Equality, Diversity and Inclusion (EDI) Resources (CPD 23-24)

Seek professional interpreter or ask if another family member can come in.

Safeguarding concerns about care responsibility for the child and the accuracy of medical information - also is child being forced to take on adult responsibilities, dealing with sensitive information about the parent that they may not otherwise be privy to, and under additional stress from these responsibilities.

GCC Responsibilities:

• Standard C1 “obtain and document the case history of each patient, using suitable methods to draw out the necessary information”
• Standard E1 “you must share with the patient accurate, relevant and clear information to enable the patient to make informed decision about their health needs and relevant options. You must also take into consideration a patient’s capacity to understand.”

An interesting article on this is available here: https://www.dynamiclanguage.com/the-dangers-of-using-children-as-their-parents-interpreters/

• Hearing aids are not a perfect solution and the patient may still face challenges in certain environments. If you require the patient to remove the hearing aids at any point, ensure you clearly communicate any instructions or information beforehand.
• Be aware that many patients with progressive hearing loss have got used to ‘passing’ as hearing, and can be very convincing in showing they have understood information- such as by nodding and responding during pauses in the conversation. It can be helpful to provide written information to these patients as well to ensure they have full understanding.
• You are not legally obligated to provide an interpreter, but there are companies that can provide an online-based interpretation service if required.
• Speaking loudly and slowly does not necessarily enhance understanding for patients with hearing loss as it can distort lip-reading cues and may not improve comprehension- in addition it may appear condescending and stigmatising.

• You have a responsibility to discharge the patient with signposting to another care provider and should carefully document your reasons for discharging the patient from your cre.
• The decision to discharge the patient should be done carefully and in accordance with guidance from your insurers, and potentially with legal advice too. In this situation, it appears not to be a decision based solely on a mental health diagnosis but rather on a thorough assessment of the patient’s behaviour and its impact on staff and other patients.
• Standard C6 of the code requires you to “cease care, or aspects of care, if this is requested by the patient or if, in your professional judgement, the care will not be effective, or if, on review, it is in the patient’s best interest to stop. You must refer the patient to another healthcare professional where it is in their best interests.”
• Remember- if a mental health disorder if severe enough to impact ADL’s (activities of daily living) then it is likely considered a disability and as such will be a protected characteristic and grounds for discrimination. You could also refer a patient back to their GP (or similar) for a review of their mental health concerns if the patient feels these are not being well-managed currently.
• Reasonable adjustments - consider offering the patient appointments during a less intense practice environment and ensuring these are scheduled far enough in advance that you have availability to do so. This may require more availability for ‘quiet’ appointments.

• A family history of cervical cancer may indicate genetic predispositions or shared environmental factors that could increase the risk of developing cervical cancer. Have any known genetic factors been identified such as mutations in genes BRCA1 or BRCA2?
• Women with a family history of cancer may need to be more vigilant with cervical screening.
• Studies show that there is widespread underutilisation of cervical screening in the LGBTQ+ community- possibly due to misconceptions about risk, discrimination, stigma, lack of awareness or assumptions about low-risk sexual behaviours.

• Incorporate guidance on mechanics of sajdah and discuss with patient how this can be adapted to incorporate better mechanics of the knee.
• Lifestyle modifications - address any weight loss concerns and underlying deficiencies from any dietary imbalances that could be contributing to knee pain. If the patient is taking pain medications, can the timing of these be adjusted to optimise pain control during periods of increased activity, such as before prayer times.
• It would not be inappropriate to suggest to the patient that they consider modification of prayer position - speak to their religious leader, speak to the patient, advise patient of use of a support and or/pillow under the knees or under the mat to provide some cushioning.

• Ensuring that all straps on the backpack are utilised, in addition to wearing the straps on both shoulders. Positioning the rucksack so it sits higher on the back can avoid extension through the lower back, and ensure that heavy items are packed at the bottom of the bag to help with weight distribution.
• Symptoms of Lyme disease (Erythema Migrans) can vary but chiropractors should always consider this in a patient with a history of recent travel to areas where Lyme disease is commonly found, including moors and heathland, and some woodland. Other symptoms may include fever, rash, intermittent flu-like symptoms, joint pains, and sometimes a bullseye rash.
• On darker skin, a lyme rash can look like a bruise, the edges may feel slightly raised.
• As Lyme disease can be easily misdiagnosed in people with black or brown skin, it is not uncommon for them to present with more advanced pathology. As such, an urgent referral should be made to the patients GP or, if presenting with more advanced neurological findings, the patient should be sent to your local emergency department.

An interesting one and sadly all too common…

• “Adjustments are about speed and specificity, not strength. Chiropractors learn how to adjust people of all shapes and sizes effectively. Now let’s get going, shall we?”
• No. I may provide more detail and/or citations if necessary, but the information remains true regardless of the manner of communication.
• Equipping team members with “stock phrases” to fall back on can be helpful, particularly for new grads. This can be useful for those “mind went blank” moments where you forget everything you’d like to say in the moment! If the associate DOES have concerns about adjustments, offering advice and clinical pearls to help them leverage their body weight more effectively can be beneficial.
• No, there are no serious grounds I could think of to refuse to treat. However, the associate needs to feel confident that their treatment is truly effective for that patient and so if they have doubts that they can provide effective interventions (for any reason) they could consider referring to another practitioner, co-management or changing their plan of management.

• Recognise and understand some of the common indicators of autism and how these might present themselves in clinic - for example literal interpretation of language, dislike of small talk and being less likely to initiate or reciprocate in a two-way conversation can affect the clinician’s interaction with that patient. Building awareness and understanding of that patient’s individual experiences and how they prefer to be interacted with can help minimise distress (if any) to the patient.
• More time may need to be given to ensure they have understood instructions and have their questions answered. People with autism may experience higher anxiety when going into new situations and, coupled with hypersensitivity in any sensory modality can mean that examination, ROF and treatment need to be spread over several treatments in order to fully support this patient.
• Clinical concerns about autism mostly link towards understanding and ensuring that they are capable of consent - they may not pick up on non-verbal cues and may take language very literally which may cause challenges. There are also a number of other common co-occurring conditions that are relevant, and difficult clinician-patient relationships may affect clinicians' interactions with patients, including reduced motivation to spend time with that patient.
• The mother should be involved as the child is only aged 15, however, he may be able to grant consent himself if it is believed he has the intelligence, competence and understanding to appreciate the treatment plan. The mother could also be helpful in ensuring the patient complies with their treatment plan and supporting the young teenager on their journey to recovery.

• Treatment may need to be modified to ensure the patient can easily access your treatment room. Other adaptations may be incorporating different soft tissue management of the remaining limbs, evaluating for leg length discrepancy, being aware of pressure points within the socket and other clinical considerations such as pressure sores, phantom limb pain and mechanical wear and tear.
• Prosthetic fittings are a long process with an initial fitting, dynamic fitting and then repeated follow up treatments for alterations and adjustments. The type of prosthesis, its purpose, design and manufacturing system will all affect how well the patient copes with it. This type of issue should be co-managed with the prosthetics team.
• Military veterans may suffer from PTSD which can affect their response to pain and treatment. This could be accompanied by depression and anxiety which will affect the patient’s motivation. An interdisciplinary team approach is best whereby clinicians can collaborate with other healthcare professionals, social workers and support teams.

Modification of techniques to ensure they’re appropriate for a pregnant patient are clearly important here, along with optimising comfort and positioning throughout her pregnancy.

• To ensure the patient is able to understand and give consent, clear and simple communication is vital, along with explaining each step of the process with demonstrations of any techniques or adjustments to be used can help the patient build an understanding of what to expect. Utilising a method such as the TeachBack method could help ensure the patient fully comprehends what has been explained along with robust documentation of consent within the medical records. Consent should be recorded in written format given at the time consent was sought, this can also be supported with additional records noting that verbal consent has also been given.
• Ice or heat therapy are both appropriate in this case, along with gentle exercises. Supporting the patient with guidance on lifestyle modifications may also be useful, this could be given in the form of a visual aid, video, photos or advice leaflet/email which can help the patient build their understanding of their condition.
• The GCC code Principle F requires chiropractors to “communicate properly and effectively with patients, colleagues and other healthcare professionals. This would indicate that yes, the involvement of the social worker and/or GP would be helpful- provided the patient provides written consent for you to do so. This could help with coordinating care and ensuring her treatment notes are fully contemporaneous. If the patient granted their consent for medical records to be released, the normal process within your clinic should be followed, and a letter to the patient should also be sent.