through it before I leave, as she has recognised that I'm just not sure that this is for me and I wonder if I will carry on doing it at all. I sometimes think I might last a year, I sometimes think I might never even start. There, I've said it. I'm glad I've got the chance to talk to her and I am extremely grateful.

Support clinic tutor summary

Round up

So, have I achieved my goals for the LPA unit? 

Revisiting my contract, I anticipated focusing on technique this year and whilst I am happy to say I do think my confidence has improved and my HVT success rate has gone up, I still feel far from the practitioner I hope to become. I do feel that spending the time arranging information visually and trying to bring together in a clinically relevant way anatomy; surface anatomy; examination & special tests; treatment & theory of treatment; differentials (musculoskeletal & systemic) and pathophysiology has been incredibly useful for me, even though it was very time consuming. With hindsight, I see that I was trying to write my own osteopathy (BSO version) "manual" which could really go on forever! In terms of the many modifications we have seen this year (which I have not managed to keep track of well) and the hours I have spent annotating charts and diagrams, it is mildly amusing to me that many students are just learning techniques straight from Laurie Hartmans' manual now! I could have saved myself the effort! I do realise that I have taken the course very literally and approached technique as if there is a "right way", adopting the first year approach for the whole four years in essence. I can see how this has probably held me back now and increased my levels of frustration, but I do need a framework in which to learn and a foundation to spring from! However, this exercise has forced me to organise my information in a better way for me and create links between subjects I seem to have learned quite separately and I have undoubtedly benefited from this. I also know that learning by testing myself (Q&A cards) is the method which suits me best. I only wish I had taken this approach earlier and had also tried to make all my learning clinically relevant from the start (and stuck to one or two books). 

The external courses, whilst draining my bank account, have really helped me fill in the gaps that I was so worried about. I hadn't attended any external courses in previous years, as I thought we would learn everything we should know within the degree course and that we were not meant to stray outside the syllabus. I really feel my soft tissue technique has now improved drastically along with my palpation as a result of these courses. Likewise, I found the IMS and ASM electives considerably helped my palpation. Somewhat unexpectedly, it is the obstetrics elective which I credit with improving my HVT success rate this year, particularly C spine, along with the fact that I did twelve weeks of extra hours in Chapman on Fridays and the tutor included technique in his excellent tutorials. There is nothing like one to one tuition and being told everyone has to try it and then getting individual feedback! Along with encouraging the belief that it is EASY! The power of persuasion. 

Including examinations again in my technique practice and increasing my knowledge of orthopaedic tests has made a big difference this year. Especially thinking about them from a differentials point of view and ruling conditions in or out. Likewise, practicing dcp more and moving from the somewhat rote fashion of last year to thinking more about justification and the actual meaning of any findings, has proved useful.

I have enjoyed going through case histories in study groups more this year as I have had more to say with regard to differentials as the weeks have gone by! I also think my new approach to pathophysiology is helping - ie: less is more - 3 sentences maximum about as many disorders as possible, rather than lots of detail about certain conditions and none about others! I have brushed up my pharmacology thanks to Darwin Court tutorials (the same tutor as Chapman clinic, forcing me to learn again!) and I am hoping I know enough to get through the CCA. Out in the real world I am happy I will be able to look things up, as the subject is vast and forever developing!

The surprise of the year was how much I learned about HIV patients. Friday tutorials were a wealth of new information and I enjoyed the clinic so much I am doing another eight weeks of extra hours this term! I was not expecting how much the external clinic tutorials would help me in general. EMC on Tuesdays, Darwin Court (Wednesdays) and Chapman (Fridays) really gave me a lot to think about. There were always tutorials in the external clinics and lots of information to be gleaned from them!

I did not spend the time I would have liked going over visceral and head and neck anatomy before the elective classes and I think I was lucky to get through the other revision I managed. The dissertation did take over towards the end of Autumn term and much of the Spring term and If I'm honest, I deeply resented its' intrusion into my precious time! Especially as my CCA results have been awful. My time could have been used much more wisely.

I have not managed to scan in anonymised case histories to back up my written descriptions of the  integration of new techniques into clinic and I have to admit that this is because of how difficult it is to get anything photocopied in clinic - eventually I just chose to avoid any hostility by giving up! I felt as if I had used up all my credit asking for photocopies of new patient histories for study groups, the returning CCA patients and the case report patient. I have volunteered to photocopy items myself, but apparently this is not allowed. Ultimately, trying to get things photocopied is an ordeal I never want to go through unless absolutely necessary!

Logs of techniques and dcp routines

Record of attendance of electives

The final countdown / Return of my patient

Summer term begins and I don't feel like someone who is close to being qualified! In many ways I'm not, with all the hoop jumping that is still left to be done. Seriously, I just don't feel good enough to be unleashed on an unsuspecting clientele. Having said that, it's not just me - I wouldn't want to employ the services of many of my colleagues either! I think I am suffering from a lifetime of seeing experienced practitioners at the top of their game. I suppose it is unrealistic to compare our abilities with what I am used to, but I am disappointed by this really.

Putting this blog together and being able to look back at it, has shown me how much work I have actually done. Bad CCA grades and a general feeling of doom, leave me feeling quite useless and as if I know nothing. At lease I can see that I tried hard! The dissertation was a real distraction though and although I had hoped to enjoy it and learn some techniques from doing it, I found this was simply not the case.

We have had some advice for our next OSPE, some of which was about avoiding the use of old favourite techniques. This is exactly the opposite of the advice I received after the mock OSPE. I am addressing this anyway and hope to widen the variety of techniques I use regularly.

My longest standing patient returned this week, following an operation to remove a cancerous tumour on his kidney. His scar was healing nicely but it seemed huge considering they had only taken part of the kidney away. The cancer was caught so early that there is no need for him to have radiotherapy or chemotherapy. He has been relaxing in the sun and looked incredibly well. The scar shocked me in some way. It was the only sign of the physical and mental trauma he had been through. I came away selfishly feeling my own mortality and thinking about how we are not safe in our own bodies. I am deeply interested it nutritional and other alternative approaches to preventing and treating cancer and I was also reminded that I want to find out more about working in palliative care. I felt really out of sorts for the rest of the day...