William G. Wilkoff, MD

In North America, breakfast is the most personal of all the traditional daily meals and usually the one at which people show the least amount of day-to-day variation.

FluxFactory/E+

For example, since retiring from active practice I eat three scrambled eggs and bowl of fresh fruit every morning (yes, I have my lipid screen done annually and it’s fine). When I was a child there were stretches measuring in years during which I would eat the same cold cereal and drink a glass of orange juice. As an adolescent trying to bulk up for football, there was a breakfast-in-a-glass that I drank along with the cereal every morning. There was the frozen waffle decade.

When I was a busy general pediatrician, the meals were short on preparation and equally short on variety. But I always had something to eat before heading out for the day. That’s what my folks did, and that’s the pattern my wife and I programmed into our children. I think my dietary history is not unique. Most people don’t have time for a complex breakfast, and in many cases, they aren’t feeling terribly adventuresome when it comes to food at 6 or 7 in the morning. Breakfast is more of a habit than an event to satisfy one’s hunger. Several generations ago, breakfast was a big deal. Men (and occasionally women) were headed out for a day of demanding physical labor and stoking the furnace at the beginning of the day made sense. In farm families, breakfast was a major meal after the morning chores were completed. Those Norman Rockwellesque days are behind us, and breakfast has receded into a minor nutritional role.

For many adults, it’s just something to chew on with a cup of a stimulant liquid. In some families, breakfast has disappeared completely. For as long as there have been dietitians and nutritionists, we have been told that breakfast can be the most important meal of the day. And for a child, the failure to eat breakfast could jeopardize his or her ability to perform in school. I guess at face value this dictum makes sense, but I’ve never been terribly impressed with the evidence supporting it. A recent study from England has gotten me thinking about the whole issue of breakfast and school performance again (“associations between habitual school-day breakfast consumption frequency and academic performance in British adolescents.” Front Public Health. 2019 Nov 20. doi. 10.3389/fpubh.2019.00283). A trio of researchers at the Human Appetite Research Unit of the School of Psychology, University of Leeds (England), found that in the study group of nearly 300 adolescents aged 16-18 years, the students who frequently skipped breakfast performed more poorly on a battery of standardized national tests. Well, I guess we have to chalk another one up for the dietitians and nutritionists. But let’s think this through again. The authors observe in the discussion of their results that “breakfast quality was not considered in the analysis and therefore conclusions regarding what aspects of breakfast are correlated with academic performance cannot be drawn.”

Maybe it’s not the food consumed at breakfast but merely taking part in the event itself that is associated with better school performance. Could it be that families who don’t give breakfast a priority also don’t prioritize school work? Maybe teenagers with poor sleep hygiene who are habitually difficult to awaken in the morning don’t have time to eat breakfast. It is likely their sleep deprivation is more of a factor in their school performance than the small nutritional deficit that they have incurred by not eating breakfast. The study that might answer these questions hasn’t been done yet. And maybe it doesn’t need to be done. We don’t need to be asking children what they have for breakfast. But we should be entering into a dialogue that begins with “Why don’t you have breakfast?” The answers may lead into a productive discussion with the family about more important contributors to poor school performance.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

In North America, breakfast is the most personal of all the traditional daily meals and usually the one at which people show the least amount of day-to-day variation.

FluxFactory/E+

For example, since retiring from active practice I eat three scrambled eggs and bowl of fresh fruit every morning (yes, I have my lipid screen done annually and it’s fine). When I was a child there were stretches measuring in years during which I would eat the same cold cereal and drink a glass of orange juice. As an adolescent trying to bulk up for football, there was a breakfast-in-a-glass that I drank along with the cereal every morning. There was the frozen waffle decade.

When I was a busy general pediatrician, the meals were short on preparation and equally short on variety. But I always had something to eat before heading out for the day. That’s what my folks did, and that’s the pattern my wife and I programmed into our children. I think my dietary history is not unique. Most people don’t have time for a complex breakfast, and in many cases, they aren’t feeling terribly adventuresome when it comes to food at 6 or 7 in the morning. Breakfast is more of a habit than an event to satisfy one’s hunger. Several generations ago, breakfast was a big deal. Men (and occasionally women) were headed out for a day of demanding physical labor and stoking the furnace at the beginning of the day made sense. In farm families, breakfast was a major meal after the morning chores were completed. Those Norman Rockwellesque days are behind us, and breakfast has receded into a minor nutritional role.

For many adults, it’s just something to chew on with a cup of a stimulant liquid. In some families, breakfast has disappeared completely. For as long as there have been dietitians and nutritionists, we have been told that breakfast can be the most important meal of the day. And for a child, the failure to eat breakfast could jeopardize his or her ability to perform in school. I guess at face value this dictum makes sense, but I’ve never been terribly impressed with the evidence supporting it. A recent study from England has gotten me thinking about the whole issue of breakfast and school performance again (“associations between habitual school-day breakfast consumption frequency and academic performance in British adolescents.” Front Public Health. 2019 Nov 20. doi. 10.3389/fpubh.2019.00283). A trio of researchers at the Human Appetite Research Unit of the School of Psychology, University of Leeds (England), found that in the study group of nearly 300 adolescents aged 16-18 years, the students who frequently skipped breakfast performed more poorly on a battery of standardized national tests. Well, I guess we have to chalk another one up for the dietitians and nutritionists. But let’s think this through again. The authors observe in the discussion of their results that “breakfast quality was not considered in the analysis and therefore conclusions regarding what aspects of breakfast are correlated with academic performance cannot be drawn.”

Maybe it’s not the food consumed at breakfast but merely taking part in the event itself that is associated with better school performance. Could it be that families who don’t give breakfast a priority also don’t prioritize school work? Maybe teenagers with poor sleep hygiene who are habitually difficult to awaken in the morning don’t have time to eat breakfast. It is likely their sleep deprivation is more of a factor in their school performance than the small nutritional deficit that they have incurred by not eating breakfast. The study that might answer these questions hasn’t been done yet. And maybe it doesn’t need to be done. We don’t need to be asking children what they have for breakfast. But we should be entering into a dialogue that begins with “Why don’t you have breakfast?” The answers may lead into a productive discussion with the family about more important contributors to poor school performance.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

In North America, breakfast is the most personal of all the traditional daily meals and usually the one at which people show the least amount of day-to-day variation.

FluxFactory/E+

For example, since retiring from active practice I eat three scrambled eggs and bowl of fresh fruit every morning (yes, I have my lipid screen done annually and it’s fine). When I was a child there were stretches measuring in years during which I would eat the same cold cereal and drink a glass of orange juice. As an adolescent trying to bulk up for football, there was a breakfast-in-a-glass that I drank along with the cereal every morning. There was the frozen waffle decade.

When I was a busy general pediatrician, the meals were short on preparation and equally short on variety. But I always had something to eat before heading out for the day. That’s what my folks did, and that’s the pattern my wife and I programmed into our children. I think my dietary history is not unique. Most people don’t have time for a complex breakfast, and in many cases, they aren’t feeling terribly adventuresome when it comes to food at 6 or 7 in the morning. Breakfast is more of a habit than an event to satisfy one’s hunger. Several generations ago, breakfast was a big deal. Men (and occasionally women) were headed out for a day of demanding physical labor and stoking the furnace at the beginning of the day made sense. In farm families, breakfast was a major meal after the morning chores were completed. Those Norman Rockwellesque days are behind us, and breakfast has receded into a minor nutritional role.

For many adults, it’s just something to chew on with a cup of a stimulant liquid. In some families, breakfast has disappeared completely. For as long as there have been dietitians and nutritionists, we have been told that breakfast can be the most important meal of the day. And for a child, the failure to eat breakfast could jeopardize his or her ability to perform in school. I guess at face value this dictum makes sense, but I’ve never been terribly impressed with the evidence supporting it. A recent study from England has gotten me thinking about the whole issue of breakfast and school performance again (“associations between habitual school-day breakfast consumption frequency and academic performance in British adolescents.” Front Public Health. 2019 Nov 20. doi. 10.3389/fpubh.2019.00283). A trio of researchers at the Human Appetite Research Unit of the School of Psychology, University of Leeds (England), found that in the study group of nearly 300 adolescents aged 16-18 years, the students who frequently skipped breakfast performed more poorly on a battery of standardized national tests. Well, I guess we have to chalk another one up for the dietitians and nutritionists. But let’s think this through again. The authors observe in the discussion of their results that “breakfast quality was not considered in the analysis and therefore conclusions regarding what aspects of breakfast are correlated with academic performance cannot be drawn.”

Maybe it’s not the food consumed at breakfast but merely taking part in the event itself that is associated with better school performance. Could it be that families who don’t give breakfast a priority also don’t prioritize school work? Maybe teenagers with poor sleep hygiene who are habitually difficult to awaken in the morning don’t have time to eat breakfast. It is likely their sleep deprivation is more of a factor in their school performance than the small nutritional deficit that they have incurred by not eating breakfast. The study that might answer these questions hasn’t been done yet. And maybe it doesn’t need to be done. We don’t need to be asking children what they have for breakfast. But we should be entering into a dialogue that begins with “Why don’t you have breakfast?” The answers may lead into a productive discussion with the family about more important contributors to poor school performance.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

A few weeks ago I was at a Friday-night football game, but not to watch the game. I’ve been there and done that too many times when I used to be the team physician. I was there to listen to my granddaughter drumming in the pep band. And there was a lot of drumming because her high school’s team is having a hot year and outscoring opponents by three and four touchdowns every week.

David Peeters/iStockphoto

At half time, the field was swarmed by 45-50 early grade schoolers looking like bobblehead dolls in their oversize helmets and surprisingly professional-appearing miniature football outfits. Under the lights, on the local college’s turf field, they were in football heaven. The pep band got into it and there was more drumming as the few kids who had a clue what football was about were scampering over and around their teammates and opponents who were roughhousing with each other, rolling around on the turf having a grand time, blissfully unimpressed by such trivial concepts as the line of scrimmage or the difference between blocking and tackling or even offense and defense.

Despite all the alarming articles both lay and professional that you and I see, this was an evening on which no one seemed particularly concerned about sports-related concussions. This is class B football in Maine, not a state well known as an incubator of Division I college football players. While there were a few scrawny kids with some speed, no one in the high school game had enough size or momentum to generate the kinds of collisions one sees with frightening regularity on television.

Watching 4- and 5-year-olds in their football uniforms seemed to me to be a rather harmless exercise and certainly a more positive investment in their time on a Friday night than sitting on the couch with an electronic device clutched in their little hands. A recent report in JAMA Pediatrics suggests that my lack of concern has some validity (“Consensus statement on sports-related concussions in youth sports using a modified delphi approach.” JAMA Pediatr. 2019 Nov 11. doi: 10.1001/jamapediatrics.2019.4006). Eleven experts in sports-related injuries were surveyed with multiple rounds of questionnaires. Their anonymous responses were aggregated and shared with the group after each round until a consensus could be arrived on for each of seven broad questions about sports-related concussions. It is a paper worth reading and like most good literature surveys determined that in many situations more study needs to be done.

Among the many findings that impressed me was the group’s failure to find an “association between repetitive head impact exposure in youth and long-term neurocognitive outcomes.” In addition, “there is little evidence that age at first exposure repetitive head impacts in sports is independently associated with neurodegenerative changes.” The experts also could find “no evidence that growth or development affect the risk of sports-related concussions.”

The problem with youth football is that it is the portal that can lead to college and professional football, in which large bodies are allowed to collide after accelerating at speeds we mortals only can achieve behind the wheel of our motor vehicles. Rules to minimize those collisions do exist, but lax enforcement has failed to prevent their cumulative damage.

Whether the culture of big-time football is going to change to a point at which a conscientious parent could encourage his or her child to play after adolescence remains to be seen. However, the evidence seems to suggest that allowing young children to bang themselves around imitating the big guys seems to be reasonably safe. At least as safe as what kids used to do to each other before we adults invented television and video games.

When my son was 3 or 4 years old, he played on a hockey team he thought was called the Toronto Make-Believes (Maple Leafs). Maybe we should be telling parents it’s safe for their children to play make-believe contact sports. The challenge comes after those kids reach puberty and want to start playing the real thing.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

A few weeks ago I was at a Friday-night football game, but not to watch the game. I’ve been there and done that too many times when I used to be the team physician. I was there to listen to my granddaughter drumming in the pep band. And there was a lot of drumming because her high school’s team is having a hot year and outscoring opponents by three and four touchdowns every week.

David Peeters/iStockphoto

At half time, the field was swarmed by 45-50 early grade schoolers looking like bobblehead dolls in their oversize helmets and surprisingly professional-appearing miniature football outfits. Under the lights, on the local college’s turf field, they were in football heaven. The pep band got into it and there was more drumming as the few kids who had a clue what football was about were scampering over and around their teammates and opponents who were roughhousing with each other, rolling around on the turf having a grand time, blissfully unimpressed by such trivial concepts as the line of scrimmage or the difference between blocking and tackling or even offense and defense.

Despite all the alarming articles both lay and professional that you and I see, this was an evening on which no one seemed particularly concerned about sports-related concussions. This is class B football in Maine, not a state well known as an incubator of Division I college football players. While there were a few scrawny kids with some speed, no one in the high school game had enough size or momentum to generate the kinds of collisions one sees with frightening regularity on television.

Watching 4- and 5-year-olds in their football uniforms seemed to me to be a rather harmless exercise and certainly a more positive investment in their time on a Friday night than sitting on the couch with an electronic device clutched in their little hands. A recent report in JAMA Pediatrics suggests that my lack of concern has some validity (“Consensus statement on sports-related concussions in youth sports using a modified delphi approach.” JAMA Pediatr. 2019 Nov 11. doi: 10.1001/jamapediatrics.2019.4006). Eleven experts in sports-related injuries were surveyed with multiple rounds of questionnaires. Their anonymous responses were aggregated and shared with the group after each round until a consensus could be arrived on for each of seven broad questions about sports-related concussions. It is a paper worth reading and like most good literature surveys determined that in many situations more study needs to be done.

Among the many findings that impressed me was the group’s failure to find an “association between repetitive head impact exposure in youth and long-term neurocognitive outcomes.” In addition, “there is little evidence that age at first exposure repetitive head impacts in sports is independently associated with neurodegenerative changes.” The experts also could find “no evidence that growth or development affect the risk of sports-related concussions.”

The problem with youth football is that it is the portal that can lead to college and professional football, in which large bodies are allowed to collide after accelerating at speeds we mortals only can achieve behind the wheel of our motor vehicles. Rules to minimize those collisions do exist, but lax enforcement has failed to prevent their cumulative damage.

Whether the culture of big-time football is going to change to a point at which a conscientious parent could encourage his or her child to play after adolescence remains to be seen. However, the evidence seems to suggest that allowing young children to bang themselves around imitating the big guys seems to be reasonably safe. At least as safe as what kids used to do to each other before we adults invented television and video games.

When my son was 3 or 4 years old, he played on a hockey team he thought was called the Toronto Make-Believes (Maple Leafs). Maybe we should be telling parents it’s safe for their children to play make-believe contact sports. The challenge comes after those kids reach puberty and want to start playing the real thing.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

A few weeks ago I was at a Friday-night football game, but not to watch the game. I’ve been there and done that too many times when I used to be the team physician. I was there to listen to my granddaughter drumming in the pep band. And there was a lot of drumming because her high school’s team is having a hot year and outscoring opponents by three and four touchdowns every week.

David Peeters/iStockphoto

At half time, the field was swarmed by 45-50 early grade schoolers looking like bobblehead dolls in their oversize helmets and surprisingly professional-appearing miniature football outfits. Under the lights, on the local college’s turf field, they were in football heaven. The pep band got into it and there was more drumming as the few kids who had a clue what football was about were scampering over and around their teammates and opponents who were roughhousing with each other, rolling around on the turf having a grand time, blissfully unimpressed by such trivial concepts as the line of scrimmage or the difference between blocking and tackling or even offense and defense.

Despite all the alarming articles both lay and professional that you and I see, this was an evening on which no one seemed particularly concerned about sports-related concussions. This is class B football in Maine, not a state well known as an incubator of Division I college football players. While there were a few scrawny kids with some speed, no one in the high school game had enough size or momentum to generate the kinds of collisions one sees with frightening regularity on television.

Watching 4- and 5-year-olds in their football uniforms seemed to me to be a rather harmless exercise and certainly a more positive investment in their time on a Friday night than sitting on the couch with an electronic device clutched in their little hands. A recent report in JAMA Pediatrics suggests that my lack of concern has some validity (“Consensus statement on sports-related concussions in youth sports using a modified delphi approach.” JAMA Pediatr. 2019 Nov 11. doi: 10.1001/jamapediatrics.2019.4006). Eleven experts in sports-related injuries were surveyed with multiple rounds of questionnaires. Their anonymous responses were aggregated and shared with the group after each round until a consensus could be arrived on for each of seven broad questions about sports-related concussions. It is a paper worth reading and like most good literature surveys determined that in many situations more study needs to be done.

Among the many findings that impressed me was the group’s failure to find an “association between repetitive head impact exposure in youth and long-term neurocognitive outcomes.” In addition, “there is little evidence that age at first exposure repetitive head impacts in sports is independently associated with neurodegenerative changes.” The experts also could find “no evidence that growth or development affect the risk of sports-related concussions.”

The problem with youth football is that it is the portal that can lead to college and professional football, in which large bodies are allowed to collide after accelerating at speeds we mortals only can achieve behind the wheel of our motor vehicles. Rules to minimize those collisions do exist, but lax enforcement has failed to prevent their cumulative damage.

Whether the culture of big-time football is going to change to a point at which a conscientious parent could encourage his or her child to play after adolescence remains to be seen. However, the evidence seems to suggest that allowing young children to bang themselves around imitating the big guys seems to be reasonably safe. At least as safe as what kids used to do to each other before we adults invented television and video games.

When my son was 3 or 4 years old, he played on a hockey team he thought was called the Toronto Make-Believes (Maple Leafs). Maybe we should be telling parents it’s safe for their children to play make-believe contact sports. The challenge comes after those kids reach puberty and want to start playing the real thing.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

The last time I saw her she was coiled up like a garter snake resting comfortable in the old toiletries travel case that was my “black bag” for more than 40 years. Joining her in peaceful solitude were a couple of ear curettes, an insufflator, and a dead pocket flashlight. The Kermit the Frog sticker on her diaphragm was faded to a barely recognizable blur. The chest piece was frozen in the diaphragm position as it had been for several decades. I never felt comfortable using the bell side.

Hiraman/Getty Images

She was the gift from a drug company back when medical students were more interested in freebies than making a statement about conflicts of interest. I have had to change her tubing several times when cracks at the bifurcation would allow me to hear my own breath sounds better than the patient’s. The ear pieces were the originals that I modified to fit my auditory canals more comfortably.

I suspect that many of you have developed a close relationship with your stethoscope, as I did. We were always close. She was either her coiled up in my pants’ pocket or clasped around my neck where she wore through collars at a costly clip. Her chest piece was kept tucked in my shirt to keep it warm for the patients. I never hung her over my shoulders the way physicians do in publicity photos. I always found that practice pretentious and impractical.

If I decided tomorrow to leave the challenges of retirement behind and reopen my practice would it make any sense to go down to the basement and roust out my old stethoscope from her slumber? There are better ways evaluate hearts and lungs and many of them will fit in my pocket just as well as that old stethoscope. Paul Wallach, MD, an executive associate dean at the Indiana University, Indianapolis, predicts that within a decade hand-held ultrasound devices with become part of a routine part of the physical exam (Lindsey Tanner. “Is the stethoscope dying? High-tech rivals pose a challenge.” Associated Press. 2019 Oct 23). Instruction in the use of these devices has already become part of the curriculum in some medical schools.

There have been several studies demonstrating that chest auscultation is a skill that some of us have lost and many others never successfully mastered. As much as I treasure my old stethoscope, is it time to get rid of those albatrosses hanging around our necks? They do bang against desks with a deafening ring. Cute infants and toddlers yank on them while we are trying to listen to their chests. If there are better ways to auscultate chests that will fit in our pockets shouldn’t we be using them?

Well, there is the cost for one thing. But, inevitably the price will come down and portability will go up. If we allow our stethoscopes to become nothing more than nostalgic museum pieces to sit along with the head mirror, what will replace them as tangible symbols of our identity as physicians? What will photographers drape over our shoulders? With very few of us in office practice wearing white coats or scrub suits, we run the risk of losing our identity.

Sadly, I fear we will have to accept the disappearance of the stethoscope as a natural consequence of the technological march. But, it also is an unfortunate reflection of the fact that the art of doing a physical exam is fading. With auscultation and palpation disappearing from our diagnostic tool kit we must be careful to preserve and improve the one skill that is indispensable to the practice of medicine.

And, that is listening to what the patient has to tell us.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

The last time I saw her she was coiled up like a garter snake resting comfortable in the old toiletries travel case that was my “black bag” for more than 40 years. Joining her in peaceful solitude were a couple of ear curettes, an insufflator, and a dead pocket flashlight. The Kermit the Frog sticker on her diaphragm was faded to a barely recognizable blur. The chest piece was frozen in the diaphragm position as it had been for several decades. I never felt comfortable using the bell side.

Hiraman/Getty Images

She was the gift from a drug company back when medical students were more interested in freebies than making a statement about conflicts of interest. I have had to change her tubing several times when cracks at the bifurcation would allow me to hear my own breath sounds better than the patient’s. The ear pieces were the originals that I modified to fit my auditory canals more comfortably.

I suspect that many of you have developed a close relationship with your stethoscope, as I did. We were always close. She was either her coiled up in my pants’ pocket or clasped around my neck where she wore through collars at a costly clip. Her chest piece was kept tucked in my shirt to keep it warm for the patients. I never hung her over my shoulders the way physicians do in publicity photos. I always found that practice pretentious and impractical.

If I decided tomorrow to leave the challenges of retirement behind and reopen my practice would it make any sense to go down to the basement and roust out my old stethoscope from her slumber? There are better ways evaluate hearts and lungs and many of them will fit in my pocket just as well as that old stethoscope. Paul Wallach, MD, an executive associate dean at the Indiana University, Indianapolis, predicts that within a decade hand-held ultrasound devices with become part of a routine part of the physical exam (Lindsey Tanner. “Is the stethoscope dying? High-tech rivals pose a challenge.” Associated Press. 2019 Oct 23). Instruction in the use of these devices has already become part of the curriculum in some medical schools.

There have been several studies demonstrating that chest auscultation is a skill that some of us have lost and many others never successfully mastered. As much as I treasure my old stethoscope, is it time to get rid of those albatrosses hanging around our necks? They do bang against desks with a deafening ring. Cute infants and toddlers yank on them while we are trying to listen to their chests. If there are better ways to auscultate chests that will fit in our pockets shouldn’t we be using them?

Well, there is the cost for one thing. But, inevitably the price will come down and portability will go up. If we allow our stethoscopes to become nothing more than nostalgic museum pieces to sit along with the head mirror, what will replace them as tangible symbols of our identity as physicians? What will photographers drape over our shoulders? With very few of us in office practice wearing white coats or scrub suits, we run the risk of losing our identity.

Sadly, I fear we will have to accept the disappearance of the stethoscope as a natural consequence of the technological march. But, it also is an unfortunate reflection of the fact that the art of doing a physical exam is fading. With auscultation and palpation disappearing from our diagnostic tool kit we must be careful to preserve and improve the one skill that is indispensable to the practice of medicine.

And, that is listening to what the patient has to tell us.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

The last time I saw her she was coiled up like a garter snake resting comfortable in the old toiletries travel case that was my “black bag” for more than 40 years. Joining her in peaceful solitude were a couple of ear curettes, an insufflator, and a dead pocket flashlight. The Kermit the Frog sticker on her diaphragm was faded to a barely recognizable blur. The chest piece was frozen in the diaphragm position as it had been for several decades. I never felt comfortable using the bell side.

Hiraman/Getty Images

She was the gift from a drug company back when medical students were more interested in freebies than making a statement about conflicts of interest. I have had to change her tubing several times when cracks at the bifurcation would allow me to hear my own breath sounds better than the patient’s. The ear pieces were the originals that I modified to fit my auditory canals more comfortably.

I suspect that many of you have developed a close relationship with your stethoscope, as I did. We were always close. She was either her coiled up in my pants’ pocket or clasped around my neck where she wore through collars at a costly clip. Her chest piece was kept tucked in my shirt to keep it warm for the patients. I never hung her over my shoulders the way physicians do in publicity photos. I always found that practice pretentious and impractical.

If I decided tomorrow to leave the challenges of retirement behind and reopen my practice would it make any sense to go down to the basement and roust out my old stethoscope from her slumber? There are better ways evaluate hearts and lungs and many of them will fit in my pocket just as well as that old stethoscope. Paul Wallach, MD, an executive associate dean at the Indiana University, Indianapolis, predicts that within a decade hand-held ultrasound devices with become part of a routine part of the physical exam (Lindsey Tanner. “Is the stethoscope dying? High-tech rivals pose a challenge.” Associated Press. 2019 Oct 23). Instruction in the use of these devices has already become part of the curriculum in some medical schools.

There have been several studies demonstrating that chest auscultation is a skill that some of us have lost and many others never successfully mastered. As much as I treasure my old stethoscope, is it time to get rid of those albatrosses hanging around our necks? They do bang against desks with a deafening ring. Cute infants and toddlers yank on them while we are trying to listen to their chests. If there are better ways to auscultate chests that will fit in our pockets shouldn’t we be using them?

Well, there is the cost for one thing. But, inevitably the price will come down and portability will go up. If we allow our stethoscopes to become nothing more than nostalgic museum pieces to sit along with the head mirror, what will replace them as tangible symbols of our identity as physicians? What will photographers drape over our shoulders? With very few of us in office practice wearing white coats or scrub suits, we run the risk of losing our identity.

Sadly, I fear we will have to accept the disappearance of the stethoscope as a natural consequence of the technological march. But, it also is an unfortunate reflection of the fact that the art of doing a physical exam is fading. With auscultation and palpation disappearing from our diagnostic tool kit we must be careful to preserve and improve the one skill that is indispensable to the practice of medicine.

And, that is listening to what the patient has to tell us.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

A study of more than 5 million Kaiser Permanente/Northern California patients suggests that the prevalence of adults diagnosed with ADHD has dramatically increased over the last 10 years (JAMA Netw Open. 2019 Nov 1. doi: 10.1001/jamanetworkopen.2019.14344).

SIphotography/Getty Images

Over the interval between 2007 and 2016, the prevalence of ADHD went from 0.43% to 0.96%, an increase of more than 120%. For adults, being white, male, younger, employed, and better educated increased one’s chances of receiving an ADHD diagnosis. Having a comorbid mental health diagnosis such as an eating disorder, anxiety, depression, or being labeled as bipolar also increased the odds of acquiring the ADHD label.

Should this observed increase in adults with ADHD be a warning to pediatricians that we have been underdiagnosing the condition in our patients? Are our screening tools too coarse, allowing a significant number of children to slip through the cracks only to land in the laps of our colleagues in internal medicine and family practice? If this were the case, does this mean that adult and youth ADHD are basically the same condition, but in some individuals the signs and symptoms become more obvious with aging? Does it also suggest that there is a genetic basis to ADHD with variable expression? Could it be that individuals with adult ADHD exhibited a few of the hallmarks of the diagnosis when they were young, but aggravating factors in the environment such as job stress or marital discord unmasked the signs and symptoms that had been percolating just under our radar for decades?

As usual, there is no simple answer that explains the findings unearthed by these researchers. One gets a sense from reading their paper that the authors feel that ADHD is being diagnosed more often as more individuals have access to physicians and other professionals who are attuned to the diagnosis. The fact that white, better-educated, and employed men are more likely to acquire the diagnosis might support the argument that as segments of the population who have been underserved by the health care system come on board we will continue to see a rise in the number of adults with the diagnosis. The more patients who see health care providers who are primed to make the diagnosis, the more often the diagnosis will be made.

I am sure there is a segment of the population who enter the world with some genetically mediated chemical or structural vulnerability that results in the signs and symptoms of ADHD. Most, but not all, of these individuals have symptoms that are so obvious that they present in childhood. However, a larger number of children and most adults who are labeled with ADHD are exhibiting the symptoms of inattention, distractibility, and impulsiveness as the result of environmental factors such as sleep deprivation, family or job stress, and other comorbid mental health conditions, or simply because they were young for their school cohort.

Pediatricians need not feel that we have missed another opportunity for prevention because the prevalence of the diagnosis of adult ADHD is increasing dramatically. However, that increase should serve as another reminder to us that there can be multiple factors that can result in signs and symptoms that attract the label of ADHD. We must be careful and look long and hard before we diagnose and reach for our prescription pad.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

A study of more than 5 million Kaiser Permanente/Northern California patients suggests that the prevalence of adults diagnosed with ADHD has dramatically increased over the last 10 years (JAMA Netw Open. 2019 Nov 1. doi: 10.1001/jamanetworkopen.2019.14344).

SIphotography/Getty Images

Over the interval between 2007 and 2016, the prevalence of ADHD went from 0.43% to 0.96%, an increase of more than 120%. For adults, being white, male, younger, employed, and better educated increased one’s chances of receiving an ADHD diagnosis. Having a comorbid mental health diagnosis such as an eating disorder, anxiety, depression, or being labeled as bipolar also increased the odds of acquiring the ADHD label.

Should this observed increase in adults with ADHD be a warning to pediatricians that we have been underdiagnosing the condition in our patients? Are our screening tools too coarse, allowing a significant number of children to slip through the cracks only to land in the laps of our colleagues in internal medicine and family practice? If this were the case, does this mean that adult and youth ADHD are basically the same condition, but in some individuals the signs and symptoms become more obvious with aging? Does it also suggest that there is a genetic basis to ADHD with variable expression? Could it be that individuals with adult ADHD exhibited a few of the hallmarks of the diagnosis when they were young, but aggravating factors in the environment such as job stress or marital discord unmasked the signs and symptoms that had been percolating just under our radar for decades?

As usual, there is no simple answer that explains the findings unearthed by these researchers. One gets a sense from reading their paper that the authors feel that ADHD is being diagnosed more often as more individuals have access to physicians and other professionals who are attuned to the diagnosis. The fact that white, better-educated, and employed men are more likely to acquire the diagnosis might support the argument that as segments of the population who have been underserved by the health care system come on board we will continue to see a rise in the number of adults with the diagnosis. The more patients who see health care providers who are primed to make the diagnosis, the more often the diagnosis will be made.

I am sure there is a segment of the population who enter the world with some genetically mediated chemical or structural vulnerability that results in the signs and symptoms of ADHD. Most, but not all, of these individuals have symptoms that are so obvious that they present in childhood. However, a larger number of children and most adults who are labeled with ADHD are exhibiting the symptoms of inattention, distractibility, and impulsiveness as the result of environmental factors such as sleep deprivation, family or job stress, and other comorbid mental health conditions, or simply because they were young for their school cohort.

Pediatricians need not feel that we have missed another opportunity for prevention because the prevalence of the diagnosis of adult ADHD is increasing dramatically. However, that increase should serve as another reminder to us that there can be multiple factors that can result in signs and symptoms that attract the label of ADHD. We must be careful and look long and hard before we diagnose and reach for our prescription pad.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

A study of more than 5 million Kaiser Permanente/Northern California patients suggests that the prevalence of adults diagnosed with ADHD has dramatically increased over the last 10 years (JAMA Netw Open. 2019 Nov 1. doi: 10.1001/jamanetworkopen.2019.14344).

SIphotography/Getty Images

Over the interval between 2007 and 2016, the prevalence of ADHD went from 0.43% to 0.96%, an increase of more than 120%. For adults, being white, male, younger, employed, and better educated increased one’s chances of receiving an ADHD diagnosis. Having a comorbid mental health diagnosis such as an eating disorder, anxiety, depression, or being labeled as bipolar also increased the odds of acquiring the ADHD label.

Should this observed increase in adults with ADHD be a warning to pediatricians that we have been underdiagnosing the condition in our patients? Are our screening tools too coarse, allowing a significant number of children to slip through the cracks only to land in the laps of our colleagues in internal medicine and family practice? If this were the case, does this mean that adult and youth ADHD are basically the same condition, but in some individuals the signs and symptoms become more obvious with aging? Does it also suggest that there is a genetic basis to ADHD with variable expression? Could it be that individuals with adult ADHD exhibited a few of the hallmarks of the diagnosis when they were young, but aggravating factors in the environment such as job stress or marital discord unmasked the signs and symptoms that had been percolating just under our radar for decades?

As usual, there is no simple answer that explains the findings unearthed by these researchers. One gets a sense from reading their paper that the authors feel that ADHD is being diagnosed more often as more individuals have access to physicians and other professionals who are attuned to the diagnosis. The fact that white, better-educated, and employed men are more likely to acquire the diagnosis might support the argument that as segments of the population who have been underserved by the health care system come on board we will continue to see a rise in the number of adults with the diagnosis. The more patients who see health care providers who are primed to make the diagnosis, the more often the diagnosis will be made.

I am sure there is a segment of the population who enter the world with some genetically mediated chemical or structural vulnerability that results in the signs and symptoms of ADHD. Most, but not all, of these individuals have symptoms that are so obvious that they present in childhood. However, a larger number of children and most adults who are labeled with ADHD are exhibiting the symptoms of inattention, distractibility, and impulsiveness as the result of environmental factors such as sleep deprivation, family or job stress, and other comorbid mental health conditions, or simply because they were young for their school cohort.

Pediatricians need not feel that we have missed another opportunity for prevention because the prevalence of the diagnosis of adult ADHD is increasing dramatically. However, that increase should serve as another reminder to us that there can be multiple factors that can result in signs and symptoms that attract the label of ADHD. We must be careful and look long and hard before we diagnose and reach for our prescription pad.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Let’s suppose your first patient of the morning is a 2-month-old you have never seen before. The family arrives 10 minutes late because they are still getting the dressing-undressing-diaper change-car seat–adjusting thing worked out. Father is a computer programmer. Mother lists her occupation as nutrition counselor. The child is gaining. Breastfeeding seems to come naturally to the dyad.

KatarzynaBialasiewicz/Thinkstock

As the visit draws to a close, you take the matter-of-fact approach and say, “The nurse will be in shortly with the vaccines do you have any questions.” Well ... it turns out the parents don’t feel comfortable with vaccines. They claim to understand the science and feel that vaccines make sense for some families. But they feel that for themselves, with a healthy lifestyle and God’s benevolence their son will be protected without having to introduce a host of foreign substances into his body.

What word best describes your reaction? Anger? Frustration? Disappointment (in our education system)? Maybe you’re angry at yourself for failing to make it clear in your office pamphlet and social media feeds that to protect your other patients, you no longer accept families who refuse immunizations for the common childhood diseases.

The American Academy of Pediatrics says it feels your pain, and its Annual Leadership Forum made eliminating nonmedical vaccine exemption laws its top priority in 2019. As part of its effort to help, the AAP Board of Directors was asked to advocate for the creation of a toolkit of strategies for Academy chapters facing the challenge of nonmedical exemptions. As an initial step to this process, three physicians in the department of pediatrics at the Denver Health Medical Center have begun interviewing religious leaders in hopes of developing “clergy-specific vaccine educational materials and deriv[ing] best practices for engaging them as vaccination advocates.” The investigators describe their plan and initial findings in Pediatrics (2019 Oct. doi: 10.1542/peds.2019-0933). Although they acknowledged that their efforts may not provide a quick solution to the nonmedical exemption problem, they hope that including more stakeholders and engendering trust will help future discussions.

Fourteen pages deeper into that issue of Pediatrics is the runner-up submission of this year’s Section on Pediatric Trainees essay competition titled “What I Learned From the Antivaccine Movement” (2019 Oct. doi: 10.1542/peds.2019-2384). Alana C. Ju, MD, describes the 2-hour ordeal she endured to testify at the California State Capitol in support of a state Senate bill aimed at tightening the regulations for vaccine medical exemptions. Totally unprepared for the “level of vitriol” aimed at her and other supporters of the bill, she was “accused of violating her duty as” a pediatrician because she was failing to protect children. The supporters were called “greedy, ignorant, and negligent.”

To her credit, Dr. Ju was able to step back from this assault and began looking at the faces of her accusers and learned that, “they too, felt strongly about children’s health.” She realized that “focusing on perceived ignorance is counterproductive.” She now hopes that by focusing on the shared goal of what is best for children, “we can all be better advocates.”

Both of these articles have a warm sort of kumbaya feel about them. It never is a bad idea to learn more about those with whom we disagree. But before huddling up too close to the campfire, we must realize that there is good evidence that sharing the scientific data with vaccine-hesitant parents doesn’t convert them into vaccine acceptors. In fact, it may strengthen their resolve to resist (Nyhan et al. “Effective Messages in Vaccine Promotion: A Randomized Trial,” Pediatrics. 2014 Apr;133[4] e835-42).

We are unlikely to convert many anti-vaxxers by sitting down together. Our target audience needs to be legislators and the majority of people who do vaccinate their children. These are the voters who will support legislation to eliminate nonmedical vaccine exemptions. To characterize anti-vaxxers as despicable ignorants is untrue and serves no purpose. We all do care about the health of children. However, the evidence is clear that nonmedical exemptions are threatening the population at large and need to be curtailed.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

*This article has been updated 1/22/2020.

Let’s suppose your first patient of the morning is a 2-month-old you have never seen before. The family arrives 10 minutes late because they are still getting the dressing-undressing-diaper change-car seat–adjusting thing worked out. Father is a computer programmer. Mother lists her occupation as nutrition counselor. The child is gaining. Breastfeeding seems to come naturally to the dyad.

KatarzynaBialasiewicz/Thinkstock

As the visit draws to a close, you take the matter-of-fact approach and say, “The nurse will be in shortly with the vaccines do you have any questions.” Well ... it turns out the parents don’t feel comfortable with vaccines. They claim to understand the science and feel that vaccines make sense for some families. But they feel that for themselves, with a healthy lifestyle and God’s benevolence their son will be protected without having to introduce a host of foreign substances into his body.

What word best describes your reaction? Anger? Frustration? Disappointment (in our education system)? Maybe you’re angry at yourself for failing to make it clear in your office pamphlet and social media feeds that to protect your other patients, you no longer accept families who refuse immunizations for the common childhood diseases.

The American Academy of Pediatrics says it feels your pain, and its Annual Leadership Forum made eliminating nonmedical vaccine exemption laws its top priority in 2019. As part of its effort to help, the AAP Board of Directors was asked to advocate for the creation of a toolkit of strategies for Academy chapters facing the challenge of nonmedical exemptions. As an initial step to this process, three physicians in the department of pediatrics at the Denver Health Medical Center have begun interviewing religious leaders in hopes of developing “clergy-specific vaccine educational materials and deriv[ing] best practices for engaging them as vaccination advocates.” The investigators describe their plan and initial findings in Pediatrics (2019 Oct. doi: 10.1542/peds.2019-0933). Although they acknowledged that their efforts may not provide a quick solution to the nonmedical exemption problem, they hope that including more stakeholders and engendering trust will help future discussions.

Fourteen pages deeper into that issue of Pediatrics is the runner-up submission of this year’s Section on Pediatric Trainees essay competition titled “What I Learned From the Antivaccine Movement” (2019 Oct. doi: 10.1542/peds.2019-2384). Alana C. Ju, MD, describes the 2-hour ordeal she endured to testify at the California State Capitol in support of a state Senate bill aimed at tightening the regulations for vaccine medical exemptions. Totally unprepared for the “level of vitriol” aimed at her and other supporters of the bill, she was “accused of violating her duty as” a pediatrician because she was failing to protect children. The supporters were called “greedy, ignorant, and negligent.”

To her credit, Dr. Ju was able to step back from this assault and began looking at the faces of her accusers and learned that, “they too, felt strongly about children’s health.” She realized that “focusing on perceived ignorance is counterproductive.” She now hopes that by focusing on the shared goal of what is best for children, “we can all be better advocates.”

Both of these articles have a warm sort of kumbaya feel about them. It never is a bad idea to learn more about those with whom we disagree. But before huddling up too close to the campfire, we must realize that there is good evidence that sharing the scientific data with vaccine-hesitant parents doesn’t convert them into vaccine acceptors. In fact, it may strengthen their resolve to resist (Nyhan et al. “Effective Messages in Vaccine Promotion: A Randomized Trial,” Pediatrics. 2014 Apr;133[4] e835-42).

We are unlikely to convert many anti-vaxxers by sitting down together. Our target audience needs to be legislators and the majority of people who do vaccinate their children. These are the voters who will support legislation to eliminate nonmedical vaccine exemptions. To characterize anti-vaxxers as despicable ignorants is untrue and serves no purpose. We all do care about the health of children. However, the evidence is clear that nonmedical exemptions are threatening the population at large and need to be curtailed.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

*This article has been updated 1/22/2020.

Let’s suppose your first patient of the morning is a 2-month-old you have never seen before. The family arrives 10 minutes late because they are still getting the dressing-undressing-diaper change-car seat–adjusting thing worked out. Father is a computer programmer. Mother lists her occupation as nutrition counselor. The child is gaining. Breastfeeding seems to come naturally to the dyad.

KatarzynaBialasiewicz/Thinkstock

As the visit draws to a close, you take the matter-of-fact approach and say, “The nurse will be in shortly with the vaccines do you have any questions.” Well ... it turns out the parents don’t feel comfortable with vaccines. They claim to understand the science and feel that vaccines make sense for some families. But they feel that for themselves, with a healthy lifestyle and God’s benevolence their son will be protected without having to introduce a host of foreign substances into his body.

What word best describes your reaction? Anger? Frustration? Disappointment (in our education system)? Maybe you’re angry at yourself for failing to make it clear in your office pamphlet and social media feeds that to protect your other patients, you no longer accept families who refuse immunizations for the common childhood diseases.

The American Academy of Pediatrics says it feels your pain, and its Annual Leadership Forum made eliminating nonmedical vaccine exemption laws its top priority in 2019. As part of its effort to help, the AAP Board of Directors was asked to advocate for the creation of a toolkit of strategies for Academy chapters facing the challenge of nonmedical exemptions. As an initial step to this process, three physicians in the department of pediatrics at the Denver Health Medical Center have begun interviewing religious leaders in hopes of developing “clergy-specific vaccine educational materials and deriv[ing] best practices for engaging them as vaccination advocates.” The investigators describe their plan and initial findings in Pediatrics (2019 Oct. doi: 10.1542/peds.2019-0933). Although they acknowledged that their efforts may not provide a quick solution to the nonmedical exemption problem, they hope that including more stakeholders and engendering trust will help future discussions.

Fourteen pages deeper into that issue of Pediatrics is the runner-up submission of this year’s Section on Pediatric Trainees essay competition titled “What I Learned From the Antivaccine Movement” (2019 Oct. doi: 10.1542/peds.2019-2384). Alana C. Ju, MD, describes the 2-hour ordeal she endured to testify at the California State Capitol in support of a state Senate bill aimed at tightening the regulations for vaccine medical exemptions. Totally unprepared for the “level of vitriol” aimed at her and other supporters of the bill, she was “accused of violating her duty as” a pediatrician because she was failing to protect children. The supporters were called “greedy, ignorant, and negligent.”

To her credit, Dr. Ju was able to step back from this assault and began looking at the faces of her accusers and learned that, “they too, felt strongly about children’s health.” She realized that “focusing on perceived ignorance is counterproductive.” She now hopes that by focusing on the shared goal of what is best for children, “we can all be better advocates.”

Both of these articles have a warm sort of kumbaya feel about them. It never is a bad idea to learn more about those with whom we disagree. But before huddling up too close to the campfire, we must realize that there is good evidence that sharing the scientific data with vaccine-hesitant parents doesn’t convert them into vaccine acceptors. In fact, it may strengthen their resolve to resist (Nyhan et al. “Effective Messages in Vaccine Promotion: A Randomized Trial,” Pediatrics. 2014 Apr;133[4] e835-42).

We are unlikely to convert many anti-vaxxers by sitting down together. Our target audience needs to be legislators and the majority of people who do vaccinate their children. These are the voters who will support legislation to eliminate nonmedical vaccine exemptions. To characterize anti-vaxxers as despicable ignorants is untrue and serves no purpose. We all do care about the health of children. However, the evidence is clear that nonmedical exemptions are threatening the population at large and need to be curtailed.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

*This article has been updated 1/22/2020.

In a Pediatrics article, Hsuan-hsiu Annie Chen, MD, offers a very personal and candid narrative of her struggle with depression during medical school and residency (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-1210). Dr. Chen knows from personal experience that she was not alone in her cohort as she faced the challenges of sleep deprivation and emotional trauma that continue to be a part of a physician’s education and training. In her discussion of how future medical trainees might be spared some of the long hours she endured, Dr. Chen suggests that this country consider expanding its physician workforce by “increasing the number of medical schools and recruiting foreign medical graduates” as some European countries have done. Dr. Chen now works in the pediatric residency office at Children’s Hospital, Los Angeles.

Cameravit/iStock/Getty Images

Ironically, or maybe it was intentionally, the editors of Pediatrics chose to open the same issue in which Dr. Chen’s personal story appears with a Pediatrics Perspective commentary that looks into the murky waters of physician workforce research (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-0469). Gary L. Freed, MD, MPH, at the Child Health Evaluation and Research Center at the University of Michigan, Ann Arbor, claims that, in general, the data currently being generated by workforce research must be interpreted with caution because many of the studies are flawed by one or more biases.

You may have survived the gauntlet of medical school and residency relatively unscathed. But does your current work environment bring back memories of how stressed you felt on the worst days during your training? Is part of the problem that your clinic is seeing too many patients with too few physicians? Do your colleagues share your opinion? Is the administration actively recruiting more physicians, but failing to find interested and qualified doctors? Is this a strictly local phenomenon limited to your community, or is it a regional shortage? Do you think your situation reflects a national trend that deserves attention?

Like Dr. Chen, do you think that more medical schools and active recruitment of foreign medical students would allow you to work less hours? Obviously, even if you were a teenager when you entered your residency, opening more medical schools is not going to allow you to shorten your workday. But are more medical schools the best solution for this country’s overworked physicians even in the long term? Dr. Freed’s observations should make you hesitant to even venture a guess.

You, I, and Dr. Chen only can report on how we perceive our own work environment. Your local physician shortage may be in part because the school system in your community has a poor reputation and young physicians don’t want to move there. It may be that the hospital that owns your practice is struggling and can’t afford to offer a competitive salary. Producing more physicians may not be the answer to the physician shortage in communities like yours, even in the long run.

This is a very large country with relatively porous boundaries between the states for physicians. Physician supply and demand seldom dictates where physicians choose to practice. In fact, a medically needy community is probably the least likely place a physician just finishing her training will choose to settle.

Although adding another physician to your practice may decrease your workload, can your personal finances handle the hit that might occur as you see less patients? Particularly, if the new hire turns out to be a rock star who siphons off more of your patients than you anticipated. On the other hand, there is always the chance that, despite careful vetting, your group hires a lemon who ends up creating more trouble than he is worth.

As Dr. Freed suggests, trying to determine just how many and what kind of physicians we need is complicated. It may be just a roll of the dice at best.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

In a Pediatrics article, Hsuan-hsiu Annie Chen, MD, offers a very personal and candid narrative of her struggle with depression during medical school and residency (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-1210). Dr. Chen knows from personal experience that she was not alone in her cohort as she faced the challenges of sleep deprivation and emotional trauma that continue to be a part of a physician’s education and training. In her discussion of how future medical trainees might be spared some of the long hours she endured, Dr. Chen suggests that this country consider expanding its physician workforce by “increasing the number of medical schools and recruiting foreign medical graduates” as some European countries have done. Dr. Chen now works in the pediatric residency office at Children’s Hospital, Los Angeles.

Cameravit/iStock/Getty Images

Ironically, or maybe it was intentionally, the editors of Pediatrics chose to open the same issue in which Dr. Chen’s personal story appears with a Pediatrics Perspective commentary that looks into the murky waters of physician workforce research (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-0469). Gary L. Freed, MD, MPH, at the Child Health Evaluation and Research Center at the University of Michigan, Ann Arbor, claims that, in general, the data currently being generated by workforce research must be interpreted with caution because many of the studies are flawed by one or more biases.

You may have survived the gauntlet of medical school and residency relatively unscathed. But does your current work environment bring back memories of how stressed you felt on the worst days during your training? Is part of the problem that your clinic is seeing too many patients with too few physicians? Do your colleagues share your opinion? Is the administration actively recruiting more physicians, but failing to find interested and qualified doctors? Is this a strictly local phenomenon limited to your community, or is it a regional shortage? Do you think your situation reflects a national trend that deserves attention?

Like Dr. Chen, do you think that more medical schools and active recruitment of foreign medical students would allow you to work less hours? Obviously, even if you were a teenager when you entered your residency, opening more medical schools is not going to allow you to shorten your workday. But are more medical schools the best solution for this country’s overworked physicians even in the long term? Dr. Freed’s observations should make you hesitant to even venture a guess.

You, I, and Dr. Chen only can report on how we perceive our own work environment. Your local physician shortage may be in part because the school system in your community has a poor reputation and young physicians don’t want to move there. It may be that the hospital that owns your practice is struggling and can’t afford to offer a competitive salary. Producing more physicians may not be the answer to the physician shortage in communities like yours, even in the long run.

This is a very large country with relatively porous boundaries between the states for physicians. Physician supply and demand seldom dictates where physicians choose to practice. In fact, a medically needy community is probably the least likely place a physician just finishing her training will choose to settle.

Although adding another physician to your practice may decrease your workload, can your personal finances handle the hit that might occur as you see less patients? Particularly, if the new hire turns out to be a rock star who siphons off more of your patients than you anticipated. On the other hand, there is always the chance that, despite careful vetting, your group hires a lemon who ends up creating more trouble than he is worth.

As Dr. Freed suggests, trying to determine just how many and what kind of physicians we need is complicated. It may be just a roll of the dice at best.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

In a Pediatrics article, Hsuan-hsiu Annie Chen, MD, offers a very personal and candid narrative of her struggle with depression during medical school and residency (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-1210). Dr. Chen knows from personal experience that she was not alone in her cohort as she faced the challenges of sleep deprivation and emotional trauma that continue to be a part of a physician’s education and training. In her discussion of how future medical trainees might be spared some of the long hours she endured, Dr. Chen suggests that this country consider expanding its physician workforce by “increasing the number of medical schools and recruiting foreign medical graduates” as some European countries have done. Dr. Chen now works in the pediatric residency office at Children’s Hospital, Los Angeles.

Cameravit/iStock/Getty Images

Ironically, or maybe it was intentionally, the editors of Pediatrics chose to open the same issue in which Dr. Chen’s personal story appears with a Pediatrics Perspective commentary that looks into the murky waters of physician workforce research (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-0469). Gary L. Freed, MD, MPH, at the Child Health Evaluation and Research Center at the University of Michigan, Ann Arbor, claims that, in general, the data currently being generated by workforce research must be interpreted with caution because many of the studies are flawed by one or more biases.

You may have survived the gauntlet of medical school and residency relatively unscathed. But does your current work environment bring back memories of how stressed you felt on the worst days during your training? Is part of the problem that your clinic is seeing too many patients with too few physicians? Do your colleagues share your opinion? Is the administration actively recruiting more physicians, but failing to find interested and qualified doctors? Is this a strictly local phenomenon limited to your community, or is it a regional shortage? Do you think your situation reflects a national trend that deserves attention?

Like Dr. Chen, do you think that more medical schools and active recruitment of foreign medical students would allow you to work less hours? Obviously, even if you were a teenager when you entered your residency, opening more medical schools is not going to allow you to shorten your workday. But are more medical schools the best solution for this country’s overworked physicians even in the long term? Dr. Freed’s observations should make you hesitant to even venture a guess.

You, I, and Dr. Chen only can report on how we perceive our own work environment. Your local physician shortage may be in part because the school system in your community has a poor reputation and young physicians don’t want to move there. It may be that the hospital that owns your practice is struggling and can’t afford to offer a competitive salary. Producing more physicians may not be the answer to the physician shortage in communities like yours, even in the long run.

This is a very large country with relatively porous boundaries between the states for physicians. Physician supply and demand seldom dictates where physicians choose to practice. In fact, a medically needy community is probably the least likely place a physician just finishing her training will choose to settle.

Although adding another physician to your practice may decrease your workload, can your personal finances handle the hit that might occur as you see less patients? Particularly, if the new hire turns out to be a rock star who siphons off more of your patients than you anticipated. On the other hand, there is always the chance that, despite careful vetting, your group hires a lemon who ends up creating more trouble than he is worth.

As Dr. Freed suggests, trying to determine just how many and what kind of physicians we need is complicated. It may be just a roll of the dice at best.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

I recently encountered an article aimed at parents who were struggling with what to do about their child’s persistent attachment to his pacifier (“How to Ditch the Pacifier,” by Anna Nowogrodski, New York Times, 2019 Sept. 16). For the most part, the author presented a sampling of sound advice from pediatricians and other health experts.

Travis Manley/Thinkstock

Most children will abandon their pacifiers at a time that is consistent with their developmental stage. Pacifiers seldom do any permanent damage, although they aren’t terribly appealing to look at when hanging out of a toddling toddler’s mouth. Parents were urged to be patient and consistent and were told that allowing the gooey thing to self-destruct often works, as does accelerating the process with a razor blade. Enlisting the aid of the Pacifier Fairy was suggested, but I’m not so sure that would work terribly well.

As I finished perusing the article, I couldn’t help think of how this vexing issue of pacifier removal can be avoided if parents follow a simple rule when they first introduced a pacifier to their child. If experienced parents think back to when they first resorted to using the pacifier, it wasn’t because the plastic and rubber gadget was a family heirloom that had been passed down from generation to generation like an engraved silver spoon. It wasn’t because the dentist told them that children who use pacifiers are less likely to need braces on their teeth. Nor was it a rumor filtered down from speech therapists that pacifiers improve articulation.

Parents reach for a pacifier in hopes that it will help their child will fall asleep. I think most parents of older children agree that at the beginning the pacifier was first and foremost a sleep aid. But here is where the critical oversight occurs: If you give your children pacifiers when you want them to go to sleep, why not simply add the stipulation of where you would like them to go to sleep as well?

Most parents prefer that their children sleep in their own space. We can argue of whether that should be in a side sleeper or their own crib, but most parents don’t want their 3-year-olds sleeping in their bed. Nor do they want their children sleeping on the couch in the living room with them while they watch a movie at 10:30 at night. And as pediatricians, we prefer that children not sleep with their necks flexed in a car seat or baby rocker, particularly if they’re a preemie.

So why not adopt the simple family rule that the child can use a pacifier whenever it seems needed, but only in bed? Augmenting the primary association between sleep and the pacifier by adding a place has several important advantages. It gives parents more control of where their children will sleep or, more importantly, where they won’t be sleeping. It helps transitions to nonhome sleeping places like day care and long trips to grandma’s house go more smoothly.

Even more importantly, the crib/pacifier association helps parents who have had trouble reading their children’s cues. If they want a pacifier, it means they are tired and want to go to where the pacifier lives: bed

Finally, maintaining the link between sleeping and the pacifier promotes a more natural weaning process than going cold turkey or hiring the Pacifier Fairy. As naps disappear, the pacifier gradually become a less obvious accessory in the child’s life. However, it may linger in the background as a reminder of when the child needs some restorative sleep.

Of course, helping parents to think clearly enough to create and enforce a simple rule long enough to forge a healthy association when they are sleep deprived themselves is just another one of those challenges we must accept as concerned primary care pediatricians.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Is My Child Overtired? The Sleep Solution for Raising Happier, Healthier Children.” Email him at [email protected].

I recently encountered an article aimed at parents who were struggling with what to do about their child’s persistent attachment to his pacifier (“How to Ditch the Pacifier,” by Anna Nowogrodski, New York Times, 2019 Sept. 16). For the most part, the author presented a sampling of sound advice from pediatricians and other health experts.

Travis Manley/Thinkstock

Most children will abandon their pacifiers at a time that is consistent with their developmental stage. Pacifiers seldom do any permanent damage, although they aren’t terribly appealing to look at when hanging out of a toddling toddler’s mouth. Parents were urged to be patient and consistent and were told that allowing the gooey thing to self-destruct often works, as does accelerating the process with a razor blade. Enlisting the aid of the Pacifier Fairy was suggested, but I’m not so sure that would work terribly well.

As I finished perusing the article, I couldn’t help think of how this vexing issue of pacifier removal can be avoided if parents follow a simple rule when they first introduced a pacifier to their child. If experienced parents think back to when they first resorted to using the pacifier, it wasn’t because the plastic and rubber gadget was a family heirloom that had been passed down from generation to generation like an engraved silver spoon. It wasn’t because the dentist told them that children who use pacifiers are less likely to need braces on their teeth. Nor was it a rumor filtered down from speech therapists that pacifiers improve articulation.

Parents reach for a pacifier in hopes that it will help their child will fall asleep. I think most parents of older children agree that at the beginning the pacifier was first and foremost a sleep aid. But here is where the critical oversight occurs: If you give your children pacifiers when you want them to go to sleep, why not simply add the stipulation of where you would like them to go to sleep as well?

Most parents prefer that their children sleep in their own space. We can argue of whether that should be in a side sleeper or their own crib, but most parents don’t want their 3-year-olds sleeping in their bed. Nor do they want their children sleeping on the couch in the living room with them while they watch a movie at 10:30 at night. And as pediatricians, we prefer that children not sleep with their necks flexed in a car seat or baby rocker, particularly if they’re a preemie.

So why not adopt the simple family rule that the child can use a pacifier whenever it seems needed, but only in bed? Augmenting the primary association between sleep and the pacifier by adding a place has several important advantages. It gives parents more control of where their children will sleep or, more importantly, where they won’t be sleeping. It helps transitions to nonhome sleeping places like day care and long trips to grandma’s house go more smoothly.

Even more importantly, the crib/pacifier association helps parents who have had trouble reading their children’s cues. If they want a pacifier, it means they are tired and want to go to where the pacifier lives: bed

Finally, maintaining the link between sleeping and the pacifier promotes a more natural weaning process than going cold turkey or hiring the Pacifier Fairy. As naps disappear, the pacifier gradually become a less obvious accessory in the child’s life. However, it may linger in the background as a reminder of when the child needs some restorative sleep.

Of course, helping parents to think clearly enough to create and enforce a simple rule long enough to forge a healthy association when they are sleep deprived themselves is just another one of those challenges we must accept as concerned primary care pediatricians.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Is My Child Overtired? The Sleep Solution for Raising Happier, Healthier Children.” Email him at [email protected].

I recently encountered an article aimed at parents who were struggling with what to do about their child’s persistent attachment to his pacifier (“How to Ditch the Pacifier,” by Anna Nowogrodski, New York Times, 2019 Sept. 16). For the most part, the author presented a sampling of sound advice from pediatricians and other health experts.

Travis Manley/Thinkstock

Most children will abandon their pacifiers at a time that is consistent with their developmental stage. Pacifiers seldom do any permanent damage, although they aren’t terribly appealing to look at when hanging out of a toddling toddler’s mouth. Parents were urged to be patient and consistent and were told that allowing the gooey thing to self-destruct often works, as does accelerating the process with a razor blade. Enlisting the aid of the Pacifier Fairy was suggested, but I’m not so sure that would work terribly well.

As I finished perusing the article, I couldn’t help think of how this vexing issue of pacifier removal can be avoided if parents follow a simple rule when they first introduced a pacifier to their child. If experienced parents think back to when they first resorted to using the pacifier, it wasn’t because the plastic and rubber gadget was a family heirloom that had been passed down from generation to generation like an engraved silver spoon. It wasn’t because the dentist told them that children who use pacifiers are less likely to need braces on their teeth. Nor was it a rumor filtered down from speech therapists that pacifiers improve articulation.

Parents reach for a pacifier in hopes that it will help their child will fall asleep. I think most parents of older children agree that at the beginning the pacifier was first and foremost a sleep aid. But here is where the critical oversight occurs: If you give your children pacifiers when you want them to go to sleep, why not simply add the stipulation of where you would like them to go to sleep as well?

Most parents prefer that their children sleep in their own space. We can argue of whether that should be in a side sleeper or their own crib, but most parents don’t want their 3-year-olds sleeping in their bed. Nor do they want their children sleeping on the couch in the living room with them while they watch a movie at 10:30 at night. And as pediatricians, we prefer that children not sleep with their necks flexed in a car seat or baby rocker, particularly if they’re a preemie.

So why not adopt the simple family rule that the child can use a pacifier whenever it seems needed, but only in bed? Augmenting the primary association between sleep and the pacifier by adding a place has several important advantages. It gives parents more control of where their children will sleep or, more importantly, where they won’t be sleeping. It helps transitions to nonhome sleeping places like day care and long trips to grandma’s house go more smoothly.

Even more importantly, the crib/pacifier association helps parents who have had trouble reading their children’s cues. If they want a pacifier, it means they are tired and want to go to where the pacifier lives: bed

Finally, maintaining the link between sleeping and the pacifier promotes a more natural weaning process than going cold turkey or hiring the Pacifier Fairy. As naps disappear, the pacifier gradually become a less obvious accessory in the child’s life. However, it may linger in the background as a reminder of when the child needs some restorative sleep.

Of course, helping parents to think clearly enough to create and enforce a simple rule long enough to forge a healthy association when they are sleep deprived themselves is just another one of those challenges we must accept as concerned primary care pediatricians.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Is My Child Overtired? The Sleep Solution for Raising Happier, Healthier Children.” Email him at [email protected].

If you are still struggling to understand the ADHD phenomenon and its meteoric rise to prominence over the last 3 or 4 decades, a study published in the September 2019 Pediatrics may help you make sense of why you are spending a large part of your professional day counseling parents and treating children whose lives are disrupted by their impulsivity, distractibility, and inattentiveness (“24-hour movement behaviors and impulsivity.” doi: 10.1542/peds.2019-0187). Researchers at the Children’s Hospital of Eastern Ontario (Canada) Research Institute used data collected over 10 years in 21 sites across the United States on more than 4,500 children aged 8-11 years, looking for possible associations between impulsivity and three factors – sleep duration, screen time, and physical activity.

Goads Agency/Getty Images

They found that children who were exposed to fewer than 2 hours of recreational screen time each day and slept 9-11 hours nightly had significantly reduced scores on a range of impulsivity scores. While participating in at least 60 minutes of vigorous physical activity per day also was associated with less impulsivity, the effect added little to the benefit of the sleep/screen time combination. Although these nonpharmacologic strategies aimed at decreasing impulsivity may not be a cure-all for every child with symptoms that suggest ADHD, the data are compelling.

I hope that the associations these Canadian researchers have unearthed is not news to you. But their observation that 30% of the sample population met none of the recommendations for sleep, screen time, and activity and that only 5% of the sample did suggests that too few of us are delivering the message with sufficient enthusiasm and/or too many parents aren’t taking it seriously.

Over the last several years I have been encouraged to find sleep and screen time limits mentioned in articles on ADHD for both professionals and parents, but these potent contributors to impulsivity and distractibility always seem to be relegated to the oh-by-the-way category at the end of the article after a lengthy discussion of the relative values of medication and cognitive-behavioral therapy. And unfortunately, meeting these behavioral guidelines can be difficult to achieve and cannot be subcontracted out to a therapist or a pharmacist. They require parents to set and enforce limits. Saying no is difficult for all of us, particularly those without much prior experience.

Have you observed the association between inadequate sleep, excessive screen time, and impulsivity? How robustly have you bought into the idea that more sleep and less screen time are, if not THE answers, at least are the two we should start with? Where do your recommendations about screen time, sleep, and physical activity fit into the script when you are talking with parents about their child’s ADHD-ish behaviors? Have you put them in the oh-by-the-way category?

Do you ever say, “I know you may be expecting me to talk about medication at this visit, but I suggest you try setting and enforcing these limits on sleep and screen time for a few months and we will see how things are going”? “And I am going to give you some suggestions on how you can do this, and we will meet again as often as you feel is necessary to ease the process.”

Do you think you have the time to try this approach? Do you feel you have the skills to counsel on sleep and behavior? Do you think you can find someone with the time and experience who shares your priorities about screen time and sleep to do the parental coaching for you? It’s an approach worth considering when you step back and take the longer look at why we are living through this decades-long ADHD phenomenon.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

If you are still struggling to understand the ADHD phenomenon and its meteoric rise to prominence over the last 3 or 4 decades, a study published in the September 2019 Pediatrics may help you make sense of why you are spending a large part of your professional day counseling parents and treating children whose lives are disrupted by their impulsivity, distractibility, and inattentiveness (“24-hour movement behaviors and impulsivity.” doi: 10.1542/peds.2019-0187). Researchers at the Children’s Hospital of Eastern Ontario (Canada) Research Institute used data collected over 10 years in 21 sites across the United States on more than 4,500 children aged 8-11 years, looking for possible associations between impulsivity and three factors – sleep duration, screen time, and physical activity.

Goads Agency/Getty Images

They found that children who were exposed to fewer than 2 hours of recreational screen time each day and slept 9-11 hours nightly had significantly reduced scores on a range of impulsivity scores. While participating in at least 60 minutes of vigorous physical activity per day also was associated with less impulsivity, the effect added little to the benefit of the sleep/screen time combination. Although these nonpharmacologic strategies aimed at decreasing impulsivity may not be a cure-all for every child with symptoms that suggest ADHD, the data are compelling.

I hope that the associations these Canadian researchers have unearthed is not news to you. But their observation that 30% of the sample population met none of the recommendations for sleep, screen time, and activity and that only 5% of the sample did suggests that too few of us are delivering the message with sufficient enthusiasm and/or too many parents aren’t taking it seriously.

Over the last several years I have been encouraged to find sleep and screen time limits mentioned in articles on ADHD for both professionals and parents, but these potent contributors to impulsivity and distractibility always seem to be relegated to the oh-by-the-way category at the end of the article after a lengthy discussion of the relative values of medication and cognitive-behavioral therapy. And unfortunately, meeting these behavioral guidelines can be difficult to achieve and cannot be subcontracted out to a therapist or a pharmacist. They require parents to set and enforce limits. Saying no is difficult for all of us, particularly those without much prior experience.

Have you observed the association between inadequate sleep, excessive screen time, and impulsivity? How robustly have you bought into the idea that more sleep and less screen time are, if not THE answers, at least are the two we should start with? Where do your recommendations about screen time, sleep, and physical activity fit into the script when you are talking with parents about their child’s ADHD-ish behaviors? Have you put them in the oh-by-the-way category?

Do you ever say, “I know you may be expecting me to talk about medication at this visit, but I suggest you try setting and enforcing these limits on sleep and screen time for a few months and we will see how things are going”? “And I am going to give you some suggestions on how you can do this, and we will meet again as often as you feel is necessary to ease the process.”

Do you think you have the time to try this approach? Do you feel you have the skills to counsel on sleep and behavior? Do you think you can find someone with the time and experience who shares your priorities about screen time and sleep to do the parental coaching for you? It’s an approach worth considering when you step back and take the longer look at why we are living through this decades-long ADHD phenomenon.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

If you are still struggling to understand the ADHD phenomenon and its meteoric rise to prominence over the last 3 or 4 decades, a study published in the September 2019 Pediatrics may help you make sense of why you are spending a large part of your professional day counseling parents and treating children whose lives are disrupted by their impulsivity, distractibility, and inattentiveness (“24-hour movement behaviors and impulsivity.” doi: 10.1542/peds.2019-0187). Researchers at the Children’s Hospital of Eastern Ontario (Canada) Research Institute used data collected over 10 years in 21 sites across the United States on more than 4,500 children aged 8-11 years, looking for possible associations between impulsivity and three factors – sleep duration, screen time, and physical activity.

Goads Agency/Getty Images

They found that children who were exposed to fewer than 2 hours of recreational screen time each day and slept 9-11 hours nightly had significantly reduced scores on a range of impulsivity scores. While participating in at least 60 minutes of vigorous physical activity per day also was associated with less impulsivity, the effect added little to the benefit of the sleep/screen time combination. Although these nonpharmacologic strategies aimed at decreasing impulsivity may not be a cure-all for every child with symptoms that suggest ADHD, the data are compelling.

I hope that the associations these Canadian researchers have unearthed is not news to you. But their observation that 30% of the sample population met none of the recommendations for sleep, screen time, and activity and that only 5% of the sample did suggests that too few of us are delivering the message with sufficient enthusiasm and/or too many parents aren’t taking it seriously.

Over the last several years I have been encouraged to find sleep and screen time limits mentioned in articles on ADHD for both professionals and parents, but these potent contributors to impulsivity and distractibility always seem to be relegated to the oh-by-the-way category at the end of the article after a lengthy discussion of the relative values of medication and cognitive-behavioral therapy. And unfortunately, meeting these behavioral guidelines can be difficult to achieve and cannot be subcontracted out to a therapist or a pharmacist. They require parents to set and enforce limits. Saying no is difficult for all of us, particularly those without much prior experience.

Have you observed the association between inadequate sleep, excessive screen time, and impulsivity? How robustly have you bought into the idea that more sleep and less screen time are, if not THE answers, at least are the two we should start with? Where do your recommendations about screen time, sleep, and physical activity fit into the script when you are talking with parents about their child’s ADHD-ish behaviors? Have you put them in the oh-by-the-way category?

Do you ever say, “I know you may be expecting me to talk about medication at this visit, but I suggest you try setting and enforcing these limits on sleep and screen time for a few months and we will see how things are going”? “And I am going to give you some suggestions on how you can do this, and we will meet again as often as you feel is necessary to ease the process.”

Do you think you have the time to try this approach? Do you feel you have the skills to counsel on sleep and behavior? Do you think you can find someone with the time and experience who shares your priorities about screen time and sleep to do the parental coaching for you? It’s an approach worth considering when you step back and take the longer look at why we are living through this decades-long ADHD phenomenon.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

You are seeing a 9-year-old for her annual health maintenance visit. A quick look at her growth chart easily confirms your first impression that she is obese. How are you going to address the weight that you know, and she probably suspects, is going to make her vulnerable to a myriad of health problems as she gets older?

SolStock/iStock/Getty Image

If she has been your patient since she was in preschool, this is certainly not the first time that her growth chart has been concerning. When did you first start discussing her weight with her parents? What words did you use? What strategies have you suggested? What referrals have you made? Maybe you have already given up and decided to not even “go there” at this visit because your experience with overweight patients has been so disappointing.

In her op ed in the New York Times, Dr. Perri Klass reconsiders these kinds of questions as she reviews an article in the journal Childhood Obesity (“Let’s Not Just Dismiss the Weight Watchers Kurbo App,” by Michelle I. Cardel, PhD, MS, RD, and Elsie M. Taveras, MD, MPH, August 2019) written by a nutrition scientist and a pediatrician who are concerned about a new weight loss app for children recently released by Weight Watchers. (The Checkup, “Helping Children Learn to Eat Well,” The New York Times, Aug. 26, 2019). Although the authors of the journal article question some of the science behind the app, their primary concerns are that the app is aimed at children without a way to guarantee parental involvement, and in their opinion the app also places too much emphasis on weight loss.

Their concerns go right to the heart of what troubles me about managing obesity in children. How should I talk to a child about her weight? What words can I choose without shaming? Maybe I shouldn’t be talking to her at all. When a child is 18 months old, we don’t talk to her about her growth chart. Not because she couldn’t understand, but because the solution rests not with her but with her parents.

At what age does a child’s obesity cease being simply a parenting problem and instead become something the child must solve? Does that point come when we have given up on the parents’ ability to create and maintain an environment that discourages obesity? Is that the point when we begin asking the child to unlearn a complex set of behaviors that have been enabled or at least tolerated and poorly modeled at home?

When we begin to talk to a child about his weight do we begin by telling him that he may not have been a contributor to the problem when it began but from now on he needs to be a major player in its management? Of course we don’t share that reality with an 8-year-old, but sometime during his struggle to manage his weight he will connect the dots.

If you are beginning to suspect that I have built my pediatric career around a scaffolding of parent blaming and shaming you are wrong. I know that there are children who have inherited a suite of genes that make them vulnerable to obesity. And I know that too many children grow up in environments in which their parents are powerless to control the family diet for economic reasons. But I am sure that like me you mutter to yourself and your colleagues about the number of patients you are seeing each day whose growth charts are a clear reflection of less than optimal parenting.

Does all of this mean we throw in the towel and stop trying to help overweight children after they turn 6 years old? Of course not. But, it does mean we must redouble our efforts to help parents manage their children’s diets and activity levels in those first critical preschool years.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

You are seeing a 9-year-old for her annual health maintenance visit. A quick look at her growth chart easily confirms your first impression that she is obese. How are you going to address the weight that you know, and she probably suspects, is going to make her vulnerable to a myriad of health problems as she gets older?

SolStock/iStock/Getty Image

If she has been your patient since she was in preschool, this is certainly not the first time that her growth chart has been concerning. When did you first start discussing her weight with her parents? What words did you use? What strategies have you suggested? What referrals have you made? Maybe you have already given up and decided to not even “go there” at this visit because your experience with overweight patients has been so disappointing.

In her op ed in the New York Times, Dr. Perri Klass reconsiders these kinds of questions as she reviews an article in the journal Childhood Obesity (“Let’s Not Just Dismiss the Weight Watchers Kurbo App,” by Michelle I. Cardel, PhD, MS, RD, and Elsie M. Taveras, MD, MPH, August 2019) written by a nutrition scientist and a pediatrician who are concerned about a new weight loss app for children recently released by Weight Watchers. (The Checkup, “Helping Children Learn to Eat Well,” The New York Times, Aug. 26, 2019). Although the authors of the journal article question some of the science behind the app, their primary concerns are that the app is aimed at children without a way to guarantee parental involvement, and in their opinion the app also places too much emphasis on weight loss.

Their concerns go right to the heart of what troubles me about managing obesity in children. How should I talk to a child about her weight? What words can I choose without shaming? Maybe I shouldn’t be talking to her at all. When a child is 18 months old, we don’t talk to her about her growth chart. Not because she couldn’t understand, but because the solution rests not with her but with her parents.

At what age does a child’s obesity cease being simply a parenting problem and instead become something the child must solve? Does that point come when we have given up on the parents’ ability to create and maintain an environment that discourages obesity? Is that the point when we begin asking the child to unlearn a complex set of behaviors that have been enabled or at least tolerated and poorly modeled at home?

When we begin to talk to a child about his weight do we begin by telling him that he may not have been a contributor to the problem when it began but from now on he needs to be a major player in its management? Of course we don’t share that reality with an 8-year-old, but sometime during his struggle to manage his weight he will connect the dots.

If you are beginning to suspect that I have built my pediatric career around a scaffolding of parent blaming and shaming you are wrong. I know that there are children who have inherited a suite of genes that make them vulnerable to obesity. And I know that too many children grow up in environments in which their parents are powerless to control the family diet for economic reasons. But I am sure that like me you mutter to yourself and your colleagues about the number of patients you are seeing each day whose growth charts are a clear reflection of less than optimal parenting.

Does all of this mean we throw in the towel and stop trying to help overweight children after they turn 6 years old? Of course not. But, it does mean we must redouble our efforts to help parents manage their children’s diets and activity levels in those first critical preschool years.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

You are seeing a 9-year-old for her annual health maintenance visit. A quick look at her growth chart easily confirms your first impression that she is obese. How are you going to address the weight that you know, and she probably suspects, is going to make her vulnerable to a myriad of health problems as she gets older?

SolStock/iStock/Getty Image

If she has been your patient since she was in preschool, this is certainly not the first time that her growth chart has been concerning. When did you first start discussing her weight with her parents? What words did you use? What strategies have you suggested? What referrals have you made? Maybe you have already given up and decided to not even “go there” at this visit because your experience with overweight patients has been so disappointing.

In her op ed in the New York Times, Dr. Perri Klass reconsiders these kinds of questions as she reviews an article in the journal Childhood Obesity (“Let’s Not Just Dismiss the Weight Watchers Kurbo App,” by Michelle I. Cardel, PhD, MS, RD, and Elsie M. Taveras, MD, MPH, August 2019) written by a nutrition scientist and a pediatrician who are concerned about a new weight loss app for children recently released by Weight Watchers. (The Checkup, “Helping Children Learn to Eat Well,” The New York Times, Aug. 26, 2019). Although the authors of the journal article question some of the science behind the app, their primary concerns are that the app is aimed at children without a way to guarantee parental involvement, and in their opinion the app also places too much emphasis on weight loss.

Their concerns go right to the heart of what troubles me about managing obesity in children. How should I talk to a child about her weight? What words can I choose without shaming? Maybe I shouldn’t be talking to her at all. When a child is 18 months old, we don’t talk to her about her growth chart. Not because she couldn’t understand, but because the solution rests not with her but with her parents.

At what age does a child’s obesity cease being simply a parenting problem and instead become something the child must solve? Does that point come when we have given up on the parents’ ability to create and maintain an environment that discourages obesity? Is that the point when we begin asking the child to unlearn a complex set of behaviors that have been enabled or at least tolerated and poorly modeled at home?

When we begin to talk to a child about his weight do we begin by telling him that he may not have been a contributor to the problem when it began but from now on he needs to be a major player in its management? Of course we don’t share that reality with an 8-year-old, but sometime during his struggle to manage his weight he will connect the dots.

If you are beginning to suspect that I have built my pediatric career around a scaffolding of parent blaming and shaming you are wrong. I know that there are children who have inherited a suite of genes that make them vulnerable to obesity. And I know that too many children grow up in environments in which their parents are powerless to control the family diet for economic reasons. But I am sure that like me you mutter to yourself and your colleagues about the number of patients you are seeing each day whose growth charts are a clear reflection of less than optimal parenting.

Does all of this mean we throw in the towel and stop trying to help overweight children after they turn 6 years old? Of course not. But, it does mean we must redouble our efforts to help parents manage their children’s diets and activity levels in those first critical preschool years.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Is your glass always half full? Is that because you’re so busy that you never have time to finish drinking it? Or is it because you are an optimist? Have you always been someone who could see a glimmer at the end of even the darkest, longest tunnels? Do you think your positive outlook is something you inherited? Or did you model it after continued exposure to an optimistic parent or medical school mentor?

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Are you aware that your optimism makes it more likely that you will live to a ripe old age? A recent study of 69,744 women and 1,429 men initiated by researchers at the Harvard School T.H. Chan School of Public Health in Boston, Boston University Medical School, and the National Center for PTSD at Veterans Affairs Boston Health Care System found that “individuals with greater optimism are more likely to live longer and to achieve ‘exceptional longevity,’ that is, living to 85 or older” (“New Evidence that optimists live longer.” Harvard T.C. Chan School of Public Health. August 27, 2019).

Do you think your optimism has been a positive contribution to your success as a physician? Or have there been times when it has been a liability?

Because I’m not going to wait for you to answer, I’ll share my own observations. I sense that optimism is something with a strong genetic component, just as is the vulnerability to anxiety and depression. My mother was an optimist. However, I suspect that being around an individual who exudes a high degree of optimism can have a positive influence on a person who already has a partly cloudy disposition.

On the other hand, I’ve found that it is very difficult for even the most optimistic people to induce a positive outlook in individuals born with a chronically half empty glass simply by radiating their own aura of optimism. In my own experience, I have found that being an optimist has definitely been an asset in my role as a physician. In most situations, sounding or just appearing hopeful can help ease the tension for a patient or family – tension that may be exacerbating their ability to cope with the presenting problem. However, I have had to learn to recognize more quickly that there are situations when my optimism isn’t going to be effective and not become frustrated by its inadequacy.

Are there downsides to being an optimistic physician? Of course; there can be a fine line between being an optimist and sounding like a Pollyanna. To avoid stepping over the line, optimists must choose their words carefully. And more importantly, they must be reading the patient’s and family’s response to attempts at injecting positivity into the situation. Optimism also can be mistaken for a nonchalant attitude that signals a lack of caring and concern.

However, the most dangerous liability of optimism occurs when it slips into the swift running and turbulent waters of denial. I have almost killed myself on a couple of occasions when my “optimistic” interpretation of my symptoms has prompted me to “tough out” a potentially fatal situation instead of seeking timely advice from my physician.

My optimism sometimes has made it difficult for me to be appropriately objective when assessing the seriousness of a patient’s condition. Given a list of positives and negatives, my tendency might be focus more on the positives. As far as I know, my overly positive attitude has never killed any of my patients, but I fear a few diagnoses and remedies may have been delayed when the Prince of Optimism became the Queen of Denial.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Is your glass always half full? Is that because you’re so busy that you never have time to finish drinking it? Or is it because you are an optimist? Have you always been someone who could see a glimmer at the end of even the darkest, longest tunnels? Do you think your positive outlook is something you inherited? Or did you model it after continued exposure to an optimistic parent or medical school mentor?

Wavebreakmedia/Thinkstock

Are you aware that your optimism makes it more likely that you will live to a ripe old age? A recent study of 69,744 women and 1,429 men initiated by researchers at the Harvard School T.H. Chan School of Public Health in Boston, Boston University Medical School, and the National Center for PTSD at Veterans Affairs Boston Health Care System found that “individuals with greater optimism are more likely to live longer and to achieve ‘exceptional longevity,’ that is, living to 85 or older” (“New Evidence that optimists live longer.” Harvard T.C. Chan School of Public Health. August 27, 2019).

Do you think your optimism has been a positive contribution to your success as a physician? Or have there been times when it has been a liability?

Because I’m not going to wait for you to answer, I’ll share my own observations. I sense that optimism is something with a strong genetic component, just as is the vulnerability to anxiety and depression. My mother was an optimist. However, I suspect that being around an individual who exudes a high degree of optimism can have a positive influence on a person who already has a partly cloudy disposition.

On the other hand, I’ve found that it is very difficult for even the most optimistic people to induce a positive outlook in individuals born with a chronically half empty glass simply by radiating their own aura of optimism. In my own experience, I have found that being an optimist has definitely been an asset in my role as a physician. In most situations, sounding or just appearing hopeful can help ease the tension for a patient or family – tension that may be exacerbating their ability to cope with the presenting problem. However, I have had to learn to recognize more quickly that there are situations when my optimism isn’t going to be effective and not become frustrated by its inadequacy.

Are there downsides to being an optimistic physician? Of course; there can be a fine line between being an optimist and sounding like a Pollyanna. To avoid stepping over the line, optimists must choose their words carefully. And more importantly, they must be reading the patient’s and family’s response to attempts at injecting positivity into the situation. Optimism also can be mistaken for a nonchalant attitude that signals a lack of caring and concern.

However, the most dangerous liability of optimism occurs when it slips into the swift running and turbulent waters of denial. I have almost killed myself on a couple of occasions when my “optimistic” interpretation of my symptoms has prompted me to “tough out” a potentially fatal situation instead of seeking timely advice from my physician.

My optimism sometimes has made it difficult for me to be appropriately objective when assessing the seriousness of a patient’s condition. Given a list of positives and negatives, my tendency might be focus more on the positives. As far as I know, my overly positive attitude has never killed any of my patients, but I fear a few diagnoses and remedies may have been delayed when the Prince of Optimism became the Queen of Denial.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Is your glass always half full? Is that because you’re so busy that you never have time to finish drinking it? Or is it because you are an optimist? Have you always been someone who could see a glimmer at the end of even the darkest, longest tunnels? Do you think your positive outlook is something you inherited? Or did you model it after continued exposure to an optimistic parent or medical school mentor?

Wavebreakmedia/Thinkstock

Are you aware that your optimism makes it more likely that you will live to a ripe old age? A recent study of 69,744 women and 1,429 men initiated by researchers at the Harvard School T.H. Chan School of Public Health in Boston, Boston University Medical School, and the National Center for PTSD at Veterans Affairs Boston Health Care System found that “individuals with greater optimism are more likely to live longer and to achieve ‘exceptional longevity,’ that is, living to 85 or older” (“New Evidence that optimists live longer.” Harvard T.C. Chan School of Public Health. August 27, 2019).

Do you think your optimism has been a positive contribution to your success as a physician? Or have there been times when it has been a liability?

Because I’m not going to wait for you to answer, I’ll share my own observations. I sense that optimism is something with a strong genetic component, just as is the vulnerability to anxiety and depression. My mother was an optimist. However, I suspect that being around an individual who exudes a high degree of optimism can have a positive influence on a person who already has a partly cloudy disposition.

On the other hand, I’ve found that it is very difficult for even the most optimistic people to induce a positive outlook in individuals born with a chronically half empty glass simply by radiating their own aura of optimism. In my own experience, I have found that being an optimist has definitely been an asset in my role as a physician. In most situations, sounding or just appearing hopeful can help ease the tension for a patient or family – tension that may be exacerbating their ability to cope with the presenting problem. However, I have had to learn to recognize more quickly that there are situations when my optimism isn’t going to be effective and not become frustrated by its inadequacy.

Are there downsides to being an optimistic physician? Of course; there can be a fine line between being an optimist and sounding like a Pollyanna. To avoid stepping over the line, optimists must choose their words carefully. And more importantly, they must be reading the patient’s and family’s response to attempts at injecting positivity into the situation. Optimism also can be mistaken for a nonchalant attitude that signals a lack of caring and concern.

However, the most dangerous liability of optimism occurs when it slips into the swift running and turbulent waters of denial. I have almost killed myself on a couple of occasions when my “optimistic” interpretation of my symptoms has prompted me to “tough out” a potentially fatal situation instead of seeking timely advice from my physician.

My optimism sometimes has made it difficult for me to be appropriately objective when assessing the seriousness of a patient’s condition. Given a list of positives and negatives, my tendency might be focus more on the positives. As far as I know, my overly positive attitude has never killed any of my patients, but I fear a few diagnoses and remedies may have been delayed when the Prince of Optimism became the Queen of Denial.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].