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Don’t ask
You walk into an examining room and discover a 3-year-old in his underpants wearing a fireman’s hat and what must be his older sister’s rubber boots. You have to ask: “Are you going to be a firefighter when you grow up?” If he is a sensitive kid he will resist answering, “What do you think, Dr. Obvious?” and instead he politely replies, “Yes, and an EMT [emergency medical technician] too.”
Adults, even ones who have devoted their professional lives to the care of children, can’t seem to stifle the urge ask every young person they meet about his or her career plans. It is a strange sort of obsession, and may simply reflect the fact that most adults are at a loss for conversation starters when it comes to talking with young people. Children don’t seem to have much concern about the weather. And most of them don’t have opinions about the current political situation. They don’t have stories about their grandchildren they would love to bore you with. You could ask if the child has a pet, but that may be picking the scab of an unresolved family issue.
Most adults realize that their career plans prior to adolescence have no relationship to their present situation. Thinking back on this disconnect in their own lives may provide them with a good chuckle. But they also may hope to store away the child’s naive answer as ammunition for a future embarrassing challenge. “Do you remember that you once told me you were going to be a forest ranger?”
It may be that the child’s answer will give the adults an opportunity to share their “wisdom” based on their own career decisions. How lucky for the child who has stumbled on an unsolicited life coach.
For the most part, these interrogations about career planning are just idle banter. But as children get older, reality begins shining its harsh light on choices and decisions. What was once a seemingly harmless question about the distant future may no longer be so innocuous. I try to sound apologetic when I say to high school juniors and seniors, “I’m sure everyone is asking you, but what about college?” However, after reading a story in The Wall Street Journal, I now wonder whether I should be skipping the apology and just simply not raising the subject of college (“What’s Worse Than Waiting to Hear From Colleges? Getting Interrogated About It,” by Sue Shellenbarger, March 8, 2017).
In communities where most high school graduates have been on a college track since middle school, tension and anxiety hangs over the older adolescents like a cloud that darkens as application deadlines herald the long and painful wait for acceptance/rejection letters and emails. High school seniors are tired of thinking about the process and certainly don’t want to talk about. They consider questions about their future an invasion of their privacy. Redbubble, an online marketplace based in Australia, is seeing rising sales of T-shirts that read “Don’t ask me about college. Thanks.”
The unwelcome interrogations don’t stop with college acceptance. Adults want to know, “Have you chosen a major?” And as college graduation nears they can’t resist asking, “Do you have any job offers?”
Most adolescents and many 20-somethings don’t seem to have a career goal. It may be that they are afraid that the process of setting a goal will make them more vulnerable to failure. It also may be that revealing, “I’ve always wanted to be a ...” will label them as being a bit childish and weird.
Where does all this adolescent discomfort with the near future leave us pediatricians? The complete evaluation of a high school–age patient should include a question or questions about how our patient is weathering the college and career planning process. The challenge is how to present those questions in a manner that makes it clear that we aren’t just another one of those career-obsessed nosy adults.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
You walk into an examining room and discover a 3-year-old in his underpants wearing a fireman’s hat and what must be his older sister’s rubber boots. You have to ask: “Are you going to be a firefighter when you grow up?” If he is a sensitive kid he will resist answering, “What do you think, Dr. Obvious?” and instead he politely replies, “Yes, and an EMT [emergency medical technician] too.”
Adults, even ones who have devoted their professional lives to the care of children, can’t seem to stifle the urge ask every young person they meet about his or her career plans. It is a strange sort of obsession, and may simply reflect the fact that most adults are at a loss for conversation starters when it comes to talking with young people. Children don’t seem to have much concern about the weather. And most of them don’t have opinions about the current political situation. They don’t have stories about their grandchildren they would love to bore you with. You could ask if the child has a pet, but that may be picking the scab of an unresolved family issue.
Most adults realize that their career plans prior to adolescence have no relationship to their present situation. Thinking back on this disconnect in their own lives may provide them with a good chuckle. But they also may hope to store away the child’s naive answer as ammunition for a future embarrassing challenge. “Do you remember that you once told me you were going to be a forest ranger?”
It may be that the child’s answer will give the adults an opportunity to share their “wisdom” based on their own career decisions. How lucky for the child who has stumbled on an unsolicited life coach.
For the most part, these interrogations about career planning are just idle banter. But as children get older, reality begins shining its harsh light on choices and decisions. What was once a seemingly harmless question about the distant future may no longer be so innocuous. I try to sound apologetic when I say to high school juniors and seniors, “I’m sure everyone is asking you, but what about college?” However, after reading a story in The Wall Street Journal, I now wonder whether I should be skipping the apology and just simply not raising the subject of college (“What’s Worse Than Waiting to Hear From Colleges? Getting Interrogated About It,” by Sue Shellenbarger, March 8, 2017).
In communities where most high school graduates have been on a college track since middle school, tension and anxiety hangs over the older adolescents like a cloud that darkens as application deadlines herald the long and painful wait for acceptance/rejection letters and emails. High school seniors are tired of thinking about the process and certainly don’t want to talk about. They consider questions about their future an invasion of their privacy. Redbubble, an online marketplace based in Australia, is seeing rising sales of T-shirts that read “Don’t ask me about college. Thanks.”
The unwelcome interrogations don’t stop with college acceptance. Adults want to know, “Have you chosen a major?” And as college graduation nears they can’t resist asking, “Do you have any job offers?”
Most adolescents and many 20-somethings don’t seem to have a career goal. It may be that they are afraid that the process of setting a goal will make them more vulnerable to failure. It also may be that revealing, “I’ve always wanted to be a ...” will label them as being a bit childish and weird.
Where does all this adolescent discomfort with the near future leave us pediatricians? The complete evaluation of a high school–age patient should include a question or questions about how our patient is weathering the college and career planning process. The challenge is how to present those questions in a manner that makes it clear that we aren’t just another one of those career-obsessed nosy adults.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
You walk into an examining room and discover a 3-year-old in his underpants wearing a fireman’s hat and what must be his older sister’s rubber boots. You have to ask: “Are you going to be a firefighter when you grow up?” If he is a sensitive kid he will resist answering, “What do you think, Dr. Obvious?” and instead he politely replies, “Yes, and an EMT [emergency medical technician] too.”
Adults, even ones who have devoted their professional lives to the care of children, can’t seem to stifle the urge ask every young person they meet about his or her career plans. It is a strange sort of obsession, and may simply reflect the fact that most adults are at a loss for conversation starters when it comes to talking with young people. Children don’t seem to have much concern about the weather. And most of them don’t have opinions about the current political situation. They don’t have stories about their grandchildren they would love to bore you with. You could ask if the child has a pet, but that may be picking the scab of an unresolved family issue.
Most adults realize that their career plans prior to adolescence have no relationship to their present situation. Thinking back on this disconnect in their own lives may provide them with a good chuckle. But they also may hope to store away the child’s naive answer as ammunition for a future embarrassing challenge. “Do you remember that you once told me you were going to be a forest ranger?”
It may be that the child’s answer will give the adults an opportunity to share their “wisdom” based on their own career decisions. How lucky for the child who has stumbled on an unsolicited life coach.
For the most part, these interrogations about career planning are just idle banter. But as children get older, reality begins shining its harsh light on choices and decisions. What was once a seemingly harmless question about the distant future may no longer be so innocuous. I try to sound apologetic when I say to high school juniors and seniors, “I’m sure everyone is asking you, but what about college?” However, after reading a story in The Wall Street Journal, I now wonder whether I should be skipping the apology and just simply not raising the subject of college (“What’s Worse Than Waiting to Hear From Colleges? Getting Interrogated About It,” by Sue Shellenbarger, March 8, 2017).
In communities where most high school graduates have been on a college track since middle school, tension and anxiety hangs over the older adolescents like a cloud that darkens as application deadlines herald the long and painful wait for acceptance/rejection letters and emails. High school seniors are tired of thinking about the process and certainly don’t want to talk about. They consider questions about their future an invasion of their privacy. Redbubble, an online marketplace based in Australia, is seeing rising sales of T-shirts that read “Don’t ask me about college. Thanks.”
The unwelcome interrogations don’t stop with college acceptance. Adults want to know, “Have you chosen a major?” And as college graduation nears they can’t resist asking, “Do you have any job offers?”
Most adolescents and many 20-somethings don’t seem to have a career goal. It may be that they are afraid that the process of setting a goal will make them more vulnerable to failure. It also may be that revealing, “I’ve always wanted to be a ...” will label them as being a bit childish and weird.
Where does all this adolescent discomfort with the near future leave us pediatricians? The complete evaluation of a high school–age patient should include a question or questions about how our patient is weathering the college and career planning process. The challenge is how to present those questions in a manner that makes it clear that we aren’t just another one of those career-obsessed nosy adults.
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].
Pardon the interruption?
Your first patient of the afternoon is a 9-year-old boy who moved to town several months ago. Mercifully, the second patient of the afternoon has canceled, giving you a few more minutes to get acquainted with this young man whose chief complaint is listed as “behavior problem.” You learn quickly that this family has relocated from a town just 20 miles away because they are seeking a school that is a “better fit” for your new patient.
Due to some miscommunications, the child’s old records have not arrived at your office. The mother says that her son is not taking any medication, and she isn’t sure if he has ever been given a diagnosis. You learn that he likes to argue and is prone to violent temper tantrums. Your initial brief exam does not suggest any cognitive deficits, but he exudes an aura of anger and discontent. You tell his mother that you will be glad to try to help, but you will need his old records and another longer visit before you can make any recommendations.
Two days later you see a fourth-grader you have known since birth. He rarely comes to the office with problems, but you understand that he is a good student, a competent athlete, and socially engaged. His chief complaint for this visit is “hair loss,” but you soon discover that he has trichotillomania and has recently begun having nightmares and experiencing enuresis. All of these symptoms began a month ago with arrival of a new student in his class whose violent outbursts have become increasingly more physical. I have borrowed this child’s scenario from a similar case study in a recent supplement to the Journal of Developmental & Behavioral Pediatrics titled, “Behavioral Changes Associated with a Disruptive New Student in the Classroom,” (J Dev Behav Pediatr. Feb/Mar 2017. doi: 10.1097/DBP.0000000000000175).
The afternoon following your visit with the hair-pulling fourth-grader, you receive the new patient’s records for which you have been waiting. The circle is completed as you read that this is his third school in 18 months, and the reports of his behavior make it clear that your two patients are classmates. This scenario of coincidence could easily have occurred in a small town like Brunswick, Maine, where I practiced, but I have manufactured it to raise several questions about social priorities and professional ethics.
Forty years ago, institutions housing individuals with Down syndrome started closing and the process of integrating children with a variety of cognitive and physical disabilities into traditional classrooms began. To the surprise of some people, this mainstreaming has generally gone well. Unfortunately, funding hasn’t always caught up with the demand for services. For the most part, children readily accept their challenged classmates who look, move, and sound different. The flailing and grunting of the child with spastic choreoathetosis using a wheelchair isn’t considered an interruption because “that’s just the way she is.”
However, there seems to be an invisible line that separates those children who seem to be incapable of stopping their potentially disruptive behavior from those children we assume “ought to know better” or whose parents we believe have failed at instilling even the most basic discipline. You can certainly question the validity of those assumptions. But it is clear that your new patient’s disruptive behavior is interfering with his classmates’ education, and in some cases threatening their health. Your patient with trichotillomania is probably the canary in a very unsettled mine.
Your dilemma as the pediatrician for these two boys is the same we face as a society. How do you effectively advocate for a positive educational atmosphere for children with a variety of special needs, some of which seem to be in direct conflict? You can ask the school system to be patient as you help the disruptive child get connected with the services he needs. But you know that could take several months at a minimum. Meanwhile your hair-pulling patient and his classmates are losing valuable educational opportunities by the day.
I don’t have the answer, but I suspect that somehow it is going to come down to affordability. Counseling, psychiatrists, and one on one classroom aids don’t come cheap, nor does the tuition for a special school in another school district. But we can’t discount the value of an education free of disruption.
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]
Your first patient of the afternoon is a 9-year-old boy who moved to town several months ago. Mercifully, the second patient of the afternoon has canceled, giving you a few more minutes to get acquainted with this young man whose chief complaint is listed as “behavior problem.” You learn quickly that this family has relocated from a town just 20 miles away because they are seeking a school that is a “better fit” for your new patient.
Due to some miscommunications, the child’s old records have not arrived at your office. The mother says that her son is not taking any medication, and she isn’t sure if he has ever been given a diagnosis. You learn that he likes to argue and is prone to violent temper tantrums. Your initial brief exam does not suggest any cognitive deficits, but he exudes an aura of anger and discontent. You tell his mother that you will be glad to try to help, but you will need his old records and another longer visit before you can make any recommendations.
Two days later you see a fourth-grader you have known since birth. He rarely comes to the office with problems, but you understand that he is a good student, a competent athlete, and socially engaged. His chief complaint for this visit is “hair loss,” but you soon discover that he has trichotillomania and has recently begun having nightmares and experiencing enuresis. All of these symptoms began a month ago with arrival of a new student in his class whose violent outbursts have become increasingly more physical. I have borrowed this child’s scenario from a similar case study in a recent supplement to the Journal of Developmental & Behavioral Pediatrics titled, “Behavioral Changes Associated with a Disruptive New Student in the Classroom,” (J Dev Behav Pediatr. Feb/Mar 2017. doi: 10.1097/DBP.0000000000000175).
The afternoon following your visit with the hair-pulling fourth-grader, you receive the new patient’s records for which you have been waiting. The circle is completed as you read that this is his third school in 18 months, and the reports of his behavior make it clear that your two patients are classmates. This scenario of coincidence could easily have occurred in a small town like Brunswick, Maine, where I practiced, but I have manufactured it to raise several questions about social priorities and professional ethics.
Forty years ago, institutions housing individuals with Down syndrome started closing and the process of integrating children with a variety of cognitive and physical disabilities into traditional classrooms began. To the surprise of some people, this mainstreaming has generally gone well. Unfortunately, funding hasn’t always caught up with the demand for services. For the most part, children readily accept their challenged classmates who look, move, and sound different. The flailing and grunting of the child with spastic choreoathetosis using a wheelchair isn’t considered an interruption because “that’s just the way she is.”
However, there seems to be an invisible line that separates those children who seem to be incapable of stopping their potentially disruptive behavior from those children we assume “ought to know better” or whose parents we believe have failed at instilling even the most basic discipline. You can certainly question the validity of those assumptions. But it is clear that your new patient’s disruptive behavior is interfering with his classmates’ education, and in some cases threatening their health. Your patient with trichotillomania is probably the canary in a very unsettled mine.
Your dilemma as the pediatrician for these two boys is the same we face as a society. How do you effectively advocate for a positive educational atmosphere for children with a variety of special needs, some of which seem to be in direct conflict? You can ask the school system to be patient as you help the disruptive child get connected with the services he needs. But you know that could take several months at a minimum. Meanwhile your hair-pulling patient and his classmates are losing valuable educational opportunities by the day.
I don’t have the answer, but I suspect that somehow it is going to come down to affordability. Counseling, psychiatrists, and one on one classroom aids don’t come cheap, nor does the tuition for a special school in another school district. But we can’t discount the value of an education free of disruption.
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]
Your first patient of the afternoon is a 9-year-old boy who moved to town several months ago. Mercifully, the second patient of the afternoon has canceled, giving you a few more minutes to get acquainted with this young man whose chief complaint is listed as “behavior problem.” You learn quickly that this family has relocated from a town just 20 miles away because they are seeking a school that is a “better fit” for your new patient.
Due to some miscommunications, the child’s old records have not arrived at your office. The mother says that her son is not taking any medication, and she isn’t sure if he has ever been given a diagnosis. You learn that he likes to argue and is prone to violent temper tantrums. Your initial brief exam does not suggest any cognitive deficits, but he exudes an aura of anger and discontent. You tell his mother that you will be glad to try to help, but you will need his old records and another longer visit before you can make any recommendations.
Two days later you see a fourth-grader you have known since birth. He rarely comes to the office with problems, but you understand that he is a good student, a competent athlete, and socially engaged. His chief complaint for this visit is “hair loss,” but you soon discover that he has trichotillomania and has recently begun having nightmares and experiencing enuresis. All of these symptoms began a month ago with arrival of a new student in his class whose violent outbursts have become increasingly more physical. I have borrowed this child’s scenario from a similar case study in a recent supplement to the Journal of Developmental & Behavioral Pediatrics titled, “Behavioral Changes Associated with a Disruptive New Student in the Classroom,” (J Dev Behav Pediatr. Feb/Mar 2017. doi: 10.1097/DBP.0000000000000175).
The afternoon following your visit with the hair-pulling fourth-grader, you receive the new patient’s records for which you have been waiting. The circle is completed as you read that this is his third school in 18 months, and the reports of his behavior make it clear that your two patients are classmates. This scenario of coincidence could easily have occurred in a small town like Brunswick, Maine, where I practiced, but I have manufactured it to raise several questions about social priorities and professional ethics.
Forty years ago, institutions housing individuals with Down syndrome started closing and the process of integrating children with a variety of cognitive and physical disabilities into traditional classrooms began. To the surprise of some people, this mainstreaming has generally gone well. Unfortunately, funding hasn’t always caught up with the demand for services. For the most part, children readily accept their challenged classmates who look, move, and sound different. The flailing and grunting of the child with spastic choreoathetosis using a wheelchair isn’t considered an interruption because “that’s just the way she is.”
However, there seems to be an invisible line that separates those children who seem to be incapable of stopping their potentially disruptive behavior from those children we assume “ought to know better” or whose parents we believe have failed at instilling even the most basic discipline. You can certainly question the validity of those assumptions. But it is clear that your new patient’s disruptive behavior is interfering with his classmates’ education, and in some cases threatening their health. Your patient with trichotillomania is probably the canary in a very unsettled mine.
Your dilemma as the pediatrician for these two boys is the same we face as a society. How do you effectively advocate for a positive educational atmosphere for children with a variety of special needs, some of which seem to be in direct conflict? You can ask the school system to be patient as you help the disruptive child get connected with the services he needs. But you know that could take several months at a minimum. Meanwhile your hair-pulling patient and his classmates are losing valuable educational opportunities by the day.
I don’t have the answer, but I suspect that somehow it is going to come down to affordability. Counseling, psychiatrists, and one on one classroom aids don’t come cheap, nor does the tuition for a special school in another school district. But we can’t discount the value of an education free of disruption.
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]
Lonely in the middle
Those of us who consider ourselves centrists are feeling pretty lonely right now. It seems everyone else, or at least all of the folks in Washington, have fled to the extreme political poles and left us to search for a patch of middle ground to stand on. It appears that without courageous leadership the silent majority has splintered and gravitated to the tails of what was once a bell-shaped curve.
One issue that might attract support from both sides of the political spectrum emerged from the Nov. 18, 2016, report from the United States Department of Agriculture that listed sweetened drinks as the No. 1 purchase by households participating in SNAP (“Foods Typically Purchased by Supplemental Nutrition Assistance Program (SNAP) Households”). The data reveal that households in this $74 billion program are spending 5% of their food dollars on soft drinks and almost 10% on sweetened beverages – soft drinks, fruit juices, energy drinks, and sweetened teas.
Several states (including Maine), dozens of other municipalities (most notably New York City under Mayor Michael Bloomberg), and a variety of medical groups have asked the USDA to reconsider its guidelines. Arguing that selectively banning certain items would generate too much red tape and be unfair to food stamp recipients, the department has been resistant to change (“In the Shopping Cart of a Food Stamp Household: Lots of Soda,” by Anahad O’Connor, New York Times, Jan. 13, 2017). One has to wonder how much of the department’s hesitancy is a reflection of the millions of dollars the food and beverage industries have invested in lobbying against change.
There are some ultra liberals (or progressives if you prefer) who feel that no one should be deprived of the privilege of buying unhealthy food simply because he or she is poor. At the other end of the spectrum there are conservatives who would prefer to scrap the whole SNAP program because it is a wasteful frill of the welfare state. However, I have to believe that the vast majority of folks on both sides of the political divide believe that feeding the less fortunate is important, but that spending their tax money on junk food and soft drinks is a bad idea.
While we still are learning that the causes of our obesity epidemic are far more complex than we once imagined, I think most people believe that soft drinks and junk food are playing a significant role – even though these same folks may have found it difficult to change their own behavior. According to the New York Times article mentioned above, Kevin Concannon, the USDA undersecretary for food, nutrition, and consumer services, said that instead of restricting food, the USDA has prioritized incentive programs to encourage participants to purchase more nutritious foods. However, a 2014 study of more than 19,000 SNAP recipients by Stanford researchers determined that an incentive program would not affect obesity rates, while banning sugary drinks would “significantly reduce obesity prevalence and type 2 diabetes incidence” (Health Aff. Jun 2014;33[6]:1032-9).
All we need now are a few courageous senators and congressmen to buck the soft drink lobby and bring this issue to the front burner. I have to believe that there are more than enough people, both liberals and conservatives, who would venture together on the middle ground and support removing sweetened drinks from the SNAP program. If I’m correct, it would be a refreshing example of some much needed legislative cooperation. Or, am I just a lonely dreamer longing for some company here in the center?
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].
Those of us who consider ourselves centrists are feeling pretty lonely right now. It seems everyone else, or at least all of the folks in Washington, have fled to the extreme political poles and left us to search for a patch of middle ground to stand on. It appears that without courageous leadership the silent majority has splintered and gravitated to the tails of what was once a bell-shaped curve.
One issue that might attract support from both sides of the political spectrum emerged from the Nov. 18, 2016, report from the United States Department of Agriculture that listed sweetened drinks as the No. 1 purchase by households participating in SNAP (“Foods Typically Purchased by Supplemental Nutrition Assistance Program (SNAP) Households”). The data reveal that households in this $74 billion program are spending 5% of their food dollars on soft drinks and almost 10% on sweetened beverages – soft drinks, fruit juices, energy drinks, and sweetened teas.
Several states (including Maine), dozens of other municipalities (most notably New York City under Mayor Michael Bloomberg), and a variety of medical groups have asked the USDA to reconsider its guidelines. Arguing that selectively banning certain items would generate too much red tape and be unfair to food stamp recipients, the department has been resistant to change (“In the Shopping Cart of a Food Stamp Household: Lots of Soda,” by Anahad O’Connor, New York Times, Jan. 13, 2017). One has to wonder how much of the department’s hesitancy is a reflection of the millions of dollars the food and beverage industries have invested in lobbying against change.
There are some ultra liberals (or progressives if you prefer) who feel that no one should be deprived of the privilege of buying unhealthy food simply because he or she is poor. At the other end of the spectrum there are conservatives who would prefer to scrap the whole SNAP program because it is a wasteful frill of the welfare state. However, I have to believe that the vast majority of folks on both sides of the political divide believe that feeding the less fortunate is important, but that spending their tax money on junk food and soft drinks is a bad idea.
While we still are learning that the causes of our obesity epidemic are far more complex than we once imagined, I think most people believe that soft drinks and junk food are playing a significant role – even though these same folks may have found it difficult to change their own behavior. According to the New York Times article mentioned above, Kevin Concannon, the USDA undersecretary for food, nutrition, and consumer services, said that instead of restricting food, the USDA has prioritized incentive programs to encourage participants to purchase more nutritious foods. However, a 2014 study of more than 19,000 SNAP recipients by Stanford researchers determined that an incentive program would not affect obesity rates, while banning sugary drinks would “significantly reduce obesity prevalence and type 2 diabetes incidence” (Health Aff. Jun 2014;33[6]:1032-9).
All we need now are a few courageous senators and congressmen to buck the soft drink lobby and bring this issue to the front burner. I have to believe that there are more than enough people, both liberals and conservatives, who would venture together on the middle ground and support removing sweetened drinks from the SNAP program. If I’m correct, it would be a refreshing example of some much needed legislative cooperation. Or, am I just a lonely dreamer longing for some company here in the center?
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].
Those of us who consider ourselves centrists are feeling pretty lonely right now. It seems everyone else, or at least all of the folks in Washington, have fled to the extreme political poles and left us to search for a patch of middle ground to stand on. It appears that without courageous leadership the silent majority has splintered and gravitated to the tails of what was once a bell-shaped curve.
One issue that might attract support from both sides of the political spectrum emerged from the Nov. 18, 2016, report from the United States Department of Agriculture that listed sweetened drinks as the No. 1 purchase by households participating in SNAP (“Foods Typically Purchased by Supplemental Nutrition Assistance Program (SNAP) Households”). The data reveal that households in this $74 billion program are spending 5% of their food dollars on soft drinks and almost 10% on sweetened beverages – soft drinks, fruit juices, energy drinks, and sweetened teas.
Several states (including Maine), dozens of other municipalities (most notably New York City under Mayor Michael Bloomberg), and a variety of medical groups have asked the USDA to reconsider its guidelines. Arguing that selectively banning certain items would generate too much red tape and be unfair to food stamp recipients, the department has been resistant to change (“In the Shopping Cart of a Food Stamp Household: Lots of Soda,” by Anahad O’Connor, New York Times, Jan. 13, 2017). One has to wonder how much of the department’s hesitancy is a reflection of the millions of dollars the food and beverage industries have invested in lobbying against change.
There are some ultra liberals (or progressives if you prefer) who feel that no one should be deprived of the privilege of buying unhealthy food simply because he or she is poor. At the other end of the spectrum there are conservatives who would prefer to scrap the whole SNAP program because it is a wasteful frill of the welfare state. However, I have to believe that the vast majority of folks on both sides of the political divide believe that feeding the less fortunate is important, but that spending their tax money on junk food and soft drinks is a bad idea.
While we still are learning that the causes of our obesity epidemic are far more complex than we once imagined, I think most people believe that soft drinks and junk food are playing a significant role – even though these same folks may have found it difficult to change their own behavior. According to the New York Times article mentioned above, Kevin Concannon, the USDA undersecretary for food, nutrition, and consumer services, said that instead of restricting food, the USDA has prioritized incentive programs to encourage participants to purchase more nutritious foods. However, a 2014 study of more than 19,000 SNAP recipients by Stanford researchers determined that an incentive program would not affect obesity rates, while banning sugary drinks would “significantly reduce obesity prevalence and type 2 diabetes incidence” (Health Aff. Jun 2014;33[6]:1032-9).
All we need now are a few courageous senators and congressmen to buck the soft drink lobby and bring this issue to the front burner. I have to believe that there are more than enough people, both liberals and conservatives, who would venture together on the middle ground and support removing sweetened drinks from the SNAP program. If I’m correct, it would be a refreshing example of some much needed legislative cooperation. Or, am I just a lonely dreamer longing for some company here in the center?
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].
Surveillance
A few weeks ago I received an email from a pediatrician thanking me for supporting her decision to quit work so that she could be home when her teenage son came home from school. She felt that by being home during her son’s adolescence, not only had she provided him a secure base but she also had helped protect him from a drug-dominated culture that permeated the community where they lived. While I hadn’t touched on it in my column, “Perfect Attendance” (Pediatric News, March 2017), this pediatrician’s experience highlights another benefit of a parental presence during those potentially stormy adolescent years.
In a recent article in the New York Times (“Teenagers Do Dumb Things, but There Are Ways to Limit Recklessness,” by Lisa Damour, March 8, 2017), Dr. Laurence Steinberg, a psychology professor at Temple University, is quoted as saying that “the context in which kids grow up must matter a great deal, and that recklessness isn’t the inevitable byproduct of the period’s biology.”
As writer Lisa Damour cogently states in her article, “For teenagers to find trouble, temptation must meet opportunity.”
Here in Brunswick, high school students finish their school day at 2:10 pm. If the student doesn’t play on a sports team and even if his or her home is at the end of the longest bus route, he or she is going to be home before 3 p.m. ... probably unsupervised. And stuff happens.
Although I may have been unsupervised, I was – or at least I believed that I was – always under constant surveillance. In the 1950s and 1960s, the population of Pleasantville, N.Y. was 5,000 and my mother had me convinced that she knew 4,000 of them. She recounted enough little things she had heard to make me believe that I was being watched by 8,000 eyes. She and the other mothers in town were masters of information sharing long before anyone had heard of networking.
These were not helicopter mothers hovering over every shady corner of our lives. They were simply concerned parents and fellow citizens going about their daily business who were not afraid to say something if they saw something. My mother’s apparent omniscience was a powerful deterrent to my adolescent recklessness. Only after I could afford to buy a car did I feel I could escape her surveillance network. And even then I wasn’t always sure.
The Internet has opened opportunities for mischief that are several orders of magnitude greater than the ones my friends and I sought to exploit in the 1950s and 1960s. However, parents today do have tools with which they can create a surveillance network to protect adolescents from their biologically predetermined urges. They simply need to have to courage to use them and not be afraid to say something if they see something.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
A few weeks ago I received an email from a pediatrician thanking me for supporting her decision to quit work so that she could be home when her teenage son came home from school. She felt that by being home during her son’s adolescence, not only had she provided him a secure base but she also had helped protect him from a drug-dominated culture that permeated the community where they lived. While I hadn’t touched on it in my column, “Perfect Attendance” (Pediatric News, March 2017), this pediatrician’s experience highlights another benefit of a parental presence during those potentially stormy adolescent years.
In a recent article in the New York Times (“Teenagers Do Dumb Things, but There Are Ways to Limit Recklessness,” by Lisa Damour, March 8, 2017), Dr. Laurence Steinberg, a psychology professor at Temple University, is quoted as saying that “the context in which kids grow up must matter a great deal, and that recklessness isn’t the inevitable byproduct of the period’s biology.”
As writer Lisa Damour cogently states in her article, “For teenagers to find trouble, temptation must meet opportunity.”
Here in Brunswick, high school students finish their school day at 2:10 pm. If the student doesn’t play on a sports team and even if his or her home is at the end of the longest bus route, he or she is going to be home before 3 p.m. ... probably unsupervised. And stuff happens.
Although I may have been unsupervised, I was – or at least I believed that I was – always under constant surveillance. In the 1950s and 1960s, the population of Pleasantville, N.Y. was 5,000 and my mother had me convinced that she knew 4,000 of them. She recounted enough little things she had heard to make me believe that I was being watched by 8,000 eyes. She and the other mothers in town were masters of information sharing long before anyone had heard of networking.
These were not helicopter mothers hovering over every shady corner of our lives. They were simply concerned parents and fellow citizens going about their daily business who were not afraid to say something if they saw something. My mother’s apparent omniscience was a powerful deterrent to my adolescent recklessness. Only after I could afford to buy a car did I feel I could escape her surveillance network. And even then I wasn’t always sure.
The Internet has opened opportunities for mischief that are several orders of magnitude greater than the ones my friends and I sought to exploit in the 1950s and 1960s. However, parents today do have tools with which they can create a surveillance network to protect adolescents from their biologically predetermined urges. They simply need to have to courage to use them and not be afraid to say something if they see something.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
A few weeks ago I received an email from a pediatrician thanking me for supporting her decision to quit work so that she could be home when her teenage son came home from school. She felt that by being home during her son’s adolescence, not only had she provided him a secure base but she also had helped protect him from a drug-dominated culture that permeated the community where they lived. While I hadn’t touched on it in my column, “Perfect Attendance” (Pediatric News, March 2017), this pediatrician’s experience highlights another benefit of a parental presence during those potentially stormy adolescent years.
In a recent article in the New York Times (“Teenagers Do Dumb Things, but There Are Ways to Limit Recklessness,” by Lisa Damour, March 8, 2017), Dr. Laurence Steinberg, a psychology professor at Temple University, is quoted as saying that “the context in which kids grow up must matter a great deal, and that recklessness isn’t the inevitable byproduct of the period’s biology.”
As writer Lisa Damour cogently states in her article, “For teenagers to find trouble, temptation must meet opportunity.”
Here in Brunswick, high school students finish their school day at 2:10 pm. If the student doesn’t play on a sports team and even if his or her home is at the end of the longest bus route, he or she is going to be home before 3 p.m. ... probably unsupervised. And stuff happens.
Although I may have been unsupervised, I was – or at least I believed that I was – always under constant surveillance. In the 1950s and 1960s, the population of Pleasantville, N.Y. was 5,000 and my mother had me convinced that she knew 4,000 of them. She recounted enough little things she had heard to make me believe that I was being watched by 8,000 eyes. She and the other mothers in town were masters of information sharing long before anyone had heard of networking.
These were not helicopter mothers hovering over every shady corner of our lives. They were simply concerned parents and fellow citizens going about their daily business who were not afraid to say something if they saw something. My mother’s apparent omniscience was a powerful deterrent to my adolescent recklessness. Only after I could afford to buy a car did I feel I could escape her surveillance network. And even then I wasn’t always sure.
The Internet has opened opportunities for mischief that are several orders of magnitude greater than the ones my friends and I sought to exploit in the 1950s and 1960s. However, parents today do have tools with which they can create a surveillance network to protect adolescents from their biologically predetermined urges. They simply need to have to courage to use them and not be afraid to say something if they see something.
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].
Wired to win
In 1929, an industrialist in Philadelphia whose factories had been plagued by vandalism sought to curtail the problem by organizing the boys in the community into athletic teams. Within a few years, his effort became Pop Warner Football. A few years later, a group of parents in Williamsport, Pa., started what was to become Little League Baseball.
Prior to the development of these two programs, kids organized their own games using shared equipment, if any at all. They drew foul lines and cobbled together goals in the bare dirt and the stubbly weeds of vacant lots and backyards. Kids shared equipment with each other. They picked teams in a manner that reflected the sometimes painful reality that some kids were proven winners and others were not. Rules were adjusted to fit the situation. Disagreements were settled without referees, or the game dissolved and a lesson was learned.
From its start in the 1930’s, the model of adult-organized and miniaturized versions of professional sports has spread from baseball and football to almost every team sport, including soccer, hockey, and lacrosse. Children may have been deprived of some self-organizing and negotiating skills, but, when one considers the electronically dominated sedentary alternatives, for the most part, adult-organized team youth sports have been a positive.
Of course, there have been some growing pains because an adult sport that has simply been miniaturized doesn’t necessarily fit well with young minds and bodies that are still developing. In some sports, adult/parent coaches now are required to undergo rigorous training in hopes of making the sport more child appropriate. However, the truth remains that, when teams compete, there are going to be winners and losers.
I recently read a newspaper article that included references to a few recent studies that suggest humans are hard wired to win (Sapolsky, Robert. “The Grim Truth Behind the ‘Winner Effect.’ ”The Wall Street Journal. Feb. 24, 2017). Well, not to win exactly but to be more likely to win again once they have been victorious, a phenomenon known as the “winner effect.”
A mouse that has been allowed to win a fixed fight with another mouse is more likely to win his next fight. Other studies on a variety of species, including humans, have found that winning can elevate testosterone levels and suppress stress-mediating hormones – winning boosts confidence and risk taking. More recent studies on zebra fish have demonstrated that a region of the habenula, a portion of the brain, seems to be critical for controlling these behaviors and chemical mediators.
Of course, the problem is that, when there are winners, there have to be losers. From time to time, the adult organizers have struggled with how to compensate for this unfortunate reality in the structure of their youth sports programs. One response has been to give every participant a trophy. Except when the children are so young that they don’t know which goal is theirs, however, awarding trophies to all is a transparent and foolish charade. The winners know who they are and so do the losers. Skillful and compassionate coaches of both winning and losing teams can cooperate to soften the cutting edge of competition, but it will never disappear. It should be fun to play, but it is always going to be more fun to win.
If there is a solution, it falls on the shoulders of parents, educators, and sometimes pediatricians to help the losers find environments and activities in which their skills and aptitudes will give them the greatest chance of enjoying the benefits of the “winner effect.” Winning isn’t everything, but it feels a lot better than losing. If we can help a child to win once – whether it is on the athletic field or in a classroom – it is more likely he or she will do it again.
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 1929, an industrialist in Philadelphia whose factories had been plagued by vandalism sought to curtail the problem by organizing the boys in the community into athletic teams. Within a few years, his effort became Pop Warner Football. A few years later, a group of parents in Williamsport, Pa., started what was to become Little League Baseball.
Prior to the development of these two programs, kids organized their own games using shared equipment, if any at all. They drew foul lines and cobbled together goals in the bare dirt and the stubbly weeds of vacant lots and backyards. Kids shared equipment with each other. They picked teams in a manner that reflected the sometimes painful reality that some kids were proven winners and others were not. Rules were adjusted to fit the situation. Disagreements were settled without referees, or the game dissolved and a lesson was learned.
From its start in the 1930’s, the model of adult-organized and miniaturized versions of professional sports has spread from baseball and football to almost every team sport, including soccer, hockey, and lacrosse. Children may have been deprived of some self-organizing and negotiating skills, but, when one considers the electronically dominated sedentary alternatives, for the most part, adult-organized team youth sports have been a positive.
Of course, there have been some growing pains because an adult sport that has simply been miniaturized doesn’t necessarily fit well with young minds and bodies that are still developing. In some sports, adult/parent coaches now are required to undergo rigorous training in hopes of making the sport more child appropriate. However, the truth remains that, when teams compete, there are going to be winners and losers.
I recently read a newspaper article that included references to a few recent studies that suggest humans are hard wired to win (Sapolsky, Robert. “The Grim Truth Behind the ‘Winner Effect.’ ”The Wall Street Journal. Feb. 24, 2017). Well, not to win exactly but to be more likely to win again once they have been victorious, a phenomenon known as the “winner effect.”
A mouse that has been allowed to win a fixed fight with another mouse is more likely to win his next fight. Other studies on a variety of species, including humans, have found that winning can elevate testosterone levels and suppress stress-mediating hormones – winning boosts confidence and risk taking. More recent studies on zebra fish have demonstrated that a region of the habenula, a portion of the brain, seems to be critical for controlling these behaviors and chemical mediators.
Of course, the problem is that, when there are winners, there have to be losers. From time to time, the adult organizers have struggled with how to compensate for this unfortunate reality in the structure of their youth sports programs. One response has been to give every participant a trophy. Except when the children are so young that they don’t know which goal is theirs, however, awarding trophies to all is a transparent and foolish charade. The winners know who they are and so do the losers. Skillful and compassionate coaches of both winning and losing teams can cooperate to soften the cutting edge of competition, but it will never disappear. It should be fun to play, but it is always going to be more fun to win.
If there is a solution, it falls on the shoulders of parents, educators, and sometimes pediatricians to help the losers find environments and activities in which their skills and aptitudes will give them the greatest chance of enjoying the benefits of the “winner effect.” Winning isn’t everything, but it feels a lot better than losing. If we can help a child to win once – whether it is on the athletic field or in a classroom – it is more likely he or she will do it again.
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 1929, an industrialist in Philadelphia whose factories had been plagued by vandalism sought to curtail the problem by organizing the boys in the community into athletic teams. Within a few years, his effort became Pop Warner Football. A few years later, a group of parents in Williamsport, Pa., started what was to become Little League Baseball.
Prior to the development of these two programs, kids organized their own games using shared equipment, if any at all. They drew foul lines and cobbled together goals in the bare dirt and the stubbly weeds of vacant lots and backyards. Kids shared equipment with each other. They picked teams in a manner that reflected the sometimes painful reality that some kids were proven winners and others were not. Rules were adjusted to fit the situation. Disagreements were settled without referees, or the game dissolved and a lesson was learned.
From its start in the 1930’s, the model of adult-organized and miniaturized versions of professional sports has spread from baseball and football to almost every team sport, including soccer, hockey, and lacrosse. Children may have been deprived of some self-organizing and negotiating skills, but, when one considers the electronically dominated sedentary alternatives, for the most part, adult-organized team youth sports have been a positive.
Of course, there have been some growing pains because an adult sport that has simply been miniaturized doesn’t necessarily fit well with young minds and bodies that are still developing. In some sports, adult/parent coaches now are required to undergo rigorous training in hopes of making the sport more child appropriate. However, the truth remains that, when teams compete, there are going to be winners and losers.
I recently read a newspaper article that included references to a few recent studies that suggest humans are hard wired to win (Sapolsky, Robert. “The Grim Truth Behind the ‘Winner Effect.’ ”The Wall Street Journal. Feb. 24, 2017). Well, not to win exactly but to be more likely to win again once they have been victorious, a phenomenon known as the “winner effect.”
A mouse that has been allowed to win a fixed fight with another mouse is more likely to win his next fight. Other studies on a variety of species, including humans, have found that winning can elevate testosterone levels and suppress stress-mediating hormones – winning boosts confidence and risk taking. More recent studies on zebra fish have demonstrated that a region of the habenula, a portion of the brain, seems to be critical for controlling these behaviors and chemical mediators.
Of course, the problem is that, when there are winners, there have to be losers. From time to time, the adult organizers have struggled with how to compensate for this unfortunate reality in the structure of their youth sports programs. One response has been to give every participant a trophy. Except when the children are so young that they don’t know which goal is theirs, however, awarding trophies to all is a transparent and foolish charade. The winners know who they are and so do the losers. Skillful and compassionate coaches of both winning and losing teams can cooperate to soften the cutting edge of competition, but it will never disappear. It should be fun to play, but it is always going to be more fun to win.
If there is a solution, it falls on the shoulders of parents, educators, and sometimes pediatricians to help the losers find environments and activities in which their skills and aptitudes will give them the greatest chance of enjoying the benefits of the “winner effect.” Winning isn’t everything, but it feels a lot better than losing. If we can help a child to win once – whether it is on the athletic field or in a classroom – it is more likely he or she will do it again.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
A familiar face
A friend of mine recently fell and sustained a complex wrist fracture. She is more than a month post injury, and her forearm, with all its external hardware, looks like an 11-year-old’s science project gone horribly wrong. As she related the story of her fall, the surgery, and her recovery, she mentioned that, since the surgery, she has had four follow-up visits, none of them with the same provider.
Two visits were with nurse practitioners and two with physicians’ assistants. Each of the folks that she saw was pleasant and courteous and appeared genuinely concerned about how she was doing. From a purely economic standpoint, I can understand why a surgeon feels he can be more productive in the operating room than when he is doing follow-ups in the office. Personally, I would have preferred to have at least a quick look at my handiwork. What I found most troubling, however, was the fact that my friend’s injury hadn’t received even the smallest dose of continuity during her recovery.
Does not seeing the same provider at each visit make a difference? In my friend’s case it may have been important because it wasn’t until the last visit that she discovered that she was supposed to be wiggling her fingers. Continuity may not have prevented this oversight, but the discontinuity didn’t help.
People feel more comfortable in situations in which they see a familiar face, whether it’s a bank teller, a barber, or the person at the check-out counter in the grocery store. This calming effect of familiarity can be even more important when it comes to transmitting bad news or supporting a patient through a challenging illness.
If you find that argument for continuity a little too touchy-feely, consider it instead as an effective efficiency booster. Does it take you longer to see one of your colleague’s patients whom you may not have seen before or a 5-year-old patient you have seen several times a year since she was born? The time-saving advantage of continuity increases exponentially with the complexity of the patient’s presenting problem.
When you are seeing patients with whom you aren’t familiar, there are always those extra minutes with your eyes on the computer screen trying to get some sense of context. There are those time-gobbling ventures down therapeutic paths that are going to blind ends, simply because the patient doesn’t know you well enough to trust your advice.
These are just some of the reasons that make continuity important and why it should be one of the driving principles behind scheduling in every physician’s office. Where does continuity sit on the priority list in the practice where you work? Do providers leave enough time in their schedules to allow for same day visits and follow-ups? Are the providers flexible enough to allow their patients to see them for almost every visit?
You may agree with me on the importance of continuity, but you may also be struggling with that quality of life/professional responsibility thing. If, like an increasing number of pediatricians, you would like to work part time, but you realize that cutting back your hours also will mean that maintaining continuity with your patients will be more difficult, careful use of a mid-level provider might help soften the transition. Would 2 full days and 2 half-days a week be more continuity-friendly than 3 full days? You’d be working the same number of hours, but the first option may create the illusion that your familiar face is in the office more often than it is. Regardless of where your practice trajectory is going, don’t discount the value of continuity.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
A friend of mine recently fell and sustained a complex wrist fracture. She is more than a month post injury, and her forearm, with all its external hardware, looks like an 11-year-old’s science project gone horribly wrong. As she related the story of her fall, the surgery, and her recovery, she mentioned that, since the surgery, she has had four follow-up visits, none of them with the same provider.
Two visits were with nurse practitioners and two with physicians’ assistants. Each of the folks that she saw was pleasant and courteous and appeared genuinely concerned about how she was doing. From a purely economic standpoint, I can understand why a surgeon feels he can be more productive in the operating room than when he is doing follow-ups in the office. Personally, I would have preferred to have at least a quick look at my handiwork. What I found most troubling, however, was the fact that my friend’s injury hadn’t received even the smallest dose of continuity during her recovery.
Does not seeing the same provider at each visit make a difference? In my friend’s case it may have been important because it wasn’t until the last visit that she discovered that she was supposed to be wiggling her fingers. Continuity may not have prevented this oversight, but the discontinuity didn’t help.
People feel more comfortable in situations in which they see a familiar face, whether it’s a bank teller, a barber, or the person at the check-out counter in the grocery store. This calming effect of familiarity can be even more important when it comes to transmitting bad news or supporting a patient through a challenging illness.
If you find that argument for continuity a little too touchy-feely, consider it instead as an effective efficiency booster. Does it take you longer to see one of your colleague’s patients whom you may not have seen before or a 5-year-old patient you have seen several times a year since she was born? The time-saving advantage of continuity increases exponentially with the complexity of the patient’s presenting problem.
When you are seeing patients with whom you aren’t familiar, there are always those extra minutes with your eyes on the computer screen trying to get some sense of context. There are those time-gobbling ventures down therapeutic paths that are going to blind ends, simply because the patient doesn’t know you well enough to trust your advice.
These are just some of the reasons that make continuity important and why it should be one of the driving principles behind scheduling in every physician’s office. Where does continuity sit on the priority list in the practice where you work? Do providers leave enough time in their schedules to allow for same day visits and follow-ups? Are the providers flexible enough to allow their patients to see them for almost every visit?
You may agree with me on the importance of continuity, but you may also be struggling with that quality of life/professional responsibility thing. If, like an increasing number of pediatricians, you would like to work part time, but you realize that cutting back your hours also will mean that maintaining continuity with your patients will be more difficult, careful use of a mid-level provider might help soften the transition. Would 2 full days and 2 half-days a week be more continuity-friendly than 3 full days? You’d be working the same number of hours, but the first option may create the illusion that your familiar face is in the office more often than it is. Regardless of where your practice trajectory is going, don’t discount the value of continuity.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
A friend of mine recently fell and sustained a complex wrist fracture. She is more than a month post injury, and her forearm, with all its external hardware, looks like an 11-year-old’s science project gone horribly wrong. As she related the story of her fall, the surgery, and her recovery, she mentioned that, since the surgery, she has had four follow-up visits, none of them with the same provider.
Two visits were with nurse practitioners and two with physicians’ assistants. Each of the folks that she saw was pleasant and courteous and appeared genuinely concerned about how she was doing. From a purely economic standpoint, I can understand why a surgeon feels he can be more productive in the operating room than when he is doing follow-ups in the office. Personally, I would have preferred to have at least a quick look at my handiwork. What I found most troubling, however, was the fact that my friend’s injury hadn’t received even the smallest dose of continuity during her recovery.
Does not seeing the same provider at each visit make a difference? In my friend’s case it may have been important because it wasn’t until the last visit that she discovered that she was supposed to be wiggling her fingers. Continuity may not have prevented this oversight, but the discontinuity didn’t help.
People feel more comfortable in situations in which they see a familiar face, whether it’s a bank teller, a barber, or the person at the check-out counter in the grocery store. This calming effect of familiarity can be even more important when it comes to transmitting bad news or supporting a patient through a challenging illness.
If you find that argument for continuity a little too touchy-feely, consider it instead as an effective efficiency booster. Does it take you longer to see one of your colleague’s patients whom you may not have seen before or a 5-year-old patient you have seen several times a year since she was born? The time-saving advantage of continuity increases exponentially with the complexity of the patient’s presenting problem.
When you are seeing patients with whom you aren’t familiar, there are always those extra minutes with your eyes on the computer screen trying to get some sense of context. There are those time-gobbling ventures down therapeutic paths that are going to blind ends, simply because the patient doesn’t know you well enough to trust your advice.
These are just some of the reasons that make continuity important and why it should be one of the driving principles behind scheduling in every physician’s office. Where does continuity sit on the priority list in the practice where you work? Do providers leave enough time in their schedules to allow for same day visits and follow-ups? Are the providers flexible enough to allow their patients to see them for almost every visit?
You may agree with me on the importance of continuity, but you may also be struggling with that quality of life/professional responsibility thing. If, like an increasing number of pediatricians, you would like to work part time, but you realize that cutting back your hours also will mean that maintaining continuity with your patients will be more difficult, careful use of a mid-level provider might help soften the transition. Would 2 full days and 2 half-days a week be more continuity-friendly than 3 full days? You’d be working the same number of hours, but the first option may create the illusion that your familiar face is in the office more often than it is. Regardless of where your practice trajectory is going, don’t discount the value of continuity.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
The last call
It’s 7:30 on a Tuesday evening, and you will be on call until 8 o’clock the next morning. You have already been in the office 9 hours. Usual start time is 8 a.m., but that extra hour at home is a perk you have earned by being on call tonight.
A quick glance at the schedule screen suggests that if nothing ugly crops up, you will finish seeing your last patient and be out the door and on your way home by 8:15 p.m. The phone has been quiet for the last half hour, but as you are making your quickstep transition between exam rooms, the nurse tells you that the receptionist has received a call from a very anxious mother who has just discovered that her 6-year-old has a fever of 103° F. The child didn’t eat any dinner and is now complaining that he has a sore throat. The mother is worried because the child had a couple of febrile seizures when he was a toddler, and she has heard of several cases of strep in his class at school.
On the other hand, you could ask the nurse to reassure the mother that a febrile seizure at age 6 is very unlikely and encourage the mother to call you if she continues to be concerned. The problem here hinges on the experience and skills of the nurse. Even if your office has a well-vetted portfolio of clinical algorithms, you may be relying on a nurse with whom you aren’t familiar. Or maybe your past experience makes you uncomfortable with this particular nurse. She or he may have missed some obvious red flags in the past or may be so unskillful at reassurance that it is very likely that you will be getting a 2 a.m. call from this worried parent.
Another option could be to suggest that after reassuring the mother, the nurse offer her a first of the morning appointment tomorrow. There are several problems with this strategy, and I have always discouraged our office staff from making these next morning appointments for sick children. The offer of the appointment seldom reassures the very anxious parents nor does it prevent the middle of the night calls. More importantly, our experience, and I suspect yours, is that half of those newly sick children with fevers will be better by the next morning or their parents ended up going to the emergency room. This will leave you with a wasted appointment slot that you would really like to have available when the phones heat up in the morning. A more efficient strategy is to promise parents that if the child is still sick in the morning, you can guarantee them a timely appointment.
Finally, there are two responses that worked best for me. The first is to have the nurse ask the parents how long it will take them to get to the office. Add 15 minutes to their estimate, and if you can accept that estimated time of arrival, have the nurse tell that family to hustle on in. Send the staff home unless they want the overtime, and see the patient yourself.
The second response is to get on the phone yourself and talk directly to the mother. You were probably going to end up speaking with her in the middle of the night anyway, so you might as well invest the time now in taking your own history. Even if your own version of reassurance fails to prevent a 2 a.m. call, at least you will have some frame of reference when you need to make one of those dangerous middle of the night clinical decisions. A quiet night may depend on how you manage that last call of the day.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
It’s 7:30 on a Tuesday evening, and you will be on call until 8 o’clock the next morning. You have already been in the office 9 hours. Usual start time is 8 a.m., but that extra hour at home is a perk you have earned by being on call tonight.
A quick glance at the schedule screen suggests that if nothing ugly crops up, you will finish seeing your last patient and be out the door and on your way home by 8:15 p.m. The phone has been quiet for the last half hour, but as you are making your quickstep transition between exam rooms, the nurse tells you that the receptionist has received a call from a very anxious mother who has just discovered that her 6-year-old has a fever of 103° F. The child didn’t eat any dinner and is now complaining that he has a sore throat. The mother is worried because the child had a couple of febrile seizures when he was a toddler, and she has heard of several cases of strep in his class at school.
On the other hand, you could ask the nurse to reassure the mother that a febrile seizure at age 6 is very unlikely and encourage the mother to call you if she continues to be concerned. The problem here hinges on the experience and skills of the nurse. Even if your office has a well-vetted portfolio of clinical algorithms, you may be relying on a nurse with whom you aren’t familiar. Or maybe your past experience makes you uncomfortable with this particular nurse. She or he may have missed some obvious red flags in the past or may be so unskillful at reassurance that it is very likely that you will be getting a 2 a.m. call from this worried parent.
Another option could be to suggest that after reassuring the mother, the nurse offer her a first of the morning appointment tomorrow. There are several problems with this strategy, and I have always discouraged our office staff from making these next morning appointments for sick children. The offer of the appointment seldom reassures the very anxious parents nor does it prevent the middle of the night calls. More importantly, our experience, and I suspect yours, is that half of those newly sick children with fevers will be better by the next morning or their parents ended up going to the emergency room. This will leave you with a wasted appointment slot that you would really like to have available when the phones heat up in the morning. A more efficient strategy is to promise parents that if the child is still sick in the morning, you can guarantee them a timely appointment.
Finally, there are two responses that worked best for me. The first is to have the nurse ask the parents how long it will take them to get to the office. Add 15 minutes to their estimate, and if you can accept that estimated time of arrival, have the nurse tell that family to hustle on in. Send the staff home unless they want the overtime, and see the patient yourself.
The second response is to get on the phone yourself and talk directly to the mother. You were probably going to end up speaking with her in the middle of the night anyway, so you might as well invest the time now in taking your own history. Even if your own version of reassurance fails to prevent a 2 a.m. call, at least you will have some frame of reference when you need to make one of those dangerous middle of the night clinical decisions. A quiet night may depend on how you manage that last call of the day.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
It’s 7:30 on a Tuesday evening, and you will be on call until 8 o’clock the next morning. You have already been in the office 9 hours. Usual start time is 8 a.m., but that extra hour at home is a perk you have earned by being on call tonight.
A quick glance at the schedule screen suggests that if nothing ugly crops up, you will finish seeing your last patient and be out the door and on your way home by 8:15 p.m. The phone has been quiet for the last half hour, but as you are making your quickstep transition between exam rooms, the nurse tells you that the receptionist has received a call from a very anxious mother who has just discovered that her 6-year-old has a fever of 103° F. The child didn’t eat any dinner and is now complaining that he has a sore throat. The mother is worried because the child had a couple of febrile seizures when he was a toddler, and she has heard of several cases of strep in his class at school.
On the other hand, you could ask the nurse to reassure the mother that a febrile seizure at age 6 is very unlikely and encourage the mother to call you if she continues to be concerned. The problem here hinges on the experience and skills of the nurse. Even if your office has a well-vetted portfolio of clinical algorithms, you may be relying on a nurse with whom you aren’t familiar. Or maybe your past experience makes you uncomfortable with this particular nurse. She or he may have missed some obvious red flags in the past or may be so unskillful at reassurance that it is very likely that you will be getting a 2 a.m. call from this worried parent.
Another option could be to suggest that after reassuring the mother, the nurse offer her a first of the morning appointment tomorrow. There are several problems with this strategy, and I have always discouraged our office staff from making these next morning appointments for sick children. The offer of the appointment seldom reassures the very anxious parents nor does it prevent the middle of the night calls. More importantly, our experience, and I suspect yours, is that half of those newly sick children with fevers will be better by the next morning or their parents ended up going to the emergency room. This will leave you with a wasted appointment slot that you would really like to have available when the phones heat up in the morning. A more efficient strategy is to promise parents that if the child is still sick in the morning, you can guarantee them a timely appointment.
Finally, there are two responses that worked best for me. The first is to have the nurse ask the parents how long it will take them to get to the office. Add 15 minutes to their estimate, and if you can accept that estimated time of arrival, have the nurse tell that family to hustle on in. Send the staff home unless they want the overtime, and see the patient yourself.
The second response is to get on the phone yourself and talk directly to the mother. You were probably going to end up speaking with her in the middle of the night anyway, so you might as well invest the time now in taking your own history. Even if your own version of reassurance fails to prevent a 2 a.m. call, at least you will have some frame of reference when you need to make one of those dangerous middle of the night clinical decisions. A quiet night may depend on how you manage that last call of the day.
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].
Dropping the A-bomb
Your first patient of the day is a 2½-year-old who has a runny nose and a cough. His mother has brought him in because his cough is more frequent and persistent than she is accustomed to hearing. He is happy and playful, and has a low-grade fever. You notice that he is slightly tachypneic, and you hear fine wheezes scattered throughout his lung fields. You also recall that at age 6 months, he was diagnosed with bronchiolitis but was never hospitalized.
Will you give him antibiotics and send him home with a nebulizer? Just the nebulizer? Just the antibiotics? Neither? We can debate those answers for hours, and you can plead for more information before you commit to an answer. But let’s skip over the question about what you are going to do and focus on what you are going to say. I want to know what diagnosis you are going to share with this mother.
Or are you going to try a pseudoscientific smoke screen and tell her that her that her son has “reactive airway disease”? You could soften it even further by reassuring her that his diagnosis is so common that it has an abbreviation: “We usually just call it RAD.”
You may not have trouble telling a parent that her child has asthma, but most clinicians struggle with dropping the A-bomb. Why? It may be that we don’t want the family to freak out. You could end up spending the rest of the morning coaxing them back off the ledge because you have diagnosed their child with a chronic illness that could kill him. This kind of exaggerated reaction is far less of a problem now than it was 30 or 40 years ago. Almost every parent knows at least one family with an asthmatic child who seems to be doing just fine. In my opinion, this apparent increase in prevalence of asthma is primarily the result of an improved awareness and a relabeling phenomenon.
Your own experience probably reflects the national statistics that less than a third of preschoolers with recurrent wheezing still have asthma by the time they finish kindergarten. And you may be hesitant to use the asthma diagnosis because you don’t want to be labeled as a clinician who cries wolf.
It may be that subconsciously you are afraid that by raising the asthma red flag you will be committing yourself to the time gobbling task of managing another patient with a chronic disease. You could gamble that he will only have one or two more episodes of wheezing, and you will be able to treat his illnesses simply as a short series of unconnected events.
Is there any harm in dancing around the asthma diagnosis? The authors of a Perspectives article in the January 2017 issue of Pediatrics argue persuasively that vague descriptive and nondiagnostic terms such as “reactive airways disease” are confusing and should be abandoned (“RAD: Reactive Airway Disease or Really Asthma Disease?” Pediatrics. 2017 Jan. doi: 10.1542/peds.2016-0625). They question why we would treat a condition with asthma medications and not call it asthma just because a child will probably out grow it later.
It’s more than just about sloppy language. Jose A. Castro-Rodriguez, MD, a physician who has pioneered one of the tools than can be used to predict persistent asthma in young children, observes that by failing to signal to parents that the child has a chronic condition, we run the risk that the child will be less adherent to the medication and management program we recommend. (“The Asthma Predictive Index,” Curr Opin Allergy Clin Immunol. 2011;11[3]:157-61).
If we are going to tighten up our language and drop the vague substitute terms like RAD, and if we are hesitant to drop the A-bomb because it sounds too much like a lifelong disease when the truth is that most young children will outgrow asthma, what should we tell all those parents of wheezing preschoolers? The authors of the article in Pediatrics have several suggestions. Their favorite and the one that appeals most to me is toddler asthma. As they observe, the term “toddler asthma” implies an endpoint and the need for reevaluation to determine if the child is one of the minority who has “real” asthma.
Although it’s almost always about the money. When it's not about the money, it's usually about the labels we use.
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].
Your first patient of the day is a 2½-year-old who has a runny nose and a cough. His mother has brought him in because his cough is more frequent and persistent than she is accustomed to hearing. He is happy and playful, and has a low-grade fever. You notice that he is slightly tachypneic, and you hear fine wheezes scattered throughout his lung fields. You also recall that at age 6 months, he was diagnosed with bronchiolitis but was never hospitalized.
Will you give him antibiotics and send him home with a nebulizer? Just the nebulizer? Just the antibiotics? Neither? We can debate those answers for hours, and you can plead for more information before you commit to an answer. But let’s skip over the question about what you are going to do and focus on what you are going to say. I want to know what diagnosis you are going to share with this mother.
Or are you going to try a pseudoscientific smoke screen and tell her that her that her son has “reactive airway disease”? You could soften it even further by reassuring her that his diagnosis is so common that it has an abbreviation: “We usually just call it RAD.”
You may not have trouble telling a parent that her child has asthma, but most clinicians struggle with dropping the A-bomb. Why? It may be that we don’t want the family to freak out. You could end up spending the rest of the morning coaxing them back off the ledge because you have diagnosed their child with a chronic illness that could kill him. This kind of exaggerated reaction is far less of a problem now than it was 30 or 40 years ago. Almost every parent knows at least one family with an asthmatic child who seems to be doing just fine. In my opinion, this apparent increase in prevalence of asthma is primarily the result of an improved awareness and a relabeling phenomenon.
Your own experience probably reflects the national statistics that less than a third of preschoolers with recurrent wheezing still have asthma by the time they finish kindergarten. And you may be hesitant to use the asthma diagnosis because you don’t want to be labeled as a clinician who cries wolf.
It may be that subconsciously you are afraid that by raising the asthma red flag you will be committing yourself to the time gobbling task of managing another patient with a chronic disease. You could gamble that he will only have one or two more episodes of wheezing, and you will be able to treat his illnesses simply as a short series of unconnected events.
Is there any harm in dancing around the asthma diagnosis? The authors of a Perspectives article in the January 2017 issue of Pediatrics argue persuasively that vague descriptive and nondiagnostic terms such as “reactive airways disease” are confusing and should be abandoned (“RAD: Reactive Airway Disease or Really Asthma Disease?” Pediatrics. 2017 Jan. doi: 10.1542/peds.2016-0625). They question why we would treat a condition with asthma medications and not call it asthma just because a child will probably out grow it later.
It’s more than just about sloppy language. Jose A. Castro-Rodriguez, MD, a physician who has pioneered one of the tools than can be used to predict persistent asthma in young children, observes that by failing to signal to parents that the child has a chronic condition, we run the risk that the child will be less adherent to the medication and management program we recommend. (“The Asthma Predictive Index,” Curr Opin Allergy Clin Immunol. 2011;11[3]:157-61).
If we are going to tighten up our language and drop the vague substitute terms like RAD, and if we are hesitant to drop the A-bomb because it sounds too much like a lifelong disease when the truth is that most young children will outgrow asthma, what should we tell all those parents of wheezing preschoolers? The authors of the article in Pediatrics have several suggestions. Their favorite and the one that appeals most to me is toddler asthma. As they observe, the term “toddler asthma” implies an endpoint and the need for reevaluation to determine if the child is one of the minority who has “real” asthma.
Although it’s almost always about the money. When it's not about the money, it's usually about the labels we use.
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].
Your first patient of the day is a 2½-year-old who has a runny nose and a cough. His mother has brought him in because his cough is more frequent and persistent than she is accustomed to hearing. He is happy and playful, and has a low-grade fever. You notice that he is slightly tachypneic, and you hear fine wheezes scattered throughout his lung fields. You also recall that at age 6 months, he was diagnosed with bronchiolitis but was never hospitalized.
Will you give him antibiotics and send him home with a nebulizer? Just the nebulizer? Just the antibiotics? Neither? We can debate those answers for hours, and you can plead for more information before you commit to an answer. But let’s skip over the question about what you are going to do and focus on what you are going to say. I want to know what diagnosis you are going to share with this mother.
Or are you going to try a pseudoscientific smoke screen and tell her that her that her son has “reactive airway disease”? You could soften it even further by reassuring her that his diagnosis is so common that it has an abbreviation: “We usually just call it RAD.”
You may not have trouble telling a parent that her child has asthma, but most clinicians struggle with dropping the A-bomb. Why? It may be that we don’t want the family to freak out. You could end up spending the rest of the morning coaxing them back off the ledge because you have diagnosed their child with a chronic illness that could kill him. This kind of exaggerated reaction is far less of a problem now than it was 30 or 40 years ago. Almost every parent knows at least one family with an asthmatic child who seems to be doing just fine. In my opinion, this apparent increase in prevalence of asthma is primarily the result of an improved awareness and a relabeling phenomenon.
Your own experience probably reflects the national statistics that less than a third of preschoolers with recurrent wheezing still have asthma by the time they finish kindergarten. And you may be hesitant to use the asthma diagnosis because you don’t want to be labeled as a clinician who cries wolf.
It may be that subconsciously you are afraid that by raising the asthma red flag you will be committing yourself to the time gobbling task of managing another patient with a chronic disease. You could gamble that he will only have one or two more episodes of wheezing, and you will be able to treat his illnesses simply as a short series of unconnected events.
Is there any harm in dancing around the asthma diagnosis? The authors of a Perspectives article in the January 2017 issue of Pediatrics argue persuasively that vague descriptive and nondiagnostic terms such as “reactive airways disease” are confusing and should be abandoned (“RAD: Reactive Airway Disease or Really Asthma Disease?” Pediatrics. 2017 Jan. doi: 10.1542/peds.2016-0625). They question why we would treat a condition with asthma medications and not call it asthma just because a child will probably out grow it later.
It’s more than just about sloppy language. Jose A. Castro-Rodriguez, MD, a physician who has pioneered one of the tools than can be used to predict persistent asthma in young children, observes that by failing to signal to parents that the child has a chronic condition, we run the risk that the child will be less adherent to the medication and management program we recommend. (“The Asthma Predictive Index,” Curr Opin Allergy Clin Immunol. 2011;11[3]:157-61).
If we are going to tighten up our language and drop the vague substitute terms like RAD, and if we are hesitant to drop the A-bomb because it sounds too much like a lifelong disease when the truth is that most young children will outgrow asthma, what should we tell all those parents of wheezing preschoolers? The authors of the article in Pediatrics have several suggestions. Their favorite and the one that appeals most to me is toddler asthma. As they observe, the term “toddler asthma” implies an endpoint and the need for reevaluation to determine if the child is one of the minority who has “real” asthma.
Although it’s almost always about the money. When it's not about the money, it's usually about the labels we use.
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].
Out to lunch
I’m sure there are folks here in town who wondered how I could keep up a professional pace that often included being on call 2 nights a week and working every third weekend. Even when I was in my early 50s, people asked me if I was getting ready to retire. I hope it wasn’t because I appeared unhappy or looked 15 years older than I was. I suspect that some parents who didn’t know me well predicted that my career would have ended far short of 40 years.
One of the secrets of what appeared to be my superhuman stamina was that almost every day at noon I was out to lunch. That doesn’t mean that I always took time to eat lunch. In fact, I must admit that more often than not my midday diet consisted of several handfuls of cashews or an energy bar eaten on the fly.
The feeling of invigoration and renewal that came in its wake fueled my commitment to my habit of lunchtime outdoor activity. Although to some people it may be counterintuitive, the physical activity energized me. The second half of my workday was no more fatiguing than the morning. However, if some thoughtless hospital or practice administrator scheduled a noon meeting, the rest of my day was a grump fest.
A recent study has demonstrated just how powerful lunchtime exercise can be in improving worker attitude and mood, even if the activity is just going for a walk. (“Changes in work affect in response to lunchtime walking in previously physically inactive employees: A randomized trial” (Scand J Med Sci Sports. 2015 Dec;25[6]:778-87). There have been other studies that have pointed to the value of an activity break, but these investigators collected real-time reports from subjects using their cell phones. “Lunchtime walks improved enthusiasm, relaxation, and nervousness at work,” the researchers noted.
The problem comes in getting employees to take that first step toward developing a lunchtime activity habit. A few, usually women, have discovered the value for themselves and enjoy the social interaction as much as they do the affect-improving aspects of the activity and change of scene. I have tried to encourage lunchtime walking in the workplace with several strategies, including small monetary rewards, prizes, and contests between groups of workers. One year we even bought umbrellas to encourage employees to walk even if it was raining. But without a vigorous and persistent support system, inertia wins, and only those who have discovered the benefits of lunchtime activity for themselves persist.
You may be asking yourself how I managed to find time in my schedule for that hour of lunchtime activity; actually it was usually an hour and half to include a shower. The answer is that I built my schedule around it, and that meant getting to the office earlier and working later. But in my mind that was a small price to pay for the benefits I received. The other secret to my apparent stamina was that I lived a 5-minute bike ride from both hospitals and my office. Don’t underestimate the toll your commute is taking on your life and happiness.
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.”
I’m sure there are folks here in town who wondered how I could keep up a professional pace that often included being on call 2 nights a week and working every third weekend. Even when I was in my early 50s, people asked me if I was getting ready to retire. I hope it wasn’t because I appeared unhappy or looked 15 years older than I was. I suspect that some parents who didn’t know me well predicted that my career would have ended far short of 40 years.
One of the secrets of what appeared to be my superhuman stamina was that almost every day at noon I was out to lunch. That doesn’t mean that I always took time to eat lunch. In fact, I must admit that more often than not my midday diet consisted of several handfuls of cashews or an energy bar eaten on the fly.
The feeling of invigoration and renewal that came in its wake fueled my commitment to my habit of lunchtime outdoor activity. Although to some people it may be counterintuitive, the physical activity energized me. The second half of my workday was no more fatiguing than the morning. However, if some thoughtless hospital or practice administrator scheduled a noon meeting, the rest of my day was a grump fest.
A recent study has demonstrated just how powerful lunchtime exercise can be in improving worker attitude and mood, even if the activity is just going for a walk. (“Changes in work affect in response to lunchtime walking in previously physically inactive employees: A randomized trial” (Scand J Med Sci Sports. 2015 Dec;25[6]:778-87). There have been other studies that have pointed to the value of an activity break, but these investigators collected real-time reports from subjects using their cell phones. “Lunchtime walks improved enthusiasm, relaxation, and nervousness at work,” the researchers noted.
The problem comes in getting employees to take that first step toward developing a lunchtime activity habit. A few, usually women, have discovered the value for themselves and enjoy the social interaction as much as they do the affect-improving aspects of the activity and change of scene. I have tried to encourage lunchtime walking in the workplace with several strategies, including small monetary rewards, prizes, and contests between groups of workers. One year we even bought umbrellas to encourage employees to walk even if it was raining. But without a vigorous and persistent support system, inertia wins, and only those who have discovered the benefits of lunchtime activity for themselves persist.
You may be asking yourself how I managed to find time in my schedule for that hour of lunchtime activity; actually it was usually an hour and half to include a shower. The answer is that I built my schedule around it, and that meant getting to the office earlier and working later. But in my mind that was a small price to pay for the benefits I received. The other secret to my apparent stamina was that I lived a 5-minute bike ride from both hospitals and my office. Don’t underestimate the toll your commute is taking on your life and happiness.
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.”
I’m sure there are folks here in town who wondered how I could keep up a professional pace that often included being on call 2 nights a week and working every third weekend. Even when I was in my early 50s, people asked me if I was getting ready to retire. I hope it wasn’t because I appeared unhappy or looked 15 years older than I was. I suspect that some parents who didn’t know me well predicted that my career would have ended far short of 40 years.
One of the secrets of what appeared to be my superhuman stamina was that almost every day at noon I was out to lunch. That doesn’t mean that I always took time to eat lunch. In fact, I must admit that more often than not my midday diet consisted of several handfuls of cashews or an energy bar eaten on the fly.
The feeling of invigoration and renewal that came in its wake fueled my commitment to my habit of lunchtime outdoor activity. Although to some people it may be counterintuitive, the physical activity energized me. The second half of my workday was no more fatiguing than the morning. However, if some thoughtless hospital or practice administrator scheduled a noon meeting, the rest of my day was a grump fest.
A recent study has demonstrated just how powerful lunchtime exercise can be in improving worker attitude and mood, even if the activity is just going for a walk. (“Changes in work affect in response to lunchtime walking in previously physically inactive employees: A randomized trial” (Scand J Med Sci Sports. 2015 Dec;25[6]:778-87). There have been other studies that have pointed to the value of an activity break, but these investigators collected real-time reports from subjects using their cell phones. “Lunchtime walks improved enthusiasm, relaxation, and nervousness at work,” the researchers noted.
The problem comes in getting employees to take that first step toward developing a lunchtime activity habit. A few, usually women, have discovered the value for themselves and enjoy the social interaction as much as they do the affect-improving aspects of the activity and change of scene. I have tried to encourage lunchtime walking in the workplace with several strategies, including small monetary rewards, prizes, and contests between groups of workers. One year we even bought umbrellas to encourage employees to walk even if it was raining. But without a vigorous and persistent support system, inertia wins, and only those who have discovered the benefits of lunchtime activity for themselves persist.
You may be asking yourself how I managed to find time in my schedule for that hour of lunchtime activity; actually it was usually an hour and half to include a shower. The answer is that I built my schedule around it, and that meant getting to the office earlier and working later. But in my mind that was a small price to pay for the benefits I received. The other secret to my apparent stamina was that I lived a 5-minute bike ride from both hospitals and my office. Don’t underestimate the toll your commute is taking on your life and happiness.
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.”
Low value
The fact that the United States spends more of its gross domestic product on health care (18%) than any other nation is old and depressing news (JAMA. 2012 Apr 11;307[14]:1513-6). There may be some debate about whether the quality of the product we are getting is worth this outsized investment. But it is safe to assume that there must be some wastage in the system. Exactly how much of our health care dollar is going down the drain is unknown. And the thorny question of who is responsible for the leaks has escaped close scrutiny, probably because the answer is guaranteed to result in an uncomfortable and ugly circle of finger pointing. Is it the insurance companies, hospitals, the superspecialists, the drug companies, impatient patients, or those dastardly lawyers? Pediatricians are such small players on the health care stage that our contribution to the wastage must be minimal. Our patients are little people who are generally healthy. Most of us drive midsized cars and live in modest homes. We try to be careful users of the expensive diagnostic and therapeutic tools at our disposal. We don’t deserve a place on the list of likely suspects, do we?
Using a claims-based measure of 20 services that according to evidenced-based guidelines do not improve health, the authors discovered that among the nearly four and half million commercially insured children they studied, 9.6% received at least one of these 20 “low-value” services in 1 year. The ticket for these worthless services was $27 million,of which more than $9 million was out of pocket expenses for families. If extrapolated to all of the commercially insured children in the United States, the total cost of low-value services would be $227 million for 1 year. Regardless of how wasteful cardiologists or plastic surgeons may be, this contribution to the national cost of health care for low-value services by pediatricians cannot be considered chump change.
I urge you to check out the online version of Dr. Chua’s article and then click on Table 1 so you can look at the 20 services that the authors have chosen to label low value. Although I am always leery of accepting a guideline simply because it is has been labeled “evidence-based,” I think you will find that it hard to argue with their choices, such as blood tests in children with a simple febrile seizure, oral antibiotics after tonsillectomy, or neuroimaging in children with headache. How does your practice’s behavior stack up against their list?
The list could be much longer. For example, the authors chose to exclude head imaging ordered for minor head trauma because their claims-based method didn’t provide enough clinical information. I suspect that with an expanded list of clearly low-value services, the annual cost for low-value pediatric services would be a half a billion dollars.
As concerning as the findings in this study may be, it doesn’t answer the question of what we should do to correct the problem. We can dance around the issue by saying that patients and parents are pressuring us to do something even if it’s a low-value service. We can complain that for decades we have been practicing under the dark cloud of a malpractice suit, and that if we don’t turn over every stone in our evaluation of a patient we’re going to trip on one of them and end up in court.
But the bottom line is that we are the ones who are making the choice to order a study or prescribe a medication that is not only of low value, but more than likely worthless and possibly damaging to the patient. With the help of the American Academy of Pediatrics, we need to swallow hard and begin cleaning house, throwing out those low-value services we have gotten in the habit of ordering and prescribing. Education helps, but sometimes we have to do some finger pointing even if the finger points to us.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
The fact that the United States spends more of its gross domestic product on health care (18%) than any other nation is old and depressing news (JAMA. 2012 Apr 11;307[14]:1513-6). There may be some debate about whether the quality of the product we are getting is worth this outsized investment. But it is safe to assume that there must be some wastage in the system. Exactly how much of our health care dollar is going down the drain is unknown. And the thorny question of who is responsible for the leaks has escaped close scrutiny, probably because the answer is guaranteed to result in an uncomfortable and ugly circle of finger pointing. Is it the insurance companies, hospitals, the superspecialists, the drug companies, impatient patients, or those dastardly lawyers? Pediatricians are such small players on the health care stage that our contribution to the wastage must be minimal. Our patients are little people who are generally healthy. Most of us drive midsized cars and live in modest homes. We try to be careful users of the expensive diagnostic and therapeutic tools at our disposal. We don’t deserve a place on the list of likely suspects, do we?
Using a claims-based measure of 20 services that according to evidenced-based guidelines do not improve health, the authors discovered that among the nearly four and half million commercially insured children they studied, 9.6% received at least one of these 20 “low-value” services in 1 year. The ticket for these worthless services was $27 million,of which more than $9 million was out of pocket expenses for families. If extrapolated to all of the commercially insured children in the United States, the total cost of low-value services would be $227 million for 1 year. Regardless of how wasteful cardiologists or plastic surgeons may be, this contribution to the national cost of health care for low-value services by pediatricians cannot be considered chump change.
I urge you to check out the online version of Dr. Chua’s article and then click on Table 1 so you can look at the 20 services that the authors have chosen to label low value. Although I am always leery of accepting a guideline simply because it is has been labeled “evidence-based,” I think you will find that it hard to argue with their choices, such as blood tests in children with a simple febrile seizure, oral antibiotics after tonsillectomy, or neuroimaging in children with headache. How does your practice’s behavior stack up against their list?
The list could be much longer. For example, the authors chose to exclude head imaging ordered for minor head trauma because their claims-based method didn’t provide enough clinical information. I suspect that with an expanded list of clearly low-value services, the annual cost for low-value pediatric services would be a half a billion dollars.
As concerning as the findings in this study may be, it doesn’t answer the question of what we should do to correct the problem. We can dance around the issue by saying that patients and parents are pressuring us to do something even if it’s a low-value service. We can complain that for decades we have been practicing under the dark cloud of a malpractice suit, and that if we don’t turn over every stone in our evaluation of a patient we’re going to trip on one of them and end up in court.
But the bottom line is that we are the ones who are making the choice to order a study or prescribe a medication that is not only of low value, but more than likely worthless and possibly damaging to the patient. With the help of the American Academy of Pediatrics, we need to swallow hard and begin cleaning house, throwing out those low-value services we have gotten in the habit of ordering and prescribing. Education helps, but sometimes we have to do some finger pointing even if the finger points to us.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
The fact that the United States spends more of its gross domestic product on health care (18%) than any other nation is old and depressing news (JAMA. 2012 Apr 11;307[14]:1513-6). There may be some debate about whether the quality of the product we are getting is worth this outsized investment. But it is safe to assume that there must be some wastage in the system. Exactly how much of our health care dollar is going down the drain is unknown. And the thorny question of who is responsible for the leaks has escaped close scrutiny, probably because the answer is guaranteed to result in an uncomfortable and ugly circle of finger pointing. Is it the insurance companies, hospitals, the superspecialists, the drug companies, impatient patients, or those dastardly lawyers? Pediatricians are such small players on the health care stage that our contribution to the wastage must be minimal. Our patients are little people who are generally healthy. Most of us drive midsized cars and live in modest homes. We try to be careful users of the expensive diagnostic and therapeutic tools at our disposal. We don’t deserve a place on the list of likely suspects, do we?
Using a claims-based measure of 20 services that according to evidenced-based guidelines do not improve health, the authors discovered that among the nearly four and half million commercially insured children they studied, 9.6% received at least one of these 20 “low-value” services in 1 year. The ticket for these worthless services was $27 million,of which more than $9 million was out of pocket expenses for families. If extrapolated to all of the commercially insured children in the United States, the total cost of low-value services would be $227 million for 1 year. Regardless of how wasteful cardiologists or plastic surgeons may be, this contribution to the national cost of health care for low-value services by pediatricians cannot be considered chump change.
I urge you to check out the online version of Dr. Chua’s article and then click on Table 1 so you can look at the 20 services that the authors have chosen to label low value. Although I am always leery of accepting a guideline simply because it is has been labeled “evidence-based,” I think you will find that it hard to argue with their choices, such as blood tests in children with a simple febrile seizure, oral antibiotics after tonsillectomy, or neuroimaging in children with headache. How does your practice’s behavior stack up against their list?
The list could be much longer. For example, the authors chose to exclude head imaging ordered for minor head trauma because their claims-based method didn’t provide enough clinical information. I suspect that with an expanded list of clearly low-value services, the annual cost for low-value pediatric services would be a half a billion dollars.
As concerning as the findings in this study may be, it doesn’t answer the question of what we should do to correct the problem. We can dance around the issue by saying that patients and parents are pressuring us to do something even if it’s a low-value service. We can complain that for decades we have been practicing under the dark cloud of a malpractice suit, and that if we don’t turn over every stone in our evaluation of a patient we’re going to trip on one of them and end up in court.
But the bottom line is that we are the ones who are making the choice to order a study or prescribe a medication that is not only of low value, but more than likely worthless and possibly damaging to the patient. With the help of the American Academy of Pediatrics, we need to swallow hard and begin cleaning house, throwing out those low-value services we have gotten in the habit of ordering and prescribing. Education helps, but sometimes we have to do some finger pointing even if the finger points to us.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].