William G. Wilkoff, MD

 

By the time you reach age 55, 18% of your pediatrician colleagues – or you yourself – will have been sued for malpractice. As many as 64% of your brother and sister obstetrician-gynecologists will have suffered the same fate. These numbers come from a pool of recent data released by the American Medical Association that suggest that nearly half of physicians in this country will be sued for malpractice by age 55 years.

tomloel/ThinkStock

A related release by the AMA details the outcomes and financial costs of malpractice suits between 2006 and 2015 (“Medical professional liability insurance indemnity payments, expenses, and claim disposition, 2006-2015,” by Jose R. Guardado, PhD, AMA Policy Research Perspectives, 2018). In a press release accompanying the publication of these two studies AMA President David O. Barbe, MD, MHA, observes, “Even though the vast majority of claims are dropped, dismissed, or withdrawn, the heavy cost associated with a litigious climate takes a significant financial toll on our health care system when the nation is working to reduce unnecessary health care costs.”

I have read the AMA’s press release and the two studies several times and didn’t see a single reference to the emotional toll taken on the health care providers who have been sued. Of course, although it is easy to imagine that the human cost of a malpractice suit is probably high, it is not one of those figures that the number crunchers can find in their data sets and spreadsheets.

As someone who has endured a malpractice suit that went to trial, I can bear personal witness to the emotional challenges that come with litigation. Although a case that goes to trial is unusual (7%), most cases like ours are won by defendants (87.5%). That number was of little or no reassurance to me and my codefendants. Every waking hour during the 7 years that it took our case to play out was darkened by the threat to my professional career. Every trip to the mailbox was an exercise in courage. Would there be another piece of voluminous communication to remind me of the terrible reality?

 

Thanks to my wife and a lawyer who was always concerned about how I was doing emotionally, my story had a happy ending. I survived with my solo practice and my marriage intact. But I know that others have not been as lucky. Chemical dependency, divorce, poor productivity, and early retirement are just part of the underreported collateral damage that can come in the wake of a malpractice case, even one that is resolved with a relatively small financial cost.

Beyond the emotional cost, there is the staggering expense of defensive medicine. It has been going on for so long that many physicians practicing today don’t realize they are practicing defensive medicine because that’s the way they have been taught by several generations of gun-shy mentors.

And, of course, the risk-averse mentality is one of the drivers of the tsunami of computerization that threatens to drown our health care delivery system. The fallacious legal argument that if it wasn’t documented, it didn’t happen, has resulted in a glut of computer-enhanced “documentation” that even the most casual observer realizes isn’t worth the electrons it takes to light up the pixels on a computer screen.

Even if we ignore their incalculable emotional costs, malpractice suits and the litigious climate in which we practice are eating away at our health care delivery system. I certainly don’t have the answers to rein in the costs. I only can recommend that you practice the best medicine you know how, and do it in a manner that demonstrates you care about the patient. And hope you have good lawyer who cares about you more than his fee.

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].

 

By the time you reach age 55, 18% of your pediatrician colleagues – or you yourself – will have been sued for malpractice. As many as 64% of your brother and sister obstetrician-gynecologists will have suffered the same fate. These numbers come from a pool of recent data released by the American Medical Association that suggest that nearly half of physicians in this country will be sued for malpractice by age 55 years.

tomloel/ThinkStock

A related release by the AMA details the outcomes and financial costs of malpractice suits between 2006 and 2015 (“Medical professional liability insurance indemnity payments, expenses, and claim disposition, 2006-2015,” by Jose R. Guardado, PhD, AMA Policy Research Perspectives, 2018). In a press release accompanying the publication of these two studies AMA President David O. Barbe, MD, MHA, observes, “Even though the vast majority of claims are dropped, dismissed, or withdrawn, the heavy cost associated with a litigious climate takes a significant financial toll on our health care system when the nation is working to reduce unnecessary health care costs.”

I have read the AMA’s press release and the two studies several times and didn’t see a single reference to the emotional toll taken on the health care providers who have been sued. Of course, although it is easy to imagine that the human cost of a malpractice suit is probably high, it is not one of those figures that the number crunchers can find in their data sets and spreadsheets.

As someone who has endured a malpractice suit that went to trial, I can bear personal witness to the emotional challenges that come with litigation. Although a case that goes to trial is unusual (7%), most cases like ours are won by defendants (87.5%). That number was of little or no reassurance to me and my codefendants. Every waking hour during the 7 years that it took our case to play out was darkened by the threat to my professional career. Every trip to the mailbox was an exercise in courage. Would there be another piece of voluminous communication to remind me of the terrible reality?

 

Thanks to my wife and a lawyer who was always concerned about how I was doing emotionally, my story had a happy ending. I survived with my solo practice and my marriage intact. But I know that others have not been as lucky. Chemical dependency, divorce, poor productivity, and early retirement are just part of the underreported collateral damage that can come in the wake of a malpractice case, even one that is resolved with a relatively small financial cost.

Beyond the emotional cost, there is the staggering expense of defensive medicine. It has been going on for so long that many physicians practicing today don’t realize they are practicing defensive medicine because that’s the way they have been taught by several generations of gun-shy mentors.

And, of course, the risk-averse mentality is one of the drivers of the tsunami of computerization that threatens to drown our health care delivery system. The fallacious legal argument that if it wasn’t documented, it didn’t happen, has resulted in a glut of computer-enhanced “documentation” that even the most casual observer realizes isn’t worth the electrons it takes to light up the pixels on a computer screen.

Even if we ignore their incalculable emotional costs, malpractice suits and the litigious climate in which we practice are eating away at our health care delivery system. I certainly don’t have the answers to rein in the costs. I only can recommend that you practice the best medicine you know how, and do it in a manner that demonstrates you care about the patient. And hope you have good lawyer who cares about you more than his fee.

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].

 

By the time you reach age 55, 18% of your pediatrician colleagues – or you yourself – will have been sued for malpractice. As many as 64% of your brother and sister obstetrician-gynecologists will have suffered the same fate. These numbers come from a pool of recent data released by the American Medical Association that suggest that nearly half of physicians in this country will be sued for malpractice by age 55 years.

tomloel/ThinkStock

A related release by the AMA details the outcomes and financial costs of malpractice suits between 2006 and 2015 (“Medical professional liability insurance indemnity payments, expenses, and claim disposition, 2006-2015,” by Jose R. Guardado, PhD, AMA Policy Research Perspectives, 2018). In a press release accompanying the publication of these two studies AMA President David O. Barbe, MD, MHA, observes, “Even though the vast majority of claims are dropped, dismissed, or withdrawn, the heavy cost associated with a litigious climate takes a significant financial toll on our health care system when the nation is working to reduce unnecessary health care costs.”

I have read the AMA’s press release and the two studies several times and didn’t see a single reference to the emotional toll taken on the health care providers who have been sued. Of course, although it is easy to imagine that the human cost of a malpractice suit is probably high, it is not one of those figures that the number crunchers can find in their data sets and spreadsheets.

As someone who has endured a malpractice suit that went to trial, I can bear personal witness to the emotional challenges that come with litigation. Although a case that goes to trial is unusual (7%), most cases like ours are won by defendants (87.5%). That number was of little or no reassurance to me and my codefendants. Every waking hour during the 7 years that it took our case to play out was darkened by the threat to my professional career. Every trip to the mailbox was an exercise in courage. Would there be another piece of voluminous communication to remind me of the terrible reality?

 

Thanks to my wife and a lawyer who was always concerned about how I was doing emotionally, my story had a happy ending. I survived with my solo practice and my marriage intact. But I know that others have not been as lucky. Chemical dependency, divorce, poor productivity, and early retirement are just part of the underreported collateral damage that can come in the wake of a malpractice case, even one that is resolved with a relatively small financial cost.

Beyond the emotional cost, there is the staggering expense of defensive medicine. It has been going on for so long that many physicians practicing today don’t realize they are practicing defensive medicine because that’s the way they have been taught by several generations of gun-shy mentors.

And, of course, the risk-averse mentality is one of the drivers of the tsunami of computerization that threatens to drown our health care delivery system. The fallacious legal argument that if it wasn’t documented, it didn’t happen, has resulted in a glut of computer-enhanced “documentation” that even the most casual observer realizes isn’t worth the electrons it takes to light up the pixels on a computer screen.

Even if we ignore their incalculable emotional costs, malpractice suits and the litigious climate in which we practice are eating away at our health care delivery system. I certainly don’t have the answers to rein in the costs. I only can recommend that you practice the best medicine you know how, and do it in a manner that demonstrates you care about the patient. And hope you have good lawyer who cares about you more than his fee.

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].

 

Our first daughter was born during my last year in medical school, and our second was born as I was finishing my second year in residency. Seeing those two little darlings grow and develop was a critical supplement to my pediatric training. And, watching my wife initially struggle and then succeed with breastfeeding provided a very personal experience and education about lactation that my interactions in the hospital and outpatient clinics didn’t offer.

We considered ourselves lucky because my wife wasn’t facing the additional challenge of returning to an out-of-the-home job. However, our good fortune did not confer immunity against the anxiety, insecurity, discomfort, and sleep deprivation–induced frustrations of breastfeeding. Watching my wife navigate the choppy waters of lactation certainly influenced my approach to counseling new mothers over my subsequent 4 decades of practice. I think I was a more sympathetic and realistic adviser based on my first-hand observations.

©Lev Olkha/iStockphoto.com

A recent article in the AAP News addresses this relationship between physicians’ personal experiences with breastfeeding and their clinical interactions with the mothers in their practices (“Facing barriers to breastfeeding may affect physicians’ advocacy for patients,” February 2018). The authors refer to a study in the Journal of Human Lactation reporting that in the group of 927 pediatric trainees who were surveyed, of which 421 had children and 346 breastfed their children, “1 in 4 did not meet their breastfeeding duration goal, and 1 in 3 did not meet their goal for extended breastfeeding,” which was 6 months (J Hum Lact. 2015 May;31[2]:240-8). Twenty-five percent either did not have access to or were not aware of a private room where they could express milk or breastfeed. The resulting failure left the trainees feeling frustrated, depressed, and devastated. More than 90% of the respondents felt that their experiences affected their interactions with mothers in their practices.

In a different survey of American Academy of Pediatrics fellows, more of the 832 pediatricians responding reported having had a personal experience with breastfeeding in 2014 than of the 620 responding in 1995 (68% vs. 42%). However, it is interesting that fewer of the respondents in 2014 felt that any mother can succeed at breastfeeding (predicted value = 70% in 1995, PV = 56% in 2014; P less than .05), and fewer in 2014 believed that the advantages of breastfeeding outweighed the difficulties than among those surveyed in 1995 (PV = 70% in 1995, PV = 50% in 2014; P less than .05) (Pediatrics. 2017 Oct;140[4]. pii: e20171229). These results suggest that, as more pediatricians gained personal experience with breastfeeding, more may have realized that the American Academy of Pediatrics recommendations for breastfeeding are unrealistic and may contribute to the negative experiences of some women, including pediatric trainees.

An implied assumption in the AAP News article is that a pediatrician who has had a negative breastfeeding experience is less likely to be a strong advocate for breastfeeding. I would argue that a pediatrician who has witnessed or personally experienced difficulties is more likely to be a sympathetic and realistic advocate of breastfeeding.

Of course, my argument begs the question of exactly for what and for whom we are advocating. The quick reflex answer might be that, of course we are advocating for children because we have data supporting the benefits for them of exclusive breastfeeding for the first 6 months and extended breastfeeding for 1 year. However, many of us who have practiced pediatrics for more than a couple of decades have observed ample anecdotal evidence that overzealous advocacy for the current breastfeeding guidelines can result in casualties among women whose “failure” has left them depressed, frustrated, and less confident in their ability to mother.

We must walk that fine line between actively advocating for lactation-friendly hospitals and work environments and supporting mothers who, due to circumstances beyond their control, can’t meet the expectations we have created for them.

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.”

 

Our first daughter was born during my last year in medical school, and our second was born as I was finishing my second year in residency. Seeing those two little darlings grow and develop was a critical supplement to my pediatric training. And, watching my wife initially struggle and then succeed with breastfeeding provided a very personal experience and education about lactation that my interactions in the hospital and outpatient clinics didn’t offer.

We considered ourselves lucky because my wife wasn’t facing the additional challenge of returning to an out-of-the-home job. However, our good fortune did not confer immunity against the anxiety, insecurity, discomfort, and sleep deprivation–induced frustrations of breastfeeding. Watching my wife navigate the choppy waters of lactation certainly influenced my approach to counseling new mothers over my subsequent 4 decades of practice. I think I was a more sympathetic and realistic adviser based on my first-hand observations.

©Lev Olkha/iStockphoto.com

A recent article in the AAP News addresses this relationship between physicians’ personal experiences with breastfeeding and their clinical interactions with the mothers in their practices (“Facing barriers to breastfeeding may affect physicians’ advocacy for patients,” February 2018). The authors refer to a study in the Journal of Human Lactation reporting that in the group of 927 pediatric trainees who were surveyed, of which 421 had children and 346 breastfed their children, “1 in 4 did not meet their breastfeeding duration goal, and 1 in 3 did not meet their goal for extended breastfeeding,” which was 6 months (J Hum Lact. 2015 May;31[2]:240-8). Twenty-five percent either did not have access to or were not aware of a private room where they could express milk or breastfeed. The resulting failure left the trainees feeling frustrated, depressed, and devastated. More than 90% of the respondents felt that their experiences affected their interactions with mothers in their practices.

In a different survey of American Academy of Pediatrics fellows, more of the 832 pediatricians responding reported having had a personal experience with breastfeeding in 2014 than of the 620 responding in 1995 (68% vs. 42%). However, it is interesting that fewer of the respondents in 2014 felt that any mother can succeed at breastfeeding (predicted value = 70% in 1995, PV = 56% in 2014; P less than .05), and fewer in 2014 believed that the advantages of breastfeeding outweighed the difficulties than among those surveyed in 1995 (PV = 70% in 1995, PV = 50% in 2014; P less than .05) (Pediatrics. 2017 Oct;140[4]. pii: e20171229). These results suggest that, as more pediatricians gained personal experience with breastfeeding, more may have realized that the American Academy of Pediatrics recommendations for breastfeeding are unrealistic and may contribute to the negative experiences of some women, including pediatric trainees.

An implied assumption in the AAP News article is that a pediatrician who has had a negative breastfeeding experience is less likely to be a strong advocate for breastfeeding. I would argue that a pediatrician who has witnessed or personally experienced difficulties is more likely to be a sympathetic and realistic advocate of breastfeeding.

Of course, my argument begs the question of exactly for what and for whom we are advocating. The quick reflex answer might be that, of course we are advocating for children because we have data supporting the benefits for them of exclusive breastfeeding for the first 6 months and extended breastfeeding for 1 year. However, many of us who have practiced pediatrics for more than a couple of decades have observed ample anecdotal evidence that overzealous advocacy for the current breastfeeding guidelines can result in casualties among women whose “failure” has left them depressed, frustrated, and less confident in their ability to mother.

We must walk that fine line between actively advocating for lactation-friendly hospitals and work environments and supporting mothers who, due to circumstances beyond their control, can’t meet the expectations we have created for them.

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.”

 

Our first daughter was born during my last year in medical school, and our second was born as I was finishing my second year in residency. Seeing those two little darlings grow and develop was a critical supplement to my pediatric training. And, watching my wife initially struggle and then succeed with breastfeeding provided a very personal experience and education about lactation that my interactions in the hospital and outpatient clinics didn’t offer.

We considered ourselves lucky because my wife wasn’t facing the additional challenge of returning to an out-of-the-home job. However, our good fortune did not confer immunity against the anxiety, insecurity, discomfort, and sleep deprivation–induced frustrations of breastfeeding. Watching my wife navigate the choppy waters of lactation certainly influenced my approach to counseling new mothers over my subsequent 4 decades of practice. I think I was a more sympathetic and realistic adviser based on my first-hand observations.

©Lev Olkha/iStockphoto.com

A recent article in the AAP News addresses this relationship between physicians’ personal experiences with breastfeeding and their clinical interactions with the mothers in their practices (“Facing barriers to breastfeeding may affect physicians’ advocacy for patients,” February 2018). The authors refer to a study in the Journal of Human Lactation reporting that in the group of 927 pediatric trainees who were surveyed, of which 421 had children and 346 breastfed their children, “1 in 4 did not meet their breastfeeding duration goal, and 1 in 3 did not meet their goal for extended breastfeeding,” which was 6 months (J Hum Lact. 2015 May;31[2]:240-8). Twenty-five percent either did not have access to or were not aware of a private room where they could express milk or breastfeed. The resulting failure left the trainees feeling frustrated, depressed, and devastated. More than 90% of the respondents felt that their experiences affected their interactions with mothers in their practices.

In a different survey of American Academy of Pediatrics fellows, more of the 832 pediatricians responding reported having had a personal experience with breastfeeding in 2014 than of the 620 responding in 1995 (68% vs. 42%). However, it is interesting that fewer of the respondents in 2014 felt that any mother can succeed at breastfeeding (predicted value = 70% in 1995, PV = 56% in 2014; P less than .05), and fewer in 2014 believed that the advantages of breastfeeding outweighed the difficulties than among those surveyed in 1995 (PV = 70% in 1995, PV = 50% in 2014; P less than .05) (Pediatrics. 2017 Oct;140[4]. pii: e20171229). These results suggest that, as more pediatricians gained personal experience with breastfeeding, more may have realized that the American Academy of Pediatrics recommendations for breastfeeding are unrealistic and may contribute to the negative experiences of some women, including pediatric trainees.

An implied assumption in the AAP News article is that a pediatrician who has had a negative breastfeeding experience is less likely to be a strong advocate for breastfeeding. I would argue that a pediatrician who has witnessed or personally experienced difficulties is more likely to be a sympathetic and realistic advocate of breastfeeding.

Of course, my argument begs the question of exactly for what and for whom we are advocating. The quick reflex answer might be that, of course we are advocating for children because we have data supporting the benefits for them of exclusive breastfeeding for the first 6 months and extended breastfeeding for 1 year. However, many of us who have practiced pediatrics for more than a couple of decades have observed ample anecdotal evidence that overzealous advocacy for the current breastfeeding guidelines can result in casualties among women whose “failure” has left them depressed, frustrated, and less confident in their ability to mother.

We must walk that fine line between actively advocating for lactation-friendly hospitals and work environments and supporting mothers who, due to circumstances beyond their control, can’t meet the expectations we have created for them.

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.”

 

When we were invited to a family gathering to celebrate a 60th birthday, we expected to hear an abundance of news about grandchildren. They are natural, and seldom controversial, topics of discussion. If there is a child still waiting in utero and destined to be the first grandchild on one or both sides of the family, the impending adventure in parenthood will dominate the conversation.

To our great surprise, despite the presence of one very pregnant young woman, who in 6 weeks would be giving birth to the first grandchild in my nephew’s family, my wife and I can recall only one brief dialogue in which I was asked about how one might go about selecting a pediatrician.

Stockbyte/Thinkstock

There were no complaints about how the mother-to-be was sleeping or eating or ambulating. There were no descriptions of the color scheme and decor in the nursery – or the plans for day care – or how expensive and complicated car seats and strollers had become. Taking a cue from the young woman’s matter-of-fact attitude toward her pregnancy, the older women in the room showed amazing restraint by not swapping tales of their obstetrical adventures. The conversation ranged far and wide from football to failed recipes for chocolate cake, while the gravid uterus rested comfortably on its owner’s lap like the proverbial elephant in the room.

I’m not sure why the blessed event to come was being ignored, but I found the oversight unusual and refreshing. It is possible that there had been so much hype about the pregnancy on her side of the family that the couple relished its absence from the birthday party’s topics for discussion.

In the spirit of full disclosure, I must add that, as a result of my frequent claims of ignorance when asked about medically related topics, I am often referred to by the extended family as “Dr. I-Don’t-Know.” It may be that my presence influenced the conversation, but regardless of the reason, I was impressed with the ease at which this couple was approaching the birth of their first child.

I am sure they harbor some anxieties, and I am sure they have listened to some horror stories from their peers about sleep and breastfeeding problems. They are bright people who acknowledge that they are going to encounter some bumps along the road of parenthood. However, they seem to be immune to the epidemic of anxiety that for decades has been sweeping over cohorts of North Americans entering their family-building years.

Generations of young, seemingly intelligent people have lost their confidence in being able to do what should come naturally. They are ravenous consumers of information about how they should be parenting. And I admit that I have tried to capitalize on their insecurity by writing several books of advice for parents. Of course, I always have hoped that in time my readers probably will realize that while there are lots of ways to do it poorly, there is no best way to parent.

The young couple my wife and I encountered are just as clueless about what parenthood has in store as their anxiety-driven peers are. The difference is that they are enjoying their pregnancy in blissful ignorance buffered by their refreshing confidence that, however they do it, they will be doing it naturally.
 

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.”

 

When we were invited to a family gathering to celebrate a 60th birthday, we expected to hear an abundance of news about grandchildren. They are natural, and seldom controversial, topics of discussion. If there is a child still waiting in utero and destined to be the first grandchild on one or both sides of the family, the impending adventure in parenthood will dominate the conversation.

To our great surprise, despite the presence of one very pregnant young woman, who in 6 weeks would be giving birth to the first grandchild in my nephew’s family, my wife and I can recall only one brief dialogue in which I was asked about how one might go about selecting a pediatrician.

Stockbyte/Thinkstock

There were no complaints about how the mother-to-be was sleeping or eating or ambulating. There were no descriptions of the color scheme and decor in the nursery – or the plans for day care – or how expensive and complicated car seats and strollers had become. Taking a cue from the young woman’s matter-of-fact attitude toward her pregnancy, the older women in the room showed amazing restraint by not swapping tales of their obstetrical adventures. The conversation ranged far and wide from football to failed recipes for chocolate cake, while the gravid uterus rested comfortably on its owner’s lap like the proverbial elephant in the room.

I’m not sure why the blessed event to come was being ignored, but I found the oversight unusual and refreshing. It is possible that there had been so much hype about the pregnancy on her side of the family that the couple relished its absence from the birthday party’s topics for discussion.

In the spirit of full disclosure, I must add that, as a result of my frequent claims of ignorance when asked about medically related topics, I am often referred to by the extended family as “Dr. I-Don’t-Know.” It may be that my presence influenced the conversation, but regardless of the reason, I was impressed with the ease at which this couple was approaching the birth of their first child.

I am sure they harbor some anxieties, and I am sure they have listened to some horror stories from their peers about sleep and breastfeeding problems. They are bright people who acknowledge that they are going to encounter some bumps along the road of parenthood. However, they seem to be immune to the epidemic of anxiety that for decades has been sweeping over cohorts of North Americans entering their family-building years.

Generations of young, seemingly intelligent people have lost their confidence in being able to do what should come naturally. They are ravenous consumers of information about how they should be parenting. And I admit that I have tried to capitalize on their insecurity by writing several books of advice for parents. Of course, I always have hoped that in time my readers probably will realize that while there are lots of ways to do it poorly, there is no best way to parent.

The young couple my wife and I encountered are just as clueless about what parenthood has in store as their anxiety-driven peers are. The difference is that they are enjoying their pregnancy in blissful ignorance buffered by their refreshing confidence that, however they do it, they will be doing it naturally.
 

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.”

 

When we were invited to a family gathering to celebrate a 60th birthday, we expected to hear an abundance of news about grandchildren. They are natural, and seldom controversial, topics of discussion. If there is a child still waiting in utero and destined to be the first grandchild on one or both sides of the family, the impending adventure in parenthood will dominate the conversation.

To our great surprise, despite the presence of one very pregnant young woman, who in 6 weeks would be giving birth to the first grandchild in my nephew’s family, my wife and I can recall only one brief dialogue in which I was asked about how one might go about selecting a pediatrician.

Stockbyte/Thinkstock

There were no complaints about how the mother-to-be was sleeping or eating or ambulating. There were no descriptions of the color scheme and decor in the nursery – or the plans for day care – or how expensive and complicated car seats and strollers had become. Taking a cue from the young woman’s matter-of-fact attitude toward her pregnancy, the older women in the room showed amazing restraint by not swapping tales of their obstetrical adventures. The conversation ranged far and wide from football to failed recipes for chocolate cake, while the gravid uterus rested comfortably on its owner’s lap like the proverbial elephant in the room.

I’m not sure why the blessed event to come was being ignored, but I found the oversight unusual and refreshing. It is possible that there had been so much hype about the pregnancy on her side of the family that the couple relished its absence from the birthday party’s topics for discussion.

In the spirit of full disclosure, I must add that, as a result of my frequent claims of ignorance when asked about medically related topics, I am often referred to by the extended family as “Dr. I-Don’t-Know.” It may be that my presence influenced the conversation, but regardless of the reason, I was impressed with the ease at which this couple was approaching the birth of their first child.

I am sure they harbor some anxieties, and I am sure they have listened to some horror stories from their peers about sleep and breastfeeding problems. They are bright people who acknowledge that they are going to encounter some bumps along the road of parenthood. However, they seem to be immune to the epidemic of anxiety that for decades has been sweeping over cohorts of North Americans entering their family-building years.

Generations of young, seemingly intelligent people have lost their confidence in being able to do what should come naturally. They are ravenous consumers of information about how they should be parenting. And I admit that I have tried to capitalize on their insecurity by writing several books of advice for parents. Of course, I always have hoped that in time my readers probably will realize that while there are lots of ways to do it poorly, there is no best way to parent.

The young couple my wife and I encountered are just as clueless about what parenthood has in store as their anxiety-driven peers are. The difference is that they are enjoying their pregnancy in blissful ignorance buffered by their refreshing confidence that, however they do it, they will be doing it naturally.
 

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.”

 

If you were born in or after the 1970s, it is very likely that you have never watched a television show on a black and white set. Although the roots of its technology extend well back into the early 20th century, the first color broadcast on a national television network didn’t occur until 1954 with NBC’s coverage of the Tournament of Roses Parade.

When we compare the popularization of color television with the rapid pace at which we adopt new technology today, the popularization of color TV was glacial. In large part because of their expense, sales of color sets did not surpass black and white sets until 1972. Our family lagged behind the curve and finally caved in and junked our black and white television around 1977.

The observable change in our viewing behavior was dramatic. While programming in black and white was interesting, the color images were magnetic. We were drawn by the visual excitement and stimulation that color offered, and our family’s viewing standards took a precipitous dip. We seemed to watch anything that was colorful and moved. The quality of the content took a back seat. Viewing in color seemed to require much less cognitive effort. Ironically what attracted our attention allowed us to invest less energy in paying attention.

As a regular reader of Letters From Maine, you know that I am convinced that sleep deprivation is a major contributor to the emergence of the ADHD phenomenon. However, I can make a similar argument that the introduction of color television is an equally potent coconspirator or confounder. The magnetism inherent in a moving color image can tempt even the most health conscious among us to stay well past a brain-friendly bedtime. The invention of the electric light may have gotten the ball rolling, but the ubiquity of moving electronic color images has certainly greased what was already a very slippery slope into an abyss of unhealthy sleep habits.

©iStock/ThinkStockPhotos.com

In the last decade, we have put this eye candy of color television literally into the hands of very small children in the form of smartphones and tablets. Whether the power of electronic color images that I have referred to as magnetism can qualify as a true addiction is currently being investigated. However, anecdotal evidence of the attention grabbing power of these devices for children of all ages is overwhelming.

There are those who argue that smartphones and tablets can open a world of creative opportunities for even very young children. And, it is obvious that parents are struggling to find a balance as they try to decide when, where, and how often to allow their infants and toddlers access to handheld electronic devices.

Recently there has been much finger-pointing at the developers and manufacturers of smartphones and tablets. How can any company with a social conscience sell a product with such dangerous attractive potential for children without providing safeguards? Isn’t it like selling a swimming pool without a gated fence?

Of course the answer to this question goes to the heart of how our society views its responsibility to protect its children. Regardless of who makes the rules and how the responsibility is assigned, it is still the child’s parents who must make sure that the gate is locked.

I recently encountered a newspaper article describing a clever strategy that might make the job of policing handheld electronic devices much easier for concerned parents (Is the Answer to Phone Addiction a Worse Phone? by Nellie Bowles, The New York Times, Jan. 12, 2018). The author describes a simple maneuver in the settings of your device that will allow you to shift the screen image from the stimulating colors to which you are accustomed to shades of gray. Apparently, there is more than a little neuroscience evidence that supports my anecdotal evidence that taking out the color will make the screens much less attractive for children … and adults. It’s certainly worth a try.

 

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.”

 

If you were born in or after the 1970s, it is very likely that you have never watched a television show on a black and white set. Although the roots of its technology extend well back into the early 20th century, the first color broadcast on a national television network didn’t occur until 1954 with NBC’s coverage of the Tournament of Roses Parade.

When we compare the popularization of color television with the rapid pace at which we adopt new technology today, the popularization of color TV was glacial. In large part because of their expense, sales of color sets did not surpass black and white sets until 1972. Our family lagged behind the curve and finally caved in and junked our black and white television around 1977.

The observable change in our viewing behavior was dramatic. While programming in black and white was interesting, the color images were magnetic. We were drawn by the visual excitement and stimulation that color offered, and our family’s viewing standards took a precipitous dip. We seemed to watch anything that was colorful and moved. The quality of the content took a back seat. Viewing in color seemed to require much less cognitive effort. Ironically what attracted our attention allowed us to invest less energy in paying attention.

As a regular reader of Letters From Maine, you know that I am convinced that sleep deprivation is a major contributor to the emergence of the ADHD phenomenon. However, I can make a similar argument that the introduction of color television is an equally potent coconspirator or confounder. The magnetism inherent in a moving color image can tempt even the most health conscious among us to stay well past a brain-friendly bedtime. The invention of the electric light may have gotten the ball rolling, but the ubiquity of moving electronic color images has certainly greased what was already a very slippery slope into an abyss of unhealthy sleep habits.

©iStock/ThinkStockPhotos.com

In the last decade, we have put this eye candy of color television literally into the hands of very small children in the form of smartphones and tablets. Whether the power of electronic color images that I have referred to as magnetism can qualify as a true addiction is currently being investigated. However, anecdotal evidence of the attention grabbing power of these devices for children of all ages is overwhelming.

There are those who argue that smartphones and tablets can open a world of creative opportunities for even very young children. And, it is obvious that parents are struggling to find a balance as they try to decide when, where, and how often to allow their infants and toddlers access to handheld electronic devices.

Recently there has been much finger-pointing at the developers and manufacturers of smartphones and tablets. How can any company with a social conscience sell a product with such dangerous attractive potential for children without providing safeguards? Isn’t it like selling a swimming pool without a gated fence?

Of course the answer to this question goes to the heart of how our society views its responsibility to protect its children. Regardless of who makes the rules and how the responsibility is assigned, it is still the child’s parents who must make sure that the gate is locked.

I recently encountered a newspaper article describing a clever strategy that might make the job of policing handheld electronic devices much easier for concerned parents (Is the Answer to Phone Addiction a Worse Phone? by Nellie Bowles, The New York Times, Jan. 12, 2018). The author describes a simple maneuver in the settings of your device that will allow you to shift the screen image from the stimulating colors to which you are accustomed to shades of gray. Apparently, there is more than a little neuroscience evidence that supports my anecdotal evidence that taking out the color will make the screens much less attractive for children … and adults. It’s certainly worth a try.

 

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.”

 

If you were born in or after the 1970s, it is very likely that you have never watched a television show on a black and white set. Although the roots of its technology extend well back into the early 20th century, the first color broadcast on a national television network didn’t occur until 1954 with NBC’s coverage of the Tournament of Roses Parade.

When we compare the popularization of color television with the rapid pace at which we adopt new technology today, the popularization of color TV was glacial. In large part because of their expense, sales of color sets did not surpass black and white sets until 1972. Our family lagged behind the curve and finally caved in and junked our black and white television around 1977.

The observable change in our viewing behavior was dramatic. While programming in black and white was interesting, the color images were magnetic. We were drawn by the visual excitement and stimulation that color offered, and our family’s viewing standards took a precipitous dip. We seemed to watch anything that was colorful and moved. The quality of the content took a back seat. Viewing in color seemed to require much less cognitive effort. Ironically what attracted our attention allowed us to invest less energy in paying attention.

As a regular reader of Letters From Maine, you know that I am convinced that sleep deprivation is a major contributor to the emergence of the ADHD phenomenon. However, I can make a similar argument that the introduction of color television is an equally potent coconspirator or confounder. The magnetism inherent in a moving color image can tempt even the most health conscious among us to stay well past a brain-friendly bedtime. The invention of the electric light may have gotten the ball rolling, but the ubiquity of moving electronic color images has certainly greased what was already a very slippery slope into an abyss of unhealthy sleep habits.

©iStock/ThinkStockPhotos.com

In the last decade, we have put this eye candy of color television literally into the hands of very small children in the form of smartphones and tablets. Whether the power of electronic color images that I have referred to as magnetism can qualify as a true addiction is currently being investigated. However, anecdotal evidence of the attention grabbing power of these devices for children of all ages is overwhelming.

There are those who argue that smartphones and tablets can open a world of creative opportunities for even very young children. And, it is obvious that parents are struggling to find a balance as they try to decide when, where, and how often to allow their infants and toddlers access to handheld electronic devices.

Recently there has been much finger-pointing at the developers and manufacturers of smartphones and tablets. How can any company with a social conscience sell a product with such dangerous attractive potential for children without providing safeguards? Isn’t it like selling a swimming pool without a gated fence?

Of course the answer to this question goes to the heart of how our society views its responsibility to protect its children. Regardless of who makes the rules and how the responsibility is assigned, it is still the child’s parents who must make sure that the gate is locked.

I recently encountered a newspaper article describing a clever strategy that might make the job of policing handheld electronic devices much easier for concerned parents (Is the Answer to Phone Addiction a Worse Phone? by Nellie Bowles, The New York Times, Jan. 12, 2018). The author describes a simple maneuver in the settings of your device that will allow you to shift the screen image from the stimulating colors to which you are accustomed to shades of gray. Apparently, there is more than a little neuroscience evidence that supports my anecdotal evidence that taking out the color will make the screens much less attractive for children … and adults. It’s certainly worth a try.

 

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.”

 

“She will eat when she is hungry.” That in so many words is the mantra of grandparents blessed with experience and common sense and of most pediatricians when consulting parents challenged with a picky eater. From birth, children understand the simple equation that to survive they must eat. With rare exception, the motivating power of hunger can be leveraged for success even with infants who have spent their first months relying on enteral feedings. I have written an entire book based solely on the premise that if you present a young child food she will eat it ... eventually (“Coping With a Picky Eater: A Guide for the Perplexed Parent” New York: Simon and Schuster, 1998).

But if we reverse the words to read, “When she is eating, she is hungry,” do we have an equally valid observation? I think we have ample evidence that it is not.

Wavebreakmedia/Thinkstock

I recently encountered an anecdote in one of the New York Times op-ed pieces by Perri Klass, MD, that got me thinking more broadly about the perception of hunger and its power to motivate (“Do parents make kids fat?” the New York Times, Jan. 8, 2018). Dr. Klass relates a story of an obesity specialist who herself had struggled with obesity. Despite her careful attention to everything she had learned about obesity management and breastfeeding, this woman was unprepared for giving birth to an infant who was “instantly a very dramatically hungry baby.”

The result was a year-long odyssey of pumping that included consultations with five different lactation consultants in the first frustrating month and a half. She eventually received some comforting advice from a pediatrician who reassured her that there was little research to guide her and to “just feed him; trust your instincts.”

While it is unfortunately true that there is very little good science we can fall back on when counseling women who are struggling with breastfeeding, I wonder about the wisdom of telling this mother to trust her instincts. I guess my hesitancy is based on 40 years of primary care pediatrics in which I could generally count on the instincts of young children, but their parents’ not so much. While maternal intuition is generally superior to the paternal version, I am hesitant to rely totally on either when facing a clinical dilemma such as defining hunger.

Is a fussy infant hungry because he seems to be comforted only by a bottle or breast? What about the fussy baby who is comforted by just a pacifier? What is the difference? There are several explanations, but it will require introducing the concept of nutrition deficiency.

Most babies who are satisfied with just a nipple, be it silicone or flesh, simply find sucking a comfort measure. A few, and I am sure you have seen some of them, are overly patient. They seem to be saying, “I need the calories, but you’re a good mom and I enjoy sucking. I can wait. Some day, you may make more milk or give me a bottle.” In the worst-case scenarios, their patience leaves these babies so nutritionally deficient that they can slip into apathy and die.

On the other end of the spectrum are infants who love to suck so much that they will ignore (or maybe lack) their own satiety center. They may be fussy for some other reason than hunger, most likely sleep deprivation, and will suck and swallow to comfort themselves even though they have met their nutritional needs. The surplus milk or formula is converted to unhealthy weight or is misdiagnosed as “reflux.” Could this phenomenon have a genetic basis? Has the mother in Dr. Klass’ scenario shared an inheritable problem with satiety with her infant?

There are no easy answers. As pediatricians, our job is to sort out those fussy “hungry” babies whose behavior means they are overtired from those who are nutritionally deficient, from those with a dysfunctional satiety center. Making the differentiation is difficult but much easier than helping parents ignore one of their instincts.
 

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].

 

“She will eat when she is hungry.” That in so many words is the mantra of grandparents blessed with experience and common sense and of most pediatricians when consulting parents challenged with a picky eater. From birth, children understand the simple equation that to survive they must eat. With rare exception, the motivating power of hunger can be leveraged for success even with infants who have spent their first months relying on enteral feedings. I have written an entire book based solely on the premise that if you present a young child food she will eat it ... eventually (“Coping With a Picky Eater: A Guide for the Perplexed Parent” New York: Simon and Schuster, 1998).

But if we reverse the words to read, “When she is eating, she is hungry,” do we have an equally valid observation? I think we have ample evidence that it is not.

Wavebreakmedia/Thinkstock

I recently encountered an anecdote in one of the New York Times op-ed pieces by Perri Klass, MD, that got me thinking more broadly about the perception of hunger and its power to motivate (“Do parents make kids fat?” the New York Times, Jan. 8, 2018). Dr. Klass relates a story of an obesity specialist who herself had struggled with obesity. Despite her careful attention to everything she had learned about obesity management and breastfeeding, this woman was unprepared for giving birth to an infant who was “instantly a very dramatically hungry baby.”

The result was a year-long odyssey of pumping that included consultations with five different lactation consultants in the first frustrating month and a half. She eventually received some comforting advice from a pediatrician who reassured her that there was little research to guide her and to “just feed him; trust your instincts.”

While it is unfortunately true that there is very little good science we can fall back on when counseling women who are struggling with breastfeeding, I wonder about the wisdom of telling this mother to trust her instincts. I guess my hesitancy is based on 40 years of primary care pediatrics in which I could generally count on the instincts of young children, but their parents’ not so much. While maternal intuition is generally superior to the paternal version, I am hesitant to rely totally on either when facing a clinical dilemma such as defining hunger.

Is a fussy infant hungry because he seems to be comforted only by a bottle or breast? What about the fussy baby who is comforted by just a pacifier? What is the difference? There are several explanations, but it will require introducing the concept of nutrition deficiency.

Most babies who are satisfied with just a nipple, be it silicone or flesh, simply find sucking a comfort measure. A few, and I am sure you have seen some of them, are overly patient. They seem to be saying, “I need the calories, but you’re a good mom and I enjoy sucking. I can wait. Some day, you may make more milk or give me a bottle.” In the worst-case scenarios, their patience leaves these babies so nutritionally deficient that they can slip into apathy and die.

On the other end of the spectrum are infants who love to suck so much that they will ignore (or maybe lack) their own satiety center. They may be fussy for some other reason than hunger, most likely sleep deprivation, and will suck and swallow to comfort themselves even though they have met their nutritional needs. The surplus milk or formula is converted to unhealthy weight or is misdiagnosed as “reflux.” Could this phenomenon have a genetic basis? Has the mother in Dr. Klass’ scenario shared an inheritable problem with satiety with her infant?

There are no easy answers. As pediatricians, our job is to sort out those fussy “hungry” babies whose behavior means they are overtired from those who are nutritionally deficient, from those with a dysfunctional satiety center. Making the differentiation is difficult but much easier than helping parents ignore one of their instincts.
 

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].

 

“She will eat when she is hungry.” That in so many words is the mantra of grandparents blessed with experience and common sense and of most pediatricians when consulting parents challenged with a picky eater. From birth, children understand the simple equation that to survive they must eat. With rare exception, the motivating power of hunger can be leveraged for success even with infants who have spent their first months relying on enteral feedings. I have written an entire book based solely on the premise that if you present a young child food she will eat it ... eventually (“Coping With a Picky Eater: A Guide for the Perplexed Parent” New York: Simon and Schuster, 1998).

But if we reverse the words to read, “When she is eating, she is hungry,” do we have an equally valid observation? I think we have ample evidence that it is not.

Wavebreakmedia/Thinkstock

I recently encountered an anecdote in one of the New York Times op-ed pieces by Perri Klass, MD, that got me thinking more broadly about the perception of hunger and its power to motivate (“Do parents make kids fat?” the New York Times, Jan. 8, 2018). Dr. Klass relates a story of an obesity specialist who herself had struggled with obesity. Despite her careful attention to everything she had learned about obesity management and breastfeeding, this woman was unprepared for giving birth to an infant who was “instantly a very dramatically hungry baby.”

The result was a year-long odyssey of pumping that included consultations with five different lactation consultants in the first frustrating month and a half. She eventually received some comforting advice from a pediatrician who reassured her that there was little research to guide her and to “just feed him; trust your instincts.”

While it is unfortunately true that there is very little good science we can fall back on when counseling women who are struggling with breastfeeding, I wonder about the wisdom of telling this mother to trust her instincts. I guess my hesitancy is based on 40 years of primary care pediatrics in which I could generally count on the instincts of young children, but their parents’ not so much. While maternal intuition is generally superior to the paternal version, I am hesitant to rely totally on either when facing a clinical dilemma such as defining hunger.

Is a fussy infant hungry because he seems to be comforted only by a bottle or breast? What about the fussy baby who is comforted by just a pacifier? What is the difference? There are several explanations, but it will require introducing the concept of nutrition deficiency.

Most babies who are satisfied with just a nipple, be it silicone or flesh, simply find sucking a comfort measure. A few, and I am sure you have seen some of them, are overly patient. They seem to be saying, “I need the calories, but you’re a good mom and I enjoy sucking. I can wait. Some day, you may make more milk or give me a bottle.” In the worst-case scenarios, their patience leaves these babies so nutritionally deficient that they can slip into apathy and die.

On the other end of the spectrum are infants who love to suck so much that they will ignore (or maybe lack) their own satiety center. They may be fussy for some other reason than hunger, most likely sleep deprivation, and will suck and swallow to comfort themselves even though they have met their nutritional needs. The surplus milk or formula is converted to unhealthy weight or is misdiagnosed as “reflux.” Could this phenomenon have a genetic basis? Has the mother in Dr. Klass’ scenario shared an inheritable problem with satiety with her infant?

There are no easy answers. As pediatricians, our job is to sort out those fussy “hungry” babies whose behavior means they are overtired from those who are nutritionally deficient, from those with a dysfunctional satiety center. Making the differentiation is difficult but much easier than helping parents ignore one of their instincts.
 

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

 

“In medicine, a lack of experience may not actually be a bad thing.” The words leapt off my tablet, and my blood pressure hit the stratosphere. How could a 30-year-old physician who is still doing his cardiology fellowship have the nerve to take a cheap shot at one of the cornerstones of my identity? (“For Doctors, Age May Be More Than a Number,” by Haider Javed Warraich, The New York Times, Jan. 6, 2018.) My reputation as a skilled pediatrician was built on the breadth and depth of my clinical experience. In the first 30 years of my professional career, I had participated in more than 300,000 patient encounters. Wasn’t that effort good for something?

Darrin Klimek/Thinkstock

I stopped reading, set the tablet down, and went for a brisk walk around the neighborhood, hoping to get my emotions under control before reading on. Refreshed and tempered by the subzero air, I read on and discovered that Dr. Warraich had done his homework and offered some evidence to support his claim that, at least in medicine, experience may be overvalued.

He wrote that in a study of hospitalists (BMJ. 2017;357:j1797), the patient death rate increased steadily from 10.8% for physicians younger than 40 years to 12.1% for those 6o years and older, except those physicians treating a high volume of patients. He also cites a study in which the authors analyzed 62 studies of quality of care. The investigators found that slightly more than half of the studies “report decreasing performance with increasing years in practice” (Ann Int Med. 2005 Feb 15;142[4]:260-73).

Still in a defensive mode, I decided to chase down the references and take a closer look. In the study demonstrating patient mortality increasing with physician age, we must consider that these physicians were hospitalists and the patients were elderly. The observations may not be applicable to those seeing younger patients in a primary care office setting.

Another caveat listed by the authors is that the association between increasing patient mortality with increasing physician age did not hold true “among physicians with high volumes of patients.” As a high-volume practitioner myself, I found this comforting. It may be that there is some threshold effect in which a little experience is a negative but a ton of experience is a plus. Experience can teach efficiency. But, of course, efficiency doesn’t always equate with quality.

The study citing a decline in quality of care with physician age is a bit more troublesome. However, it may be that, rightly or wrongly, older physicians who have seen the tide go in and out enough times are more hesitant to accept and adhere to “evidence-based” quality measures that they see as ephemeral.

It was Dr. Warraich’s citation from the journal Cancer that I had the most difficult time rationalizing. This study found that younger physicians were more likely to discuss end of life issues with patients (Cancer. 2010 Feb 15;116[4]:998-1006). I suspect this is a valid observation as I have always struggled with discussing subjects such as sexuality and end of life issues with patients.

After what for me was an inflammatory opening, Dr. Warraich’s article closes with the observation that “mentorship is a two-way street.” Any physician who has worked with medical students and inquisitive house officers realizes that our surplus of experience always can stand to gain a little refreshing from those who have little of their own.
 

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.”

 

“In medicine, a lack of experience may not actually be a bad thing.” The words leapt off my tablet, and my blood pressure hit the stratosphere. How could a 30-year-old physician who is still doing his cardiology fellowship have the nerve to take a cheap shot at one of the cornerstones of my identity? (“For Doctors, Age May Be More Than a Number,” by Haider Javed Warraich, The New York Times, Jan. 6, 2018.) My reputation as a skilled pediatrician was built on the breadth and depth of my clinical experience. In the first 30 years of my professional career, I had participated in more than 300,000 patient encounters. Wasn’t that effort good for something?

Darrin Klimek/Thinkstock

I stopped reading, set the tablet down, and went for a brisk walk around the neighborhood, hoping to get my emotions under control before reading on. Refreshed and tempered by the subzero air, I read on and discovered that Dr. Warraich had done his homework and offered some evidence to support his claim that, at least in medicine, experience may be overvalued.

He wrote that in a study of hospitalists (BMJ. 2017;357:j1797), the patient death rate increased steadily from 10.8% for physicians younger than 40 years to 12.1% for those 6o years and older, except those physicians treating a high volume of patients. He also cites a study in which the authors analyzed 62 studies of quality of care. The investigators found that slightly more than half of the studies “report decreasing performance with increasing years in practice” (Ann Int Med. 2005 Feb 15;142[4]:260-73).

Still in a defensive mode, I decided to chase down the references and take a closer look. In the study demonstrating patient mortality increasing with physician age, we must consider that these physicians were hospitalists and the patients were elderly. The observations may not be applicable to those seeing younger patients in a primary care office setting.

Another caveat listed by the authors is that the association between increasing patient mortality with increasing physician age did not hold true “among physicians with high volumes of patients.” As a high-volume practitioner myself, I found this comforting. It may be that there is some threshold effect in which a little experience is a negative but a ton of experience is a plus. Experience can teach efficiency. But, of course, efficiency doesn’t always equate with quality.

The study citing a decline in quality of care with physician age is a bit more troublesome. However, it may be that, rightly or wrongly, older physicians who have seen the tide go in and out enough times are more hesitant to accept and adhere to “evidence-based” quality measures that they see as ephemeral.

It was Dr. Warraich’s citation from the journal Cancer that I had the most difficult time rationalizing. This study found that younger physicians were more likely to discuss end of life issues with patients (Cancer. 2010 Feb 15;116[4]:998-1006). I suspect this is a valid observation as I have always struggled with discussing subjects such as sexuality and end of life issues with patients.

After what for me was an inflammatory opening, Dr. Warraich’s article closes with the observation that “mentorship is a two-way street.” Any physician who has worked with medical students and inquisitive house officers realizes that our surplus of experience always can stand to gain a little refreshing from those who have little of their own.
 

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.”

 

“In medicine, a lack of experience may not actually be a bad thing.” The words leapt off my tablet, and my blood pressure hit the stratosphere. How could a 30-year-old physician who is still doing his cardiology fellowship have the nerve to take a cheap shot at one of the cornerstones of my identity? (“For Doctors, Age May Be More Than a Number,” by Haider Javed Warraich, The New York Times, Jan. 6, 2018.) My reputation as a skilled pediatrician was built on the breadth and depth of my clinical experience. In the first 30 years of my professional career, I had participated in more than 300,000 patient encounters. Wasn’t that effort good for something?

Darrin Klimek/Thinkstock

I stopped reading, set the tablet down, and went for a brisk walk around the neighborhood, hoping to get my emotions under control before reading on. Refreshed and tempered by the subzero air, I read on and discovered that Dr. Warraich had done his homework and offered some evidence to support his claim that, at least in medicine, experience may be overvalued.

He wrote that in a study of hospitalists (BMJ. 2017;357:j1797), the patient death rate increased steadily from 10.8% for physicians younger than 40 years to 12.1% for those 6o years and older, except those physicians treating a high volume of patients. He also cites a study in which the authors analyzed 62 studies of quality of care. The investigators found that slightly more than half of the studies “report decreasing performance with increasing years in practice” (Ann Int Med. 2005 Feb 15;142[4]:260-73).

Still in a defensive mode, I decided to chase down the references and take a closer look. In the study demonstrating patient mortality increasing with physician age, we must consider that these physicians were hospitalists and the patients were elderly. The observations may not be applicable to those seeing younger patients in a primary care office setting.

Another caveat listed by the authors is that the association between increasing patient mortality with increasing physician age did not hold true “among physicians with high volumes of patients.” As a high-volume practitioner myself, I found this comforting. It may be that there is some threshold effect in which a little experience is a negative but a ton of experience is a plus. Experience can teach efficiency. But, of course, efficiency doesn’t always equate with quality.

The study citing a decline in quality of care with physician age is a bit more troublesome. However, it may be that, rightly or wrongly, older physicians who have seen the tide go in and out enough times are more hesitant to accept and adhere to “evidence-based” quality measures that they see as ephemeral.

It was Dr. Warraich’s citation from the journal Cancer that I had the most difficult time rationalizing. This study found that younger physicians were more likely to discuss end of life issues with patients (Cancer. 2010 Feb 15;116[4]:998-1006). I suspect this is a valid observation as I have always struggled with discussing subjects such as sexuality and end of life issues with patients.

After what for me was an inflammatory opening, Dr. Warraich’s article closes with the observation that “mentorship is a two-way street.” Any physician who has worked with medical students and inquisitive house officers realizes that our surplus of experience always can stand to gain a little refreshing from those who have little of their own.
 

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.”

 

It’s very likely that you have at least one or two female patients who play lacrosse. The sport has been reported to be the fastest-growing high school sport in the United States. (“Lacrosse is Actually America’s Fastest-Growing Sport,” by John Templon, BuzzFeed News, June 30, 2014). When I played in college, most of my teammates were products of prep schools in the Northeast or one of the few local hotbeds in Baltimore, Long Island, or the Finger Lakes Region of New York. But pickings were slim, and there was room for walk-ons like me looking to learn a new sport and stay in shape for football. Now hundreds of high schools in all parts of the country offer the sport for both boys and girls.

Although the two versions of the sport use similar-appearing sticks, the same ball and goal, confrontations between the players and their sticks are forbidden in the girls’ game. Women are not even allowed to windup and fire the hard rubber ball with maximum force because it might injure an opponent. Surrounded by a surplus of rules governing body contact and stick control, female lacrosse players have traditionally played without protective equipment other than a lightweight eye cage. The goalies, however, are amply padded and helmeted.

With growing awareness of the long-term effects of repeated head trauma, there has been a call from some parents and organizers of women’s lacrosse to require helmets on all players (“As Concussion Worries Rise, Girls’ Lacrosse Turns to Headgear,” by Bill Pennington, The New York Times, Nov 23, 2017). To those of us who have committed our professional lives to the health of children, the inclusion of helmets to the standard equipment for a female lacrosse player sounds like a good idea.

However, the proposed mandate has its critics, including several college coaches. Karen Corbett, women’s lacrosse coach at the University of Pennsylvania, has said that, players “will start to lead with their head because they feel protected, and that causes more injuries. We’ll become a more physical sport and a very different sport than we are today.”

kjuniper/Thinkstock

This is not some old-school traditionalist, no-change-is-good blather. One only has to look at the evolution men’s ice hockey to validate her concern. In 1977, Dr. Daniel Hanley, the chief physician of the United States Olympic Team, told me he was sure that, in the wake of the National Collegiate Athletic Association’s upcoming mandate of full face masks for college hockey players, the character of the game would change, and not for the better. He felt that sticks would come up off the ice more often and be wielded more carelessly. Of greater concern to him was that players, emboldened by their false sense of invulnerability from behind their masks, would begin to take more risks with their head and neck.

Although I’m afraid that there are few data to support the validity of Dr. Hanley’s prediction, any observer of college hockey over the last 3 or 4 decades will tell you that he was unfortunately correct. There have been certainly fewer lacerations and eye injuries since face masks were introduced, but the game has become far more violent, and head, neck, and spine injuries have become more frequent. I think part of the problem is that game officials have been duped by the same false assumption as the players that more protection would make the game safer, and enforcement of the rules has not kept up with the technological changes.

There will always be injuries in any sport, but before we as physicians lend our support to a proposed change in protective equipment, we should step back and look at the broader picture. While the loss of an eye for an individual player is a tragedy, did we put several dozen more players at greater risk for spinal injury in college hockey with more protective gear? If adding headgear protects female lacrosse players from concussions, what might be the result if play becomes more physical? Protection can come with a price.


 

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

 

It’s very likely that you have at least one or two female patients who play lacrosse. The sport has been reported to be the fastest-growing high school sport in the United States. (“Lacrosse is Actually America’s Fastest-Growing Sport,” by John Templon, BuzzFeed News, June 30, 2014). When I played in college, most of my teammates were products of prep schools in the Northeast or one of the few local hotbeds in Baltimore, Long Island, or the Finger Lakes Region of New York. But pickings were slim, and there was room for walk-ons like me looking to learn a new sport and stay in shape for football. Now hundreds of high schools in all parts of the country offer the sport for both boys and girls.

Although the two versions of the sport use similar-appearing sticks, the same ball and goal, confrontations between the players and their sticks are forbidden in the girls’ game. Women are not even allowed to windup and fire the hard rubber ball with maximum force because it might injure an opponent. Surrounded by a surplus of rules governing body contact and stick control, female lacrosse players have traditionally played without protective equipment other than a lightweight eye cage. The goalies, however, are amply padded and helmeted.

With growing awareness of the long-term effects of repeated head trauma, there has been a call from some parents and organizers of women’s lacrosse to require helmets on all players (“As Concussion Worries Rise, Girls’ Lacrosse Turns to Headgear,” by Bill Pennington, The New York Times, Nov 23, 2017). To those of us who have committed our professional lives to the health of children, the inclusion of helmets to the standard equipment for a female lacrosse player sounds like a good idea.

However, the proposed mandate has its critics, including several college coaches. Karen Corbett, women’s lacrosse coach at the University of Pennsylvania, has said that, players “will start to lead with their head because they feel protected, and that causes more injuries. We’ll become a more physical sport and a very different sport than we are today.”

kjuniper/Thinkstock

This is not some old-school traditionalist, no-change-is-good blather. One only has to look at the evolution men’s ice hockey to validate her concern. In 1977, Dr. Daniel Hanley, the chief physician of the United States Olympic Team, told me he was sure that, in the wake of the National Collegiate Athletic Association’s upcoming mandate of full face masks for college hockey players, the character of the game would change, and not for the better. He felt that sticks would come up off the ice more often and be wielded more carelessly. Of greater concern to him was that players, emboldened by their false sense of invulnerability from behind their masks, would begin to take more risks with their head and neck.

Although I’m afraid that there are few data to support the validity of Dr. Hanley’s prediction, any observer of college hockey over the last 3 or 4 decades will tell you that he was unfortunately correct. There have been certainly fewer lacerations and eye injuries since face masks were introduced, but the game has become far more violent, and head, neck, and spine injuries have become more frequent. I think part of the problem is that game officials have been duped by the same false assumption as the players that more protection would make the game safer, and enforcement of the rules has not kept up with the technological changes.

There will always be injuries in any sport, but before we as physicians lend our support to a proposed change in protective equipment, we should step back and look at the broader picture. While the loss of an eye for an individual player is a tragedy, did we put several dozen more players at greater risk for spinal injury in college hockey with more protective gear? If adding headgear protects female lacrosse players from concussions, what might be the result if play becomes more physical? Protection can come with a price.


 

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

 

It’s very likely that you have at least one or two female patients who play lacrosse. The sport has been reported to be the fastest-growing high school sport in the United States. (“Lacrosse is Actually America’s Fastest-Growing Sport,” by John Templon, BuzzFeed News, June 30, 2014). When I played in college, most of my teammates were products of prep schools in the Northeast or one of the few local hotbeds in Baltimore, Long Island, or the Finger Lakes Region of New York. But pickings were slim, and there was room for walk-ons like me looking to learn a new sport and stay in shape for football. Now hundreds of high schools in all parts of the country offer the sport for both boys and girls.

Although the two versions of the sport use similar-appearing sticks, the same ball and goal, confrontations between the players and their sticks are forbidden in the girls’ game. Women are not even allowed to windup and fire the hard rubber ball with maximum force because it might injure an opponent. Surrounded by a surplus of rules governing body contact and stick control, female lacrosse players have traditionally played without protective equipment other than a lightweight eye cage. The goalies, however, are amply padded and helmeted.

With growing awareness of the long-term effects of repeated head trauma, there has been a call from some parents and organizers of women’s lacrosse to require helmets on all players (“As Concussion Worries Rise, Girls’ Lacrosse Turns to Headgear,” by Bill Pennington, The New York Times, Nov 23, 2017). To those of us who have committed our professional lives to the health of children, the inclusion of helmets to the standard equipment for a female lacrosse player sounds like a good idea.

However, the proposed mandate has its critics, including several college coaches. Karen Corbett, women’s lacrosse coach at the University of Pennsylvania, has said that, players “will start to lead with their head because they feel protected, and that causes more injuries. We’ll become a more physical sport and a very different sport than we are today.”

kjuniper/Thinkstock

This is not some old-school traditionalist, no-change-is-good blather. One only has to look at the evolution men’s ice hockey to validate her concern. In 1977, Dr. Daniel Hanley, the chief physician of the United States Olympic Team, told me he was sure that, in the wake of the National Collegiate Athletic Association’s upcoming mandate of full face masks for college hockey players, the character of the game would change, and not for the better. He felt that sticks would come up off the ice more often and be wielded more carelessly. Of greater concern to him was that players, emboldened by their false sense of invulnerability from behind their masks, would begin to take more risks with their head and neck.

Although I’m afraid that there are few data to support the validity of Dr. Hanley’s prediction, any observer of college hockey over the last 3 or 4 decades will tell you that he was unfortunately correct. There have been certainly fewer lacerations and eye injuries since face masks were introduced, but the game has become far more violent, and head, neck, and spine injuries have become more frequent. I think part of the problem is that game officials have been duped by the same false assumption as the players that more protection would make the game safer, and enforcement of the rules has not kept up with the technological changes.

There will always be injuries in any sport, but before we as physicians lend our support to a proposed change in protective equipment, we should step back and look at the broader picture. While the loss of an eye for an individual player is a tragedy, did we put several dozen more players at greater risk for spinal injury in college hockey with more protective gear? If adding headgear protects female lacrosse players from concussions, what might be the result if play becomes more physical? Protection can come with a price.


 

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].

 

Within the academic pediatric community, there is little argument that the concepts “evidence based” and “early intervention” are gold standards against which we must measure our efforts.

It should be obvious to everyone that if we can intervene early in a child’s developmental trajectory, our chances of affecting his/her outcome are improved. And the earlier the better. If we aren’t supremely committed to prevention, then what sets pediatrics apart from the other specialties?

Likewise, if we aren’t willing to systematically measure our efforts at improving the health of our patients, we run the risk of simply spinning our wheels and even worse, squandering our patients’ time and their parents’ energies. However, a recent article in Pediatrics and a companion commentary suggest that we need to be more careful as we interpret the buzz that surrounds the terms “early intervention” and “evidence based.”

In their one-sentence conclusion of a paper reviewing 48 studies of early intervention in early childhood development, the authors observe, “Although several interventions resulted in improved child development outcomes age 0 to 3 years, comparison across studies and interventions is limited by the use of different outcome measures, time of evaluation, and variability of results” (“Primary Care Interventions for Early Childhood Development: A Systematic Review,” Peacock-Chambers et al. Pediatrics. 2017, Nov 14. doi: 10.1542/peds.2017-1661). Unless you are looking for another reason to slip further into an abyss of despair, I urge that you skip reading the details of the Peacock-Chambers paper and turn instead to Dr. Jack P. Shonkoff’s excellent commentary (“Rethinking the Definition of Evidence-Based Interventions to Promote Early Child Development,” Pediatrics. 2017, Dec. doi: 10.1542/peds.2017-3136).

Dr. Shonkoff observes that there is ample evidence to support the general concept of early intervention as it relates to childhood development. However, he acknowledges that the improvements observed generally have been small. And there has been little success in scaling these few successes to larger populations. It would seem that the sacred cow of early intervention remains standing, albeit on somewhat shaky legs.

However, when it comes to the usefulness of an evidence-based yardstick, Dr. Shonkoff is understandably less reassuring. The results of the Peacock-Chambers paper alone should give us pause rather than our blindly accepting results of a trial just because it has appeared in a peer-reviewed journal. As Peacock-Cambers et al. remind us, comparing interventions that differ in outcomes measured and time sequences is difficult, if not impossible.

Dr. Shonkoff points out that an obsession with statistical significance often has blinded some of us to the importance of the magnitude of (or the lack of) impact when interpreting studies of early intervention. As a result, we may have failed to realize how far research in early childhood development has fallen behind the other fields of biomedical research such as cancer, HIV, and AIDS. His plea is that we begin to leverage our successes in fields such as molecular biology, epigenetics, and neuroscience when designing future studies of early childhood development. He asserts that this kind of basic science – in concert with “on-the-ground experience” (that’s you and me) and “authentic parental engagement” – is more likely to result in greater scalable impact for our patients threatened by developmental delays.

It is refreshing and encouraging reading a critical consideration of the evidence-based sacred cow. Evidence can be viewed from a variety of perspectives. If we continue to filter all of our observations through a statistical significance filter, we run the risk of missing both the forest and the trees.
 

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].

 

Within the academic pediatric community, there is little argument that the concepts “evidence based” and “early intervention” are gold standards against which we must measure our efforts.

It should be obvious to everyone that if we can intervene early in a child’s developmental trajectory, our chances of affecting his/her outcome are improved. And the earlier the better. If we aren’t supremely committed to prevention, then what sets pediatrics apart from the other specialties?

Likewise, if we aren’t willing to systematically measure our efforts at improving the health of our patients, we run the risk of simply spinning our wheels and even worse, squandering our patients’ time and their parents’ energies. However, a recent article in Pediatrics and a companion commentary suggest that we need to be more careful as we interpret the buzz that surrounds the terms “early intervention” and “evidence based.”

In their one-sentence conclusion of a paper reviewing 48 studies of early intervention in early childhood development, the authors observe, “Although several interventions resulted in improved child development outcomes age 0 to 3 years, comparison across studies and interventions is limited by the use of different outcome measures, time of evaluation, and variability of results” (“Primary Care Interventions for Early Childhood Development: A Systematic Review,” Peacock-Chambers et al. Pediatrics. 2017, Nov 14. doi: 10.1542/peds.2017-1661). Unless you are looking for another reason to slip further into an abyss of despair, I urge that you skip reading the details of the Peacock-Chambers paper and turn instead to Dr. Jack P. Shonkoff’s excellent commentary (“Rethinking the Definition of Evidence-Based Interventions to Promote Early Child Development,” Pediatrics. 2017, Dec. doi: 10.1542/peds.2017-3136).

Dr. Shonkoff observes that there is ample evidence to support the general concept of early intervention as it relates to childhood development. However, he acknowledges that the improvements observed generally have been small. And there has been little success in scaling these few successes to larger populations. It would seem that the sacred cow of early intervention remains standing, albeit on somewhat shaky legs.

However, when it comes to the usefulness of an evidence-based yardstick, Dr. Shonkoff is understandably less reassuring. The results of the Peacock-Chambers paper alone should give us pause rather than our blindly accepting results of a trial just because it has appeared in a peer-reviewed journal. As Peacock-Cambers et al. remind us, comparing interventions that differ in outcomes measured and time sequences is difficult, if not impossible.

Dr. Shonkoff points out that an obsession with statistical significance often has blinded some of us to the importance of the magnitude of (or the lack of) impact when interpreting studies of early intervention. As a result, we may have failed to realize how far research in early childhood development has fallen behind the other fields of biomedical research such as cancer, HIV, and AIDS. His plea is that we begin to leverage our successes in fields such as molecular biology, epigenetics, and neuroscience when designing future studies of early childhood development. He asserts that this kind of basic science – in concert with “on-the-ground experience” (that’s you and me) and “authentic parental engagement” – is more likely to result in greater scalable impact for our patients threatened by developmental delays.

It is refreshing and encouraging reading a critical consideration of the evidence-based sacred cow. Evidence can be viewed from a variety of perspectives. If we continue to filter all of our observations through a statistical significance filter, we run the risk of missing both the forest and the trees.
 

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].

 

Within the academic pediatric community, there is little argument that the concepts “evidence based” and “early intervention” are gold standards against which we must measure our efforts.

It should be obvious to everyone that if we can intervene early in a child’s developmental trajectory, our chances of affecting his/her outcome are improved. And the earlier the better. If we aren’t supremely committed to prevention, then what sets pediatrics apart from the other specialties?

Likewise, if we aren’t willing to systematically measure our efforts at improving the health of our patients, we run the risk of simply spinning our wheels and even worse, squandering our patients’ time and their parents’ energies. However, a recent article in Pediatrics and a companion commentary suggest that we need to be more careful as we interpret the buzz that surrounds the terms “early intervention” and “evidence based.”

In their one-sentence conclusion of a paper reviewing 48 studies of early intervention in early childhood development, the authors observe, “Although several interventions resulted in improved child development outcomes age 0 to 3 years, comparison across studies and interventions is limited by the use of different outcome measures, time of evaluation, and variability of results” (“Primary Care Interventions for Early Childhood Development: A Systematic Review,” Peacock-Chambers et al. Pediatrics. 2017, Nov 14. doi: 10.1542/peds.2017-1661). Unless you are looking for another reason to slip further into an abyss of despair, I urge that you skip reading the details of the Peacock-Chambers paper and turn instead to Dr. Jack P. Shonkoff’s excellent commentary (“Rethinking the Definition of Evidence-Based Interventions to Promote Early Child Development,” Pediatrics. 2017, Dec. doi: 10.1542/peds.2017-3136).

Dr. Shonkoff observes that there is ample evidence to support the general concept of early intervention as it relates to childhood development. However, he acknowledges that the improvements observed generally have been small. And there has been little success in scaling these few successes to larger populations. It would seem that the sacred cow of early intervention remains standing, albeit on somewhat shaky legs.

However, when it comes to the usefulness of an evidence-based yardstick, Dr. Shonkoff is understandably less reassuring. The results of the Peacock-Chambers paper alone should give us pause rather than our blindly accepting results of a trial just because it has appeared in a peer-reviewed journal. As Peacock-Cambers et al. remind us, comparing interventions that differ in outcomes measured and time sequences is difficult, if not impossible.

Dr. Shonkoff points out that an obsession with statistical significance often has blinded some of us to the importance of the magnitude of (or the lack of) impact when interpreting studies of early intervention. As a result, we may have failed to realize how far research in early childhood development has fallen behind the other fields of biomedical research such as cancer, HIV, and AIDS. His plea is that we begin to leverage our successes in fields such as molecular biology, epigenetics, and neuroscience when designing future studies of early childhood development. He asserts that this kind of basic science – in concert with “on-the-ground experience” (that’s you and me) and “authentic parental engagement” – is more likely to result in greater scalable impact for our patients threatened by developmental delays.

It is refreshing and encouraging reading a critical consideration of the evidence-based sacred cow. Evidence can be viewed from a variety of perspectives. If we continue to filter all of our observations through a statistical significance filter, we run the risk of missing both the forest and the trees.
 

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].

 

About 800 million radiology exams were performed in this country in the past year, and they generated approximately 60 billion images, according to an article published in 2017 in the Wall Street Journal (“No need for radiologists to be negative on AI,” by Greg Ip, Nov. 24, 2017). How many of those millions of radiology studies did you order? And how many of the scores of images you requested did you see with your own two eyes? In fact, how many of the radiologists’ reports that were sent to you did you read in their entirety? How often did you just skip over the radiologist’s CYA disclaimers and simply read the final summary, “exam negative”?

XiXinXing/Thinkstock

Can you sense that I’m warming up for a when-I-was-your-age lecture? Good! You won’t be disappointed when I tell you that, when I was a house officer, we were expected to shuffle off to the darkened bowels of the hospital (the radiology department had no need for windows) and take a look at any x-ray we had ordered on our patients. During the day, this exercise was intended to be an educational field trip. But, at night, when the radiologists were sleeping comfortably at home in the suburbs, this trip to the basement was a fact-finding mission in which we were asked to rely on our memory bank of images we had seen during our brief training. Of course, we could call in the radiologist if we felt the patient’s situation was so critical that we needed an official interpretation of the study we had ordered. But often, house officer machismo kept us from reaching for the phone. To some extent, this rule of if-you-order-it-you-look-at-it functioned as a healthy deterrent against frivolous ordering of marginally valuable studies.

I enjoy the challenge of interpreting x-ray images. In fact, I toyed with becoming a pediatric radiologist, but that career path would have meant settling in or near a large city, a compromise my wife and I were unwilling to make. I hoped to continue my habit of looking at all my patients’ x-rays, but because my practice was not in or near the hospital, I reluctantly had to bend my rules and admit I didn’t see every image I had ordered. But, I did read every report in its entirety. In one case, an offhand comment buried in the middle of the radiologist’s report referring to the “residual barium from a previous study” caught my eye, because I knew the patient hadn’t had a previous contrast study. Unfortunately, the neuroblastoma that the radiologist had missed initially, and I had seen the next day, never responded to treatment.

Toward the end of my career, digital imagery allowed me to view my patients’ x-rays without having to leave my desk, which got me closer to my goal of seeing all my patients’ studies. However, the advent of computerized axial tomography and magnetic resonance imaging meant that an increasing number of studies pushed my anatomic knowledge beyond its limits.

I suspect that many of you benefited from the if-you-order-it-look-at-it mantra during your training. How many of you have continued to follow the dictum? With the advent of digitized imagery, there is really little excuse for not taking a minute or 2 to pull up your patients’ images on your desktop. One could argue that looking inside your patient is part of a complete exam. Forcing yourself to take that extra step and look at the study may nudge you into thinking twice about whether you really needed the information the imaging study might add to the diagnostic process. Was your click to order the study just a reflex subliminally related to the fear of a lawsuit? Was it important enough to deserve a firsthand look?

At the very least, being able to say, “I’ve looked at your x-rays myself, and they look fine” may be more comforting to your patient than a third-hand relay of a “negative reading” performed by someone whom they have likely never met.

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.”

 

About 800 million radiology exams were performed in this country in the past year, and they generated approximately 60 billion images, according to an article published in 2017 in the Wall Street Journal (“No need for radiologists to be negative on AI,” by Greg Ip, Nov. 24, 2017). How many of those millions of radiology studies did you order? And how many of the scores of images you requested did you see with your own two eyes? In fact, how many of the radiologists’ reports that were sent to you did you read in their entirety? How often did you just skip over the radiologist’s CYA disclaimers and simply read the final summary, “exam negative”?

XiXinXing/Thinkstock

Can you sense that I’m warming up for a when-I-was-your-age lecture? Good! You won’t be disappointed when I tell you that, when I was a house officer, we were expected to shuffle off to the darkened bowels of the hospital (the radiology department had no need for windows) and take a look at any x-ray we had ordered on our patients. During the day, this exercise was intended to be an educational field trip. But, at night, when the radiologists were sleeping comfortably at home in the suburbs, this trip to the basement was a fact-finding mission in which we were asked to rely on our memory bank of images we had seen during our brief training. Of course, we could call in the radiologist if we felt the patient’s situation was so critical that we needed an official interpretation of the study we had ordered. But often, house officer machismo kept us from reaching for the phone. To some extent, this rule of if-you-order-it-you-look-at-it functioned as a healthy deterrent against frivolous ordering of marginally valuable studies.

I enjoy the challenge of interpreting x-ray images. In fact, I toyed with becoming a pediatric radiologist, but that career path would have meant settling in or near a large city, a compromise my wife and I were unwilling to make. I hoped to continue my habit of looking at all my patients’ x-rays, but because my practice was not in or near the hospital, I reluctantly had to bend my rules and admit I didn’t see every image I had ordered. But, I did read every report in its entirety. In one case, an offhand comment buried in the middle of the radiologist’s report referring to the “residual barium from a previous study” caught my eye, because I knew the patient hadn’t had a previous contrast study. Unfortunately, the neuroblastoma that the radiologist had missed initially, and I had seen the next day, never responded to treatment.

Toward the end of my career, digital imagery allowed me to view my patients’ x-rays without having to leave my desk, which got me closer to my goal of seeing all my patients’ studies. However, the advent of computerized axial tomography and magnetic resonance imaging meant that an increasing number of studies pushed my anatomic knowledge beyond its limits.

I suspect that many of you benefited from the if-you-order-it-look-at-it mantra during your training. How many of you have continued to follow the dictum? With the advent of digitized imagery, there is really little excuse for not taking a minute or 2 to pull up your patients’ images on your desktop. One could argue that looking inside your patient is part of a complete exam. Forcing yourself to take that extra step and look at the study may nudge you into thinking twice about whether you really needed the information the imaging study might add to the diagnostic process. Was your click to order the study just a reflex subliminally related to the fear of a lawsuit? Was it important enough to deserve a firsthand look?

At the very least, being able to say, “I’ve looked at your x-rays myself, and they look fine” may be more comforting to your patient than a third-hand relay of a “negative reading” performed by someone whom they have likely never met.

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.”

 

About 800 million radiology exams were performed in this country in the past year, and they generated approximately 60 billion images, according to an article published in 2017 in the Wall Street Journal (“No need for radiologists to be negative on AI,” by Greg Ip, Nov. 24, 2017). How many of those millions of radiology studies did you order? And how many of the scores of images you requested did you see with your own two eyes? In fact, how many of the radiologists’ reports that were sent to you did you read in their entirety? How often did you just skip over the radiologist’s CYA disclaimers and simply read the final summary, “exam negative”?

XiXinXing/Thinkstock

Can you sense that I’m warming up for a when-I-was-your-age lecture? Good! You won’t be disappointed when I tell you that, when I was a house officer, we were expected to shuffle off to the darkened bowels of the hospital (the radiology department had no need for windows) and take a look at any x-ray we had ordered on our patients. During the day, this exercise was intended to be an educational field trip. But, at night, when the radiologists were sleeping comfortably at home in the suburbs, this trip to the basement was a fact-finding mission in which we were asked to rely on our memory bank of images we had seen during our brief training. Of course, we could call in the radiologist if we felt the patient’s situation was so critical that we needed an official interpretation of the study we had ordered. But often, house officer machismo kept us from reaching for the phone. To some extent, this rule of if-you-order-it-you-look-at-it functioned as a healthy deterrent against frivolous ordering of marginally valuable studies.

I enjoy the challenge of interpreting x-ray images. In fact, I toyed with becoming a pediatric radiologist, but that career path would have meant settling in or near a large city, a compromise my wife and I were unwilling to make. I hoped to continue my habit of looking at all my patients’ x-rays, but because my practice was not in or near the hospital, I reluctantly had to bend my rules and admit I didn’t see every image I had ordered. But, I did read every report in its entirety. In one case, an offhand comment buried in the middle of the radiologist’s report referring to the “residual barium from a previous study” caught my eye, because I knew the patient hadn’t had a previous contrast study. Unfortunately, the neuroblastoma that the radiologist had missed initially, and I had seen the next day, never responded to treatment.

Toward the end of my career, digital imagery allowed me to view my patients’ x-rays without having to leave my desk, which got me closer to my goal of seeing all my patients’ studies. However, the advent of computerized axial tomography and magnetic resonance imaging meant that an increasing number of studies pushed my anatomic knowledge beyond its limits.

I suspect that many of you benefited from the if-you-order-it-look-at-it mantra during your training. How many of you have continued to follow the dictum? With the advent of digitized imagery, there is really little excuse for not taking a minute or 2 to pull up your patients’ images on your desktop. One could argue that looking inside your patient is part of a complete exam. Forcing yourself to take that extra step and look at the study may nudge you into thinking twice about whether you really needed the information the imaging study might add to the diagnostic process. Was your click to order the study just a reflex subliminally related to the fear of a lawsuit? Was it important enough to deserve a firsthand look?

At the very least, being able to say, “I’ve looked at your x-rays myself, and they look fine” may be more comforting to your patient than a third-hand relay of a “negative reading” performed by someone whom they have likely never met.

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.”

 

Most accomplished public speakers will tell you that critical to their success is the ability to understand and adapt to their audiences. It turns out that even chimpanzees accept and use this cornerstone of effective communication.

In a study published in Science Advances (2017 Nov 15;3[11]:e1701742), three scientists working in Uganda reported that chimpanzees who encounter a potential threat in the form of a realistic snake model will vocalize significantly fewer alert hoots if they hear other alert calls coming from the jungle in the vicinity. In other words, the chimp is saying to himself, “Why should I bother wasting my time and lung power hooting to warn my troop mates? Those guys already know about the snake.”

gpointstudio/Thinkstock

At the risk of doing some preaching to the choir myself, I am going to remind you that, as primary care pediatricians, we must continue to work on our communication skills by adjusting our message to fit our audiences. With only 15 minutes of face-to-face contact with a patient and his or her parents for a health maintenance visit, it is impossible to touch on all the anticipatory guidance topics that we are expected to address. Each threat to the health of children has its own advocacy group. Whether the issue is gun safety, sleep position, vaccines, breastfeeding, or postpartum depression detection, to name just a few, there is someone out there who would like us to keep their favorite cause near the top of our list.

To select which anticipatory guidance topics to include and still be effective communicators, we have to know the families we are trying to help. Gaining this more nuanced picture of a family takes time and is fostered by continuity. Seeing a different provider at each visit doesn’t work very well here. What are this unique family’s concerns, regardless of what some committee thinks we should be asking?

How much can we rely on the media and groups such as the American Academy of Pediatrics and the Centers for Disease Control and Prevention to get out the messages that we have decided to skip over to address this family’s special concerns? Is the message about the benefits of breastfeeding so widely known that we will be wasting our limited office time repeating it? Is the same true for gun safety and seat belts? This is where research can help us decide where to target messages on a national level. But large population studies don’t always apply to our communities and the families we serve.

Where does our role as primary care physicians fit into the bigger picture of health education? The warning messages issued on a national level may have little relevance for our individual patients’ concerns. Is it our role to echo the message, or are we the ones who must do the fine-tuning?

And then there are the recent depressing and counterintuitive findings that for hot-button topics like immunization, education has little if any value. Those families with firmly held beliefs might acknowledge the rationale of our reasoning, but then quickly slide to another argument to tighten their grips on their original position.

Finally, we must be careful to avoid being labeled as the folks whose message is all about what parents should be afraid of. There are plenty of snakes out there in the jungle, but the chimpanzees have realized that when enough of the population is aware of the threat, then it is time to adjust their message. Certainly enough health problems exist on a national level to warrant continued messaging from the large groups in organized medicine. However, it is up to us out in the jungle to learn enough about our patients to know when we should echo those alerts and when it’s time to save our breath. We can’t hoot about every snake in the grass.

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.”

 

Most accomplished public speakers will tell you that critical to their success is the ability to understand and adapt to their audiences. It turns out that even chimpanzees accept and use this cornerstone of effective communication.

In a study published in Science Advances (2017 Nov 15;3[11]:e1701742), three scientists working in Uganda reported that chimpanzees who encounter a potential threat in the form of a realistic snake model will vocalize significantly fewer alert hoots if they hear other alert calls coming from the jungle in the vicinity. In other words, the chimp is saying to himself, “Why should I bother wasting my time and lung power hooting to warn my troop mates? Those guys already know about the snake.”

gpointstudio/Thinkstock

At the risk of doing some preaching to the choir myself, I am going to remind you that, as primary care pediatricians, we must continue to work on our communication skills by adjusting our message to fit our audiences. With only 15 minutes of face-to-face contact with a patient and his or her parents for a health maintenance visit, it is impossible to touch on all the anticipatory guidance topics that we are expected to address. Each threat to the health of children has its own advocacy group. Whether the issue is gun safety, sleep position, vaccines, breastfeeding, or postpartum depression detection, to name just a few, there is someone out there who would like us to keep their favorite cause near the top of our list.

To select which anticipatory guidance topics to include and still be effective communicators, we have to know the families we are trying to help. Gaining this more nuanced picture of a family takes time and is fostered by continuity. Seeing a different provider at each visit doesn’t work very well here. What are this unique family’s concerns, regardless of what some committee thinks we should be asking?

How much can we rely on the media and groups such as the American Academy of Pediatrics and the Centers for Disease Control and Prevention to get out the messages that we have decided to skip over to address this family’s special concerns? Is the message about the benefits of breastfeeding so widely known that we will be wasting our limited office time repeating it? Is the same true for gun safety and seat belts? This is where research can help us decide where to target messages on a national level. But large population studies don’t always apply to our communities and the families we serve.

Where does our role as primary care physicians fit into the bigger picture of health education? The warning messages issued on a national level may have little relevance for our individual patients’ concerns. Is it our role to echo the message, or are we the ones who must do the fine-tuning?

And then there are the recent depressing and counterintuitive findings that for hot-button topics like immunization, education has little if any value. Those families with firmly held beliefs might acknowledge the rationale of our reasoning, but then quickly slide to another argument to tighten their grips on their original position.

Finally, we must be careful to avoid being labeled as the folks whose message is all about what parents should be afraid of. There are plenty of snakes out there in the jungle, but the chimpanzees have realized that when enough of the population is aware of the threat, then it is time to adjust their message. Certainly enough health problems exist on a national level to warrant continued messaging from the large groups in organized medicine. However, it is up to us out in the jungle to learn enough about our patients to know when we should echo those alerts and when it’s time to save our breath. We can’t hoot about every snake in the grass.

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.”

 

Most accomplished public speakers will tell you that critical to their success is the ability to understand and adapt to their audiences. It turns out that even chimpanzees accept and use this cornerstone of effective communication.

In a study published in Science Advances (2017 Nov 15;3[11]:e1701742), three scientists working in Uganda reported that chimpanzees who encounter a potential threat in the form of a realistic snake model will vocalize significantly fewer alert hoots if they hear other alert calls coming from the jungle in the vicinity. In other words, the chimp is saying to himself, “Why should I bother wasting my time and lung power hooting to warn my troop mates? Those guys already know about the snake.”

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At the risk of doing some preaching to the choir myself, I am going to remind you that, as primary care pediatricians, we must continue to work on our communication skills by adjusting our message to fit our audiences. With only 15 minutes of face-to-face contact with a patient and his or her parents for a health maintenance visit, it is impossible to touch on all the anticipatory guidance topics that we are expected to address. Each threat to the health of children has its own advocacy group. Whether the issue is gun safety, sleep position, vaccines, breastfeeding, or postpartum depression detection, to name just a few, there is someone out there who would like us to keep their favorite cause near the top of our list.

To select which anticipatory guidance topics to include and still be effective communicators, we have to know the families we are trying to help. Gaining this more nuanced picture of a family takes time and is fostered by continuity. Seeing a different provider at each visit doesn’t work very well here. What are this unique family’s concerns, regardless of what some committee thinks we should be asking?

How much can we rely on the media and groups such as the American Academy of Pediatrics and the Centers for Disease Control and Prevention to get out the messages that we have decided to skip over to address this family’s special concerns? Is the message about the benefits of breastfeeding so widely known that we will be wasting our limited office time repeating it? Is the same true for gun safety and seat belts? This is where research can help us decide where to target messages on a national level. But large population studies don’t always apply to our communities and the families we serve.

Where does our role as primary care physicians fit into the bigger picture of health education? The warning messages issued on a national level may have little relevance for our individual patients’ concerns. Is it our role to echo the message, or are we the ones who must do the fine-tuning?

And then there are the recent depressing and counterintuitive findings that for hot-button topics like immunization, education has little if any value. Those families with firmly held beliefs might acknowledge the rationale of our reasoning, but then quickly slide to another argument to tighten their grips on their original position.

Finally, we must be careful to avoid being labeled as the folks whose message is all about what parents should be afraid of. There are plenty of snakes out there in the jungle, but the chimpanzees have realized that when enough of the population is aware of the threat, then it is time to adjust their message. Certainly enough health problems exist on a national level to warrant continued messaging from the large groups in organized medicine. However, it is up to us out in the jungle to learn enough about our patients to know when we should echo those alerts and when it’s time to save our breath. We can’t hoot about every snake in the grass.

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.”