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.