HOW TO TREAT 21 part of the clinician. Here it is important to learn of the ego strengths of the patient. Who among their family or friends may be able to help build up their self-esteem and confidence, at times aided by further visits, therapy and / or medications?
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HOW TO TREAT 21 part of the clinician. Here it is important to learn of the ego strengths of the patient. Who among their family or friends may be able to help build up their self-esteem and confidence, at times aided by further visits, therapy and / or medications?
ADDITIONAL TASKS FOR THE CLINICIAN
Non-presenting symptom
AN astute and / or thorough clinician may recognise the non-presenting symptom, over and above the patient’ s presenting complaint. 17 These may include unrecognised physical abnormalities or ignored physical findings, such as obesity or persistent hypertension, and / or unrecognised or ignored emotional issues. The assumption is that the doctor will assess the‘ whole patient’, ideally the norm for all clinical encounters. That is certainly expected of the general paediatrician / general physician but has become increasingly the role of the GP, if provided with adequate resources. However, the patients’ responses may vary from grateful acceptance( for example, diagnosing an asymptomatic glue ear), to non-acceptance and even anger, especially if there is a need for much effort on the part of the patient / parent to bring about a change.
Unconscious motivations of the patient come into play. Even if recognised, it is inappropriate for clinicians to verbalise the possible unconscious motivations, as there is no therapeutic ongoing relationship. In that setting, their role is to clarify and elucidate the problem, provide an understanding of its possible causes and potential consequences, and then consider the best options with respect to its management( see later). At times, a gentle confrontation may be required to emphasise the clinician’ s concerns. This needs to be done tactfully, after deciding the best time to do so. Avoid colluding with the patient / parent’ s inappropriate or incorrect perceptions, as suggested by the following quotation:“ By not raising issues which are readily apparent in an interview setting in which the child( patient) may readily manifest, the physician implies acceptance and approval of a suboptimal state of health or behaviour, reinforcing parental( patient) opinion or behaviour”. 17
The hidden agenda
Multiple terms, such as hidden agenda or misdiagnosis or second diagnosis, are used to describe the covert concerns or second diagnosis
Figure 2. Sitting next to and facing the patient enhances communication.
Figure 3. Anger may be expressed overtly or in other formats, not uncommonly directed towards the person“ breaking the bad news”.
Box 3. Examples of a hidden agenda
• In 1961 Dr S Yudkin, a paediatrician, considered this in terms of asking“ Why is the patient seeing you now?” as opposed to“ What is the matter with the patient?”. 5 A example he provided was of a mother who presented with her child who had a cough. As she was undressing the boy, she asked,“ Don’ t you think he is too thin?” Further exploration revealed the mother’ s ongoing difficulties with her mother-in-law who blamed her as“ the child was not properly cared for”. That was what was really troubling this mother.— Therefore, even though the traditional diagnosis is clinically important, it is necessary to deal with the second diagnosis before the patient can be helped. If this is unrecognised, some patients may leave the consultation quite unhappy and others may seek further opinions.
• Reports penned by B M Korsch in 1968 and G Raimbault in 1975, a paediatrician and paediatric endocrinologist respectively, succinctly described the problems that occur when doctors fail to recognise the‘ hidden’ concern behind the presenting problem. 6, 7
— Korsch et al described how parents repeated themselves, and if they were still not heard, they become mute. 6— Raimbault et al provided an example of a mother who offered“ because of ketones during the pregnancy” as a cause of her child’ s Turner syndrome. The doctor ignored the mother’ s indirectly voiced but unfounded guilt and replied,“ No, because of chromosomal abnormality.” 7
• Clinical experience certainly helps in recognising and attending to the hidden agenda during the course of a consultation. Further examples are provided from a 1981 study that compared medical students with consultants seeing children in an outpatient setting. 18 Consultants participating in the study usually recognised the hidden agenda as the interview progressed and addressed the
18, 19
concerns during the consultation.
— A mother presented with her daughter, aged 33 months, and reported the child had“ pain in her stomach”. She volunteered,“ My mother, my auntie and most of the females [ in my family ] have a lot of kidney problems. My sister lost a baby... she died because she had problems with her kidneys, that’ s all”. The student responded,“ No hypertension, no diabetes.” He had failed to recognise the mother’ s concern that her own daughter may have a kidney problem that may eventually kill her, as it did her sister’ s daughter.
— A mother attended with her six-year-old son who had a convulsion while febrile. She offered,“ I came to this hospital because I had epilepsy myself. Then when I was pregnant, doctors doing research would check‘ D’ to see if he is alright. Is he?” Father interjected,“ That was to check if the pill you were taking for epilepsy had an effect on him.” The student replied,“ I do not know.” The mother responded,“ Sometimes children have convulsions with temperature and infections,” trying to play down her concerns that her son may also have epilepsy which she‘ caused’ by taking anticonvulsants during her pregnancy, and that he may be like her with epilepsy requiring ongoing medication.