“Wisdom of the Week – One”: from a post ent to me – Sermo ….

The wisdom of saying the right words that both explain & inspire.

Patient Case Submission: “Wisdom of the Week – One”: The wisdom of saying the right words that both explain & inspire.

I really like what American print & broadcast journalist Germany Kent opined, “It’s a funny thing about life, once you begin to take note of the things you are grateful for, you begin to lose sight of the things that you lack”.

It perfectly summarized how a wise neurosurgeon I knew explained to a 10-year-old boy about his paraplegia, inspiring him to accept & live with his lifelong disability & to achieve in his life. The boy had a spinal cord glioma that presented with paraplegia. It was resected & radiated. He was cured of his tumor but the paraplegia persisted.

The wise neurosurgeon found the right words to explain the paraplegia to the boy.

He said, “What are the things you like to do best?” The boy said, “I like working on my computer. I am very good at it. I am also very good at basket-ball”.

The neurosurgeon said, “There you are! You can become the best computer-programmer in the world when you grow up. And you can also be a champion wheelchair basket-ball player!” The boy stared at the neurosurgeon, gulped & blinked back his tears. He got the message. He understood that he would never walk again.

And do you what, he did accomplished both his goals, above & beyond everybody’s expectations.

Dear All

Thank you for participation in the Zoom session today.

In RRR we discussed:

• Urinary Tract Investigations – different modalities
• Preterm 27 weeks: Expected medical problems
• VSD

The Clinical Station was evaluation of a 8 year old who fainted at school sports day. Universal cues included a murmur clip. Dr D took the hotseat and made a very good attempt.

Learning points:

• Structured examination is a MUST.
• Time management is ESSENTIAL.
• General physical examination is part of every examination.
• Consider Universal Cues have not been seen by the examiner
• You should ‘Demonstrate / notice’ them during your examination
• In Conclusion: DO NOT repeat all Examiner has just told you
• Give your impression of Diagnosis – supported by cues
• Marks are for Management hence do not over run your time getting there

Please visit www.mrcpchonline.org to add your comments or any points I may have missed.

Anil Garg

Dear All
Thank you for participating in the session today. We welcomed new members.

We covered Video station today. There was PowerPoint presentation on Do’s & Don’ts for the station by AG. We did not discuss Rapid Random Reviews today.
The Video was of a 2 day old baby in a head box, with abnormal movements. Lip smacking, abnormal eye movements, jerking of left arm, right arm lying with no movement.Dr A was in the hot seat and covered the observations well. Discussion was a little more tricky.
The learning points are:

• With background information and Video clues – develop a Differential diagnosis
• If diagnosis is very obvious – DONOT look for other farfetched possibilities
• Think of possible causes / aetiology for the Obvious diagnosis
• Ask 2-3 focused questions to help with your differential diagnosis
• Investigations – mention with expected results – NOT a list of To Dos.
• Management plan – in broad brush initially
• Escalate to your consultant
• Mention Specific ‘treatment’ before going through ABCD…
• Visit www.mrcpchonline to add your comments or points I may have missed.

Anil Garg

Thank you for participating in the session today.
In RRR we discussed:

• Diabetes Insipidus – what, diagnosis & management
• Cystic Fibrosis: Diagnosis
• Blood spot test vs Guthrie test

In the Communication we took scenario of disclosure of information to a 12 year old with likely diagnosis of Leukemia. Parents had asked Medical team not to inform the child. Student nurse is unhappy with the decision. Dr A was in the hotseat and Dr A & Dr AG were role players. The scenario is a difficult one but relates to a number of topics that regularly come in the exam.
Learning points:

• Ethical communication – important to have a structure
• Use correct terminology
• Be anatomically correct when discussing
• Do NOT give up if you feel you have NO idea of where to go
• If Role Player keeps coming back – refuses to move forward
• Throw back to Role player – ‘Why are you concerned: What do you know of it?”
• Role player has information they will give ONLY if ASKED.
• Use 4 minutes wisely and prepare ‘well’.

Visit www.mrcpchonline.org to add your comments or anything I have missed.
Anil Garg

Dear All
Thank you for attending the session today and making it a very useful learning experience.I will need a volunteer for the role play on Thursday.

We did not touch RRR today and instead took extra time on the communication scenario that was of a drug error – 5 week old infant given Phenobabritone 75 mg instead of 15 mg.
A common scenario of an angry role player.

DR AG was the role player. Dr A was in the hot seat and Dr D tried the scenario again with Dr A in the hot seat. Good attempt in face of a very angry and upset parent.
Learning points:

• Systematic approach
• Build rapport
• Do NOT start with – I have come to inform you of an error.
• Apology ONLY after you have informed of ERROR.
• NOT vice-versa.
• Prepare your ‘agenda’ for first 2 minutes – get cues from Role player from there on.
• 30 sec rule – DO NOT forget
• Empathy.
• ‘I understand how you feel’. Look as you mean it – pause.
• DO not just say as if you have to.
• You DONOT have to tell EVERY THING you know.

Visit www.mrcpchonline.org to add your comment or points I may have missed.
Anil Garg

Dear All

We look forward to seeing you on Thursday 13:30 UK time.

Anil Garg is inviting you to a scheduled Zoom meeting.

Topic: Anil Garg’s Zoom Meeting
Time: Jan 20, 2022 01:30 PM London

Join Zoom Meeting
https://us02web.zoom.us/j/2191937091?pwd=Wm1LazJFT3VWY0owMXNXNmtnNk5pdz09

Meeting ID: 219 193 7091
Passcode: @Autumn

Dear All
Thank you for participating in the session today.
We practised a focused history of a 3 month old brought to A&E by her mother for cough, cold and not feeding for 4-5 days. Extended clinical station had universal cues demonstrating healing rib fracture and subdural haematoma. Dr A & Dr A were in the hot seat and made good attempt.
Learning points:

• Watch Universal cues carefully 
• Make a differential of possible causes
• Share information with Role Player
• Learn when to interrupt RP when going off track or rambling on
• Systematic approach is essential.

We reviewed the stations covered in the past three months 3 this course.

Rapid Random Topics:      75

Communication: 6, : Video:  5, : Clinical Stations: 9

Development: 4 : History & M.: 1

We will start the winter session from Tuesday 25 January 2022.

Visit www.mrcpchonline.org to add your comments.

Anil Garg

Dear All
Thank you for your participation in the sessions today.In RRR we discussed:

• Alpha 1 – Antitrypsin deficiency. Presentation.
• 4 year old with periorbital swelling and lateral outward displacement of eye
• Chronic inflammatory Bowel Disease

The clinical Development scenario was of a 18 month whose mother is concerned about speech development. We discussed the expected mile stones to demonstrate. Dr D & Dr A took the hotseat. IT is a ‘different’ station to other clinical stations and needs more practice.
Learning points were:

• Receptive vs Expressive speech
• Fluent examination technique
• Have a Transcript of how you will ‘run’ the station
• Choose appropriate ‘commands’.
• Observe the child, demonstrate signs
• If child not playing ball – ASK parents help.
• If STILL successful – examiner will allow you to ask ‘parent’ direct question
• Important to keep time for the last option
• Red flags: Not talking by 2 years & Not walking by 18 months

I attach a thematic approach and mile stones.
Visit www.mrcpchonline.org to add your comments or points I may have missed.
Anil Garg

Dear All
Thank you for participating in the session today.In RRR we discussed:

• VECTRAL association and it’s relevance / importance
• 7 year old with Headache and nausea. 

It is important to keep common conditions on top of your list vs more rare. Common cause I have seen is Migraine but most serious to rule out is a Space Occupying Lesion. Benin Intracranial Hypertension – should not be a first diagnosis as differential.
In Development station we first saw a boy of 3.5 yrs with concerns regarding inability to common daily tasks like his brother. The video of fine motor assessment was seen. Good points noted. Then Dr S and Dr A were in the hotseat to verbalize the same / similar examination.
Learning points:

• Observe the whole child – do NOT miss obvious association / signs
• Hand preference vs inability to use the other hand freely.
• Verbalizing is harder and there are not commonly practised.
• Use SIMPLE commands – important for child to understand
• Practice, Practice, Practice
• In summarizing – ‘I could not get him to do xyz on this occasion’.

Vist www.mrcpchonline.org to add your comment or anything I may have missed.
Anil Garg

Dear All
Thank you for participating in the session even when some of you were on long shift.
We moved on to Development station. In the RRR we discussed:

• GMFCS. Score of 1-5.
• 6 stages of play – age related to 4+ years
• ADHD & ASD – screening

Development station is an important component of the clinical exam and a comparatively difficult station for most of us. Exposure to Community paediatrics is limited for most trainees – specially overseas.
AG discussed a PP presentation on the Development station on What and How?

Next few sessions we will watch and verbalize actual tasks after watching simulated attempts.
Learning points:

• Scared. Is the first thought that comes to mind
• Practice, practice, practice.
• Sit in Community / development clinics in hospital – if time permits
• Start development – lower age – work upwards.
• One tool / toy at a time
• Do not confuse or overwhelm the child

Visit www.mrcpcholonie.org to add your comments or points I may have missed.
Anil Garg