Job versus Career: Does it apply to medical profession?

“You can apply for a job, but you cannot apply for a career.”

A job is a specific occupational position within a business or organisation. When we complete medical school, doctors are taught that our career means pursuing a post-graduation. Is it so?

Let’s take a simple example of a vocational career like teaching. We want the people who are teaching our children to think of it as a career, not just a job. We want them to have an interest in our children and care about the success of our children.

Same applies to us as doctors! The patient assesses the technical quality of medical care indirectly by evidence of the interest and concern of professionals with their health and wellbeing. Such evidence is perceived through empathy. To achieve this, we need to love our jobs.

Jobs can help people start careers in many ways – experience, knowledge, learning about what they like and dislike. Eventually though, striving for a career is a very positive step because it means you want more out of the work you do than a paycheck.

I can share my own journey of a job to career. When I worked as an ENT Surgeon dealing with deaf children, I knew to perform surgeries to improve their hearing. I was one of the few surgeons in the country performing the cochlear implant surgery. However, performing surgery was a job and I knew that outcome of the surgery was dependent on post implantation habilitation. There was a dearth of well-trained habilitationists. I needed to strengthen my team and improve my surgical outcomes. This started the journey of my career.

First, I went for further training in cochlear implantation by the best surgeons in the world. I learnt performing cochlear implantation in anomalous cochlea by the surgeon who gave the classification of vestibular cochlear malformation to us. It was a lifetime experience to see his involvement with the deaf children and the outcomes of his implantees.

Next step was to strengthen the habilitation of my implantees and lead a strong team. We not only trained our staff but I did a deaf educator course and certificate course in early intervention in children with disabilities.

As I went looking for options to upgrade my skills, I realised they were unlimited. I completed various courses on Edx and Coursera platforms ranging from “Medical ethics” to “how to become a resilient person”. I am pleased to inform that many of these courses are free. I am now a mentor for Coursera and would recommend everyone reading this article to take at least one course.

Whether a job or career is the right fit for you will depend on your stage of life. Jobs can help people start careers in many ways – experience, knowledge, learning about what they like and dislike. In addition, earning potential is much higher in a career than in a job in most cases.

There is a lot of unrest amongst doctors these days. Doctors are stuck between good medical practices and economics of getting that paycheck. I personally feel that the balance can be struck if we develop our jobs into careers. Every specialty has something to add to the quality of patient’s life than just treating a disease.

So as you can see, while one can work very hard at a job and even be paid well to work a job, a career takes much more motivation and forward-thinking effort than a job

 “A job is given to you, but a career is made by you”

Dr Sheelu Srinivas

Consultant ENT and Cochlear Implant Surgeon

Columbia Asia Hospitals, Sarjapur, Bangalore

Sheelu.S@columbiaasia.com

9902846770

“Disability is not just a health problem”

“Disability is not just a health problem”

On International Day of persons with Disabilities 3rd December, this is the only message I would like to convey to public and professionals alike.

Theme for IDPD 2017: “Transformation towards sustainable and resilient society for all”

Disability has extensive generic meaning. It may refer to any state of existence that limits an individual to perform effectively and efficiently in her/his routines. In India, approximately 10% of population suffers from disabilities related to locomotion, vision, hearing and intellect as per the NSSO 2010 report.

The Rights of persons with Disabilities Bill- 2016 replaced the Persons with Disability act 1995 (India). This new bill has defined disability based on an evolving and dynamic concept. The types of disabilities have been increased from 7 to 21. Speech and Language disability and specific learning disability have been added for the first time in the 2016 bill. Following link gives a nutshell information http://pib.nic.in/newsite/PrintRelease.aspx?relid=155592

Speech and language delay lead to communication disability. 
Communication delays can be due to primary presenting symptom of other physical, sensory or mental disability, commonest example being sensorineural deafness. However, it can also be associated with other forms of disabilities like Autism. Now with Speech and Language included as a separate disability, an ENT specialist and the team of audiologists and speech therapist cater for almost 40 % of the disabilities.

Children who suffer from speech, language and communication disorders in early childhood may face difficulty with language learning, education, social interaction, employment and beyond.

Let’s pledge that we work towards the early diagnosis and habilitation of these children and be a supportive society.

And for the professionals, let’s have an approach of treating disability and not a disease.

Where did I start and where am I led to..in my professional journey.

Looking back at my professional life  ....I create this profile.
However it is definitely incomplete as it does not lists the beautiful souls I have met and exchanged so much of joy in working with them.It does not lists my colleagues, hospital staff, my team members, mentors, teachers and family and extended families of patients who have been my strength.That particular list of my support pillars is very exhaustive and I can only say that I am here because of them.

Profile: Dr Sheelu Srinivas, M.S.ENT, DORL (Mumbai), DLO (RCS, London)

Dr. Sheelu Srinivas is an ENT Surgeon with over 17 years of experience. She studied ENT at K.E.M. Medical College, Mumbai and underwent further training in Otolaryngology in the U.K. She pursued her further surgical training in Otology and Pediatric ENT in France, Turkey and Switzerland. Her interest in deafness and communication disorders in children has led her to successfully complete hands on training and certificate courses on deaf education as well as early intervention in children with Autism and other communication disorders.

Dr. Sheelu Srinivas was the Director and Coordinator - ENT Department at Fortis Hospitals, Bannerghetta Road for a decade where she developed tertiary ENT unit along with Cochlear Implant and Pediatric Airway Programs. She also worked as Honorary Consultant at Indira Gandhi Institute of Child Health and Spastics Society of Karnataka. She runs her own ENT Diagnostic Center along with Pediatric hearing and Speech Rehabilitation Unit.

Her surgical expertise includes Otology, Cochlear Implantation, Endoscopic Sinus Surgery and Pediatric ENT Surgeries. She is known for her thorough clinical diagnosis and a holistic approach towards patients including the little ones.

Dr. Sheelu is a regular speaker and presenter at various national and international conferences including WHO Symposium on deafness at IFOS Seoul.

She has been involved in starting the newborn hearing screening and deafness habilitation programs in private and public sectors. She ran the first pilot project of Universal Hearing Screening in babies at K.C. General Hospital, Bangalore and went on to introduce Anganwadi projects for screening hearing and speech disorders in the young.

She has been advisor to National Program for Prevention and Control of Deafness, Karnataka and Member of State Cochlear Implant Committee. Her comprehensive work in this field from diagnosis to habilitation led her team to be the finalists of BMJ South Asia Awards 2015 in Healthcare Advocacy category. She is the member of Association of Otolaryngologists of India, Indian Association of Pediatric Otolaryngologists, Indian Academy of Pediatrics, Allergy Chapter and Interamerican Association of Pediatric Otorhinolaryngology.

Importance of the nasal breathing in children

Babies are nasal breathers and do not know how to breath through the mouth when they are born.
At birth, human babies are obligate nasal breathers.

Breathing through the nose enables adequate facial growth and proper positioning of the teeth. It also leads to calm and restoring sleep.

Noisy breathing or snoring is not normal in children. The commonest cause of nose block is allergic rhinitis. A child with blocked nose leads may have bad breath and suffer with sinusitis more frequently. Also these children are less interested in eating as they cannot smell food and hence enjoy it.
Another common cause of mouth breathing in children is Adenoid hypertrophy or Adenoid enlargement. These are lymphoid tissues like tonsils in the space at the back of the nose. The size of adenoids is usually confirmed with a nasoendoscopy.

Breathing through the mouth can cause the following

• Unexpressive face; 
• Changes in positioning of the teeth; 
• Dental caries; 
• Aesthetic facial alterations (elongated face, hypotonic lips);
• Gritting or grinding of teeth (bruxism); 
• Sleep disorders (superficial or restless sleep); 
• Attention deficit or learning disorder; 
• Mood swings.

Read more on allergies,sinusitis and adenoids in the following links:

http://sheelusrinivas-entpractice.blogspot.in/2013/01/allergen-avoidance-is-it-worthwhile.html

http://sheelusrinivas-entpractice.blogspot.in/2017/01/sinusitis-in-children.html

http://sheelusrinivas-entpractice.blogspot.in/2015/05/removal-of-adenoids-and-tonsilswhich.html

When to consult an ENT Doctor for my child?

"Your child's Pediatrician is the primary care provider and incharge of your child's health."

Parents should consult a Pediatric ENT only if the child's Pediatrician has suggested them to do so.

Pediatric otolaryngologists are concerned with treatment of medical and surgical ENT disorders in children. They have been trained to take care of children from newborn period to teenage years.

Children are not just small adults.The disease presentations and management can differ from adults.Right from the clinical approach for diagnosis differs in children.It needs specialised training and experience in working with children to keep them comfortable while examining them.

A child will not always be cooperative and will not be able to answer medical questions or express their problems. Sometimes they have their own ways of expressing concerns. I cannot forget a 3 year old telling me her ears are "singing" and we did go ahead and found a cause.

If we learn to interact with kids, they are also capable of giving information.They may not answer direct questions or get overwhelmed with questioning.

Interaction with the child is a must for a pediatric otolaryngologists as child is the one who needs attention.This is especially useful in diagnosing social and communication disabilities.Many times parents are in denial or do not know age appropriate behaviours,in these situations direct interaction with the child is a must.

All of the above requires experience,skill and judgement with the team including the primary treating pediatrician.

Finally be a child with the child....and the doctor for the family.

Preschool Health Screening: Is it necessary and what does it involve?

Schools have started and I have started getting visits of little ones whose parents are advised to see ENT doctor following the childs health screenings in school.

 Preschooler

There are a few points about school/pre school health screenings,I would like to discuss here.

Before we start, lets talk about "Neural Plasticity" and 'Critical Period" 

During early period of life, neurons in brains are moldable (plastic) and it is easy to teach any skill to a child. Once the child is above 5 years,it is difficult to do rehabilitaton and bring them age appropriate. Hence we say that the critical period is the early infant or toddler years.

Let me take you through some common questions asked by parents:

1. Preschool screening: Is it mandatory? Should it be made mandatory by law?
My toddler has been visiting pediatrician regularly,why another screening?

The pediatrician is definitely your child's primary physician.When you visit a pediatrician in well baby clinics/immunization clinic, usually they record the growth and development of the child.
However, there are other aspects of development like speech,language,cognition,social and emotional behaviour.
In many parts of the world,it is mandatory by law.

2. Parent permission is compulsory for any screening.

3. Child's birth records and health records should be available during screenings.This is for the screening practioner to understand the child's growth (age appropriate) or to make provisions for any insults at birth and need extra time required to achieve age appropriate milestones.

4. Who should do it?
A health practitioner or a registered nurse trained in screening.

5. What does it involve?
Apart from physical examination and interacting with the child, they may also plan some activities (like blocks/scribbling etc age appropriate)

6. What are the components in a standard screening?

Eye contact, motor control and body language in a typical kindergardener

Any screening should involve hearing and vision tests.Apart from this: motor development,language development (mother tongue or a language which is spoken at home around the baby),social emotional development and cognition is informally checked.

7. Will they "label" or diagnose my child?
No! its only a screening.If there is any concern, child will be sent to appropriate specialists for confirmatory diagnosis or sometimes only a re screening is advised.

8. Should I be rest assured if my child passes screening for any future health or disability issues?
No.If at any time parents have concerns about the child's growth or development, tey should bring it to the notice of pediatrician who can advise you further.

9. Finally and most important, screening should be done as early as possible,We have better chance of correction and treatment early, best being a child below 3 years of age.
This will give us enough time for intervention and make the child school ready.

10. My child is shy and will not allow screening?
The health practitioners are trained to handle kids and very well trained that each child is different.

Geriatric ENT: ENT Care for the Elderly

The patient population of people more than 65 years old in the population are an integral part of ENT Outpatients.
Like pediatric,Geriatric patients also need a targeted approach to their diseases because they have special issues unique to their population.

The commonest problems I get refereed in the elderly is dizziness and hearing loss. I must mention here that chronic ear infections commonly called as CSOM is the third common diagnosis.
When I used to work in a tertiary care cardiac center, the common presentation was nose bleed due to blood thinners.
Apart from above common presentations,we are very careful in the elderly who present with any swellings or change invoice or breathing and swallowing problems to rule out Head and Neck masses.If the symptoms are of more than 4-6 weeks or any suspicion, a transnasal flexible laryngoscopy is immediately performed in outpatients.

I love interacting with the senior citizens.Its not all about me advicing them, I also get to learn lessons from their wisdom. 

Team for Early Intervention of 0-6 years children with communication disorders

This is not really a blog post with medical information but its a platform I am using to request readers to connect me with like minded professionals.

I am Dr Sheelu Srinivas with following qualifications 

and practising in Bangalore for a decade now.

M.S. ENT (G.S.M.C.and K.E.M.Hospital, Mumbai),MBBS (T.N.M.C.& BYL Nair Hospital, Mumbai)

Specialist Registrar and Associate Specialist U.K. 2001-2006 May

Consultant ENT Surgeon and Department Coordinator Fortis B.G.Rd June 2006-Mar 2015

Honorary Consultant  at Indira Gandhi Institute of Child Health and Spastics Society of Karnataka

•Specialised Training in Pediatric ENT including airway reconstruction and Cochlear implants at CHUV Lausanne, Switzerland (Prof Monnier) and Hacettappe University Ankara Turkey (Prof Seneroglu: Pioneer in operating Anomalous Cochlea)

•Pediatric Disability Training: Deafness and communication disorders including Autism

Balavidyalaya Chennai ,DHVANI Methodolody for Deaf children ,Training the trainer course

Com DEALL, Bangalore: Certificate course in communication disorders in children with disabilities

AVT Courses by Advanced Bionics, Medel and Cochlear Companies

I want to start an Early intervention Center for children with Speech and communication delays.This includes kids from birth to 6 years who may have various childhood concerns like hearing loss,Autism spectrum disorder and so on.

I am looking for investors and also building a team.This team needs passionate psychologists,special educators,occupations therapists and audiologists and speech language therapist.

Iam sure there are many dedicated individuals doing this kind of work and would like to connect with them.Kindly message us on sheelusent@gmail.com 

Tongue tie

Tongue-tie (ankyloglossia) is where the strip of skin connecting the baby's tongue to the floor of their mouth is shorter than usual.

Some babies who have tongue-tie don't seem to be bothered by it.

In others, it can restrict the tongue's movement, making it harder to breastfeed.

Other potential problems could be difficulty in sticking tongue out and sticking it side to side.

Treatment of choice depends on the infant's ability to feed. 

Division with scissors in outpatients is the optimum treatment up until the age of 12 weeks after which, without general anaesthetic, it is not feasible

There is anxiety among parents that child will not learn speech and language due to tongue:this is not true. Learning speech and language is a higher skill.

Drooling in Children | ENT E-Learning Hub

Drooling in Children | ENT E-Learning Hub

OPD Consultations: Messages buried in the words.

In clinical practice, patients come and tell their stories.Some just say a few words and for others there can be many things going on.
And the clinician listens,not just listens,actively listens.

OPD consultations requires professional judgment and expertise, it can be quite tiring when done well. To completely empty oneself of ones own prejudices, patterns of responding and frame of reference, and to try to understand all of this about another person is an act of great generosity and respect. It is a commitment of not only time, but mental energy and a preparedness to explore another person’s world and see the way life appears to them. 

Active listening is an advanced communication skill, which takes practise and constant awareness to avoid slipping into the patterns summarised as roadblocks.These type of ‘roadblocks’ include: • ordering • threatening • moralising • excessive/inappropriate questioning • advising.

When we suggest solutions after all this listening, interactions and examinations, we take responsibilities.

However some people still leave the consultations unhappy.

Following are excerpts from a well written article I was reading as to why this can happen:
"However, there can be risks in suggesting solutions. It takes responsibility away from the other person. It implicitly disempowers the other person by saying: ‘You can’t solve the problem, but I am better/smarter/more worldly than you, so I have to do it for you’. This can make the person feel belittled or patronised. A person will usually have been pondering their problem for some time before they present with it. If a solution seems obvious to the listener after only a short time, the chances are it is obvious enough to have occurred to the person with the problem as well. To suggest otherwise is an insult to their intelligence. Therefore the issues then become: have they already tried the solution? Presumably it has already failed, what factors led to its failure? If they have not tried the obvious solution, why not? What are the other factors about the situation that means they have decided not to proceed with the obvious solution? More active listening is needed! A sign that suggesting solutions at this particular point is not appropriate is when the speaker starts to block the suggestions. This can be frustrating to both parties, and distract them from teasing out all the thoughts and emotions about the problem. Alternatively, some people simply ‘shut down’, outwardly appearing passive and compliant, but inwardly disengaged and resigned to not getting the help they really need. Avoiding the other’s concerns A third type of ‘roadblock’ is avoiding the other’s concerns by: • diverting • logical argument • reassuring. These roadblocks deny the person the opportunity to talk about their problems, or worse still, try to convince them that they really aren’t serious problems, and they are foolish to be worried about them."
Active listening More than just paying attention 
Kathryn Robertson, MBBS, FRACGP, MEd, is Senior Lecturer, Department of General Practice, University of Melbourne, and a general practitioner, Victoria. k.robertson@unimelb.edu.au
http://www.racgp.org.au/afpbackissues/2005/200512/200512robinson.pdf

‘You can learn to be a better listener, but learning it is not like learning a skill that is added to what we know. It is a peeling away of things that interfere with listening, our preoccupations, our fear, of how we might respond to what we hear’. Ian McWhinney

Family Centered Early Intervention Africa 2017

Issuing Medical Certificate

As an ENT Surgeon,I issue post operative off work certificate to patients.However in the outpatients,we should be careful in issuing certificates.
On personal ground,I disagree taking off work for small cough colds.Most of the people who ask such certificate are people who are bored of their work and have already taken off before consulting me.When they visit the clinic,they will argue that they were not well previous day and now they have paid my consultation fees.Well! consultation was done for your medical ailments and if it was told by patient that they are visiting me for a certificate-I would have refused to see them in the first place.

Another group who come for certificates are parents of school going kids.The family would have gone on holidays or to attend family functions and then appear to the doctors for a certificate.I blindly refuse to give such certificates.

I was once called for an enquiry where I had written date of resuming as 2/2/13 and the patient made it 12/12/13.This is true and I was so very overwhelmed that after that I never gave certificates for about 2 years .For operated ones,I used to ask ward secretary to type.Handwritten can easily be played around!Also in below article it has mentioned that take the signature of patient and an unrelated witness on the certificate which we occasionally follow in practice.

Here I share a well written article on docplus by DR Professor Prabhakar.Also the comments following it are informative
https://www.docplexus.in/#/app/posts/8fcb924f-a49b-494f-8c40-ff5874088220?utm_term=Email-Digest-0-eve&utm_campaign=Email-Digest&utm_medium=Email&utm_source=Docplexus.in&utm_content=CTA

Criteria For Issuance Of Medical Certificate

What kind of legal precautions can we take against violent incidents of non-issue of medical certificates? Patients seek medical certificates (MC) even for cold and cough these days to remain absent from work since they are bored with the same routine and mechanical working conditions. The purpose of seeking medical certificate documentation by any kind of patients is most important whether for the government or private sector. If for government purpose, patient is informed that certificate issued by a private physician will be invalid in such a condition so that the patient should at once convince of regarding this legal statement. Even then patient forces and insists for MC, certificates may be issued mentioning and confirming that the genuine purpose of MC whether it is true to patients knowledge free of cost. God alone knows how these so called certificates are accepted in working places whether government or private industries that are issued by government or private doctors and vice-versa. It is very well known that authorization should be mandatory to issue such medical certificates; however there is paucity of this issue in government protocols because MC issued by the private doctor is also valid in some companies. In such conditions it is always worth to ask the patient convincingly what is the purpose of MC and what he/she is going to do with that and whether MC granted by private doctor is valid or not valid in her/his company etc. These are the preliminary questions that may help to gain the confidence of any patient more so with poor and pity psychiatric patients. Once the purpose is revealed we will have to ask is it true and what for- very soothingly. Why all this in-patients will come deciding everything about MC issuing problems and even ready for fight and assault if the same is not issued, so much fixed in their minds, and prejudiced and preplanned, that’s how our mind works for the future consequences management, of course. Nicely we will have to solace the patients regarding invalidity and unacceptability of these so called MC stories issued by private firms. Repeatedly confirm whether patient is asking for medical treatment certificate or medical consultation fees certification if so we will have to issue both. When so called law protectors exhibit such irrelevance and carelessness towards such type of incidents, then God alone is the ultimate protector and destroyer of this material world. In the first instance police stayed away from this incidence because they thought they are dealing with a psychiatric patient and why to give trouble this is mercy and kindness always shown towards any patient suffering from disease of mind. Therefore prophylactic cautions that work are important than so-called these legal precautions. These are very few precautions not amounting to cautions only, when private doctor issuing MC to adamant patients who insist upon and force doctors to grant MC. Only we can take these simple cordial precautionary steps to prevent further legal mishaps-so enough of this violation. 

Read more at: https://www.docplexus.in/#/app/posts/8fcb924f-a49b-494f-8c40-ff5874088220?utm_term=Email-Digest-0-eve&utm_campaign=Email-Digest&utm_medium=Email&utm_source=Docplexus.in&utm_content=CTA
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Nasal Polyps in Children

Nasal Polyps are common nasal swellings or masses seen in children.

The paranasal sinuses (“the sinuses”) are air-filled cavities located within the bones of the face and around the nasal cavity and eyes. 

Each sinus is named for the bone in which it is located:

Maxillary sinus- one sinus located within the bone of each cheek  

Ethmoid sinus- located under the bone of the inside corner of each eye, although this is often shown as a single sinus in diagrams   this is really a honeycomb-like structure of 6-12 small sinuses that is better appreciated on CT scan images through the face  

Frontal- one sinus per side, located within the bone of the forehead above the level of the eyes and nasal bridge  

Sphenoid- one sinus per side, located behind the ethmoid sinuses; the sphenoid is not seen in a head-on view but is better appreciated looking at a side view

However in children sinuses are still developing and when we refer to sinuses in children;it is mainly maxillary and ethmoids.

Nasal polyps in children can be inflamatory (bacterial),allergic or associated with cystic fibrosis. 

The nasal polyps are of two kinds mainly : Antrochoanal or Sinonasal.

Antrochoanal are ususally single polyps aising from the maxillay antrum and going towards the choana (posterior opening of nostrils).They are usually one sided.

Sinonasal usually arise from the sinus lining of both sides of sinuses.

The common symptoms of polyps are 

nasal block

obstructive sleep apnoea or snoring in children

sometimes nose bleed

Usually the ENT surgeon will ask for CT scan to know the extend of disease.

The nasal polyps require surgical removal.Nowadays in children it is usually endoscopic approach.Sometimes transoral and other approaches are require for complete removal.

As a surgeon,I always consider the growing anatomy of sinuses,unerupted teeth and concern for facial growth in children while deciding the surgery.

Sinusitis in children

Sinusitis is the inflammation of the sinuses.Though an adult has four pairs of sinuses,in children it is usually the maxillary and ethmoid sinuses are involved as the sphenoid and frontal sinuses are still developing.

In children,common cold or viral infection is the commonest cause of sinusitis.
Other common cause is foreign body in the nostrils or untreated allergic rhinitis leading to sinusitis.

Common symptoms the child will have are
Nasal discharge: green or yellow
fever
cough
headache
facial pain or pressure over face
swelling or redness over face or cheeks
swelling around the eyes

Child should be immediately seen by their physician who will decide the treatment starting from decongestion of the nose to allergy treatment or antibiotics depending on diagnosis.
Ocassionally scans are ordered:CT scan of sinuses especially if eye is involved.