William G. Wilkoff, MD

What are the age parameters for your practice? I suspect that at one end of the spectrum, you feel that a child is never too young to come to your practice. In fact you may even go out of your way to encourage expectant mothers to make a get-acquainted visit before they deliver because you know that a face-to-face encounter is very likely to make your job easier for the next decade or two.

On the other hand, I suspect that you have set an upper age limit above which you suggest that your patients transition to a physician whose practice is focused on adult care. Is this limit stated as a number – 18? 19? 21? Or are you so uncomfortable with the challenges of adolescent medicine that you urge the teenagers in your practice to find another medical home?

Catherine Yeulet/Thinkstockphotos

You may not have an official upper age limit, but the architecture and decor of your office scream out, “We love little kids! Maybe it’s time for you preteens to move on.” Is your waiting room shared by all ages? Are there zebras on the walls and giraffes on the exam room doors? Is “The Hungry Caterpillar” the most mature reading material in the basket of books and magazines in your waiting room? Do you and your staff dress in scrub suits and jackets plastered with cartoon characters? Is there a monkey hanging from the yoke of your stethoscope?

In my practice, I had a very simple and seldom-enforced upper age limit. A patient who was still a student, not even a full-time student, was welcome to keep coming to see me. This made us very popular with college students who knew that we would be there for them when they came home between semesters with a sore throat or needed a refill for their anxiety medicine. No long waits to see a customer-unfriendly internist. Of course, this meant that it was not unusual for me to see patients who were working on their master’s degree or just a few months short of their doctoral dissertation.

One of our exam rooms had large plywood cutouts of the number 1-10 on the walls, but otherwise I avoided large murals of jungle figures or cartoon characters. A checked shirt and a muted wine-red knit tie were about as wild and crazy as my professional wardrobe ever got. I never really bought into the notion that I could put a nervous young child at ease by dressing like a clown. In my experience, it was the personality and warmth radiating from the caregiver that set the tone of the visit, not what he or she was wearing.

We didn’t have the space or the time to allow adolescents and young adults to have their own waiting room. I am sure that a few moved on to other practices because they felt they were too old to be sharing the waiting room with crying infants and shrieking toddlers. More often, I heard from older patients that they enjoyed the patient mix, and on occasion some of them told me they enjoyed playing with the younger patients.

Recently, the American Academy of Pediatrics published a recommendation discouraging pediatricians from setting upper age limits for their patients (Pediatrics. 2017;140[3]:e20172151). As someone who practiced most of his career with a very lenient age limit policy, I think this is an excellent and long overdue recommendation.

Patients in their older teens and early twenties seldom present with problems that are beyond our professional competency. Furthermore, one cannot underestimate the value that comes from the years of continuity we can fall back on, particularly for those patients with chronic and multiorgan system disease. But most of all, the chance to spend a few quiet minutes having an adult conversation and catching up with someone you have known since infancy can be a pleasant oasis in an otherwise hectic day spent seeing unappreciative, inarticulate infants and whining toddlers.

[polldaddy:{"method":"iframe","type":"survey","src":"//newspolls2017.polldaddy.com/s/never-too-old?iframe=1"}]

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.”

What are the age parameters for your practice? I suspect that at one end of the spectrum, you feel that a child is never too young to come to your practice. In fact you may even go out of your way to encourage expectant mothers to make a get-acquainted visit before they deliver because you know that a face-to-face encounter is very likely to make your job easier for the next decade or two.

On the other hand, I suspect that you have set an upper age limit above which you suggest that your patients transition to a physician whose practice is focused on adult care. Is this limit stated as a number – 18? 19? 21? Or are you so uncomfortable with the challenges of adolescent medicine that you urge the teenagers in your practice to find another medical home?

Catherine Yeulet/Thinkstockphotos

You may not have an official upper age limit, but the architecture and decor of your office scream out, “We love little kids! Maybe it’s time for you preteens to move on.” Is your waiting room shared by all ages? Are there zebras on the walls and giraffes on the exam room doors? Is “The Hungry Caterpillar” the most mature reading material in the basket of books and magazines in your waiting room? Do you and your staff dress in scrub suits and jackets plastered with cartoon characters? Is there a monkey hanging from the yoke of your stethoscope?

In my practice, I had a very simple and seldom-enforced upper age limit. A patient who was still a student, not even a full-time student, was welcome to keep coming to see me. This made us very popular with college students who knew that we would be there for them when they came home between semesters with a sore throat or needed a refill for their anxiety medicine. No long waits to see a customer-unfriendly internist. Of course, this meant that it was not unusual for me to see patients who were working on their master’s degree or just a few months short of their doctoral dissertation.

One of our exam rooms had large plywood cutouts of the number 1-10 on the walls, but otherwise I avoided large murals of jungle figures or cartoon characters. A checked shirt and a muted wine-red knit tie were about as wild and crazy as my professional wardrobe ever got. I never really bought into the notion that I could put a nervous young child at ease by dressing like a clown. In my experience, it was the personality and warmth radiating from the caregiver that set the tone of the visit, not what he or she was wearing.

We didn’t have the space or the time to allow adolescents and young adults to have their own waiting room. I am sure that a few moved on to other practices because they felt they were too old to be sharing the waiting room with crying infants and shrieking toddlers. More often, I heard from older patients that they enjoyed the patient mix, and on occasion some of them told me they enjoyed playing with the younger patients.

Recently, the American Academy of Pediatrics published a recommendation discouraging pediatricians from setting upper age limits for their patients (Pediatrics. 2017;140[3]:e20172151). As someone who practiced most of his career with a very lenient age limit policy, I think this is an excellent and long overdue recommendation.

Patients in their older teens and early twenties seldom present with problems that are beyond our professional competency. Furthermore, one cannot underestimate the value that comes from the years of continuity we can fall back on, particularly for those patients with chronic and multiorgan system disease. But most of all, the chance to spend a few quiet minutes having an adult conversation and catching up with someone you have known since infancy can be a pleasant oasis in an otherwise hectic day spent seeing unappreciative, inarticulate infants and whining toddlers.

[polldaddy:{"method":"iframe","type":"survey","src":"//newspolls2017.polldaddy.com/s/never-too-old?iframe=1"}]

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.”

What are the age parameters for your practice? I suspect that at one end of the spectrum, you feel that a child is never too young to come to your practice. In fact you may even go out of your way to encourage expectant mothers to make a get-acquainted visit before they deliver because you know that a face-to-face encounter is very likely to make your job easier for the next decade or two.

On the other hand, I suspect that you have set an upper age limit above which you suggest that your patients transition to a physician whose practice is focused on adult care. Is this limit stated as a number – 18? 19? 21? Or are you so uncomfortable with the challenges of adolescent medicine that you urge the teenagers in your practice to find another medical home?

Catherine Yeulet/Thinkstockphotos

You may not have an official upper age limit, but the architecture and decor of your office scream out, “We love little kids! Maybe it’s time for you preteens to move on.” Is your waiting room shared by all ages? Are there zebras on the walls and giraffes on the exam room doors? Is “The Hungry Caterpillar” the most mature reading material in the basket of books and magazines in your waiting room? Do you and your staff dress in scrub suits and jackets plastered with cartoon characters? Is there a monkey hanging from the yoke of your stethoscope?

In my practice, I had a very simple and seldom-enforced upper age limit. A patient who was still a student, not even a full-time student, was welcome to keep coming to see me. This made us very popular with college students who knew that we would be there for them when they came home between semesters with a sore throat or needed a refill for their anxiety medicine. No long waits to see a customer-unfriendly internist. Of course, this meant that it was not unusual for me to see patients who were working on their master’s degree or just a few months short of their doctoral dissertation.

One of our exam rooms had large plywood cutouts of the number 1-10 on the walls, but otherwise I avoided large murals of jungle figures or cartoon characters. A checked shirt and a muted wine-red knit tie were about as wild and crazy as my professional wardrobe ever got. I never really bought into the notion that I could put a nervous young child at ease by dressing like a clown. In my experience, it was the personality and warmth radiating from the caregiver that set the tone of the visit, not what he or she was wearing.

We didn’t have the space or the time to allow adolescents and young adults to have their own waiting room. I am sure that a few moved on to other practices because they felt they were too old to be sharing the waiting room with crying infants and shrieking toddlers. More often, I heard from older patients that they enjoyed the patient mix, and on occasion some of them told me they enjoyed playing with the younger patients.

Recently, the American Academy of Pediatrics published a recommendation discouraging pediatricians from setting upper age limits for their patients (Pediatrics. 2017;140[3]:e20172151). As someone who practiced most of his career with a very lenient age limit policy, I think this is an excellent and long overdue recommendation.

Patients in their older teens and early twenties seldom present with problems that are beyond our professional competency. Furthermore, one cannot underestimate the value that comes from the years of continuity we can fall back on, particularly for those patients with chronic and multiorgan system disease. But most of all, the chance to spend a few quiet minutes having an adult conversation and catching up with someone you have known since infancy can be a pleasant oasis in an otherwise hectic day spent seeing unappreciative, inarticulate infants and whining toddlers.

[polldaddy:{"method":"iframe","type":"survey","src":"//newspolls2017.polldaddy.com/s/never-too-old?iframe=1"}]

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.”

You probably aren’t surprised to learn that the jobless rate for young people aged 16-24 years has fallen to the lowest rate recorded since 1969. Those “Hiring” signs you see in every storefront tell the story. Although the jobless rate for young people is still twice that for adults, clearly there are jobs out there.

However, it appears that there are fewer young people looking for those jobs. In fact, the decline in what is referred to as the “labor force participation rate” is down significantly to 60.6% from a high point of 77.5% in 1989 (Summer Youth Unemployment Falls to Lowest Level Since 1969, by Eric Morath. Wall Street Journal. 2017 Aug 17).

Koji_Ishii/Thinkstock

Although I haven’t found any statistics that might explain this lack of interest in joining, even temporarily, the job market, several things come to mind. It may be that the overall improvement in the job market means that families are more secure financially and children feel less pressure to contribute to family coffers. The author of the Wall Street Journal article suggests that some young people see going to school during the summer as a way to shorten their path to graduation, and a full-time job as a better investment than a low-paying summer job. The lure of adventure and the chance to sample other cultures may prompt those who can afford it to travel instead of work.

But it may be that the concept of having a job, particularly a first job, lacks the appeal it did for my generation. While I’m sure my parents would have appreciated any financial contribution I could provide, I felt no direct pressure from them to get a summer job. My mother’s only concern was that without something to do, I would be getting into trouble or hanging around the house and getting in her way. She could easily find me work to do around the house that wasn’t going to be fun or pay me anything.

It was peer pressure that nudged me into working. I had watched my friends and their older siblings reaping the benefits of a summer job – disposable income. Money could buy an old car, pay for insurance and gas, fund dates, and buy 45 rpm records. The money provided some independence. Even the most menial job could allow you to feel a bit more like a grown-up.

In retrospect, my summer job experiences gave me the opportunity to meet people who resided out of my socioeconomic and ethnic comfort zones. I learned the value of good customer service and some of the skills involved in providing it – skills that should be in the toolbox of every practicing physician.

While I don’t think it is our job as pediatricians to instill a work ethic in our patients, it doesn’t hurt to encourage those who seem to be at loose ends to consider getting a job. Unfortunately, many of the businesses hiring young people are offering hours that are certainly not schoolwork- and sleep-friendly. And we must caution our patients to avoid making bad compromises when facing the lure of a steady supply of spending money.

I would hate to see us return to the bad old days when children were enslaved in sweat shops, in dangerous and unhealthy working conditions. However, I fear that in some cases, in our zeal to protect young people from unsafe working conditions, we have made so many rules that we have seriously limited the opportunities for them to get a taste of the hands-on technical skills that our country desperately needs. Just try to get a plumber or electrician when you need one, and you will understand what I mean. A summer spent as an electrician’s gofer just might trigger a floundering 13-year-old to invest more energy in his studies when he sees them as a critical step to a well-paying job he would enjoy.

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.”

You probably aren’t surprised to learn that the jobless rate for young people aged 16-24 years has fallen to the lowest rate recorded since 1969. Those “Hiring” signs you see in every storefront tell the story. Although the jobless rate for young people is still twice that for adults, clearly there are jobs out there.

However, it appears that there are fewer young people looking for those jobs. In fact, the decline in what is referred to as the “labor force participation rate” is down significantly to 60.6% from a high point of 77.5% in 1989 (Summer Youth Unemployment Falls to Lowest Level Since 1969, by Eric Morath. Wall Street Journal. 2017 Aug 17).

Koji_Ishii/Thinkstock

Although I haven’t found any statistics that might explain this lack of interest in joining, even temporarily, the job market, several things come to mind. It may be that the overall improvement in the job market means that families are more secure financially and children feel less pressure to contribute to family coffers. The author of the Wall Street Journal article suggests that some young people see going to school during the summer as a way to shorten their path to graduation, and a full-time job as a better investment than a low-paying summer job. The lure of adventure and the chance to sample other cultures may prompt those who can afford it to travel instead of work.

But it may be that the concept of having a job, particularly a first job, lacks the appeal it did for my generation. While I’m sure my parents would have appreciated any financial contribution I could provide, I felt no direct pressure from them to get a summer job. My mother’s only concern was that without something to do, I would be getting into trouble or hanging around the house and getting in her way. She could easily find me work to do around the house that wasn’t going to be fun or pay me anything.

It was peer pressure that nudged me into working. I had watched my friends and their older siblings reaping the benefits of a summer job – disposable income. Money could buy an old car, pay for insurance and gas, fund dates, and buy 45 rpm records. The money provided some independence. Even the most menial job could allow you to feel a bit more like a grown-up.

In retrospect, my summer job experiences gave me the opportunity to meet people who resided out of my socioeconomic and ethnic comfort zones. I learned the value of good customer service and some of the skills involved in providing it – skills that should be in the toolbox of every practicing physician.

While I don’t think it is our job as pediatricians to instill a work ethic in our patients, it doesn’t hurt to encourage those who seem to be at loose ends to consider getting a job. Unfortunately, many of the businesses hiring young people are offering hours that are certainly not schoolwork- and sleep-friendly. And we must caution our patients to avoid making bad compromises when facing the lure of a steady supply of spending money.

I would hate to see us return to the bad old days when children were enslaved in sweat shops, in dangerous and unhealthy working conditions. However, I fear that in some cases, in our zeal to protect young people from unsafe working conditions, we have made so many rules that we have seriously limited the opportunities for them to get a taste of the hands-on technical skills that our country desperately needs. Just try to get a plumber or electrician when you need one, and you will understand what I mean. A summer spent as an electrician’s gofer just might trigger a floundering 13-year-old to invest more energy in his studies when he sees them as a critical step to a well-paying job he would enjoy.

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.”

You probably aren’t surprised to learn that the jobless rate for young people aged 16-24 years has fallen to the lowest rate recorded since 1969. Those “Hiring” signs you see in every storefront tell the story. Although the jobless rate for young people is still twice that for adults, clearly there are jobs out there.

However, it appears that there are fewer young people looking for those jobs. In fact, the decline in what is referred to as the “labor force participation rate” is down significantly to 60.6% from a high point of 77.5% in 1989 (Summer Youth Unemployment Falls to Lowest Level Since 1969, by Eric Morath. Wall Street Journal. 2017 Aug 17).

Koji_Ishii/Thinkstock

Although I haven’t found any statistics that might explain this lack of interest in joining, even temporarily, the job market, several things come to mind. It may be that the overall improvement in the job market means that families are more secure financially and children feel less pressure to contribute to family coffers. The author of the Wall Street Journal article suggests that some young people see going to school during the summer as a way to shorten their path to graduation, and a full-time job as a better investment than a low-paying summer job. The lure of adventure and the chance to sample other cultures may prompt those who can afford it to travel instead of work.

But it may be that the concept of having a job, particularly a first job, lacks the appeal it did for my generation. While I’m sure my parents would have appreciated any financial contribution I could provide, I felt no direct pressure from them to get a summer job. My mother’s only concern was that without something to do, I would be getting into trouble or hanging around the house and getting in her way. She could easily find me work to do around the house that wasn’t going to be fun or pay me anything.

It was peer pressure that nudged me into working. I had watched my friends and their older siblings reaping the benefits of a summer job – disposable income. Money could buy an old car, pay for insurance and gas, fund dates, and buy 45 rpm records. The money provided some independence. Even the most menial job could allow you to feel a bit more like a grown-up.

In retrospect, my summer job experiences gave me the opportunity to meet people who resided out of my socioeconomic and ethnic comfort zones. I learned the value of good customer service and some of the skills involved in providing it – skills that should be in the toolbox of every practicing physician.

While I don’t think it is our job as pediatricians to instill a work ethic in our patients, it doesn’t hurt to encourage those who seem to be at loose ends to consider getting a job. Unfortunately, many of the businesses hiring young people are offering hours that are certainly not schoolwork- and sleep-friendly. And we must caution our patients to avoid making bad compromises when facing the lure of a steady supply of spending money.

I would hate to see us return to the bad old days when children were enslaved in sweat shops, in dangerous and unhealthy working conditions. However, I fear that in some cases, in our zeal to protect young people from unsafe working conditions, we have made so many rules that we have seriously limited the opportunities for them to get a taste of the hands-on technical skills that our country desperately needs. Just try to get a plumber or electrician when you need one, and you will understand what I mean. A summer spent as an electrician’s gofer just might trigger a floundering 13-year-old to invest more energy in his studies when he sees them as a critical step to a well-paying job he would enjoy.

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.”

 

The title caught my eye as I skimmed through my daughter’s copy of the New Yorker. “When should a child be taken from his parents?” (Larissa MacFarquar, Aug. 7 & 14, 2017). It is a very complex question, and one for which there has never been an easy answer, certainly not an answer that can be applied universally. However, my reflex response was “sooner rather than later!”

What prompted my hasty from-the-hip answer is 40-plus years of watching the legal system grind along at a pace that too often fails to take into account the emotional needs of a child’s developing personality. While lawyers file for extensions and wait for slots in dockets bloated with less time-sensitive cases, children float in limbo waiting to hear where their home will be and who will constitute their family.

Courtesy Dr. William G. Wilkoff

If a child is lucky, he may pass the time with a single caring family who eventually may adopt him. Or he may be housed with a family member who can offer more stability than his troubled parent(s). More likely he will bounce from foster home to foster home that may be adequate in terms of the basics of food, shelter, and temporary comfort but offer no hope of a lasting relationship.

Even if he is lucky enough to be housed with a single foster home, the odds are that his stays there will be punctuated with returns to his parent as the parent is given one more chance to beat back the demons that have stood in the way of at least an adequate, if not a model, parenthood. The New Yorker article chronicles one such odyssey that spans a mother’s four pregnancies with several fathers.

In the crudest terms, here is the question: “How many strikes does one get before one loses his or her parental rights?” It is a bit easier to make the call when there have been incidents in which a parent’s action or inaction has put the child’s physical health in jeopardy. However, the social workers, physicians, and law enforcement officials who must shoulder the burden of these decisions involving the abusive parent often find themselves in no-win situations. Giving the parent who is suspected of physical abuse having been “just a little heavy handed” one more chance could result in death or life-long impairment.

fiorigianluigi/Thinkstock

The more difficult decisions and one that seems to take much longer come when the parent is struggling with addiction or a mental health illness that has been resistant to therapy. In some cases, the failure is because the parent hasn’t adhered to the therapeutic plan. However, often the relapses are simply part of the expected course of the parent’s illness or addiction. But how many chances should the parent be given? How long do we let a 3-year-old’s or a 13-year-old’s emotions yo-yo up and down before someone says, “Enough is enough – your child is at increasing risk for lifelong mental health problems because of your inconsistent parenting?” In my experience, the decision makers have erred too often in giving the parent one more chance.

I suspect the rationale for giving the parent another chance is based on the belief that the biologic family should always be the preferred option; an assumption that can be called into question. While I don’t think these decisions should be made with the strict application of an algorithm, I believe there is more room for evidence-based decision-making. That evidence may not be currently available, but I think we should be asking questions to get that information. For example, for an individual with a specific substance addiction or mental illness with a certain diagnosis, what are the chances of a remedy that will allow that individual to become a functional parent? And how long will it take?

Information like this may be helpful for those folks with the difficult job of deciding when a parent should lose his parental rights in a time course that takes into account the emotional needs of his children.
 

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

 

The title caught my eye as I skimmed through my daughter’s copy of the New Yorker. “When should a child be taken from his parents?” (Larissa MacFarquar, Aug. 7 & 14, 2017). It is a very complex question, and one for which there has never been an easy answer, certainly not an answer that can be applied universally. However, my reflex response was “sooner rather than later!”

What prompted my hasty from-the-hip answer is 40-plus years of watching the legal system grind along at a pace that too often fails to take into account the emotional needs of a child’s developing personality. While lawyers file for extensions and wait for slots in dockets bloated with less time-sensitive cases, children float in limbo waiting to hear where their home will be and who will constitute their family.

Courtesy Dr. William G. Wilkoff

If a child is lucky, he may pass the time with a single caring family who eventually may adopt him. Or he may be housed with a family member who can offer more stability than his troubled parent(s). More likely he will bounce from foster home to foster home that may be adequate in terms of the basics of food, shelter, and temporary comfort but offer no hope of a lasting relationship.

Even if he is lucky enough to be housed with a single foster home, the odds are that his stays there will be punctuated with returns to his parent as the parent is given one more chance to beat back the demons that have stood in the way of at least an adequate, if not a model, parenthood. The New Yorker article chronicles one such odyssey that spans a mother’s four pregnancies with several fathers.

In the crudest terms, here is the question: “How many strikes does one get before one loses his or her parental rights?” It is a bit easier to make the call when there have been incidents in which a parent’s action or inaction has put the child’s physical health in jeopardy. However, the social workers, physicians, and law enforcement officials who must shoulder the burden of these decisions involving the abusive parent often find themselves in no-win situations. Giving the parent who is suspected of physical abuse having been “just a little heavy handed” one more chance could result in death or life-long impairment.

fiorigianluigi/Thinkstock

The more difficult decisions and one that seems to take much longer come when the parent is struggling with addiction or a mental health illness that has been resistant to therapy. In some cases, the failure is because the parent hasn’t adhered to the therapeutic plan. However, often the relapses are simply part of the expected course of the parent’s illness or addiction. But how many chances should the parent be given? How long do we let a 3-year-old’s or a 13-year-old’s emotions yo-yo up and down before someone says, “Enough is enough – your child is at increasing risk for lifelong mental health problems because of your inconsistent parenting?” In my experience, the decision makers have erred too often in giving the parent one more chance.

I suspect the rationale for giving the parent another chance is based on the belief that the biologic family should always be the preferred option; an assumption that can be called into question. While I don’t think these decisions should be made with the strict application of an algorithm, I believe there is more room for evidence-based decision-making. That evidence may not be currently available, but I think we should be asking questions to get that information. For example, for an individual with a specific substance addiction or mental illness with a certain diagnosis, what are the chances of a remedy that will allow that individual to become a functional parent? And how long will it take?

Information like this may be helpful for those folks with the difficult job of deciding when a parent should lose his parental rights in a time course that takes into account the emotional needs of his children.
 

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

 

The title caught my eye as I skimmed through my daughter’s copy of the New Yorker. “When should a child be taken from his parents?” (Larissa MacFarquar, Aug. 7 & 14, 2017). It is a very complex question, and one for which there has never been an easy answer, certainly not an answer that can be applied universally. However, my reflex response was “sooner rather than later!”

What prompted my hasty from-the-hip answer is 40-plus years of watching the legal system grind along at a pace that too often fails to take into account the emotional needs of a child’s developing personality. While lawyers file for extensions and wait for slots in dockets bloated with less time-sensitive cases, children float in limbo waiting to hear where their home will be and who will constitute their family.

Courtesy Dr. William G. Wilkoff

If a child is lucky, he may pass the time with a single caring family who eventually may adopt him. Or he may be housed with a family member who can offer more stability than his troubled parent(s). More likely he will bounce from foster home to foster home that may be adequate in terms of the basics of food, shelter, and temporary comfort but offer no hope of a lasting relationship.

Even if he is lucky enough to be housed with a single foster home, the odds are that his stays there will be punctuated with returns to his parent as the parent is given one more chance to beat back the demons that have stood in the way of at least an adequate, if not a model, parenthood. The New Yorker article chronicles one such odyssey that spans a mother’s four pregnancies with several fathers.

In the crudest terms, here is the question: “How many strikes does one get before one loses his or her parental rights?” It is a bit easier to make the call when there have been incidents in which a parent’s action or inaction has put the child’s physical health in jeopardy. However, the social workers, physicians, and law enforcement officials who must shoulder the burden of these decisions involving the abusive parent often find themselves in no-win situations. Giving the parent who is suspected of physical abuse having been “just a little heavy handed” one more chance could result in death or life-long impairment.

fiorigianluigi/Thinkstock

The more difficult decisions and one that seems to take much longer come when the parent is struggling with addiction or a mental health illness that has been resistant to therapy. In some cases, the failure is because the parent hasn’t adhered to the therapeutic plan. However, often the relapses are simply part of the expected course of the parent’s illness or addiction. But how many chances should the parent be given? How long do we let a 3-year-old’s or a 13-year-old’s emotions yo-yo up and down before someone says, “Enough is enough – your child is at increasing risk for lifelong mental health problems because of your inconsistent parenting?” In my experience, the decision makers have erred too often in giving the parent one more chance.

I suspect the rationale for giving the parent another chance is based on the belief that the biologic family should always be the preferred option; an assumption that can be called into question. While I don’t think these decisions should be made with the strict application of an algorithm, I believe there is more room for evidence-based decision-making. That evidence may not be currently available, but I think we should be asking questions to get that information. For example, for an individual with a specific substance addiction or mental illness with a certain diagnosis, what are the chances of a remedy that will allow that individual to become a functional parent? And how long will it take?

Information like this may be helpful for those folks with the difficult job of deciding when a parent should lose his parental rights in a time course that takes into account the emotional needs of his children.
 

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].

 

Like many adults, I suspect that I may have been living under the cloud of an undiagnosed case of attention-deficit/hyperactivity disorder (ADHD). What else could explain why my mind wanders during the second hole of my wife’s narrative of her morning golf outing with her friends? Why have I never been in a class or lecture in which after 20 minutes I began wishing I were somewhere else? In my student days, I felt compelled to leave my studies and go to the refrigerator every 15 minutes – even though I wasn’t hungry. Sounds like ADHD to me.

But I know what you are thinking. This guy graduated from medical school, and has been married to the same woman for nearly 50 years. He has no criminal record and has held the same job for more than 40 years. I will admit that my life trajectory is atypical for someone even with a mild case of adult ADHD.

Actually, I don’t really believe that I have an undiagnosed case of ADHD. But I do feel that my attention span is at the short end of the normal spectrum. And I think that by good fortune I stumbled on several strategies that helped me thrive in an academic environment despite my relative attention deficit.

Most noteworthy among those strategies was my habit of listening to heavy metal music with a throbbing beat while I was studying. At my recent college reunion, former classmates whom I hadn’t seen in 50 years reminded me of how often I drove them to quieter study oases with the driving rhythms of the Rolling Stones’ misogynistic anthem “Under My Thumb.”My wife still recalls her amazement the first (and last) time she offered to keep me company while I studied for a pathophysiology exam. She found me hunched over my notes spread out on a coffee table, my knees bouncing to the beat of Joe Cocker crowing the Beatles’ classic “She Came in Through the Bathroom Window” (still one of my all-time favorites). Earbuds hadn’t been invented, and I considered earphones the size of chili bowls too dorky.

I always have assumed that my study habits were just a little weird. But recently I discovered an article describing the work of Alexander Pantelyat, MD, assistant professor of neurology and cofounder of the Johns Hopkins Center for Music and Medicine (“Does Listening to Music Improve Your Focus?” by Heidi Mitchell, Wall Street Journal, July 26, 2017). Dr. Pantelyat notes that the early enthusiasm for playing Mozart to newborns has faded with the understanding that any improvement in learning skills was short-lived. However, he sees some evidence that hearing music of a genre you enjoy may help you focus better than listening to music that you don’t like. He says, “If you enjoy heavy metal, you might be more focused when you listen to it.”

monkeybusinessimages/Thinkstock

Dr. Pantelyat goes on to discuss his theory about how music affects various parts of the brain, the names of which I have long forgotten. I prefer to explain my rhythm-fueled study strategy as simply another example of how stimulants, in my case loud music, can keep a sleep-deprived normal individual awake long enough to pay attention to the task at hand.

As Dr. Pantelyat cautions, the response to music is highly individual. I generally have not recommended my peculiar study habits to my patients. However, my experience has left me more open-minded when trying to help young people struggling to find a study strategy that works. You may not share my affinity for the Rolling Stones and Joe Cocker, but you have to admit you would rather have your patients listen to their music than take drugs they may not need.
 

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].

 

Like many adults, I suspect that I may have been living under the cloud of an undiagnosed case of attention-deficit/hyperactivity disorder (ADHD). What else could explain why my mind wanders during the second hole of my wife’s narrative of her morning golf outing with her friends? Why have I never been in a class or lecture in which after 20 minutes I began wishing I were somewhere else? In my student days, I felt compelled to leave my studies and go to the refrigerator every 15 minutes – even though I wasn’t hungry. Sounds like ADHD to me.

But I know what you are thinking. This guy graduated from medical school, and has been married to the same woman for nearly 50 years. He has no criminal record and has held the same job for more than 40 years. I will admit that my life trajectory is atypical for someone even with a mild case of adult ADHD.

Actually, I don’t really believe that I have an undiagnosed case of ADHD. But I do feel that my attention span is at the short end of the normal spectrum. And I think that by good fortune I stumbled on several strategies that helped me thrive in an academic environment despite my relative attention deficit.

Most noteworthy among those strategies was my habit of listening to heavy metal music with a throbbing beat while I was studying. At my recent college reunion, former classmates whom I hadn’t seen in 50 years reminded me of how often I drove them to quieter study oases with the driving rhythms of the Rolling Stones’ misogynistic anthem “Under My Thumb.”My wife still recalls her amazement the first (and last) time she offered to keep me company while I studied for a pathophysiology exam. She found me hunched over my notes spread out on a coffee table, my knees bouncing to the beat of Joe Cocker crowing the Beatles’ classic “She Came in Through the Bathroom Window” (still one of my all-time favorites). Earbuds hadn’t been invented, and I considered earphones the size of chili bowls too dorky.

I always have assumed that my study habits were just a little weird. But recently I discovered an article describing the work of Alexander Pantelyat, MD, assistant professor of neurology and cofounder of the Johns Hopkins Center for Music and Medicine (“Does Listening to Music Improve Your Focus?” by Heidi Mitchell, Wall Street Journal, July 26, 2017). Dr. Pantelyat notes that the early enthusiasm for playing Mozart to newborns has faded with the understanding that any improvement in learning skills was short-lived. However, he sees some evidence that hearing music of a genre you enjoy may help you focus better than listening to music that you don’t like. He says, “If you enjoy heavy metal, you might be more focused when you listen to it.”

monkeybusinessimages/Thinkstock

Dr. Pantelyat goes on to discuss his theory about how music affects various parts of the brain, the names of which I have long forgotten. I prefer to explain my rhythm-fueled study strategy as simply another example of how stimulants, in my case loud music, can keep a sleep-deprived normal individual awake long enough to pay attention to the task at hand.

As Dr. Pantelyat cautions, the response to music is highly individual. I generally have not recommended my peculiar study habits to my patients. However, my experience has left me more open-minded when trying to help young people struggling to find a study strategy that works. You may not share my affinity for the Rolling Stones and Joe Cocker, but you have to admit you would rather have your patients listen to their music than take drugs they may not need.
 

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].

 

Like many adults, I suspect that I may have been living under the cloud of an undiagnosed case of attention-deficit/hyperactivity disorder (ADHD). What else could explain why my mind wanders during the second hole of my wife’s narrative of her morning golf outing with her friends? Why have I never been in a class or lecture in which after 20 minutes I began wishing I were somewhere else? In my student days, I felt compelled to leave my studies and go to the refrigerator every 15 minutes – even though I wasn’t hungry. Sounds like ADHD to me.

But I know what you are thinking. This guy graduated from medical school, and has been married to the same woman for nearly 50 years. He has no criminal record and has held the same job for more than 40 years. I will admit that my life trajectory is atypical for someone even with a mild case of adult ADHD.

Actually, I don’t really believe that I have an undiagnosed case of ADHD. But I do feel that my attention span is at the short end of the normal spectrum. And I think that by good fortune I stumbled on several strategies that helped me thrive in an academic environment despite my relative attention deficit.

Most noteworthy among those strategies was my habit of listening to heavy metal music with a throbbing beat while I was studying. At my recent college reunion, former classmates whom I hadn’t seen in 50 years reminded me of how often I drove them to quieter study oases with the driving rhythms of the Rolling Stones’ misogynistic anthem “Under My Thumb.”My wife still recalls her amazement the first (and last) time she offered to keep me company while I studied for a pathophysiology exam. She found me hunched over my notes spread out on a coffee table, my knees bouncing to the beat of Joe Cocker crowing the Beatles’ classic “She Came in Through the Bathroom Window” (still one of my all-time favorites). Earbuds hadn’t been invented, and I considered earphones the size of chili bowls too dorky.

I always have assumed that my study habits were just a little weird. But recently I discovered an article describing the work of Alexander Pantelyat, MD, assistant professor of neurology and cofounder of the Johns Hopkins Center for Music and Medicine (“Does Listening to Music Improve Your Focus?” by Heidi Mitchell, Wall Street Journal, July 26, 2017). Dr. Pantelyat notes that the early enthusiasm for playing Mozart to newborns has faded with the understanding that any improvement in learning skills was short-lived. However, he sees some evidence that hearing music of a genre you enjoy may help you focus better than listening to music that you don’t like. He says, “If you enjoy heavy metal, you might be more focused when you listen to it.”

monkeybusinessimages/Thinkstock

Dr. Pantelyat goes on to discuss his theory about how music affects various parts of the brain, the names of which I have long forgotten. I prefer to explain my rhythm-fueled study strategy as simply another example of how stimulants, in my case loud music, can keep a sleep-deprived normal individual awake long enough to pay attention to the task at hand.

As Dr. Pantelyat cautions, the response to music is highly individual. I generally have not recommended my peculiar study habits to my patients. However, my experience has left me more open-minded when trying to help young people struggling to find a study strategy that works. You may not share my affinity for the Rolling Stones and Joe Cocker, but you have to admit you would rather have your patients listen to their music than take drugs they may not need.
 

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].

 

As a physician or a patient, you probably have noticed that the quality of health care is better when there is a continuous relationship between the physician and the patient. Discontinuity can make doctor-patient communication less fluid, but familiarity can breed comfort and confidence. Patients often complain when they see a different physician at every visit. And physicians know they are less efficient when they are seeing a patient they have never seen before.

Tomwang112/Thinkstock

It seems to me that the benefits of continuity in medical care are so numerous and intuitive that we don’t need another study in a peer-reviewed journal to confirm the obvious. But I forget that the powers holding the purse strings of health care would like to see some evidence before they fund a delivery system such as the medical home that touts continuity as a cost saving benefit. In light of that reality, I dove into a new study published in the June 2017 Pediatrics (“Continuity of Care in Infancy and Early Childhood Health Outcomes,” doi: 10.1542/peds.2017-0339). The Philadelphia-based researchers looked at a cohort of more than 17,000 infants from birth to age 3 years receiving primary care in a variety of settings.

They discovered that less continuity was associated with more ambulatory sick visits and more ambulatory sensitive hospitalizations, particularly for children with chronic conditions. Interestingly, they could find no association between continuity measured at well visits and patients’ health outcomes.

With only a gut level and personal relationship with the subject, I wondered how the researchers measured something as nebulous as continuity. It turns out there are several ways to measure continuity, of which the investigators focused on two. The Usual Provider of Care is calculated by dividing the number of visits with the most common provider by the total number of primary care visits. The Bice and Boxerman Continuity of Care Index is more difficult to calculate because, rather than using a single provider, it lumps a small core of providers together (such as a team) as the most the common provider.

As a curmudgeonly, old school, egotistical kind of guy, I was surprised and disappointed to learn from this paper’s references of another study that found, in at least one scenario, the individual-based (Usual Provider of Care) and team-based (Bice and Boxerman Continuity of Care Index) methods of defining continuity yielded comparable results (Med Care. 2016 May;54[5]:e30-4). I always have assumed that, regardless of how well it had been crafted, that I could provide better continuity than a team of providers.

I know what you are thinking: This guy hasn’t bought into the maxim that “There is no I in team.” No, no, I do believe in it, but in the context of continuity of care, it seemed to me that sometimes the more links there are in the chain, the more chances there are for miscommunication. And we all know that primary care is 90% communication.

It is interesting that in this study from Philadelphia, despite the small advantage of single provider continuity in their unpublished data, there was basically little difference in the outcomes when continuity was provided by an individual or a small team. So, I guess this is just another example of my decades long self-delusion. However, the real take-home message is that continuity is important, and it is incumbent on all of us to maintain it as best we can – either as individuals or as members of a small team.
 

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].

 

As a physician or a patient, you probably have noticed that the quality of health care is better when there is a continuous relationship between the physician and the patient. Discontinuity can make doctor-patient communication less fluid, but familiarity can breed comfort and confidence. Patients often complain when they see a different physician at every visit. And physicians know they are less efficient when they are seeing a patient they have never seen before.

Tomwang112/Thinkstock

It seems to me that the benefits of continuity in medical care are so numerous and intuitive that we don’t need another study in a peer-reviewed journal to confirm the obvious. But I forget that the powers holding the purse strings of health care would like to see some evidence before they fund a delivery system such as the medical home that touts continuity as a cost saving benefit. In light of that reality, I dove into a new study published in the June 2017 Pediatrics (“Continuity of Care in Infancy and Early Childhood Health Outcomes,” doi: 10.1542/peds.2017-0339). The Philadelphia-based researchers looked at a cohort of more than 17,000 infants from birth to age 3 years receiving primary care in a variety of settings.

They discovered that less continuity was associated with more ambulatory sick visits and more ambulatory sensitive hospitalizations, particularly for children with chronic conditions. Interestingly, they could find no association between continuity measured at well visits and patients’ health outcomes.

With only a gut level and personal relationship with the subject, I wondered how the researchers measured something as nebulous as continuity. It turns out there are several ways to measure continuity, of which the investigators focused on two. The Usual Provider of Care is calculated by dividing the number of visits with the most common provider by the total number of primary care visits. The Bice and Boxerman Continuity of Care Index is more difficult to calculate because, rather than using a single provider, it lumps a small core of providers together (such as a team) as the most the common provider.

As a curmudgeonly, old school, egotistical kind of guy, I was surprised and disappointed to learn from this paper’s references of another study that found, in at least one scenario, the individual-based (Usual Provider of Care) and team-based (Bice and Boxerman Continuity of Care Index) methods of defining continuity yielded comparable results (Med Care. 2016 May;54[5]:e30-4). I always have assumed that, regardless of how well it had been crafted, that I could provide better continuity than a team of providers.

I know what you are thinking: This guy hasn’t bought into the maxim that “There is no I in team.” No, no, I do believe in it, but in the context of continuity of care, it seemed to me that sometimes the more links there are in the chain, the more chances there are for miscommunication. And we all know that primary care is 90% communication.

It is interesting that in this study from Philadelphia, despite the small advantage of single provider continuity in their unpublished data, there was basically little difference in the outcomes when continuity was provided by an individual or a small team. So, I guess this is just another example of my decades long self-delusion. However, the real take-home message is that continuity is important, and it is incumbent on all of us to maintain it as best we can – either as individuals or as members of a small team.
 

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].

 

As a physician or a patient, you probably have noticed that the quality of health care is better when there is a continuous relationship between the physician and the patient. Discontinuity can make doctor-patient communication less fluid, but familiarity can breed comfort and confidence. Patients often complain when they see a different physician at every visit. And physicians know they are less efficient when they are seeing a patient they have never seen before.

Tomwang112/Thinkstock

It seems to me that the benefits of continuity in medical care are so numerous and intuitive that we don’t need another study in a peer-reviewed journal to confirm the obvious. But I forget that the powers holding the purse strings of health care would like to see some evidence before they fund a delivery system such as the medical home that touts continuity as a cost saving benefit. In light of that reality, I dove into a new study published in the June 2017 Pediatrics (“Continuity of Care in Infancy and Early Childhood Health Outcomes,” doi: 10.1542/peds.2017-0339). The Philadelphia-based researchers looked at a cohort of more than 17,000 infants from birth to age 3 years receiving primary care in a variety of settings.

They discovered that less continuity was associated with more ambulatory sick visits and more ambulatory sensitive hospitalizations, particularly for children with chronic conditions. Interestingly, they could find no association between continuity measured at well visits and patients’ health outcomes.

With only a gut level and personal relationship with the subject, I wondered how the researchers measured something as nebulous as continuity. It turns out there are several ways to measure continuity, of which the investigators focused on two. The Usual Provider of Care is calculated by dividing the number of visits with the most common provider by the total number of primary care visits. The Bice and Boxerman Continuity of Care Index is more difficult to calculate because, rather than using a single provider, it lumps a small core of providers together (such as a team) as the most the common provider.

As a curmudgeonly, old school, egotistical kind of guy, I was surprised and disappointed to learn from this paper’s references of another study that found, in at least one scenario, the individual-based (Usual Provider of Care) and team-based (Bice and Boxerman Continuity of Care Index) methods of defining continuity yielded comparable results (Med Care. 2016 May;54[5]:e30-4). I always have assumed that, regardless of how well it had been crafted, that I could provide better continuity than a team of providers.

I know what you are thinking: This guy hasn’t bought into the maxim that “There is no I in team.” No, no, I do believe in it, but in the context of continuity of care, it seemed to me that sometimes the more links there are in the chain, the more chances there are for miscommunication. And we all know that primary care is 90% communication.

It is interesting that in this study from Philadelphia, despite the small advantage of single provider continuity in their unpublished data, there was basically little difference in the outcomes when continuity was provided by an individual or a small team. So, I guess this is just another example of my decades long self-delusion. However, the real take-home message is that continuity is important, and it is incumbent on all of us to maintain it as best we can – either as individuals or as members of a small team.
 

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

 

If you weren’t a young male living in the United States in the 1960s, it may be hard for you to understand my situation. It was a little more than 6 months from my college graduation. Because I couldn’t think of anything else to do, I had applied for and been accepted in a postgraduate fellowship in art history. However, it was clear that this country was becoming entangled in a confusing, unpopular – and from my personal perspective – a dangerous war.

While I was in college I was protected from the draft. But upon graduation, if I were to pursue my studies in something as unrelated to the war effort as art history, I would be ripe for the picking. I’m not sure why, but luckily I had been banking science credits for a rainy day. And in the winter of 1965-1966, it was raining big time.

Although I had never even remotely considered becoming a physician, medical school represented a temporary safe haven. The rest is a 50-year history in pediatrics that included serving 2 years in the Navy seeing dependent children as the war wound down.

I was not alone. Even if the term “gap year” had been coined, taking a year off to “find oneself” was not an option for young American males on the verge of high school or college graduation. I share this unflattering anecdote as evidence that there are times when circumstances can provide a floundering young person with a much needed sense of direction.

In May 2017, the Chicago Board of Education approved a plan sponsored by Mayor Rahm Emanuel that will require all high school students planning to graduate to provide evidence that they have secured a job or have been accepted by a college, trade apprenticeship, structured gap year program, or the military. (“Chicago won’t allow high school students to graduate without a plan for the future,” by Emma Brown, the Washington Post, July 3, 2017). Critics of the plan complain, probably with good reason, that the cash-strapped school system with more than 300,000 students doesn’t have the resources to provide its students with the counseling they will need to create the required post-graduation plans.

Even if there are too many devils in too many details in the Chicago plan, the principle underlying it is worth a try and deserves consideration by other school systems. It is not a universal military service requirement. Although, I wonder at times if this country should consider such a thing. It also is not a scheme cooked up by the business community to provide itself with cheap labor, although, it probably will.

In my mind, the intent of the Chicago plan simply is to remind its students that being an adult and a member of a society means doing something. Hopefully something that is productive or creative or at least something that improves your chances of living a life that is more likely to provide you with some degree of happiness. It offers a broad enough range of choices so that it is not overly prescriptive. If well administered, the plan would send the message to the graduating student that you must at least have a Plan A.

Regardless of whether a student’s patients come from affluent families with a myriad of post-graduation opportunities or from an economically challenged neighborhood in Chicago, I suspect that many of them would benefit from an artificial dose of necessity in the form of a message that doing nothing is not going to be an option.

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

 

If you weren’t a young male living in the United States in the 1960s, it may be hard for you to understand my situation. It was a little more than 6 months from my college graduation. Because I couldn’t think of anything else to do, I had applied for and been accepted in a postgraduate fellowship in art history. However, it was clear that this country was becoming entangled in a confusing, unpopular – and from my personal perspective – a dangerous war.

While I was in college I was protected from the draft. But upon graduation, if I were to pursue my studies in something as unrelated to the war effort as art history, I would be ripe for the picking. I’m not sure why, but luckily I had been banking science credits for a rainy day. And in the winter of 1965-1966, it was raining big time.

Although I had never even remotely considered becoming a physician, medical school represented a temporary safe haven. The rest is a 50-year history in pediatrics that included serving 2 years in the Navy seeing dependent children as the war wound down.

I was not alone. Even if the term “gap year” had been coined, taking a year off to “find oneself” was not an option for young American males on the verge of high school or college graduation. I share this unflattering anecdote as evidence that there are times when circumstances can provide a floundering young person with a much needed sense of direction.

In May 2017, the Chicago Board of Education approved a plan sponsored by Mayor Rahm Emanuel that will require all high school students planning to graduate to provide evidence that they have secured a job or have been accepted by a college, trade apprenticeship, structured gap year program, or the military. (“Chicago won’t allow high school students to graduate without a plan for the future,” by Emma Brown, the Washington Post, July 3, 2017). Critics of the plan complain, probably with good reason, that the cash-strapped school system with more than 300,000 students doesn’t have the resources to provide its students with the counseling they will need to create the required post-graduation plans.

Even if there are too many devils in too many details in the Chicago plan, the principle underlying it is worth a try and deserves consideration by other school systems. It is not a universal military service requirement. Although, I wonder at times if this country should consider such a thing. It also is not a scheme cooked up by the business community to provide itself with cheap labor, although, it probably will.

In my mind, the intent of the Chicago plan simply is to remind its students that being an adult and a member of a society means doing something. Hopefully something that is productive or creative or at least something that improves your chances of living a life that is more likely to provide you with some degree of happiness. It offers a broad enough range of choices so that it is not overly prescriptive. If well administered, the plan would send the message to the graduating student that you must at least have a Plan A.

Regardless of whether a student’s patients come from affluent families with a myriad of post-graduation opportunities or from an economically challenged neighborhood in Chicago, I suspect that many of them would benefit from an artificial dose of necessity in the form of a message that doing nothing is not going to be an option.

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

 

If you weren’t a young male living in the United States in the 1960s, it may be hard for you to understand my situation. It was a little more than 6 months from my college graduation. Because I couldn’t think of anything else to do, I had applied for and been accepted in a postgraduate fellowship in art history. However, it was clear that this country was becoming entangled in a confusing, unpopular – and from my personal perspective – a dangerous war.

While I was in college I was protected from the draft. But upon graduation, if I were to pursue my studies in something as unrelated to the war effort as art history, I would be ripe for the picking. I’m not sure why, but luckily I had been banking science credits for a rainy day. And in the winter of 1965-1966, it was raining big time.

Although I had never even remotely considered becoming a physician, medical school represented a temporary safe haven. The rest is a 50-year history in pediatrics that included serving 2 years in the Navy seeing dependent children as the war wound down.

I was not alone. Even if the term “gap year” had been coined, taking a year off to “find oneself” was not an option for young American males on the verge of high school or college graduation. I share this unflattering anecdote as evidence that there are times when circumstances can provide a floundering young person with a much needed sense of direction.

In May 2017, the Chicago Board of Education approved a plan sponsored by Mayor Rahm Emanuel that will require all high school students planning to graduate to provide evidence that they have secured a job or have been accepted by a college, trade apprenticeship, structured gap year program, or the military. (“Chicago won’t allow high school students to graduate without a plan for the future,” by Emma Brown, the Washington Post, July 3, 2017). Critics of the plan complain, probably with good reason, that the cash-strapped school system with more than 300,000 students doesn’t have the resources to provide its students with the counseling they will need to create the required post-graduation plans.

Even if there are too many devils in too many details in the Chicago plan, the principle underlying it is worth a try and deserves consideration by other school systems. It is not a universal military service requirement. Although, I wonder at times if this country should consider such a thing. It also is not a scheme cooked up by the business community to provide itself with cheap labor, although, it probably will.

In my mind, the intent of the Chicago plan simply is to remind its students that being an adult and a member of a society means doing something. Hopefully something that is productive or creative or at least something that improves your chances of living a life that is more likely to provide you with some degree of happiness. It offers a broad enough range of choices so that it is not overly prescriptive. If well administered, the plan would send the message to the graduating student that you must at least have a Plan A.

Regardless of whether a student’s patients come from affluent families with a myriad of post-graduation opportunities or from an economically challenged neighborhood in Chicago, I suspect that many of them would benefit from an artificial dose of necessity in the form of a message that doing nothing is not going to be an option.

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

 

In a recent column entitled “To the limit,” I tried to make the case that the negative consequences of permissive parenting are numerous enough to warrant the attention of primary care pediatricians and family physicians. The evidence linking atypical sensory adaptation, behavior difficulties, sleep deprivation, and obesity to a permissive parenting style is just beginning to appear in the literature, but the numbers are in sync with the anecdotal observations of many experienced pediatricians like me. In that previous column, I offered to provide a more nuanced discussion of when and how clinicians might address the issue of permissive parenting with families in their practices.

First, let me make it clear that I don’t consider parenting style to be a topic that needs to occur on the checklist of every patient at every health maintenance visit. You already are overburdened with the demands of experts who have lobbied to have their favorite hot button issues included in your 15 minutes of face-to-face time with your young patients.

ChamilleWhite/Thinkstock

In the study linking atypical sensory adaptation and increased behavioral difficulties with parenting style, Mary Lauren Neel, MD, found that only 11% of the parents in her study group could be categorized as permissive (“Parenting style link to atypical toddler sensory adaption” by Tara Haelle ). Our target group would appear to be relatively small.

We also must accept our limited role as advisors. There are many ways to skin a cat and to raise a child. Homogeneity is not our goal. We must respect the cultural and philosophical differences that exist in our society. However, in my opinion, the unhealthy consequences of permissive parenting deserve a sensitive attempt at education and some gentle anticipatory guidance ... hopefully without an aroma of condescension.

The opportunities for our input begin in the first few months of life when parents are faced with the difficult questions of whether it is safe and appropriate to allow their infant to cry himself to sleep and whether a mom must allow her infant to use her breast as a pacifier. With the transition to solid food comes the challenge of how to manage the inevitable rejection of new tastes, colors, and textures. Of course, most parents find these issues challenging, but to what degree a parent can internalize your reassurance and advice is a good reflection on where he or she sits on the permissive to authoritarian spectrum of parenting.

With an infant’s rapidly advancing motor skills comes the question of when, where, and how to create boundaries to keep the child safe ... and to protect the environment from the surprisingly destructive power of an inquisitive toddler. Here the permissive parent will be continually challenged when he or she finds that simply saying “No” or “Don’t” doesn’t always work ... to some extent because, up to this point, the child has never encountered a situation in which s/he hasn’t gotten what s/he wants.

It is possible that your advice on when and how to say “No” will meet immediate resistance from a parent who simply believes that every child will eventually self-correct herself. Or, you may encounter a parent who has been told that setting limits will stifle her young child’s creative impulses. Of course, this is hogwash because you know as well as I do that carefully considered age-appropriate limits can keep a child safe and still give him plenty of room to exercise his creativity.

This is not an issue in which we should allow ourselves to get bogged down in circuitous philosophical arguments. We must keep our advice practical and focused on issues of safety and health. I have found that a significant number of permissive parents can learn the difficult skill of saying “No” to their children. It takes time, but it is time well spent.

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

 

In a recent column entitled “To the limit,” I tried to make the case that the negative consequences of permissive parenting are numerous enough to warrant the attention of primary care pediatricians and family physicians. The evidence linking atypical sensory adaptation, behavior difficulties, sleep deprivation, and obesity to a permissive parenting style is just beginning to appear in the literature, but the numbers are in sync with the anecdotal observations of many experienced pediatricians like me. In that previous column, I offered to provide a more nuanced discussion of when and how clinicians might address the issue of permissive parenting with families in their practices.

First, let me make it clear that I don’t consider parenting style to be a topic that needs to occur on the checklist of every patient at every health maintenance visit. You already are overburdened with the demands of experts who have lobbied to have their favorite hot button issues included in your 15 minutes of face-to-face time with your young patients.

ChamilleWhite/Thinkstock

In the study linking atypical sensory adaptation and increased behavioral difficulties with parenting style, Mary Lauren Neel, MD, found that only 11% of the parents in her study group could be categorized as permissive (“Parenting style link to atypical toddler sensory adaption” by Tara Haelle ). Our target group would appear to be relatively small.

We also must accept our limited role as advisors. There are many ways to skin a cat and to raise a child. Homogeneity is not our goal. We must respect the cultural and philosophical differences that exist in our society. However, in my opinion, the unhealthy consequences of permissive parenting deserve a sensitive attempt at education and some gentle anticipatory guidance ... hopefully without an aroma of condescension.

The opportunities for our input begin in the first few months of life when parents are faced with the difficult questions of whether it is safe and appropriate to allow their infant to cry himself to sleep and whether a mom must allow her infant to use her breast as a pacifier. With the transition to solid food comes the challenge of how to manage the inevitable rejection of new tastes, colors, and textures. Of course, most parents find these issues challenging, but to what degree a parent can internalize your reassurance and advice is a good reflection on where he or she sits on the permissive to authoritarian spectrum of parenting.

With an infant’s rapidly advancing motor skills comes the question of when, where, and how to create boundaries to keep the child safe ... and to protect the environment from the surprisingly destructive power of an inquisitive toddler. Here the permissive parent will be continually challenged when he or she finds that simply saying “No” or “Don’t” doesn’t always work ... to some extent because, up to this point, the child has never encountered a situation in which s/he hasn’t gotten what s/he wants.

It is possible that your advice on when and how to say “No” will meet immediate resistance from a parent who simply believes that every child will eventually self-correct herself. Or, you may encounter a parent who has been told that setting limits will stifle her young child’s creative impulses. Of course, this is hogwash because you know as well as I do that carefully considered age-appropriate limits can keep a child safe and still give him plenty of room to exercise his creativity.

This is not an issue in which we should allow ourselves to get bogged down in circuitous philosophical arguments. We must keep our advice practical and focused on issues of safety and health. I have found that a significant number of permissive parents can learn the difficult skill of saying “No” to their children. It takes time, but it is time well spent.

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

 

In a recent column entitled “To the limit,” I tried to make the case that the negative consequences of permissive parenting are numerous enough to warrant the attention of primary care pediatricians and family physicians. The evidence linking atypical sensory adaptation, behavior difficulties, sleep deprivation, and obesity to a permissive parenting style is just beginning to appear in the literature, but the numbers are in sync with the anecdotal observations of many experienced pediatricians like me. In that previous column, I offered to provide a more nuanced discussion of when and how clinicians might address the issue of permissive parenting with families in their practices.

First, let me make it clear that I don’t consider parenting style to be a topic that needs to occur on the checklist of every patient at every health maintenance visit. You already are overburdened with the demands of experts who have lobbied to have their favorite hot button issues included in your 15 minutes of face-to-face time with your young patients.

ChamilleWhite/Thinkstock

In the study linking atypical sensory adaptation and increased behavioral difficulties with parenting style, Mary Lauren Neel, MD, found that only 11% of the parents in her study group could be categorized as permissive (“Parenting style link to atypical toddler sensory adaption” by Tara Haelle ). Our target group would appear to be relatively small.

We also must accept our limited role as advisors. There are many ways to skin a cat and to raise a child. Homogeneity is not our goal. We must respect the cultural and philosophical differences that exist in our society. However, in my opinion, the unhealthy consequences of permissive parenting deserve a sensitive attempt at education and some gentle anticipatory guidance ... hopefully without an aroma of condescension.

The opportunities for our input begin in the first few months of life when parents are faced with the difficult questions of whether it is safe and appropriate to allow their infant to cry himself to sleep and whether a mom must allow her infant to use her breast as a pacifier. With the transition to solid food comes the challenge of how to manage the inevitable rejection of new tastes, colors, and textures. Of course, most parents find these issues challenging, but to what degree a parent can internalize your reassurance and advice is a good reflection on where he or she sits on the permissive to authoritarian spectrum of parenting.

With an infant’s rapidly advancing motor skills comes the question of when, where, and how to create boundaries to keep the child safe ... and to protect the environment from the surprisingly destructive power of an inquisitive toddler. Here the permissive parent will be continually challenged when he or she finds that simply saying “No” or “Don’t” doesn’t always work ... to some extent because, up to this point, the child has never encountered a situation in which s/he hasn’t gotten what s/he wants.

It is possible that your advice on when and how to say “No” will meet immediate resistance from a parent who simply believes that every child will eventually self-correct herself. Or, you may encounter a parent who has been told that setting limits will stifle her young child’s creative impulses. Of course, this is hogwash because you know as well as I do that carefully considered age-appropriate limits can keep a child safe and still give him plenty of room to exercise his creativity.

This is not an issue in which we should allow ourselves to get bogged down in circuitous philosophical arguments. We must keep our advice practical and focused on issues of safety and health. I have found that a significant number of permissive parents can learn the difficult skill of saying “No” to their children. It takes time, but it is time well spent.

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

 

Do you believe that children whose parents can make and enforce rules are more likely to thrive than those children whose parents are hesitant to set limits? If you don’t see limit setting as a critical function of parenting, you and I are not only marching to different drummers, we aren’t even in the same parade.

You may be tempted to write me off as just another old school ranter because I believe that limit setting is one of the cornerstones of parenting. But, let’s look at some of the evidence. There are several studies demonstrating that children whose parents set bedtimes get more sleep. One recent survey also found that teenagers who got more sleep as a result of enforced bedtimes functioned better in school (Sleep. 2011 Jun 1;34[6]:797-800).

©iStockphoto

As reported in the June 2017 Pediatric News, Mary Lauren Neel, MD, a fellow in neonatal perinatal medicine at Vanderbilt University, Nashville, Tenn., has found that children of parents who were permissive “were more likely to have atypical sensory adaptation at age 1 year and increased behavior difficulties at 2 years” than were those whose parents had an authoritative or authoritarian style (“Parenting style linked to atypical toddler sensory adaption” by Tara Haelle). In this unpublished study, children of permissive parents were 2.6 times more likely to exhibit atypical sensory adaptation, were more than twice as likely to have internalizing behavior at age 2 years, and were three times more likely to have externalizing behaviors by age 3 years.

An important question is whether permissive parenting is a problem that warrants our concern as pediatricians. We always are on alert for the red flags of abusive parenting, and, obviously, failure to intervene in cases of abuse can be disastrous. However, if we can believe the results from the studies that have already been completed, it seems pretty clear that permissive parenting can spawn behavioral problems, sleep problems, and the myriad of downstream effects that can result from sleep deprivation. And I haven’t even touched on the possible relationship between permissive parenting and the obesity epidemic.

If we still consider ourselves the preventive medicine specialists, shouldn’t pediatricians and family medicine physicians be more invested in minimizing the unhealthy consequences of permissive parenting? If we can agree on a firm “Yes!” the next question is, When and how should we address the issue?

A more nuanced discussion can be the germ of a future Letters from Maine, but the short answer is that we need to sound as nonjudgmental as possible as we present our case for limit setting. We need to start early before the die is cast, and we should be better about publicizing our supporting evidence. Setting a bedtime can begin in the first 6 months of life. Helping parents learn to say, “No, we aren’t going to feed you only what you like to eat!” can start as an infant makes what can be an unsettling transition to solid food.

Our message needs to be that not only is it okay to say “No!” but that, when done correctly, it is the healthy thing to do.

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.”

 

Do you believe that children whose parents can make and enforce rules are more likely to thrive than those children whose parents are hesitant to set limits? If you don’t see limit setting as a critical function of parenting, you and I are not only marching to different drummers, we aren’t even in the same parade.

You may be tempted to write me off as just another old school ranter because I believe that limit setting is one of the cornerstones of parenting. But, let’s look at some of the evidence. There are several studies demonstrating that children whose parents set bedtimes get more sleep. One recent survey also found that teenagers who got more sleep as a result of enforced bedtimes functioned better in school (Sleep. 2011 Jun 1;34[6]:797-800).

©iStockphoto

As reported in the June 2017 Pediatric News, Mary Lauren Neel, MD, a fellow in neonatal perinatal medicine at Vanderbilt University, Nashville, Tenn., has found that children of parents who were permissive “were more likely to have atypical sensory adaptation at age 1 year and increased behavior difficulties at 2 years” than were those whose parents had an authoritative or authoritarian style (“Parenting style linked to atypical toddler sensory adaption” by Tara Haelle). In this unpublished study, children of permissive parents were 2.6 times more likely to exhibit atypical sensory adaptation, were more than twice as likely to have internalizing behavior at age 2 years, and were three times more likely to have externalizing behaviors by age 3 years.

An important question is whether permissive parenting is a problem that warrants our concern as pediatricians. We always are on alert for the red flags of abusive parenting, and, obviously, failure to intervene in cases of abuse can be disastrous. However, if we can believe the results from the studies that have already been completed, it seems pretty clear that permissive parenting can spawn behavioral problems, sleep problems, and the myriad of downstream effects that can result from sleep deprivation. And I haven’t even touched on the possible relationship between permissive parenting and the obesity epidemic.

If we still consider ourselves the preventive medicine specialists, shouldn’t pediatricians and family medicine physicians be more invested in minimizing the unhealthy consequences of permissive parenting? If we can agree on a firm “Yes!” the next question is, When and how should we address the issue?

A more nuanced discussion can be the germ of a future Letters from Maine, but the short answer is that we need to sound as nonjudgmental as possible as we present our case for limit setting. We need to start early before the die is cast, and we should be better about publicizing our supporting evidence. Setting a bedtime can begin in the first 6 months of life. Helping parents learn to say, “No, we aren’t going to feed you only what you like to eat!” can start as an infant makes what can be an unsettling transition to solid food.

Our message needs to be that not only is it okay to say “No!” but that, when done correctly, it is the healthy thing to do.

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.”

 

Do you believe that children whose parents can make and enforce rules are more likely to thrive than those children whose parents are hesitant to set limits? If you don’t see limit setting as a critical function of parenting, you and I are not only marching to different drummers, we aren’t even in the same parade.

You may be tempted to write me off as just another old school ranter because I believe that limit setting is one of the cornerstones of parenting. But, let’s look at some of the evidence. There are several studies demonstrating that children whose parents set bedtimes get more sleep. One recent survey also found that teenagers who got more sleep as a result of enforced bedtimes functioned better in school (Sleep. 2011 Jun 1;34[6]:797-800).

©iStockphoto

As reported in the June 2017 Pediatric News, Mary Lauren Neel, MD, a fellow in neonatal perinatal medicine at Vanderbilt University, Nashville, Tenn., has found that children of parents who were permissive “were more likely to have atypical sensory adaptation at age 1 year and increased behavior difficulties at 2 years” than were those whose parents had an authoritative or authoritarian style (“Parenting style linked to atypical toddler sensory adaption” by Tara Haelle). In this unpublished study, children of permissive parents were 2.6 times more likely to exhibit atypical sensory adaptation, were more than twice as likely to have internalizing behavior at age 2 years, and were three times more likely to have externalizing behaviors by age 3 years.

An important question is whether permissive parenting is a problem that warrants our concern as pediatricians. We always are on alert for the red flags of abusive parenting, and, obviously, failure to intervene in cases of abuse can be disastrous. However, if we can believe the results from the studies that have already been completed, it seems pretty clear that permissive parenting can spawn behavioral problems, sleep problems, and the myriad of downstream effects that can result from sleep deprivation. And I haven’t even touched on the possible relationship between permissive parenting and the obesity epidemic.

If we still consider ourselves the preventive medicine specialists, shouldn’t pediatricians and family medicine physicians be more invested in minimizing the unhealthy consequences of permissive parenting? If we can agree on a firm “Yes!” the next question is, When and how should we address the issue?

A more nuanced discussion can be the germ of a future Letters from Maine, but the short answer is that we need to sound as nonjudgmental as possible as we present our case for limit setting. We need to start early before the die is cast, and we should be better about publicizing our supporting evidence. Setting a bedtime can begin in the first 6 months of life. Helping parents learn to say, “No, we aren’t going to feed you only what you like to eat!” can start as an infant makes what can be an unsettling transition to solid food.

Our message needs to be that not only is it okay to say “No!” but that, when done correctly, it is the healthy thing to do.

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 are a busy primary care physician, wouldn’t you like to get some quick confirmation that your patient with a fever and runny nose has a viral upper respiratory infection? If there were a test or a simple physical finding that could give you the answer while the patient was still in the office, you could dispense a quick dose of reassurance and send him or her on their way. It would probably help you inch a bit closer to relieving the congestion in your waiting room.

I am sure most of you realize that relying on the patient’s temperature or the color of his or her nasal mucus is not going to give you that reliable and swift answer you would like. There have been rapid diagnostic tests for influenza on the market for several years, but I have not been aware of a similar test for rhinovirus. But I recently came across a study that offers some hope that such a test might become a reality in the future (EBioMedicine. 2017 Mar;17:172-81). In the study, researchers at Duke University and elsewhere identified a group of proteins in mucus that can confirm – with 86% accuracy – that the patient is infected with a cold or flu virus. They anticipate that this discovery could be adapted into a rapid test that could be performed in the doctor’s office.

Sounds pretty neat, doesn’t it? You could have an assistant swab all patients with a runny nose just after they check in with the receptionist. If you were really stressed and willing to risk damaging your reputation, you could simply send those positive for rhinovirus home with nothing more than a cursory touch with a stethoscope and a “call me” if they get sicker.

However, I am sure that most of you would do a careful exam and spend a few minutes on a slightly more detailed discussion of what worrisome symptoms the parents should be watching for. But let’s be honest. Isn’t it likely that knowing that the patient has a rhinovirus infection might derail your diagnostic process short of a full consideration? Isn’t it tempting to say to yourself, “He only has a viral URI, and I even know the name of the virus. My job is done.”

Although the odds are that the virus is causing all your patient’s symptoms, there is always the chance that he or she is harboring a bacterial coinfection. Or, that what appears to be “only” a virus is actually an early step in the deadly spiral of the first episode of diabetic ketoacidosis.

This quandary is another example of the paradox in which more information can make your job as a diagnostician more difficult. Does your patient’s positive rapid strep test mean that strep is the primary cause of your patient’s fever and sore throat? Couldn’t he or she just be a carrier? Should a positive test that confirms your clinical impression put an end to your evaluation of the patient?

You could answer that you don’t have the time to go looking for zebra stripes hidden on the underbelly of every equine that gallops into your exam room. Of course you don’t. But, you are obligated to keep your mind open to the possibility that a lab test promising to make your job easy may not be telling you the whole story.
 

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

 

If you are a busy primary care physician, wouldn’t you like to get some quick confirmation that your patient with a fever and runny nose has a viral upper respiratory infection? If there were a test or a simple physical finding that could give you the answer while the patient was still in the office, you could dispense a quick dose of reassurance and send him or her on their way. It would probably help you inch a bit closer to relieving the congestion in your waiting room.

I am sure most of you realize that relying on the patient’s temperature or the color of his or her nasal mucus is not going to give you that reliable and swift answer you would like. There have been rapid diagnostic tests for influenza on the market for several years, but I have not been aware of a similar test for rhinovirus. But I recently came across a study that offers some hope that such a test might become a reality in the future (EBioMedicine. 2017 Mar;17:172-81). In the study, researchers at Duke University and elsewhere identified a group of proteins in mucus that can confirm – with 86% accuracy – that the patient is infected with a cold or flu virus. They anticipate that this discovery could be adapted into a rapid test that could be performed in the doctor’s office.

Sounds pretty neat, doesn’t it? You could have an assistant swab all patients with a runny nose just after they check in with the receptionist. If you were really stressed and willing to risk damaging your reputation, you could simply send those positive for rhinovirus home with nothing more than a cursory touch with a stethoscope and a “call me” if they get sicker.

However, I am sure that most of you would do a careful exam and spend a few minutes on a slightly more detailed discussion of what worrisome symptoms the parents should be watching for. But let’s be honest. Isn’t it likely that knowing that the patient has a rhinovirus infection might derail your diagnostic process short of a full consideration? Isn’t it tempting to say to yourself, “He only has a viral URI, and I even know the name of the virus. My job is done.”

Although the odds are that the virus is causing all your patient’s symptoms, there is always the chance that he or she is harboring a bacterial coinfection. Or, that what appears to be “only” a virus is actually an early step in the deadly spiral of the first episode of diabetic ketoacidosis.

This quandary is another example of the paradox in which more information can make your job as a diagnostician more difficult. Does your patient’s positive rapid strep test mean that strep is the primary cause of your patient’s fever and sore throat? Couldn’t he or she just be a carrier? Should a positive test that confirms your clinical impression put an end to your evaluation of the patient?

You could answer that you don’t have the time to go looking for zebra stripes hidden on the underbelly of every equine that gallops into your exam room. Of course you don’t. But, you are obligated to keep your mind open to the possibility that a lab test promising to make your job easy may not be telling you the whole story.
 

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

 

If you are a busy primary care physician, wouldn’t you like to get some quick confirmation that your patient with a fever and runny nose has a viral upper respiratory infection? If there were a test or a simple physical finding that could give you the answer while the patient was still in the office, you could dispense a quick dose of reassurance and send him or her on their way. It would probably help you inch a bit closer to relieving the congestion in your waiting room.

I am sure most of you realize that relying on the patient’s temperature or the color of his or her nasal mucus is not going to give you that reliable and swift answer you would like. There have been rapid diagnostic tests for influenza on the market for several years, but I have not been aware of a similar test for rhinovirus. But I recently came across a study that offers some hope that such a test might become a reality in the future (EBioMedicine. 2017 Mar;17:172-81). In the study, researchers at Duke University and elsewhere identified a group of proteins in mucus that can confirm – with 86% accuracy – that the patient is infected with a cold or flu virus. They anticipate that this discovery could be adapted into a rapid test that could be performed in the doctor’s office.

Sounds pretty neat, doesn’t it? You could have an assistant swab all patients with a runny nose just after they check in with the receptionist. If you were really stressed and willing to risk damaging your reputation, you could simply send those positive for rhinovirus home with nothing more than a cursory touch with a stethoscope and a “call me” if they get sicker.

However, I am sure that most of you would do a careful exam and spend a few minutes on a slightly more detailed discussion of what worrisome symptoms the parents should be watching for. But let’s be honest. Isn’t it likely that knowing that the patient has a rhinovirus infection might derail your diagnostic process short of a full consideration? Isn’t it tempting to say to yourself, “He only has a viral URI, and I even know the name of the virus. My job is done.”

Although the odds are that the virus is causing all your patient’s symptoms, there is always the chance that he or she is harboring a bacterial coinfection. Or, that what appears to be “only” a virus is actually an early step in the deadly spiral of the first episode of diabetic ketoacidosis.

This quandary is another example of the paradox in which more information can make your job as a diagnostician more difficult. Does your patient’s positive rapid strep test mean that strep is the primary cause of your patient’s fever and sore throat? Couldn’t he or she just be a carrier? Should a positive test that confirms your clinical impression put an end to your evaluation of the patient?

You could answer that you don’t have the time to go looking for zebra stripes hidden on the underbelly of every equine that gallops into your exam room. Of course you don’t. But, you are obligated to keep your mind open to the possibility that a lab test promising to make your job easy may not be telling you the whole story.
 

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].

 

When the first issue of Pediatric News was published 50 years ago, I was starting the second half of my first year in medical school. Over the ensuing 50 years, I have lived through and witnessed some dramatic changes in pediatrics. Here are just a few of the transitions that I’ve observed and Pediatric News has covered:

The birth of interventional neonatology

When I was an intern at Duke University Medical Center in Durham, N.C., a paper appeared in the New England Journal of Medicine describing the use of a simple continuous positive pressure apparatus for the treatment of respiratory distress syndrome entitled, “Treatment of idiopathic respiratory-distress syndrome with continuous positive airway pressure,” (1971 Jun 17;284[24]:1333-40). After seeing the paper, George Brumley, MD, the head of nursery, immediately had the hospital engineers build us our own setup, and we became part of what could arguably be called the revolution that turned neonatology into an interventional specialty.

Courtesy Dr. William G. Wilkoff

Prior to that, we offered preemies a warm environment with increased ambient oxygen and watched. We did exchange transfusions for Rh disease and hyperbilirubinemia, but the introduction of RhoGAM and phototherapy gradually made that procedure a rarity. I performed my last exchange transfusion in the mid-1980s. The strong and the lucky neonates survived. Survival of a baby smaller than 1,500 g was almost unheard of. The ability to effectively treat babies compromised by respiratory distress syndrome (then still referred to as hyaline membrane disease) using continuous positive airway pressure (CPAP) opened the door for other lifesaving interventions for babies who had problems with all the other organ systems.

From meningitis to mental health

Although it came gradually, one of the most significant changes over the last 50 years has been the shift in the mix of pathology presenting to the general pediatrician. In the 1970s and 1980s, the threat of invasive bacterial disease, usually from Haemophilus influenzae, was always hanging over us. It was not unusual for a single community pediatrician to see four or five cases of meningitis in a year. The introduction of effective vaccines and more potent antibiotics lessened the threat of serious bacterial infection, and in its place came a flood of mental health complaints, including anxiety (25% prevalence among 13- to 18-year-olds, depression (13% prevalence among 12- to 17-year-olds) and attention-deficit/hyperactivity disorder (ADHD) (9% prevalence among 13- to 18-year-olds). The result is the impression that, at times, being a general pediatrician today feels like being a more than part-time psychiatrist/psychologist.

Mental retardation and autism

In the 1970s and 1980s, the diagnosis of autism was usually reserved for children with serious communication difficulties. Many physicians and the lay public expected that a child who was diagnosed with autism would have no speech at all. The prevalence of the condition in the last quarter of the century was felt to be about 1 in 2,000.

The more common diagnosis during that period was mental retardation. However, as the result of insensitive stereotyping, “mental retardation” has become an offensive term and has vanished from the pediatric lexicon.

Autism, however, has flourished, and a recent estimate cited by the CDC pegs its prevalence at 1 in 68. Based on my observations, I expect that much, if not most, of this increase is the result of expanded diagnostic criteria and relabeling.

Chicken scratches to mouse clicks

In keeping with a long tradition in medicine, my office notes when I began in practice were unreadable by anyone except a very few my long-term coworkers. My scribbles were brief and often included sketches of wounds and body parts. Their primary purpose was to remind me what had transpired at that office visit and to record the biometrics. Unfortunately, as the cloud of malpractice crept over the landscape, with it came the nonsensical mantra, “if it wasn’t documented, it didn’t happen.”

With the introduction of computers, medical records became inflated and often inaccurate, documents to be used primarily for data collection and risk management. The physician now is tasked with being the data entry clerk who must keep her eyes on the computer screen at the expense of a meaningful interaction with the patient. Sadly, the physician-unfriendliness of electronic medical records has driven many older and experienced pediatricians into premature retirement, robbing general pediatrics of their accumulated wisdom.

A part-time job

In 1975, there were 22,730 practicing pediatricians, of whom 23% were women. In 2011, there were 80,992 pediatricians, of whom 56.6% were women. The percentage of women practicing pediatrics continues to climb, with the most recent figure being 58%. From the patient perspective, this shift in gender dominance has been well received.

 

At the same time, there has been a trend toward more pediatricians of both genders pursuing part-time employment. The model of the physician being the owner/operator of a medical practice that was flourishing when I began in practice has been replaced by one in which the physician is an employee of a much larger entity, which is pressured from all sides to cut costs. To make matters worse, the Medical Home model that currently is in vogue is proving to be a more expensive vehicle for delivering health care. The patient now is asked to view his physician as the director of a team and may see him or her only infrequently, at the expense of the therapeutic benefits of familiarity.

When I was in medical school, the tuition was around $2,500/year, and I graduated with a debt of about $3,000 – with an interest rate so low that I was in no rush to pay it off. Now a student entering medical school can expect to pay around $60,000/year – an amount that has far outstripped inflation.

These realities combine to create a potentially unsustainable economic climate for pediatricians. I have had a wonderful 50 years being a pediatrician. But I can’t promise the same level of enjoyment to the next generation of pediatricians, unless someone can figure how to cut the expense of medical school and/or make part-time employment fit into a health care delivery system that must contain costs to survive.
 

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].

 

When the first issue of Pediatric News was published 50 years ago, I was starting the second half of my first year in medical school. Over the ensuing 50 years, I have lived through and witnessed some dramatic changes in pediatrics. Here are just a few of the transitions that I’ve observed and Pediatric News has covered:

The birth of interventional neonatology

When I was an intern at Duke University Medical Center in Durham, N.C., a paper appeared in the New England Journal of Medicine describing the use of a simple continuous positive pressure apparatus for the treatment of respiratory distress syndrome entitled, “Treatment of idiopathic respiratory-distress syndrome with continuous positive airway pressure,” (1971 Jun 17;284[24]:1333-40). After seeing the paper, George Brumley, MD, the head of nursery, immediately had the hospital engineers build us our own setup, and we became part of what could arguably be called the revolution that turned neonatology into an interventional specialty.

Courtesy Dr. William G. Wilkoff

Prior to that, we offered preemies a warm environment with increased ambient oxygen and watched. We did exchange transfusions for Rh disease and hyperbilirubinemia, but the introduction of RhoGAM and phototherapy gradually made that procedure a rarity. I performed my last exchange transfusion in the mid-1980s. The strong and the lucky neonates survived. Survival of a baby smaller than 1,500 g was almost unheard of. The ability to effectively treat babies compromised by respiratory distress syndrome (then still referred to as hyaline membrane disease) using continuous positive airway pressure (CPAP) opened the door for other lifesaving interventions for babies who had problems with all the other organ systems.

From meningitis to mental health

Although it came gradually, one of the most significant changes over the last 50 years has been the shift in the mix of pathology presenting to the general pediatrician. In the 1970s and 1980s, the threat of invasive bacterial disease, usually from Haemophilus influenzae, was always hanging over us. It was not unusual for a single community pediatrician to see four or five cases of meningitis in a year. The introduction of effective vaccines and more potent antibiotics lessened the threat of serious bacterial infection, and in its place came a flood of mental health complaints, including anxiety (25% prevalence among 13- to 18-year-olds, depression (13% prevalence among 12- to 17-year-olds) and attention-deficit/hyperactivity disorder (ADHD) (9% prevalence among 13- to 18-year-olds). The result is the impression that, at times, being a general pediatrician today feels like being a more than part-time psychiatrist/psychologist.

Mental retardation and autism

In the 1970s and 1980s, the diagnosis of autism was usually reserved for children with serious communication difficulties. Many physicians and the lay public expected that a child who was diagnosed with autism would have no speech at all. The prevalence of the condition in the last quarter of the century was felt to be about 1 in 2,000.

The more common diagnosis during that period was mental retardation. However, as the result of insensitive stereotyping, “mental retardation” has become an offensive term and has vanished from the pediatric lexicon.

Autism, however, has flourished, and a recent estimate cited by the CDC pegs its prevalence at 1 in 68. Based on my observations, I expect that much, if not most, of this increase is the result of expanded diagnostic criteria and relabeling.

Chicken scratches to mouse clicks

In keeping with a long tradition in medicine, my office notes when I began in practice were unreadable by anyone except a very few my long-term coworkers. My scribbles were brief and often included sketches of wounds and body parts. Their primary purpose was to remind me what had transpired at that office visit and to record the biometrics. Unfortunately, as the cloud of malpractice crept over the landscape, with it came the nonsensical mantra, “if it wasn’t documented, it didn’t happen.”

With the introduction of computers, medical records became inflated and often inaccurate, documents to be used primarily for data collection and risk management. The physician now is tasked with being the data entry clerk who must keep her eyes on the computer screen at the expense of a meaningful interaction with the patient. Sadly, the physician-unfriendliness of electronic medical records has driven many older and experienced pediatricians into premature retirement, robbing general pediatrics of their accumulated wisdom.

A part-time job

In 1975, there were 22,730 practicing pediatricians, of whom 23% were women. In 2011, there were 80,992 pediatricians, of whom 56.6% were women. The percentage of women practicing pediatrics continues to climb, with the most recent figure being 58%. From the patient perspective, this shift in gender dominance has been well received.

 

At the same time, there has been a trend toward more pediatricians of both genders pursuing part-time employment. The model of the physician being the owner/operator of a medical practice that was flourishing when I began in practice has been replaced by one in which the physician is an employee of a much larger entity, which is pressured from all sides to cut costs. To make matters worse, the Medical Home model that currently is in vogue is proving to be a more expensive vehicle for delivering health care. The patient now is asked to view his physician as the director of a team and may see him or her only infrequently, at the expense of the therapeutic benefits of familiarity.

When I was in medical school, the tuition was around $2,500/year, and I graduated with a debt of about $3,000 – with an interest rate so low that I was in no rush to pay it off. Now a student entering medical school can expect to pay around $60,000/year – an amount that has far outstripped inflation.

These realities combine to create a potentially unsustainable economic climate for pediatricians. I have had a wonderful 50 years being a pediatrician. But I can’t promise the same level of enjoyment to the next generation of pediatricians, unless someone can figure how to cut the expense of medical school and/or make part-time employment fit into a health care delivery system that must contain costs to survive.
 

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].

 

When the first issue of Pediatric News was published 50 years ago, I was starting the second half of my first year in medical school. Over the ensuing 50 years, I have lived through and witnessed some dramatic changes in pediatrics. Here are just a few of the transitions that I’ve observed and Pediatric News has covered:

The birth of interventional neonatology

When I was an intern at Duke University Medical Center in Durham, N.C., a paper appeared in the New England Journal of Medicine describing the use of a simple continuous positive pressure apparatus for the treatment of respiratory distress syndrome entitled, “Treatment of idiopathic respiratory-distress syndrome with continuous positive airway pressure,” (1971 Jun 17;284[24]:1333-40). After seeing the paper, George Brumley, MD, the head of nursery, immediately had the hospital engineers build us our own setup, and we became part of what could arguably be called the revolution that turned neonatology into an interventional specialty.

Courtesy Dr. William G. Wilkoff

Prior to that, we offered preemies a warm environment with increased ambient oxygen and watched. We did exchange transfusions for Rh disease and hyperbilirubinemia, but the introduction of RhoGAM and phototherapy gradually made that procedure a rarity. I performed my last exchange transfusion in the mid-1980s. The strong and the lucky neonates survived. Survival of a baby smaller than 1,500 g was almost unheard of. The ability to effectively treat babies compromised by respiratory distress syndrome (then still referred to as hyaline membrane disease) using continuous positive airway pressure (CPAP) opened the door for other lifesaving interventions for babies who had problems with all the other organ systems.

From meningitis to mental health

Although it came gradually, one of the most significant changes over the last 50 years has been the shift in the mix of pathology presenting to the general pediatrician. In the 1970s and 1980s, the threat of invasive bacterial disease, usually from Haemophilus influenzae, was always hanging over us. It was not unusual for a single community pediatrician to see four or five cases of meningitis in a year. The introduction of effective vaccines and more potent antibiotics lessened the threat of serious bacterial infection, and in its place came a flood of mental health complaints, including anxiety (25% prevalence among 13- to 18-year-olds, depression (13% prevalence among 12- to 17-year-olds) and attention-deficit/hyperactivity disorder (ADHD) (9% prevalence among 13- to 18-year-olds). The result is the impression that, at times, being a general pediatrician today feels like being a more than part-time psychiatrist/psychologist.

Mental retardation and autism

In the 1970s and 1980s, the diagnosis of autism was usually reserved for children with serious communication difficulties. Many physicians and the lay public expected that a child who was diagnosed with autism would have no speech at all. The prevalence of the condition in the last quarter of the century was felt to be about 1 in 2,000.

The more common diagnosis during that period was mental retardation. However, as the result of insensitive stereotyping, “mental retardation” has become an offensive term and has vanished from the pediatric lexicon.

Autism, however, has flourished, and a recent estimate cited by the CDC pegs its prevalence at 1 in 68. Based on my observations, I expect that much, if not most, of this increase is the result of expanded diagnostic criteria and relabeling.

Chicken scratches to mouse clicks

In keeping with a long tradition in medicine, my office notes when I began in practice were unreadable by anyone except a very few my long-term coworkers. My scribbles were brief and often included sketches of wounds and body parts. Their primary purpose was to remind me what had transpired at that office visit and to record the biometrics. Unfortunately, as the cloud of malpractice crept over the landscape, with it came the nonsensical mantra, “if it wasn’t documented, it didn’t happen.”

With the introduction of computers, medical records became inflated and often inaccurate, documents to be used primarily for data collection and risk management. The physician now is tasked with being the data entry clerk who must keep her eyes on the computer screen at the expense of a meaningful interaction with the patient. Sadly, the physician-unfriendliness of electronic medical records has driven many older and experienced pediatricians into premature retirement, robbing general pediatrics of their accumulated wisdom.

A part-time job

In 1975, there were 22,730 practicing pediatricians, of whom 23% were women. In 2011, there were 80,992 pediatricians, of whom 56.6% were women. The percentage of women practicing pediatrics continues to climb, with the most recent figure being 58%. From the patient perspective, this shift in gender dominance has been well received.

 

At the same time, there has been a trend toward more pediatricians of both genders pursuing part-time employment. The model of the physician being the owner/operator of a medical practice that was flourishing when I began in practice has been replaced by one in which the physician is an employee of a much larger entity, which is pressured from all sides to cut costs. To make matters worse, the Medical Home model that currently is in vogue is proving to be a more expensive vehicle for delivering health care. The patient now is asked to view his physician as the director of a team and may see him or her only infrequently, at the expense of the therapeutic benefits of familiarity.

When I was in medical school, the tuition was around $2,500/year, and I graduated with a debt of about $3,000 – with an interest rate so low that I was in no rush to pay it off. Now a student entering medical school can expect to pay around $60,000/year – an amount that has far outstripped inflation.

These realities combine to create a potentially unsustainable economic climate for pediatricians. I have had a wonderful 50 years being a pediatrician. But I can’t promise the same level of enjoyment to the next generation of pediatricians, unless someone can figure how to cut the expense of medical school and/or make part-time employment fit into a health care delivery system that must contain costs to survive.
 

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].