Well the first disconcerting thing to note about this edition of the osteopath is that the cover photo looks a bit like Edzard Ernst, who I recently heard talk at Eastbourne “Sceptics in the Pub.”   But I think this is simply meant to be a generic patient looking expectantly at their osteopath, as theosteopath follows on from the last edition with more findings from the recent public and patient perceptions survey.

What do patients want?

First thing to be aware of (and keep reminding ourselves of) is that while it’s just another day at work for us, patients are often very anxious about their first appointment.  The four most highly rated  things patients “want to know before the first visit” were

• benefits
• what the treatment will be
• costs
• risks

Just behind those they want to know

• how many sessions will be needed
• how long the treatment will last
• will symptoms worsen at first
• what if something goes wrong

And then slightly less important, but still at an “importance rating” of over 60%

• details of prior complaints
• the complaints process
• what clothing to wear

Now I’m not sure what questions were put, and how much the regulator was involved, as this seems quite a cautious attitude.  I’ve never had a patient explicitly ask about a complaints procedure, and it is not uppermost in my mind when I visit any practitioner, but there you are, these are the results.  Even patients who are not first-timers want to know many of these things, so don’t take for granted you can fob them off with vague prognoses and skipping the benefits, risks and consent explanations.

What patients want once they’re in the room

Once they’ve made it in, two actions were deemed the most important in giving patients a positive experience:

• The osteopath discussing options for treatment thoroughly
• The osteopath taking a medical history

Most of us are pretty good at the latter, I reckon, but in terms of discussing treatment options I wonder if there is a tendency amongst osteopaths to believe so strongly in their chosen style of treatment that we don’t really consider other options, or objectively recommend them?  I remember at college we used to say, (disparagingly in our naive arrogance) “To a man with a scalpel, everything looks like an operation”.  Well, to the cranial practitioner, everything looks like an SBS strain; to the manipulator, everything looks like a stuck L4, and to the visceral expert, everything is a twisted organ and so on.  Maybe we do need to look a little wider and appreciate other approaches, and even other orthodox and alternative treatments.  It ‘s an aim.   New patients also want to know

• costs of treatment
• that the osteopath will liaise with the GP
• potential risks

Costs of treatment obviously can be difficult to estimate sometimes, but explain why and what your expectations are.

Once you have earned a patient’s trust, they don’t seem to mind that you are operating independently of the GP, but it pays to realise that some communication can be really important to them in the early stages.  I used to jot down some findings and/or diagnosis on a compliments slip for patients to show any other practitioner they saw, but maybe I should post or email a brief note directly to their surgery.

With regard to risks, the ground seems to be shifting beneath us as we treat, but more of that later as NCOR have devoted a whole page to this.

Seasoned patients are more likely to appreciate

• a diagnosis
• being made to feel at ease
• an holistic approach (whatever they mean by that)

Finally, patients feel that confidence comes from good treatment, good advice, and the practitioner listening to what they say, giving them a clear diagnosis in a language they understand, and being treated with dignity, put at ease, and involved in discussions about their treatment.  So maybe the days of the paternalistic figure who baffles you with scientific jargon and tells you not to worry they know what they are doing, just lie down and “crrrrack!…haha, didn’t expect that did you”, have good reason to be gone.

Feedback

Oh, the dreaded feedback. In these days of Tripadvisor, public feedback is everywhere and potentially nervewracking.  A couple of my patients have come in quite unsettled by unfavourable online comments about their businesses.  I stumbled unexpectedly across an unsolicited review of myself online and was delighted to find it favourable. But would I dare seek or encourage feedback? Well, at least if we are the only people reading it we don’t have public shame to deal with.  I think we have to brace ourselves.  Self-awareness and self-knowledge come at a price, and that price might be the discomfort of finding out your weaknesses through other people telling you what they are.  9 out of 10 patients think feedback is important, mostly preferring to do it online. You can’t even buy a kettle these days without being prompted to rank if for boiling speed and ease of pouring, so people expect and some want to be asked.

OK, You Want Patient Feedback,  You’re going to use it for CPD, How do you Get it?

1. Well, there’s a handy sample form on page 15 which looks good and is easy to copy.  It has 6 questions.
2. There is another one developed in Scotland and used by over 3000 GPs, which has 10 questions, takes 10 minutes to complete, and is available at caremeasure.org. You end up with a score out of 50 here, and if you are interested or even just competitive, once you have data from 25 patients you can enter the results into a website and get a report showing how you compare to other practitioners..
3.  NCOR have 2 examples which you should be available to find here: one is a patient satisfaction survey, and the other is a survey of patients who didn’t complete their course of treatment, which tries to find out why.  Whether you will actually get people saying things like “I thought it was a total waste of money”, or “you seemed a bit creepy” is debatable, but at least we can try.
4. PREOS is an online system developed by NCOR which stands for Patient Reported Experiences of Osteopathic Services.  Please download the patient leaflet here because it is a great way for patients to give anonymous feedback to the osteopathic profession as a whole, without worrying about you reading what they’ve written.  You don’t have to worry about being struck off as reports flood in detailing your clumsy manipulation, body odour and outrageous political views either, as anything that could identify you personally are also removed.  This might be the fairest, easiest and most useful way we can identify needs of the osteopathic profession in its entirety, and it needs you to promote it.

Leaflets

There is some guidance on preparing information for patients’ first appointments, and I suppose these days many osteopaths have a website they can direct patients to.  Just try to make sure it includes all the obvious things, and the information mentioned above, and don’t assume it is a substitute for explaining treatment options or consent or risks or benefits in person.  Consent is not even valid unless the patient has understood it.

GOsC also have some free leaflets (What to expect from your osteopath, Standards of osteopathic care, and they also have Making a complaint although they don’t mention it here) which you can download here and put on your own website.  You can order printed copies for what they call a “nominal charge” by contacting GOsC through info@osteopathy.org.uk or calling 020 7357 6655 x242.  The Mint Practice also produce excellent leaflets, visually appealing and very concise and clear, though you have to pay for them.

Advertising – over 50 recent complaints

This rumbles on, and the sceptical scientific community are actively campaigning to ensure that we all conform to the CAP code, so chances are if you are not you will attract a complaint.  So I here repeat what I wrote in theosteopath Jun/July 2015.

Don’t ignore this, it is important

(unless you’ve already made sure your advertising is fully ASA compliant)

If you don’t make sure your advertising is ASA compliant you run the risk of a complaint being made to the ASA (most probably by a committed sceptic from the Nightingale Collaboration or the Good Thinking Society.)   I think that what then happens is that no further action is taken if you agree to remove the offending non-evidence-based claim.  But if you don’t, and the ASA makes a ruling which you then fail to comply with, you would be in breach of the Osteopathic Practice Standards (and I guess the law?) and would be investigated.  Basically, it’s not worth it.  Bored, anti-alternative, science fanatics are sitting at home trawling through websites looking to find reasons to complain.  Here’s the list of things you can claim to treat according to the Committee of Advertising Practice

• generalized aches and pains
• joint pains (inc hip and knee pain from OA as an adjunct to core OA treatments and exercise)
• arthritic pain
• general acute and chronic back pain (not arising from injury or accident)
• Uncomplicated mechanical neck pain (as opposed to neck pain following injury i.e.whiplash)
• cervicogenic headache/migraine prevention
• frozen shoulder/shoulder and elbow pain/tennis elbow (lateral epicondylitis) arising from associated musculoskeletal conditions of the back and neck, but not isolated occurrences
• circulatory problems
• cramp
• digestion problems
• joint pains, lumbago
• sciatica
• muscle spasms
• neuralgia
• fibromyalgia
• inability to relax
• rheumatic pain
• minor sports injuries and tensions

A slightly curious list, but there you are.  What is lumbago anyway? I thought it was old-fashioned speak for low back pain. Sciatica can be caused by a number of things.  I am surprised to see digestion problems included.  And circulatory problems.  Does that mean we can claim to treat any dysfunction or malfunction of the entire cardiovascular and gastrointestinal systems, but not whiplash? Nor low back pain arising from an accident or injury, the thing we’re so good at?  We can’t claim to treat tennis elbow unless it is associated with back problems?  How many lay people would know or care about the distinction? How many clinicians could make the distinction?  Hey, let’s just include it in the category minor sports injuries instead.

Still, as we know, we treat the body not the condition, so this does not affect our treatment, just our advertising.  And this list is reasonably extensive.  Understandably twitchy about the law, CAP emphasises that the provision of this list does not constitute legal advice.  They have a page specifically about osteopathy on their website here.

Clinic Staff

Do also make sure your receptionist and staff know the limits of what they can say.  I once had a receptionist who had to be gently deterred from advising patients on a variety of treatments from icebaths for ME to olive oil drops for ear infections.

Testimonials

Patient testimonials and outcome studies are NOT considered robust enough to constitute evidence, and be careful that testimonials don’t mislead by including opinions or impressions from the patient that are “likely to be interpreted as factual”.  Also make sure that you have evidence that each testimonial is 1) from a real person and 2) you have been given permission to use it.

Free website check

An amazingly useful sounding (but again not legally binding) service is provided by ASA.  They will apparently check your website to make sure it is ASA compliant, free of charge, here.

Up to date research

But the buck stops with you, ultimately, and while sticking to the CAP list and being aware of what you can say means you are unlikely to attract any complaints, GOsC urge you to maintain up-to-date knowledge of research, most easily done through the excellent NCOR.  Where would we be without them?

Full marks to GOsC by PSA (Professional Standards Authority)

The PSA is the regulators regulator.  As GOsC is to us, the PSA is to GOsC, as far as I can make out.  GOsC have ticked all the boxes, met their approval, and been commended for their achievements.  If you are so inclined you can read it for yourself.  Find the GOsC bit on pages 98-108 of the full PSA report on the 9 regulators.

Twenty osteopathic leaders are hatched

There is an Osteopathic Leadership Programme, part of the programme of the ODG (Osteopathic Development Group).  They have teamed up with the Open University and began in July with a workshop.  Another workshop, an open university course, and an online leadership course will follow.  This programme was oversubscribed by more than 2:1 so it seems there are plenty of ambitious young (and old) things in our profession.  The programme is expected to run for at least 3 years.  If you’re interested email twalker@osteopathy.org.uk. Details are also on the Institue of Osteopathy website here.

Patient Charter and Service Standards

The ODG (yes, it’s the Osteopathic Development Group again) is proposing the development of service standards for osteopaths and the adoption of a ‘Patient Charter’.  The charter would be a series of best-practice statements reflecting the OPS (Osteopathic Practice Standards) which they believe will help improve confidence and set patients’ expectations regarding osteopathic treatment.  The service standards would take this even further in some way not particularly spelt out, but involving self audit using a self-assessment pack.  There is a definite feedback and audit theme afoot these days!  Now before you groan under the weight of more policing and complexity, these standards would be entirely voluntary, and according to ODG Programme Coordinator Matthew Rogers would be “simple and easily applied”.  Please do share your views with Katie Griffiths at katie@osteopathy.org.uk

Clinical Interest Groups – or Specialization

The ODG ‘s Advanced Clinical Practice project has now identified 3 options for communicating and promoting osteopaths’ special interests.

1.  Groups (eg online forums, public registers, specialist CPD)
2. ‘Credentialing’ – a mouthful of a word to say, but apparently a word in common use, though evidently not widely used enough to exist without apostrophes around it.  This basically means having accreditations or qualifications in a field of expertise.  This wouldn’t limit other osteopaths’ scope of practice though.
3. Knowledge and Skills Framework.  This is my personal favourite of the three.  An idea of the knowledge, skills and capabilities required to practise at a range of levels in different contexts and roles.  Again that last bit needs a bit more explanation I think, but it sounds like a list of “what you should know and be able to do if you want to be a paediatric (or visceral, or headache, or other) specialist”.

The survey closed on August 28 but maybe if you had strong views you could still get in touch.

Mentoring

So, onto another ODG scheme.  I am now aware of four – leadership, specialisms, the Patients’ Charter, and here’s another:  mentoring for recent graduates.

It can be hard being an osteopath, and recently when I had some counselling the counsellor was flabbergasted that we had no supervisory support system for the profession, so I think this is probably a good idea.  How it works in practice is what they’re trying to work out.  Unfortunately this survey is also shut now, but again if you feel strongly I’m sure an email to any email address at GOsC will get through.

Get your needs met – CPD-wise, I mean

We all have different needs:  freedom, security, adventure, chocolate, but it’s always good to know what your particular needs are so you can go about fulfilling them.  Otherwise you’ll just be miserable.  Or, professionally, you’ll not reach your full potential as a therapist.  Sometimes you need a bit of structure to reflect, and GOsC have a form to download to “help you record your thoughts”  here.  Appendix A of the CPD guidelines has an example here of how you might fill it out.  It sounds quite a useful way to figure out what CPD to do next.

Is it time to launch your bid for power?

GOsC need up to 5 osteopaths to serve on the Council, 2 for the IC (Investigating Committee), and 2 for the PCC (Professional Conduct Committee).  All will be appointed on April 1st next year.  There’s a bit of a time commitment: you must be able to spare 18 days a year for the Council, 20 for the PCC and the Investigating Committee is probably similar.  You are reimbursed for your time and trouble though.  You can find full details on the GOsC website from sometime early in September here.  There is a workshop on Saturday 12 Sept if you want help knowing how to present yourself and get a decent CV together.  It’s at GOsC Towers in London and goes from 10am – 3pm, and you need to let head honcho Tim Walker know by emailing him at twalker@osteopathy.org.uk.  Lunch is provided.

Answers to FAQs

1.  An osteopath nearby can set up a website with a similar name as yours without being guilty of unacceptable professional conduct.  This probably would not be referred for hearing.
2. Osteopaths on the Isle of Man must now be registered with GOsC.
3. If you have the address to the online Register of Osteopaths on your website, please update it as it has changed to http://www.osteopathy.org.uk/register-search/.  You can also get a registration mark on your website here.

Council Decisions July 2015

You can see my previous post on the meeting here.  The next Council meeting is on Thursday 12 November.  Phone Marica on 020 7357 6655 x246 or email mscott@osteopathy.org.uk.  If you want to see what they do it’s worth a visit.  You will be warmly welcomed.

Fitness to Practice

GOsC want to know what you think of three draft guidance documents to help their committees in Fitness to Practice cases.

1.  For the Health Committee.  This draft sets out the questions the committee should ask itself when formulating conditions to impose on an osteopath while they get treatment for whatever health issue they have, and it provides sample wording for those.  Have a look at it here.
2. For the PCC (Professional Conduct Committee).  To make sure the decision are fair and consistent, a guidance document has been produced.  Find it here. It should make determinations by the committee more transparent and consistent.
3. Interim Suspension Orders.  (ISOs, not ASBOS  – whatever happened to them?) . An ISO is imposed to stop us practising if any committee feels a complaint is serious enough that the public need protecting.  There is a revised draft on this too here.

Again GOsC want feedback.  Remember that this is your chance to comment, while these things are being formulated.  It’s no use complaining after the event, so if you do want your say visit http://bit.ly/gosc-consultations, complete the relevant response form and return it to regulation@osteopathy.org.uk.  Closing dates vary but are in October. They promise to take “every response received into consideration”. You don’t have to make your name public.

How to Write a Case Study

A write up of an interesting case might be one of the easiest ways for osteopaths in practice to get research published.  We all tell each other all the time about interesting of unusual cases, and writing it up is the next step.  Brett Vaughan from IJOM has a great little piece here on how to get going.  (By the way, IJOM has attained a “high impact factor” meaning even more people are citing its articles than previously, so get going if you have aspirations in this field.)  There are 3 types of study

1. Case report (about one patient presentation or unexpected response) – example here
2. Case problem outlining the differential diagnosis and clinical reasoning of a presenting complaint
3. Evidence in practice, showing how evidence has been applied – a really interesting sounding one here on validity of cervical pre-manipulative testing

You need to get to these via the ozone using this link.

The patient must be anonymous but also must give consent (ideally in writing), and the manuscript itself should have a statement of consent from the patient.)

There is a template  provided by the CAse REports initiative (CARE) to follow: title, abstract, key words, introduction, patient’s presenting concerns, clinical findings, timeline, diagnostic focus and assessment, therapeutic focus and assessment, follow up and outcomes, discussion, patient perspective, informed consent, references.  Find the full descriptions here

Elsevier can help with the style here in Writing for Books and Journals. There’s also useful info on IJOM’s Guide for Authors

More research is pretty vital, and Brett (along with Steve Vogel, editor-in-cheif) sounds very approachable for anyone wanting any help or direction at Brett.vaughan@vu.edu.au.

Research Hubs

It’s only the lack of childcare stopping me going along to Haywards Heath’s NCOR Research Hub tomorrow night for a civilized networking opportunity with 5 or 6 friendly local osteopaths, while we drink coffee, swap gossip, get treatments tips, and go through 5 or 6 research papers on ankle injuries.  I love it.  It’s a social event, a brain workout, CPD points, and the satisfaction, rare in osteopathy,  of actually knowing something for sure that is based on solid evidence (or not, but you’ll be alerted to poor research by the highly knowledgeable Carol Fawkes who can sort the wheat from the chaff and teach you how to do that too).  Just go to one, and see if you like it!  They are in Bristol, Exeter, Haywards Heath and Leeds. Website here.

Communicating Risk

Risk.  It’s a biggie.  We have to tell patients what they are, but we don’t know what they are.  They might frighten people, or contribute to a nocebo effect (if you don’t know, that’s a kind of negative version of placebo, for example where you tell someone they’ll ache the next day, so they do).  There’s a lot of guesswork as there is likely to be under-reporting; but there is an estimate that one serious incident occurs in every 36 079 treatments – not all from HVT.

How to discuss risks without frightening people

If anyone asks you about risks before the appointment, NCOR’s Austin Plunkett recommends you point out that it’s very low, but varies with each individual and is best discussed at the consultation when you have identified a course of treatment.  One interesting point is that patients don’t like risks to be compared with risks of natural disasters or recreational activities, but you CAN compare them with the risks of doing nothing, or travel, or alternative treatments.  Does this mean you can say it’s like the risk of a plane crashing, but not like the risk of injuring yourself horseriding?  Frame the risk positively (eg 50% have no adverse effects are treatment rather than 50% are sore after treatment).  And personalize it:  ie in my experience I have rarely seen this, etc

There is a chart provided showing comparative likelihoods of serious accidents which is from a paper here. This estimates serious HVT injuries at between 1 per 100 000 and 1 per 1 000 000.  If you want a sobering read, though, I’d recommend the chapter in Preston Long’s book Chiropractic Abuse where real patients who have been left quadriplegic after cervical manipulations went wrong tell their stories.

iO Convention

It’s at Runnymede-on-Thames in Egham on 20-22 November.  For the first time there will be an applied research stream.  For details click here

New CPD group in Havering

John Chaffey has launched this, kicking off with a free foot and ankle talk by a local surgeon on Thursday Sept 10 7pm at the In Health diagnostic centre, Westlands Ave, Hornchurch. Email him at hornchurch-cpd@bodybalance.co.uk

Been an osteopath for 15 years?  Want 8 hours free CPD?  Want to help research?

Three yeses and you could call Jerry Draper-Rodi on 07935969532 or email j.rodi@bso.ac.uk.  I think I might do this myself.  You get an e-learning course on the most up-to-date evidence on non-specific low back pain, in return for giving feedback about the quality of the programme.  Sounds fab.

Book Review:  Muscle Energy Techniques (4th ed.) by Leon Chaitow

There always seems to be a book by Leon Chaitow being reviewed.  He must be one of osteopathy’s most productive writers.  Lauren Jardine found the history of MET interesting, but some of the research sections a bit hardgoing.  (That’s research for you, I suppose).  She liked descriptions of muscle group and joint METs, having previously seen METs as more specific to isolated muscles.   65 videos are available through a linked website, and it seems reading this book has transformed Lauren’s practice somewhat, getting better results and understanding of what she is doing.  She says it’s great for anyone working in a rehabilitation setting, which, as she points out, we all are to some degree.  That’s an interesting point in itself for future exploration.

Book Review:  Fascia in Sport and Movement  ed. Robert Schleip and Amanda Baker

A book in 2 sections reviewed by Kathleen Hill:  more hardgoing scientific language in the first Theory section;  the second, on Clinical Application, explores fascial fitness including elastic storage and recoil dynamics.  It also describes how fascial training can be useful in specific sports.  Not all this is evidence-backed, but Kathleen found it shone some light on a somewhat neglected and poorly understood area.

How to Lie With Statistics

There I was basking in the glow from the recent survey findings that 96% of osteopathic patients give us a high confidence rating, when David Rodway goes and confuses me, by pointing out that only 10% of people who haven’t been to us have ‘a lot of confidence’ in us.  Theostoepath editor makes a spirited defence, and it is true that 55% have a fair amount of confidence, making 65% of people who’ve never seen an osteopath at least having some confidence, and about a third saying they don’t’ know.  A relatively small percentage have no confidence.,  You can get in a muddle with all these numbers and what they mean.  Maybe we do just choose what statistics we want and apply them how we like, really.

So there we are, another edition over, hope I’ve picked out all the bits you need to know.  CPD, the ODG,  patients perceptions and risk seem to feature pretty strongly.  See you in 2 months.

Catch up with the June/July edition here