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Duped
While folks my age are sometimes referred to as “elderly” victims in newspaper stories about phone and Internet scams, I resist and object to the implication that I am less than sharp and worrisomely vulnerable to being duped.
I hang up when a stranger calls to warn me that I am about to be audited by the Internal Revenue Service and asks for my Social Security number. I double-delete e-mails purported to come from my Internet provider that ask for my e-mail address and password. I’m no pushover.
However, I fear that over the last 20 years of my practice career, I was duped by several of my adolescent patients on more than one occasion. I hope that I had a reputation in town as one of the physicians least likely to leap to the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and even less likely to pull out my pad and prescribe stimulants.
I was particularly hesitant to make the diagnosis of ADHD in an adolescent whose academic career and behavior in grade school had been unremarkable. But from time to time I was presented with a case that included a combination of apparently reliable teachers’ reports, parental pleas, and patient complaints that was hard to ignore. Having ruled out anxiety, depression, learning disabilities, and severe sleep deprivation (all my teenage patients were sleep deprived to some degree) I would reluctantly agree to a trial of stimulant medication.
As you can imagine, assessing success or failure took time because we were usually looking for improvement in academic performance. For adolescents, this often means waiting to the end of the semester or grading period. If the academic improvement was less than dramatic as it was in the usual scenario, I was left relying on the patient’s report of his subjective observations and waiting another 6 months for more information from the school. Occasionally, the patient would report that the medication made him feel weird and that he wanted to stop it. More often, the patient would report that he was able to pay attention in class more easily, even though he had difficulty pointing to a documented improvement in his performance.
So what does one do? Sometimes I could convince the patient and his family that the trial had failed and that we should stop the medication and work harder to find a better match between his learning style, study habits, and the demands of the school. In other cases, I would adjust dosages and switch medications. The results were seldom dramatic. However, if the patient continued to claim a benefit, I would continue to prescribe the stimulant. I would make phone assessments with every refill, and face-to-face visits at least once a year.
While it may be that a few of those adolescents without clearly demonstrable benefit were indeed being helped by the stimulants, I am now convinced that I was being duped more often than I cared to admit then. I know there were stimulants available on the streets and in the school hallways and parking lots because some of my patients told me that they were easy to find and had tried them. I have to believe that some of those pills on the street were ones I had prescribed. I worry when I consider how many.
The national statistics are staggering and embarrassing. In 2013, the federal Substance Abuse and Mental Health Services Administration reported that ED visits associated with the nonmedical use of prescribed stimulants among adults aged 18-34 years had tripled from 2005 to 2011. (“Workers Seeking Productivity in a Pill Are Abusing ADHD Drugs,” by Alan Schwarz, New York Times, April 18, 2015). How many of the pills associated with those visits were originally prescribed for adolescent who didn’t have ADHD?
How many of my patients were just trying to be good friends by sharing their pills and how many were selling them? How many of the pills I prescribed were fueling all-night parties, and how many were being used as performance-enhancing drugs by students who needed to finish a term paper on time?
I don’t know. But I do know that although I miss practicing pediatrics, I am glad I no longer have to face the dilemma of the adolescent with ADHD-like complaints, because I hate being duped.
While folks my age are sometimes referred to as “elderly” victims in newspaper stories about phone and Internet scams, I resist and object to the implication that I am less than sharp and worrisomely vulnerable to being duped.
I hang up when a stranger calls to warn me that I am about to be audited by the Internal Revenue Service and asks for my Social Security number. I double-delete e-mails purported to come from my Internet provider that ask for my e-mail address and password. I’m no pushover.
However, I fear that over the last 20 years of my practice career, I was duped by several of my adolescent patients on more than one occasion. I hope that I had a reputation in town as one of the physicians least likely to leap to the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and even less likely to pull out my pad and prescribe stimulants.
I was particularly hesitant to make the diagnosis of ADHD in an adolescent whose academic career and behavior in grade school had been unremarkable. But from time to time I was presented with a case that included a combination of apparently reliable teachers’ reports, parental pleas, and patient complaints that was hard to ignore. Having ruled out anxiety, depression, learning disabilities, and severe sleep deprivation (all my teenage patients were sleep deprived to some degree) I would reluctantly agree to a trial of stimulant medication.
As you can imagine, assessing success or failure took time because we were usually looking for improvement in academic performance. For adolescents, this often means waiting to the end of the semester or grading period. If the academic improvement was less than dramatic as it was in the usual scenario, I was left relying on the patient’s report of his subjective observations and waiting another 6 months for more information from the school. Occasionally, the patient would report that the medication made him feel weird and that he wanted to stop it. More often, the patient would report that he was able to pay attention in class more easily, even though he had difficulty pointing to a documented improvement in his performance.
So what does one do? Sometimes I could convince the patient and his family that the trial had failed and that we should stop the medication and work harder to find a better match between his learning style, study habits, and the demands of the school. In other cases, I would adjust dosages and switch medications. The results were seldom dramatic. However, if the patient continued to claim a benefit, I would continue to prescribe the stimulant. I would make phone assessments with every refill, and face-to-face visits at least once a year.
While it may be that a few of those adolescents without clearly demonstrable benefit were indeed being helped by the stimulants, I am now convinced that I was being duped more often than I cared to admit then. I know there were stimulants available on the streets and in the school hallways and parking lots because some of my patients told me that they were easy to find and had tried them. I have to believe that some of those pills on the street were ones I had prescribed. I worry when I consider how many.
The national statistics are staggering and embarrassing. In 2013, the federal Substance Abuse and Mental Health Services Administration reported that ED visits associated with the nonmedical use of prescribed stimulants among adults aged 18-34 years had tripled from 2005 to 2011. (“Workers Seeking Productivity in a Pill Are Abusing ADHD Drugs,” by Alan Schwarz, New York Times, April 18, 2015). How many of the pills associated with those visits were originally prescribed for adolescent who didn’t have ADHD?
How many of my patients were just trying to be good friends by sharing their pills and how many were selling them? How many of the pills I prescribed were fueling all-night parties, and how many were being used as performance-enhancing drugs by students who needed to finish a term paper on time?
I don’t know. But I do know that although I miss practicing pediatrics, I am glad I no longer have to face the dilemma of the adolescent with ADHD-like complaints, because I hate being duped.
While folks my age are sometimes referred to as “elderly” victims in newspaper stories about phone and Internet scams, I resist and object to the implication that I am less than sharp and worrisomely vulnerable to being duped.
I hang up when a stranger calls to warn me that I am about to be audited by the Internal Revenue Service and asks for my Social Security number. I double-delete e-mails purported to come from my Internet provider that ask for my e-mail address and password. I’m no pushover.
However, I fear that over the last 20 years of my practice career, I was duped by several of my adolescent patients on more than one occasion. I hope that I had a reputation in town as one of the physicians least likely to leap to the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and even less likely to pull out my pad and prescribe stimulants.
I was particularly hesitant to make the diagnosis of ADHD in an adolescent whose academic career and behavior in grade school had been unremarkable. But from time to time I was presented with a case that included a combination of apparently reliable teachers’ reports, parental pleas, and patient complaints that was hard to ignore. Having ruled out anxiety, depression, learning disabilities, and severe sleep deprivation (all my teenage patients were sleep deprived to some degree) I would reluctantly agree to a trial of stimulant medication.
As you can imagine, assessing success or failure took time because we were usually looking for improvement in academic performance. For adolescents, this often means waiting to the end of the semester or grading period. If the academic improvement was less than dramatic as it was in the usual scenario, I was left relying on the patient’s report of his subjective observations and waiting another 6 months for more information from the school. Occasionally, the patient would report that the medication made him feel weird and that he wanted to stop it. More often, the patient would report that he was able to pay attention in class more easily, even though he had difficulty pointing to a documented improvement in his performance.
So what does one do? Sometimes I could convince the patient and his family that the trial had failed and that we should stop the medication and work harder to find a better match between his learning style, study habits, and the demands of the school. In other cases, I would adjust dosages and switch medications. The results were seldom dramatic. However, if the patient continued to claim a benefit, I would continue to prescribe the stimulant. I would make phone assessments with every refill, and face-to-face visits at least once a year.
While it may be that a few of those adolescents without clearly demonstrable benefit were indeed being helped by the stimulants, I am now convinced that I was being duped more often than I cared to admit then. I know there were stimulants available on the streets and in the school hallways and parking lots because some of my patients told me that they were easy to find and had tried them. I have to believe that some of those pills on the street were ones I had prescribed. I worry when I consider how many.
The national statistics are staggering and embarrassing. In 2013, the federal Substance Abuse and Mental Health Services Administration reported that ED visits associated with the nonmedical use of prescribed stimulants among adults aged 18-34 years had tripled from 2005 to 2011. (“Workers Seeking Productivity in a Pill Are Abusing ADHD Drugs,” by Alan Schwarz, New York Times, April 18, 2015). How many of the pills associated with those visits were originally prescribed for adolescent who didn’t have ADHD?
How many of my patients were just trying to be good friends by sharing their pills and how many were selling them? How many of the pills I prescribed were fueling all-night parties, and how many were being used as performance-enhancing drugs by students who needed to finish a term paper on time?
I don’t know. But I do know that although I miss practicing pediatrics, I am glad I no longer have to face the dilemma of the adolescent with ADHD-like complaints, because I hate being duped.
Squeaking up
I don’t harbor many regrets. Oh, there was the ocean front lot next to our cottage I should have bought for a third of what it’s worth now. But, like most congenitally happy people, I have a very short memory for unfortunate situations. It’s not that I haven’t done things I should be regretting. It’s just that they have disappeared into the haze of my distant memory.
The one glaring exception to my blissfulness is the regret that I didn’t venture beyond the boundaries of a traditional primary care practice often enough to help some of my neediest patients. Sure, I went out in the middle of the night to meet concerned families in my office. I view those trips as well within the scope of practice for a pediatrician in a small community. I made one or two house calls per decade, but it was usually because they were more convenient for me.
What I regret is that too often I was content with making the diagnosis that superficially appeared to best fit the patient’s presenting symptoms and complaints. Then I would prescribe the standard textbook remedy, although many times I knew that the patient’s social situation or a flaw in the bureaucracy of medical care was really at the root of the problem.
For example, let’s say I have a 9-year-old patient with asthma who is usually fairly well controlled, but when he goes to stay with his father on one weekend every other month he will often end up in the emergency room with an exacerbation. None of these episodes are very serious, but ... they do affect his quality of life. Once or twice a year he may miss school on Mondays following a visit to his father’s home. The boy’s mother has some suspicions about environmental conditions and medication compliance issues, but doesn’t seem very concerned about the situation.
I knew – or at least strongly suspected – that the answer to this child’s less than optimal management was a deeper look into what was going on at his father’s home and his behavior. But this would mean taking the initiative on my part to ask the father, who lived out of state and whom I had never met, to come in and be interviewed. My attempts to investigate might stir up some postmarital ugliness, that at least according to the mother, seems to have subsided to an acceptable level. By retreating into my comfort zone of traditional practice, wasn’t I failing to advocate for my patient?
A recent article in Pediatrics entitled “A Common Thread: Pediatric Advocacy Training” by Dr. Kristin Schwarz and associates (2015;135:7-9) suggests that had my training included a few weeks of advocacy training, I might have been better prepared to address this young asthmatic patient’s situation. As the authors of the article point out, advocacy can occur at a variety of levels, all the way from speaking out at a national or state level or becoming involved in community efforts to improve child health to the very personal example I’ve described. They define advocacy as “endorsing effective solutions.” Although my inaction may have been rather minor, clearly I was not truly providing an effective solution.
I’m not a going-to-meeting kind of guy, and I don’t have the patience to navigate the bureaucratic scaffolding on which governments and insurance companies are built. So it is unlikely that I will ever be much of an advocate on a grand scale. But there was an abundance of situations in which the best thing for my patient would have been to step out of my passive let-the-problems-come-to-me approach and make a few extra phone calls to advocate. Of course, I did make those calls from time to time, but I regret not having done it often enough.
There was always an abundance of excuses. I didn’t get paid for phone calls; I was too busy with the scores of patients with squeaky wheels that needed to be greased. If I had to do it all over again, I would do a lot more squeaking myself to create solutions to the real problems of my most vulnerable patients.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected]. Scan this QR code to read similar articles or go to pediatricnews.com.
I don’t harbor many regrets. Oh, there was the ocean front lot next to our cottage I should have bought for a third of what it’s worth now. But, like most congenitally happy people, I have a very short memory for unfortunate situations. It’s not that I haven’t done things I should be regretting. It’s just that they have disappeared into the haze of my distant memory.
The one glaring exception to my blissfulness is the regret that I didn’t venture beyond the boundaries of a traditional primary care practice often enough to help some of my neediest patients. Sure, I went out in the middle of the night to meet concerned families in my office. I view those trips as well within the scope of practice for a pediatrician in a small community. I made one or two house calls per decade, but it was usually because they were more convenient for me.
What I regret is that too often I was content with making the diagnosis that superficially appeared to best fit the patient’s presenting symptoms and complaints. Then I would prescribe the standard textbook remedy, although many times I knew that the patient’s social situation or a flaw in the bureaucracy of medical care was really at the root of the problem.
For example, let’s say I have a 9-year-old patient with asthma who is usually fairly well controlled, but when he goes to stay with his father on one weekend every other month he will often end up in the emergency room with an exacerbation. None of these episodes are very serious, but ... they do affect his quality of life. Once or twice a year he may miss school on Mondays following a visit to his father’s home. The boy’s mother has some suspicions about environmental conditions and medication compliance issues, but doesn’t seem very concerned about the situation.
I knew – or at least strongly suspected – that the answer to this child’s less than optimal management was a deeper look into what was going on at his father’s home and his behavior. But this would mean taking the initiative on my part to ask the father, who lived out of state and whom I had never met, to come in and be interviewed. My attempts to investigate might stir up some postmarital ugliness, that at least according to the mother, seems to have subsided to an acceptable level. By retreating into my comfort zone of traditional practice, wasn’t I failing to advocate for my patient?
A recent article in Pediatrics entitled “A Common Thread: Pediatric Advocacy Training” by Dr. Kristin Schwarz and associates (2015;135:7-9) suggests that had my training included a few weeks of advocacy training, I might have been better prepared to address this young asthmatic patient’s situation. As the authors of the article point out, advocacy can occur at a variety of levels, all the way from speaking out at a national or state level or becoming involved in community efforts to improve child health to the very personal example I’ve described. They define advocacy as “endorsing effective solutions.” Although my inaction may have been rather minor, clearly I was not truly providing an effective solution.
I’m not a going-to-meeting kind of guy, and I don’t have the patience to navigate the bureaucratic scaffolding on which governments and insurance companies are built. So it is unlikely that I will ever be much of an advocate on a grand scale. But there was an abundance of situations in which the best thing for my patient would have been to step out of my passive let-the-problems-come-to-me approach and make a few extra phone calls to advocate. Of course, I did make those calls from time to time, but I regret not having done it often enough.
There was always an abundance of excuses. I didn’t get paid for phone calls; I was too busy with the scores of patients with squeaky wheels that needed to be greased. If I had to do it all over again, I would do a lot more squeaking myself to create solutions to the real problems of my most vulnerable patients.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected]. Scan this QR code to read similar articles or go to pediatricnews.com.
I don’t harbor many regrets. Oh, there was the ocean front lot next to our cottage I should have bought for a third of what it’s worth now. But, like most congenitally happy people, I have a very short memory for unfortunate situations. It’s not that I haven’t done things I should be regretting. It’s just that they have disappeared into the haze of my distant memory.
The one glaring exception to my blissfulness is the regret that I didn’t venture beyond the boundaries of a traditional primary care practice often enough to help some of my neediest patients. Sure, I went out in the middle of the night to meet concerned families in my office. I view those trips as well within the scope of practice for a pediatrician in a small community. I made one or two house calls per decade, but it was usually because they were more convenient for me.
What I regret is that too often I was content with making the diagnosis that superficially appeared to best fit the patient’s presenting symptoms and complaints. Then I would prescribe the standard textbook remedy, although many times I knew that the patient’s social situation or a flaw in the bureaucracy of medical care was really at the root of the problem.
For example, let’s say I have a 9-year-old patient with asthma who is usually fairly well controlled, but when he goes to stay with his father on one weekend every other month he will often end up in the emergency room with an exacerbation. None of these episodes are very serious, but ... they do affect his quality of life. Once or twice a year he may miss school on Mondays following a visit to his father’s home. The boy’s mother has some suspicions about environmental conditions and medication compliance issues, but doesn’t seem very concerned about the situation.
I knew – or at least strongly suspected – that the answer to this child’s less than optimal management was a deeper look into what was going on at his father’s home and his behavior. But this would mean taking the initiative on my part to ask the father, who lived out of state and whom I had never met, to come in and be interviewed. My attempts to investigate might stir up some postmarital ugliness, that at least according to the mother, seems to have subsided to an acceptable level. By retreating into my comfort zone of traditional practice, wasn’t I failing to advocate for my patient?
A recent article in Pediatrics entitled “A Common Thread: Pediatric Advocacy Training” by Dr. Kristin Schwarz and associates (2015;135:7-9) suggests that had my training included a few weeks of advocacy training, I might have been better prepared to address this young asthmatic patient’s situation. As the authors of the article point out, advocacy can occur at a variety of levels, all the way from speaking out at a national or state level or becoming involved in community efforts to improve child health to the very personal example I’ve described. They define advocacy as “endorsing effective solutions.” Although my inaction may have been rather minor, clearly I was not truly providing an effective solution.
I’m not a going-to-meeting kind of guy, and I don’t have the patience to navigate the bureaucratic scaffolding on which governments and insurance companies are built. So it is unlikely that I will ever be much of an advocate on a grand scale. But there was an abundance of situations in which the best thing for my patient would have been to step out of my passive let-the-problems-come-to-me approach and make a few extra phone calls to advocate. Of course, I did make those calls from time to time, but I regret not having done it often enough.
There was always an abundance of excuses. I didn’t get paid for phone calls; I was too busy with the scores of patients with squeaky wheels that needed to be greased. If I had to do it all over again, I would do a lot more squeaking myself to create solutions to the real problems of my most vulnerable patients.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected]. Scan this QR code to read similar articles or go to pediatricnews.com.
