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How are you at coping with transparency?
As reported in the Wall Street Journal, the current administration has proposed a suite of initiatives that could improve patients’ access to their health data, including doctors’ and hospitals’ electronic records as well as insurance claim information (“Rules to Ease Patient Access to Health Data Are Proposed,” by Anna Wilde Mathews, Feb. 11, 2019). One of the draft rules would mandate new technology standards that allow health information data to flow seamlessly between providers and hospitals using different electronic systems, a step that should have been taken well before the federal government began cajoling physicians into adopting not-ready-for-prime-time EMR systems and rewarding their “meaningful use.” Other rules are aimed at discouraging the patient-unfriendly practice of delaying and charging for the transfer of medical records.
Apple already has begun research and development on systems and tools that would allow patients to receive and store their health information on their smart phones and tablets. Arriving at the ED or a consulting physician, the patient would need only unlock his or her device to share his or her medical record.
These proposals are long overdue and in the long run should save providers and patients time and expense. As long as they also include rules mandating true transparency in hospital billing, these initiatives appear to be heading us in the right direction.
Do you create your office notes with the assumption that your patient will be reading them? Seventy-five years ago, physicians, many of whom were in solo practice, scrawled their notes as simple mnemonics. They could barely decipher their own scribbles. If they needed to share information with a consultant, it was with a phone call or dictated letter. You probably are more aware of creating a readable note because you rely on covering physicians ... and you know that the folks who pay you will be auditing your charts.
Depending on your patient mix, most of the notes you generate probably don’t contain many observations that you are hesitant to share with the patient. If you haven’t already discussed his body mass index with the patient you have described as “obese,” you aren’t doing your job. However, occasionally there are topics that have arisen in the family and social history that may not be pertinent to the patient’s current problem, but provide a more nuanced picture of her and serve as a mnemonic at a later visit. Will the patient mind if you include these tidbits in an electronic record that may be shared by a wide audience outside the confines of your exam room?
How do you deal with situations like this when the threat of transparency could interfere with our relationship with our patients? You could ask the patient, “ Do you mind if I include that event you just told me, in your EMR?” You could create a “shadow record” that includes information the patient prefers not to be shared and your own observations that you don’t feel comfortable sharing with the patient. Is this “shadow record” something electronic that could be redacted by simply toggling a clickable box? Or is it an old-fashioned paper note you keep in a separate file in a locked drawer in a file cabinet (if you even have a file cabinet)? I fear the lawyers would have something to say about both those options. The best solution may simply be to rely on your memory. If you have so many patients that you can’t remember those occasional sensitive issues that have been shared with you, then maybe you have too many patients.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” Email him at [email protected].
As reported in the Wall Street Journal, the current administration has proposed a suite of initiatives that could improve patients’ access to their health data, including doctors’ and hospitals’ electronic records as well as insurance claim information (“Rules to Ease Patient Access to Health Data Are Proposed,” by Anna Wilde Mathews, Feb. 11, 2019). One of the draft rules would mandate new technology standards that allow health information data to flow seamlessly between providers and hospitals using different electronic systems, a step that should have been taken well before the federal government began cajoling physicians into adopting not-ready-for-prime-time EMR systems and rewarding their “meaningful use.” Other rules are aimed at discouraging the patient-unfriendly practice of delaying and charging for the transfer of medical records.
Apple already has begun research and development on systems and tools that would allow patients to receive and store their health information on their smart phones and tablets. Arriving at the ED or a consulting physician, the patient would need only unlock his or her device to share his or her medical record.
These proposals are long overdue and in the long run should save providers and patients time and expense. As long as they also include rules mandating true transparency in hospital billing, these initiatives appear to be heading us in the right direction.
Do you create your office notes with the assumption that your patient will be reading them? Seventy-five years ago, physicians, many of whom were in solo practice, scrawled their notes as simple mnemonics. They could barely decipher their own scribbles. If they needed to share information with a consultant, it was with a phone call or dictated letter. You probably are more aware of creating a readable note because you rely on covering physicians ... and you know that the folks who pay you will be auditing your charts.
Depending on your patient mix, most of the notes you generate probably don’t contain many observations that you are hesitant to share with the patient. If you haven’t already discussed his body mass index with the patient you have described as “obese,” you aren’t doing your job. However, occasionally there are topics that have arisen in the family and social history that may not be pertinent to the patient’s current problem, but provide a more nuanced picture of her and serve as a mnemonic at a later visit. Will the patient mind if you include these tidbits in an electronic record that may be shared by a wide audience outside the confines of your exam room?
How do you deal with situations like this when the threat of transparency could interfere with our relationship with our patients? You could ask the patient, “ Do you mind if I include that event you just told me, in your EMR?” You could create a “shadow record” that includes information the patient prefers not to be shared and your own observations that you don’t feel comfortable sharing with the patient. Is this “shadow record” something electronic that could be redacted by simply toggling a clickable box? Or is it an old-fashioned paper note you keep in a separate file in a locked drawer in a file cabinet (if you even have a file cabinet)? I fear the lawyers would have something to say about both those options. The best solution may simply be to rely on your memory. If you have so many patients that you can’t remember those occasional sensitive issues that have been shared with you, then maybe you have too many patients.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” Email him at [email protected].
As reported in the Wall Street Journal, the current administration has proposed a suite of initiatives that could improve patients’ access to their health data, including doctors’ and hospitals’ electronic records as well as insurance claim information (“Rules to Ease Patient Access to Health Data Are Proposed,” by Anna Wilde Mathews, Feb. 11, 2019). One of the draft rules would mandate new technology standards that allow health information data to flow seamlessly between providers and hospitals using different electronic systems, a step that should have been taken well before the federal government began cajoling physicians into adopting not-ready-for-prime-time EMR systems and rewarding their “meaningful use.” Other rules are aimed at discouraging the patient-unfriendly practice of delaying and charging for the transfer of medical records.
Apple already has begun research and development on systems and tools that would allow patients to receive and store their health information on their smart phones and tablets. Arriving at the ED or a consulting physician, the patient would need only unlock his or her device to share his or her medical record.
These proposals are long overdue and in the long run should save providers and patients time and expense. As long as they also include rules mandating true transparency in hospital billing, these initiatives appear to be heading us in the right direction.
Do you create your office notes with the assumption that your patient will be reading them? Seventy-five years ago, physicians, many of whom were in solo practice, scrawled their notes as simple mnemonics. They could barely decipher their own scribbles. If they needed to share information with a consultant, it was with a phone call or dictated letter. You probably are more aware of creating a readable note because you rely on covering physicians ... and you know that the folks who pay you will be auditing your charts.
Depending on your patient mix, most of the notes you generate probably don’t contain many observations that you are hesitant to share with the patient. If you haven’t already discussed his body mass index with the patient you have described as “obese,” you aren’t doing your job. However, occasionally there are topics that have arisen in the family and social history that may not be pertinent to the patient’s current problem, but provide a more nuanced picture of her and serve as a mnemonic at a later visit. Will the patient mind if you include these tidbits in an electronic record that may be shared by a wide audience outside the confines of your exam room?
How do you deal with situations like this when the threat of transparency could interfere with our relationship with our patients? You could ask the patient, “ Do you mind if I include that event you just told me, in your EMR?” You could create a “shadow record” that includes information the patient prefers not to be shared and your own observations that you don’t feel comfortable sharing with the patient. Is this “shadow record” something electronic that could be redacted by simply toggling a clickable box? Or is it an old-fashioned paper note you keep in a separate file in a locked drawer in a file cabinet (if you even have a file cabinet)? I fear the lawyers would have something to say about both those options. The best solution may simply be to rely on your memory. If you have so many patients that you can’t remember those occasional sensitive issues that have been shared with you, then maybe you have too many patients.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” Email him at [email protected].
In search of an ear
On our way up north to go backcountry skiing with another couple, we stopped at a roadside restaurant/tavern for lunch. We seated ourselves and, after a long 10 minutes, our waitperson arrived like a tornado, looking frazzled. She offered an apology and the first installment of her tale of woe. Before taking our order, she explained it all began when her car wouldn’t start, and then her day care provider called to say that she was sick and our server would have to find some other arrangement for the day. When our meal finally arrived, it looked appetizing but didn’t quite match our order. Again, our waitperson apologized, adding that it has been a particularly hard week because her husband was out of town and not around to help with her three children.
Had we been dining at a high-end restaurant with a white tablecloth and a candle, we would have considered our server’s behavior unprofessional and off-putting. However, we were in no hurry as the light snow had turned to a ski-unfriendly drizzle. While our original intent had been to simply have lunch, we accepted our role as a sympathetic audience for this unfortunate woman. In fact, we asked a few open-ended questions to help the cathartic process along.
The need to share one’s troubles seems to be a universal human trait. Our server had no illusions that we were going to provide any solutions to her problems. Nor was she seeking any expression of sympathy beyond our patience. However, I’m sure that unburdening herself by telling the story made her feel better, at least temporarily. Hopefully, there would be additional understanding diners to help her through the day.
For many people, the workplace serves as a therapeutic outlet where they can share their troubles and concerns. At times, the whining can be annoying to coworkers but in general, woe sharing is a harmless and valuable perk of having a job. Unless, of course, one’s job is primarily serving the public.
As physicians we are accustomed listening to our patients’ troubles. However, our job is not one of those that affords much opportunity to unburden ourselves of our own concerns. The patients assume that we are the problem solvers and don’t have any of our own. Or, if we do have some troubles, their office visit is not the time for us to share them.
The occasional sharing, such as that we are running late because we’ve had a flat on the way to the office, is harmless and can remind patients that we are human. But one must be careful stay off the slippery slope that leads to unprofessional oversharing.
Without that luxury of a workplace that allows for occasional catharsis, physicians have an additional risk for burnout. There are no easy solutions. Sharing with patients is unprofessional. Our peers are as busy as we are and probably don’t have the time to listen. Or at least they don’t seem to have the time. And then there is that ego-vulnerability issue where we are hesitant to reveal to anyone, be they staff or peers, that we have a soft underbelly.
I don’t have any easy answers to the problem beyond the usual suggestion that, Personally, I have to admit that, when my bad day was the result of an accumulation of minor bumps, I would follow our waitperson’s example and share them selectively with patients whom I deluded myself into believing had the time and concern to listen. It probably was unprofessional, but it made me feel better.
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].
On our way up north to go backcountry skiing with another couple, we stopped at a roadside restaurant/tavern for lunch. We seated ourselves and, after a long 10 minutes, our waitperson arrived like a tornado, looking frazzled. She offered an apology and the first installment of her tale of woe. Before taking our order, she explained it all began when her car wouldn’t start, and then her day care provider called to say that she was sick and our server would have to find some other arrangement for the day. When our meal finally arrived, it looked appetizing but didn’t quite match our order. Again, our waitperson apologized, adding that it has been a particularly hard week because her husband was out of town and not around to help with her three children.
Had we been dining at a high-end restaurant with a white tablecloth and a candle, we would have considered our server’s behavior unprofessional and off-putting. However, we were in no hurry as the light snow had turned to a ski-unfriendly drizzle. While our original intent had been to simply have lunch, we accepted our role as a sympathetic audience for this unfortunate woman. In fact, we asked a few open-ended questions to help the cathartic process along.
The need to share one’s troubles seems to be a universal human trait. Our server had no illusions that we were going to provide any solutions to her problems. Nor was she seeking any expression of sympathy beyond our patience. However, I’m sure that unburdening herself by telling the story made her feel better, at least temporarily. Hopefully, there would be additional understanding diners to help her through the day.
For many people, the workplace serves as a therapeutic outlet where they can share their troubles and concerns. At times, the whining can be annoying to coworkers but in general, woe sharing is a harmless and valuable perk of having a job. Unless, of course, one’s job is primarily serving the public.
As physicians we are accustomed listening to our patients’ troubles. However, our job is not one of those that affords much opportunity to unburden ourselves of our own concerns. The patients assume that we are the problem solvers and don’t have any of our own. Or, if we do have some troubles, their office visit is not the time for us to share them.
The occasional sharing, such as that we are running late because we’ve had a flat on the way to the office, is harmless and can remind patients that we are human. But one must be careful stay off the slippery slope that leads to unprofessional oversharing.
Without that luxury of a workplace that allows for occasional catharsis, physicians have an additional risk for burnout. There are no easy solutions. Sharing with patients is unprofessional. Our peers are as busy as we are and probably don’t have the time to listen. Or at least they don’t seem to have the time. And then there is that ego-vulnerability issue where we are hesitant to reveal to anyone, be they staff or peers, that we have a soft underbelly.
I don’t have any easy answers to the problem beyond the usual suggestion that, Personally, I have to admit that, when my bad day was the result of an accumulation of minor bumps, I would follow our waitperson’s example and share them selectively with patients whom I deluded myself into believing had the time and concern to listen. It probably was unprofessional, but it made me feel better.
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].
On our way up north to go backcountry skiing with another couple, we stopped at a roadside restaurant/tavern for lunch. We seated ourselves and, after a long 10 minutes, our waitperson arrived like a tornado, looking frazzled. She offered an apology and the first installment of her tale of woe. Before taking our order, she explained it all began when her car wouldn’t start, and then her day care provider called to say that she was sick and our server would have to find some other arrangement for the day. When our meal finally arrived, it looked appetizing but didn’t quite match our order. Again, our waitperson apologized, adding that it has been a particularly hard week because her husband was out of town and not around to help with her three children.
Had we been dining at a high-end restaurant with a white tablecloth and a candle, we would have considered our server’s behavior unprofessional and off-putting. However, we were in no hurry as the light snow had turned to a ski-unfriendly drizzle. While our original intent had been to simply have lunch, we accepted our role as a sympathetic audience for this unfortunate woman. In fact, we asked a few open-ended questions to help the cathartic process along.
The need to share one’s troubles seems to be a universal human trait. Our server had no illusions that we were going to provide any solutions to her problems. Nor was she seeking any expression of sympathy beyond our patience. However, I’m sure that unburdening herself by telling the story made her feel better, at least temporarily. Hopefully, there would be additional understanding diners to help her through the day.
For many people, the workplace serves as a therapeutic outlet where they can share their troubles and concerns. At times, the whining can be annoying to coworkers but in general, woe sharing is a harmless and valuable perk of having a job. Unless, of course, one’s job is primarily serving the public.
As physicians we are accustomed listening to our patients’ troubles. However, our job is not one of those that affords much opportunity to unburden ourselves of our own concerns. The patients assume that we are the problem solvers and don’t have any of our own. Or, if we do have some troubles, their office visit is not the time for us to share them.
The occasional sharing, such as that we are running late because we’ve had a flat on the way to the office, is harmless and can remind patients that we are human. But one must be careful stay off the slippery slope that leads to unprofessional oversharing.
Without that luxury of a workplace that allows for occasional catharsis, physicians have an additional risk for burnout. There are no easy solutions. Sharing with patients is unprofessional. Our peers are as busy as we are and probably don’t have the time to listen. Or at least they don’t seem to have the time. And then there is that ego-vulnerability issue where we are hesitant to reveal to anyone, be they staff or peers, that we have a soft underbelly.
I don’t have any easy answers to the problem beyond the usual suggestion that, Personally, I have to admit that, when my bad day was the result of an accumulation of minor bumps, I would follow our waitperson’s example and share them selectively with patients whom I deluded myself into believing had the time and concern to listen. It probably was unprofessional, but it made me feel better.
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].
Speaking in code
If you live in Spokane, Wash., 99213 and 99214 are important numbers. Interchanging the last two digits can send your mail into the Twilight Zone. Otherwise those five digit sequences have little significance to most Americans ... unless of course you are a physician. You have been told multiple times by practice administrators and business consultants that the failure to attach the proper sequence to your bill for services can threaten the sustainability of your practice’s bottom line or put you at risk for a costly fine.
Numerical codes for office visits were not handed down on stone tablets. There was a time when a physician simply charged for something he called an “office visit” and about half that for a “short” office visit that took less time and probably nothing for a “quick recheck.” He chose the fees based on what he felt was reasonable. I remember reading of one physician who pegged his charges at a dollar per penny of the cost of a regular postage stamp. For a variety of obvious and some unfortunate reasons, these loosely structured fee structures have disappeared.
Now a physician is asked to justify his or her charges by documenting what transpired during the office visit. The patient always has been the best witness, and at least has some sense of how much work the physician has had to do to arrive at diagnosis and suggest a treatment plan. Because the patient usually was paying the bill and had a personal stake in the value of the services provided, this system seemed to make sense.
However, now some large corporate entity or government agency probably is paying the bill and would like some idea of what it is being billed for. Justifying the service provided now falls on the physician. When the billing codes were first introduced and before the payers became more curious, it was easy. I simply applied 99213 to all my office visits and once or twice a day I would code out a visit that seemed more complex as a 99214. I wasn’t keeping track of how many minutes I spent in each visit, how many questions I asked, or how many body parts I examined. Except for patients with injured extremities, everyone was pretty much getting the same exam. My coding was based on my perception of value and effort. If it took more time than usual to remove a bit of cerumen or reassure an unusually concerned parent I chalked that up as my misfortune, not a reason to code the visit as a 99214. If I felt I needed more money, I assumed that my best option was to see more patients. Neither the patients nor the payers seemed to be complaining.
But obviously somewhere someone felt that there were too many providers gaming the system and there needed to be a better way to assign value to what a physician was doing in his or her examining room. I don’t have a workable alternative. However, I always have felt that if the folks who were paying the bills would come visit my office (unannounced if they wish) and spend a morning watching me see patients, they could more accurately assign a value to my work. I’m not sure how many of you would be comfortable with that degree of transparency. But for me it would be worth it if it freed me from the burden of coding to justify my effort.
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 live in Spokane, Wash., 99213 and 99214 are important numbers. Interchanging the last two digits can send your mail into the Twilight Zone. Otherwise those five digit sequences have little significance to most Americans ... unless of course you are a physician. You have been told multiple times by practice administrators and business consultants that the failure to attach the proper sequence to your bill for services can threaten the sustainability of your practice’s bottom line or put you at risk for a costly fine.
Numerical codes for office visits were not handed down on stone tablets. There was a time when a physician simply charged for something he called an “office visit” and about half that for a “short” office visit that took less time and probably nothing for a “quick recheck.” He chose the fees based on what he felt was reasonable. I remember reading of one physician who pegged his charges at a dollar per penny of the cost of a regular postage stamp. For a variety of obvious and some unfortunate reasons, these loosely structured fee structures have disappeared.
Now a physician is asked to justify his or her charges by documenting what transpired during the office visit. The patient always has been the best witness, and at least has some sense of how much work the physician has had to do to arrive at diagnosis and suggest a treatment plan. Because the patient usually was paying the bill and had a personal stake in the value of the services provided, this system seemed to make sense.
However, now some large corporate entity or government agency probably is paying the bill and would like some idea of what it is being billed for. Justifying the service provided now falls on the physician. When the billing codes were first introduced and before the payers became more curious, it was easy. I simply applied 99213 to all my office visits and once or twice a day I would code out a visit that seemed more complex as a 99214. I wasn’t keeping track of how many minutes I spent in each visit, how many questions I asked, or how many body parts I examined. Except for patients with injured extremities, everyone was pretty much getting the same exam. My coding was based on my perception of value and effort. If it took more time than usual to remove a bit of cerumen or reassure an unusually concerned parent I chalked that up as my misfortune, not a reason to code the visit as a 99214. If I felt I needed more money, I assumed that my best option was to see more patients. Neither the patients nor the payers seemed to be complaining.
But obviously somewhere someone felt that there were too many providers gaming the system and there needed to be a better way to assign value to what a physician was doing in his or her examining room. I don’t have a workable alternative. However, I always have felt that if the folks who were paying the bills would come visit my office (unannounced if they wish) and spend a morning watching me see patients, they could more accurately assign a value to my work. I’m not sure how many of you would be comfortable with that degree of transparency. But for me it would be worth it if it freed me from the burden of coding to justify my effort.
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 live in Spokane, Wash., 99213 and 99214 are important numbers. Interchanging the last two digits can send your mail into the Twilight Zone. Otherwise those five digit sequences have little significance to most Americans ... unless of course you are a physician. You have been told multiple times by practice administrators and business consultants that the failure to attach the proper sequence to your bill for services can threaten the sustainability of your practice’s bottom line or put you at risk for a costly fine.
Numerical codes for office visits were not handed down on stone tablets. There was a time when a physician simply charged for something he called an “office visit” and about half that for a “short” office visit that took less time and probably nothing for a “quick recheck.” He chose the fees based on what he felt was reasonable. I remember reading of one physician who pegged his charges at a dollar per penny of the cost of a regular postage stamp. For a variety of obvious and some unfortunate reasons, these loosely structured fee structures have disappeared.
Now a physician is asked to justify his or her charges by documenting what transpired during the office visit. The patient always has been the best witness, and at least has some sense of how much work the physician has had to do to arrive at diagnosis and suggest a treatment plan. Because the patient usually was paying the bill and had a personal stake in the value of the services provided, this system seemed to make sense.
However, now some large corporate entity or government agency probably is paying the bill and would like some idea of what it is being billed for. Justifying the service provided now falls on the physician. When the billing codes were first introduced and before the payers became more curious, it was easy. I simply applied 99213 to all my office visits and once or twice a day I would code out a visit that seemed more complex as a 99214. I wasn’t keeping track of how many minutes I spent in each visit, how many questions I asked, or how many body parts I examined. Except for patients with injured extremities, everyone was pretty much getting the same exam. My coding was based on my perception of value and effort. If it took more time than usual to remove a bit of cerumen or reassure an unusually concerned parent I chalked that up as my misfortune, not a reason to code the visit as a 99214. If I felt I needed more money, I assumed that my best option was to see more patients. Neither the patients nor the payers seemed to be complaining.
But obviously somewhere someone felt that there were too many providers gaming the system and there needed to be a better way to assign value to what a physician was doing in his or her examining room. I don’t have a workable alternative. However, I always have felt that if the folks who were paying the bills would come visit my office (unannounced if they wish) and spend a morning watching me see patients, they could more accurately assign a value to my work. I’m not sure how many of you would be comfortable with that degree of transparency. But for me it would be worth it if it freed me from the burden of coding to justify my effort.
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 fog may be lifting
One of the common symptoms described by postconcussion patients is that their heads feel a bit foggy. It may not be simply by chance that “foggy” is the best word to describe the atmosphere surrounding the entire field of concussion diagnosis and management.
Back in the Dark Ages, when the diagnosis of concussion was a simpler binary call, the issue of management seldom created much discussion. If the patient lost consciousness or was amnesic, he (it was less frequently she) could return to activity when his headache was gone and he could remember what he was supposed to do when the quarterback called for a “Red 34, Drive Right Smash” play. That may have even been during the second half of the game in which he was injured.
As it became more widely understood that the diagnosis of concussion didn’t require loss of consciousness and that repeated concussions could have serious sequelae, management became a bit fuzzier. No one had thought much about the recuperative process. Into this vacuum came a wide variety of researchers and providers. Not surprisingly, much of their advice was based on unproven assumptions, including the concept of “brain rest.”
It has taken time, but fortunately, folks with patience and wisdom have questioned these assumptions and begun collecting data. The result of these investigations and others has prompted the American Academy of Pediatrics to publish an updated set of guidelines on concussion management that includes the observation that extended school absence may slow the rehabilitation process (Pediatrics. 2018 Dec. doi: 10.1542/peds.2018-3074).
It is becoming clear that management of concussion can be rather complex and must be individualized to each patient. In my experience, the postconcussion period can unmask behavioral, cognitive, and emotional problems that were preexisting but had received little or no attention. For example, the trauma of the event may trigger anxiety about further injury or exacerbate depression that had been building for years. The student who “couldn’t do algebra” following a head injury may have had a lifelong learning disability that had gone unnoticed. The student athlete with prolonged postconcussion symptoms may indeed have another more serious problem. Hopefully, the new guidelines from the AAP will be a first step toward a more thoughtful and scientifically driven approach to concussion management.
It would be nice if that approach could filter down to the management of the more common but less dramatic pediatric injuries. There is hope. Choosing Wisely – a patient/parent–targeted initiative by the American Board of Internal Medicine Foundation in cooperation with the AAP – points out that, although half of the pediatric head injury patients seen in emergency departments received CT scan, only a third of those studies were indicated. Parents are encouraged to learn more about the risks of CT scans and question the physician when one is recommended.
But, doctors’ habits and old wives’ tales die slowly. I hope that you no longer recommend that parents keep their children awake after a head injury, or wake them every hour to check their pupils. Those counterproductive recommendations make about as much sense as staying out of the swimming pool for an hour after eating a chocolate chip cookie.
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].
One of the common symptoms described by postconcussion patients is that their heads feel a bit foggy. It may not be simply by chance that “foggy” is the best word to describe the atmosphere surrounding the entire field of concussion diagnosis and management.
Back in the Dark Ages, when the diagnosis of concussion was a simpler binary call, the issue of management seldom created much discussion. If the patient lost consciousness or was amnesic, he (it was less frequently she) could return to activity when his headache was gone and he could remember what he was supposed to do when the quarterback called for a “Red 34, Drive Right Smash” play. That may have even been during the second half of the game in which he was injured.
As it became more widely understood that the diagnosis of concussion didn’t require loss of consciousness and that repeated concussions could have serious sequelae, management became a bit fuzzier. No one had thought much about the recuperative process. Into this vacuum came a wide variety of researchers and providers. Not surprisingly, much of their advice was based on unproven assumptions, including the concept of “brain rest.”
It has taken time, but fortunately, folks with patience and wisdom have questioned these assumptions and begun collecting data. The result of these investigations and others has prompted the American Academy of Pediatrics to publish an updated set of guidelines on concussion management that includes the observation that extended school absence may slow the rehabilitation process (Pediatrics. 2018 Dec. doi: 10.1542/peds.2018-3074).
It is becoming clear that management of concussion can be rather complex and must be individualized to each patient. In my experience, the postconcussion period can unmask behavioral, cognitive, and emotional problems that were preexisting but had received little or no attention. For example, the trauma of the event may trigger anxiety about further injury or exacerbate depression that had been building for years. The student who “couldn’t do algebra” following a head injury may have had a lifelong learning disability that had gone unnoticed. The student athlete with prolonged postconcussion symptoms may indeed have another more serious problem. Hopefully, the new guidelines from the AAP will be a first step toward a more thoughtful and scientifically driven approach to concussion management.
It would be nice if that approach could filter down to the management of the more common but less dramatic pediatric injuries. There is hope. Choosing Wisely – a patient/parent–targeted initiative by the American Board of Internal Medicine Foundation in cooperation with the AAP – points out that, although half of the pediatric head injury patients seen in emergency departments received CT scan, only a third of those studies were indicated. Parents are encouraged to learn more about the risks of CT scans and question the physician when one is recommended.
But, doctors’ habits and old wives’ tales die slowly. I hope that you no longer recommend that parents keep their children awake after a head injury, or wake them every hour to check their pupils. Those counterproductive recommendations make about as much sense as staying out of the swimming pool for an hour after eating a chocolate chip cookie.
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].
One of the common symptoms described by postconcussion patients is that their heads feel a bit foggy. It may not be simply by chance that “foggy” is the best word to describe the atmosphere surrounding the entire field of concussion diagnosis and management.
Back in the Dark Ages, when the diagnosis of concussion was a simpler binary call, the issue of management seldom created much discussion. If the patient lost consciousness or was amnesic, he (it was less frequently she) could return to activity when his headache was gone and he could remember what he was supposed to do when the quarterback called for a “Red 34, Drive Right Smash” play. That may have even been during the second half of the game in which he was injured.
As it became more widely understood that the diagnosis of concussion didn’t require loss of consciousness and that repeated concussions could have serious sequelae, management became a bit fuzzier. No one had thought much about the recuperative process. Into this vacuum came a wide variety of researchers and providers. Not surprisingly, much of their advice was based on unproven assumptions, including the concept of “brain rest.”
It has taken time, but fortunately, folks with patience and wisdom have questioned these assumptions and begun collecting data. The result of these investigations and others has prompted the American Academy of Pediatrics to publish an updated set of guidelines on concussion management that includes the observation that extended school absence may slow the rehabilitation process (Pediatrics. 2018 Dec. doi: 10.1542/peds.2018-3074).
It is becoming clear that management of concussion can be rather complex and must be individualized to each patient. In my experience, the postconcussion period can unmask behavioral, cognitive, and emotional problems that were preexisting but had received little or no attention. For example, the trauma of the event may trigger anxiety about further injury or exacerbate depression that had been building for years. The student who “couldn’t do algebra” following a head injury may have had a lifelong learning disability that had gone unnoticed. The student athlete with prolonged postconcussion symptoms may indeed have another more serious problem. Hopefully, the new guidelines from the AAP will be a first step toward a more thoughtful and scientifically driven approach to concussion management.
It would be nice if that approach could filter down to the management of the more common but less dramatic pediatric injuries. There is hope. Choosing Wisely – a patient/parent–targeted initiative by the American Board of Internal Medicine Foundation in cooperation with the AAP – points out that, although half of the pediatric head injury patients seen in emergency departments received CT scan, only a third of those studies were indicated. Parents are encouraged to learn more about the risks of CT scans and question the physician when one is recommended.
But, doctors’ habits and old wives’ tales die slowly. I hope that you no longer recommend that parents keep their children awake after a head injury, or wake them every hour to check their pupils. Those counterproductive recommendations make about as much sense as staying out of the swimming pool for an hour after eating a chocolate chip cookie.
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 other side of activity
While the increasing prevalence of obesity has been obvious for nearly half a century, it is only in the last decade or two that the focus has broadened to include the associated decline in physical activity.
A recent paper attempts to sharpen that focus by examining the timeline of that decline (Pediatrics 2019 Jan. doi: 10.1542/peds.2018-0994.). Using a device incorporating five sensors, one of which was an accelerometer, the investigators collected data from 600 children from five European countries accumulating more than 1,200 observations. What they discovered was that their subjects’ physical activity declined by 75 minutes per day from ages 6 to 11 years of age while sedentary behavior increased more than 100 minutes over that same interval. This observation is concerning because previous attention has focused intervention on adolescents assuming that the erosion of physical activity was occurring primarily during the teen years.
Not surprisingly the authors suggest that more studies should be performed to aid in the design of more sharply targeted interventions. While more information may be helpful, their current findings and an abundance of anecdotal observations suggest that to be effective that intervention must begin well before children reach school age.
What should this intervention look like? Currently, the emphasis seems to have been on programs that encourage activity. The National Football League is promoting its NFL Play 60 initiative. The Afterschool Alliance has its Kids on the Move programs. Former First Lady Michelle Obama has been the spokesperson and driving force behind Let’s Move. And, the American Academy of Pediatrics has recently been encouraging both parents and pediatricians to appreciate The Power of Play to encourage children to get into more physical activity. All of these initiatives are well meaning, but I suspect their effectiveness is usually limited to the public awareness they generate.
We seem to have forgotten that there are two sides to the equation. The accelerometer study from Europe should remind us that our initiatives should also be addressing the problem of epidemic inactivity with equal vigor. Creating programs that focus on increasing activity can be expensive. There may be costs for equipment, spaces to be maintained, and staff to be paid. On the other hand, curbing sedentary behavior requires only an adult with the courage to say, “No.” “No, we will have the television for only an hour today.” “No, you can’t play your video game until after dinner.”
While addressing the disciplinary side of the activity-inactivity dichotomy may be relatively inexpensive, it does seem to have a cost on parents. It requires them to buy into the idea that, given even the most-limited supply of objects and infrastructure, most children can keep themselves entertained and active. There does seem to be a small subset of children who enter the world with a sedentary mindset, possibly inherited from their parents. This unfortunate minority will require some creative intervention to achieve a healthy level of activity.
However, most young children who have become accustomed to being amused by sedentary “activities” such as television and video games still retain their innate creativity and natural inclination to be physically active. Unfortunately, unmasking these health-sustaining attributes may require a long and unpleasant weaning period that many parents don’t seem to have the patience to endure. The longer the child has been allowed to engage in sedentary behaviors, the longer this adjustment period will be, yet another argument for early intervention.
Encouraging physical activity is something we should be doing every day in our offices, but it must go hand in hand with an equivalent emphasis on helping parents create a discipline framework that discourages sedentary behavior.
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].
While the increasing prevalence of obesity has been obvious for nearly half a century, it is only in the last decade or two that the focus has broadened to include the associated decline in physical activity.
A recent paper attempts to sharpen that focus by examining the timeline of that decline (Pediatrics 2019 Jan. doi: 10.1542/peds.2018-0994.). Using a device incorporating five sensors, one of which was an accelerometer, the investigators collected data from 600 children from five European countries accumulating more than 1,200 observations. What they discovered was that their subjects’ physical activity declined by 75 minutes per day from ages 6 to 11 years of age while sedentary behavior increased more than 100 minutes over that same interval. This observation is concerning because previous attention has focused intervention on adolescents assuming that the erosion of physical activity was occurring primarily during the teen years.
Not surprisingly the authors suggest that more studies should be performed to aid in the design of more sharply targeted interventions. While more information may be helpful, their current findings and an abundance of anecdotal observations suggest that to be effective that intervention must begin well before children reach school age.
What should this intervention look like? Currently, the emphasis seems to have been on programs that encourage activity. The National Football League is promoting its NFL Play 60 initiative. The Afterschool Alliance has its Kids on the Move programs. Former First Lady Michelle Obama has been the spokesperson and driving force behind Let’s Move. And, the American Academy of Pediatrics has recently been encouraging both parents and pediatricians to appreciate The Power of Play to encourage children to get into more physical activity. All of these initiatives are well meaning, but I suspect their effectiveness is usually limited to the public awareness they generate.
We seem to have forgotten that there are two sides to the equation. The accelerometer study from Europe should remind us that our initiatives should also be addressing the problem of epidemic inactivity with equal vigor. Creating programs that focus on increasing activity can be expensive. There may be costs for equipment, spaces to be maintained, and staff to be paid. On the other hand, curbing sedentary behavior requires only an adult with the courage to say, “No.” “No, we will have the television for only an hour today.” “No, you can’t play your video game until after dinner.”
While addressing the disciplinary side of the activity-inactivity dichotomy may be relatively inexpensive, it does seem to have a cost on parents. It requires them to buy into the idea that, given even the most-limited supply of objects and infrastructure, most children can keep themselves entertained and active. There does seem to be a small subset of children who enter the world with a sedentary mindset, possibly inherited from their parents. This unfortunate minority will require some creative intervention to achieve a healthy level of activity.
However, most young children who have become accustomed to being amused by sedentary “activities” such as television and video games still retain their innate creativity and natural inclination to be physically active. Unfortunately, unmasking these health-sustaining attributes may require a long and unpleasant weaning period that many parents don’t seem to have the patience to endure. The longer the child has been allowed to engage in sedentary behaviors, the longer this adjustment period will be, yet another argument for early intervention.
Encouraging physical activity is something we should be doing every day in our offices, but it must go hand in hand with an equivalent emphasis on helping parents create a discipline framework that discourages sedentary behavior.
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].
While the increasing prevalence of obesity has been obvious for nearly half a century, it is only in the last decade or two that the focus has broadened to include the associated decline in physical activity.
A recent paper attempts to sharpen that focus by examining the timeline of that decline (Pediatrics 2019 Jan. doi: 10.1542/peds.2018-0994.). Using a device incorporating five sensors, one of which was an accelerometer, the investigators collected data from 600 children from five European countries accumulating more than 1,200 observations. What they discovered was that their subjects’ physical activity declined by 75 minutes per day from ages 6 to 11 years of age while sedentary behavior increased more than 100 minutes over that same interval. This observation is concerning because previous attention has focused intervention on adolescents assuming that the erosion of physical activity was occurring primarily during the teen years.
Not surprisingly the authors suggest that more studies should be performed to aid in the design of more sharply targeted interventions. While more information may be helpful, their current findings and an abundance of anecdotal observations suggest that to be effective that intervention must begin well before children reach school age.
What should this intervention look like? Currently, the emphasis seems to have been on programs that encourage activity. The National Football League is promoting its NFL Play 60 initiative. The Afterschool Alliance has its Kids on the Move programs. Former First Lady Michelle Obama has been the spokesperson and driving force behind Let’s Move. And, the American Academy of Pediatrics has recently been encouraging both parents and pediatricians to appreciate The Power of Play to encourage children to get into more physical activity. All of these initiatives are well meaning, but I suspect their effectiveness is usually limited to the public awareness they generate.
We seem to have forgotten that there are two sides to the equation. The accelerometer study from Europe should remind us that our initiatives should also be addressing the problem of epidemic inactivity with equal vigor. Creating programs that focus on increasing activity can be expensive. There may be costs for equipment, spaces to be maintained, and staff to be paid. On the other hand, curbing sedentary behavior requires only an adult with the courage to say, “No.” “No, we will have the television for only an hour today.” “No, you can’t play your video game until after dinner.”
While addressing the disciplinary side of the activity-inactivity dichotomy may be relatively inexpensive, it does seem to have a cost on parents. It requires them to buy into the idea that, given even the most-limited supply of objects and infrastructure, most children can keep themselves entertained and active. There does seem to be a small subset of children who enter the world with a sedentary mindset, possibly inherited from their parents. This unfortunate minority will require some creative intervention to achieve a healthy level of activity.
However, most young children who have become accustomed to being amused by sedentary “activities” such as television and video games still retain their innate creativity and natural inclination to be physically active. Unfortunately, unmasking these health-sustaining attributes may require a long and unpleasant weaning period that many parents don’t seem to have the patience to endure. The longer the child has been allowed to engage in sedentary behaviors, the longer this adjustment period will be, yet another argument for early intervention.
Encouraging physical activity is something we should be doing every day in our offices, but it must go hand in hand with an equivalent emphasis on helping parents create a discipline framework that discourages sedentary behavior.
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].
Timeout or not?
However, when it comes to timeout, child behavior specialists have failed to reach consensus. In a recent Washington Post article, Claire Gillespie quotes several experts who feel that timeout is ineffective at best and damaging and dangerous at its worst. (Timeouts are a dated and ineffective parenting strategy. So what’s a good alternative? Washington Post, Nov. 29, 2019.)
How do you feel about timeouts? Do you think they are effective? Do you think that brief periods of isolation in a home setting will increase a child’s anxiety? Will the threat of isolation create long-lasting psychological harm? Or do you believe that properly done timeout can be a safe consequence when a child misbehaves?
The disagreement seems to be another one of those issues of apples and oranges. Do I believe that solitary confinement in a prison or chained to a metal cot in the basement of mentally deranged and obsessive parent will leave psychological scars? Of course I do. But, do I believe that a few minutes alone in a child’s own room in a home in which her parents frequently express their affection will cause any harm? Not for a moment. It’s not so much where the child is. It’s where she isn’t. Of course, she doesn’t want to be isolated from the family and that sends a powerful but not harmful message. A big hug and a kiss at the end of the timeout wipes the slate clear.
Some critics believe that timeout should be condemned because it is a punishment. Here again, it’s a case of semantics. Punishments in my mind are inhumane, “a pound of flesh” or “an eye for an eye” response. A well-done timeout is a harmless consequence and one that particularly makes sense when the misbehavior has been or is creating an unpleasant atmosphere in the family.
Other critics will claim that timeouts aren’t an effective deterrent. Correct! They aren’t meant to be a deterrent. A detailed discussion, more likely a lecture, about the misbehavior before and even immediately after a timeout is a waste of time. If timeouts are a deterrent it is because of their safety. Parents will be more likely to use them as a consequence, and most importantly to follow up on their threats. A parent whose words can be believed is his or her own best deterrent.
Finally, many parents who have tried timeouts will claim that they don’t work. This is true if they were talking about deterrent value. Maybe the timeouts have been too long or too short. About 30-60 seconds after the child stops crying may be enough. However, if the parents mean that the child wouldn’t stay in timeout in his room, then they have not taken the difficult final step. If the parent doesn’t have the stamina to keep walking the child back into his room, then it is time to put a latch on the door. Whoops. ... I may have lost some of you who up to this point have been nodding agreement along with my rationale. I know, I know it smacks of prison. It may be used only once or twice, but it will remain as a tangible reminder that sometimes enough is enough. Frequent trips into the room to help the child self-calm make it clear he hasn’t been abandoned.
It’s hard to provide a fully nuanced argument for including timeout in the consequence arsenal in 500 words. I’m eager to hear how you feel on the subject. I can take the heat.
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].
However, when it comes to timeout, child behavior specialists have failed to reach consensus. In a recent Washington Post article, Claire Gillespie quotes several experts who feel that timeout is ineffective at best and damaging and dangerous at its worst. (Timeouts are a dated and ineffective parenting strategy. So what’s a good alternative? Washington Post, Nov. 29, 2019.)
How do you feel about timeouts? Do you think they are effective? Do you think that brief periods of isolation in a home setting will increase a child’s anxiety? Will the threat of isolation create long-lasting psychological harm? Or do you believe that properly done timeout can be a safe consequence when a child misbehaves?
The disagreement seems to be another one of those issues of apples and oranges. Do I believe that solitary confinement in a prison or chained to a metal cot in the basement of mentally deranged and obsessive parent will leave psychological scars? Of course I do. But, do I believe that a few minutes alone in a child’s own room in a home in which her parents frequently express their affection will cause any harm? Not for a moment. It’s not so much where the child is. It’s where she isn’t. Of course, she doesn’t want to be isolated from the family and that sends a powerful but not harmful message. A big hug and a kiss at the end of the timeout wipes the slate clear.
Some critics believe that timeout should be condemned because it is a punishment. Here again, it’s a case of semantics. Punishments in my mind are inhumane, “a pound of flesh” or “an eye for an eye” response. A well-done timeout is a harmless consequence and one that particularly makes sense when the misbehavior has been or is creating an unpleasant atmosphere in the family.
Other critics will claim that timeouts aren’t an effective deterrent. Correct! They aren’t meant to be a deterrent. A detailed discussion, more likely a lecture, about the misbehavior before and even immediately after a timeout is a waste of time. If timeouts are a deterrent it is because of their safety. Parents will be more likely to use them as a consequence, and most importantly to follow up on their threats. A parent whose words can be believed is his or her own best deterrent.
Finally, many parents who have tried timeouts will claim that they don’t work. This is true if they were talking about deterrent value. Maybe the timeouts have been too long or too short. About 30-60 seconds after the child stops crying may be enough. However, if the parents mean that the child wouldn’t stay in timeout in his room, then they have not taken the difficult final step. If the parent doesn’t have the stamina to keep walking the child back into his room, then it is time to put a latch on the door. Whoops. ... I may have lost some of you who up to this point have been nodding agreement along with my rationale. I know, I know it smacks of prison. It may be used only once or twice, but it will remain as a tangible reminder that sometimes enough is enough. Frequent trips into the room to help the child self-calm make it clear he hasn’t been abandoned.
It’s hard to provide a fully nuanced argument for including timeout in the consequence arsenal in 500 words. I’m eager to hear how you feel on the subject. I can take the heat.
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].
However, when it comes to timeout, child behavior specialists have failed to reach consensus. In a recent Washington Post article, Claire Gillespie quotes several experts who feel that timeout is ineffective at best and damaging and dangerous at its worst. (Timeouts are a dated and ineffective parenting strategy. So what’s a good alternative? Washington Post, Nov. 29, 2019.)
How do you feel about timeouts? Do you think they are effective? Do you think that brief periods of isolation in a home setting will increase a child’s anxiety? Will the threat of isolation create long-lasting psychological harm? Or do you believe that properly done timeout can be a safe consequence when a child misbehaves?
The disagreement seems to be another one of those issues of apples and oranges. Do I believe that solitary confinement in a prison or chained to a metal cot in the basement of mentally deranged and obsessive parent will leave psychological scars? Of course I do. But, do I believe that a few minutes alone in a child’s own room in a home in which her parents frequently express their affection will cause any harm? Not for a moment. It’s not so much where the child is. It’s where she isn’t. Of course, she doesn’t want to be isolated from the family and that sends a powerful but not harmful message. A big hug and a kiss at the end of the timeout wipes the slate clear.
Some critics believe that timeout should be condemned because it is a punishment. Here again, it’s a case of semantics. Punishments in my mind are inhumane, “a pound of flesh” or “an eye for an eye” response. A well-done timeout is a harmless consequence and one that particularly makes sense when the misbehavior has been or is creating an unpleasant atmosphere in the family.
Other critics will claim that timeouts aren’t an effective deterrent. Correct! They aren’t meant to be a deterrent. A detailed discussion, more likely a lecture, about the misbehavior before and even immediately after a timeout is a waste of time. If timeouts are a deterrent it is because of their safety. Parents will be more likely to use them as a consequence, and most importantly to follow up on their threats. A parent whose words can be believed is his or her own best deterrent.
Finally, many parents who have tried timeouts will claim that they don’t work. This is true if they were talking about deterrent value. Maybe the timeouts have been too long or too short. About 30-60 seconds after the child stops crying may be enough. However, if the parents mean that the child wouldn’t stay in timeout in his room, then they have not taken the difficult final step. If the parent doesn’t have the stamina to keep walking the child back into his room, then it is time to put a latch on the door. Whoops. ... I may have lost some of you who up to this point have been nodding agreement along with my rationale. I know, I know it smacks of prison. It may be used only once or twice, but it will remain as a tangible reminder that sometimes enough is enough. Frequent trips into the room to help the child self-calm make it clear he hasn’t been abandoned.
It’s hard to provide a fully nuanced argument for including timeout in the consequence arsenal in 500 words. I’m eager to hear how you feel on the subject. I can take the heat.
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].
Beware of the Ides of August
I suspect, like me, you have never put much stock in astrology. It just doesn’t feel like a good fit with our science-based training. But recent evidence suggests that maybe we should be paying more attention to the whether our patient is a Taurus or a Leo when we are hunting for a diagnosis.
Three researchers from Harvard’s Schools of Medicine and Public Health have followed several hundred thousand children born between 2007 and 2009 until 2016 (“Attention deficit–hyperactivity disorder and month of school enrollment,” N Engl J Med. 2018;379:2122-30). Their data revealed that, in states with a Sept. 1 school entry cutoff, children born in August had rates of diagnosis and treatment of ADHD that were 34% higher than those born in other months.
Their findings could mean that astrology deserves a lot more credibility than we have been giving it. More likely it suggests that those of us committed to the health and education of children deserve a booby prize for objectivity. In a New York Times Op-Ed piece, the study’s investigators point out that their data show that the relative immaturity of the youngest children in a class too often is interpreted as a symptom of ADHD (“The Link Between August Birthdays and ADHD,” 2018 Nov 28. Jena AB et al.).
For many of us who practiced pediatrics before the ADHD phenomenon erupted, this new study substantiates our suspicion that the condition is currently being both overdiagnosed and overtreated. The data leave unanswered the question of whom or what is to blame for starting the epidemic. However, the study does suggest that physicians and educators deserve some culpability by failing to maintain their objectivity when interpreting childhood behavior.
I clearly can recall the first time I spoke to a group of teachers about the articles I had been reading that suggested a beneficial effect of treating “hyperactive” children with stimulant medication. The teachers uniformly were incredulous and repulsed by the counterintuitive notion of medicating children whom they saw as difficult, but not out of the broad range of age and developmental maturity they could expect to see in their classrooms.
The next part of the narrative is where the story gets sad. Deceived by those success stories we – doctors, parents, and educators – began to narrow our view of normal behavior because we now had a medication to “correct” a certain constellation of problem behaviors. Pharmaceutical companies joined us with their best efforts to meet the demand we were creating.
Forgotten was the fact that children mature at different rates and that normal but less mature children can exhibit many of the behaviors we now place under the ADHD umbrella and be considered as candidates for medication. Until recently, other causes of hyperactivity such as sleep deprivation were ignored. Hopefully, this new study will rekindle an interest in how parents, pediatricians, and educators evaluate and manage those children who arrive in school several months behind their peers in emotional and behavioral development.
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 suspect, like me, you have never put much stock in astrology. It just doesn’t feel like a good fit with our science-based training. But recent evidence suggests that maybe we should be paying more attention to the whether our patient is a Taurus or a Leo when we are hunting for a diagnosis.
Three researchers from Harvard’s Schools of Medicine and Public Health have followed several hundred thousand children born between 2007 and 2009 until 2016 (“Attention deficit–hyperactivity disorder and month of school enrollment,” N Engl J Med. 2018;379:2122-30). Their data revealed that, in states with a Sept. 1 school entry cutoff, children born in August had rates of diagnosis and treatment of ADHD that were 34% higher than those born in other months.
Their findings could mean that astrology deserves a lot more credibility than we have been giving it. More likely it suggests that those of us committed to the health and education of children deserve a booby prize for objectivity. In a New York Times Op-Ed piece, the study’s investigators point out that their data show that the relative immaturity of the youngest children in a class too often is interpreted as a symptom of ADHD (“The Link Between August Birthdays and ADHD,” 2018 Nov 28. Jena AB et al.).
For many of us who practiced pediatrics before the ADHD phenomenon erupted, this new study substantiates our suspicion that the condition is currently being both overdiagnosed and overtreated. The data leave unanswered the question of whom or what is to blame for starting the epidemic. However, the study does suggest that physicians and educators deserve some culpability by failing to maintain their objectivity when interpreting childhood behavior.
I clearly can recall the first time I spoke to a group of teachers about the articles I had been reading that suggested a beneficial effect of treating “hyperactive” children with stimulant medication. The teachers uniformly were incredulous and repulsed by the counterintuitive notion of medicating children whom they saw as difficult, but not out of the broad range of age and developmental maturity they could expect to see in their classrooms.
The next part of the narrative is where the story gets sad. Deceived by those success stories we – doctors, parents, and educators – began to narrow our view of normal behavior because we now had a medication to “correct” a certain constellation of problem behaviors. Pharmaceutical companies joined us with their best efforts to meet the demand we were creating.
Forgotten was the fact that children mature at different rates and that normal but less mature children can exhibit many of the behaviors we now place under the ADHD umbrella and be considered as candidates for medication. Until recently, other causes of hyperactivity such as sleep deprivation were ignored. Hopefully, this new study will rekindle an interest in how parents, pediatricians, and educators evaluate and manage those children who arrive in school several months behind their peers in emotional and behavioral development.
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 suspect, like me, you have never put much stock in astrology. It just doesn’t feel like a good fit with our science-based training. But recent evidence suggests that maybe we should be paying more attention to the whether our patient is a Taurus or a Leo when we are hunting for a diagnosis.
Three researchers from Harvard’s Schools of Medicine and Public Health have followed several hundred thousand children born between 2007 and 2009 until 2016 (“Attention deficit–hyperactivity disorder and month of school enrollment,” N Engl J Med. 2018;379:2122-30). Their data revealed that, in states with a Sept. 1 school entry cutoff, children born in August had rates of diagnosis and treatment of ADHD that were 34% higher than those born in other months.
Their findings could mean that astrology deserves a lot more credibility than we have been giving it. More likely it suggests that those of us committed to the health and education of children deserve a booby prize for objectivity. In a New York Times Op-Ed piece, the study’s investigators point out that their data show that the relative immaturity of the youngest children in a class too often is interpreted as a symptom of ADHD (“The Link Between August Birthdays and ADHD,” 2018 Nov 28. Jena AB et al.).
For many of us who practiced pediatrics before the ADHD phenomenon erupted, this new study substantiates our suspicion that the condition is currently being both overdiagnosed and overtreated. The data leave unanswered the question of whom or what is to blame for starting the epidemic. However, the study does suggest that physicians and educators deserve some culpability by failing to maintain their objectivity when interpreting childhood behavior.
I clearly can recall the first time I spoke to a group of teachers about the articles I had been reading that suggested a beneficial effect of treating “hyperactive” children with stimulant medication. The teachers uniformly were incredulous and repulsed by the counterintuitive notion of medicating children whom they saw as difficult, but not out of the broad range of age and developmental maturity they could expect to see in their classrooms.
The next part of the narrative is where the story gets sad. Deceived by those success stories we – doctors, parents, and educators – began to narrow our view of normal behavior because we now had a medication to “correct” a certain constellation of problem behaviors. Pharmaceutical companies joined us with their best efforts to meet the demand we were creating.
Forgotten was the fact that children mature at different rates and that normal but less mature children can exhibit many of the behaviors we now place under the ADHD umbrella and be considered as candidates for medication. Until recently, other causes of hyperactivity such as sleep deprivation were ignored. Hopefully, this new study will rekindle an interest in how parents, pediatricians, and educators evaluate and manage those children who arrive in school several months behind their peers in emotional and behavioral development.
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 risks of intensive parenting
“Parenthood in the United States has become much more demanding than it used to be.” It is hard to argue with this opening sentence in Clair Cain Miller’s op-ed piece titled “The Relentlessness of Modern Parenting,” published in the Dec. 25, 2018, electronic edition of the New York Times. But just in case you don’t agree with her premise, she lays out her case with evidence that parents in this country are investing more time, attention, and money into raising their children than was the norm several decades ago. She goes on to describe how this “intensive parenting” is taking its toll on parents on both sides of our nation’s widening economic divide. I’m sure you have seen it in your office in the tired faces and stooped shoulders of your patients’ parents. You may even be struggling yourself to find the time and energy to be the parent you believe your children need and deserve.
While there is debate on whether “parent” is inherently a verb or a noun (“Parent is a Noun, Not a Verb,” Cliff Price, the Australian Family Association; “Parent is a Verb – and we All do it,” Zaeli Kane, mother.ly), it is clear that “parenting” used as a verb has become one of the hot topics in pediatrics over the last quarter century and with it an epidemic of parental anxiety. What are the driving forces behind this shift in attitude? How has a relatively relaxed nature-will-take-its-course philosophy become an anxiety-provoking, stress-inducing phenomenon that will inevitably result in a disturbed and disappointed adult without a parent’s relentless attention to creating a nurturing and optimally stimulating environment?
Of course, parents have always worried about the health of their children and hope that they will be successful, regardless of how one defines success. But this natural parental concern seems to have gotten out of hand.
Is it because North Americans are having fewer children? Is it because in smaller families children become adults with little or no practical experience with hands-on child rearing? Are parents reacting to the predictions that the next generation may not be able to earn enough to match their parents’ lifestyle?
How much blame should fall on those of us who market ourselves as child health experts? Have we failed to put the research supporting the importance of early life experiences in the proper perspective? Are our recommendations creating unrealistic goals for parents? The American Academy of Pediatrics advice on breastfeeding duration and room sharing come to mind immediately. How realistic is it for parents to coview the majority of television shows their children are watching?
On one hand, we are beginning to realize that free play is important, but for years pediatricians have been one of the loudest voices supporting playground and toy safety. These two initiatives can certainly coexist, but I fear that at times we have begun to sound a bit like that annoying parent who is constantly warning his or her child, “Don’t do that, you’ll hurt yourself?”
Have we become the worry merchants? As a marketing strategy it seems to be working well. If we generate enough advice that supports an intensive parenting style, we can fill our waiting rooms with families struggling to meet the expectations we have been promoting.
A child can thrive without intensive parenting as long as he feels loved and he has been provided an environment with sensible limits to keep him safe.
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].
“Parenthood in the United States has become much more demanding than it used to be.” It is hard to argue with this opening sentence in Clair Cain Miller’s op-ed piece titled “The Relentlessness of Modern Parenting,” published in the Dec. 25, 2018, electronic edition of the New York Times. But just in case you don’t agree with her premise, she lays out her case with evidence that parents in this country are investing more time, attention, and money into raising their children than was the norm several decades ago. She goes on to describe how this “intensive parenting” is taking its toll on parents on both sides of our nation’s widening economic divide. I’m sure you have seen it in your office in the tired faces and stooped shoulders of your patients’ parents. You may even be struggling yourself to find the time and energy to be the parent you believe your children need and deserve.
While there is debate on whether “parent” is inherently a verb or a noun (“Parent is a Noun, Not a Verb,” Cliff Price, the Australian Family Association; “Parent is a Verb – and we All do it,” Zaeli Kane, mother.ly), it is clear that “parenting” used as a verb has become one of the hot topics in pediatrics over the last quarter century and with it an epidemic of parental anxiety. What are the driving forces behind this shift in attitude? How has a relatively relaxed nature-will-take-its-course philosophy become an anxiety-provoking, stress-inducing phenomenon that will inevitably result in a disturbed and disappointed adult without a parent’s relentless attention to creating a nurturing and optimally stimulating environment?
Of course, parents have always worried about the health of their children and hope that they will be successful, regardless of how one defines success. But this natural parental concern seems to have gotten out of hand.
Is it because North Americans are having fewer children? Is it because in smaller families children become adults with little or no practical experience with hands-on child rearing? Are parents reacting to the predictions that the next generation may not be able to earn enough to match their parents’ lifestyle?
How much blame should fall on those of us who market ourselves as child health experts? Have we failed to put the research supporting the importance of early life experiences in the proper perspective? Are our recommendations creating unrealistic goals for parents? The American Academy of Pediatrics advice on breastfeeding duration and room sharing come to mind immediately. How realistic is it for parents to coview the majority of television shows their children are watching?
On one hand, we are beginning to realize that free play is important, but for years pediatricians have been one of the loudest voices supporting playground and toy safety. These two initiatives can certainly coexist, but I fear that at times we have begun to sound a bit like that annoying parent who is constantly warning his or her child, “Don’t do that, you’ll hurt yourself?”
Have we become the worry merchants? As a marketing strategy it seems to be working well. If we generate enough advice that supports an intensive parenting style, we can fill our waiting rooms with families struggling to meet the expectations we have been promoting.
A child can thrive without intensive parenting as long as he feels loved and he has been provided an environment with sensible limits to keep him safe.
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].
“Parenthood in the United States has become much more demanding than it used to be.” It is hard to argue with this opening sentence in Clair Cain Miller’s op-ed piece titled “The Relentlessness of Modern Parenting,” published in the Dec. 25, 2018, electronic edition of the New York Times. But just in case you don’t agree with her premise, she lays out her case with evidence that parents in this country are investing more time, attention, and money into raising their children than was the norm several decades ago. She goes on to describe how this “intensive parenting” is taking its toll on parents on both sides of our nation’s widening economic divide. I’m sure you have seen it in your office in the tired faces and stooped shoulders of your patients’ parents. You may even be struggling yourself to find the time and energy to be the parent you believe your children need and deserve.
While there is debate on whether “parent” is inherently a verb or a noun (“Parent is a Noun, Not a Verb,” Cliff Price, the Australian Family Association; “Parent is a Verb – and we All do it,” Zaeli Kane, mother.ly), it is clear that “parenting” used as a verb has become one of the hot topics in pediatrics over the last quarter century and with it an epidemic of parental anxiety. What are the driving forces behind this shift in attitude? How has a relatively relaxed nature-will-take-its-course philosophy become an anxiety-provoking, stress-inducing phenomenon that will inevitably result in a disturbed and disappointed adult without a parent’s relentless attention to creating a nurturing and optimally stimulating environment?
Of course, parents have always worried about the health of their children and hope that they will be successful, regardless of how one defines success. But this natural parental concern seems to have gotten out of hand.
Is it because North Americans are having fewer children? Is it because in smaller families children become adults with little or no practical experience with hands-on child rearing? Are parents reacting to the predictions that the next generation may not be able to earn enough to match their parents’ lifestyle?
How much blame should fall on those of us who market ourselves as child health experts? Have we failed to put the research supporting the importance of early life experiences in the proper perspective? Are our recommendations creating unrealistic goals for parents? The American Academy of Pediatrics advice on breastfeeding duration and room sharing come to mind immediately. How realistic is it for parents to coview the majority of television shows their children are watching?
On one hand, we are beginning to realize that free play is important, but for years pediatricians have been one of the loudest voices supporting playground and toy safety. These two initiatives can certainly coexist, but I fear that at times we have begun to sound a bit like that annoying parent who is constantly warning his or her child, “Don’t do that, you’ll hurt yourself?”
Have we become the worry merchants? As a marketing strategy it seems to be working well. If we generate enough advice that supports an intensive parenting style, we can fill our waiting rooms with families struggling to meet the expectations we have been promoting.
A child can thrive without intensive parenting as long as he feels loved and he has been provided an environment with sensible limits to keep him safe.
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].
Tidying up a motley crew
It probably is buried in a box in your parents’ basement, but try to remember your soccer or football or track team picture from when you were in eighth grade. Tragically but predictably, most of your peers who were chubby in third grade are nowhere to be seen in the photo. But still it was a pretty motley crew. Some of you weren’t even up to the armpits of your taller teammates. Some guys were shaving. Others had little boys’ voices. Half the girls had reached menarche. Another third were still waiting impatiently for a breast bud.
The precocious and the late bloomers, you were all on the team. But it was pretty clear that those who had matured first generally were the more talented and successful athletes. By the time you were juniors in high school, many of those who matured late had quit the sport or been cut from the team, unable to catch up. Others may have been forced to give up the sport by their parents, who were concerned about the risk of injury when bodies of disparate size collide. A few of the early bloomers may have become depressed, older adolescents who had failed to match the hype and expectations that came when they were a head taller than their grade school teammates.
These natural consequences of biological variation are not small potatoes for the fragile egos of adolescents and preadolescents. The lead article in the November 2018 Pediatrics offers a partial solution for the issue of sports participation in a population with widely discrepant states of maturity (“Biobanding: A New Paradigm for Youth Sports and Training,” Pediatrics. 2018 Nov;142[5]:e20180423). The authors describe a system they call biobanding, in which “the percentage of predicted adult stature attained at the time of observation as the indicator of maturity status” is used to create groups or bands of participants with similar levels of maturity. They argue that this method is easy to use and report and that has been used with some success in Great Britain.
At first blush, biobanding sounds appealing, particularly for large communities. However, as someone who grew up in and practiced in a small town, I’m not sure how successfully it could be scaled down. There have been years when I could easily have disqualified a third of the high school football team were I to take into consideration the size and maturity of the competition they would be facing. But I didn’t. The fading interest in football in Maine has prompted some schools to consider moving to less-than-11-player competition or even to flag football. To some extent, the problem is taking care of itself.
How much tinkering should we be doing with something that is arguably a distorted natural selection process? With thoughtfully crafted rules, diligent supervision, and officiating, most of the issues of safety that one might attribute to discrepancies in maturity can be minimized. There always will be children who become discouraged and quit when they see the handwriting on the wall that reads “those who mature early win.” I’m certainly not wild about parents holding their children out of school to give them a jump on their peers. It can spiral out of control.
A more appealing solution is to do a better job of advertising the many successful late bloomers in professional sports ... and making sure that late-blooming children are given an abundance of active and competitive (if they wish) alternatives to sports dominated by their early maturing peers.
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].
It probably is buried in a box in your parents’ basement, but try to remember your soccer or football or track team picture from when you were in eighth grade. Tragically but predictably, most of your peers who were chubby in third grade are nowhere to be seen in the photo. But still it was a pretty motley crew. Some of you weren’t even up to the armpits of your taller teammates. Some guys were shaving. Others had little boys’ voices. Half the girls had reached menarche. Another third were still waiting impatiently for a breast bud.
The precocious and the late bloomers, you were all on the team. But it was pretty clear that those who had matured first generally were the more talented and successful athletes. By the time you were juniors in high school, many of those who matured late had quit the sport or been cut from the team, unable to catch up. Others may have been forced to give up the sport by their parents, who were concerned about the risk of injury when bodies of disparate size collide. A few of the early bloomers may have become depressed, older adolescents who had failed to match the hype and expectations that came when they were a head taller than their grade school teammates.
These natural consequences of biological variation are not small potatoes for the fragile egos of adolescents and preadolescents. The lead article in the November 2018 Pediatrics offers a partial solution for the issue of sports participation in a population with widely discrepant states of maturity (“Biobanding: A New Paradigm for Youth Sports and Training,” Pediatrics. 2018 Nov;142[5]:e20180423). The authors describe a system they call biobanding, in which “the percentage of predicted adult stature attained at the time of observation as the indicator of maturity status” is used to create groups or bands of participants with similar levels of maturity. They argue that this method is easy to use and report and that has been used with some success in Great Britain.
At first blush, biobanding sounds appealing, particularly for large communities. However, as someone who grew up in and practiced in a small town, I’m not sure how successfully it could be scaled down. There have been years when I could easily have disqualified a third of the high school football team were I to take into consideration the size and maturity of the competition they would be facing. But I didn’t. The fading interest in football in Maine has prompted some schools to consider moving to less-than-11-player competition or even to flag football. To some extent, the problem is taking care of itself.
How much tinkering should we be doing with something that is arguably a distorted natural selection process? With thoughtfully crafted rules, diligent supervision, and officiating, most of the issues of safety that one might attribute to discrepancies in maturity can be minimized. There always will be children who become discouraged and quit when they see the handwriting on the wall that reads “those who mature early win.” I’m certainly not wild about parents holding their children out of school to give them a jump on their peers. It can spiral out of control.
A more appealing solution is to do a better job of advertising the many successful late bloomers in professional sports ... and making sure that late-blooming children are given an abundance of active and competitive (if they wish) alternatives to sports dominated by their early maturing peers.
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].
It probably is buried in a box in your parents’ basement, but try to remember your soccer or football or track team picture from when you were in eighth grade. Tragically but predictably, most of your peers who were chubby in third grade are nowhere to be seen in the photo. But still it was a pretty motley crew. Some of you weren’t even up to the armpits of your taller teammates. Some guys were shaving. Others had little boys’ voices. Half the girls had reached menarche. Another third were still waiting impatiently for a breast bud.
The precocious and the late bloomers, you were all on the team. But it was pretty clear that those who had matured first generally were the more talented and successful athletes. By the time you were juniors in high school, many of those who matured late had quit the sport or been cut from the team, unable to catch up. Others may have been forced to give up the sport by their parents, who were concerned about the risk of injury when bodies of disparate size collide. A few of the early bloomers may have become depressed, older adolescents who had failed to match the hype and expectations that came when they were a head taller than their grade school teammates.
These natural consequences of biological variation are not small potatoes for the fragile egos of adolescents and preadolescents. The lead article in the November 2018 Pediatrics offers a partial solution for the issue of sports participation in a population with widely discrepant states of maturity (“Biobanding: A New Paradigm for Youth Sports and Training,” Pediatrics. 2018 Nov;142[5]:e20180423). The authors describe a system they call biobanding, in which “the percentage of predicted adult stature attained at the time of observation as the indicator of maturity status” is used to create groups or bands of participants with similar levels of maturity. They argue that this method is easy to use and report and that has been used with some success in Great Britain.
At first blush, biobanding sounds appealing, particularly for large communities. However, as someone who grew up in and practiced in a small town, I’m not sure how successfully it could be scaled down. There have been years when I could easily have disqualified a third of the high school football team were I to take into consideration the size and maturity of the competition they would be facing. But I didn’t. The fading interest in football in Maine has prompted some schools to consider moving to less-than-11-player competition or even to flag football. To some extent, the problem is taking care of itself.
How much tinkering should we be doing with something that is arguably a distorted natural selection process? With thoughtfully crafted rules, diligent supervision, and officiating, most of the issues of safety that one might attribute to discrepancies in maturity can be minimized. There always will be children who become discouraged and quit when they see the handwriting on the wall that reads “those who mature early win.” I’m certainly not wild about parents holding their children out of school to give them a jump on their peers. It can spiral out of control.
A more appealing solution is to do a better job of advertising the many successful late bloomers in professional sports ... and making sure that late-blooming children are given an abundance of active and competitive (if they wish) alternatives to sports dominated by their early maturing peers.
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].
What is an “early and accurate” diagnosis?
For the last few weeks, the eye-grabber at the top of the American Academy of Pediatrics shopAAP email has been “Early and Accurate Diagnosis.” The unstated claim is that a practitioner who subscribes to one of their continuing education products will improve his or her chances of making an early and accurate diagnosis that “Also Cures Missed School, Soccer Practice, and Music Lessons.” The tagline, Early and Accurate Diagnosis, got me ruminating.
What exactly is an accurate diagnosis? And how does one define an early diagnosis? These are not merely questions of semantics. An honest attempt to answer them scratches through the surface of some serious issues facing a primary care physician.
Who are the judges deciding whether a physician’s diagnosis is accurate? Should it be a panel of academic physicians, most of who are specialists and subspecialists, and who are most comfortable seeing patients with array of signs and symptoms that your patient has presented? Or, should it be a collection of your primary care peers working with limited resources miles away from a tertiary care center?
Is there such a thing as a diagnosis that is close enough? How often is it important that your diagnosis is spot on? Is it like a high school algebra problem in which you could get partial credit for showing how you arrived at the not-quite-right-answer? It really makes a difference only when you start acting (or, in some cases, not acting) on your diagnosis.
Let’s be honest. How often have you made the wrong diagnosis and the patient got better with your management plan? Your therapy may have worked for Diagnosis A even though you were targeting Diagnosis B. Or, more likely, the patient was going to get better without any intervention.
Don’t get me wrong. I think a correct diagnosis can be, and often is, extremely important, but it is really the patient who is the judge of whether you got it right. He doesn’t care what you called it. He is happy knowing that he got better and you didn’t hurt him.
Now, what about that “early” piece? Again, the patient might have something to say about this. You may have made the correct diagnosis but because your productivity is limited by a clunky EMR or your appointment desk does a poor job of triage, the patient was forced to wait an unconscionable amount of time to be seen.
A timely diagnosis certainly is important in many situations. But particularly, early in your career, you may not have the experience to make those quick one look and you’ve got it right diagnoses. These are times to come clean and tell the patient that you aren’t sure what they have. Of course, you might want to choose a better phrase than, “I don’t have clue.”
If I had been asked to write the AAP’s tag line, I would have chosen “efficient” instead of early. If you made the correct diagnosis and it was reasonably timely but you ordered a barrage of unnecessary and expensive tests that inconvenienced the patient, you should have done a better job.
Finally, if you make the correct and early diagnosis but deliver it to the patient poorly, your therapy may not work. Again, it boils down to being an artful and caring physician.
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].
For the last few weeks, the eye-grabber at the top of the American Academy of Pediatrics shopAAP email has been “Early and Accurate Diagnosis.” The unstated claim is that a practitioner who subscribes to one of their continuing education products will improve his or her chances of making an early and accurate diagnosis that “Also Cures Missed School, Soccer Practice, and Music Lessons.” The tagline, Early and Accurate Diagnosis, got me ruminating.
What exactly is an accurate diagnosis? And how does one define an early diagnosis? These are not merely questions of semantics. An honest attempt to answer them scratches through the surface of some serious issues facing a primary care physician.
Who are the judges deciding whether a physician’s diagnosis is accurate? Should it be a panel of academic physicians, most of who are specialists and subspecialists, and who are most comfortable seeing patients with array of signs and symptoms that your patient has presented? Or, should it be a collection of your primary care peers working with limited resources miles away from a tertiary care center?
Is there such a thing as a diagnosis that is close enough? How often is it important that your diagnosis is spot on? Is it like a high school algebra problem in which you could get partial credit for showing how you arrived at the not-quite-right-answer? It really makes a difference only when you start acting (or, in some cases, not acting) on your diagnosis.
Let’s be honest. How often have you made the wrong diagnosis and the patient got better with your management plan? Your therapy may have worked for Diagnosis A even though you were targeting Diagnosis B. Or, more likely, the patient was going to get better without any intervention.
Don’t get me wrong. I think a correct diagnosis can be, and often is, extremely important, but it is really the patient who is the judge of whether you got it right. He doesn’t care what you called it. He is happy knowing that he got better and you didn’t hurt him.
Now, what about that “early” piece? Again, the patient might have something to say about this. You may have made the correct diagnosis but because your productivity is limited by a clunky EMR or your appointment desk does a poor job of triage, the patient was forced to wait an unconscionable amount of time to be seen.
A timely diagnosis certainly is important in many situations. But particularly, early in your career, you may not have the experience to make those quick one look and you’ve got it right diagnoses. These are times to come clean and tell the patient that you aren’t sure what they have. Of course, you might want to choose a better phrase than, “I don’t have clue.”
If I had been asked to write the AAP’s tag line, I would have chosen “efficient” instead of early. If you made the correct diagnosis and it was reasonably timely but you ordered a barrage of unnecessary and expensive tests that inconvenienced the patient, you should have done a better job.
Finally, if you make the correct and early diagnosis but deliver it to the patient poorly, your therapy may not work. Again, it boils down to being an artful and caring physician.
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].
For the last few weeks, the eye-grabber at the top of the American Academy of Pediatrics shopAAP email has been “Early and Accurate Diagnosis.” The unstated claim is that a practitioner who subscribes to one of their continuing education products will improve his or her chances of making an early and accurate diagnosis that “Also Cures Missed School, Soccer Practice, and Music Lessons.” The tagline, Early and Accurate Diagnosis, got me ruminating.
What exactly is an accurate diagnosis? And how does one define an early diagnosis? These are not merely questions of semantics. An honest attempt to answer them scratches through the surface of some serious issues facing a primary care physician.
Who are the judges deciding whether a physician’s diagnosis is accurate? Should it be a panel of academic physicians, most of who are specialists and subspecialists, and who are most comfortable seeing patients with array of signs and symptoms that your patient has presented? Or, should it be a collection of your primary care peers working with limited resources miles away from a tertiary care center?
Is there such a thing as a diagnosis that is close enough? How often is it important that your diagnosis is spot on? Is it like a high school algebra problem in which you could get partial credit for showing how you arrived at the not-quite-right-answer? It really makes a difference only when you start acting (or, in some cases, not acting) on your diagnosis.
Let’s be honest. How often have you made the wrong diagnosis and the patient got better with your management plan? Your therapy may have worked for Diagnosis A even though you were targeting Diagnosis B. Or, more likely, the patient was going to get better without any intervention.
Don’t get me wrong. I think a correct diagnosis can be, and often is, extremely important, but it is really the patient who is the judge of whether you got it right. He doesn’t care what you called it. He is happy knowing that he got better and you didn’t hurt him.
Now, what about that “early” piece? Again, the patient might have something to say about this. You may have made the correct diagnosis but because your productivity is limited by a clunky EMR or your appointment desk does a poor job of triage, the patient was forced to wait an unconscionable amount of time to be seen.
A timely diagnosis certainly is important in many situations. But particularly, early in your career, you may not have the experience to make those quick one look and you’ve got it right diagnoses. These are times to come clean and tell the patient that you aren’t sure what they have. Of course, you might want to choose a better phrase than, “I don’t have clue.”
If I had been asked to write the AAP’s tag line, I would have chosen “efficient” instead of early. If you made the correct diagnosis and it was reasonably timely but you ordered a barrage of unnecessary and expensive tests that inconvenienced the patient, you should have done a better job.
Finally, if you make the correct and early diagnosis but deliver it to the patient poorly, your therapy may not work. Again, it boils down to being an artful and caring physician.
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].