William G. Wilkoff, MD

“Just say no to overprescribing!” It has such a straightforward Nancy Reagan-ish sound to it. But when it comes to drugs, whether it is crack cocaine or a prescription antibiotic, simple slogans don’t alter behavior.

While most physicians aren’t drug addicts, we do share something in common with other substance abusers. We are all human, and we are all influenced by the social contexts that we inhabit. The global health problems rippling out from the overuse of antibiotics are significant, unmistakable, and well documented. Certainly, we physicians must share some of the blame with the food industry for this unfortunate situation. There is some glimmer of hope that pressure from consumers has begun to convince a few food producers to be more judicious in their use of antibiotics.

However, there seems to be little or no pressure from patients on physicians to curtail our antibiotic prescribing habits. If physicians feel any pressure from patients, it is in the form of stated or more often unstated requests for antibiotics to treat conditions for which we know they are inappropriate. There is some question as to how often this perception of patient pressure actually occurs. It may be that the pressure physicians are feeling could be better described as fear – fear that the patient will die because of an undiscovered and untreated infection. Regardless of what motivates physicians to overprescribe antibiotics, the fact is that this kind of clinical misbehavior is difficult to change.

I recently read an article in which three medical school professors describe several behavior modification strategies that they have found to be effective in discouraging overprescribing (“How to Stop Overprescribing Antibiotics,” by Craig R. Fox, Jeffrey A. Linder, and Jason N. Doctor, New York Times, March 25, 2016). In one study, the researchers found that physicians who posted a pledge to follow antibiotic guidelines reduced inappropriate prescribing by 20%. In another study the investigators found that when physicians were presented with a list of medications in a format that presented the “more aggressive” drugs in a group, as opposed to singly in a vertical column, the physicians were 12% less likely to prescribe those medications.

Better results were achieved when physicians were provided with monthly reports of their prescribing habits in comparison with those of their peers. The physicians whose prescribing patterns followed accepted guidelines most closely were complimented as being “top performers.” Those physicians who did less well were told, “You are not a top performer.” This strategy nearly eliminated inappropriate prescribing. Similar improvement occurred when physicians who clicked their mouse on an antibiotic in a clinical scenario where it was not appropriate were given a screen prompt asking them to type in a short “antibiotic justification note.”

What all of these strategies have in common is that none of them uses financial gain as a motivator. Previous studies have shown that if financial rewards work, it is only for short periods of time. Instead, these strategies leverage our inherent competitive nature and take advantage of the fact that most of us want to do the right thing. We just need a little nudge every now and then. It is also encouraging to learn that none of these strategies incorporates a punishment.

I suspect that further studies will show that a screen prompt in the medical record requiring the overprescribing physician to justify his or her prescription will be the most effective in the long run. In my experience, physicians will do anything to shorten the amount of time they spend at their office computers.

At least two of these strategies hold the promise of being very powerful behavior modifiers. Those wielding these powerful tools must exercise that power carefully and be sure that evidence supporting their target behaviors is solid and continually updated. More importantly, those of us whose behavior is being modified should have a voice in the choice of which behaviors are to be modified.

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.”

“Just say no to overprescribing!” It has such a straightforward Nancy Reagan-ish sound to it. But when it comes to drugs, whether it is crack cocaine or a prescription antibiotic, simple slogans don’t alter behavior.

While most physicians aren’t drug addicts, we do share something in common with other substance abusers. We are all human, and we are all influenced by the social contexts that we inhabit. The global health problems rippling out from the overuse of antibiotics are significant, unmistakable, and well documented. Certainly, we physicians must share some of the blame with the food industry for this unfortunate situation. There is some glimmer of hope that pressure from consumers has begun to convince a few food producers to be more judicious in their use of antibiotics.

However, there seems to be little or no pressure from patients on physicians to curtail our antibiotic prescribing habits. If physicians feel any pressure from patients, it is in the form of stated or more often unstated requests for antibiotics to treat conditions for which we know they are inappropriate. There is some question as to how often this perception of patient pressure actually occurs. It may be that the pressure physicians are feeling could be better described as fear – fear that the patient will die because of an undiscovered and untreated infection. Regardless of what motivates physicians to overprescribe antibiotics, the fact is that this kind of clinical misbehavior is difficult to change.

I recently read an article in which three medical school professors describe several behavior modification strategies that they have found to be effective in discouraging overprescribing (“How to Stop Overprescribing Antibiotics,” by Craig R. Fox, Jeffrey A. Linder, and Jason N. Doctor, New York Times, March 25, 2016). In one study, the researchers found that physicians who posted a pledge to follow antibiotic guidelines reduced inappropriate prescribing by 20%. In another study the investigators found that when physicians were presented with a list of medications in a format that presented the “more aggressive” drugs in a group, as opposed to singly in a vertical column, the physicians were 12% less likely to prescribe those medications.

Better results were achieved when physicians were provided with monthly reports of their prescribing habits in comparison with those of their peers. The physicians whose prescribing patterns followed accepted guidelines most closely were complimented as being “top performers.” Those physicians who did less well were told, “You are not a top performer.” This strategy nearly eliminated inappropriate prescribing. Similar improvement occurred when physicians who clicked their mouse on an antibiotic in a clinical scenario where it was not appropriate were given a screen prompt asking them to type in a short “antibiotic justification note.”

What all of these strategies have in common is that none of them uses financial gain as a motivator. Previous studies have shown that if financial rewards work, it is only for short periods of time. Instead, these strategies leverage our inherent competitive nature and take advantage of the fact that most of us want to do the right thing. We just need a little nudge every now and then. It is also encouraging to learn that none of these strategies incorporates a punishment.

I suspect that further studies will show that a screen prompt in the medical record requiring the overprescribing physician to justify his or her prescription will be the most effective in the long run. In my experience, physicians will do anything to shorten the amount of time they spend at their office computers.

At least two of these strategies hold the promise of being very powerful behavior modifiers. Those wielding these powerful tools must exercise that power carefully and be sure that evidence supporting their target behaviors is solid and continually updated. More importantly, those of us whose behavior is being modified should have a voice in the choice of which behaviors are to be modified.

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.”

“Just say no to overprescribing!” It has such a straightforward Nancy Reagan-ish sound to it. But when it comes to drugs, whether it is crack cocaine or a prescription antibiotic, simple slogans don’t alter behavior.

While most physicians aren’t drug addicts, we do share something in common with other substance abusers. We are all human, and we are all influenced by the social contexts that we inhabit. The global health problems rippling out from the overuse of antibiotics are significant, unmistakable, and well documented. Certainly, we physicians must share some of the blame with the food industry for this unfortunate situation. There is some glimmer of hope that pressure from consumers has begun to convince a few food producers to be more judicious in their use of antibiotics.

However, there seems to be little or no pressure from patients on physicians to curtail our antibiotic prescribing habits. If physicians feel any pressure from patients, it is in the form of stated or more often unstated requests for antibiotics to treat conditions for which we know they are inappropriate. There is some question as to how often this perception of patient pressure actually occurs. It may be that the pressure physicians are feeling could be better described as fear – fear that the patient will die because of an undiscovered and untreated infection. Regardless of what motivates physicians to overprescribe antibiotics, the fact is that this kind of clinical misbehavior is difficult to change.

I recently read an article in which three medical school professors describe several behavior modification strategies that they have found to be effective in discouraging overprescribing (“How to Stop Overprescribing Antibiotics,” by Craig R. Fox, Jeffrey A. Linder, and Jason N. Doctor, New York Times, March 25, 2016). In one study, the researchers found that physicians who posted a pledge to follow antibiotic guidelines reduced inappropriate prescribing by 20%. In another study the investigators found that when physicians were presented with a list of medications in a format that presented the “more aggressive” drugs in a group, as opposed to singly in a vertical column, the physicians were 12% less likely to prescribe those medications.

Better results were achieved when physicians were provided with monthly reports of their prescribing habits in comparison with those of their peers. The physicians whose prescribing patterns followed accepted guidelines most closely were complimented as being “top performers.” Those physicians who did less well were told, “You are not a top performer.” This strategy nearly eliminated inappropriate prescribing. Similar improvement occurred when physicians who clicked their mouse on an antibiotic in a clinical scenario where it was not appropriate were given a screen prompt asking them to type in a short “antibiotic justification note.”

What all of these strategies have in common is that none of them uses financial gain as a motivator. Previous studies have shown that if financial rewards work, it is only for short periods of time. Instead, these strategies leverage our inherent competitive nature and take advantage of the fact that most of us want to do the right thing. We just need a little nudge every now and then. It is also encouraging to learn that none of these strategies incorporates a punishment.

I suspect that further studies will show that a screen prompt in the medical record requiring the overprescribing physician to justify his or her prescription will be the most effective in the long run. In my experience, physicians will do anything to shorten the amount of time they spend at their office computers.

At least two of these strategies hold the promise of being very powerful behavior modifiers. Those wielding these powerful tools must exercise that power carefully and be sure that evidence supporting their target behaviors is solid and continually updated. More importantly, those of us whose behavior is being modified should have a voice in the choice of which behaviors are to be modified.

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.”

Okay, let’s try this one more time. We agree that vaccine rates are declining and that the outbreak of measles believed to have spread from an index case at Disneyland is an example of the risk this country faces from those declining rates. In the last few years, there has been at least one study that found that providing vaccine-hesitant families with factual provaccine information failed to change parental attitudes. In fact, the educational effort backfired in some cases, and hesitant parents found other arguments to support their flawed positions. An equally discouraging study presented in the last year suggests that parents have already decided whether they will vaccinate even before they enter into childbearing, long before pediatricians have an opportunity to present their case.

In the face of this dismal landscape of antiscience, some pediatricians have decided to discharge vaccine-refusing families from their practices. Although this approach may create a thin shell of protection against some malpractice suits, and provide their youngest patients a shred of protection from waiting-room acquired infection, it has no effect on the larger problem facing this country.

A study from the University of Illinois published in the Proceedings of the National Academy of Sciences entitled, “Countering anti-vaccine attitudes” (PNAS 2015 Aug 18;112[33]:10321-4) suggests that we may have been too timid in choosing our strategies to combat the antivaccine epidemic. From a group of more than 800 individuals across a broad economic base, a smaller group of 315 was culled using several strategies to ensure that the participants were paying attention. They were then divided into three subgroups whose pretest vaccine attitudes did not differ.

One group was presented with materials that included photographs of ill children with rashes and a testimonial from the mother whose child had had measles. A second group was presented with articles exposing the myth of a relationship between autism and the measles-mumps-rubella vaccine. This group was labeled the “autism correction” group. The control group was presented with several scientific articles unrelated to vaccines.

The researchers found that while the control group and the autism correction group showed no change in their attitudes to vaccines, those individuals presented with graphic evidence of the risk of disease did demonstrate a significant change in attitude. So, the message would seem to be that scaring parents might work.

I’m not sure why pediatricians have been so hesitant to employ scare tactics in the past. While you and I may be more easily convinced by science-based evidence than the average parent, we also have seen children with vaccine-preventable diseases or at least seen pictures and heard their horrible histories. I suspect that our provaccine attitudes are colored more by the horrors that we have seen and heard than by our lip service to the sanctity of science.

We may have been too worried about being labeled as fear mongers if we showed graphic pictures of sick and dying children and promoted tear-jerking testimonials from parents. If we were a business whose bottom line depended on selling vaccines, our marketing and advertising folks would have sent us on the fear-generating pathway long ago.

It is time to ask ourselves if the situation is so dire that it is time to stop pussyfooting around with soft educational messages and begin trying to scare the vaccine deniers into protecting their children – and everyone else’s.

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.”

Okay, let’s try this one more time. We agree that vaccine rates are declining and that the outbreak of measles believed to have spread from an index case at Disneyland is an example of the risk this country faces from those declining rates. In the last few years, there has been at least one study that found that providing vaccine-hesitant families with factual provaccine information failed to change parental attitudes. In fact, the educational effort backfired in some cases, and hesitant parents found other arguments to support their flawed positions. An equally discouraging study presented in the last year suggests that parents have already decided whether they will vaccinate even before they enter into childbearing, long before pediatricians have an opportunity to present their case.

In the face of this dismal landscape of antiscience, some pediatricians have decided to discharge vaccine-refusing families from their practices. Although this approach may create a thin shell of protection against some malpractice suits, and provide their youngest patients a shred of protection from waiting-room acquired infection, it has no effect on the larger problem facing this country.

A study from the University of Illinois published in the Proceedings of the National Academy of Sciences entitled, “Countering anti-vaccine attitudes” (PNAS 2015 Aug 18;112[33]:10321-4) suggests that we may have been too timid in choosing our strategies to combat the antivaccine epidemic. From a group of more than 800 individuals across a broad economic base, a smaller group of 315 was culled using several strategies to ensure that the participants were paying attention. They were then divided into three subgroups whose pretest vaccine attitudes did not differ.

One group was presented with materials that included photographs of ill children with rashes and a testimonial from the mother whose child had had measles. A second group was presented with articles exposing the myth of a relationship between autism and the measles-mumps-rubella vaccine. This group was labeled the “autism correction” group. The control group was presented with several scientific articles unrelated to vaccines.

The researchers found that while the control group and the autism correction group showed no change in their attitudes to vaccines, those individuals presented with graphic evidence of the risk of disease did demonstrate a significant change in attitude. So, the message would seem to be that scaring parents might work.

I’m not sure why pediatricians have been so hesitant to employ scare tactics in the past. While you and I may be more easily convinced by science-based evidence than the average parent, we also have seen children with vaccine-preventable diseases or at least seen pictures and heard their horrible histories. I suspect that our provaccine attitudes are colored more by the horrors that we have seen and heard than by our lip service to the sanctity of science.

We may have been too worried about being labeled as fear mongers if we showed graphic pictures of sick and dying children and promoted tear-jerking testimonials from parents. If we were a business whose bottom line depended on selling vaccines, our marketing and advertising folks would have sent us on the fear-generating pathway long ago.

It is time to ask ourselves if the situation is so dire that it is time to stop pussyfooting around with soft educational messages and begin trying to scare the vaccine deniers into protecting their children – and everyone else’s.

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.”

Okay, let’s try this one more time. We agree that vaccine rates are declining and that the outbreak of measles believed to have spread from an index case at Disneyland is an example of the risk this country faces from those declining rates. In the last few years, there has been at least one study that found that providing vaccine-hesitant families with factual provaccine information failed to change parental attitudes. In fact, the educational effort backfired in some cases, and hesitant parents found other arguments to support their flawed positions. An equally discouraging study presented in the last year suggests that parents have already decided whether they will vaccinate even before they enter into childbearing, long before pediatricians have an opportunity to present their case.

In the face of this dismal landscape of antiscience, some pediatricians have decided to discharge vaccine-refusing families from their practices. Although this approach may create a thin shell of protection against some malpractice suits, and provide their youngest patients a shred of protection from waiting-room acquired infection, it has no effect on the larger problem facing this country.

A study from the University of Illinois published in the Proceedings of the National Academy of Sciences entitled, “Countering anti-vaccine attitudes” (PNAS 2015 Aug 18;112[33]:10321-4) suggests that we may have been too timid in choosing our strategies to combat the antivaccine epidemic. From a group of more than 800 individuals across a broad economic base, a smaller group of 315 was culled using several strategies to ensure that the participants were paying attention. They were then divided into three subgroups whose pretest vaccine attitudes did not differ.

One group was presented with materials that included photographs of ill children with rashes and a testimonial from the mother whose child had had measles. A second group was presented with articles exposing the myth of a relationship between autism and the measles-mumps-rubella vaccine. This group was labeled the “autism correction” group. The control group was presented with several scientific articles unrelated to vaccines.

The researchers found that while the control group and the autism correction group showed no change in their attitudes to vaccines, those individuals presented with graphic evidence of the risk of disease did demonstrate a significant change in attitude. So, the message would seem to be that scaring parents might work.

I’m not sure why pediatricians have been so hesitant to employ scare tactics in the past. While you and I may be more easily convinced by science-based evidence than the average parent, we also have seen children with vaccine-preventable diseases or at least seen pictures and heard their horrible histories. I suspect that our provaccine attitudes are colored more by the horrors that we have seen and heard than by our lip service to the sanctity of science.

We may have been too worried about being labeled as fear mongers if we showed graphic pictures of sick and dying children and promoted tear-jerking testimonials from parents. If we were a business whose bottom line depended on selling vaccines, our marketing and advertising folks would have sent us on the fear-generating pathway long ago.

It is time to ask ourselves if the situation is so dire that it is time to stop pussyfooting around with soft educational messages and begin trying to scare the vaccine deniers into protecting their children – and everyone else’s.

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

It has been clear for a long time that a child who grows up in an environment dominated by adversity is more likely to enter adulthood scarred psychologically, and as a result is less likely to succeed. This well-described association has in the last few years become a hot button topic. A 2012 American Academy of Pediatrics policy statement alerted pediatricians to their potential role in identifying and managing what is now referred to as “toxic stress” (“Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health”).

Although a childhood in which challenges outnumber advantages is often followed by an adult life characterized by failure and dysfunction, there are a few individuals who not only survive a disadvantaged childhood unscathed but somehow manage to thrive in its wake. For example, Joe Rantz, the central figure in Daniel James Brown’s nonfiction best seller “The Boys in the Boat” (New York: Viking Press, 2013) was abandoned several times by his family but emerged to power the University of Washington crew team to victory in the 1936 Olympics. Intrigued by these outliers, a developmental psychologist and clinician from the University of Minnesota named Norman Garmezy began looking for features that may have allowed these exceptional people to succeed and even excel despite incredibly difficult circumstances (“How People Learn to Become Resilient,” Maria Konnikova, The New Yorker, Feb. 11, 2016). His search for the characteristics that might have protected these individuals as children from the acute and chronic environmental threats of their disadvantaged childhoods has spawned a breed of developmental psychologists who devote their research to a quality now referred to as “resilience.”

In 1989, Emmy E. Werner, Ph.D., published a study of 698 children on the island of Kauai in Hawaii and identified several elements that might predict resilience (“Children of the Garden Island,” Sci Am. 1989;260[4]:106-11). Not surprisingly, one factor was the good luck of having formed a strong bond with a supportive person such as a caregiver or mentor. However, Dr. Werner also discovered that resilient individuals possessed a set of psychological characteristics that included a positive social orientation prompting them to “meet the world on their own terms.” They were likely to be autonomous and independent and had the attitude that “they, and not their circumstances, affected their achievements.”

These findings lead to the obvious question of whether those attributes that can protect against adversity can be taught. George Bonanno, a clinical psychologist at Columbia University’s Teachers College, found that an individual’s perception of the situation is the key element in resilience. In the New Yorker article on resilience, he was quoted in an interview as saying, “Events are not traumatic until we experience them as traumatic.” In his studies he has found that individuals can be taught how to reframe an event in positive terms that was initially perceived as negative. Unfortunately, the reverse can occur, and as Dr. Bonanno also said in the interview, “We can create or exaggerate stressors very easily in our own minds.” Every event is potentially traumatic if we perceive it that way.

Could it be that in some situations our behavior as adults, parents, and professionals creates an environment that transforms an event into one that is more easily perceived by a child as traumatizing? While it is important to be on the lookout for children who have been emotionally traumatized by an unfortunate event such as a school shooting, we must be careful to keep our responses measured and positive. Children should be reminded that it is they who control their own behavior and achievements, not the circumstances in which they find themselves.

Parents should be reminded that hovering and overinvolvement in their children’s lives is preventing the development of independence and a sense of autonomy, two important characteristics of resilience. The trend in education that emphasizes group solutions may be helping some children learn to cooperate with others and function as a team. But, we must also remember to offer each individual child abundant opportunities to learn so that he or she can also rely on himself or herself to solve problems.

Few of us will ever have the capacity for resiliency demonstrated by Louis Zamperini in the nonfiction best seller Unbroken, but we can and should be doing a better job helping children learn that even in the most adverse conditions, they have some control – if not over the circumstance, then at least over their perception of it.

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

It has been clear for a long time that a child who grows up in an environment dominated by adversity is more likely to enter adulthood scarred psychologically, and as a result is less likely to succeed. This well-described association has in the last few years become a hot button topic. A 2012 American Academy of Pediatrics policy statement alerted pediatricians to their potential role in identifying and managing what is now referred to as “toxic stress” (“Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health”).

Although a childhood in which challenges outnumber advantages is often followed by an adult life characterized by failure and dysfunction, there are a few individuals who not only survive a disadvantaged childhood unscathed but somehow manage to thrive in its wake. For example, Joe Rantz, the central figure in Daniel James Brown’s nonfiction best seller “The Boys in the Boat” (New York: Viking Press, 2013) was abandoned several times by his family but emerged to power the University of Washington crew team to victory in the 1936 Olympics. Intrigued by these outliers, a developmental psychologist and clinician from the University of Minnesota named Norman Garmezy began looking for features that may have allowed these exceptional people to succeed and even excel despite incredibly difficult circumstances (“How People Learn to Become Resilient,” Maria Konnikova, The New Yorker, Feb. 11, 2016). His search for the characteristics that might have protected these individuals as children from the acute and chronic environmental threats of their disadvantaged childhoods has spawned a breed of developmental psychologists who devote their research to a quality now referred to as “resilience.”

In 1989, Emmy E. Werner, Ph.D., published a study of 698 children on the island of Kauai in Hawaii and identified several elements that might predict resilience (“Children of the Garden Island,” Sci Am. 1989;260[4]:106-11). Not surprisingly, one factor was the good luck of having formed a strong bond with a supportive person such as a caregiver or mentor. However, Dr. Werner also discovered that resilient individuals possessed a set of psychological characteristics that included a positive social orientation prompting them to “meet the world on their own terms.” They were likely to be autonomous and independent and had the attitude that “they, and not their circumstances, affected their achievements.”

These findings lead to the obvious question of whether those attributes that can protect against adversity can be taught. George Bonanno, a clinical psychologist at Columbia University’s Teachers College, found that an individual’s perception of the situation is the key element in resilience. In the New Yorker article on resilience, he was quoted in an interview as saying, “Events are not traumatic until we experience them as traumatic.” In his studies he has found that individuals can be taught how to reframe an event in positive terms that was initially perceived as negative. Unfortunately, the reverse can occur, and as Dr. Bonanno also said in the interview, “We can create or exaggerate stressors very easily in our own minds.” Every event is potentially traumatic if we perceive it that way.

Could it be that in some situations our behavior as adults, parents, and professionals creates an environment that transforms an event into one that is more easily perceived by a child as traumatizing? While it is important to be on the lookout for children who have been emotionally traumatized by an unfortunate event such as a school shooting, we must be careful to keep our responses measured and positive. Children should be reminded that it is they who control their own behavior and achievements, not the circumstances in which they find themselves.

Parents should be reminded that hovering and overinvolvement in their children’s lives is preventing the development of independence and a sense of autonomy, two important characteristics of resilience. The trend in education that emphasizes group solutions may be helping some children learn to cooperate with others and function as a team. But, we must also remember to offer each individual child abundant opportunities to learn so that he or she can also rely on himself or herself to solve problems.

Few of us will ever have the capacity for resiliency demonstrated by Louis Zamperini in the nonfiction best seller Unbroken, but we can and should be doing a better job helping children learn that even in the most adverse conditions, they have some control – if not over the circumstance, then at least over their perception of it.

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

It has been clear for a long time that a child who grows up in an environment dominated by adversity is more likely to enter adulthood scarred psychologically, and as a result is less likely to succeed. This well-described association has in the last few years become a hot button topic. A 2012 American Academy of Pediatrics policy statement alerted pediatricians to their potential role in identifying and managing what is now referred to as “toxic stress” (“Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health”).

Although a childhood in which challenges outnumber advantages is often followed by an adult life characterized by failure and dysfunction, there are a few individuals who not only survive a disadvantaged childhood unscathed but somehow manage to thrive in its wake. For example, Joe Rantz, the central figure in Daniel James Brown’s nonfiction best seller “The Boys in the Boat” (New York: Viking Press, 2013) was abandoned several times by his family but emerged to power the University of Washington crew team to victory in the 1936 Olympics. Intrigued by these outliers, a developmental psychologist and clinician from the University of Minnesota named Norman Garmezy began looking for features that may have allowed these exceptional people to succeed and even excel despite incredibly difficult circumstances (“How People Learn to Become Resilient,” Maria Konnikova, The New Yorker, Feb. 11, 2016). His search for the characteristics that might have protected these individuals as children from the acute and chronic environmental threats of their disadvantaged childhoods has spawned a breed of developmental psychologists who devote their research to a quality now referred to as “resilience.”

In 1989, Emmy E. Werner, Ph.D., published a study of 698 children on the island of Kauai in Hawaii and identified several elements that might predict resilience (“Children of the Garden Island,” Sci Am. 1989;260[4]:106-11). Not surprisingly, one factor was the good luck of having formed a strong bond with a supportive person such as a caregiver or mentor. However, Dr. Werner also discovered that resilient individuals possessed a set of psychological characteristics that included a positive social orientation prompting them to “meet the world on their own terms.” They were likely to be autonomous and independent and had the attitude that “they, and not their circumstances, affected their achievements.”

These findings lead to the obvious question of whether those attributes that can protect against adversity can be taught. George Bonanno, a clinical psychologist at Columbia University’s Teachers College, found that an individual’s perception of the situation is the key element in resilience. In the New Yorker article on resilience, he was quoted in an interview as saying, “Events are not traumatic until we experience them as traumatic.” In his studies he has found that individuals can be taught how to reframe an event in positive terms that was initially perceived as negative. Unfortunately, the reverse can occur, and as Dr. Bonanno also said in the interview, “We can create or exaggerate stressors very easily in our own minds.” Every event is potentially traumatic if we perceive it that way.

Could it be that in some situations our behavior as adults, parents, and professionals creates an environment that transforms an event into one that is more easily perceived by a child as traumatizing? While it is important to be on the lookout for children who have been emotionally traumatized by an unfortunate event such as a school shooting, we must be careful to keep our responses measured and positive. Children should be reminded that it is they who control their own behavior and achievements, not the circumstances in which they find themselves.

Parents should be reminded that hovering and overinvolvement in their children’s lives is preventing the development of independence and a sense of autonomy, two important characteristics of resilience. The trend in education that emphasizes group solutions may be helping some children learn to cooperate with others and function as a team. But, we must also remember to offer each individual child abundant opportunities to learn so that he or she can also rely on himself or herself to solve problems.

Few of us will ever have the capacity for resiliency demonstrated by Louis Zamperini in the nonfiction best seller Unbroken, but we can and should be doing a better job helping children learn that even in the most adverse conditions, they have some control – if not over the circumstance, then at least over their perception of it.

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.”

How do you feel about hunger? Do you trust in its power? Having written one book on picky eating based solely on my mother’s wisdom, supplemented with a scanty amount of Internet-based research, I have spent and continue to spend a good bit of time thinking about hunger.

I have concluded that it is a very powerful force and that when a child gets hungry enough, he will eat, even foods that he has previously rejected. It is that assumption that is at the core of my advice to parents of picky eaters. I suspect that many of you share that same philosophy and recommend a strategy that is heavy on patience. Of course the problem lies in getting parents to adopt that attitude and accept the fact that if they just present a healthy diet and step back, hunger will eventually win, and the child will eat.

However, the devil is in the details. Have the parents set rules that will prevent the child from overdrinking? Have they really stopped talking about what the child, and everyone else in the family, is or isn’t eating? Are the parents setting good examples with their own eating habits and comments about food?

Because 99% of my patient population have been healthy, I have always felt comfortable relying on the power of hunger to win the battle over picky eating. If properly managed, none of my patients was going to die or suffer permanent consequences from picky eating. However, I have always wondered whether hunger could be leveraged to safely manage selective eating in children with serious health problems. I have a suspicion that it would succeed, but luckily I have never been presented with a case to test my hunch.

I recently read a very personal account written by the mother of a child with severe congenital cardiac disease that supports my gut feeling that when carefully monitored, starvation can be an effective strategy in managing selective eating (“When Your Baby Won’t Eat,” by Virginia Sole-Smith, The New York Times Magazine, Feb. 4, 2016). Three surgeries in the first few months of life necessitated that the child be fed by gavage. Attempts at breastfeeding failed, as it often does in situations like this. Struggles with gavage tube placement at home became such an emotionally traumatic ordeal that eventually a gastrostomy tube was placed when the child was 6 months old.

The family was led to believe that an important window in the child’s oral development had closed as a result of interventions necessitated by the child’s cardiac malformations. Although she was neurologically and physically capable of eating, getting her to do so was going to require long-term behavior modification, and there was no guarantee that this approach would completely undo what bad luck and prior management strategies had created. She might never relate to food as a normal child does.

After several attempts at behavior management using one-to-one reinforcement, this mother began to do some research. She discovered that of the nearly 30 feeding programs in children’s hospitals and private clinics, almost all use variations of a similar behavior modification strategy that had not worked for her daughter. As she observed: “This behavioral model presumes that children who don’t eat need external motivation.”

Eventually, the family found help in one of the few feeding programs in the United States that has adopted a dramatically different “child-centered” approach in which “therapists believe that all children have some internal motivation to eat, as well as an innate ability to effectively self-regulate their intake.” The solution to this child’s problem didn’t occur overnight. It began by exposing the child to a variety of foods in situations free of attempts to get her to eat – no coercion or rewards, regardless of how subtle they might have seemed. Once the child was experimenting with food, her tube feedings were gradually decreased in volume and caloric content. And, voila! Hunger won and the child began meeting her total nutritional needs by eating, in some cases with gusto.

Of course I was easy to convince because the results confirmed my hunch. But, do you believe that hunger can and should be used as the centerpiece in the management of selective eating, even in cases well beyond the parameters of garden variety picky eating? Are you willing to play the hunger game along with me?

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.”

How do you feel about hunger? Do you trust in its power? Having written one book on picky eating based solely on my mother’s wisdom, supplemented with a scanty amount of Internet-based research, I have spent and continue to spend a good bit of time thinking about hunger.

I have concluded that it is a very powerful force and that when a child gets hungry enough, he will eat, even foods that he has previously rejected. It is that assumption that is at the core of my advice to parents of picky eaters. I suspect that many of you share that same philosophy and recommend a strategy that is heavy on patience. Of course the problem lies in getting parents to adopt that attitude and accept the fact that if they just present a healthy diet and step back, hunger will eventually win, and the child will eat.

However, the devil is in the details. Have the parents set rules that will prevent the child from overdrinking? Have they really stopped talking about what the child, and everyone else in the family, is or isn’t eating? Are the parents setting good examples with their own eating habits and comments about food?

Because 99% of my patient population have been healthy, I have always felt comfortable relying on the power of hunger to win the battle over picky eating. If properly managed, none of my patients was going to die or suffer permanent consequences from picky eating. However, I have always wondered whether hunger could be leveraged to safely manage selective eating in children with serious health problems. I have a suspicion that it would succeed, but luckily I have never been presented with a case to test my hunch.

I recently read a very personal account written by the mother of a child with severe congenital cardiac disease that supports my gut feeling that when carefully monitored, starvation can be an effective strategy in managing selective eating (“When Your Baby Won’t Eat,” by Virginia Sole-Smith, The New York Times Magazine, Feb. 4, 2016). Three surgeries in the first few months of life necessitated that the child be fed by gavage. Attempts at breastfeeding failed, as it often does in situations like this. Struggles with gavage tube placement at home became such an emotionally traumatic ordeal that eventually a gastrostomy tube was placed when the child was 6 months old.

The family was led to believe that an important window in the child’s oral development had closed as a result of interventions necessitated by the child’s cardiac malformations. Although she was neurologically and physically capable of eating, getting her to do so was going to require long-term behavior modification, and there was no guarantee that this approach would completely undo what bad luck and prior management strategies had created. She might never relate to food as a normal child does.

After several attempts at behavior management using one-to-one reinforcement, this mother began to do some research. She discovered that of the nearly 30 feeding programs in children’s hospitals and private clinics, almost all use variations of a similar behavior modification strategy that had not worked for her daughter. As she observed: “This behavioral model presumes that children who don’t eat need external motivation.”

Eventually, the family found help in one of the few feeding programs in the United States that has adopted a dramatically different “child-centered” approach in which “therapists believe that all children have some internal motivation to eat, as well as an innate ability to effectively self-regulate their intake.” The solution to this child’s problem didn’t occur overnight. It began by exposing the child to a variety of foods in situations free of attempts to get her to eat – no coercion or rewards, regardless of how subtle they might have seemed. Once the child was experimenting with food, her tube feedings were gradually decreased in volume and caloric content. And, voila! Hunger won and the child began meeting her total nutritional needs by eating, in some cases with gusto.

Of course I was easy to convince because the results confirmed my hunch. But, do you believe that hunger can and should be used as the centerpiece in the management of selective eating, even in cases well beyond the parameters of garden variety picky eating? Are you willing to play the hunger game along with me?

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.”

How do you feel about hunger? Do you trust in its power? Having written one book on picky eating based solely on my mother’s wisdom, supplemented with a scanty amount of Internet-based research, I have spent and continue to spend a good bit of time thinking about hunger.

I have concluded that it is a very powerful force and that when a child gets hungry enough, he will eat, even foods that he has previously rejected. It is that assumption that is at the core of my advice to parents of picky eaters. I suspect that many of you share that same philosophy and recommend a strategy that is heavy on patience. Of course the problem lies in getting parents to adopt that attitude and accept the fact that if they just present a healthy diet and step back, hunger will eventually win, and the child will eat.

However, the devil is in the details. Have the parents set rules that will prevent the child from overdrinking? Have they really stopped talking about what the child, and everyone else in the family, is or isn’t eating? Are the parents setting good examples with their own eating habits and comments about food?

Because 99% of my patient population have been healthy, I have always felt comfortable relying on the power of hunger to win the battle over picky eating. If properly managed, none of my patients was going to die or suffer permanent consequences from picky eating. However, I have always wondered whether hunger could be leveraged to safely manage selective eating in children with serious health problems. I have a suspicion that it would succeed, but luckily I have never been presented with a case to test my hunch.

I recently read a very personal account written by the mother of a child with severe congenital cardiac disease that supports my gut feeling that when carefully monitored, starvation can be an effective strategy in managing selective eating (“When Your Baby Won’t Eat,” by Virginia Sole-Smith, The New York Times Magazine, Feb. 4, 2016). Three surgeries in the first few months of life necessitated that the child be fed by gavage. Attempts at breastfeeding failed, as it often does in situations like this. Struggles with gavage tube placement at home became such an emotionally traumatic ordeal that eventually a gastrostomy tube was placed when the child was 6 months old.

The family was led to believe that an important window in the child’s oral development had closed as a result of interventions necessitated by the child’s cardiac malformations. Although she was neurologically and physically capable of eating, getting her to do so was going to require long-term behavior modification, and there was no guarantee that this approach would completely undo what bad luck and prior management strategies had created. She might never relate to food as a normal child does.

After several attempts at behavior management using one-to-one reinforcement, this mother began to do some research. She discovered that of the nearly 30 feeding programs in children’s hospitals and private clinics, almost all use variations of a similar behavior modification strategy that had not worked for her daughter. As she observed: “This behavioral model presumes that children who don’t eat need external motivation.”

Eventually, the family found help in one of the few feeding programs in the United States that has adopted a dramatically different “child-centered” approach in which “therapists believe that all children have some internal motivation to eat, as well as an innate ability to effectively self-regulate their intake.” The solution to this child’s problem didn’t occur overnight. It began by exposing the child to a variety of foods in situations free of attempts to get her to eat – no coercion or rewards, regardless of how subtle they might have seemed. Once the child was experimenting with food, her tube feedings were gradually decreased in volume and caloric content. And, voila! Hunger won and the child began meeting her total nutritional needs by eating, in some cases with gusto.

Of course I was easy to convince because the results confirmed my hunch. But, do you believe that hunger can and should be used as the centerpiece in the management of selective eating, even in cases well beyond the parameters of garden variety picky eating? Are you willing to play the hunger game along with me?

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 hope I am correct, but it seems to me that the “holistic” label is fading into the sunset. I never quite got what a holistic physician was doing that I wasn’t. Was I ignoring the fact that my patient came from a certain ethnic group and that his family had a particular set of religious beliefs? I may not have understood or agreed with those customs or beliefs. But I knew that I had better take them into account as I tried to find what was troubling the patient and help him search for a solution.

When the patient with frequent abdominal pains asked me for advice, did I fail to ask a social history because I didn’t think that the fact that her father had just lost his job or that her favorite grandmother was dying of cancer was important? Did I simply write prescriptions and avoid making recommendations about bedtimes, diet, exercise, and relaxation strategies? Did I stop my exam at the clavicles when the patient’s chief complaint was headache?

I’m sure that most physicians who marketed themselves as being holistic passionately believed that a good doctor must consider the whole patient. But what troubled me was the implication that the rest of us didn’t. I suspect that the fading popularity of the label reflects that patients began to realize that it was meaningless.

However, another buzzword has begun to flutter across the medical landscape. Every few days I open a magazine or journal in which someone is suggesting that I need to be more mindful. And they are more than willing to show me or sell me a technique for achieving mindfulness.

Is this just another packaging ploy, or should I begin paddling out to catch this new wave? The more I began to see mindfulness offered and promoted in a wider variety of settings, the more confused I became. So I did what anyone with a WiFi connection would do. I Googled “mindfulness” and discovered that I had good reason to feel confused.

It turns out that in some form or another mindfulness has been a practice in the Buddhist tradition with a history dating back hundreds of years. The first definition I found in Wikipedia read: “being aware moment-to-moment of one’s subjective conscious experience from a first-person perspective.” However, as I read further I discovered a reference to no fewer than 13 disparate definitions across a spectrum from attention and awareness on one end to retention and remindfulness on the other.

Some advocates feel that meditation should be used to prepare oneself to be mindful or that meditation is integral to mindfulness. Other folks don’t seem to see meditation as particularly necessary.

There is a growing body of literature reporting that something labeled mindfulness has helped patients and practitioners improve one or more aspects of wellness. Although the quality of these reports varies widely, it suggests along with the long Buddhist tradition that there is something out there called mindfulness worth investigating.

However, I wonder why it is becoming so widely ballyhooed. It seems to me that at its core, being mindful is simply just trying to do a better job of paying attention to the world around us and our fellow inhabitants. Is it simply the flip side of an attention deficiency? Or, is it an attempt to give a more exotic and mysterious Asian-influenced label to cognitive-behavioral therapy? Could it just be a less judgmental way of asking ourselves, “What were (are) you thinking?”

“Mindfulness” appears to have considerably more substance than “holistic,” but I fear that its indiscriminant use is going to damage its credibility. The overexposure has certainly triggered my skepticism.

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 hope I am correct, but it seems to me that the “holistic” label is fading into the sunset. I never quite got what a holistic physician was doing that I wasn’t. Was I ignoring the fact that my patient came from a certain ethnic group and that his family had a particular set of religious beliefs? I may not have understood or agreed with those customs or beliefs. But I knew that I had better take them into account as I tried to find what was troubling the patient and help him search for a solution.

When the patient with frequent abdominal pains asked me for advice, did I fail to ask a social history because I didn’t think that the fact that her father had just lost his job or that her favorite grandmother was dying of cancer was important? Did I simply write prescriptions and avoid making recommendations about bedtimes, diet, exercise, and relaxation strategies? Did I stop my exam at the clavicles when the patient’s chief complaint was headache?

I’m sure that most physicians who marketed themselves as being holistic passionately believed that a good doctor must consider the whole patient. But what troubled me was the implication that the rest of us didn’t. I suspect that the fading popularity of the label reflects that patients began to realize that it was meaningless.

However, another buzzword has begun to flutter across the medical landscape. Every few days I open a magazine or journal in which someone is suggesting that I need to be more mindful. And they are more than willing to show me or sell me a technique for achieving mindfulness.

Is this just another packaging ploy, or should I begin paddling out to catch this new wave? The more I began to see mindfulness offered and promoted in a wider variety of settings, the more confused I became. So I did what anyone with a WiFi connection would do. I Googled “mindfulness” and discovered that I had good reason to feel confused.

It turns out that in some form or another mindfulness has been a practice in the Buddhist tradition with a history dating back hundreds of years. The first definition I found in Wikipedia read: “being aware moment-to-moment of one’s subjective conscious experience from a first-person perspective.” However, as I read further I discovered a reference to no fewer than 13 disparate definitions across a spectrum from attention and awareness on one end to retention and remindfulness on the other.

Some advocates feel that meditation should be used to prepare oneself to be mindful or that meditation is integral to mindfulness. Other folks don’t seem to see meditation as particularly necessary.

There is a growing body of literature reporting that something labeled mindfulness has helped patients and practitioners improve one or more aspects of wellness. Although the quality of these reports varies widely, it suggests along with the long Buddhist tradition that there is something out there called mindfulness worth investigating.

However, I wonder why it is becoming so widely ballyhooed. It seems to me that at its core, being mindful is simply just trying to do a better job of paying attention to the world around us and our fellow inhabitants. Is it simply the flip side of an attention deficiency? Or, is it an attempt to give a more exotic and mysterious Asian-influenced label to cognitive-behavioral therapy? Could it just be a less judgmental way of asking ourselves, “What were (are) you thinking?”

“Mindfulness” appears to have considerably more substance than “holistic,” but I fear that its indiscriminant use is going to damage its credibility. The overexposure has certainly triggered my skepticism.

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 hope I am correct, but it seems to me that the “holistic” label is fading into the sunset. I never quite got what a holistic physician was doing that I wasn’t. Was I ignoring the fact that my patient came from a certain ethnic group and that his family had a particular set of religious beliefs? I may not have understood or agreed with those customs or beliefs. But I knew that I had better take them into account as I tried to find what was troubling the patient and help him search for a solution.

When the patient with frequent abdominal pains asked me for advice, did I fail to ask a social history because I didn’t think that the fact that her father had just lost his job or that her favorite grandmother was dying of cancer was important? Did I simply write prescriptions and avoid making recommendations about bedtimes, diet, exercise, and relaxation strategies? Did I stop my exam at the clavicles when the patient’s chief complaint was headache?

I’m sure that most physicians who marketed themselves as being holistic passionately believed that a good doctor must consider the whole patient. But what troubled me was the implication that the rest of us didn’t. I suspect that the fading popularity of the label reflects that patients began to realize that it was meaningless.

However, another buzzword has begun to flutter across the medical landscape. Every few days I open a magazine or journal in which someone is suggesting that I need to be more mindful. And they are more than willing to show me or sell me a technique for achieving mindfulness.

Is this just another packaging ploy, or should I begin paddling out to catch this new wave? The more I began to see mindfulness offered and promoted in a wider variety of settings, the more confused I became. So I did what anyone with a WiFi connection would do. I Googled “mindfulness” and discovered that I had good reason to feel confused.

It turns out that in some form or another mindfulness has been a practice in the Buddhist tradition with a history dating back hundreds of years. The first definition I found in Wikipedia read: “being aware moment-to-moment of one’s subjective conscious experience from a first-person perspective.” However, as I read further I discovered a reference to no fewer than 13 disparate definitions across a spectrum from attention and awareness on one end to retention and remindfulness on the other.

Some advocates feel that meditation should be used to prepare oneself to be mindful or that meditation is integral to mindfulness. Other folks don’t seem to see meditation as particularly necessary.

There is a growing body of literature reporting that something labeled mindfulness has helped patients and practitioners improve one or more aspects of wellness. Although the quality of these reports varies widely, it suggests along with the long Buddhist tradition that there is something out there called mindfulness worth investigating.

However, I wonder why it is becoming so widely ballyhooed. It seems to me that at its core, being mindful is simply just trying to do a better job of paying attention to the world around us and our fellow inhabitants. Is it simply the flip side of an attention deficiency? Or, is it an attempt to give a more exotic and mysterious Asian-influenced label to cognitive-behavioral therapy? Could it just be a less judgmental way of asking ourselves, “What were (are) you thinking?”

“Mindfulness” appears to have considerably more substance than “holistic,” but I fear that its indiscriminant use is going to damage its credibility. The overexposure has certainly triggered my skepticism.

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 have had a long and circuitous relationship with the radius. When I was 9 years old, I slipped on the wet grass of our front yard in an attempt to make a highlight-reel baseball catch and landed awkwardly on my left arm. After I continued to complain for a day and a half, my mother took me to see our pediatrician, Dr. Blum. After feeling up and down my forearm and asking me to squeeze his fingers, he pronounced me well.

A week and a half later, when I was still favoring what is my dominant arm, we returned to Dr. Blum. Apparently still unimpressed with my physical exam, he begrudgingly ordered an x-ray. Hurrah! I had a fracture! But then he announced that we would treat it with a splint and an ace wrap. Come on! Everyone knows that if you break a bone you get a cast. From then on he was Dr. Bum to me.

For the next 2 weeks, I was forbidden to play sports, meanwhile losing serious credibility points with my peers who suspected that I was a wimp and had fabricated the whole story. And of course, does anyone go around asking their friends to sign his ace wrap ... really? It took me years of overcompensation to regain even a hint of preteen machismo.

During my last year of medical school, I leapt at the opportunity to take an elective in pediatric orthopedics. It was great! With coaching from the residents, I learned when to suspect a buckle fracture of the radius, identify it on x-ray, and best of all, how to apply a cast.

When I finally entered practice here in Brunswick, we were seriously short of specialists, including orthopedists. When it was discovered that I knew how to apply a forearm cast, the orthopedists encouraged me to treat my own patients with simple forearm fractures. They were more than busy enough with really exciting stuff.

As an artist at heart, the chance to mold in plaster and plastic was a special treat. I took great pride in my creations, and making a beautiful crafted cast was sometimes the high point of my day. No splints or wimpy ace wraps for my patients!

Parents loved the one-stop shopping. History, exam, x-ray, casting, and out the door in less than an hour. Because I was the only primary care physician in town who was casting fractures, I occasionally had to remind the emergency room physicians to send me my patients with buckle fractures instead of knee-jerking a referral to an orthopedist.

But then about 10 years ago, some party-pooping orthopedists from who-knows-where looked at a very large series of pediatric patients with buckle fractures of the radius and discovered that those patients treated with splints had at least as good results as those who had been casted. And ... the patients and parents preferred the splints. I had to admit that maybe Dr. Blum wasn’t such a bum after all. Sadly, I had to respond to the evidence by giving up my hobby except when a child’s temperament or past history of injury suggested that he or she might benefit from the extra protection a cast could afford.

A recent study from Toronto published in Pediatrics, “Primary Care Physician Follow-up of Distal Radius Buckle Fractures,” by Koelink et al., makes me wonder whether a splint and ace wrap may even be overtreatment (Pediatrics. 2016 Jan;137[1]:11-9. doi: 10.1542/peds.2015-2262). In this review of 200 pediatric patients with distal radius buckle fractures, the investigators found that regardless of whether the primary care physician discussed how long to use the splint or when to return to activity, more than two-thirds of the patients wore their splints less than 3 weeks. Despite what the authors considered suboptimal primary care physician guidance, 99% of the patients returned to usual activities within 4 weeks.

My mother and Dr. Blum were on the right track from the beginning. They just needed to ignore my complaints a few days longer.

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 have had a long and circuitous relationship with the radius. When I was 9 years old, I slipped on the wet grass of our front yard in an attempt to make a highlight-reel baseball catch and landed awkwardly on my left arm. After I continued to complain for a day and a half, my mother took me to see our pediatrician, Dr. Blum. After feeling up and down my forearm and asking me to squeeze his fingers, he pronounced me well.

A week and a half later, when I was still favoring what is my dominant arm, we returned to Dr. Blum. Apparently still unimpressed with my physical exam, he begrudgingly ordered an x-ray. Hurrah! I had a fracture! But then he announced that we would treat it with a splint and an ace wrap. Come on! Everyone knows that if you break a bone you get a cast. From then on he was Dr. Bum to me.

For the next 2 weeks, I was forbidden to play sports, meanwhile losing serious credibility points with my peers who suspected that I was a wimp and had fabricated the whole story. And of course, does anyone go around asking their friends to sign his ace wrap ... really? It took me years of overcompensation to regain even a hint of preteen machismo.

During my last year of medical school, I leapt at the opportunity to take an elective in pediatric orthopedics. It was great! With coaching from the residents, I learned when to suspect a buckle fracture of the radius, identify it on x-ray, and best of all, how to apply a cast.

When I finally entered practice here in Brunswick, we were seriously short of specialists, including orthopedists. When it was discovered that I knew how to apply a forearm cast, the orthopedists encouraged me to treat my own patients with simple forearm fractures. They were more than busy enough with really exciting stuff.

As an artist at heart, the chance to mold in plaster and plastic was a special treat. I took great pride in my creations, and making a beautiful crafted cast was sometimes the high point of my day. No splints or wimpy ace wraps for my patients!

Parents loved the one-stop shopping. History, exam, x-ray, casting, and out the door in less than an hour. Because I was the only primary care physician in town who was casting fractures, I occasionally had to remind the emergency room physicians to send me my patients with buckle fractures instead of knee-jerking a referral to an orthopedist.

But then about 10 years ago, some party-pooping orthopedists from who-knows-where looked at a very large series of pediatric patients with buckle fractures of the radius and discovered that those patients treated with splints had at least as good results as those who had been casted. And ... the patients and parents preferred the splints. I had to admit that maybe Dr. Blum wasn’t such a bum after all. Sadly, I had to respond to the evidence by giving up my hobby except when a child’s temperament or past history of injury suggested that he or she might benefit from the extra protection a cast could afford.

A recent study from Toronto published in Pediatrics, “Primary Care Physician Follow-up of Distal Radius Buckle Fractures,” by Koelink et al., makes me wonder whether a splint and ace wrap may even be overtreatment (Pediatrics. 2016 Jan;137[1]:11-9. doi: 10.1542/peds.2015-2262). In this review of 200 pediatric patients with distal radius buckle fractures, the investigators found that regardless of whether the primary care physician discussed how long to use the splint or when to return to activity, more than two-thirds of the patients wore their splints less than 3 weeks. Despite what the authors considered suboptimal primary care physician guidance, 99% of the patients returned to usual activities within 4 weeks.

My mother and Dr. Blum were on the right track from the beginning. They just needed to ignore my complaints a few days longer.

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 have had a long and circuitous relationship with the radius. When I was 9 years old, I slipped on the wet grass of our front yard in an attempt to make a highlight-reel baseball catch and landed awkwardly on my left arm. After I continued to complain for a day and a half, my mother took me to see our pediatrician, Dr. Blum. After feeling up and down my forearm and asking me to squeeze his fingers, he pronounced me well.

A week and a half later, when I was still favoring what is my dominant arm, we returned to Dr. Blum. Apparently still unimpressed with my physical exam, he begrudgingly ordered an x-ray. Hurrah! I had a fracture! But then he announced that we would treat it with a splint and an ace wrap. Come on! Everyone knows that if you break a bone you get a cast. From then on he was Dr. Bum to me.

For the next 2 weeks, I was forbidden to play sports, meanwhile losing serious credibility points with my peers who suspected that I was a wimp and had fabricated the whole story. And of course, does anyone go around asking their friends to sign his ace wrap ... really? It took me years of overcompensation to regain even a hint of preteen machismo.

During my last year of medical school, I leapt at the opportunity to take an elective in pediatric orthopedics. It was great! With coaching from the residents, I learned when to suspect a buckle fracture of the radius, identify it on x-ray, and best of all, how to apply a cast.

When I finally entered practice here in Brunswick, we were seriously short of specialists, including orthopedists. When it was discovered that I knew how to apply a forearm cast, the orthopedists encouraged me to treat my own patients with simple forearm fractures. They were more than busy enough with really exciting stuff.

As an artist at heart, the chance to mold in plaster and plastic was a special treat. I took great pride in my creations, and making a beautiful crafted cast was sometimes the high point of my day. No splints or wimpy ace wraps for my patients!

Parents loved the one-stop shopping. History, exam, x-ray, casting, and out the door in less than an hour. Because I was the only primary care physician in town who was casting fractures, I occasionally had to remind the emergency room physicians to send me my patients with buckle fractures instead of knee-jerking a referral to an orthopedist.

But then about 10 years ago, some party-pooping orthopedists from who-knows-where looked at a very large series of pediatric patients with buckle fractures of the radius and discovered that those patients treated with splints had at least as good results as those who had been casted. And ... the patients and parents preferred the splints. I had to admit that maybe Dr. Blum wasn’t such a bum after all. Sadly, I had to respond to the evidence by giving up my hobby except when a child’s temperament or past history of injury suggested that he or she might benefit from the extra protection a cast could afford.

A recent study from Toronto published in Pediatrics, “Primary Care Physician Follow-up of Distal Radius Buckle Fractures,” by Koelink et al., makes me wonder whether a splint and ace wrap may even be overtreatment (Pediatrics. 2016 Jan;137[1]:11-9. doi: 10.1542/peds.2015-2262). In this review of 200 pediatric patients with distal radius buckle fractures, the investigators found that regardless of whether the primary care physician discussed how long to use the splint or when to return to activity, more than two-thirds of the patients wore their splints less than 3 weeks. Despite what the authors considered suboptimal primary care physician guidance, 99% of the patients returned to usual activities within 4 weeks.

My mother and Dr. Blum were on the right track from the beginning. They just needed to ignore my complaints a few days longer.

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

In her role as the Dowager Countess on Public Broadcasting Service’s Downton Abbey, Maggie Smith has delivered many memorable one-liners, but none as revealing of her character’s social isolation as the clueless query, “What is a weekend?” How could anyone not appreciate the qualitative differences between the first 4 days of the week and the trio of Friday, Saturday, and Sunday?

A recent study by two Stanford University sociologists suggests that one doesn’t even need to have a job to place a higher value on the weekend (“You Don’t Need More Free Time,” by Cristobal Young, New York Times, Jan. 8, 2016). Using data from more than 500,000 respondents to a Gallup Daily Poll, the investigators found that a variety of indicators of well-being were lowest during the beginning of the workweek and then not surprisingly began to climb on Friday, reaching a peak on Saturday and Sunday. However, it turns out that the emotions of the unemployed respondents tracked exactly the same pattern as those of the people who had jobs.

In an effort to explain this unexpected finding, one of the investigators points out that time, particularly free time, is a “network good.” And in sociologist lingo, “Network goods are things that derive their value from being widely shared.” Although someone without a job may have an abundance of free time, the majority of the people with whom he or she could share that time are busy at work.

This study suggests that you may feel that you would be happier if you had more time off from work; part of the problem may be that there is a mismatch between your schedule and the schedules of the people and activities that you value most. You may have done this kind of self-assessment when you were looking for a job, but how successful were you in negotiating your schedule? Have you been able to renegotiate your schedule to match changes in your social situation? Spouse? Children?

How creative have you been in seeking out arrangements with coworkers who don’t share your time-off value profile? Although you might be tempted to say that based on this recent Stanford study, everyone places the same high value on weekend time off, is this really the case? There are a few people out there whose interests, personalities, and social situations make them value time off when you would just as soon work.

For example, I recently encountered a new word as I was scanning the classified advertisements in the back of this month’s Pediatrics. A hospital in California was looking for a “nocturnist.” An Internet search quickly confirmed my suspicion that a nocturnist is a physician, often a hospitalist, who prefers to work the night shift. Now, it may be just for the money, but if I were an avid birdwatcher, I can imagine wanting to maximize my time off when the sun was up.

Of course the trick is finding those coworkers whose lifestyles are as dissimilar from yours as possible ... and who are willing to trade work schedules. While I think that on many campuses, “diversity” has become an overused buzzword, diversity at your workplace might give you the best chance of finding a time-off arrangement that better matches your value profile.

Finally, if you are really unhappy, it may be time to swallow hard and entertain an arrangement in which you worked more and actually had less total free time, but the time you do have off is time you can share with the people you value and the activities you enjoy. It’s all about choosing the right set of compromises and learning to live with them. Good luck!

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

In her role as the Dowager Countess on Public Broadcasting Service’s Downton Abbey, Maggie Smith has delivered many memorable one-liners, but none as revealing of her character’s social isolation as the clueless query, “What is a weekend?” How could anyone not appreciate the qualitative differences between the first 4 days of the week and the trio of Friday, Saturday, and Sunday?

A recent study by two Stanford University sociologists suggests that one doesn’t even need to have a job to place a higher value on the weekend (“You Don’t Need More Free Time,” by Cristobal Young, New York Times, Jan. 8, 2016). Using data from more than 500,000 respondents to a Gallup Daily Poll, the investigators found that a variety of indicators of well-being were lowest during the beginning of the workweek and then not surprisingly began to climb on Friday, reaching a peak on Saturday and Sunday. However, it turns out that the emotions of the unemployed respondents tracked exactly the same pattern as those of the people who had jobs.

In an effort to explain this unexpected finding, one of the investigators points out that time, particularly free time, is a “network good.” And in sociologist lingo, “Network goods are things that derive their value from being widely shared.” Although someone without a job may have an abundance of free time, the majority of the people with whom he or she could share that time are busy at work.

This study suggests that you may feel that you would be happier if you had more time off from work; part of the problem may be that there is a mismatch between your schedule and the schedules of the people and activities that you value most. You may have done this kind of self-assessment when you were looking for a job, but how successful were you in negotiating your schedule? Have you been able to renegotiate your schedule to match changes in your social situation? Spouse? Children?

How creative have you been in seeking out arrangements with coworkers who don’t share your time-off value profile? Although you might be tempted to say that based on this recent Stanford study, everyone places the same high value on weekend time off, is this really the case? There are a few people out there whose interests, personalities, and social situations make them value time off when you would just as soon work.

For example, I recently encountered a new word as I was scanning the classified advertisements in the back of this month’s Pediatrics. A hospital in California was looking for a “nocturnist.” An Internet search quickly confirmed my suspicion that a nocturnist is a physician, often a hospitalist, who prefers to work the night shift. Now, it may be just for the money, but if I were an avid birdwatcher, I can imagine wanting to maximize my time off when the sun was up.

Of course the trick is finding those coworkers whose lifestyles are as dissimilar from yours as possible ... and who are willing to trade work schedules. While I think that on many campuses, “diversity” has become an overused buzzword, diversity at your workplace might give you the best chance of finding a time-off arrangement that better matches your value profile.

Finally, if you are really unhappy, it may be time to swallow hard and entertain an arrangement in which you worked more and actually had less total free time, but the time you do have off is time you can share with the people you value and the activities you enjoy. It’s all about choosing the right set of compromises and learning to live with them. Good luck!

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

In her role as the Dowager Countess on Public Broadcasting Service’s Downton Abbey, Maggie Smith has delivered many memorable one-liners, but none as revealing of her character’s social isolation as the clueless query, “What is a weekend?” How could anyone not appreciate the qualitative differences between the first 4 days of the week and the trio of Friday, Saturday, and Sunday?

A recent study by two Stanford University sociologists suggests that one doesn’t even need to have a job to place a higher value on the weekend (“You Don’t Need More Free Time,” by Cristobal Young, New York Times, Jan. 8, 2016). Using data from more than 500,000 respondents to a Gallup Daily Poll, the investigators found that a variety of indicators of well-being were lowest during the beginning of the workweek and then not surprisingly began to climb on Friday, reaching a peak on Saturday and Sunday. However, it turns out that the emotions of the unemployed respondents tracked exactly the same pattern as those of the people who had jobs.

In an effort to explain this unexpected finding, one of the investigators points out that time, particularly free time, is a “network good.” And in sociologist lingo, “Network goods are things that derive their value from being widely shared.” Although someone without a job may have an abundance of free time, the majority of the people with whom he or she could share that time are busy at work.

This study suggests that you may feel that you would be happier if you had more time off from work; part of the problem may be that there is a mismatch between your schedule and the schedules of the people and activities that you value most. You may have done this kind of self-assessment when you were looking for a job, but how successful were you in negotiating your schedule? Have you been able to renegotiate your schedule to match changes in your social situation? Spouse? Children?

How creative have you been in seeking out arrangements with coworkers who don’t share your time-off value profile? Although you might be tempted to say that based on this recent Stanford study, everyone places the same high value on weekend time off, is this really the case? There are a few people out there whose interests, personalities, and social situations make them value time off when you would just as soon work.

For example, I recently encountered a new word as I was scanning the classified advertisements in the back of this month’s Pediatrics. A hospital in California was looking for a “nocturnist.” An Internet search quickly confirmed my suspicion that a nocturnist is a physician, often a hospitalist, who prefers to work the night shift. Now, it may be just for the money, but if I were an avid birdwatcher, I can imagine wanting to maximize my time off when the sun was up.

Of course the trick is finding those coworkers whose lifestyles are as dissimilar from yours as possible ... and who are willing to trade work schedules. While I think that on many campuses, “diversity” has become an overused buzzword, diversity at your workplace might give you the best chance of finding a time-off arrangement that better matches your value profile.

Finally, if you are really unhappy, it may be time to swallow hard and entertain an arrangement in which you worked more and actually had less total free time, but the time you do have off is time you can share with the people you value and the activities you enjoy. It’s all about choosing the right set of compromises and learning to live with them. Good luck!

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 few years ago I wrote a column about what promised to be an exciting development in blood testing technology. Using the money her parents had set aside for her education, a young woman dropped out of Stanford University at age 19 and started a company that she claimed would be able to offer hundreds of lab tests on just a few drops of blood. Results would be available in just minutes instead of hours or days. At the time I wrote the column, the company had just landed a contract with a large drug store chain with an arrangement that would eventually allow nearly every resident of the United States to be within a few miles of a site that would offer rapid response blood tests with nothing more than a finger prick.

It seemed a little hard to believe, but the prospect of pediatricians being able to make a diagnosis without running the risk of exsanguinating our smallest patients sounded appealing. On the other hand, I worried that a quick and easy technology might encourage some physicians to use a shotgun approach to diagnosing illness rather than a more rational and cost-effective process based on the traditional skills of history taking and physical examination. Some patients who foolishly wanted to know “everything” about themselves might be tempted to ask their physicians to order the whole smorgasbord of tests. “Hey, it’s only a few drops of blood.”

Turns out there were enough people with more money than reservations and the company quickly attracted hundreds of millions of dollars in venture capital. The company, now calling itself Theranos, has been valued at nine billion dollars. But, recently this startup star has encountered some serious bumps in the road to a full-scale launch (“Hot Startup Theranos Has Struggled With Its Blood-Test Technology” by John Carreyrou, The Wall Street Journal, updated Oct. 16, 2015). The Wall Street Journal reported that despite promises, only a few of the 240 tests offered by the company are currently performed using their proprietary microtechnique. In the days following the Journal article, the Food and Drug Administration warned Theranos that their “nanotainer” is considered a new medical device that must first clear the agency’s time consuming and costly vetting process (“Hot Startup Theranos Dials Back Lab Tests at FDA’s Behest” by John Carreyrou, The Wall Street Journal, updated Oct. 16, 2015).

The venture capitalists who had climbed on the Theranos bandwagon tempted by the just-a-few-drops promise may end up seeing their bank accounts hemorrhage. But I don’t think we should be too critical of their investment decision. It was and may still be good idea that has simply run afoul of the details. However, I recently learned about another new business that I don’t consider to have even started with a good idea, but still has managed to attract enough capital to get itself off the ground (“Should Breast Milk Be Nutritionally Analyzed?” by Laura Johannes, The Wall Street Journal, Dec. 28, 2015).

I’m sure you have seen some new mothers who were concerned that their breast milk was not enough for their babies. But how many of them would pay $150 for a start-up kit and then more than $300 to find out the nutritional content of their breast milk? What if it meant pumping and freezing three samples 2 or 3 days apart and then shipping them in a cooler to a lab? What if you told them that neither you nor anyone else could reliably interpret the results because there aren’t any published guidelines for the optimal composition of human breast milk? Even if your practice is packed to the rafters with anxiety-driven, irrational parents, I don’t think you would find many takers. But that doesn’t seem to have bothered the folks who have invested in Happy Vitals, a company in Washington that is offering a service similar to the one I have just described.

You and I might not have invested in a company whose business plan was to offer such a service. But I fear there may be enough health care “providers” practicing without the benefit of an evidence-based education that what I consider a capital misadventure may actually be able to pay back its investors.

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 few years ago I wrote a column about what promised to be an exciting development in blood testing technology. Using the money her parents had set aside for her education, a young woman dropped out of Stanford University at age 19 and started a company that she claimed would be able to offer hundreds of lab tests on just a few drops of blood. Results would be available in just minutes instead of hours or days. At the time I wrote the column, the company had just landed a contract with a large drug store chain with an arrangement that would eventually allow nearly every resident of the United States to be within a few miles of a site that would offer rapid response blood tests with nothing more than a finger prick.

It seemed a little hard to believe, but the prospect of pediatricians being able to make a diagnosis without running the risk of exsanguinating our smallest patients sounded appealing. On the other hand, I worried that a quick and easy technology might encourage some physicians to use a shotgun approach to diagnosing illness rather than a more rational and cost-effective process based on the traditional skills of history taking and physical examination. Some patients who foolishly wanted to know “everything” about themselves might be tempted to ask their physicians to order the whole smorgasbord of tests. “Hey, it’s only a few drops of blood.”

Turns out there were enough people with more money than reservations and the company quickly attracted hundreds of millions of dollars in venture capital. The company, now calling itself Theranos, has been valued at nine billion dollars. But, recently this startup star has encountered some serious bumps in the road to a full-scale launch (“Hot Startup Theranos Has Struggled With Its Blood-Test Technology” by John Carreyrou, The Wall Street Journal, updated Oct. 16, 2015). The Wall Street Journal reported that despite promises, only a few of the 240 tests offered by the company are currently performed using their proprietary microtechnique. In the days following the Journal article, the Food and Drug Administration warned Theranos that their “nanotainer” is considered a new medical device that must first clear the agency’s time consuming and costly vetting process (“Hot Startup Theranos Dials Back Lab Tests at FDA’s Behest” by John Carreyrou, The Wall Street Journal, updated Oct. 16, 2015).

The venture capitalists who had climbed on the Theranos bandwagon tempted by the just-a-few-drops promise may end up seeing their bank accounts hemorrhage. But I don’t think we should be too critical of their investment decision. It was and may still be good idea that has simply run afoul of the details. However, I recently learned about another new business that I don’t consider to have even started with a good idea, but still has managed to attract enough capital to get itself off the ground (“Should Breast Milk Be Nutritionally Analyzed?” by Laura Johannes, The Wall Street Journal, Dec. 28, 2015).

I’m sure you have seen some new mothers who were concerned that their breast milk was not enough for their babies. But how many of them would pay $150 for a start-up kit and then more than $300 to find out the nutritional content of their breast milk? What if it meant pumping and freezing three samples 2 or 3 days apart and then shipping them in a cooler to a lab? What if you told them that neither you nor anyone else could reliably interpret the results because there aren’t any published guidelines for the optimal composition of human breast milk? Even if your practice is packed to the rafters with anxiety-driven, irrational parents, I don’t think you would find many takers. But that doesn’t seem to have bothered the folks who have invested in Happy Vitals, a company in Washington that is offering a service similar to the one I have just described.

You and I might not have invested in a company whose business plan was to offer such a service. But I fear there may be enough health care “providers” practicing without the benefit of an evidence-based education that what I consider a capital misadventure may actually be able to pay back its investors.

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 few years ago I wrote a column about what promised to be an exciting development in blood testing technology. Using the money her parents had set aside for her education, a young woman dropped out of Stanford University at age 19 and started a company that she claimed would be able to offer hundreds of lab tests on just a few drops of blood. Results would be available in just minutes instead of hours or days. At the time I wrote the column, the company had just landed a contract with a large drug store chain with an arrangement that would eventually allow nearly every resident of the United States to be within a few miles of a site that would offer rapid response blood tests with nothing more than a finger prick.

It seemed a little hard to believe, but the prospect of pediatricians being able to make a diagnosis without running the risk of exsanguinating our smallest patients sounded appealing. On the other hand, I worried that a quick and easy technology might encourage some physicians to use a shotgun approach to diagnosing illness rather than a more rational and cost-effective process based on the traditional skills of history taking and physical examination. Some patients who foolishly wanted to know “everything” about themselves might be tempted to ask their physicians to order the whole smorgasbord of tests. “Hey, it’s only a few drops of blood.”

Turns out there were enough people with more money than reservations and the company quickly attracted hundreds of millions of dollars in venture capital. The company, now calling itself Theranos, has been valued at nine billion dollars. But, recently this startup star has encountered some serious bumps in the road to a full-scale launch (“Hot Startup Theranos Has Struggled With Its Blood-Test Technology” by John Carreyrou, The Wall Street Journal, updated Oct. 16, 2015). The Wall Street Journal reported that despite promises, only a few of the 240 tests offered by the company are currently performed using their proprietary microtechnique. In the days following the Journal article, the Food and Drug Administration warned Theranos that their “nanotainer” is considered a new medical device that must first clear the agency’s time consuming and costly vetting process (“Hot Startup Theranos Dials Back Lab Tests at FDA’s Behest” by John Carreyrou, The Wall Street Journal, updated Oct. 16, 2015).

The venture capitalists who had climbed on the Theranos bandwagon tempted by the just-a-few-drops promise may end up seeing their bank accounts hemorrhage. But I don’t think we should be too critical of their investment decision. It was and may still be good idea that has simply run afoul of the details. However, I recently learned about another new business that I don’t consider to have even started with a good idea, but still has managed to attract enough capital to get itself off the ground (“Should Breast Milk Be Nutritionally Analyzed?” by Laura Johannes, The Wall Street Journal, Dec. 28, 2015).

I’m sure you have seen some new mothers who were concerned that their breast milk was not enough for their babies. But how many of them would pay $150 for a start-up kit and then more than $300 to find out the nutritional content of their breast milk? What if it meant pumping and freezing three samples 2 or 3 days apart and then shipping them in a cooler to a lab? What if you told them that neither you nor anyone else could reliably interpret the results because there aren’t any published guidelines for the optimal composition of human breast milk? Even if your practice is packed to the rafters with anxiety-driven, irrational parents, I don’t think you would find many takers. But that doesn’t seem to have bothered the folks who have invested in Happy Vitals, a company in Washington that is offering a service similar to the one I have just described.

You and I might not have invested in a company whose business plan was to offer such a service. But I fear there may be enough health care “providers” practicing without the benefit of an evidence-based education that what I consider a capital misadventure may actually be able to pay back its investors.

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

The dream unfolds late in the semester with just a week to go, usually my final semester. My college career has been exemplary … good grades, honor society member, academic behavior any parent would be proud of. But for some reason I realize that I have failed to attend any of the classes of one of my courses, usually a math course. In fact, I’m not sure I have the text or maybe I never purchased it. More frighteningly, I can’t remember in which classroom it meets or even the hour. No one else seems to have noticed my failure to show up for class. Remember, it’s a math course and BSing doesn’t work in math. There is no way I will be able to resurrect myself from this academic disaster. The dream eventually dissolves without resolution, but it will return in some permutation, fortunately less often as I have gotten older. My wife and many of our friends share similar nightmares.

There are many angles from which one can interpret a dream like this, but one explanation is that I finally have been discovered as an impostor. I had studied hard, gotten good grades but at the core of things I was a goof-off and really wasn’t worthy of the adulation I had received. My good works were merely a shell over a life of not doing all the things that other people thought I had been doing.

It turns out that I had fallen into a surprisingly common psychological trap, probably during medical school. Despite accumulating significant amounts of clinical acumen, and in my later years what some might call wisdom, my dream suggests that I still have been unable to free myself of a nagging self-doubt. In 1978, two American psychologists Pauline Clance and Suzanne Imes labeled this phenomenon “the impostor syndrome” (“Learning to Deal with the Impostor Syndrome” by Carl Richards [The New York Times, Oct. 26, 2015]). They characterized it as a feeling “of phoniness in people who believe that they are not intelligent, capable, or creative despite evidence of high achievement.” The victims “are highly motivated to achieve” but “live in fear of being ‘found out’ or exposed as frauds.”

In college, I was in awe of those classmates who could play bridge for hours day after day, write their papers in the wee morning hours on the day they were due, and still get very acceptable grades. I imagined that if these guys had studied a third as much as I did or had simply begun their term papers on the day before they were due, their academic credentials would have blown mine out of the water.

In medical school I always had a sense that I didn’t belong there. I had never heard of anyone else who had gotten into an elite medical school off the waiting list as I had. There must have been a clerical error, and I had been mistaken for the scion of a wealthy benefactor with a similar sounding name. I had been around some smart people before, but my medical school classmates were in a different league altogether.

It turns out I was not alone bobbing in my sea of self-doubt. I learned from a blog entry on KevinMD.com (“The effect of impostor syndrome on medical students” by Aryeh Goldberg, March 1, 2014) of a lecture by Suzanne Poirier at Northwestern’s Feinberg School of Medicine, during which she reported on her analysis of more than forty book-length medical school memoirs. She discovered that a theme of a sense of not belonging ran through most (if not all) of the sources she reviewed. Other observers have wondered how much the impostor syndrome contributes to burnout, depression, and suicidal ideation in medical students.

I suffered from none of those maladies, but my feeling of unworthiness followed me into practice. Even as I acquired more experience during hundreds of thousands of patient encounters, I continued to worry that the next patient through the door would be the end of a decade’s long string of good fortune and my clinical ineptitude would be unmasked.

One of the most effective strategies for dealing with such feelings is sharing them. Unfortunately, most physicians don’t often find themselves in settings in which they can comfortably share these feelings with their peers. And of course it is probably not the best idea to share your self-doubts when you are trying to reassure a patient who is feeling vulnerable herself. Finding the balance between admitting that we don’t know everything and projecting the image that we know more than enough to help our patients is one of the biggest challenges facing us as we struggle to master the art of clinical medicine.

I will leave the question of whether I was an impostor to those who can be more objective. All I know is that I was damn lucky for 40 years.

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

The dream unfolds late in the semester with just a week to go, usually my final semester. My college career has been exemplary … good grades, honor society member, academic behavior any parent would be proud of. But for some reason I realize that I have failed to attend any of the classes of one of my courses, usually a math course. In fact, I’m not sure I have the text or maybe I never purchased it. More frighteningly, I can’t remember in which classroom it meets or even the hour. No one else seems to have noticed my failure to show up for class. Remember, it’s a math course and BSing doesn’t work in math. There is no way I will be able to resurrect myself from this academic disaster. The dream eventually dissolves without resolution, but it will return in some permutation, fortunately less often as I have gotten older. My wife and many of our friends share similar nightmares.

There are many angles from which one can interpret a dream like this, but one explanation is that I finally have been discovered as an impostor. I had studied hard, gotten good grades but at the core of things I was a goof-off and really wasn’t worthy of the adulation I had received. My good works were merely a shell over a life of not doing all the things that other people thought I had been doing.

It turns out that I had fallen into a surprisingly common psychological trap, probably during medical school. Despite accumulating significant amounts of clinical acumen, and in my later years what some might call wisdom, my dream suggests that I still have been unable to free myself of a nagging self-doubt. In 1978, two American psychologists Pauline Clance and Suzanne Imes labeled this phenomenon “the impostor syndrome” (“Learning to Deal with the Impostor Syndrome” by Carl Richards [The New York Times, Oct. 26, 2015]). They characterized it as a feeling “of phoniness in people who believe that they are not intelligent, capable, or creative despite evidence of high achievement.” The victims “are highly motivated to achieve” but “live in fear of being ‘found out’ or exposed as frauds.”

In college, I was in awe of those classmates who could play bridge for hours day after day, write their papers in the wee morning hours on the day they were due, and still get very acceptable grades. I imagined that if these guys had studied a third as much as I did or had simply begun their term papers on the day before they were due, their academic credentials would have blown mine out of the water.

In medical school I always had a sense that I didn’t belong there. I had never heard of anyone else who had gotten into an elite medical school off the waiting list as I had. There must have been a clerical error, and I had been mistaken for the scion of a wealthy benefactor with a similar sounding name. I had been around some smart people before, but my medical school classmates were in a different league altogether.

It turns out I was not alone bobbing in my sea of self-doubt. I learned from a blog entry on KevinMD.com (“The effect of impostor syndrome on medical students” by Aryeh Goldberg, March 1, 2014) of a lecture by Suzanne Poirier at Northwestern’s Feinberg School of Medicine, during which she reported on her analysis of more than forty book-length medical school memoirs. She discovered that a theme of a sense of not belonging ran through most (if not all) of the sources she reviewed. Other observers have wondered how much the impostor syndrome contributes to burnout, depression, and suicidal ideation in medical students.

I suffered from none of those maladies, but my feeling of unworthiness followed me into practice. Even as I acquired more experience during hundreds of thousands of patient encounters, I continued to worry that the next patient through the door would be the end of a decade’s long string of good fortune and my clinical ineptitude would be unmasked.

One of the most effective strategies for dealing with such feelings is sharing them. Unfortunately, most physicians don’t often find themselves in settings in which they can comfortably share these feelings with their peers. And of course it is probably not the best idea to share your self-doubts when you are trying to reassure a patient who is feeling vulnerable herself. Finding the balance between admitting that we don’t know everything and projecting the image that we know more than enough to help our patients is one of the biggest challenges facing us as we struggle to master the art of clinical medicine.

I will leave the question of whether I was an impostor to those who can be more objective. All I know is that I was damn lucky for 40 years.

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

The dream unfolds late in the semester with just a week to go, usually my final semester. My college career has been exemplary … good grades, honor society member, academic behavior any parent would be proud of. But for some reason I realize that I have failed to attend any of the classes of one of my courses, usually a math course. In fact, I’m not sure I have the text or maybe I never purchased it. More frighteningly, I can’t remember in which classroom it meets or even the hour. No one else seems to have noticed my failure to show up for class. Remember, it’s a math course and BSing doesn’t work in math. There is no way I will be able to resurrect myself from this academic disaster. The dream eventually dissolves without resolution, but it will return in some permutation, fortunately less often as I have gotten older. My wife and many of our friends share similar nightmares.

There are many angles from which one can interpret a dream like this, but one explanation is that I finally have been discovered as an impostor. I had studied hard, gotten good grades but at the core of things I was a goof-off and really wasn’t worthy of the adulation I had received. My good works were merely a shell over a life of not doing all the things that other people thought I had been doing.

It turns out that I had fallen into a surprisingly common psychological trap, probably during medical school. Despite accumulating significant amounts of clinical acumen, and in my later years what some might call wisdom, my dream suggests that I still have been unable to free myself of a nagging self-doubt. In 1978, two American psychologists Pauline Clance and Suzanne Imes labeled this phenomenon “the impostor syndrome” (“Learning to Deal with the Impostor Syndrome” by Carl Richards [The New York Times, Oct. 26, 2015]). They characterized it as a feeling “of phoniness in people who believe that they are not intelligent, capable, or creative despite evidence of high achievement.” The victims “are highly motivated to achieve” but “live in fear of being ‘found out’ or exposed as frauds.”

In college, I was in awe of those classmates who could play bridge for hours day after day, write their papers in the wee morning hours on the day they were due, and still get very acceptable grades. I imagined that if these guys had studied a third as much as I did or had simply begun their term papers on the day before they were due, their academic credentials would have blown mine out of the water.

In medical school I always had a sense that I didn’t belong there. I had never heard of anyone else who had gotten into an elite medical school off the waiting list as I had. There must have been a clerical error, and I had been mistaken for the scion of a wealthy benefactor with a similar sounding name. I had been around some smart people before, but my medical school classmates were in a different league altogether.

It turns out I was not alone bobbing in my sea of self-doubt. I learned from a blog entry on KevinMD.com (“The effect of impostor syndrome on medical students” by Aryeh Goldberg, March 1, 2014) of a lecture by Suzanne Poirier at Northwestern’s Feinberg School of Medicine, during which she reported on her analysis of more than forty book-length medical school memoirs. She discovered that a theme of a sense of not belonging ran through most (if not all) of the sources she reviewed. Other observers have wondered how much the impostor syndrome contributes to burnout, depression, and suicidal ideation in medical students.

I suffered from none of those maladies, but my feeling of unworthiness followed me into practice. Even as I acquired more experience during hundreds of thousands of patient encounters, I continued to worry that the next patient through the door would be the end of a decade’s long string of good fortune and my clinical ineptitude would be unmasked.

One of the most effective strategies for dealing with such feelings is sharing them. Unfortunately, most physicians don’t often find themselves in settings in which they can comfortably share these feelings with their peers. And of course it is probably not the best idea to share your self-doubts when you are trying to reassure a patient who is feeling vulnerable herself. Finding the balance between admitting that we don’t know everything and projecting the image that we know more than enough to help our patients is one of the biggest challenges facing us as we struggle to master the art of clinical medicine.

I will leave the question of whether I was an impostor to those who can be more objective. All I know is that I was damn lucky for 40 years.

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

If you haven’t already stopped investing your limited supply of office time in fruitless attempts to convince vaccine-hesitant parents to immunize their children, a small study at the University of North Carolina Women’s Hospital in Chapel Hill might finally convince you it’s time to save your breath for other more achievable goals. In a survey of 171 parents, 72% reported that they already had settled on their vaccine preferences prior to pregnancy.

This was a limited survey and may not reflect the responses of a national sample of parents, but it is concerning in light of several other studies that paint a similar gloomy picture. One such study found that even when vaccine-denying parents were presented with educational materials that they acknowledged seemed valid, they continued to withhold vaccines by falling back on other arguments to support their views (“Effective Messages in Vaccine Promotion: A Randomized Trial” by Nyhan et al. [Pediatrics. 2014 Apr;133(4):e835-42]).

If a larger and more geographically diverse study continues to find that the die is cast well before pediatricians have gotten our chance to discuss vaccines with parents-to-be, we will need to rethink our strategies for dealing with vaccine refusers. For those pediatricians who already ask vaccine decliners to find another practice, this new study suggests that they could save themselves time and trouble by advertising their policy to the obstetricians in their communities. This proactive advertising would require some courage, but in the long run it probably makes economic sense.

However, for most pediatricians it may be better to wait in hopes that future research can determine exactly when and under what circumstances most vaccine decliners arrive at their unfortunate decisions. How often was it a philosophy that they inherited from their parents? How often did it reflect their religious views? How often did it evolve from something they heard in school? Junior high, high school, college? Was it a science class, or history, or philosophy?

Was it the result of some media story? TV? Print? Internet? If they can recall a particular show or website, what was it that made it sound so convincing? If it was an individual, was it a friend, celebrity, or a teacher?

A study this detailed would be time consuming and labor intensive, as it would be best done in face-to-face structured interviews by someone who could project a nonjudgmental aura. It would necessarily be retrospective. But it might yield some surprising and helpful information that could be used to target our attack on the epidemic of vaccine refusal.

We know that outbreaks of certain infectious diseases, smallpox being the prime example, do not respond to media blitzes and immunization campaigns. Epidemics will continue to roll along unchecked until a labor-intensive, boots-on-the-ground, door-to-door case-finding effort is undertaken. Vaccine refusal may be similar to smallpox. It appears to be unresponsive to mass media and educational initiatives. It may continue to plague us until we chase down its roots.

Whatever strategy we try next, it is clear that although most parents report that they consider pediatricians among their most trusted sources of health information for their children, we are failing to reach a segment of our target audience. We are too late, long after the die is cast.

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.”

*This story was updated 1/28/2016.

If you haven’t already stopped investing your limited supply of office time in fruitless attempts to convince vaccine-hesitant parents to immunize their children, a small study at the University of North Carolina Women’s Hospital in Chapel Hill might finally convince you it’s time to save your breath for other more achievable goals. In a survey of 171 parents, 72% reported that they already had settled on their vaccine preferences prior to pregnancy.

This was a limited survey and may not reflect the responses of a national sample of parents, but it is concerning in light of several other studies that paint a similar gloomy picture. One such study found that even when vaccine-denying parents were presented with educational materials that they acknowledged seemed valid, they continued to withhold vaccines by falling back on other arguments to support their views (“Effective Messages in Vaccine Promotion: A Randomized Trial” by Nyhan et al. [Pediatrics. 2014 Apr;133(4):e835-42]).

If a larger and more geographically diverse study continues to find that the die is cast well before pediatricians have gotten our chance to discuss vaccines with parents-to-be, we will need to rethink our strategies for dealing with vaccine refusers. For those pediatricians who already ask vaccine decliners to find another practice, this new study suggests that they could save themselves time and trouble by advertising their policy to the obstetricians in their communities. This proactive advertising would require some courage, but in the long run it probably makes economic sense.

However, for most pediatricians it may be better to wait in hopes that future research can determine exactly when and under what circumstances most vaccine decliners arrive at their unfortunate decisions. How often was it a philosophy that they inherited from their parents? How often did it reflect their religious views? How often did it evolve from something they heard in school? Junior high, high school, college? Was it a science class, or history, or philosophy?

Was it the result of some media story? TV? Print? Internet? If they can recall a particular show or website, what was it that made it sound so convincing? If it was an individual, was it a friend, celebrity, or a teacher?

A study this detailed would be time consuming and labor intensive, as it would be best done in face-to-face structured interviews by someone who could project a nonjudgmental aura. It would necessarily be retrospective. But it might yield some surprising and helpful information that could be used to target our attack on the epidemic of vaccine refusal.

We know that outbreaks of certain infectious diseases, smallpox being the prime example, do not respond to media blitzes and immunization campaigns. Epidemics will continue to roll along unchecked until a labor-intensive, boots-on-the-ground, door-to-door case-finding effort is undertaken. Vaccine refusal may be similar to smallpox. It appears to be unresponsive to mass media and educational initiatives. It may continue to plague us until we chase down its roots.

Whatever strategy we try next, it is clear that although most parents report that they consider pediatricians among their most trusted sources of health information for their children, we are failing to reach a segment of our target audience. We are too late, long after the die is cast.

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.”

*This story was updated 1/28/2016.

If you haven’t already stopped investing your limited supply of office time in fruitless attempts to convince vaccine-hesitant parents to immunize their children, a small study at the University of North Carolina Women’s Hospital in Chapel Hill might finally convince you it’s time to save your breath for other more achievable goals. In a survey of 171 parents, 72% reported that they already had settled on their vaccine preferences prior to pregnancy.

This was a limited survey and may not reflect the responses of a national sample of parents, but it is concerning in light of several other studies that paint a similar gloomy picture. One such study found that even when vaccine-denying parents were presented with educational materials that they acknowledged seemed valid, they continued to withhold vaccines by falling back on other arguments to support their views (“Effective Messages in Vaccine Promotion: A Randomized Trial” by Nyhan et al. [Pediatrics. 2014 Apr;133(4):e835-42]).

If a larger and more geographically diverse study continues to find that the die is cast well before pediatricians have gotten our chance to discuss vaccines with parents-to-be, we will need to rethink our strategies for dealing with vaccine refusers. For those pediatricians who already ask vaccine decliners to find another practice, this new study suggests that they could save themselves time and trouble by advertising their policy to the obstetricians in their communities. This proactive advertising would require some courage, but in the long run it probably makes economic sense.

However, for most pediatricians it may be better to wait in hopes that future research can determine exactly when and under what circumstances most vaccine decliners arrive at their unfortunate decisions. How often was it a philosophy that they inherited from their parents? How often did it reflect their religious views? How often did it evolve from something they heard in school? Junior high, high school, college? Was it a science class, or history, or philosophy?

Was it the result of some media story? TV? Print? Internet? If they can recall a particular show or website, what was it that made it sound so convincing? If it was an individual, was it a friend, celebrity, or a teacher?

A study this detailed would be time consuming and labor intensive, as it would be best done in face-to-face structured interviews by someone who could project a nonjudgmental aura. It would necessarily be retrospective. But it might yield some surprising and helpful information that could be used to target our attack on the epidemic of vaccine refusal.

We know that outbreaks of certain infectious diseases, smallpox being the prime example, do not respond to media blitzes and immunization campaigns. Epidemics will continue to roll along unchecked until a labor-intensive, boots-on-the-ground, door-to-door case-finding effort is undertaken. Vaccine refusal may be similar to smallpox. It appears to be unresponsive to mass media and educational initiatives. It may continue to plague us until we chase down its roots.

Whatever strategy we try next, it is clear that although most parents report that they consider pediatricians among their most trusted sources of health information for their children, we are failing to reach a segment of our target audience. We are too late, long after the die is cast.

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.”

*This story was updated 1/28/2016.