William G. Wilkoff, MD

How thorough are you when you prescribe medication? You check the patient’s list of allergies and current medications. You make sure that the dose is appropriate for the patient’s weight. Hopefully, you spend a minute or 2 describing the most common side effects. You prescribe the correct amount of medication and an appropriate number of refills. If you think you can distill it into one or two sentences, you also explain the medication’s mechanism of action. That is if you understand it yourself.

megaflopp/Thinkstock

What about placebos? How often do you believe that your patient has gotten better because of the placebo effect? Do you ever intentionally recommend or prescribe a placebo? Do you share with the patient that there is no current explanation of why the treatment you are recommending should work? Or, do you just play dumb?

Whether you admit to being a frequent prescriber of placebos or not you should take the 20 minutes it will take to read a New York Times article titled “What if the Placebo Effect Isn’t a Trick” (Gary Greenberg, Nov 7, 2018). You will learn a bit about the history of the placebo effect including some recent functional MRI studies that have uncovered consistent brain activity patterns in subjects that respond to placebos.

You will read about some exciting research indicating that certain people with a genomic variant of an enzyme that has been shown to affect the response to painkillers generally have the weakest response to placebo. While in some studies the association between the patient’s response and the level of the enzyme is the reverse, Kathryn Hall, PhD, the molecular biologist overseeing these studies, feels that at this point in her research the fact that there is an association that varies with genotype is a critical finding. She suspects that the placebo effect and the drug operate on the same biochemical highway that includes this enzyme and that “clinician warmth” is particularly effective in patients with a certain genotype.

Ted Kaptchuk, who heads up Harvard Medical School’s Program in Placebo Studies and the Therapeutic Encounter and has collaborated with Dr. Hall, hypothesizes “that the placebo effect is a biological response to an act of caring.” Is Dr. Hall’s work the first step in defining that response?

What does all of this new information mean for us as care dispensers? I think it means that caring is important and can make a critical difference if we have chosen a patient with the favorable genome. Of course, how are we to know whether we are working with such a patient? All the caring in the world may not change the outcome if we have selected incorrectly.

And then there is the other side of the practitioner-patient relationship and the definition and quantification of “caring.” Are there practitioners who are so inept and/or devoid of caring that even patients with the most favorable genome are not going to respond to their attempts at dispensing placebos?

Are there some practitioners who are born with a knack for caring? Can it be taught? Do we select for the quality of caring with the Medical College Admission Test (MCAT)? Do we weed out those who obviously don’t have it during their training?

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].

How thorough are you when you prescribe medication? You check the patient’s list of allergies and current medications. You make sure that the dose is appropriate for the patient’s weight. Hopefully, you spend a minute or 2 describing the most common side effects. You prescribe the correct amount of medication and an appropriate number of refills. If you think you can distill it into one or two sentences, you also explain the medication’s mechanism of action. That is if you understand it yourself.

megaflopp/Thinkstock

What about placebos? How often do you believe that your patient has gotten better because of the placebo effect? Do you ever intentionally recommend or prescribe a placebo? Do you share with the patient that there is no current explanation of why the treatment you are recommending should work? Or, do you just play dumb?

Whether you admit to being a frequent prescriber of placebos or not you should take the 20 minutes it will take to read a New York Times article titled “What if the Placebo Effect Isn’t a Trick” (Gary Greenberg, Nov 7, 2018). You will learn a bit about the history of the placebo effect including some recent functional MRI studies that have uncovered consistent brain activity patterns in subjects that respond to placebos.

You will read about some exciting research indicating that certain people with a genomic variant of an enzyme that has been shown to affect the response to painkillers generally have the weakest response to placebo. While in some studies the association between the patient’s response and the level of the enzyme is the reverse, Kathryn Hall, PhD, the molecular biologist overseeing these studies, feels that at this point in her research the fact that there is an association that varies with genotype is a critical finding. She suspects that the placebo effect and the drug operate on the same biochemical highway that includes this enzyme and that “clinician warmth” is particularly effective in patients with a certain genotype.

Ted Kaptchuk, who heads up Harvard Medical School’s Program in Placebo Studies and the Therapeutic Encounter and has collaborated with Dr. Hall, hypothesizes “that the placebo effect is a biological response to an act of caring.” Is Dr. Hall’s work the first step in defining that response?

What does all of this new information mean for us as care dispensers? I think it means that caring is important and can make a critical difference if we have chosen a patient with the favorable genome. Of course, how are we to know whether we are working with such a patient? All the caring in the world may not change the outcome if we have selected incorrectly.

And then there is the other side of the practitioner-patient relationship and the definition and quantification of “caring.” Are there practitioners who are so inept and/or devoid of caring that even patients with the most favorable genome are not going to respond to their attempts at dispensing placebos?

Are there some practitioners who are born with a knack for caring? Can it be taught? Do we select for the quality of caring with the Medical College Admission Test (MCAT)? Do we weed out those who obviously don’t have it during their training?

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].

How thorough are you when you prescribe medication? You check the patient’s list of allergies and current medications. You make sure that the dose is appropriate for the patient’s weight. Hopefully, you spend a minute or 2 describing the most common side effects. You prescribe the correct amount of medication and an appropriate number of refills. If you think you can distill it into one or two sentences, you also explain the medication’s mechanism of action. That is if you understand it yourself.

megaflopp/Thinkstock

What about placebos? How often do you believe that your patient has gotten better because of the placebo effect? Do you ever intentionally recommend or prescribe a placebo? Do you share with the patient that there is no current explanation of why the treatment you are recommending should work? Or, do you just play dumb?

Whether you admit to being a frequent prescriber of placebos or not you should take the 20 minutes it will take to read a New York Times article titled “What if the Placebo Effect Isn’t a Trick” (Gary Greenberg, Nov 7, 2018). You will learn a bit about the history of the placebo effect including some recent functional MRI studies that have uncovered consistent brain activity patterns in subjects that respond to placebos.

You will read about some exciting research indicating that certain people with a genomic variant of an enzyme that has been shown to affect the response to painkillers generally have the weakest response to placebo. While in some studies the association between the patient’s response and the level of the enzyme is the reverse, Kathryn Hall, PhD, the molecular biologist overseeing these studies, feels that at this point in her research the fact that there is an association that varies with genotype is a critical finding. She suspects that the placebo effect and the drug operate on the same biochemical highway that includes this enzyme and that “clinician warmth” is particularly effective in patients with a certain genotype.

Ted Kaptchuk, who heads up Harvard Medical School’s Program in Placebo Studies and the Therapeutic Encounter and has collaborated with Dr. Hall, hypothesizes “that the placebo effect is a biological response to an act of caring.” Is Dr. Hall’s work the first step in defining that response?

What does all of this new information mean for us as care dispensers? I think it means that caring is important and can make a critical difference if we have chosen a patient with the favorable genome. Of course, how are we to know whether we are working with such a patient? All the caring in the world may not change the outcome if we have selected incorrectly.

And then there is the other side of the practitioner-patient relationship and the definition and quantification of “caring.” Are there practitioners who are so inept and/or devoid of caring that even patients with the most favorable genome are not going to respond to their attempts at dispensing placebos?

Are there some practitioners who are born with a knack for caring? Can it be taught? Do we select for the quality of caring with the Medical College Admission Test (MCAT)? Do we weed out those who obviously don’t have it during their training?

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 2 short years in the cocoon of residency ended, and I was flying solo on the picturesque but sparsely populated coast of Maine. My colleagues and I were fulfilling our 2-year military obligations at the Brunswick Naval Air Station, hundreds of miles from the support systems our tertiary care centers had provided. As the only pediatrician on the dispensary staff, I felt particularly vulnerable.

At least I was in the same time zone in which I had trained. I still knew most of the beeper numbers or could remember the extensions and the first names of the department secretaries. Usually within minutes, the familiar and calming voice of one of my favorite subspecialists or pediatric mentors would set me on the path to the correct diagnosis and management plan. Of course, I could have asked one of the pediatricians in town for advice, and eventually, I did. But, in the beginning, I was embarrassed to reveal my soft underbelly to the townies.

Within a few months, I was moonlighting for a local pediatrician and, after 2 years, I joined him as a partner. However, it took another several years to wean myself off my dependency on the subspecialists at the big-city medical center where I had trained. To some extent, this was because in the 1970s and 1980s, Maine had few pediatric subspecialists.

Eventually, I developed my own list of favorite local consultants. While the quality of advice was the prime determinant in my choice of a consultant, availability was a close second. How easy was it to get the specialist on the phone? If the clinical situation was not terribly time sensitive and I knew the consultant always was painfully overbooked, I would ask my question in a short typed note, and even include a S.A.S.E. (self-addressed stamped envelope). This – of course – was before email had been invented.

How likely was the consultant going to provide the answer I wanted to hear? If I thought the patient needed P-E (pressure equalizer) tubes, I could choose any ENT specialist. If, on the other hand, I felt that watching and waiting was the better option, I would choose the physician I knew was least likely to advise surgery.

I am unaware that any of the physicians I consulted ever charged the patient for my phone calls or notes. In some cases, their reward came in the opportunity to perform surgery. I rarely received small gifts during the holidays from consultants who were trying to build their practices. And I never gave tokens of appreciation to consultants or their staff to secure their timely response to my pleas for help. However, I always included a personal thank-you note with the self-designed holiday cards I sent to my favorites. And when a consultant had bailed me out of a particularly challenging situation, I often sent a handwritten note in follow-up.

But, for me, the care and grooming of a good stable of consultants began with acknowledging that their time was at least as valuable as mine. The more carefully I crafted my question and the more complete the history I could provide, the more efficiently the consultant could provide me with the answer I needed.

Regrettably, but predictably, those days of free advice are fading away. The new revision of the CPT codes includes at least twelve codes for “interprofessional consultation.” Time is – and has always been – money. As everyone’s time is increasingly being gobbled up by electronic advancements that promised to save us time, no one seems to have time to make or answer that call that begins, “Can I ask you a quick question about a patient?”

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 2 short years in the cocoon of residency ended, and I was flying solo on the picturesque but sparsely populated coast of Maine. My colleagues and I were fulfilling our 2-year military obligations at the Brunswick Naval Air Station, hundreds of miles from the support systems our tertiary care centers had provided. As the only pediatrician on the dispensary staff, I felt particularly vulnerable.

At least I was in the same time zone in which I had trained. I still knew most of the beeper numbers or could remember the extensions and the first names of the department secretaries. Usually within minutes, the familiar and calming voice of one of my favorite subspecialists or pediatric mentors would set me on the path to the correct diagnosis and management plan. Of course, I could have asked one of the pediatricians in town for advice, and eventually, I did. But, in the beginning, I was embarrassed to reveal my soft underbelly to the townies.

Within a few months, I was moonlighting for a local pediatrician and, after 2 years, I joined him as a partner. However, it took another several years to wean myself off my dependency on the subspecialists at the big-city medical center where I had trained. To some extent, this was because in the 1970s and 1980s, Maine had few pediatric subspecialists.

Eventually, I developed my own list of favorite local consultants. While the quality of advice was the prime determinant in my choice of a consultant, availability was a close second. How easy was it to get the specialist on the phone? If the clinical situation was not terribly time sensitive and I knew the consultant always was painfully overbooked, I would ask my question in a short typed note, and even include a S.A.S.E. (self-addressed stamped envelope). This – of course – was before email had been invented.

How likely was the consultant going to provide the answer I wanted to hear? If I thought the patient needed P-E (pressure equalizer) tubes, I could choose any ENT specialist. If, on the other hand, I felt that watching and waiting was the better option, I would choose the physician I knew was least likely to advise surgery.

I am unaware that any of the physicians I consulted ever charged the patient for my phone calls or notes. In some cases, their reward came in the opportunity to perform surgery. I rarely received small gifts during the holidays from consultants who were trying to build their practices. And I never gave tokens of appreciation to consultants or their staff to secure their timely response to my pleas for help. However, I always included a personal thank-you note with the self-designed holiday cards I sent to my favorites. And when a consultant had bailed me out of a particularly challenging situation, I often sent a handwritten note in follow-up.

But, for me, the care and grooming of a good stable of consultants began with acknowledging that their time was at least as valuable as mine. The more carefully I crafted my question and the more complete the history I could provide, the more efficiently the consultant could provide me with the answer I needed.

Regrettably, but predictably, those days of free advice are fading away. The new revision of the CPT codes includes at least twelve codes for “interprofessional consultation.” Time is – and has always been – money. As everyone’s time is increasingly being gobbled up by electronic advancements that promised to save us time, no one seems to have time to make or answer that call that begins, “Can I ask you a quick question about a patient?”

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 2 short years in the cocoon of residency ended, and I was flying solo on the picturesque but sparsely populated coast of Maine. My colleagues and I were fulfilling our 2-year military obligations at the Brunswick Naval Air Station, hundreds of miles from the support systems our tertiary care centers had provided. As the only pediatrician on the dispensary staff, I felt particularly vulnerable.

At least I was in the same time zone in which I had trained. I still knew most of the beeper numbers or could remember the extensions and the first names of the department secretaries. Usually within minutes, the familiar and calming voice of one of my favorite subspecialists or pediatric mentors would set me on the path to the correct diagnosis and management plan. Of course, I could have asked one of the pediatricians in town for advice, and eventually, I did. But, in the beginning, I was embarrassed to reveal my soft underbelly to the townies.

Within a few months, I was moonlighting for a local pediatrician and, after 2 years, I joined him as a partner. However, it took another several years to wean myself off my dependency on the subspecialists at the big-city medical center where I had trained. To some extent, this was because in the 1970s and 1980s, Maine had few pediatric subspecialists.

Eventually, I developed my own list of favorite local consultants. While the quality of advice was the prime determinant in my choice of a consultant, availability was a close second. How easy was it to get the specialist on the phone? If the clinical situation was not terribly time sensitive and I knew the consultant always was painfully overbooked, I would ask my question in a short typed note, and even include a S.A.S.E. (self-addressed stamped envelope). This – of course – was before email had been invented.

How likely was the consultant going to provide the answer I wanted to hear? If I thought the patient needed P-E (pressure equalizer) tubes, I could choose any ENT specialist. If, on the other hand, I felt that watching and waiting was the better option, I would choose the physician I knew was least likely to advise surgery.

I am unaware that any of the physicians I consulted ever charged the patient for my phone calls or notes. In some cases, their reward came in the opportunity to perform surgery. I rarely received small gifts during the holidays from consultants who were trying to build their practices. And I never gave tokens of appreciation to consultants or their staff to secure their timely response to my pleas for help. However, I always included a personal thank-you note with the self-designed holiday cards I sent to my favorites. And when a consultant had bailed me out of a particularly challenging situation, I often sent a handwritten note in follow-up.

But, for me, the care and grooming of a good stable of consultants began with acknowledging that their time was at least as valuable as mine. The more carefully I crafted my question and the more complete the history I could provide, the more efficiently the consultant could provide me with the answer I needed.

Regrettably, but predictably, those days of free advice are fading away. The new revision of the CPT codes includes at least twelve codes for “interprofessional consultation.” Time is – and has always been – money. As everyone’s time is increasingly being gobbled up by electronic advancements that promised to save us time, no one seems to have time to make or answer that call that begins, “Can I ask you a quick question about a patient?”

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’m fine. How are your kids?”

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“They’re doing great, but we miss you. It hasn’t been the same at that group since you retired.”

I thanked her for her kind words. But the truth is that there were certainly physicians remaining at that practice who were at least as skillful and probably more caring than I had been. However, they were being increasingly challenged by an organization that struggled with how to be customer friendly and patient centered although it claimed to be both.

It must have been 8 years since I first met this young woman. She had just delivered her first child and was finishing her last year of family practice residency. In the nearly a decade since I had last spoken to her, she had worked in a couple primary care practices and was now the administrator of a rehabilitation facility. She described the all too common scenario of spending hours at home trying to complete her charting when she was doing primary care. Now she spends a good chunk of her time on the phone arguing with insurance companies trying to get coverage for her aging patients.

As she told me how frustrated she was with her current job and how pessimistic she was about the future of health care in this country, I realized that it wasn’t me that she really missed. I, and my old practice, are just examples of what primary care used to be.

As I walked home from the grocery store after our encounter, I wondered how deeply I shared her pessimism. We mostly talked about how bad things have gotten now. But we didn’t talk much about where we thought the state of health care in the Unite States was headed.

Are you an optimist or a pessimist? To what degree will your answer to be colored by your career trajectory? Would you tell a young person that you think our health care system is so messed up that you would discourage them from becoming a physician because the work environment is becoming increasingly toxic?

Or would you acknowledge that health care in this country is going through a difficult time, but the potential reward of knowing that every day you have helped, or at least tried to help, someone is worth riding out storm?

For a moment, step back from your narrow focus as a health care provider. What would you tell a 40-something father of two children who is worried about what health care is going to look like when he is as old as his parents are now?

If you have come down on the positive side of this coin, where are the solutions going to come from? Is technology going to come up with the answers? Is a nationwide electronic medical record system that allows all providers to communicate seamlessly with each other a realistic possibility? Will physicians and patients eventually adapt to and accept a new reality in which health care providers are primarily technicians following algorithms generated by a team of scientists and payers?

Or will we continue to muddle along and hope that our system will get over the hiccups and arrive at some political solution? I am eager to hear what you think. ... and feel.
 

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’m fine. How are your kids?”

Thinkstock

“They’re doing great, but we miss you. It hasn’t been the same at that group since you retired.”

I thanked her for her kind words. But the truth is that there were certainly physicians remaining at that practice who were at least as skillful and probably more caring than I had been. However, they were being increasingly challenged by an organization that struggled with how to be customer friendly and patient centered although it claimed to be both.

It must have been 8 years since I first met this young woman. She had just delivered her first child and was finishing her last year of family practice residency. In the nearly a decade since I had last spoken to her, she had worked in a couple primary care practices and was now the administrator of a rehabilitation facility. She described the all too common scenario of spending hours at home trying to complete her charting when she was doing primary care. Now she spends a good chunk of her time on the phone arguing with insurance companies trying to get coverage for her aging patients.

As she told me how frustrated she was with her current job and how pessimistic she was about the future of health care in this country, I realized that it wasn’t me that she really missed. I, and my old practice, are just examples of what primary care used to be.

As I walked home from the grocery store after our encounter, I wondered how deeply I shared her pessimism. We mostly talked about how bad things have gotten now. But we didn’t talk much about where we thought the state of health care in the Unite States was headed.

Are you an optimist or a pessimist? To what degree will your answer to be colored by your career trajectory? Would you tell a young person that you think our health care system is so messed up that you would discourage them from becoming a physician because the work environment is becoming increasingly toxic?

Or would you acknowledge that health care in this country is going through a difficult time, but the potential reward of knowing that every day you have helped, or at least tried to help, someone is worth riding out storm?

For a moment, step back from your narrow focus as a health care provider. What would you tell a 40-something father of two children who is worried about what health care is going to look like when he is as old as his parents are now?

If you have come down on the positive side of this coin, where are the solutions going to come from? Is technology going to come up with the answers? Is a nationwide electronic medical record system that allows all providers to communicate seamlessly with each other a realistic possibility? Will physicians and patients eventually adapt to and accept a new reality in which health care providers are primarily technicians following algorithms generated by a team of scientists and payers?

Or will we continue to muddle along and hope that our system will get over the hiccups and arrive at some political solution? I am eager to hear what you think. ... and feel.
 

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’m fine. How are your kids?”

Thinkstock

“They’re doing great, but we miss you. It hasn’t been the same at that group since you retired.”

I thanked her for her kind words. But the truth is that there were certainly physicians remaining at that practice who were at least as skillful and probably more caring than I had been. However, they were being increasingly challenged by an organization that struggled with how to be customer friendly and patient centered although it claimed to be both.

It must have been 8 years since I first met this young woman. She had just delivered her first child and was finishing her last year of family practice residency. In the nearly a decade since I had last spoken to her, she had worked in a couple primary care practices and was now the administrator of a rehabilitation facility. She described the all too common scenario of spending hours at home trying to complete her charting when she was doing primary care. Now she spends a good chunk of her time on the phone arguing with insurance companies trying to get coverage for her aging patients.

As she told me how frustrated she was with her current job and how pessimistic she was about the future of health care in this country, I realized that it wasn’t me that she really missed. I, and my old practice, are just examples of what primary care used to be.

As I walked home from the grocery store after our encounter, I wondered how deeply I shared her pessimism. We mostly talked about how bad things have gotten now. But we didn’t talk much about where we thought the state of health care in the Unite States was headed.

Are you an optimist or a pessimist? To what degree will your answer to be colored by your career trajectory? Would you tell a young person that you think our health care system is so messed up that you would discourage them from becoming a physician because the work environment is becoming increasingly toxic?

Or would you acknowledge that health care in this country is going through a difficult time, but the potential reward of knowing that every day you have helped, or at least tried to help, someone is worth riding out storm?

For a moment, step back from your narrow focus as a health care provider. What would you tell a 40-something father of two children who is worried about what health care is going to look like when he is as old as his parents are now?

If you have come down on the positive side of this coin, where are the solutions going to come from? Is technology going to come up with the answers? Is a nationwide electronic medical record system that allows all providers to communicate seamlessly with each other a realistic possibility? Will physicians and patients eventually adapt to and accept a new reality in which health care providers are primarily technicians following algorithms generated by a team of scientists and payers?

Or will we continue to muddle along and hope that our system will get over the hiccups and arrive at some political solution? I am eager to hear what you think. ... and feel.
 

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].

Unless you decide to start a second career as an expert witness, giving a deposition is a challenge you should avoid at all costs. I have given a few depositions myself, as both a defendant and a witness, and I have reviewed a dozen or more as a consultant for a local law firm. It is an unnatural and artificial format for transferring information. You will survive the depositions rigid and arbitrary rules only by listening to and following your lawyer’s coaching both before and during the deposition. Hopefully you never will be deposed. However, it may be instructive to consider the deposition’s unsettling format as a way to improve your communication skills with patients, parents, and nonphysicians.

belchonock/Thinkstock

First, in a deposition every word you utter is recorded. There are no second chances to edit or clarify what you have said. Your words must be carefully chosen. Several times each year I encounter the parent of a former patient in the grocery store who quotes to me some advice they claim I gave them 2 or 3 decades ago. Although I can imagine that I might have voiced the message they are remembering, sometimes I have to cringe at the bluntness and the crude choice of words they are attributing to me. Obviously, I got away with my fast and loose handling of the English language most of the time and am flattered that it was memorable. But I wonder how often I offended a family with my shoot-from-the-hip advice.

In a similar vein, I found that one of the benefits of having medical students shadow me around the office was that their presence forced me to listen to myself. Did I really say that? How sloppy had I gotten in my explanations to parents and patients? Having another pair of ears in the office can be like having a court stenographer at your deposition.

The situation can be particularly insidious when a parent asks what you take to be a rhetorical question or more likely makes a statement that is incorrect, but you fail to correct it because it is off topic and you are in a hurry to get to the next exam room. If in a deposition the plaintiff’s lawyer prefaces a question with “We all know that sugar makes children hyper,” before you leap over his preface and give your answer you should respond that you are unaware of any scientific evidence that supports his assertion. But if a parent offhandedly mentions that his child was on a “sugar high” you might not take the time to disagree because the parent’s observation had no significance to the history he was relating. However, the parent could interpret from your silence that you believe sugar causes hyperactivity.

Of course the volume of old wives tales, urban legends, and chat room myths that float by you in the office every day makes it impractical to counter every bit of misinformation we hear. But the rules of deposition should remind us that our failure to disagree might sometimes be interpreted as an agreement.

One of the more difficult concepts challenging the deposed physician is avoiding the too much information trap. Your answers in a deposition should be simple and to the point. Physicians are trained to teach. How often are we clouding the answers the patients want by trying to impress them with our breadth of knowledge and command of scientific language?

Although you may have a scribe helping you craft your electronic medical records, hopefully he or she won’t be a court stenographer. And even more fortunately, most patients and parents aren’t listening to every word you say. But from time to time, it helps to pretend you are being deposed. Or at least take a moment to listen to what you have been saying.
 

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].

Unless you decide to start a second career as an expert witness, giving a deposition is a challenge you should avoid at all costs. I have given a few depositions myself, as both a defendant and a witness, and I have reviewed a dozen or more as a consultant for a local law firm. It is an unnatural and artificial format for transferring information. You will survive the depositions rigid and arbitrary rules only by listening to and following your lawyer’s coaching both before and during the deposition. Hopefully you never will be deposed. However, it may be instructive to consider the deposition’s unsettling format as a way to improve your communication skills with patients, parents, and nonphysicians.

belchonock/Thinkstock

First, in a deposition every word you utter is recorded. There are no second chances to edit or clarify what you have said. Your words must be carefully chosen. Several times each year I encounter the parent of a former patient in the grocery store who quotes to me some advice they claim I gave them 2 or 3 decades ago. Although I can imagine that I might have voiced the message they are remembering, sometimes I have to cringe at the bluntness and the crude choice of words they are attributing to me. Obviously, I got away with my fast and loose handling of the English language most of the time and am flattered that it was memorable. But I wonder how often I offended a family with my shoot-from-the-hip advice.

In a similar vein, I found that one of the benefits of having medical students shadow me around the office was that their presence forced me to listen to myself. Did I really say that? How sloppy had I gotten in my explanations to parents and patients? Having another pair of ears in the office can be like having a court stenographer at your deposition.

The situation can be particularly insidious when a parent asks what you take to be a rhetorical question or more likely makes a statement that is incorrect, but you fail to correct it because it is off topic and you are in a hurry to get to the next exam room. If in a deposition the plaintiff’s lawyer prefaces a question with “We all know that sugar makes children hyper,” before you leap over his preface and give your answer you should respond that you are unaware of any scientific evidence that supports his assertion. But if a parent offhandedly mentions that his child was on a “sugar high” you might not take the time to disagree because the parent’s observation had no significance to the history he was relating. However, the parent could interpret from your silence that you believe sugar causes hyperactivity.

Of course the volume of old wives tales, urban legends, and chat room myths that float by you in the office every day makes it impractical to counter every bit of misinformation we hear. But the rules of deposition should remind us that our failure to disagree might sometimes be interpreted as an agreement.

One of the more difficult concepts challenging the deposed physician is avoiding the too much information trap. Your answers in a deposition should be simple and to the point. Physicians are trained to teach. How often are we clouding the answers the patients want by trying to impress them with our breadth of knowledge and command of scientific language?

Although you may have a scribe helping you craft your electronic medical records, hopefully he or she won’t be a court stenographer. And even more fortunately, most patients and parents aren’t listening to every word you say. But from time to time, it helps to pretend you are being deposed. Or at least take a moment to listen to what you have been saying.
 

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].

Unless you decide to start a second career as an expert witness, giving a deposition is a challenge you should avoid at all costs. I have given a few depositions myself, as both a defendant and a witness, and I have reviewed a dozen or more as a consultant for a local law firm. It is an unnatural and artificial format for transferring information. You will survive the depositions rigid and arbitrary rules only by listening to and following your lawyer’s coaching both before and during the deposition. Hopefully you never will be deposed. However, it may be instructive to consider the deposition’s unsettling format as a way to improve your communication skills with patients, parents, and nonphysicians.

belchonock/Thinkstock

First, in a deposition every word you utter is recorded. There are no second chances to edit or clarify what you have said. Your words must be carefully chosen. Several times each year I encounter the parent of a former patient in the grocery store who quotes to me some advice they claim I gave them 2 or 3 decades ago. Although I can imagine that I might have voiced the message they are remembering, sometimes I have to cringe at the bluntness and the crude choice of words they are attributing to me. Obviously, I got away with my fast and loose handling of the English language most of the time and am flattered that it was memorable. But I wonder how often I offended a family with my shoot-from-the-hip advice.

In a similar vein, I found that one of the benefits of having medical students shadow me around the office was that their presence forced me to listen to myself. Did I really say that? How sloppy had I gotten in my explanations to parents and patients? Having another pair of ears in the office can be like having a court stenographer at your deposition.

The situation can be particularly insidious when a parent asks what you take to be a rhetorical question or more likely makes a statement that is incorrect, but you fail to correct it because it is off topic and you are in a hurry to get to the next exam room. If in a deposition the plaintiff’s lawyer prefaces a question with “We all know that sugar makes children hyper,” before you leap over his preface and give your answer you should respond that you are unaware of any scientific evidence that supports his assertion. But if a parent offhandedly mentions that his child was on a “sugar high” you might not take the time to disagree because the parent’s observation had no significance to the history he was relating. However, the parent could interpret from your silence that you believe sugar causes hyperactivity.

Of course the volume of old wives tales, urban legends, and chat room myths that float by you in the office every day makes it impractical to counter every bit of misinformation we hear. But the rules of deposition should remind us that our failure to disagree might sometimes be interpreted as an agreement.

One of the more difficult concepts challenging the deposed physician is avoiding the too much information trap. Your answers in a deposition should be simple and to the point. Physicians are trained to teach. How often are we clouding the answers the patients want by trying to impress them with our breadth of knowledge and command of scientific language?

Although you may have a scribe helping you craft your electronic medical records, hopefully he or she won’t be a court stenographer. And even more fortunately, most patients and parents aren’t listening to every word you say. But from time to time, it helps to pretend you are being deposed. Or at least take a moment to listen to what you have been saying.
 

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’m not sure why I read the “Letter from the President” in the American Academy of Pediatrics’ AAP News every month. I guess it is out of curiosity about how far the guild to which I belong is drifting from where I think it should be going.

Getty Images

In her August 2018 letter, Colleen A. Kraft, MD, lays out the challenges pediatricians will be facing in the next several decades as the “era of health care consumerism” engulfs us, a change that she suggests will mean “redefining the patient/provider relationship.” As an example, she observes that millennial parents who want “personalized care when and where they want it” have become our “new target market.” Dr. Kraft goes on to suggest that telemedicine may provide a way to reconcile the millennials’ two seemingly incompatible demands. However, she notes that only “15% of pediatricians report using telehealth technologies to provide patient care.” Dr. Kraft recommends that to survive the rising waters of health consumerism more of us should consider climbing onto the telemedicine ship.

There is no question that millennials are aging into the childbearing and child-rearing phases of their lives. They have become the major consumers of pediatric services. Is Dr. Kraft correct that we must change how we practice pediatrics to accommodate the I-want-it-now-delivered-to-my-inbox mentality of the millennials? If we fail to adjust, will we be committing financial suicide?

She makes a valid point. If your practice isn’t providing evening and weekend hours, if your patients’ calls aren’t being answered in a timely manner, and if your receptionists are more about deflecting calls than helping patients get their questions answered, you are running the risk of choking off your income stream to an unsustainable trickle.

But how far should we chase that “target market” made up of people who believe that they can receive personalized care without putting a wrinkle in their device-driven lives? It may be that they have never experienced the benefits of real personalized service from the same person encounter after encounter. I’m convinced that if you provide quality care that is reasonably available, enough patients will stick with you to make your practice sustainable. You will lose some impatient patients to walk-in-quick-care operations, but if you are giving good personalized care, many will return to the quality you are offering. But if you aren’t willing to consider improving your availability, even being the most personable provider in town isn’t going to keep you afloat.

Now to the claim that telemedicine may hold the answer to surviving consumerism. I think we must move cautiously. The fact that only 15% of us aren’t climbing on board doesn’t mean we are all Luddites. It is very likely that many of us are still feeling the sting of investing large amounts of money and time to computerize our health records and seeing little benefit. Telemedicine means lots of things to lots of people. It won’t hurt to keep an open mind and listen as technology evolves. But if you had it to do all over again, wouldn’t you have taken more time and given more thought into signing on for your electronic medical records system?

Finally, let’s remember millennials will be followed by another generation. Although some “experts” suggest that the post-millennials will be just more of the same, I’m not so sure. Millennials and their expectations have become fodder for comedians, even from within their own cohort. The post-millennials may surprise us and provide a refreshing breath of retro and a market that is much easier to reconcile with the realities of good patient care.
 

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’m not sure why I read the “Letter from the President” in the American Academy of Pediatrics’ AAP News every month. I guess it is out of curiosity about how far the guild to which I belong is drifting from where I think it should be going.

Getty Images

In her August 2018 letter, Colleen A. Kraft, MD, lays out the challenges pediatricians will be facing in the next several decades as the “era of health care consumerism” engulfs us, a change that she suggests will mean “redefining the patient/provider relationship.” As an example, she observes that millennial parents who want “personalized care when and where they want it” have become our “new target market.” Dr. Kraft goes on to suggest that telemedicine may provide a way to reconcile the millennials’ two seemingly incompatible demands. However, she notes that only “15% of pediatricians report using telehealth technologies to provide patient care.” Dr. Kraft recommends that to survive the rising waters of health consumerism more of us should consider climbing onto the telemedicine ship.

There is no question that millennials are aging into the childbearing and child-rearing phases of their lives. They have become the major consumers of pediatric services. Is Dr. Kraft correct that we must change how we practice pediatrics to accommodate the I-want-it-now-delivered-to-my-inbox mentality of the millennials? If we fail to adjust, will we be committing financial suicide?

She makes a valid point. If your practice isn’t providing evening and weekend hours, if your patients’ calls aren’t being answered in a timely manner, and if your receptionists are more about deflecting calls than helping patients get their questions answered, you are running the risk of choking off your income stream to an unsustainable trickle.

But how far should we chase that “target market” made up of people who believe that they can receive personalized care without putting a wrinkle in their device-driven lives? It may be that they have never experienced the benefits of real personalized service from the same person encounter after encounter. I’m convinced that if you provide quality care that is reasonably available, enough patients will stick with you to make your practice sustainable. You will lose some impatient patients to walk-in-quick-care operations, but if you are giving good personalized care, many will return to the quality you are offering. But if you aren’t willing to consider improving your availability, even being the most personable provider in town isn’t going to keep you afloat.

Now to the claim that telemedicine may hold the answer to surviving consumerism. I think we must move cautiously. The fact that only 15% of us aren’t climbing on board doesn’t mean we are all Luddites. It is very likely that many of us are still feeling the sting of investing large amounts of money and time to computerize our health records and seeing little benefit. Telemedicine means lots of things to lots of people. It won’t hurt to keep an open mind and listen as technology evolves. But if you had it to do all over again, wouldn’t you have taken more time and given more thought into signing on for your electronic medical records system?

Finally, let’s remember millennials will be followed by another generation. Although some “experts” suggest that the post-millennials will be just more of the same, I’m not so sure. Millennials and their expectations have become fodder for comedians, even from within their own cohort. The post-millennials may surprise us and provide a refreshing breath of retro and a market that is much easier to reconcile with the realities of good patient care.
 

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’m not sure why I read the “Letter from the President” in the American Academy of Pediatrics’ AAP News every month. I guess it is out of curiosity about how far the guild to which I belong is drifting from where I think it should be going.

Getty Images

In her August 2018 letter, Colleen A. Kraft, MD, lays out the challenges pediatricians will be facing in the next several decades as the “era of health care consumerism” engulfs us, a change that she suggests will mean “redefining the patient/provider relationship.” As an example, she observes that millennial parents who want “personalized care when and where they want it” have become our “new target market.” Dr. Kraft goes on to suggest that telemedicine may provide a way to reconcile the millennials’ two seemingly incompatible demands. However, she notes that only “15% of pediatricians report using telehealth technologies to provide patient care.” Dr. Kraft recommends that to survive the rising waters of health consumerism more of us should consider climbing onto the telemedicine ship.

There is no question that millennials are aging into the childbearing and child-rearing phases of their lives. They have become the major consumers of pediatric services. Is Dr. Kraft correct that we must change how we practice pediatrics to accommodate the I-want-it-now-delivered-to-my-inbox mentality of the millennials? If we fail to adjust, will we be committing financial suicide?

She makes a valid point. If your practice isn’t providing evening and weekend hours, if your patients’ calls aren’t being answered in a timely manner, and if your receptionists are more about deflecting calls than helping patients get their questions answered, you are running the risk of choking off your income stream to an unsustainable trickle.

But how far should we chase that “target market” made up of people who believe that they can receive personalized care without putting a wrinkle in their device-driven lives? It may be that they have never experienced the benefits of real personalized service from the same person encounter after encounter. I’m convinced that if you provide quality care that is reasonably available, enough patients will stick with you to make your practice sustainable. You will lose some impatient patients to walk-in-quick-care operations, but if you are giving good personalized care, many will return to the quality you are offering. But if you aren’t willing to consider improving your availability, even being the most personable provider in town isn’t going to keep you afloat.

Now to the claim that telemedicine may hold the answer to surviving consumerism. I think we must move cautiously. The fact that only 15% of us aren’t climbing on board doesn’t mean we are all Luddites. It is very likely that many of us are still feeling the sting of investing large amounts of money and time to computerize our health records and seeing little benefit. Telemedicine means lots of things to lots of people. It won’t hurt to keep an open mind and listen as technology evolves. But if you had it to do all over again, wouldn’t you have taken more time and given more thought into signing on for your electronic medical records system?

Finally, let’s remember millennials will be followed by another generation. Although some “experts” suggest that the post-millennials will be just more of the same, I’m not so sure. Millennials and their expectations have become fodder for comedians, even from within their own cohort. The post-millennials may surprise us and provide a refreshing breath of retro and a market that is much easier to reconcile with the realities of good patient care.
 

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].

“Breast Milk From Bottle May Not Be As Beneficial As Feeding Directly From The Breast, Researchers Say.” This was the headline on the AAP Daily Briefing that was sent to American Academy of Pediatrics members on Sept 25, 2018.

©Jaimie Duplass/Fotolia.com

I suspect that this finding doesn’t surprise you. I can imagine a dozen factors that could make bottled breast milk less advantageous for a baby than milk received directly from the mother’s breast. Antibodies might adhere to the glass surface. A few degrees above or below body temperature could interfere with gastric emptying. Or a temptation to focus on the level in the bottle and inadvertently overfeed could inflate the baby’s body mass index at 3 months, as was found in the study published online in the September 2018 issue of Pediatrics (“Infant Feeding and Weight Gain: Separating Breast Milk From Breastfeeding and Formula From Food”).

I agree that the title of the actual paper is rather dry; it’s a scientific research paper. But the distillation chosen by the folks at AAP Daily Briefing seems ill advised. They were not alone. CCN-Health chose “Breastfeeding better for babies’ weight gain than pumping, new study says” (Michael Nedelman, Sept. 24, 2018). HealthDay News headlined its story with “Milk straight from breast best for baby’s weight” (Sept. 24, 2018).

The articles themselves were well balanced and accurately described this research based on more than 2,500 Canadian mother-infant dyads. But not everyone – including mothers who are struggling with or considering breastfeeding – reads beyond the headlines. How many realize that “better for babies’ weight gain” means a slower weight gain? For the mother who has found that, for a variety of reasons, pumping is the only way she can provide her baby the benefits of breast milk, what these headlines suggest is another blow to her already fragile sense of self-worth.

This research article is excellent and should be read by all of us who counsel young families. It suggests that one of the contributors to our epidemic of childhood obesity may be that bottle-feeding discourages the infant’s own self-regulation skills. It should prompt us to ask every parent who is bottle-feeding his or her baby – regardless of what is in the bottle – exactly how they decide how much to put in the bottle and how long a feeding takes. Even if we are comfortable with the infant’s weight gain, we should caution parents to be more aware of the baby’s cues that he or she has had enough. Not every baby provides cues that are obvious, and parents may need our coaching in deciding how much to feed. This research paper also suggests that as long as breastfeeding was continued, introduction of solids as early as 5 months was not associated with an unhealthy BMI trajectory.

Unfortunately, the reporting of this research article is another example of the hazards of the explosive growth of the Internet. There really is no reason to keep the results of well-crafted research from the lay public, particularly if they are explained in common sense language. However, this places a burden of responsibility on the editors of websites to consider the damage that can be done by a poorly chosen headline.

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].

“Breast Milk From Bottle May Not Be As Beneficial As Feeding Directly From The Breast, Researchers Say.” This was the headline on the AAP Daily Briefing that was sent to American Academy of Pediatrics members on Sept 25, 2018.

©Jaimie Duplass/Fotolia.com

I suspect that this finding doesn’t surprise you. I can imagine a dozen factors that could make bottled breast milk less advantageous for a baby than milk received directly from the mother’s breast. Antibodies might adhere to the glass surface. A few degrees above or below body temperature could interfere with gastric emptying. Or a temptation to focus on the level in the bottle and inadvertently overfeed could inflate the baby’s body mass index at 3 months, as was found in the study published online in the September 2018 issue of Pediatrics (“Infant Feeding and Weight Gain: Separating Breast Milk From Breastfeeding and Formula From Food”).

I agree that the title of the actual paper is rather dry; it’s a scientific research paper. But the distillation chosen by the folks at AAP Daily Briefing seems ill advised. They were not alone. CCN-Health chose “Breastfeeding better for babies’ weight gain than pumping, new study says” (Michael Nedelman, Sept. 24, 2018). HealthDay News headlined its story with “Milk straight from breast best for baby’s weight” (Sept. 24, 2018).

The articles themselves were well balanced and accurately described this research based on more than 2,500 Canadian mother-infant dyads. But not everyone – including mothers who are struggling with or considering breastfeeding – reads beyond the headlines. How many realize that “better for babies’ weight gain” means a slower weight gain? For the mother who has found that, for a variety of reasons, pumping is the only way she can provide her baby the benefits of breast milk, what these headlines suggest is another blow to her already fragile sense of self-worth.

This research article is excellent and should be read by all of us who counsel young families. It suggests that one of the contributors to our epidemic of childhood obesity may be that bottle-feeding discourages the infant’s own self-regulation skills. It should prompt us to ask every parent who is bottle-feeding his or her baby – regardless of what is in the bottle – exactly how they decide how much to put in the bottle and how long a feeding takes. Even if we are comfortable with the infant’s weight gain, we should caution parents to be more aware of the baby’s cues that he or she has had enough. Not every baby provides cues that are obvious, and parents may need our coaching in deciding how much to feed. This research paper also suggests that as long as breastfeeding was continued, introduction of solids as early as 5 months was not associated with an unhealthy BMI trajectory.

Unfortunately, the reporting of this research article is another example of the hazards of the explosive growth of the Internet. There really is no reason to keep the results of well-crafted research from the lay public, particularly if they are explained in common sense language. However, this places a burden of responsibility on the editors of websites to consider the damage that can be done by a poorly chosen headline.

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].

“Breast Milk From Bottle May Not Be As Beneficial As Feeding Directly From The Breast, Researchers Say.” This was the headline on the AAP Daily Briefing that was sent to American Academy of Pediatrics members on Sept 25, 2018.

©Jaimie Duplass/Fotolia.com

I suspect that this finding doesn’t surprise you. I can imagine a dozen factors that could make bottled breast milk less advantageous for a baby than milk received directly from the mother’s breast. Antibodies might adhere to the glass surface. A few degrees above or below body temperature could interfere with gastric emptying. Or a temptation to focus on the level in the bottle and inadvertently overfeed could inflate the baby’s body mass index at 3 months, as was found in the study published online in the September 2018 issue of Pediatrics (“Infant Feeding and Weight Gain: Separating Breast Milk From Breastfeeding and Formula From Food”).

I agree that the title of the actual paper is rather dry; it’s a scientific research paper. But the distillation chosen by the folks at AAP Daily Briefing seems ill advised. They were not alone. CCN-Health chose “Breastfeeding better for babies’ weight gain than pumping, new study says” (Michael Nedelman, Sept. 24, 2018). HealthDay News headlined its story with “Milk straight from breast best for baby’s weight” (Sept. 24, 2018).

The articles themselves were well balanced and accurately described this research based on more than 2,500 Canadian mother-infant dyads. But not everyone – including mothers who are struggling with or considering breastfeeding – reads beyond the headlines. How many realize that “better for babies’ weight gain” means a slower weight gain? For the mother who has found that, for a variety of reasons, pumping is the only way she can provide her baby the benefits of breast milk, what these headlines suggest is another blow to her already fragile sense of self-worth.

This research article is excellent and should be read by all of us who counsel young families. It suggests that one of the contributors to our epidemic of childhood obesity may be that bottle-feeding discourages the infant’s own self-regulation skills. It should prompt us to ask every parent who is bottle-feeding his or her baby – regardless of what is in the bottle – exactly how they decide how much to put in the bottle and how long a feeding takes. Even if we are comfortable with the infant’s weight gain, we should caution parents to be more aware of the baby’s cues that he or she has had enough. Not every baby provides cues that are obvious, and parents may need our coaching in deciding how much to feed. This research paper also suggests that as long as breastfeeding was continued, introduction of solids as early as 5 months was not associated with an unhealthy BMI trajectory.

Unfortunately, the reporting of this research article is another example of the hazards of the explosive growth of the Internet. There really is no reason to keep the results of well-crafted research from the lay public, particularly if they are explained in common sense language. However, this places a burden of responsibility on the editors of websites to consider the damage that can be done by a poorly chosen headline.

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].

“Alex, I understand that you are upset that you left your little bulldozer at home. Let’s try to think of something else you can play with here at the restaurant that is kind of like a bulldozer.”

Ambernectar 13/CC BY-ND 2.0

Sounds like a reasonable strategy to calm an unruly preschooler, and it might have been had it not been the fifth attempt in a 45-minute dialogue between a mother and her overtired, misbehaving 3-year-old. There had been a lot of “I understand how you feel” and “use your words” woven into a gag-worthy and futile effort to forge a collaborative parent-child solution to the problem of an exhausted preschooler who is up past his bedtime in a public place.

My wife and I enjoy a night out with friends and prefer a quiet dining atmosphere. However, some evenings we eat earlier and choose a restaurant we know appeals to families with young children. At those meals, we anticipate being serenaded by a loud background buzz punctuated by the occasional shriek or short bout of crying. We expect a degree of childish behavior to come with the territory, and watching the dramas unfold brings back fond “been there, done that” memories. But, listening to those behaviors being horribly mismanaged can ruin even the most tolerant adult’s appetite in less time than it takes a parent to say, “I can see you’re unhappy, and we need to talk about why.”

In an op-ed piece, a psychotherapist asks the legitimate question, and provides the correct quick answer (“Which Is Better, Rewards or Punishments? Neither,” New York Times, Aug. 21, 2018). I couldn’t agree more. In my experience, rewards have a very short half-life and can become disastrously inflationary in the blink of an eye. On the other hand, punishments can be either too heavy-handed or so irrational that the child fails to make a logical connection between his misbehavior and his sentence.

Unfortunately, many child behavior advisers, including the op-ed author, offer alternatives to rewards and punishment that are unworkable in real-world circumstances, such as the restaurant scenario my wife and I endured.

While it sounds very democratic to ask a 3-year-old why he is misbehaving, more often than not it should be the parent who is asking what he or she could have done differently to avoid the situation. It is likely the child has been allowed to become overtired and/or the parent may be in denial about his/her child’s intolerance for stimulating environments.

Too often the parent takes too long to realize that the water is spilling over the dam and it is time to head for shore. Children who are overtired and having a tantrum can’t participate in a rational discussion about their feelings. If that dialogue needs to happen, and that is seldom, it should be the next day after the parent has time to consider his or her own mistakes.

When it comes to managing misbehaving children, I prefer well-tailored consequences and my favorite is a humanely crafted time-out. When presented and executed properly, a time-out can break the cycle of misbehavior and give both parent and child a chance to reconsider their positions.

But at 7 p.m. on a Friday evening in a busy restaurant, neither a time-out nor philosophizing with a 3-year-old is going to work. It’s time to ask for the check and head home to bed.

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].

“Alex, I understand that you are upset that you left your little bulldozer at home. Let’s try to think of something else you can play with here at the restaurant that is kind of like a bulldozer.”

Ambernectar 13/CC BY-ND 2.0

Sounds like a reasonable strategy to calm an unruly preschooler, and it might have been had it not been the fifth attempt in a 45-minute dialogue between a mother and her overtired, misbehaving 3-year-old. There had been a lot of “I understand how you feel” and “use your words” woven into a gag-worthy and futile effort to forge a collaborative parent-child solution to the problem of an exhausted preschooler who is up past his bedtime in a public place.

My wife and I enjoy a night out with friends and prefer a quiet dining atmosphere. However, some evenings we eat earlier and choose a restaurant we know appeals to families with young children. At those meals, we anticipate being serenaded by a loud background buzz punctuated by the occasional shriek or short bout of crying. We expect a degree of childish behavior to come with the territory, and watching the dramas unfold brings back fond “been there, done that” memories. But, listening to those behaviors being horribly mismanaged can ruin even the most tolerant adult’s appetite in less time than it takes a parent to say, “I can see you’re unhappy, and we need to talk about why.”

In an op-ed piece, a psychotherapist asks the legitimate question, and provides the correct quick answer (“Which Is Better, Rewards or Punishments? Neither,” New York Times, Aug. 21, 2018). I couldn’t agree more. In my experience, rewards have a very short half-life and can become disastrously inflationary in the blink of an eye. On the other hand, punishments can be either too heavy-handed or so irrational that the child fails to make a logical connection between his misbehavior and his sentence.

Unfortunately, many child behavior advisers, including the op-ed author, offer alternatives to rewards and punishment that are unworkable in real-world circumstances, such as the restaurant scenario my wife and I endured.

While it sounds very democratic to ask a 3-year-old why he is misbehaving, more often than not it should be the parent who is asking what he or she could have done differently to avoid the situation. It is likely the child has been allowed to become overtired and/or the parent may be in denial about his/her child’s intolerance for stimulating environments.

Too often the parent takes too long to realize that the water is spilling over the dam and it is time to head for shore. Children who are overtired and having a tantrum can’t participate in a rational discussion about their feelings. If that dialogue needs to happen, and that is seldom, it should be the next day after the parent has time to consider his or her own mistakes.

When it comes to managing misbehaving children, I prefer well-tailored consequences and my favorite is a humanely crafted time-out. When presented and executed properly, a time-out can break the cycle of misbehavior and give both parent and child a chance to reconsider their positions.

But at 7 p.m. on a Friday evening in a busy restaurant, neither a time-out nor philosophizing with a 3-year-old is going to work. It’s time to ask for the check and head home to bed.

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].

“Alex, I understand that you are upset that you left your little bulldozer at home. Let’s try to think of something else you can play with here at the restaurant that is kind of like a bulldozer.”

Ambernectar 13/CC BY-ND 2.0

Sounds like a reasonable strategy to calm an unruly preschooler, and it might have been had it not been the fifth attempt in a 45-minute dialogue between a mother and her overtired, misbehaving 3-year-old. There had been a lot of “I understand how you feel” and “use your words” woven into a gag-worthy and futile effort to forge a collaborative parent-child solution to the problem of an exhausted preschooler who is up past his bedtime in a public place.

My wife and I enjoy a night out with friends and prefer a quiet dining atmosphere. However, some evenings we eat earlier and choose a restaurant we know appeals to families with young children. At those meals, we anticipate being serenaded by a loud background buzz punctuated by the occasional shriek or short bout of crying. We expect a degree of childish behavior to come with the territory, and watching the dramas unfold brings back fond “been there, done that” memories. But, listening to those behaviors being horribly mismanaged can ruin even the most tolerant adult’s appetite in less time than it takes a parent to say, “I can see you’re unhappy, and we need to talk about why.”

In an op-ed piece, a psychotherapist asks the legitimate question, and provides the correct quick answer (“Which Is Better, Rewards or Punishments? Neither,” New York Times, Aug. 21, 2018). I couldn’t agree more. In my experience, rewards have a very short half-life and can become disastrously inflationary in the blink of an eye. On the other hand, punishments can be either too heavy-handed or so irrational that the child fails to make a logical connection between his misbehavior and his sentence.

Unfortunately, many child behavior advisers, including the op-ed author, offer alternatives to rewards and punishment that are unworkable in real-world circumstances, such as the restaurant scenario my wife and I endured.

While it sounds very democratic to ask a 3-year-old why he is misbehaving, more often than not it should be the parent who is asking what he or she could have done differently to avoid the situation. It is likely the child has been allowed to become overtired and/or the parent may be in denial about his/her child’s intolerance for stimulating environments.

Too often the parent takes too long to realize that the water is spilling over the dam and it is time to head for shore. Children who are overtired and having a tantrum can’t participate in a rational discussion about their feelings. If that dialogue needs to happen, and that is seldom, it should be the next day after the parent has time to consider his or her own mistakes.

When it comes to managing misbehaving children, I prefer well-tailored consequences and my favorite is a humanely crafted time-out. When presented and executed properly, a time-out can break the cycle of misbehavior and give both parent and child a chance to reconsider their positions.

But at 7 p.m. on a Friday evening in a busy restaurant, neither a time-out nor philosophizing with a 3-year-old is going to work. It’s time to ask for the check and head home to bed.

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].

“We’ll have one strawberry sugar cone, two chocolate swirls, and a mocha almond.”

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“Dr. Wilkoff, I haven’t seen you in ... must be 5 years. You look great! How’s retirement going?”

“You look great too, Kim. The neighborhood has needed an ice cream parlor like yours for a long time. How’s the family?”

Alerted by the commotion of our catching up, Kim’s husband came outside to see what was going on. Looking at my wife, he said, “You know he saved our daughter’s life?”

Well, not exactly. A timely referral to a psychologist I knew was good with eating disorders had started the slow process of returning their anorectic daughter to health. I thanked him and tried to put a more historically correct spin on his story.

Most of my encounters with former patients and their parents aren’t as dramatic as this one at Kim’s Ice Cream Shack, but they always leave me with a warm, positive feeling that stays with me all day. Every now and then they include a compliment or a thank you, but most of the time the conversations are dominated by questions about how the other are doing and what our families are up to.

One of the perks of living in the town where you practice is that your patients also are your neighbors. Not every physician views this proximity as a positive, but for me, it was a gift that has kept on giving after I retired.

Our house phone number was always listed in the phone book, and I can count on the fingers of two hands how many times in 40 years that I received what I would consider an inappropriate or invasive call. Our office offered evening and weekend hours and a generous schedule of phone-in call times. But I’m convinced that it was the neighbor-to-neighbor relationship that kept the work/home balance intact. Even though I may have helped a plumber and his wife with their sick children, that professional arrangement didn’t include a free pass to call him after hours if I knew my leaking faucet could wait until the weekend was over.

By the same token, when a patient or a customer is also your neighbor there is an unspoken ethic that the service you provide must be your best effort. That’s not an admission that I was in the habit of offering substandard care to “folks from away,” but there is special motivation when your work is being scrutinized by people you’re likely to see next week at the grocery store checkout.

Office visits with neighbors often tended to take longer because there was a tendency to drift off topic and ask about a sibling’s baseball game I had read about in the paper or how the lobster catch was running that season. On the other hand, I must admit that I did my share of reporting (really it was bragging) on my own children’s accomplishments.

But now I’m reaping the benefits of those extra minutes invested in the office, because I suspect former patients and their families are more likely to want to reminisce when we meet in a restaurant or at the farmers’ market.

If you are a young physician and worrying about finding a good work/life balance, I urge you to consider living and working and then staying on in a place in which your patients also will be your neighbors. It will enrich your work experience and repay you many times over when it’s time to retire.

If you can’t find that place, at least treat your patients as though they were your neighbors.
 

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].

“We’ll have one strawberry sugar cone, two chocolate swirls, and a mocha almond.”

iStock

“Dr. Wilkoff, I haven’t seen you in ... must be 5 years. You look great! How’s retirement going?”

“You look great too, Kim. The neighborhood has needed an ice cream parlor like yours for a long time. How’s the family?”

Alerted by the commotion of our catching up, Kim’s husband came outside to see what was going on. Looking at my wife, he said, “You know he saved our daughter’s life?”

Well, not exactly. A timely referral to a psychologist I knew was good with eating disorders had started the slow process of returning their anorectic daughter to health. I thanked him and tried to put a more historically correct spin on his story.

Most of my encounters with former patients and their parents aren’t as dramatic as this one at Kim’s Ice Cream Shack, but they always leave me with a warm, positive feeling that stays with me all day. Every now and then they include a compliment or a thank you, but most of the time the conversations are dominated by questions about how the other are doing and what our families are up to.

One of the perks of living in the town where you practice is that your patients also are your neighbors. Not every physician views this proximity as a positive, but for me, it was a gift that has kept on giving after I retired.

Our house phone number was always listed in the phone book, and I can count on the fingers of two hands how many times in 40 years that I received what I would consider an inappropriate or invasive call. Our office offered evening and weekend hours and a generous schedule of phone-in call times. But I’m convinced that it was the neighbor-to-neighbor relationship that kept the work/home balance intact. Even though I may have helped a plumber and his wife with their sick children, that professional arrangement didn’t include a free pass to call him after hours if I knew my leaking faucet could wait until the weekend was over.

By the same token, when a patient or a customer is also your neighbor there is an unspoken ethic that the service you provide must be your best effort. That’s not an admission that I was in the habit of offering substandard care to “folks from away,” but there is special motivation when your work is being scrutinized by people you’re likely to see next week at the grocery store checkout.

Office visits with neighbors often tended to take longer because there was a tendency to drift off topic and ask about a sibling’s baseball game I had read about in the paper or how the lobster catch was running that season. On the other hand, I must admit that I did my share of reporting (really it was bragging) on my own children’s accomplishments.

But now I’m reaping the benefits of those extra minutes invested in the office, because I suspect former patients and their families are more likely to want to reminisce when we meet in a restaurant or at the farmers’ market.

If you are a young physician and worrying about finding a good work/life balance, I urge you to consider living and working and then staying on in a place in which your patients also will be your neighbors. It will enrich your work experience and repay you many times over when it’s time to retire.

If you can’t find that place, at least treat your patients as though they were your neighbors.
 

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].

“We’ll have one strawberry sugar cone, two chocolate swirls, and a mocha almond.”

iStock

“Dr. Wilkoff, I haven’t seen you in ... must be 5 years. You look great! How’s retirement going?”

“You look great too, Kim. The neighborhood has needed an ice cream parlor like yours for a long time. How’s the family?”

Alerted by the commotion of our catching up, Kim’s husband came outside to see what was going on. Looking at my wife, he said, “You know he saved our daughter’s life?”

Well, not exactly. A timely referral to a psychologist I knew was good with eating disorders had started the slow process of returning their anorectic daughter to health. I thanked him and tried to put a more historically correct spin on his story.

Most of my encounters with former patients and their parents aren’t as dramatic as this one at Kim’s Ice Cream Shack, but they always leave me with a warm, positive feeling that stays with me all day. Every now and then they include a compliment or a thank you, but most of the time the conversations are dominated by questions about how the other are doing and what our families are up to.

One of the perks of living in the town where you practice is that your patients also are your neighbors. Not every physician views this proximity as a positive, but for me, it was a gift that has kept on giving after I retired.

Our house phone number was always listed in the phone book, and I can count on the fingers of two hands how many times in 40 years that I received what I would consider an inappropriate or invasive call. Our office offered evening and weekend hours and a generous schedule of phone-in call times. But I’m convinced that it was the neighbor-to-neighbor relationship that kept the work/home balance intact. Even though I may have helped a plumber and his wife with their sick children, that professional arrangement didn’t include a free pass to call him after hours if I knew my leaking faucet could wait until the weekend was over.

By the same token, when a patient or a customer is also your neighbor there is an unspoken ethic that the service you provide must be your best effort. That’s not an admission that I was in the habit of offering substandard care to “folks from away,” but there is special motivation when your work is being scrutinized by people you’re likely to see next week at the grocery store checkout.

Office visits with neighbors often tended to take longer because there was a tendency to drift off topic and ask about a sibling’s baseball game I had read about in the paper or how the lobster catch was running that season. On the other hand, I must admit that I did my share of reporting (really it was bragging) on my own children’s accomplishments.

But now I’m reaping the benefits of those extra minutes invested in the office, because I suspect former patients and their families are more likely to want to reminisce when we meet in a restaurant or at the farmers’ market.

If you are a young physician and worrying about finding a good work/life balance, I urge you to consider living and working and then staying on in a place in which your patients also will be your neighbors. It will enrich your work experience and repay you many times over when it’s time to retire.

If you can’t find that place, at least treat your patients as though they were your neighbors.
 

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].

Defensive medicine exists. The question is how often it happens and how large a role it plays in making medical care in the United States so costly. When Dr. Tom Price was a congressman, he was quoted as saying that defensive medicine is responsible for more than 25% of every dollar this country spends on health care. (“A Fear of Lawsuits Really Does Seem to Result in Extra Medical Tests” Margot Sanger-Katz, New York Times, July 23, 2018). Neither I nor anyone else had any data to support or refute Dr. Price’s claim in 2010, but based on 50 years of practicing and observing medicine, I don’t find his claim completely unreasonable.

iStock

Defensive medicine has been going on for so many generations of physicians that most doctors practicing today don’t realize they are doing it. A physician may order a full battery of chemistries on a patient presenting with mild anemia when only a CBC is necessary because that’s the way he was trained.

However, the evidence to support my suspicion that defensive medicine is a significant financial drain on our economy has been difficult to tease out of the tangled web of confounders that is woven into our patchwork health care system. A recent study by two economists provides a glimpse into the role of defensive medicine in the cost of health care (“Defensive Medicine: Evidence from Military Immunity” Michael D. Frakes and Jonathan Gruber, National Bureau of Economic Research, July 2018). Using the unusual combination of circumstances in which military personnel and their dependents can or cannot sue depending on where they are receiving care, the investigators found that “liability immunity reduces inpatient spending by 5% with no measurable negative effect on patient outcomes.” While that may not be as high as Dr. Price or I think it may be, 5% of three trillion dollars is serious money.

The bigger problem is that defensive medicine is ugly, artless, and intellectually unsatisfying. While the patient may not view your diagnosis of his chronic debilitating or terminal illness as a work of art, there are such things as beautiful diagnoses. One may be beautiful in its simplicity and its ability to unify a variety of previously unexplained symptoms. Another diagnosis may be the intellectually stimulating result of a carefully thought out branching decision tree to solve a puzzling array of complaints using a minimum of costly studies.

Defensive medicine decisions are made primarily to avoid mistakes and omissions. Physicians often behave as though we believe our errors will always be fatal. That may be somewhat true for surgeons, but for the rest of us errors can be an important part of learning. The unfortunate outcome of an error, particularly one of omission, can usually be avoided by following the patient closely, remaining available ... and continuing to exude an aura of caring.

With close and thoughtful follow-up, you are going to discover pretty quickly when you have missed the target. Patients understand that we aren’t going to get the correct diagnosis or prescribe the best treatment on the first try every time. What patients don’t understand and what may prompt them to sue is feeling that they are being ignored.

While practicing defensive medicine isn’t usually listed as one of the cardinal symptoms of physician burnout, it probably deserves more attention. With some introspection and a bit of courage, recasting what you do in terms of its artistry and intellectual integrity could add a new and positive dimension to how you practice medicine. How many of your decisions are being made to avoid an error? Wouldn’t it be more fun to be making beautiful diagnoses you can be proud of?

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

Defensive medicine exists. The question is how often it happens and how large a role it plays in making medical care in the United States so costly. When Dr. Tom Price was a congressman, he was quoted as saying that defensive medicine is responsible for more than 25% of every dollar this country spends on health care. (“A Fear of Lawsuits Really Does Seem to Result in Extra Medical Tests” Margot Sanger-Katz, New York Times, July 23, 2018). Neither I nor anyone else had any data to support or refute Dr. Price’s claim in 2010, but based on 50 years of practicing and observing medicine, I don’t find his claim completely unreasonable.

iStock

Defensive medicine has been going on for so many generations of physicians that most doctors practicing today don’t realize they are doing it. A physician may order a full battery of chemistries on a patient presenting with mild anemia when only a CBC is necessary because that’s the way he was trained.

However, the evidence to support my suspicion that defensive medicine is a significant financial drain on our economy has been difficult to tease out of the tangled web of confounders that is woven into our patchwork health care system. A recent study by two economists provides a glimpse into the role of defensive medicine in the cost of health care (“Defensive Medicine: Evidence from Military Immunity” Michael D. Frakes and Jonathan Gruber, National Bureau of Economic Research, July 2018). Using the unusual combination of circumstances in which military personnel and their dependents can or cannot sue depending on where they are receiving care, the investigators found that “liability immunity reduces inpatient spending by 5% with no measurable negative effect on patient outcomes.” While that may not be as high as Dr. Price or I think it may be, 5% of three trillion dollars is serious money.

The bigger problem is that defensive medicine is ugly, artless, and intellectually unsatisfying. While the patient may not view your diagnosis of his chronic debilitating or terminal illness as a work of art, there are such things as beautiful diagnoses. One may be beautiful in its simplicity and its ability to unify a variety of previously unexplained symptoms. Another diagnosis may be the intellectually stimulating result of a carefully thought out branching decision tree to solve a puzzling array of complaints using a minimum of costly studies.

Defensive medicine decisions are made primarily to avoid mistakes and omissions. Physicians often behave as though we believe our errors will always be fatal. That may be somewhat true for surgeons, but for the rest of us errors can be an important part of learning. The unfortunate outcome of an error, particularly one of omission, can usually be avoided by following the patient closely, remaining available ... and continuing to exude an aura of caring.

With close and thoughtful follow-up, you are going to discover pretty quickly when you have missed the target. Patients understand that we aren’t going to get the correct diagnosis or prescribe the best treatment on the first try every time. What patients don’t understand and what may prompt them to sue is feeling that they are being ignored.

While practicing defensive medicine isn’t usually listed as one of the cardinal symptoms of physician burnout, it probably deserves more attention. With some introspection and a bit of courage, recasting what you do in terms of its artistry and intellectual integrity could add a new and positive dimension to how you practice medicine. How many of your decisions are being made to avoid an error? Wouldn’t it be more fun to be making beautiful diagnoses you can be proud of?

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

Defensive medicine exists. The question is how often it happens and how large a role it plays in making medical care in the United States so costly. When Dr. Tom Price was a congressman, he was quoted as saying that defensive medicine is responsible for more than 25% of every dollar this country spends on health care. (“A Fear of Lawsuits Really Does Seem to Result in Extra Medical Tests” Margot Sanger-Katz, New York Times, July 23, 2018). Neither I nor anyone else had any data to support or refute Dr. Price’s claim in 2010, but based on 50 years of practicing and observing medicine, I don’t find his claim completely unreasonable.

iStock

Defensive medicine has been going on for so many generations of physicians that most doctors practicing today don’t realize they are doing it. A physician may order a full battery of chemistries on a patient presenting with mild anemia when only a CBC is necessary because that’s the way he was trained.

However, the evidence to support my suspicion that defensive medicine is a significant financial drain on our economy has been difficult to tease out of the tangled web of confounders that is woven into our patchwork health care system. A recent study by two economists provides a glimpse into the role of defensive medicine in the cost of health care (“Defensive Medicine: Evidence from Military Immunity” Michael D. Frakes and Jonathan Gruber, National Bureau of Economic Research, July 2018). Using the unusual combination of circumstances in which military personnel and their dependents can or cannot sue depending on where they are receiving care, the investigators found that “liability immunity reduces inpatient spending by 5% with no measurable negative effect on patient outcomes.” While that may not be as high as Dr. Price or I think it may be, 5% of three trillion dollars is serious money.

The bigger problem is that defensive medicine is ugly, artless, and intellectually unsatisfying. While the patient may not view your diagnosis of his chronic debilitating or terminal illness as a work of art, there are such things as beautiful diagnoses. One may be beautiful in its simplicity and its ability to unify a variety of previously unexplained symptoms. Another diagnosis may be the intellectually stimulating result of a carefully thought out branching decision tree to solve a puzzling array of complaints using a minimum of costly studies.

Defensive medicine decisions are made primarily to avoid mistakes and omissions. Physicians often behave as though we believe our errors will always be fatal. That may be somewhat true for surgeons, but for the rest of us errors can be an important part of learning. The unfortunate outcome of an error, particularly one of omission, can usually be avoided by following the patient closely, remaining available ... and continuing to exude an aura of caring.

With close and thoughtful follow-up, you are going to discover pretty quickly when you have missed the target. Patients understand that we aren’t going to get the correct diagnosis or prescribe the best treatment on the first try every time. What patients don’t understand and what may prompt them to sue is feeling that they are being ignored.

While practicing defensive medicine isn’t usually listed as one of the cardinal symptoms of physician burnout, it probably deserves more attention. With some introspection and a bit of courage, recasting what you do in terms of its artistry and intellectual integrity could add a new and positive dimension to how you practice medicine. How many of your decisions are being made to avoid an error? Wouldn’t it be more fun to be making beautiful diagnoses you can be proud of?

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

Do the images of Syrian refugee children kindle a desire to leave the privileged suburban-dwelling patients in your practice for just a few weeks and donate your clinical skills to help the victims of political conflict? Or, are you looking for a way to give your post-retirement life some meaning by volunteering on a typhoon-ravaged island in Southeast Asia?

Rachel Unkovic/International Rescue Committee/CC BY 2.0

Before you ask your partners for a 1-month leave of absence or try to convince your spouse that camping out in a refugee camp would be a better way to spend this year’s travel budget, I urge you to read Pediatricians and Global Health: Opportunities and Considerations for Meaningful Engagement, published in Pediatrics. This lengthy and thorough report by the American Board of Pediatrics Global Health Task Force will give you pause and should serve as an important reality check before you run off to buy the plane tickets for your personal mission of mercy.

Gitanjli Arora, MD, of the Children’s Hospital of Los Angeles, and her coauthors point out that, just because there appears to be a need for people with clinical expertise does not mean that your little black bag of skills honed in the privileged bubble of a first-world country is going to be of much help. This question is one I have pondered on several occasions when I have been offered what might be called “medical voluntourism” opportunities.

If I have distinguished myself as a clinician, that skill has been based on my ability to listen and communicate. Dropped into a community where I have little or no language facility and cultural awareness, I would need to rely on my observational skills. While I pride myself on my ability to make a visual diagnosis, the truth is that my diagnostic successes based solely on observation are almost exclusively dermatologic ones. And, let me add, my familiarity with tropical skin rashes is severely limited. I’m sure I could learn but not in a stay as short as a month.

Taking a history and communicating a treatment plan would force me to rely on the skills of a translator. In settings dominated by upheaval, many of the presenting complaints are going to be the result of, or at least heavily colored by, the chaos induced by anxiety. The ability to sort out where the mind and body connect is difficult enough in a community in which I have spent 40 years and speak the language. Regardless of how much sympathy I feel for the victims of tragic events, my clinical skills would have little value in the short term. Even worse, I would probably just be in the way. As the Task Force points out, my presence could also be squandering local resources as on-site providers worked to get me up to speed.

The authors also explore the numerous other complicating factors that must be considered by those of us who feel the pull to help the victims of global strife and natural disaster. While the authors discourage physicians like you and me from “dropping in” to help, they offer an abundance of suggestions on how we can act globally and stay locally.

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].

Do the images of Syrian refugee children kindle a desire to leave the privileged suburban-dwelling patients in your practice for just a few weeks and donate your clinical skills to help the victims of political conflict? Or, are you looking for a way to give your post-retirement life some meaning by volunteering on a typhoon-ravaged island in Southeast Asia?

Rachel Unkovic/International Rescue Committee/CC BY 2.0

Before you ask your partners for a 1-month leave of absence or try to convince your spouse that camping out in a refugee camp would be a better way to spend this year’s travel budget, I urge you to read Pediatricians and Global Health: Opportunities and Considerations for Meaningful Engagement, published in Pediatrics. This lengthy and thorough report by the American Board of Pediatrics Global Health Task Force will give you pause and should serve as an important reality check before you run off to buy the plane tickets for your personal mission of mercy.

Gitanjli Arora, MD, of the Children’s Hospital of Los Angeles, and her coauthors point out that, just because there appears to be a need for people with clinical expertise does not mean that your little black bag of skills honed in the privileged bubble of a first-world country is going to be of much help. This question is one I have pondered on several occasions when I have been offered what might be called “medical voluntourism” opportunities.

If I have distinguished myself as a clinician, that skill has been based on my ability to listen and communicate. Dropped into a community where I have little or no language facility and cultural awareness, I would need to rely on my observational skills. While I pride myself on my ability to make a visual diagnosis, the truth is that my diagnostic successes based solely on observation are almost exclusively dermatologic ones. And, let me add, my familiarity with tropical skin rashes is severely limited. I’m sure I could learn but not in a stay as short as a month.

Taking a history and communicating a treatment plan would force me to rely on the skills of a translator. In settings dominated by upheaval, many of the presenting complaints are going to be the result of, or at least heavily colored by, the chaos induced by anxiety. The ability to sort out where the mind and body connect is difficult enough in a community in which I have spent 40 years and speak the language. Regardless of how much sympathy I feel for the victims of tragic events, my clinical skills would have little value in the short term. Even worse, I would probably just be in the way. As the Task Force points out, my presence could also be squandering local resources as on-site providers worked to get me up to speed.

The authors also explore the numerous other complicating factors that must be considered by those of us who feel the pull to help the victims of global strife and natural disaster. While the authors discourage physicians like you and me from “dropping in” to help, they offer an abundance of suggestions on how we can act globally and stay locally.

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].

Do the images of Syrian refugee children kindle a desire to leave the privileged suburban-dwelling patients in your practice for just a few weeks and donate your clinical skills to help the victims of political conflict? Or, are you looking for a way to give your post-retirement life some meaning by volunteering on a typhoon-ravaged island in Southeast Asia?

Rachel Unkovic/International Rescue Committee/CC BY 2.0

Before you ask your partners for a 1-month leave of absence or try to convince your spouse that camping out in a refugee camp would be a better way to spend this year’s travel budget, I urge you to read Pediatricians and Global Health: Opportunities and Considerations for Meaningful Engagement, published in Pediatrics. This lengthy and thorough report by the American Board of Pediatrics Global Health Task Force will give you pause and should serve as an important reality check before you run off to buy the plane tickets for your personal mission of mercy.

Gitanjli Arora, MD, of the Children’s Hospital of Los Angeles, and her coauthors point out that, just because there appears to be a need for people with clinical expertise does not mean that your little black bag of skills honed in the privileged bubble of a first-world country is going to be of much help. This question is one I have pondered on several occasions when I have been offered what might be called “medical voluntourism” opportunities.

If I have distinguished myself as a clinician, that skill has been based on my ability to listen and communicate. Dropped into a community where I have little or no language facility and cultural awareness, I would need to rely on my observational skills. While I pride myself on my ability to make a visual diagnosis, the truth is that my diagnostic successes based solely on observation are almost exclusively dermatologic ones. And, let me add, my familiarity with tropical skin rashes is severely limited. I’m sure I could learn but not in a stay as short as a month.

Taking a history and communicating a treatment plan would force me to rely on the skills of a translator. In settings dominated by upheaval, many of the presenting complaints are going to be the result of, or at least heavily colored by, the chaos induced by anxiety. The ability to sort out where the mind and body connect is difficult enough in a community in which I have spent 40 years and speak the language. Regardless of how much sympathy I feel for the victims of tragic events, my clinical skills would have little value in the short term. Even worse, I would probably just be in the way. As the Task Force points out, my presence could also be squandering local resources as on-site providers worked to get me up to speed.

The authors also explore the numerous other complicating factors that must be considered by those of us who feel the pull to help the victims of global strife and natural disaster. While the authors discourage physicians like you and me from “dropping in” to help, they offer an abundance of suggestions on how we can act globally and stay locally.

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].