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‘And a child shall lead them’
With a moistened index finger pointing skyward, I always have tried to remain alert to where the winds of change are blowing. But every now and then I miss a trend in child care, and that is the case with something known as “baby-led weaning.” Influenced by the questionable notion that there is a “natural” way of doing almost everything, the concept hinges on the belief that an infant will “tell” his mother when it is time to stop nursing and begin solids, aka complementary feeding.
At face value, the concept of allowing the baby to lead is a good one simply because of universality of biologic variation. Just as with the question of how much sleep a baby needs, I don’t think anyone (let alone clinicians) can give with assurance an answer that can easily be applied to all infants. There are just too many variables.
For most dyads, breastfeeding is more than just passing calories from one individual to another. Nursing can offer a sense of security and calming both for infants and their mothers. In many cases, the breast unfortunately has become a critical ingredient in the infant’s ritual for falling to sleep. For some mothers, success at breastfeeding becomes an important validation of her feelings of confidence and self-worth that in the past may have been battered by a male-dominated environment. If breastfeeding has been an unpleasant experience, a mother may be more likely to interpret her infant’s behavior as a message that it is time to wean. The bottom line is that a mother’s perception of her baby’s messages about weaning often reflects her own feelings about nursing.
Of course, we clinicians can influence a mother’s perception of her baby’s messages by introducing our own biases about what we believe is the safest, most nutritionally sound way to introduce complementary feeding. And let’s be honest and acknowledge that those are biases mostly unsupported by good scientific study. In many cases, they are more of a reflection of the cultures in which we have grown up.
When asked by parents how they will know when their infant is ready for complementary feeding, I suggest that it’s time when the infant is not only curious about what the adults around him are eating, but obviously is upset that he isn’t being offered a taste. I add that exactly what that food should be is a matter of debate and common sense.
I also encourage parents to allow the child to do as much self-feeding as possible and not worry about the mess. An old shower curtain floor and plenty of sponges and paper towels are a must.
In most cases, I think we can trust babies to take the lead in weaning. But I also believe that as clinicians we must remain alert to the few situations when extended nursing is not in the best interest for the baby who is not growing well or for the mother for whom the nursing is taking an unreasonable toll on her physical and mental health.
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].
With a moistened index finger pointing skyward, I always have tried to remain alert to where the winds of change are blowing. But every now and then I miss a trend in child care, and that is the case with something known as “baby-led weaning.” Influenced by the questionable notion that there is a “natural” way of doing almost everything, the concept hinges on the belief that an infant will “tell” his mother when it is time to stop nursing and begin solids, aka complementary feeding.
At face value, the concept of allowing the baby to lead is a good one simply because of universality of biologic variation. Just as with the question of how much sleep a baby needs, I don’t think anyone (let alone clinicians) can give with assurance an answer that can easily be applied to all infants. There are just too many variables.
For most dyads, breastfeeding is more than just passing calories from one individual to another. Nursing can offer a sense of security and calming both for infants and their mothers. In many cases, the breast unfortunately has become a critical ingredient in the infant’s ritual for falling to sleep. For some mothers, success at breastfeeding becomes an important validation of her feelings of confidence and self-worth that in the past may have been battered by a male-dominated environment. If breastfeeding has been an unpleasant experience, a mother may be more likely to interpret her infant’s behavior as a message that it is time to wean. The bottom line is that a mother’s perception of her baby’s messages about weaning often reflects her own feelings about nursing.
Of course, we clinicians can influence a mother’s perception of her baby’s messages by introducing our own biases about what we believe is the safest, most nutritionally sound way to introduce complementary feeding. And let’s be honest and acknowledge that those are biases mostly unsupported by good scientific study. In many cases, they are more of a reflection of the cultures in which we have grown up.
When asked by parents how they will know when their infant is ready for complementary feeding, I suggest that it’s time when the infant is not only curious about what the adults around him are eating, but obviously is upset that he isn’t being offered a taste. I add that exactly what that food should be is a matter of debate and common sense.
I also encourage parents to allow the child to do as much self-feeding as possible and not worry about the mess. An old shower curtain floor and plenty of sponges and paper towels are a must.
In most cases, I think we can trust babies to take the lead in weaning. But I also believe that as clinicians we must remain alert to the few situations when extended nursing is not in the best interest for the baby who is not growing well or for the mother for whom the nursing is taking an unreasonable toll on her physical and mental health.
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].
With a moistened index finger pointing skyward, I always have tried to remain alert to where the winds of change are blowing. But every now and then I miss a trend in child care, and that is the case with something known as “baby-led weaning.” Influenced by the questionable notion that there is a “natural” way of doing almost everything, the concept hinges on the belief that an infant will “tell” his mother when it is time to stop nursing and begin solids, aka complementary feeding.
At face value, the concept of allowing the baby to lead is a good one simply because of universality of biologic variation. Just as with the question of how much sleep a baby needs, I don’t think anyone (let alone clinicians) can give with assurance an answer that can easily be applied to all infants. There are just too many variables.
For most dyads, breastfeeding is more than just passing calories from one individual to another. Nursing can offer a sense of security and calming both for infants and their mothers. In many cases, the breast unfortunately has become a critical ingredient in the infant’s ritual for falling to sleep. For some mothers, success at breastfeeding becomes an important validation of her feelings of confidence and self-worth that in the past may have been battered by a male-dominated environment. If breastfeeding has been an unpleasant experience, a mother may be more likely to interpret her infant’s behavior as a message that it is time to wean. The bottom line is that a mother’s perception of her baby’s messages about weaning often reflects her own feelings about nursing.
Of course, we clinicians can influence a mother’s perception of her baby’s messages by introducing our own biases about what we believe is the safest, most nutritionally sound way to introduce complementary feeding. And let’s be honest and acknowledge that those are biases mostly unsupported by good scientific study. In many cases, they are more of a reflection of the cultures in which we have grown up.
When asked by parents how they will know when their infant is ready for complementary feeding, I suggest that it’s time when the infant is not only curious about what the adults around him are eating, but obviously is upset that he isn’t being offered a taste. I add that exactly what that food should be is a matter of debate and common sense.
I also encourage parents to allow the child to do as much self-feeding as possible and not worry about the mess. An old shower curtain floor and plenty of sponges and paper towels are a must.
In most cases, I think we can trust babies to take the lead in weaning. But I also believe that as clinicians we must remain alert to the few situations when extended nursing is not in the best interest for the baby who is not growing well or for the mother for whom the nursing is taking an unreasonable toll on her physical and mental health.
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].
Perfect attendance
A few years ago I audited a college course on leadership taught by Angus King (I-ME), former governor and now independent Senator from Maine. He emphasized that an important characteristic of effective leaders is that they show up for work. They are there, present, on the scene. Attempting to lead in absentia is seldom successful. Knowledge gathered firsthand can be critical when it’s decision-making time. And the connectedness fostered by the leader’s physical presence can bolster morale in a crisis.
Being a parent is more complex than simply being a leader, but showing up is just as important to being a good parent as it is to being an effective leader. Most parents already believe that “being there” is important, and feel guilty when they have obligations that prevent them from maintaining a perfect attendance record.
Common sense also may suggest to parents that their presence is less important as their children get older. Certainly, the behavior of most teenagers would suggest that adolescents couldn’t care less whether their parents were at home or vacationing in the Bahamas. However, this is one of those situations where appearances may be deceiving. The author of an opinion piece in the New York Times presents some compelling evidence that in fact, adolescents place a higher value on their parents’ presence than the common stereotype of teenage behavior would suggest (”What Do Teenagers Want? Potted Plants Parents,” By Lisa Damour, Dec. 14, 2016).
Citing her own experience as a psychologist in private practice in Ohio and several recent studies from the psychology literature, the author observes that “sheer proximity confers a benefit [to the adolescent’s psychological health] over and above feeling of closeness or connectedness between parent and child.” At present there is no explanation for this benefit of just being there for your teenage child. But it may be that a parental presence, even if it is silent, provides a stable base and comfort zone that the adolescent can return to as he or she tests the ability to function independently in the world outside of the family.
I suspect that most of you have observed this counter-intuitive phenomenon in which teenagers who give every outward appearance of wanting nothing to do with their parents actually would like to have at least one parent be at home. They just don’t want to be hovered over. Ninety-nine percent of the time the parent will receive no positive feedback for just being there like a “potted plant” to use Ms. Damour’s analogy.
The problem is how to get this message to parents early enough in their parenting trajectory that they can adjust work schedules and priorities to be home with their adolescents. It was not unusual for new parents to ask for my thoughts as they were considering various day care and work schedule options for their infants. If I thought they were really going to take my advice seriously I would add, “You know you should also be thinking ahead when she is a teen. She won’t ask, but she probably would like it if you were home in the afternoon when she gets home from school.”
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 years ago I audited a college course on leadership taught by Angus King (I-ME), former governor and now independent Senator from Maine. He emphasized that an important characteristic of effective leaders is that they show up for work. They are there, present, on the scene. Attempting to lead in absentia is seldom successful. Knowledge gathered firsthand can be critical when it’s decision-making time. And the connectedness fostered by the leader’s physical presence can bolster morale in a crisis.
Being a parent is more complex than simply being a leader, but showing up is just as important to being a good parent as it is to being an effective leader. Most parents already believe that “being there” is important, and feel guilty when they have obligations that prevent them from maintaining a perfect attendance record.
Common sense also may suggest to parents that their presence is less important as their children get older. Certainly, the behavior of most teenagers would suggest that adolescents couldn’t care less whether their parents were at home or vacationing in the Bahamas. However, this is one of those situations where appearances may be deceiving. The author of an opinion piece in the New York Times presents some compelling evidence that in fact, adolescents place a higher value on their parents’ presence than the common stereotype of teenage behavior would suggest (”What Do Teenagers Want? Potted Plants Parents,” By Lisa Damour, Dec. 14, 2016).
Citing her own experience as a psychologist in private practice in Ohio and several recent studies from the psychology literature, the author observes that “sheer proximity confers a benefit [to the adolescent’s psychological health] over and above feeling of closeness or connectedness between parent and child.” At present there is no explanation for this benefit of just being there for your teenage child. But it may be that a parental presence, even if it is silent, provides a stable base and comfort zone that the adolescent can return to as he or she tests the ability to function independently in the world outside of the family.
I suspect that most of you have observed this counter-intuitive phenomenon in which teenagers who give every outward appearance of wanting nothing to do with their parents actually would like to have at least one parent be at home. They just don’t want to be hovered over. Ninety-nine percent of the time the parent will receive no positive feedback for just being there like a “potted plant” to use Ms. Damour’s analogy.
The problem is how to get this message to parents early enough in their parenting trajectory that they can adjust work schedules and priorities to be home with their adolescents. It was not unusual for new parents to ask for my thoughts as they were considering various day care and work schedule options for their infants. If I thought they were really going to take my advice seriously I would add, “You know you should also be thinking ahead when she is a teen. She won’t ask, but she probably would like it if you were home in the afternoon when she gets home from school.”
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 years ago I audited a college course on leadership taught by Angus King (I-ME), former governor and now independent Senator from Maine. He emphasized that an important characteristic of effective leaders is that they show up for work. They are there, present, on the scene. Attempting to lead in absentia is seldom successful. Knowledge gathered firsthand can be critical when it’s decision-making time. And the connectedness fostered by the leader’s physical presence can bolster morale in a crisis.
Being a parent is more complex than simply being a leader, but showing up is just as important to being a good parent as it is to being an effective leader. Most parents already believe that “being there” is important, and feel guilty when they have obligations that prevent them from maintaining a perfect attendance record.
Common sense also may suggest to parents that their presence is less important as their children get older. Certainly, the behavior of most teenagers would suggest that adolescents couldn’t care less whether their parents were at home or vacationing in the Bahamas. However, this is one of those situations where appearances may be deceiving. The author of an opinion piece in the New York Times presents some compelling evidence that in fact, adolescents place a higher value on their parents’ presence than the common stereotype of teenage behavior would suggest (”What Do Teenagers Want? Potted Plants Parents,” By Lisa Damour, Dec. 14, 2016).
Citing her own experience as a psychologist in private practice in Ohio and several recent studies from the psychology literature, the author observes that “sheer proximity confers a benefit [to the adolescent’s psychological health] over and above feeling of closeness or connectedness between parent and child.” At present there is no explanation for this benefit of just being there for your teenage child. But it may be that a parental presence, even if it is silent, provides a stable base and comfort zone that the adolescent can return to as he or she tests the ability to function independently in the world outside of the family.
I suspect that most of you have observed this counter-intuitive phenomenon in which teenagers who give every outward appearance of wanting nothing to do with their parents actually would like to have at least one parent be at home. They just don’t want to be hovered over. Ninety-nine percent of the time the parent will receive no positive feedback for just being there like a “potted plant” to use Ms. Damour’s analogy.
The problem is how to get this message to parents early enough in their parenting trajectory that they can adjust work schedules and priorities to be home with their adolescents. It was not unusual for new parents to ask for my thoughts as they were considering various day care and work schedule options for their infants. If I thought they were really going to take my advice seriously I would add, “You know you should also be thinking ahead when she is a teen. She won’t ask, but she probably would like it if you were home in the afternoon when she gets home from school.”
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 war on pain
When your peer group is dominated by folks in their early 70s, conversations at dinner parties and lobster bakes invariably morph into storytelling competitions between the survivors of recent hospitalizations and medical procedures. I try to redirect this tedious and repetitive chatter with a topic from my standard collection of conversation re-starters that includes “How about those Red Sox?” and “How’s your granddaughter’s soccer season going?” But sadly I am not always successful.
Often embedded in these tales of medical misadventure are stories of unfortunate experiences with pain medications. Sometimes the story includes a description of how prescribed pain medication created symptoms that were far worse than the pain it was intended to treat. Vomiting, constipation, and “feeling goofy” are high on the list of complaints.
These caches of unused opioids, many of which were never needed in the first place, are evidence of why our health care has become so expensive, and also represent the seeds from which the addiction epidemic has grown. Ironically, they also are collateral damage from an unsuccessful and sometimes misguided war on pain.
It isn’t clear exactly when or where the war on pain began, but I’m sure those who fired the first shots were understandably concerned that many patients with incurable and terminal conditions were suffering needlessly because their pain was being under-treated. Coincidently came the realization that the sooner we could get postoperative patients on their feet and taking deep breaths, the fewer complications we would see. And the more adequately we treated their pain, the sooner we could get those patients moving and breathing optimally.
In a good faith effort to be more “scientific” about pain management, patients were asked to rate their pain and smiley face charts appeared. Unfortunately, somewhere along the line came the mantra that not only should no patient’s pain go unmeasured, but no patient’s pain should go unmedicated.
The federal government entered the war when the Centers for Medicare & Medicaid Services issued the directive that hospitals ask patients who were being discharged if their pain had been well controlled and how often did the hospital staff do what they could to ease their pain? The answers to these questions, along with others, was collected and used in assessing a hospital’s quality of care and determining its level of reimbursement.
So far, there is insufficient data to determine how frequently this directive on pain management induced hospitals to over-prescribe medication, but it certainly hasn’t been associated with a decline in opioid abuse. It is reasonable to suspect that this salvo by the government has resulted in some collateral damage as it encouraged a steady flow of unused and unnecessary prescription narcotics out of the hospital and on to the streets.
The good news is that there has been enough concern voiced about the unintended effect of these pain management questions that the CMS has decided to eliminate financial pressure clinicians might feel to over-prescribe medications by withdrawing the questions from the patient discharge questionnaire.
The bad news is that we continue to fight the war on pain with a limited arsenal. As long as clinicians simply believe that no pain should go unmedicated, they will continue to miss opportunities to use other modalities such as counseling, physical therapy, and education that can be effective without the risk of collateral damage. Instead of asking the patient (who may not know the answer), we should be asking ourselves if we have been doing everything we could to help the patient deal with his pain. The answer is often not written on prescription pads.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”
When your peer group is dominated by folks in their early 70s, conversations at dinner parties and lobster bakes invariably morph into storytelling competitions between the survivors of recent hospitalizations and medical procedures. I try to redirect this tedious and repetitive chatter with a topic from my standard collection of conversation re-starters that includes “How about those Red Sox?” and “How’s your granddaughter’s soccer season going?” But sadly I am not always successful.
Often embedded in these tales of medical misadventure are stories of unfortunate experiences with pain medications. Sometimes the story includes a description of how prescribed pain medication created symptoms that were far worse than the pain it was intended to treat. Vomiting, constipation, and “feeling goofy” are high on the list of complaints.
These caches of unused opioids, many of which were never needed in the first place, are evidence of why our health care has become so expensive, and also represent the seeds from which the addiction epidemic has grown. Ironically, they also are collateral damage from an unsuccessful and sometimes misguided war on pain.
It isn’t clear exactly when or where the war on pain began, but I’m sure those who fired the first shots were understandably concerned that many patients with incurable and terminal conditions were suffering needlessly because their pain was being under-treated. Coincidently came the realization that the sooner we could get postoperative patients on their feet and taking deep breaths, the fewer complications we would see. And the more adequately we treated their pain, the sooner we could get those patients moving and breathing optimally.
In a good faith effort to be more “scientific” about pain management, patients were asked to rate their pain and smiley face charts appeared. Unfortunately, somewhere along the line came the mantra that not only should no patient’s pain go unmeasured, but no patient’s pain should go unmedicated.
The federal government entered the war when the Centers for Medicare & Medicaid Services issued the directive that hospitals ask patients who were being discharged if their pain had been well controlled and how often did the hospital staff do what they could to ease their pain? The answers to these questions, along with others, was collected and used in assessing a hospital’s quality of care and determining its level of reimbursement.
So far, there is insufficient data to determine how frequently this directive on pain management induced hospitals to over-prescribe medication, but it certainly hasn’t been associated with a decline in opioid abuse. It is reasonable to suspect that this salvo by the government has resulted in some collateral damage as it encouraged a steady flow of unused and unnecessary prescription narcotics out of the hospital and on to the streets.
The good news is that there has been enough concern voiced about the unintended effect of these pain management questions that the CMS has decided to eliminate financial pressure clinicians might feel to over-prescribe medications by withdrawing the questions from the patient discharge questionnaire.
The bad news is that we continue to fight the war on pain with a limited arsenal. As long as clinicians simply believe that no pain should go unmedicated, they will continue to miss opportunities to use other modalities such as counseling, physical therapy, and education that can be effective without the risk of collateral damage. Instead of asking the patient (who may not know the answer), we should be asking ourselves if we have been doing everything we could to help the patient deal with his pain. The answer is often not written on prescription pads.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”
When your peer group is dominated by folks in their early 70s, conversations at dinner parties and lobster bakes invariably morph into storytelling competitions between the survivors of recent hospitalizations and medical procedures. I try to redirect this tedious and repetitive chatter with a topic from my standard collection of conversation re-starters that includes “How about those Red Sox?” and “How’s your granddaughter’s soccer season going?” But sadly I am not always successful.
Often embedded in these tales of medical misadventure are stories of unfortunate experiences with pain medications. Sometimes the story includes a description of how prescribed pain medication created symptoms that were far worse than the pain it was intended to treat. Vomiting, constipation, and “feeling goofy” are high on the list of complaints.
These caches of unused opioids, many of which were never needed in the first place, are evidence of why our health care has become so expensive, and also represent the seeds from which the addiction epidemic has grown. Ironically, they also are collateral damage from an unsuccessful and sometimes misguided war on pain.
It isn’t clear exactly when or where the war on pain began, but I’m sure those who fired the first shots were understandably concerned that many patients with incurable and terminal conditions were suffering needlessly because their pain was being under-treated. Coincidently came the realization that the sooner we could get postoperative patients on their feet and taking deep breaths, the fewer complications we would see. And the more adequately we treated their pain, the sooner we could get those patients moving and breathing optimally.
In a good faith effort to be more “scientific” about pain management, patients were asked to rate their pain and smiley face charts appeared. Unfortunately, somewhere along the line came the mantra that not only should no patient’s pain go unmeasured, but no patient’s pain should go unmedicated.
The federal government entered the war when the Centers for Medicare & Medicaid Services issued the directive that hospitals ask patients who were being discharged if their pain had been well controlled and how often did the hospital staff do what they could to ease their pain? The answers to these questions, along with others, was collected and used in assessing a hospital’s quality of care and determining its level of reimbursement.
So far, there is insufficient data to determine how frequently this directive on pain management induced hospitals to over-prescribe medication, but it certainly hasn’t been associated with a decline in opioid abuse. It is reasonable to suspect that this salvo by the government has resulted in some collateral damage as it encouraged a steady flow of unused and unnecessary prescription narcotics out of the hospital and on to the streets.
The good news is that there has been enough concern voiced about the unintended effect of these pain management questions that the CMS has decided to eliminate financial pressure clinicians might feel to over-prescribe medications by withdrawing the questions from the patient discharge questionnaire.
The bad news is that we continue to fight the war on pain with a limited arsenal. As long as clinicians simply believe that no pain should go unmedicated, they will continue to miss opportunities to use other modalities such as counseling, physical therapy, and education that can be effective without the risk of collateral damage. Instead of asking the patient (who may not know the answer), we should be asking ourselves if we have been doing everything we could to help the patient deal with his pain. The answer is often not written on prescription pads.
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.”
Pencils and paper ready!
No, this isn’t a test, this is an admonishment. For years, I have been using these letters to vent my frustration with the federal government and practice administrators who have foisted several generations of user-unfriendly electronic health records on us. Maybe it’s time to accept the ugly fact that, for the near future, clunky and time-gobbling EHRs are the reality, and we need to think of strategies to make the best of a bad situation.
It’s not only physicians who are complaining about EHRs. Listen to your friends and relatives at cookouts and in the line at the grocery story. You’ve heard what they are saying about us. “He always has his eyes on the computer screen. Never looks at me, and I’m not sure he’s listening.” “She asks me the same questions the nurse and that other woman already asked me. Hasn’t she already looked at my chart?” If you haven’t heard those complaints, make an appointment to see a doctor and experience the distortion of the doctor-patient interaction that the computer has created.
It might take some reordering of how you do things. Take a look at the patient’s chart before you go in to see the patient. Many of you may do this already. It’s the courteous thing to do. In the few cases you don’t think you can trust your memory on the trip between your office computer and the exam room, scribble a few notes on a scrap of paper.
Ask the patient to repeat his chief complaint; it may have a completely different ring to it than the one the nurse/receptionist entered in the computer. Apologize to the patient for asking the history again. Or even better, why not be the first and only person to take the history? Scribble a few more notes and a few more after the physical exam if necessary.
At the end of the visit, return to your office to order any lab work and prescriptions the visit required. Take a few minutes to look at the next patient’s medical record and then repeat, repeat. I have found that, in a general pediatric practice, when I was busy, I could batch three, rarely four, patients together before returning to my desk for a more lengthy sit down to finalize the charts, sometimes using my few scribbled notes to jog my memory.
I am confident that most of you are capable of the same mental gymnastics. You’ve passed the MCAT, graduated from medical school, passed the state board, and probably your specialty boards. You should be the master of retention. If a skilled wait person at a good restaurant can keep four patrons’ orders in his/her head, you should be able to retain the basic clinical information on a couple of patients with the help of a pencil and paper. The reward for your mental effort will be dramatically improved doctor-patient interaction. The patients will be impressed that you are looking at and listening to them, and not a computer screen. You will get more and better information from them, and this will make for more accurate diagnoses and better targeted therapies.
If you can’t imagine this working because your office system demands that a diagnosis and billing code be entered before that patient checks out, it may be time to demand a scribe.
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] .
No, this isn’t a test, this is an admonishment. For years, I have been using these letters to vent my frustration with the federal government and practice administrators who have foisted several generations of user-unfriendly electronic health records on us. Maybe it’s time to accept the ugly fact that, for the near future, clunky and time-gobbling EHRs are the reality, and we need to think of strategies to make the best of a bad situation.
It’s not only physicians who are complaining about EHRs. Listen to your friends and relatives at cookouts and in the line at the grocery story. You’ve heard what they are saying about us. “He always has his eyes on the computer screen. Never looks at me, and I’m not sure he’s listening.” “She asks me the same questions the nurse and that other woman already asked me. Hasn’t she already looked at my chart?” If you haven’t heard those complaints, make an appointment to see a doctor and experience the distortion of the doctor-patient interaction that the computer has created.
It might take some reordering of how you do things. Take a look at the patient’s chart before you go in to see the patient. Many of you may do this already. It’s the courteous thing to do. In the few cases you don’t think you can trust your memory on the trip between your office computer and the exam room, scribble a few notes on a scrap of paper.
Ask the patient to repeat his chief complaint; it may have a completely different ring to it than the one the nurse/receptionist entered in the computer. Apologize to the patient for asking the history again. Or even better, why not be the first and only person to take the history? Scribble a few more notes and a few more after the physical exam if necessary.
At the end of the visit, return to your office to order any lab work and prescriptions the visit required. Take a few minutes to look at the next patient’s medical record and then repeat, repeat. I have found that, in a general pediatric practice, when I was busy, I could batch three, rarely four, patients together before returning to my desk for a more lengthy sit down to finalize the charts, sometimes using my few scribbled notes to jog my memory.
I am confident that most of you are capable of the same mental gymnastics. You’ve passed the MCAT, graduated from medical school, passed the state board, and probably your specialty boards. You should be the master of retention. If a skilled wait person at a good restaurant can keep four patrons’ orders in his/her head, you should be able to retain the basic clinical information on a couple of patients with the help of a pencil and paper. The reward for your mental effort will be dramatically improved doctor-patient interaction. The patients will be impressed that you are looking at and listening to them, and not a computer screen. You will get more and better information from them, and this will make for more accurate diagnoses and better targeted therapies.
If you can’t imagine this working because your office system demands that a diagnosis and billing code be entered before that patient checks out, it may be time to demand a scribe.
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] .
No, this isn’t a test, this is an admonishment. For years, I have been using these letters to vent my frustration with the federal government and practice administrators who have foisted several generations of user-unfriendly electronic health records on us. Maybe it’s time to accept the ugly fact that, for the near future, clunky and time-gobbling EHRs are the reality, and we need to think of strategies to make the best of a bad situation.
It’s not only physicians who are complaining about EHRs. Listen to your friends and relatives at cookouts and in the line at the grocery story. You’ve heard what they are saying about us. “He always has his eyes on the computer screen. Never looks at me, and I’m not sure he’s listening.” “She asks me the same questions the nurse and that other woman already asked me. Hasn’t she already looked at my chart?” If you haven’t heard those complaints, make an appointment to see a doctor and experience the distortion of the doctor-patient interaction that the computer has created.
It might take some reordering of how you do things. Take a look at the patient’s chart before you go in to see the patient. Many of you may do this already. It’s the courteous thing to do. In the few cases you don’t think you can trust your memory on the trip between your office computer and the exam room, scribble a few notes on a scrap of paper.
Ask the patient to repeat his chief complaint; it may have a completely different ring to it than the one the nurse/receptionist entered in the computer. Apologize to the patient for asking the history again. Or even better, why not be the first and only person to take the history? Scribble a few more notes and a few more after the physical exam if necessary.
At the end of the visit, return to your office to order any lab work and prescriptions the visit required. Take a few minutes to look at the next patient’s medical record and then repeat, repeat. I have found that, in a general pediatric practice, when I was busy, I could batch three, rarely four, patients together before returning to my desk for a more lengthy sit down to finalize the charts, sometimes using my few scribbled notes to jog my memory.
I am confident that most of you are capable of the same mental gymnastics. You’ve passed the MCAT, graduated from medical school, passed the state board, and probably your specialty boards. You should be the master of retention. If a skilled wait person at a good restaurant can keep four patrons’ orders in his/her head, you should be able to retain the basic clinical information on a couple of patients with the help of a pencil and paper. The reward for your mental effort will be dramatically improved doctor-patient interaction. The patients will be impressed that you are looking at and listening to them, and not a computer screen. You will get more and better information from them, and this will make for more accurate diagnoses and better targeted therapies.
If you can’t imagine this working because your office system demands that a diagnosis and billing code be entered before that patient checks out, it may be time to demand a scribe.
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] .
Addiction potential
By nature, my wife and I are risk-averse people. Our investment strategy is just a few baby steps short of hiding our money under the mattress. We have never tried marijuana, though to some extent this is because we were out of college and already married when its popularity surged across this country’s campuses. We do drink alcohol, which was so ubiquitous when we were teenagers that it seemed innocuous.
Given my personality, you can understand why I have trouble understanding why anyone would ever try heroin or any opiate. I realize that many of the young addicts don’t follow the news closely enough to realize the risks. But the epidemic of addiction is so entrenched here in rural Maine that they must have known someone who has died of an overdose.
A recent op-ed piece in the New York Times describes a program that attempts to do just that (“The 4 Traits That Put Kids at Risk for Addiction,” by Maia Szalavitz, Sept. 29, 2016). The program is called Preventure and is the result of some work by Patricia Conrod, a psychiatry professor at the University of Montreal. It has been tried in Britain, Canada, Australia, and the Netherlands with some success in reducing binge drinking. In other studies, it reduced symptoms of depression, panic attacks, and impulsive behavior.
The program begins with testing middle school students and focuses on the traits of hopelessness, sensation-seeking, impulsiveness, and anxiety sensitivity. Hopeless is not a surprising choice given that many of the areas of this country with highest rates of opiate addiction are economically depressed. And it is easy to see why impulsivity and sensation-seeking are related to addiction potential. Anxiety-sensitivity is a less intuitive choice.
With the results of this testing in hand, the program administrators wait several months before approaching the outliers. The next step offers two 90-minute workshops to the entire school with the stated goal of showing how the students can channel their personalities toward success. Although the workshops are advertised as being open to everyone but limited in number of attendees, only the students identified as being at the highest risk are actually selected. It is hoped that this deception will avoid having the participants feel that they have been labeled. However, if a student asks about the selection process, he is given an honest answer. The workshops are targeted to the students’ specific emotional and behavioral vulnerabilities, and teaches cognitive behavioral techniques on how they can be managed.
While I think the deceptive selection process is a clever to wrinkle to avoid labeling, I wonder how long the ruse will survive should the program become more universally adopted. With increased popularity and publicity, every parent and most of the children in a school will realize why the test is being administered and what being selected for the workshop means. There is the threat that being identified as at risk for addiction will become a self-fulfilling prophecy and a trigger for depression.
Preventure sounds like a program worth watching. If larger series and long-term outcomes continue to be favorable, it will remain to be seen whether labeling is a hazard worth worrying about.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
By nature, my wife and I are risk-averse people. Our investment strategy is just a few baby steps short of hiding our money under the mattress. We have never tried marijuana, though to some extent this is because we were out of college and already married when its popularity surged across this country’s campuses. We do drink alcohol, which was so ubiquitous when we were teenagers that it seemed innocuous.
Given my personality, you can understand why I have trouble understanding why anyone would ever try heroin or any opiate. I realize that many of the young addicts don’t follow the news closely enough to realize the risks. But the epidemic of addiction is so entrenched here in rural Maine that they must have known someone who has died of an overdose.
A recent op-ed piece in the New York Times describes a program that attempts to do just that (“The 4 Traits That Put Kids at Risk for Addiction,” by Maia Szalavitz, Sept. 29, 2016). The program is called Preventure and is the result of some work by Patricia Conrod, a psychiatry professor at the University of Montreal. It has been tried in Britain, Canada, Australia, and the Netherlands with some success in reducing binge drinking. In other studies, it reduced symptoms of depression, panic attacks, and impulsive behavior.
The program begins with testing middle school students and focuses on the traits of hopelessness, sensation-seeking, impulsiveness, and anxiety sensitivity. Hopeless is not a surprising choice given that many of the areas of this country with highest rates of opiate addiction are economically depressed. And it is easy to see why impulsivity and sensation-seeking are related to addiction potential. Anxiety-sensitivity is a less intuitive choice.
With the results of this testing in hand, the program administrators wait several months before approaching the outliers. The next step offers two 90-minute workshops to the entire school with the stated goal of showing how the students can channel their personalities toward success. Although the workshops are advertised as being open to everyone but limited in number of attendees, only the students identified as being at the highest risk are actually selected. It is hoped that this deception will avoid having the participants feel that they have been labeled. However, if a student asks about the selection process, he is given an honest answer. The workshops are targeted to the students’ specific emotional and behavioral vulnerabilities, and teaches cognitive behavioral techniques on how they can be managed.
While I think the deceptive selection process is a clever to wrinkle to avoid labeling, I wonder how long the ruse will survive should the program become more universally adopted. With increased popularity and publicity, every parent and most of the children in a school will realize why the test is being administered and what being selected for the workshop means. There is the threat that being identified as at risk for addiction will become a self-fulfilling prophecy and a trigger for depression.
Preventure sounds like a program worth watching. If larger series and long-term outcomes continue to be favorable, it will remain to be seen whether labeling is a hazard worth worrying about.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
By nature, my wife and I are risk-averse people. Our investment strategy is just a few baby steps short of hiding our money under the mattress. We have never tried marijuana, though to some extent this is because we were out of college and already married when its popularity surged across this country’s campuses. We do drink alcohol, which was so ubiquitous when we were teenagers that it seemed innocuous.
Given my personality, you can understand why I have trouble understanding why anyone would ever try heroin or any opiate. I realize that many of the young addicts don’t follow the news closely enough to realize the risks. But the epidemic of addiction is so entrenched here in rural Maine that they must have known someone who has died of an overdose.
A recent op-ed piece in the New York Times describes a program that attempts to do just that (“The 4 Traits That Put Kids at Risk for Addiction,” by Maia Szalavitz, Sept. 29, 2016). The program is called Preventure and is the result of some work by Patricia Conrod, a psychiatry professor at the University of Montreal. It has been tried in Britain, Canada, Australia, and the Netherlands with some success in reducing binge drinking. In other studies, it reduced symptoms of depression, panic attacks, and impulsive behavior.
The program begins with testing middle school students and focuses on the traits of hopelessness, sensation-seeking, impulsiveness, and anxiety sensitivity. Hopeless is not a surprising choice given that many of the areas of this country with highest rates of opiate addiction are economically depressed. And it is easy to see why impulsivity and sensation-seeking are related to addiction potential. Anxiety-sensitivity is a less intuitive choice.
With the results of this testing in hand, the program administrators wait several months before approaching the outliers. The next step offers two 90-minute workshops to the entire school with the stated goal of showing how the students can channel their personalities toward success. Although the workshops are advertised as being open to everyone but limited in number of attendees, only the students identified as being at the highest risk are actually selected. It is hoped that this deception will avoid having the participants feel that they have been labeled. However, if a student asks about the selection process, he is given an honest answer. The workshops are targeted to the students’ specific emotional and behavioral vulnerabilities, and teaches cognitive behavioral techniques on how they can be managed.
While I think the deceptive selection process is a clever to wrinkle to avoid labeling, I wonder how long the ruse will survive should the program become more universally adopted. With increased popularity and publicity, every parent and most of the children in a school will realize why the test is being administered and what being selected for the workshop means. There is the threat that being identified as at risk for addiction will become a self-fulfilling prophecy and a trigger for depression.
Preventure sounds like a program worth watching. If larger series and long-term outcomes continue to be favorable, it will remain to be seen whether labeling is a hazard worth worrying about.
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].
Roommates
The American Academy of Pediatrics has recently released a new policy for parents on safe sleep practices that in addition to the previous warnings about bed sharing and positioning includes the recommendation that an infant sleep in the same room as her parent for at least the first 6 months (Pediatrics. 2016 Oct;138[5]:e20162938). Apparently what prompted this new set of recommendations is the observation that deaths from sudden unexpected infant deaths (SUIDS) and sudden infant deaths (SIDS) has plateaued since the dramatic decline we witnessed in the 1990s following the Back-to-Sleep campaign.
Although the policy statement refers to “new research” that has become available since the last policy statement was released in 2011, I have had trouble finding convincing evidence in the references I reviewed to support the room sharing recommendation. In some studies, room sharing was the cultural norm, making it difficult to establish a control group. In one of the most frequently cited papers from New Zealand, the authors could not sort out the effects of prone sleeping and sleeping alone, and wonder whether both factors may be affecting risk “through a common mechanism” (Lancet. 1996 Jan 6;347[8993]:7-12).
For some, parents attempting to follow this recommendation may not be without its negative consequences. Sleeping like a baby is not the same as sleeping quietly. Infants often breathe in a pattern that includes long, anxiety-provoking pauses. The implication of this policy recommendation is that parents can prevent crib death by being more vigilant at night. Do we have enough evidence that this is indeed the case?
Most parents are already anxious, and none of them are getting enough sleep. I can envision that trying to follow this recommendation could aggravate both conditions for some parents. Sleep-deprived parents often are not as capable parents as they could be. And they certainly aren’t as happy as they could be. Postpartum depression compounded by sleep deprivation continues to be an underreported and inadequately managed condition that can have negative effects for the health of the child.
For some parents, room sharing is something they gravitate toward naturally, and it can help them deal with the anxiety of new parenthood. They may sleep better with their infant close by. But for others, the better solution to their own sleep deprivation lies in sleep training, a strategy that is very difficult, if not impossible, for parents who are sharing their bedroom with their infant.
As the authors of one of the most frequently quoted papers that supports room sharing have written, “the traditional habit of labeling one sleep arrangement as being superior to another without awareness of the family context is not only wrong but potentially harmful” (Paediatric Resp Review. 2005, Jun;6[2]:134-52).
I think the academy has gone too far or at least moved prematurely with its room sharing recommendation. For some families, room sharing is a better arrangement, for others it is not. It may well be that the plateau in crib deaths is telling us that we have reached the limits of our abilities to effect any further decline with our recommendations about sleep environments. But more research needs to be done.
On a more positive note, the new recommendation may force parents to reevaluate their habit of having a television in their bedroom. Will it be baby or TV in the bedroom? Unfortunately, I fear too many will opt to have both.
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 American Academy of Pediatrics has recently released a new policy for parents on safe sleep practices that in addition to the previous warnings about bed sharing and positioning includes the recommendation that an infant sleep in the same room as her parent for at least the first 6 months (Pediatrics. 2016 Oct;138[5]:e20162938). Apparently what prompted this new set of recommendations is the observation that deaths from sudden unexpected infant deaths (SUIDS) and sudden infant deaths (SIDS) has plateaued since the dramatic decline we witnessed in the 1990s following the Back-to-Sleep campaign.
Although the policy statement refers to “new research” that has become available since the last policy statement was released in 2011, I have had trouble finding convincing evidence in the references I reviewed to support the room sharing recommendation. In some studies, room sharing was the cultural norm, making it difficult to establish a control group. In one of the most frequently cited papers from New Zealand, the authors could not sort out the effects of prone sleeping and sleeping alone, and wonder whether both factors may be affecting risk “through a common mechanism” (Lancet. 1996 Jan 6;347[8993]:7-12).
For some, parents attempting to follow this recommendation may not be without its negative consequences. Sleeping like a baby is not the same as sleeping quietly. Infants often breathe in a pattern that includes long, anxiety-provoking pauses. The implication of this policy recommendation is that parents can prevent crib death by being more vigilant at night. Do we have enough evidence that this is indeed the case?
Most parents are already anxious, and none of them are getting enough sleep. I can envision that trying to follow this recommendation could aggravate both conditions for some parents. Sleep-deprived parents often are not as capable parents as they could be. And they certainly aren’t as happy as they could be. Postpartum depression compounded by sleep deprivation continues to be an underreported and inadequately managed condition that can have negative effects for the health of the child.
For some parents, room sharing is something they gravitate toward naturally, and it can help them deal with the anxiety of new parenthood. They may sleep better with their infant close by. But for others, the better solution to their own sleep deprivation lies in sleep training, a strategy that is very difficult, if not impossible, for parents who are sharing their bedroom with their infant.
As the authors of one of the most frequently quoted papers that supports room sharing have written, “the traditional habit of labeling one sleep arrangement as being superior to another without awareness of the family context is not only wrong but potentially harmful” (Paediatric Resp Review. 2005, Jun;6[2]:134-52).
I think the academy has gone too far or at least moved prematurely with its room sharing recommendation. For some families, room sharing is a better arrangement, for others it is not. It may well be that the plateau in crib deaths is telling us that we have reached the limits of our abilities to effect any further decline with our recommendations about sleep environments. But more research needs to be done.
On a more positive note, the new recommendation may force parents to reevaluate their habit of having a television in their bedroom. Will it be baby or TV in the bedroom? Unfortunately, I fear too many will opt to have both.
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 American Academy of Pediatrics has recently released a new policy for parents on safe sleep practices that in addition to the previous warnings about bed sharing and positioning includes the recommendation that an infant sleep in the same room as her parent for at least the first 6 months (Pediatrics. 2016 Oct;138[5]:e20162938). Apparently what prompted this new set of recommendations is the observation that deaths from sudden unexpected infant deaths (SUIDS) and sudden infant deaths (SIDS) has plateaued since the dramatic decline we witnessed in the 1990s following the Back-to-Sleep campaign.
Although the policy statement refers to “new research” that has become available since the last policy statement was released in 2011, I have had trouble finding convincing evidence in the references I reviewed to support the room sharing recommendation. In some studies, room sharing was the cultural norm, making it difficult to establish a control group. In one of the most frequently cited papers from New Zealand, the authors could not sort out the effects of prone sleeping and sleeping alone, and wonder whether both factors may be affecting risk “through a common mechanism” (Lancet. 1996 Jan 6;347[8993]:7-12).
For some, parents attempting to follow this recommendation may not be without its negative consequences. Sleeping like a baby is not the same as sleeping quietly. Infants often breathe in a pattern that includes long, anxiety-provoking pauses. The implication of this policy recommendation is that parents can prevent crib death by being more vigilant at night. Do we have enough evidence that this is indeed the case?
Most parents are already anxious, and none of them are getting enough sleep. I can envision that trying to follow this recommendation could aggravate both conditions for some parents. Sleep-deprived parents often are not as capable parents as they could be. And they certainly aren’t as happy as they could be. Postpartum depression compounded by sleep deprivation continues to be an underreported and inadequately managed condition that can have negative effects for the health of the child.
For some parents, room sharing is something they gravitate toward naturally, and it can help them deal with the anxiety of new parenthood. They may sleep better with their infant close by. But for others, the better solution to their own sleep deprivation lies in sleep training, a strategy that is very difficult, if not impossible, for parents who are sharing their bedroom with their infant.
As the authors of one of the most frequently quoted papers that supports room sharing have written, “the traditional habit of labeling one sleep arrangement as being superior to another without awareness of the family context is not only wrong but potentially harmful” (Paediatric Resp Review. 2005, Jun;6[2]:134-52).
I think the academy has gone too far or at least moved prematurely with its room sharing recommendation. For some families, room sharing is a better arrangement, for others it is not. It may well be that the plateau in crib deaths is telling us that we have reached the limits of our abilities to effect any further decline with our recommendations about sleep environments. But more research needs to be done.
On a more positive note, the new recommendation may force parents to reevaluate their habit of having a television in their bedroom. Will it be baby or TV in the bedroom? Unfortunately, I fear too many will opt to have both.
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].
Little drops of gold
Is it more difficult to get blood from a stone or urine from a 3-month-old infant with a fever for which there is no apparent cause? Silly question? Not if you’re a pediatrician, and it’s 4:30 on a Friday afternoon before a 3-day holiday weekend.
You would probably prefer your chances with the stone. You have been there before. You have been peed on more than once by a 3-month-old baby you were examining. But you know from experience that when you really need just a milliliter or two of urine from a sick infant to rule out a diagnosis, those few drops of golden liquid will be hard to come by.
But of course the child’s exam hasn’t changed, and you can’t convince yourself that your training can be ignored. You must have that urine. Can you bring yourself to launch an invasive attack on the child with a catheter? Despite your reassurances and explanations and your confidence with the technique, catheterization isn’t easy with the child’s parents watching. You wonder again, “Do I really need that urine?” You have done one or two needle bladder aspirations during your training years ago, but that prospect has even less appeal than the catheterization. Of course, there is always the urine bag and its significant risk of providing you with a contaminated sample or leaking even if it has been properly applied.
If only the patient were old enough to follow directions and give you a clean catch midstream sample. But you have chosen to be a pediatrician, and with that comes the reality that most of your sick young patients with unexplained fevers aren’t going to be able to comply by producing a urine sample. Sometimes you get lucky, and as the child is being prepped for catheterization or application of the collecting bag, she will surprise you by squirting out a small arc of urine that can be caught in midair – that is, if you or your assistant is prepared with an open sterile (or even just clean) cup and quick hands. After several missed opportunities over the first several years in practice, I have tried to remember to always have my assistants ready with an open container. And remind them to keep their eyes on the exposed perineum of any infant from whom we might need a clean urine sample.
But there is another option, and you can find it in this September’s Pediatrics (Evaluation of a New Strategy for Clean-Catch Urine in Infants, Labrosse et al. 2016 Sept;138[3]). The Canadian investigators describe a technique in which the infant is stimulated to void. After giving the child 20 minutes to drink and gently cleaning the perineum, the child is held vertically, the girls with their hips flexed. The physician or nurse then taps the suprapubic area at a rate of 100 taps per minute for 30 seconds and then gently massages the lumbar paravertebral area for 30 seconds. The two stimulation maneuvers are then alternated until the child voids. The investigators recommend stopping if no urine is obtained in 300 seconds, or 5 minutes.
The results are very encouraging with a success rate of 49% on a series of 126 infants. The investigators report a contamination rate of 16% that is not statistically different from collections using an invasive technique. Median time to success was 45 seconds.
You can look at the photos for yourself, but it looks like you would need at least one assistant in addition to a parent who is holding the child. I suspect that it also helps to have quick hands once the voiding starts.
It certainly sounds like a technique worth trying. The authors claim that when used as the first attempt at collection, the number of catheterizations could be cut by a third. I suspect that just like with any technique, some folks on your staff will emerge as the ones with the magic hands and might have a success rate well above that reported in this article. Groom and treasure those in-house experts at collecting those little yellow drops. They are worth their weight in gold.
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].
Is it more difficult to get blood from a stone or urine from a 3-month-old infant with a fever for which there is no apparent cause? Silly question? Not if you’re a pediatrician, and it’s 4:30 on a Friday afternoon before a 3-day holiday weekend.
You would probably prefer your chances with the stone. You have been there before. You have been peed on more than once by a 3-month-old baby you were examining. But you know from experience that when you really need just a milliliter or two of urine from a sick infant to rule out a diagnosis, those few drops of golden liquid will be hard to come by.
But of course the child’s exam hasn’t changed, and you can’t convince yourself that your training can be ignored. You must have that urine. Can you bring yourself to launch an invasive attack on the child with a catheter? Despite your reassurances and explanations and your confidence with the technique, catheterization isn’t easy with the child’s parents watching. You wonder again, “Do I really need that urine?” You have done one or two needle bladder aspirations during your training years ago, but that prospect has even less appeal than the catheterization. Of course, there is always the urine bag and its significant risk of providing you with a contaminated sample or leaking even if it has been properly applied.
If only the patient were old enough to follow directions and give you a clean catch midstream sample. But you have chosen to be a pediatrician, and with that comes the reality that most of your sick young patients with unexplained fevers aren’t going to be able to comply by producing a urine sample. Sometimes you get lucky, and as the child is being prepped for catheterization or application of the collecting bag, she will surprise you by squirting out a small arc of urine that can be caught in midair – that is, if you or your assistant is prepared with an open sterile (or even just clean) cup and quick hands. After several missed opportunities over the first several years in practice, I have tried to remember to always have my assistants ready with an open container. And remind them to keep their eyes on the exposed perineum of any infant from whom we might need a clean urine sample.
But there is another option, and you can find it in this September’s Pediatrics (Evaluation of a New Strategy for Clean-Catch Urine in Infants, Labrosse et al. 2016 Sept;138[3]). The Canadian investigators describe a technique in which the infant is stimulated to void. After giving the child 20 minutes to drink and gently cleaning the perineum, the child is held vertically, the girls with their hips flexed. The physician or nurse then taps the suprapubic area at a rate of 100 taps per minute for 30 seconds and then gently massages the lumbar paravertebral area for 30 seconds. The two stimulation maneuvers are then alternated until the child voids. The investigators recommend stopping if no urine is obtained in 300 seconds, or 5 minutes.
The results are very encouraging with a success rate of 49% on a series of 126 infants. The investigators report a contamination rate of 16% that is not statistically different from collections using an invasive technique. Median time to success was 45 seconds.
You can look at the photos for yourself, but it looks like you would need at least one assistant in addition to a parent who is holding the child. I suspect that it also helps to have quick hands once the voiding starts.
It certainly sounds like a technique worth trying. The authors claim that when used as the first attempt at collection, the number of catheterizations could be cut by a third. I suspect that just like with any technique, some folks on your staff will emerge as the ones with the magic hands and might have a success rate well above that reported in this article. Groom and treasure those in-house experts at collecting those little yellow drops. They are worth their weight in gold.
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].
Is it more difficult to get blood from a stone or urine from a 3-month-old infant with a fever for which there is no apparent cause? Silly question? Not if you’re a pediatrician, and it’s 4:30 on a Friday afternoon before a 3-day holiday weekend.
You would probably prefer your chances with the stone. You have been there before. You have been peed on more than once by a 3-month-old baby you were examining. But you know from experience that when you really need just a milliliter or two of urine from a sick infant to rule out a diagnosis, those few drops of golden liquid will be hard to come by.
But of course the child’s exam hasn’t changed, and you can’t convince yourself that your training can be ignored. You must have that urine. Can you bring yourself to launch an invasive attack on the child with a catheter? Despite your reassurances and explanations and your confidence with the technique, catheterization isn’t easy with the child’s parents watching. You wonder again, “Do I really need that urine?” You have done one or two needle bladder aspirations during your training years ago, but that prospect has even less appeal than the catheterization. Of course, there is always the urine bag and its significant risk of providing you with a contaminated sample or leaking even if it has been properly applied.
If only the patient were old enough to follow directions and give you a clean catch midstream sample. But you have chosen to be a pediatrician, and with that comes the reality that most of your sick young patients with unexplained fevers aren’t going to be able to comply by producing a urine sample. Sometimes you get lucky, and as the child is being prepped for catheterization or application of the collecting bag, she will surprise you by squirting out a small arc of urine that can be caught in midair – that is, if you or your assistant is prepared with an open sterile (or even just clean) cup and quick hands. After several missed opportunities over the first several years in practice, I have tried to remember to always have my assistants ready with an open container. And remind them to keep their eyes on the exposed perineum of any infant from whom we might need a clean urine sample.
But there is another option, and you can find it in this September’s Pediatrics (Evaluation of a New Strategy for Clean-Catch Urine in Infants, Labrosse et al. 2016 Sept;138[3]). The Canadian investigators describe a technique in which the infant is stimulated to void. After giving the child 20 minutes to drink and gently cleaning the perineum, the child is held vertically, the girls with their hips flexed. The physician or nurse then taps the suprapubic area at a rate of 100 taps per minute for 30 seconds and then gently massages the lumbar paravertebral area for 30 seconds. The two stimulation maneuvers are then alternated until the child voids. The investigators recommend stopping if no urine is obtained in 300 seconds, or 5 minutes.
The results are very encouraging with a success rate of 49% on a series of 126 infants. The investigators report a contamination rate of 16% that is not statistically different from collections using an invasive technique. Median time to success was 45 seconds.
You can look at the photos for yourself, but it looks like you would need at least one assistant in addition to a parent who is holding the child. I suspect that it also helps to have quick hands once the voiding starts.
It certainly sounds like a technique worth trying. The authors claim that when used as the first attempt at collection, the number of catheterizations could be cut by a third. I suspect that just like with any technique, some folks on your staff will emerge as the ones with the magic hands and might have a success rate well above that reported in this article. Groom and treasure those in-house experts at collecting those little yellow drops. They are worth their weight in gold.
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 job to love
I would like to think it was the culmination of a series of clever decisions, but finding myself in a job that I enjoyed was more than likely the result of blind luck. Even as I filled out medical school applications during my senior year in college, I had no intention of actually becoming a physician. I was more focused on not becoming cannon fodder in Vietnam. I am hesitant to use the word love to describe my affection for a job I did for 40 years. But I can’t imagine any work I could have enjoyed more than being a general pediatrician in a small town.
Were there moments when I would have rather been watching one of my children play in a postseason soccer game than see a patient in the office? Sure, but I can’t recall a morning when I dreaded going to work. Having listened to many other people, including my father, complain about their work, I consider myself fortunate to have discovered a job that wasn’t just tolerable and a way to support my family, but one that I actually enjoyed enough to not mind working nights and weekends.
What was it about being a pediatrician that fueled my affection for it? Social scientists have asked the same question, and one of the answers they discovered is that jobs that offer a degree of autonomy and contribute positively to society are more likely to have satisfied workers (“The Incalculable Value of Finding a Job You Love,” by Robert Frank, the New York Times, July 22, 2016). If one assumes that the mission of pediatrics is to help children become and stay healthy, then when I was practicing solo or in a small physician-owned practice, my job easily met these two criteria. But autonomy and a good cause don’t necessarily pay the rent. However, unless I had foolishly chosen to open a practice in an area already saturated with physicians, doing pediatrics meant I would have an adequate income.
Like any craft, practicing pediatrics became easier and more enjoyable as I gained experience. I made fewer time-gobbling errors and had more therapeutic successes. It’s not that more children got better or better quicker under my care. They were going to get better, regardless of what I did. But over time, an increasing number of parents and patients seemed to be appreciative of my role in educating and reassuring them.
So what happened? I retired from office practice 3 years ago. Had I fallen out of love with pediatrics? My physical stamina was and still is good. I just go to bed earlier. But as my practice was swallowed by larger and larger entities, I lost most of the autonomy that had been so appealing. Practicing medicine has always been a business. It has to be unless you are living off an inherited trust fund. But despite praiseworthy mission statements, corporate decisions were being made that were no longer consistent with the kind of individualized care I thought the patients deserved. It was frustrating to hear families who I had been seeing for decades complain that the care delivery system in our office had taken several steps back.
At the risk of whipping the same old tired horse, I must say that it was the impending introduction of a third new and increasingly less-patient and physician-friendly EHR that made it too difficult to accept the accumulation of negatives in exchange for the wonderful feeling at the end of the workday during which at least one person had thanked me or told me I had done a good job.
For those of you that remain on the job, I urge you to fight the good fight to preserve what it is about practicing pediatrics that allows you to get up in the morning and head off to work without grumbling. It won’t be easy, but if you can make it into a job you love, the patients are going to benefit along with you.
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 would like to think it was the culmination of a series of clever decisions, but finding myself in a job that I enjoyed was more than likely the result of blind luck. Even as I filled out medical school applications during my senior year in college, I had no intention of actually becoming a physician. I was more focused on not becoming cannon fodder in Vietnam. I am hesitant to use the word love to describe my affection for a job I did for 40 years. But I can’t imagine any work I could have enjoyed more than being a general pediatrician in a small town.
Were there moments when I would have rather been watching one of my children play in a postseason soccer game than see a patient in the office? Sure, but I can’t recall a morning when I dreaded going to work. Having listened to many other people, including my father, complain about their work, I consider myself fortunate to have discovered a job that wasn’t just tolerable and a way to support my family, but one that I actually enjoyed enough to not mind working nights and weekends.
What was it about being a pediatrician that fueled my affection for it? Social scientists have asked the same question, and one of the answers they discovered is that jobs that offer a degree of autonomy and contribute positively to society are more likely to have satisfied workers (“The Incalculable Value of Finding a Job You Love,” by Robert Frank, the New York Times, July 22, 2016). If one assumes that the mission of pediatrics is to help children become and stay healthy, then when I was practicing solo or in a small physician-owned practice, my job easily met these two criteria. But autonomy and a good cause don’t necessarily pay the rent. However, unless I had foolishly chosen to open a practice in an area already saturated with physicians, doing pediatrics meant I would have an adequate income.
Like any craft, practicing pediatrics became easier and more enjoyable as I gained experience. I made fewer time-gobbling errors and had more therapeutic successes. It’s not that more children got better or better quicker under my care. They were going to get better, regardless of what I did. But over time, an increasing number of parents and patients seemed to be appreciative of my role in educating and reassuring them.
So what happened? I retired from office practice 3 years ago. Had I fallen out of love with pediatrics? My physical stamina was and still is good. I just go to bed earlier. But as my practice was swallowed by larger and larger entities, I lost most of the autonomy that had been so appealing. Practicing medicine has always been a business. It has to be unless you are living off an inherited trust fund. But despite praiseworthy mission statements, corporate decisions were being made that were no longer consistent with the kind of individualized care I thought the patients deserved. It was frustrating to hear families who I had been seeing for decades complain that the care delivery system in our office had taken several steps back.
At the risk of whipping the same old tired horse, I must say that it was the impending introduction of a third new and increasingly less-patient and physician-friendly EHR that made it too difficult to accept the accumulation of negatives in exchange for the wonderful feeling at the end of the workday during which at least one person had thanked me or told me I had done a good job.
For those of you that remain on the job, I urge you to fight the good fight to preserve what it is about practicing pediatrics that allows you to get up in the morning and head off to work without grumbling. It won’t be easy, but if you can make it into a job you love, the patients are going to benefit along with you.
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 would like to think it was the culmination of a series of clever decisions, but finding myself in a job that I enjoyed was more than likely the result of blind luck. Even as I filled out medical school applications during my senior year in college, I had no intention of actually becoming a physician. I was more focused on not becoming cannon fodder in Vietnam. I am hesitant to use the word love to describe my affection for a job I did for 40 years. But I can’t imagine any work I could have enjoyed more than being a general pediatrician in a small town.
Were there moments when I would have rather been watching one of my children play in a postseason soccer game than see a patient in the office? Sure, but I can’t recall a morning when I dreaded going to work. Having listened to many other people, including my father, complain about their work, I consider myself fortunate to have discovered a job that wasn’t just tolerable and a way to support my family, but one that I actually enjoyed enough to not mind working nights and weekends.
What was it about being a pediatrician that fueled my affection for it? Social scientists have asked the same question, and one of the answers they discovered is that jobs that offer a degree of autonomy and contribute positively to society are more likely to have satisfied workers (“The Incalculable Value of Finding a Job You Love,” by Robert Frank, the New York Times, July 22, 2016). If one assumes that the mission of pediatrics is to help children become and stay healthy, then when I was practicing solo or in a small physician-owned practice, my job easily met these two criteria. But autonomy and a good cause don’t necessarily pay the rent. However, unless I had foolishly chosen to open a practice in an area already saturated with physicians, doing pediatrics meant I would have an adequate income.
Like any craft, practicing pediatrics became easier and more enjoyable as I gained experience. I made fewer time-gobbling errors and had more therapeutic successes. It’s not that more children got better or better quicker under my care. They were going to get better, regardless of what I did. But over time, an increasing number of parents and patients seemed to be appreciative of my role in educating and reassuring them.
So what happened? I retired from office practice 3 years ago. Had I fallen out of love with pediatrics? My physical stamina was and still is good. I just go to bed earlier. But as my practice was swallowed by larger and larger entities, I lost most of the autonomy that had been so appealing. Practicing medicine has always been a business. It has to be unless you are living off an inherited trust fund. But despite praiseworthy mission statements, corporate decisions were being made that were no longer consistent with the kind of individualized care I thought the patients deserved. It was frustrating to hear families who I had been seeing for decades complain that the care delivery system in our office had taken several steps back.
At the risk of whipping the same old tired horse, I must say that it was the impending introduction of a third new and increasingly less-patient and physician-friendly EHR that made it too difficult to accept the accumulation of negatives in exchange for the wonderful feeling at the end of the workday during which at least one person had thanked me or told me I had done a good job.
For those of you that remain on the job, I urge you to fight the good fight to preserve what it is about practicing pediatrics that allows you to get up in the morning and head off to work without grumbling. It won’t be easy, but if you can make it into a job you love, the patients are going to benefit along with you.
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.”
A different Thanksgiving
Thanksgiving is at least one time when families sit down and focus on the meal. While the turkey may be the centerpiece, at least in our family we are presented with a variety of vegetables, salads, baked goods, and desserts. Some of the dishes remain on the traditional menu because “Aunt Martha always brings her molded salad,” although if the truth be known, she had fallen out of love with making it years ago. Other selections survive as memorials to long-departed family members: “Remember how much Grampy Stevens loved that pickled watermelon rind” that no one has touched since he died 10 years ago?
And although Thanksgiving may be all about the food, it’s really about sitting down together and celebrating each other over a meal. It should really be a happy meal but not one that comes in a box with a plastic toy. But for the parents of a picky eater, Thanksgiving is often destined to be another stressful dining experience. They know that despite the bountiful spread of food, there isn’t going to be anything on the table their child is going to eat.
They can cope with the situation in one of two ways. They can bring something they know he will eat, such as a can of corn or a microwaveable macaroni and cheese so he won’t “starve.” Or they can cast a pall on the festivities by attempting to badger, coax, and coerce him to eat something, as they do every night at home.
Parents may be assisted in their efforts by other family members who will bring something from the picky eater’s “might eat list.” Or, more likely, they will join in a chorus of old favorites such as “Don’t you want to grow up to be big and strong?” Or “You won’t be able to have any of Grandma’s cookies if you don’t eat some dinner.”
Either approach will be another step toward solidifying the child’s reputation in the family as a picky eater. Rachel is the cousin who plays the piano, and everyone knows that Brandon is going to be a great soccer player. Bobby is the one who won’t eat anything but mac and cheese.
A few years ago I had the thought that instead of allowing Thanksgiving to become an event that highlights and perpetuates the picky eater’s unfortunate habits, why not use the holiday as an opportunity to turn the page and begin a more sensible approach to selective eating?
So for some parents of picky eaters, I have begun to recommend the following: Tell everyone who will be coming to Thanksgiving that the pediatrician says everyone should agree that the event will be all about having a good time and not about who eats or doesn’t eat what’s on the table. And there will be no discussion about the picky eater’s habits – positive or negative.
It might be nice to include on the menu a dish or dessert that the picky eater has eaten in the past. But this is done without ceremony, comment, or preconditions such as “You have to eat some of this to get that.” This silent gesture of kindness also may reassure nervous grandparents who are worried that the child will starve if he doesn’t eat anything for a day despite your reassurance to them that the pediatrician said it was okay.
While I admit that one Thanksgiving with these new rules is unlikely to convert a 6-year-old picky eater into a voracious omnivore, it can be a first step toward helping a family adopt a sensible approach to the child’s eating habits. At least it won’t make things worse and is likely to turn unhappy meals at home into mini feasts that celebrate togetherness.
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.”
Thanksgiving is at least one time when families sit down and focus on the meal. While the turkey may be the centerpiece, at least in our family we are presented with a variety of vegetables, salads, baked goods, and desserts. Some of the dishes remain on the traditional menu because “Aunt Martha always brings her molded salad,” although if the truth be known, she had fallen out of love with making it years ago. Other selections survive as memorials to long-departed family members: “Remember how much Grampy Stevens loved that pickled watermelon rind” that no one has touched since he died 10 years ago?
And although Thanksgiving may be all about the food, it’s really about sitting down together and celebrating each other over a meal. It should really be a happy meal but not one that comes in a box with a plastic toy. But for the parents of a picky eater, Thanksgiving is often destined to be another stressful dining experience. They know that despite the bountiful spread of food, there isn’t going to be anything on the table their child is going to eat.
They can cope with the situation in one of two ways. They can bring something they know he will eat, such as a can of corn or a microwaveable macaroni and cheese so he won’t “starve.” Or they can cast a pall on the festivities by attempting to badger, coax, and coerce him to eat something, as they do every night at home.
Parents may be assisted in their efforts by other family members who will bring something from the picky eater’s “might eat list.” Or, more likely, they will join in a chorus of old favorites such as “Don’t you want to grow up to be big and strong?” Or “You won’t be able to have any of Grandma’s cookies if you don’t eat some dinner.”
Either approach will be another step toward solidifying the child’s reputation in the family as a picky eater. Rachel is the cousin who plays the piano, and everyone knows that Brandon is going to be a great soccer player. Bobby is the one who won’t eat anything but mac and cheese.
A few years ago I had the thought that instead of allowing Thanksgiving to become an event that highlights and perpetuates the picky eater’s unfortunate habits, why not use the holiday as an opportunity to turn the page and begin a more sensible approach to selective eating?
So for some parents of picky eaters, I have begun to recommend the following: Tell everyone who will be coming to Thanksgiving that the pediatrician says everyone should agree that the event will be all about having a good time and not about who eats or doesn’t eat what’s on the table. And there will be no discussion about the picky eater’s habits – positive or negative.
It might be nice to include on the menu a dish or dessert that the picky eater has eaten in the past. But this is done without ceremony, comment, or preconditions such as “You have to eat some of this to get that.” This silent gesture of kindness also may reassure nervous grandparents who are worried that the child will starve if he doesn’t eat anything for a day despite your reassurance to them that the pediatrician said it was okay.
While I admit that one Thanksgiving with these new rules is unlikely to convert a 6-year-old picky eater into a voracious omnivore, it can be a first step toward helping a family adopt a sensible approach to the child’s eating habits. At least it won’t make things worse and is likely to turn unhappy meals at home into mini feasts that celebrate togetherness.
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.”
Thanksgiving is at least one time when families sit down and focus on the meal. While the turkey may be the centerpiece, at least in our family we are presented with a variety of vegetables, salads, baked goods, and desserts. Some of the dishes remain on the traditional menu because “Aunt Martha always brings her molded salad,” although if the truth be known, she had fallen out of love with making it years ago. Other selections survive as memorials to long-departed family members: “Remember how much Grampy Stevens loved that pickled watermelon rind” that no one has touched since he died 10 years ago?
And although Thanksgiving may be all about the food, it’s really about sitting down together and celebrating each other over a meal. It should really be a happy meal but not one that comes in a box with a plastic toy. But for the parents of a picky eater, Thanksgiving is often destined to be another stressful dining experience. They know that despite the bountiful spread of food, there isn’t going to be anything on the table their child is going to eat.
They can cope with the situation in one of two ways. They can bring something they know he will eat, such as a can of corn or a microwaveable macaroni and cheese so he won’t “starve.” Or they can cast a pall on the festivities by attempting to badger, coax, and coerce him to eat something, as they do every night at home.
Parents may be assisted in their efforts by other family members who will bring something from the picky eater’s “might eat list.” Or, more likely, they will join in a chorus of old favorites such as “Don’t you want to grow up to be big and strong?” Or “You won’t be able to have any of Grandma’s cookies if you don’t eat some dinner.”
Either approach will be another step toward solidifying the child’s reputation in the family as a picky eater. Rachel is the cousin who plays the piano, and everyone knows that Brandon is going to be a great soccer player. Bobby is the one who won’t eat anything but mac and cheese.
A few years ago I had the thought that instead of allowing Thanksgiving to become an event that highlights and perpetuates the picky eater’s unfortunate habits, why not use the holiday as an opportunity to turn the page and begin a more sensible approach to selective eating?
So for some parents of picky eaters, I have begun to recommend the following: Tell everyone who will be coming to Thanksgiving that the pediatrician says everyone should agree that the event will be all about having a good time and not about who eats or doesn’t eat what’s on the table. And there will be no discussion about the picky eater’s habits – positive or negative.
It might be nice to include on the menu a dish or dessert that the picky eater has eaten in the past. But this is done without ceremony, comment, or preconditions such as “You have to eat some of this to get that.” This silent gesture of kindness also may reassure nervous grandparents who are worried that the child will starve if he doesn’t eat anything for a day despite your reassurance to them that the pediatrician said it was okay.
While I admit that one Thanksgiving with these new rules is unlikely to convert a 6-year-old picky eater into a voracious omnivore, it can be a first step toward helping a family adopt a sensible approach to the child’s eating habits. At least it won’t make things worse and is likely to turn unhappy meals at home into mini feasts that celebrate togetherness.
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.”
Size does matter
I grew up in a small town. I went to a small college. And I live and practiced in a small town in a sparsely populated state. Clearly, I’m partial to smallness. I have practiced in a two-man partnership, a solo practice, a small group, and finally in a large multicenter organization. The 10 years I practiced by myself were the most productive. It was also the most rewarding period of my life both professionally and financially.
The small group environment was a close second as a far as job satisfaction. What little I lost in autonomy was almost balanced by professional stimulation and camaraderie or working shoulder to shoulder with peers. However, all that was lost as our small group was engulfed by a larger entity. Our overhead inflated to a point that it was almost unsustainable. Meetings gobbled up productive office time. Even making little changes that might have allowed us to adapt to the changing clinical landscape seemed to take forever. That is, if they ever happened at all.
From my personal experience, health care delivery doesn’t benefit from the economics of scale that is claimed by other industries. Bigger is not better for health care delivery.
When the promoters of the Affordable Care Act promised that it would encourage cost saving and quality enhancing mergers of health delivery organizations, many other physicians and I had serious doubts about this claim. It turns that our concerns were well founded. The consolidations that were predicted and so eagerly anticipated by the architects of the ACA have occurred, but have not resulted in the promised cost savings or quality improvement.
The results have been so disappointing that Dr. Bob Kocher, special assistant to President Obama for health care and economic policy from 2009 to 2010, has felt the need to issue a mea culpa in the form of an op-ed piece in the Wall Street Journal (“How I Was Wrong About ObamaCare,” July 31, 2016). Although Dr. Kocher still believes organizing medicine into networks “that can share information, coordinate care for patients, and manage risk is critical for delivering higher-quality care, generating cost savings and improving the experience for patients,” he acknowledges, “having every provider in health care ‘owned’ by a single organization is more likely to be a barrier to better care.”
He cites recent evidence that “savings and quality improvement are generated much more often by independent primary care doctors than large hospital-centric health systems.” Small independent practices know their patients better. Unencumbered by the weight of multiple organizational layers, they can more nimbly adjust to change. And there will always be change.
Dr. Kocher also admits that he and his co-crafters of the ACA were mistaken in their belief that “it would take three to five years for physicians to use electronic health records effectively.” Unfortunately, he places the failure on what he views as delay tactics by organized medicine. Sadly, he shares this blind spot with too many other former and current government health care officials, most of whom who have never suffered under the burden of a user-unfriendly, free time–wasting, electronic medical record system.
While it is nice of Dr. Kocher to acknowledge his revelation about size, it comes too late. The bridges have already been burned. Most of the smaller independent practices he now realizes could have provided a solution to the accelerating cost of medical care are gone. In some cases, one of forces driving small practices to merge was the cost and complexity of converting to electronic medical records.
The mea culpa that we really need to hear now is the one admitting that the roll out of the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009 and meaningful use requirements were poorly conceived and implemented. Electronic health record systems that are capable of seamlessly communicating with one another, and are inexpensive, intuitive, and user friendly might have allowed more small independent practices to survive.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
I grew up in a small town. I went to a small college. And I live and practiced in a small town in a sparsely populated state. Clearly, I’m partial to smallness. I have practiced in a two-man partnership, a solo practice, a small group, and finally in a large multicenter organization. The 10 years I practiced by myself were the most productive. It was also the most rewarding period of my life both professionally and financially.
The small group environment was a close second as a far as job satisfaction. What little I lost in autonomy was almost balanced by professional stimulation and camaraderie or working shoulder to shoulder with peers. However, all that was lost as our small group was engulfed by a larger entity. Our overhead inflated to a point that it was almost unsustainable. Meetings gobbled up productive office time. Even making little changes that might have allowed us to adapt to the changing clinical landscape seemed to take forever. That is, if they ever happened at all.
From my personal experience, health care delivery doesn’t benefit from the economics of scale that is claimed by other industries. Bigger is not better for health care delivery.
When the promoters of the Affordable Care Act promised that it would encourage cost saving and quality enhancing mergers of health delivery organizations, many other physicians and I had serious doubts about this claim. It turns that our concerns were well founded. The consolidations that were predicted and so eagerly anticipated by the architects of the ACA have occurred, but have not resulted in the promised cost savings or quality improvement.
The results have been so disappointing that Dr. Bob Kocher, special assistant to President Obama for health care and economic policy from 2009 to 2010, has felt the need to issue a mea culpa in the form of an op-ed piece in the Wall Street Journal (“How I Was Wrong About ObamaCare,” July 31, 2016). Although Dr. Kocher still believes organizing medicine into networks “that can share information, coordinate care for patients, and manage risk is critical for delivering higher-quality care, generating cost savings and improving the experience for patients,” he acknowledges, “having every provider in health care ‘owned’ by a single organization is more likely to be a barrier to better care.”
He cites recent evidence that “savings and quality improvement are generated much more often by independent primary care doctors than large hospital-centric health systems.” Small independent practices know their patients better. Unencumbered by the weight of multiple organizational layers, they can more nimbly adjust to change. And there will always be change.
Dr. Kocher also admits that he and his co-crafters of the ACA were mistaken in their belief that “it would take three to five years for physicians to use electronic health records effectively.” Unfortunately, he places the failure on what he views as delay tactics by organized medicine. Sadly, he shares this blind spot with too many other former and current government health care officials, most of whom who have never suffered under the burden of a user-unfriendly, free time–wasting, electronic medical record system.
While it is nice of Dr. Kocher to acknowledge his revelation about size, it comes too late. The bridges have already been burned. Most of the smaller independent practices he now realizes could have provided a solution to the accelerating cost of medical care are gone. In some cases, one of forces driving small practices to merge was the cost and complexity of converting to electronic medical records.
The mea culpa that we really need to hear now is the one admitting that the roll out of the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009 and meaningful use requirements were poorly conceived and implemented. Electronic health record systems that are capable of seamlessly communicating with one another, and are inexpensive, intuitive, and user friendly might have allowed more small independent practices to survive.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
I grew up in a small town. I went to a small college. And I live and practiced in a small town in a sparsely populated state. Clearly, I’m partial to smallness. I have practiced in a two-man partnership, a solo practice, a small group, and finally in a large multicenter organization. The 10 years I practiced by myself were the most productive. It was also the most rewarding period of my life both professionally and financially.
The small group environment was a close second as a far as job satisfaction. What little I lost in autonomy was almost balanced by professional stimulation and camaraderie or working shoulder to shoulder with peers. However, all that was lost as our small group was engulfed by a larger entity. Our overhead inflated to a point that it was almost unsustainable. Meetings gobbled up productive office time. Even making little changes that might have allowed us to adapt to the changing clinical landscape seemed to take forever. That is, if they ever happened at all.
From my personal experience, health care delivery doesn’t benefit from the economics of scale that is claimed by other industries. Bigger is not better for health care delivery.
When the promoters of the Affordable Care Act promised that it would encourage cost saving and quality enhancing mergers of health delivery organizations, many other physicians and I had serious doubts about this claim. It turns that our concerns were well founded. The consolidations that were predicted and so eagerly anticipated by the architects of the ACA have occurred, but have not resulted in the promised cost savings or quality improvement.
The results have been so disappointing that Dr. Bob Kocher, special assistant to President Obama for health care and economic policy from 2009 to 2010, has felt the need to issue a mea culpa in the form of an op-ed piece in the Wall Street Journal (“How I Was Wrong About ObamaCare,” July 31, 2016). Although Dr. Kocher still believes organizing medicine into networks “that can share information, coordinate care for patients, and manage risk is critical for delivering higher-quality care, generating cost savings and improving the experience for patients,” he acknowledges, “having every provider in health care ‘owned’ by a single organization is more likely to be a barrier to better care.”
He cites recent evidence that “savings and quality improvement are generated much more often by independent primary care doctors than large hospital-centric health systems.” Small independent practices know their patients better. Unencumbered by the weight of multiple organizational layers, they can more nimbly adjust to change. And there will always be change.
Dr. Kocher also admits that he and his co-crafters of the ACA were mistaken in their belief that “it would take three to five years for physicians to use electronic health records effectively.” Unfortunately, he places the failure on what he views as delay tactics by organized medicine. Sadly, he shares this blind spot with too many other former and current government health care officials, most of whom who have never suffered under the burden of a user-unfriendly, free time–wasting, electronic medical record system.
While it is nice of Dr. Kocher to acknowledge his revelation about size, it comes too late. The bridges have already been burned. Most of the smaller independent practices he now realizes could have provided a solution to the accelerating cost of medical care are gone. In some cases, one of forces driving small practices to merge was the cost and complexity of converting to electronic medical records.
The mea culpa that we really need to hear now is the one admitting that the roll out of the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009 and meaningful use requirements were poorly conceived and implemented. Electronic health record systems that are capable of seamlessly communicating with one another, and are inexpensive, intuitive, and user friendly might have allowed more small independent practices to survive.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
