William G. Wilkoff, MD

I try to avoid revisiting a subject I have pontificated on in the recent past, but when I encounter a situation in which scientists are behaving unscientifically it is hard to remain silent. In 2002, a Pittsburgh neuropathologist named Bennet Omalu performed an autopsy on Mike Webster, a former National Football League (NFL) lineman who had died in his 50s. Webster had been exhibiting bizarre behaviors and was developing dementia. What Dr. Omalu found in Webster’s brain was a collection of changes that have become known as chronic traumatic encephalopathy (CTE).

In the decade following the publication of Dr. Omalu’s findings in the journal Neurosurgery in 2005, there has been some unsavory back and forths between the NFL’s Mild Traumatic Brain Injury Committee and Dr. Omalu that I learned about in the Wall Street Journal (“The Doctor the NFL Tried to Silence,” by Jeanne Marie Laskas, Nov 24, 2015). The doctor’s side of the story has been published in a book, “Concussion” (New York: Penguin Random House, 2015). “Concussion,” the movie based on the book, was slated for release in December.

The tangle of he said – our experts don’t agree has involved the University of Michigan and Boston University, and the smell of conflict of interest hangs over the NFL’s choice of experts and its decisions to publish or not publish the results of various studies. It now appears that Dr. Omalu’s discovery was the tip of an iceberg of undetermined size. As happens far too often, assumptions and attributions have been made in haste based on scanty evidence from small studies that have surely failed to control for all of the possible contributors.

Considering the results of the autopsies on a few NFL players, it is probably reasonable to suspect that there is something in the culture surrounding professional football that makes some of the players vulnerable to central nervous system damage. And blows to the head are likely to be one of those factors. However, leaping to the conclusion that parents shouldn’t allow their young children to play football is another story. But that is just what Dr. Omalu has done in an op-ed piece that has appeared in the New York Times (“Don’t Let Kids Play Football,” Dec 7, 2015).

Relying heavily on the analogy with cumulative effects of cigarette smoking, Dr. Omalu continues to fan the flame that he ignited with his initial autopsy finding. The timing of the piece is interesting in light of the movie’s release date of Dec. 25. While his discovery of CTE in a professional player is important, Dr. Omalu’s case for prohibiting children from playing football is rife with half-truths and unwarranted conclusions.

For example, he states that in his 30 years as a neuropathologist he has yet to see a “neuron that naturally creates a new neuron to regenerate itself.” True, but he fails to report that there is new evidence that the long-held dictum that neurons can’t heal themselves may be wrong.

Dr. Omalu observes that “if a child who plays football is subjected to advanced radiological and neurocognitive studies during the season and several months after there can be evidence of brain damage at the cellular level even if there were no documented concussions or reported symptoms.” It took some time, but I eventually found the study to which I assume he is referring, by Dr. Christopher T. Whitlow of Wake Forest University, Winston-Salem, N.C., presented at the Radiological Society of North America meeting in December of 2014. Its lead author is careful to state that conclusions should not be drawn from this small preliminary study and observes, “it is unclear whether or not these effects will be associated with any long-term consequences.” However, Dr. Omalu asserts that “If that child continues to play over many seasons, these cellular injuries accumulate to cause irreversible brain damage.” He states this as fact without any supporting evidence.

Fortunately, the American Academy of Pediatrics has presented a more balanced perspective on allowing children to participate in football in light of what we are learning about the health of professional players (“Tackling in Youth Football” [Pediatrics. 2015;136(5)e1419-31]). Dr. William P. Meehan III and Dr. Gregory L. Landry, speaking for the Council on Sports Medicine and Fitness, point out that serious head and neck injury in young football players is very unlikely, and that by teaching proper tackling technique, these injuries can be further decreased.

The real solution to the problem that Dr. Omalu first brought to light in 2002 lies with zero tolerance for the practice of tackling headfirst at all levels of football. Although the NFL has made some feeble attempts to discipline its teams, there is still more that should be done. Every professional and college football game is being video recorded, often from multiple angles. Retrospective analysis of these images should be used to discipline players whose injury-threatening tactics have not been detected by the officials during the game. Multiple game suspensions meted out promptly, and without possibility of appeal, would go a long way to return football to being the safer sport it was when leather helmets discouraged players from using their heads as lethal weapons.

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 try to avoid revisiting a subject I have pontificated on in the recent past, but when I encounter a situation in which scientists are behaving unscientifically it is hard to remain silent. In 2002, a Pittsburgh neuropathologist named Bennet Omalu performed an autopsy on Mike Webster, a former National Football League (NFL) lineman who had died in his 50s. Webster had been exhibiting bizarre behaviors and was developing dementia. What Dr. Omalu found in Webster’s brain was a collection of changes that have become known as chronic traumatic encephalopathy (CTE).

In the decade following the publication of Dr. Omalu’s findings in the journal Neurosurgery in 2005, there has been some unsavory back and forths between the NFL’s Mild Traumatic Brain Injury Committee and Dr. Omalu that I learned about in the Wall Street Journal (“The Doctor the NFL Tried to Silence,” by Jeanne Marie Laskas, Nov 24, 2015). The doctor’s side of the story has been published in a book, “Concussion” (New York: Penguin Random House, 2015). “Concussion,” the movie based on the book, was slated for release in December.

The tangle of he said – our experts don’t agree has involved the University of Michigan and Boston University, and the smell of conflict of interest hangs over the NFL’s choice of experts and its decisions to publish or not publish the results of various studies. It now appears that Dr. Omalu’s discovery was the tip of an iceberg of undetermined size. As happens far too often, assumptions and attributions have been made in haste based on scanty evidence from small studies that have surely failed to control for all of the possible contributors.

Considering the results of the autopsies on a few NFL players, it is probably reasonable to suspect that there is something in the culture surrounding professional football that makes some of the players vulnerable to central nervous system damage. And blows to the head are likely to be one of those factors. However, leaping to the conclusion that parents shouldn’t allow their young children to play football is another story. But that is just what Dr. Omalu has done in an op-ed piece that has appeared in the New York Times (“Don’t Let Kids Play Football,” Dec 7, 2015).

Relying heavily on the analogy with cumulative effects of cigarette smoking, Dr. Omalu continues to fan the flame that he ignited with his initial autopsy finding. The timing of the piece is interesting in light of the movie’s release date of Dec. 25. While his discovery of CTE in a professional player is important, Dr. Omalu’s case for prohibiting children from playing football is rife with half-truths and unwarranted conclusions.

For example, he states that in his 30 years as a neuropathologist he has yet to see a “neuron that naturally creates a new neuron to regenerate itself.” True, but he fails to report that there is new evidence that the long-held dictum that neurons can’t heal themselves may be wrong.

Dr. Omalu observes that “if a child who plays football is subjected to advanced radiological and neurocognitive studies during the season and several months after there can be evidence of brain damage at the cellular level even if there were no documented concussions or reported symptoms.” It took some time, but I eventually found the study to which I assume he is referring, by Dr. Christopher T. Whitlow of Wake Forest University, Winston-Salem, N.C., presented at the Radiological Society of North America meeting in December of 2014. Its lead author is careful to state that conclusions should not be drawn from this small preliminary study and observes, “it is unclear whether or not these effects will be associated with any long-term consequences.” However, Dr. Omalu asserts that “If that child continues to play over many seasons, these cellular injuries accumulate to cause irreversible brain damage.” He states this as fact without any supporting evidence.

Fortunately, the American Academy of Pediatrics has presented a more balanced perspective on allowing children to participate in football in light of what we are learning about the health of professional players (“Tackling in Youth Football” [Pediatrics. 2015;136(5)e1419-31]). Dr. William P. Meehan III and Dr. Gregory L. Landry, speaking for the Council on Sports Medicine and Fitness, point out that serious head and neck injury in young football players is very unlikely, and that by teaching proper tackling technique, these injuries can be further decreased.

The real solution to the problem that Dr. Omalu first brought to light in 2002 lies with zero tolerance for the practice of tackling headfirst at all levels of football. Although the NFL has made some feeble attempts to discipline its teams, there is still more that should be done. Every professional and college football game is being video recorded, often from multiple angles. Retrospective analysis of these images should be used to discipline players whose injury-threatening tactics have not been detected by the officials during the game. Multiple game suspensions meted out promptly, and without possibility of appeal, would go a long way to return football to being the safer sport it was when leather helmets discouraged players from using their heads as lethal weapons.

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 try to avoid revisiting a subject I have pontificated on in the recent past, but when I encounter a situation in which scientists are behaving unscientifically it is hard to remain silent. In 2002, a Pittsburgh neuropathologist named Bennet Omalu performed an autopsy on Mike Webster, a former National Football League (NFL) lineman who had died in his 50s. Webster had been exhibiting bizarre behaviors and was developing dementia. What Dr. Omalu found in Webster’s brain was a collection of changes that have become known as chronic traumatic encephalopathy (CTE).

In the decade following the publication of Dr. Omalu’s findings in the journal Neurosurgery in 2005, there has been some unsavory back and forths between the NFL’s Mild Traumatic Brain Injury Committee and Dr. Omalu that I learned about in the Wall Street Journal (“The Doctor the NFL Tried to Silence,” by Jeanne Marie Laskas, Nov 24, 2015). The doctor’s side of the story has been published in a book, “Concussion” (New York: Penguin Random House, 2015). “Concussion,” the movie based on the book, was slated for release in December.

The tangle of he said – our experts don’t agree has involved the University of Michigan and Boston University, and the smell of conflict of interest hangs over the NFL’s choice of experts and its decisions to publish or not publish the results of various studies. It now appears that Dr. Omalu’s discovery was the tip of an iceberg of undetermined size. As happens far too often, assumptions and attributions have been made in haste based on scanty evidence from small studies that have surely failed to control for all of the possible contributors.

Considering the results of the autopsies on a few NFL players, it is probably reasonable to suspect that there is something in the culture surrounding professional football that makes some of the players vulnerable to central nervous system damage. And blows to the head are likely to be one of those factors. However, leaping to the conclusion that parents shouldn’t allow their young children to play football is another story. But that is just what Dr. Omalu has done in an op-ed piece that has appeared in the New York Times (“Don’t Let Kids Play Football,” Dec 7, 2015).

Relying heavily on the analogy with cumulative effects of cigarette smoking, Dr. Omalu continues to fan the flame that he ignited with his initial autopsy finding. The timing of the piece is interesting in light of the movie’s release date of Dec. 25. While his discovery of CTE in a professional player is important, Dr. Omalu’s case for prohibiting children from playing football is rife with half-truths and unwarranted conclusions.

For example, he states that in his 30 years as a neuropathologist he has yet to see a “neuron that naturally creates a new neuron to regenerate itself.” True, but he fails to report that there is new evidence that the long-held dictum that neurons can’t heal themselves may be wrong.

Dr. Omalu observes that “if a child who plays football is subjected to advanced radiological and neurocognitive studies during the season and several months after there can be evidence of brain damage at the cellular level even if there were no documented concussions or reported symptoms.” It took some time, but I eventually found the study to which I assume he is referring, by Dr. Christopher T. Whitlow of Wake Forest University, Winston-Salem, N.C., presented at the Radiological Society of North America meeting in December of 2014. Its lead author is careful to state that conclusions should not be drawn from this small preliminary study and observes, “it is unclear whether or not these effects will be associated with any long-term consequences.” However, Dr. Omalu asserts that “If that child continues to play over many seasons, these cellular injuries accumulate to cause irreversible brain damage.” He states this as fact without any supporting evidence.

Fortunately, the American Academy of Pediatrics has presented a more balanced perspective on allowing children to participate in football in light of what we are learning about the health of professional players (“Tackling in Youth Football” [Pediatrics. 2015;136(5)e1419-31]). Dr. William P. Meehan III and Dr. Gregory L. Landry, speaking for the Council on Sports Medicine and Fitness, point out that serious head and neck injury in young football players is very unlikely, and that by teaching proper tackling technique, these injuries can be further decreased.

The real solution to the problem that Dr. Omalu first brought to light in 2002 lies with zero tolerance for the practice of tackling headfirst at all levels of football. Although the NFL has made some feeble attempts to discipline its teams, there is still more that should be done. Every professional and college football game is being video recorded, often from multiple angles. Retrospective analysis of these images should be used to discipline players whose injury-threatening tactics have not been detected by the officials during the game. Multiple game suspensions meted out promptly, and without possibility of appeal, would go a long way to return football to being the safer sport it was when leather helmets discouraged players from using their heads as lethal weapons.

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.”

To those of us who live and practice in the northeast, it comes as no surprise that the mortality rate for middle class whites is climbing. Obituaries in our local papers often include men and women in their forties “dying at home,” with no mention of cancer or chronic disease. Rarely, the family can bring itself to announce that their loved one has died of a drug overdose.

Deaths attributable to prescription opioid overdoses quadrupled in the decade from 1999 to 2010, and the trend shows little sign of abating as the number of prescriptions for opioids has risen tenfold over the last 20 years (“How Doctors Helped Drive the Addiction Crisis,” by Dr. Richard Friedman, New York Times, Nov. 7, 2015). Could physician behavior have contributed to outbreak of this deadly plague of addiction? That is like asking if something the zookeeper did or didn’t do could have been responsible for the escape of the man-eating tiger that is devouring the neighborhood children. Regardless of what other factors might be responsible for the epidemic of fatal prescription opioid overdoses, physicians must admit some culpability.

Until recently, I assumed that the problem of prescription opioids finding their way to addicts was unique to physicians treating adults. However, a study reported at the annual meeting of the American Society of Anesthesiologists reveals pediatricians and other clinicians prescribing for children must share in the blame.

Dr. Myron Yaster at Johns Hopkins University Hospital, Baltimore, has found that in a group of nearly 300 pediatric patients (average age, 11 years and average weight of 44 kg), overall the patients used only 42% of the prescribed amount of opioids. Almost half of the patients had a teenage sibling, a group that Dr. Yaster describes as the “target population of drug abuse.”

What’s going on here? Some of the problem dates back to the 1990s when physicians were urged to shift their focus toward the problem of inadequately treated pain. With the help of nurses armed with pain-rating schemes and smiley/grumpy face charts, the mantra became “no pain shall go unmedicated,” when the better response should have been “no pain shall go unmanaged.” But good pain management takes time. It requires that the physician and staff consider each patient as a unique individual. In many cases, reassurance and education can make a non–opioid medication or even no medication a better choice.

However, according to Dr. Yaster, “leftover medicine is the most important element in drug addiction.” Why did physicians prescribe 10 days of medication when his study revealed that most patients took the medication for only 5? It could just be a bad habit. Or it could be ignorance or inexperience. How many physicians ask at follow-up appointments “How long did you take your medication? Tell me the history of your pain.”

Or could it be that physicians are simply trying to prevent those annoying calls from patients who have run out of their medication? Dr. Yaster’s findings suggest that those calls would be few and far between. More careful thought into how much medication we prescribe also would mean that when a patient called for more medication that there was a problem. Either the patient’s recuperation has hit a worrisome bump in the road or possibly her medication is being diverted.

History tells us that physicians, even pediatricians, have been poor stewards of the powerful medications with which we have been entrusted. First, it was antibiotics and now opioids have joined the list.

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

To those of us who live and practice in the northeast, it comes as no surprise that the mortality rate for middle class whites is climbing. Obituaries in our local papers often include men and women in their forties “dying at home,” with no mention of cancer or chronic disease. Rarely, the family can bring itself to announce that their loved one has died of a drug overdose.

Deaths attributable to prescription opioid overdoses quadrupled in the decade from 1999 to 2010, and the trend shows little sign of abating as the number of prescriptions for opioids has risen tenfold over the last 20 years (“How Doctors Helped Drive the Addiction Crisis,” by Dr. Richard Friedman, New York Times, Nov. 7, 2015). Could physician behavior have contributed to outbreak of this deadly plague of addiction? That is like asking if something the zookeeper did or didn’t do could have been responsible for the escape of the man-eating tiger that is devouring the neighborhood children. Regardless of what other factors might be responsible for the epidemic of fatal prescription opioid overdoses, physicians must admit some culpability.

Until recently, I assumed that the problem of prescription opioids finding their way to addicts was unique to physicians treating adults. However, a study reported at the annual meeting of the American Society of Anesthesiologists reveals pediatricians and other clinicians prescribing for children must share in the blame.

Dr. Myron Yaster at Johns Hopkins University Hospital, Baltimore, has found that in a group of nearly 300 pediatric patients (average age, 11 years and average weight of 44 kg), overall the patients used only 42% of the prescribed amount of opioids. Almost half of the patients had a teenage sibling, a group that Dr. Yaster describes as the “target population of drug abuse.”

What’s going on here? Some of the problem dates back to the 1990s when physicians were urged to shift their focus toward the problem of inadequately treated pain. With the help of nurses armed with pain-rating schemes and smiley/grumpy face charts, the mantra became “no pain shall go unmedicated,” when the better response should have been “no pain shall go unmanaged.” But good pain management takes time. It requires that the physician and staff consider each patient as a unique individual. In many cases, reassurance and education can make a non–opioid medication or even no medication a better choice.

However, according to Dr. Yaster, “leftover medicine is the most important element in drug addiction.” Why did physicians prescribe 10 days of medication when his study revealed that most patients took the medication for only 5? It could just be a bad habit. Or it could be ignorance or inexperience. How many physicians ask at follow-up appointments “How long did you take your medication? Tell me the history of your pain.”

Or could it be that physicians are simply trying to prevent those annoying calls from patients who have run out of their medication? Dr. Yaster’s findings suggest that those calls would be few and far between. More careful thought into how much medication we prescribe also would mean that when a patient called for more medication that there was a problem. Either the patient’s recuperation has hit a worrisome bump in the road or possibly her medication is being diverted.

History tells us that physicians, even pediatricians, have been poor stewards of the powerful medications with which we have been entrusted. First, it was antibiotics and now opioids have joined the list.

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

To those of us who live and practice in the northeast, it comes as no surprise that the mortality rate for middle class whites is climbing. Obituaries in our local papers often include men and women in their forties “dying at home,” with no mention of cancer or chronic disease. Rarely, the family can bring itself to announce that their loved one has died of a drug overdose.

Deaths attributable to prescription opioid overdoses quadrupled in the decade from 1999 to 2010, and the trend shows little sign of abating as the number of prescriptions for opioids has risen tenfold over the last 20 years (“How Doctors Helped Drive the Addiction Crisis,” by Dr. Richard Friedman, New York Times, Nov. 7, 2015). Could physician behavior have contributed to outbreak of this deadly plague of addiction? That is like asking if something the zookeeper did or didn’t do could have been responsible for the escape of the man-eating tiger that is devouring the neighborhood children. Regardless of what other factors might be responsible for the epidemic of fatal prescription opioid overdoses, physicians must admit some culpability.

Until recently, I assumed that the problem of prescription opioids finding their way to addicts was unique to physicians treating adults. However, a study reported at the annual meeting of the American Society of Anesthesiologists reveals pediatricians and other clinicians prescribing for children must share in the blame.

Dr. Myron Yaster at Johns Hopkins University Hospital, Baltimore, has found that in a group of nearly 300 pediatric patients (average age, 11 years and average weight of 44 kg), overall the patients used only 42% of the prescribed amount of opioids. Almost half of the patients had a teenage sibling, a group that Dr. Yaster describes as the “target population of drug abuse.”

What’s going on here? Some of the problem dates back to the 1990s when physicians were urged to shift their focus toward the problem of inadequately treated pain. With the help of nurses armed with pain-rating schemes and smiley/grumpy face charts, the mantra became “no pain shall go unmedicated,” when the better response should have been “no pain shall go unmanaged.” But good pain management takes time. It requires that the physician and staff consider each patient as a unique individual. In many cases, reassurance and education can make a non–opioid medication or even no medication a better choice.

However, according to Dr. Yaster, “leftover medicine is the most important element in drug addiction.” Why did physicians prescribe 10 days of medication when his study revealed that most patients took the medication for only 5? It could just be a bad habit. Or it could be ignorance or inexperience. How many physicians ask at follow-up appointments “How long did you take your medication? Tell me the history of your pain.”

Or could it be that physicians are simply trying to prevent those annoying calls from patients who have run out of their medication? Dr. Yaster’s findings suggest that those calls would be few and far between. More careful thought into how much medication we prescribe also would mean that when a patient called for more medication that there was a problem. Either the patient’s recuperation has hit a worrisome bump in the road or possibly her medication is being diverted.

History tells us that physicians, even pediatricians, have been poor stewards of the powerful medications with which we have been entrusted. First, it was antibiotics and now opioids have joined the list.

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

It’s 7:30 Monday evening and the good news is that you were able to leave the office a little after 7:00 and are now at home. The bad news is that you are on call tonight and you are scheduled to work a usual 10-hour day tomorrow.

Should you:

A) Tuck the kids in, warm up a bowl of chili, and lie down on the couch in the den and hope to get a few hours of prophylactic sleep?

B) Go to bed at your usual bedtime of 10:30?

C) Stay up until midnight when experience tells you that the likelihood of getting a call drops significantly ... but unfortunately never approaches zero?

D) Say “To hell with it” and stay up all night binge-watching a whole season of “Justified?”

E) Or, stay up all night surfing the Internet looking for job opportunities that don’t include night call?

Of course, there is no correct answer because stuff happens whenever it chooses to and no strategy will ever guarantee you an uninterrupted 8 hours of sleep when you are on call. However, I learned from a recent article in the Wall Street Journal (A Good Night’s Sleep Is Tied to Interruptions, Not Just Hours – Sumathi Reddy – Nov. 30, 2015) that there is some evidence that “C” clearly is the best choice.

A study from John Hopkins University, Baltimore, published in the journal Sleep found that subjects who were awakened multiple times during the night exhibited a greater decline in positive mood than did those subjects who were sleep deprived by being made to stay up past their usual bedtime (2015 Nov 1;38[11]:1735-42).

Another study from the University of Pittsburgh discovered that elderly subjects’ cognitive performance was impaired when their sleep was interrupted but not when they were allowed to sleep uninterrupted for a shorter period of time (J Gerontol B Psychol Sci Soc Sci. 2009 Mar;64B[2]:180-7).

And, investigators at the University of Tel Aviv have found that subjects who endured 8 hours of fragmented sleep demonstrated declines in their positive mood and ability to attend that were similar to subjects who were allowed only 4 hours of uninterrupted sleep (Sleep Med. 2011 Mar;12[3]:257-61).

Where were these sleep researchers 45 years ago, when I was experimenting with my own strategies for navigating a night on call with a minimum of emotional and cognitive damage? It took me several years to discover that it was fruitless to try grabbing an hour or two of prophylactic sleep early in the evening when the risk of being awakened by a call was still relatively high. The rare occasion when I slept without interruption was of little comfort on the other nights when I could feel every wakening erode my feeble attempts at projecting a pleasant bedside (my bed that is) manner.

It took another few years of trial and error to improve my skill at determining the optimal time to turn in on a given night. It was never perfect, but eventually, I developed an instinct – based on the level of disease in the community, the pulse of the office during the day, and the weather – that kept the interruptions to a minimum. Despite what you may have heard, I never found the phase of moon to be terribly helpful in predicting when I could more safely go to bed.

There is no avoiding the unpleasant truth that being on call puts you at risk for sleep deprivation. One way or another, you are going to be sleep deprived when you show up at the office the next day. But, your best chance of continuing to appear to be a sensitive and intelligent physician is staying up late until the likelihood you will be awakened by a call has reached its traditional nadir.

It’s 7:30 Monday evening and the good news is that you were able to leave the office a little after 7:00 and are now at home. The bad news is that you are on call tonight and you are scheduled to work a usual 10-hour day tomorrow.

Should you:

A) Tuck the kids in, warm up a bowl of chili, and lie down on the couch in the den and hope to get a few hours of prophylactic sleep?

B) Go to bed at your usual bedtime of 10:30?

C) Stay up until midnight when experience tells you that the likelihood of getting a call drops significantly ... but unfortunately never approaches zero?

D) Say “To hell with it” and stay up all night binge-watching a whole season of “Justified?”

E) Or, stay up all night surfing the Internet looking for job opportunities that don’t include night call?

Of course, there is no correct answer because stuff happens whenever it chooses to and no strategy will ever guarantee you an uninterrupted 8 hours of sleep when you are on call. However, I learned from a recent article in the Wall Street Journal (A Good Night’s Sleep Is Tied to Interruptions, Not Just Hours – Sumathi Reddy – Nov. 30, 2015) that there is some evidence that “C” clearly is the best choice.

A study from John Hopkins University, Baltimore, published in the journal Sleep found that subjects who were awakened multiple times during the night exhibited a greater decline in positive mood than did those subjects who were sleep deprived by being made to stay up past their usual bedtime (2015 Nov 1;38[11]:1735-42).

Another study from the University of Pittsburgh discovered that elderly subjects’ cognitive performance was impaired when their sleep was interrupted but not when they were allowed to sleep uninterrupted for a shorter period of time (J Gerontol B Psychol Sci Soc Sci. 2009 Mar;64B[2]:180-7).

And, investigators at the University of Tel Aviv have found that subjects who endured 8 hours of fragmented sleep demonstrated declines in their positive mood and ability to attend that were similar to subjects who were allowed only 4 hours of uninterrupted sleep (Sleep Med. 2011 Mar;12[3]:257-61).

Where were these sleep researchers 45 years ago, when I was experimenting with my own strategies for navigating a night on call with a minimum of emotional and cognitive damage? It took me several years to discover that it was fruitless to try grabbing an hour or two of prophylactic sleep early in the evening when the risk of being awakened by a call was still relatively high. The rare occasion when I slept without interruption was of little comfort on the other nights when I could feel every wakening erode my feeble attempts at projecting a pleasant bedside (my bed that is) manner.

It took another few years of trial and error to improve my skill at determining the optimal time to turn in on a given night. It was never perfect, but eventually, I developed an instinct – based on the level of disease in the community, the pulse of the office during the day, and the weather – that kept the interruptions to a minimum. Despite what you may have heard, I never found the phase of moon to be terribly helpful in predicting when I could more safely go to bed.

There is no avoiding the unpleasant truth that being on call puts you at risk for sleep deprivation. One way or another, you are going to be sleep deprived when you show up at the office the next day. But, your best chance of continuing to appear to be a sensitive and intelligent physician is staying up late until the likelihood you will be awakened by a call has reached its traditional nadir.

It’s 7:30 Monday evening and the good news is that you were able to leave the office a little after 7:00 and are now at home. The bad news is that you are on call tonight and you are scheduled to work a usual 10-hour day tomorrow.

Should you:

A) Tuck the kids in, warm up a bowl of chili, and lie down on the couch in the den and hope to get a few hours of prophylactic sleep?

B) Go to bed at your usual bedtime of 10:30?

C) Stay up until midnight when experience tells you that the likelihood of getting a call drops significantly ... but unfortunately never approaches zero?

D) Say “To hell with it” and stay up all night binge-watching a whole season of “Justified?”

E) Or, stay up all night surfing the Internet looking for job opportunities that don’t include night call?

Of course, there is no correct answer because stuff happens whenever it chooses to and no strategy will ever guarantee you an uninterrupted 8 hours of sleep when you are on call. However, I learned from a recent article in the Wall Street Journal (A Good Night’s Sleep Is Tied to Interruptions, Not Just Hours – Sumathi Reddy – Nov. 30, 2015) that there is some evidence that “C” clearly is the best choice.

A study from John Hopkins University, Baltimore, published in the journal Sleep found that subjects who were awakened multiple times during the night exhibited a greater decline in positive mood than did those subjects who were sleep deprived by being made to stay up past their usual bedtime (2015 Nov 1;38[11]:1735-42).

Another study from the University of Pittsburgh discovered that elderly subjects’ cognitive performance was impaired when their sleep was interrupted but not when they were allowed to sleep uninterrupted for a shorter period of time (J Gerontol B Psychol Sci Soc Sci. 2009 Mar;64B[2]:180-7).

And, investigators at the University of Tel Aviv have found that subjects who endured 8 hours of fragmented sleep demonstrated declines in their positive mood and ability to attend that were similar to subjects who were allowed only 4 hours of uninterrupted sleep (Sleep Med. 2011 Mar;12[3]:257-61).

Where were these sleep researchers 45 years ago, when I was experimenting with my own strategies for navigating a night on call with a minimum of emotional and cognitive damage? It took me several years to discover that it was fruitless to try grabbing an hour or two of prophylactic sleep early in the evening when the risk of being awakened by a call was still relatively high. The rare occasion when I slept without interruption was of little comfort on the other nights when I could feel every wakening erode my feeble attempts at projecting a pleasant bedside (my bed that is) manner.

It took another few years of trial and error to improve my skill at determining the optimal time to turn in on a given night. It was never perfect, but eventually, I developed an instinct – based on the level of disease in the community, the pulse of the office during the day, and the weather – that kept the interruptions to a minimum. Despite what you may have heard, I never found the phase of moon to be terribly helpful in predicting when I could more safely go to bed.

There is no avoiding the unpleasant truth that being on call puts you at risk for sleep deprivation. One way or another, you are going to be sleep deprived when you show up at the office the next day. But, your best chance of continuing to appear to be a sensitive and intelligent physician is staying up late until the likelihood you will be awakened by a call has reached its traditional nadir.

If you have ever waited anxiously for the results of a blood test or biopsy, you may be surprised to learn that some psychologists at the University of California, Riverside, believe that there can be a bright side to those dark days you spent worrying (“Two Definitions of Waiting Well.” Emotion 2015 Oct 12 [epub ahead of print]).

Surveying more than 200 recent law school graduates every 2 weeks during their 4-month wait for the results of the California bar exam, the researchers discovered that those who rode it out anxiously and pessimistically handled the bad news of failure “more productively.” And they welcomed the good news “more joyously” than did their peers who had “suffered little during the wait.”

While these psychologists’ findings may be of some help to aspiring lawyers or freshly minted physicians waiting to hear if they have passed their boards, I don’t think we should take them to heart when ordering lab work or imaging studies on our patients. After all, flunking the bar exam may be a life-altering event, but it isn’t a life-ending one such as learning that the biopsy you waited a week for has detected a cancer that has metastasized beyond the reaches of radiation and chemotherapy.

The bottom line is that waiting for potentially bad news is anxiety provoking regardless of whether it is for the results of a qualifying exam or a simple CBC. And, as physicians, it is our responsibility to do whatever we can to minimize that anxiety by following some simple commonsense rules of courtesy and decency.

First, we must understand that even low-risk preop screening lab work that we may view as innocuous may trigger significant anxiety in many patients. For example, a patient who knew someone whose leukemia was discovered as the result of a preop screening CBC may worry that a similar fate will be revealed by his blood test.

Second, we should ask ourselves every time we order some lab work or imaging study if it is really necessary. Are we just trying to cover our behinds and protect ourselves from a malpractice suit? Do we know what we are going to do with an equivocal borderline result? An unnecessary blood test isn’t just a waste of someone’s money and a symptom of sloppy medicine. It can be the cause of an anxiety-provoking wait for the patient.

Finally, if we are going to order a lab test, even if it is just for preop screening, it is our obligation to inform the patient of the result in a timely fashion. In my universe, that means the same day that the physician receives the result. In today’s world with its panoply of communication platforms, informing the patient can be as simple as leaving a message on a system previously approved by the patient. Obviously, bad or complicated news should be delivered directly by the physician with a phone call. Of course, informing the patient of even normal lab work results takes time, but it is the courteous and decent thing to do and signals to the patient that she has a physician who cares. If it seems like too much work, it may be that the physician is ordering too much lab work.

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 have ever waited anxiously for the results of a blood test or biopsy, you may be surprised to learn that some psychologists at the University of California, Riverside, believe that there can be a bright side to those dark days you spent worrying (“Two Definitions of Waiting Well.” Emotion 2015 Oct 12 [epub ahead of print]).

Surveying more than 200 recent law school graduates every 2 weeks during their 4-month wait for the results of the California bar exam, the researchers discovered that those who rode it out anxiously and pessimistically handled the bad news of failure “more productively.” And they welcomed the good news “more joyously” than did their peers who had “suffered little during the wait.”

While these psychologists’ findings may be of some help to aspiring lawyers or freshly minted physicians waiting to hear if they have passed their boards, I don’t think we should take them to heart when ordering lab work or imaging studies on our patients. After all, flunking the bar exam may be a life-altering event, but it isn’t a life-ending one such as learning that the biopsy you waited a week for has detected a cancer that has metastasized beyond the reaches of radiation and chemotherapy.

The bottom line is that waiting for potentially bad news is anxiety provoking regardless of whether it is for the results of a qualifying exam or a simple CBC. And, as physicians, it is our responsibility to do whatever we can to minimize that anxiety by following some simple commonsense rules of courtesy and decency.

First, we must understand that even low-risk preop screening lab work that we may view as innocuous may trigger significant anxiety in many patients. For example, a patient who knew someone whose leukemia was discovered as the result of a preop screening CBC may worry that a similar fate will be revealed by his blood test.

Second, we should ask ourselves every time we order some lab work or imaging study if it is really necessary. Are we just trying to cover our behinds and protect ourselves from a malpractice suit? Do we know what we are going to do with an equivocal borderline result? An unnecessary blood test isn’t just a waste of someone’s money and a symptom of sloppy medicine. It can be the cause of an anxiety-provoking wait for the patient.

Finally, if we are going to order a lab test, even if it is just for preop screening, it is our obligation to inform the patient of the result in a timely fashion. In my universe, that means the same day that the physician receives the result. In today’s world with its panoply of communication platforms, informing the patient can be as simple as leaving a message on a system previously approved by the patient. Obviously, bad or complicated news should be delivered directly by the physician with a phone call. Of course, informing the patient of even normal lab work results takes time, but it is the courteous and decent thing to do and signals to the patient that she has a physician who cares. If it seems like too much work, it may be that the physician is ordering too much lab work.

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 have ever waited anxiously for the results of a blood test or biopsy, you may be surprised to learn that some psychologists at the University of California, Riverside, believe that there can be a bright side to those dark days you spent worrying (“Two Definitions of Waiting Well.” Emotion 2015 Oct 12 [epub ahead of print]).

Surveying more than 200 recent law school graduates every 2 weeks during their 4-month wait for the results of the California bar exam, the researchers discovered that those who rode it out anxiously and pessimistically handled the bad news of failure “more productively.” And they welcomed the good news “more joyously” than did their peers who had “suffered little during the wait.”

While these psychologists’ findings may be of some help to aspiring lawyers or freshly minted physicians waiting to hear if they have passed their boards, I don’t think we should take them to heart when ordering lab work or imaging studies on our patients. After all, flunking the bar exam may be a life-altering event, but it isn’t a life-ending one such as learning that the biopsy you waited a week for has detected a cancer that has metastasized beyond the reaches of radiation and chemotherapy.

The bottom line is that waiting for potentially bad news is anxiety provoking regardless of whether it is for the results of a qualifying exam or a simple CBC. And, as physicians, it is our responsibility to do whatever we can to minimize that anxiety by following some simple commonsense rules of courtesy and decency.

First, we must understand that even low-risk preop screening lab work that we may view as innocuous may trigger significant anxiety in many patients. For example, a patient who knew someone whose leukemia was discovered as the result of a preop screening CBC may worry that a similar fate will be revealed by his blood test.

Second, we should ask ourselves every time we order some lab work or imaging study if it is really necessary. Are we just trying to cover our behinds and protect ourselves from a malpractice suit? Do we know what we are going to do with an equivocal borderline result? An unnecessary blood test isn’t just a waste of someone’s money and a symptom of sloppy medicine. It can be the cause of an anxiety-provoking wait for the patient.

Finally, if we are going to order a lab test, even if it is just for preop screening, it is our obligation to inform the patient of the result in a timely fashion. In my universe, that means the same day that the physician receives the result. In today’s world with its panoply of communication platforms, informing the patient can be as simple as leaving a message on a system previously approved by the patient. Obviously, bad or complicated news should be delivered directly by the physician with a phone call. Of course, informing the patient of even normal lab work results takes time, but it is the courteous and decent thing to do and signals to the patient that she has a physician who cares. If it seems like too much work, it may be that the physician is ordering too much lab work.

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

When you finish reading this column … on second thought, stop now and read the Oct. 17, 2015, opinion piece titled “Overselling Breast-Feeding.” You will discover a well-researched and thoughtfully crafted article by Courtney Jung, a political science professor at the University of Toronto, in which she dares to carefully dissect one of our most revered sacred cows. The result is a convincing argument for rethinking how we present and promote breastfeeding. I won’t attempt to reconstruct her rationale. You can read it for yourself. But, I suspect that if you spend any part of your day trying to help new parents navigate the choppy waters of those first 6 months, you will find what she has to say strikes more than a few familiar chords.

Like most of you, what I learned about breastfeeding came as on the job training. Marilyn and I started our family while I was still in medical school, giving me the advantage of having watched the process bump along twice before I found myself on the frontline of private practice. I had been taught in school about all the advantages breast milk, but it didn’t take long in the real world to discover that breastfeeding could have a dark side.

I had to become a chameleon. I needed to be strong advocate for the advantages of breast milk and support new mothers as they tried to match the American Academy of Pediatrics’ guidelines. However, there were situations in which despite everyone’s best efforts, the handwriting on the wall said, “This isn’t working.” Then it was time to change my colors and convincingly convey the new truth that even a baby that isn’t breastfed is going to be fine. That a woman who doesn’t breastfeed can and will be a mother every bit as good as one who doesn’t breastfed her baby for 6 months or a year.

©Jupiterimages/thinkstockphotos.com

The tension between the party line and reality became so great that in frustration I decided to write my third book about breastfeeding. The result was “The Maternity Leave Breastfeeding Plan” (New York: Simon and Schuster, 2002). The watered-down title was chosen by the publisher. The subtitle, “How to Enjoy Nursing for 3 Months and Go Back to Work Guilt-Free,” was a better reflection of my message that there can be some serious challenges to breastfeeding and not to worry if it doesn’t work. Surprisingly, it found itself on a La Leche League list of recommended books – that is until someone in the organization actually read it.

Although I had always harbored doubts that many of the studies purporting to show the advantages of breastfeeding were poorly controlled, in 2002, I couldn’t find any data to support my concerns. But over the last decade those studies have begun to emerge and Professor Jung has found them and included them in her new book, “Lactivism: How Feminists and Fundamentalists, Hippies and Yuppies, and Physicians and Politicians Made Breastfeeding Big Business and Bad Policy” (New York: Basic Books, 2015).

It will be interesting to see how her observations play to the wider audience it deserves. The discussions may be lively and heated, and public opinion may shift a bit. But what won’t change is that those of us who deal with mothers and babies in a very personal way will still have to struggle with promoting a good product that isn’t always easy to obtain.

Breast milk is good … but it isn’t always better or best.

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

When you finish reading this column … on second thought, stop now and read the Oct. 17, 2015, opinion piece titled “Overselling Breast-Feeding.” You will discover a well-researched and thoughtfully crafted article by Courtney Jung, a political science professor at the University of Toronto, in which she dares to carefully dissect one of our most revered sacred cows. The result is a convincing argument for rethinking how we present and promote breastfeeding. I won’t attempt to reconstruct her rationale. You can read it for yourself. But, I suspect that if you spend any part of your day trying to help new parents navigate the choppy waters of those first 6 months, you will find what she has to say strikes more than a few familiar chords.

Like most of you, what I learned about breastfeeding came as on the job training. Marilyn and I started our family while I was still in medical school, giving me the advantage of having watched the process bump along twice before I found myself on the frontline of private practice. I had been taught in school about all the advantages breast milk, but it didn’t take long in the real world to discover that breastfeeding could have a dark side.

I had to become a chameleon. I needed to be strong advocate for the advantages of breast milk and support new mothers as they tried to match the American Academy of Pediatrics’ guidelines. However, there were situations in which despite everyone’s best efforts, the handwriting on the wall said, “This isn’t working.” Then it was time to change my colors and convincingly convey the new truth that even a baby that isn’t breastfed is going to be fine. That a woman who doesn’t breastfeed can and will be a mother every bit as good as one who doesn’t breastfed her baby for 6 months or a year.

©Jupiterimages/thinkstockphotos.com

The tension between the party line and reality became so great that in frustration I decided to write my third book about breastfeeding. The result was “The Maternity Leave Breastfeeding Plan” (New York: Simon and Schuster, 2002). The watered-down title was chosen by the publisher. The subtitle, “How to Enjoy Nursing for 3 Months and Go Back to Work Guilt-Free,” was a better reflection of my message that there can be some serious challenges to breastfeeding and not to worry if it doesn’t work. Surprisingly, it found itself on a La Leche League list of recommended books – that is until someone in the organization actually read it.

Although I had always harbored doubts that many of the studies purporting to show the advantages of breastfeeding were poorly controlled, in 2002, I couldn’t find any data to support my concerns. But over the last decade those studies have begun to emerge and Professor Jung has found them and included them in her new book, “Lactivism: How Feminists and Fundamentalists, Hippies and Yuppies, and Physicians and Politicians Made Breastfeeding Big Business and Bad Policy” (New York: Basic Books, 2015).

It will be interesting to see how her observations play to the wider audience it deserves. The discussions may be lively and heated, and public opinion may shift a bit. But what won’t change is that those of us who deal with mothers and babies in a very personal way will still have to struggle with promoting a good product that isn’t always easy to obtain.

Breast milk is good … but it isn’t always better or best.

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

When you finish reading this column … on second thought, stop now and read the Oct. 17, 2015, opinion piece titled “Overselling Breast-Feeding.” You will discover a well-researched and thoughtfully crafted article by Courtney Jung, a political science professor at the University of Toronto, in which she dares to carefully dissect one of our most revered sacred cows. The result is a convincing argument for rethinking how we present and promote breastfeeding. I won’t attempt to reconstruct her rationale. You can read it for yourself. But, I suspect that if you spend any part of your day trying to help new parents navigate the choppy waters of those first 6 months, you will find what she has to say strikes more than a few familiar chords.

Like most of you, what I learned about breastfeeding came as on the job training. Marilyn and I started our family while I was still in medical school, giving me the advantage of having watched the process bump along twice before I found myself on the frontline of private practice. I had been taught in school about all the advantages breast milk, but it didn’t take long in the real world to discover that breastfeeding could have a dark side.

I had to become a chameleon. I needed to be strong advocate for the advantages of breast milk and support new mothers as they tried to match the American Academy of Pediatrics’ guidelines. However, there were situations in which despite everyone’s best efforts, the handwriting on the wall said, “This isn’t working.” Then it was time to change my colors and convincingly convey the new truth that even a baby that isn’t breastfed is going to be fine. That a woman who doesn’t breastfeed can and will be a mother every bit as good as one who doesn’t breastfed her baby for 6 months or a year.

©Jupiterimages/thinkstockphotos.com

The tension between the party line and reality became so great that in frustration I decided to write my third book about breastfeeding. The result was “The Maternity Leave Breastfeeding Plan” (New York: Simon and Schuster, 2002). The watered-down title was chosen by the publisher. The subtitle, “How to Enjoy Nursing for 3 Months and Go Back to Work Guilt-Free,” was a better reflection of my message that there can be some serious challenges to breastfeeding and not to worry if it doesn’t work. Surprisingly, it found itself on a La Leche League list of recommended books – that is until someone in the organization actually read it.

Although I had always harbored doubts that many of the studies purporting to show the advantages of breastfeeding were poorly controlled, in 2002, I couldn’t find any data to support my concerns. But over the last decade those studies have begun to emerge and Professor Jung has found them and included them in her new book, “Lactivism: How Feminists and Fundamentalists, Hippies and Yuppies, and Physicians and Politicians Made Breastfeeding Big Business and Bad Policy” (New York: Basic Books, 2015).

It will be interesting to see how her observations play to the wider audience it deserves. The discussions may be lively and heated, and public opinion may shift a bit. But what won’t change is that those of us who deal with mothers and babies in a very personal way will still have to struggle with promoting a good product that isn’t always easy to obtain.

Breast milk is good … but it isn’t always better or best.

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.”

Imagine yourself in a small community hospital standing at the bedside of a tiny preemie waiting for the neonatal transport team to return your call for help.

With one eye shifting between the clock and the oximeter, you have the other one looking out the window hoping that the predicted snow and freezing rain will hold out for another hour. You have done everything you can do, but clearly it’s not going to be enough to rescue this little person who had the misfortune of exiting the birth canal several months too early.

You have been able to insert an umbilical vein catheter and miraculously have threaded an endotracheal tube into a trachea that looked no bigger than a piece of spaghetti, or maybe you have failed and the nurses are taking turns bagging. The transport team returns your call for help and with apologies reports that they are tied up with a similar scenario further south; they predict that it may be an hour and a half before they will be able to get back to their hospital, which is a half hour down the road from you.

They suggest some things that you have already done. Should you wait for more skilled hands and their equipment or transport the patient yourself and get on the road before it becomes a skating rink? There is an antique transport isolette gathering dust in the storage room down the hall, and the local fire department ambulance crew with whom you are on a first-name basis is always ready to help. Is it time to gather the troops and tell them, “Let’s roll!” ?

If you have ever lived through a similar scenario, you may find a recent study interesting (Ann Intern Med. 2015;163[9]:681-90). What these investigators found was that for adults who had suffered major trauma, stroke, respiratory failure, and acute myocardial infarction, those who were transported by crews with basic life support (BLS) skills had significantly better long-term survival and neurologic outcomes than did those victims transported by crews with advanced life support (ALS) skills.

In the flurry of comments that circulated following the release of the study were a few questions about the methodology, but most commentators were searching for an explanation. Was critical time lost by the ALS crews doing stuff when the better course of action would have been to get the ambulance rolling to the hospital and more definitive care? Does the temptation to do things because you can do them sometimes cloud the decision-making process?

Although I have lived the scenario I described, it is less likely to happen now. Backup teams from other institutions may be activated. The teams are so well equipped and trained that the gaps between their capabilities and the neonatal intensive care unit have narrowed, but there is no question that they remain and are significant.

The other thing that hasn’t changed is the weather here in Maine. While we have beautiful summers that prompt us to put “Vacationland” on our license plates, our winters are a challenge. In addition to the patient’s condition and the availability of resources, the decision of whether to invest time in stabilization or get moving toward the referral center also must include the risk to the patient and staff who will be traveling on weather-threatened roads.

On the other hand, we can’t ignore the elephant that occasionally finds its way into the room when decisions are made about how thoroughly a critically ill patient is stabilized and how speedily he is transferred. And, that ponderous pachyderm is the hot potato factor and sometimes answers to its acronym, NIMBY (“not in my back yard”). You know as well as I do that despite the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations, there are cases when a patient is hustled out the door without being appropriately stabilized primarily to avoid having that patient die in the referring hospital. We must continue to ask ourselves if we have done everything that we can do to stabilize the patient before we say, “Let’s roll!”

William G. Wilkoff, M.D., 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.”

Imagine yourself in a small community hospital standing at the bedside of a tiny preemie waiting for the neonatal transport team to return your call for help.

With one eye shifting between the clock and the oximeter, you have the other one looking out the window hoping that the predicted snow and freezing rain will hold out for another hour. You have done everything you can do, but clearly it’s not going to be enough to rescue this little person who had the misfortune of exiting the birth canal several months too early.

You have been able to insert an umbilical vein catheter and miraculously have threaded an endotracheal tube into a trachea that looked no bigger than a piece of spaghetti, or maybe you have failed and the nurses are taking turns bagging. The transport team returns your call for help and with apologies reports that they are tied up with a similar scenario further south; they predict that it may be an hour and a half before they will be able to get back to their hospital, which is a half hour down the road from you.

They suggest some things that you have already done. Should you wait for more skilled hands and their equipment or transport the patient yourself and get on the road before it becomes a skating rink? There is an antique transport isolette gathering dust in the storage room down the hall, and the local fire department ambulance crew with whom you are on a first-name basis is always ready to help. Is it time to gather the troops and tell them, “Let’s roll!” ?

If you have ever lived through a similar scenario, you may find a recent study interesting (Ann Intern Med. 2015;163[9]:681-90). What these investigators found was that for adults who had suffered major trauma, stroke, respiratory failure, and acute myocardial infarction, those who were transported by crews with basic life support (BLS) skills had significantly better long-term survival and neurologic outcomes than did those victims transported by crews with advanced life support (ALS) skills.

In the flurry of comments that circulated following the release of the study were a few questions about the methodology, but most commentators were searching for an explanation. Was critical time lost by the ALS crews doing stuff when the better course of action would have been to get the ambulance rolling to the hospital and more definitive care? Does the temptation to do things because you can do them sometimes cloud the decision-making process?

Although I have lived the scenario I described, it is less likely to happen now. Backup teams from other institutions may be activated. The teams are so well equipped and trained that the gaps between their capabilities and the neonatal intensive care unit have narrowed, but there is no question that they remain and are significant.

The other thing that hasn’t changed is the weather here in Maine. While we have beautiful summers that prompt us to put “Vacationland” on our license plates, our winters are a challenge. In addition to the patient’s condition and the availability of resources, the decision of whether to invest time in stabilization or get moving toward the referral center also must include the risk to the patient and staff who will be traveling on weather-threatened roads.

On the other hand, we can’t ignore the elephant that occasionally finds its way into the room when decisions are made about how thoroughly a critically ill patient is stabilized and how speedily he is transferred. And, that ponderous pachyderm is the hot potato factor and sometimes answers to its acronym, NIMBY (“not in my back yard”). You know as well as I do that despite the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations, there are cases when a patient is hustled out the door without being appropriately stabilized primarily to avoid having that patient die in the referring hospital. We must continue to ask ourselves if we have done everything that we can do to stabilize the patient before we say, “Let’s roll!”

William G. Wilkoff, M.D., 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.”

Imagine yourself in a small community hospital standing at the bedside of a tiny preemie waiting for the neonatal transport team to return your call for help.

With one eye shifting between the clock and the oximeter, you have the other one looking out the window hoping that the predicted snow and freezing rain will hold out for another hour. You have done everything you can do, but clearly it’s not going to be enough to rescue this little person who had the misfortune of exiting the birth canal several months too early.

You have been able to insert an umbilical vein catheter and miraculously have threaded an endotracheal tube into a trachea that looked no bigger than a piece of spaghetti, or maybe you have failed and the nurses are taking turns bagging. The transport team returns your call for help and with apologies reports that they are tied up with a similar scenario further south; they predict that it may be an hour and a half before they will be able to get back to their hospital, which is a half hour down the road from you.

They suggest some things that you have already done. Should you wait for more skilled hands and their equipment or transport the patient yourself and get on the road before it becomes a skating rink? There is an antique transport isolette gathering dust in the storage room down the hall, and the local fire department ambulance crew with whom you are on a first-name basis is always ready to help. Is it time to gather the troops and tell them, “Let’s roll!” ?

If you have ever lived through a similar scenario, you may find a recent study interesting (Ann Intern Med. 2015;163[9]:681-90). What these investigators found was that for adults who had suffered major trauma, stroke, respiratory failure, and acute myocardial infarction, those who were transported by crews with basic life support (BLS) skills had significantly better long-term survival and neurologic outcomes than did those victims transported by crews with advanced life support (ALS) skills.

In the flurry of comments that circulated following the release of the study were a few questions about the methodology, but most commentators were searching for an explanation. Was critical time lost by the ALS crews doing stuff when the better course of action would have been to get the ambulance rolling to the hospital and more definitive care? Does the temptation to do things because you can do them sometimes cloud the decision-making process?

Although I have lived the scenario I described, it is less likely to happen now. Backup teams from other institutions may be activated. The teams are so well equipped and trained that the gaps between their capabilities and the neonatal intensive care unit have narrowed, but there is no question that they remain and are significant.

The other thing that hasn’t changed is the weather here in Maine. While we have beautiful summers that prompt us to put “Vacationland” on our license plates, our winters are a challenge. In addition to the patient’s condition and the availability of resources, the decision of whether to invest time in stabilization or get moving toward the referral center also must include the risk to the patient and staff who will be traveling on weather-threatened roads.

On the other hand, we can’t ignore the elephant that occasionally finds its way into the room when decisions are made about how thoroughly a critically ill patient is stabilized and how speedily he is transferred. And, that ponderous pachyderm is the hot potato factor and sometimes answers to its acronym, NIMBY (“not in my back yard”). You know as well as I do that despite the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations, there are cases when a patient is hustled out the door without being appropriately stabilized primarily to avoid having that patient die in the referring hospital. We must continue to ask ourselves if we have done everything that we can do to stabilize the patient before we say, “Let’s roll!”

William G. Wilkoff, M.D., 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 May 2015, the American Academy of Pediatrics convened an invitation-only symposium titled Growing Up Digital. Its goal was to reconsider the Academy’s advice on “screen time” and make sure that its policies were “science-driven, not based merely on the precautionary principle.” (“Beyond ‘turn it off’: How to advice families on media use,” Brown et al. AAP News, October 2015). Driven by the concern that the current AAP advice was becoming obsolete and as a result likely to be ignored by parents faced with the realities of our digital culture, the participants investigated the available data on “early learning, game-based learning, social/emotional and developmental concerns, and strategies to foster digital citizenship.”

Their findings have been distilled into a collection of “key messages” for parents published in the October, 2015 AAP News. It’s hard to argue with most of the common sense advice that includes “Role modeling is critical; playtime is important; co-engagement counts; set limits; and create tech-free zones.” A set of formal recommendations is in the works and will be published at a later date.

It is comforting to learn of the academy’s concern to keep its advice current and evidence-based. It is frustrating for those of us expected to deliver the party line when we suspect that parents are muttering to themselves, “Really?” I assume that most pediatricians at the parent/doctor interface will join me in welcoming much of the more nuanced advice in the final recommendations, particularly those for older children and adolescents.

However, if the new document is not carefully worded and promoted, I fear that the potent message of “no screen time under age 2” will be lost or diluted. While the symposium participants may have uncovered some evidence of benefit or at least no serious harm from some digital platforms, does this warrant softening the catchy and clear advice of “no screen time under 2?” I have to ask myself when would a child under the age of 2 being raised in a healthy environment have time for electronic distraction?

As Dr. Ari Brown, Dr. Donald L. Shifrin, and Dr. David L. Hill ask parents in their AAP News piece, “Does your child’s technology use help or hinder participation in other activities?” Just doing a little quick math: Wake up at 7 a.m., breakfast, playground time, maybe a midmorning nap, snack, lunch, afternoon nap, afternoon playground time, maybe another snack, dinner, bedtime story and lights out at 7 p.m. I don’t see a spot to shoehorn in some screen time without eliminating a developmentally and socially important activity. You could replace the hard cover book at bedtime with an electronic one on a tablet, but in my experience that runs the risk of replacing a soporific activity with one that is too visually stimulating.

One could argue that depriving a young child of screen time is going to put him behind his peers who have become masterful web navigators by the time they are 18 months. Rubbish. The learning curve for most electronic devices is so short that the “deprived” child will catch up in a couple of dozen clicks. However, screens require little more than a moving and tapping index finger. What about those other manipulative skills and the strength and coordination of the muscles sitting unused during screen time?

Unfortunately, the crafters of these new guidelines have repeated the same mistake the academy has made before when they observe, “The quality of the content is more important than the platform or time spent with media.” In my opinion, if the time spent on a screen is kept sufficiently short, children won’t squander it on bad stuff for very long nor will what they see be that harmful. Burdening parents with the task of determining quality is unrealistic. However, setting a time limit is far more workable and enforceable.

Finally, when it comes to parents enforcing no screen time under 2, everyone knows that Skyping with Grandma and Grandpa gets a free pass.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.” Email him at [email protected].

In May 2015, the American Academy of Pediatrics convened an invitation-only symposium titled Growing Up Digital. Its goal was to reconsider the Academy’s advice on “screen time” and make sure that its policies were “science-driven, not based merely on the precautionary principle.” (“Beyond ‘turn it off’: How to advice families on media use,” Brown et al. AAP News, October 2015). Driven by the concern that the current AAP advice was becoming obsolete and as a result likely to be ignored by parents faced with the realities of our digital culture, the participants investigated the available data on “early learning, game-based learning, social/emotional and developmental concerns, and strategies to foster digital citizenship.”

Their findings have been distilled into a collection of “key messages” for parents published in the October, 2015 AAP News. It’s hard to argue with most of the common sense advice that includes “Role modeling is critical; playtime is important; co-engagement counts; set limits; and create tech-free zones.” A set of formal recommendations is in the works and will be published at a later date.

It is comforting to learn of the academy’s concern to keep its advice current and evidence-based. It is frustrating for those of us expected to deliver the party line when we suspect that parents are muttering to themselves, “Really?” I assume that most pediatricians at the parent/doctor interface will join me in welcoming much of the more nuanced advice in the final recommendations, particularly those for older children and adolescents.

However, if the new document is not carefully worded and promoted, I fear that the potent message of “no screen time under age 2” will be lost or diluted. While the symposium participants may have uncovered some evidence of benefit or at least no serious harm from some digital platforms, does this warrant softening the catchy and clear advice of “no screen time under 2?” I have to ask myself when would a child under the age of 2 being raised in a healthy environment have time for electronic distraction?

As Dr. Ari Brown, Dr. Donald L. Shifrin, and Dr. David L. Hill ask parents in their AAP News piece, “Does your child’s technology use help or hinder participation in other activities?” Just doing a little quick math: Wake up at 7 a.m., breakfast, playground time, maybe a midmorning nap, snack, lunch, afternoon nap, afternoon playground time, maybe another snack, dinner, bedtime story and lights out at 7 p.m. I don’t see a spot to shoehorn in some screen time without eliminating a developmentally and socially important activity. You could replace the hard cover book at bedtime with an electronic one on a tablet, but in my experience that runs the risk of replacing a soporific activity with one that is too visually stimulating.

One could argue that depriving a young child of screen time is going to put him behind his peers who have become masterful web navigators by the time they are 18 months. Rubbish. The learning curve for most electronic devices is so short that the “deprived” child will catch up in a couple of dozen clicks. However, screens require little more than a moving and tapping index finger. What about those other manipulative skills and the strength and coordination of the muscles sitting unused during screen time?

Unfortunately, the crafters of these new guidelines have repeated the same mistake the academy has made before when they observe, “The quality of the content is more important than the platform or time spent with media.” In my opinion, if the time spent on a screen is kept sufficiently short, children won’t squander it on bad stuff for very long nor will what they see be that harmful. Burdening parents with the task of determining quality is unrealistic. However, setting a time limit is far more workable and enforceable.

Finally, when it comes to parents enforcing no screen time under 2, everyone knows that Skyping with Grandma and Grandpa gets a free pass.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.” Email him at [email protected].

In May 2015, the American Academy of Pediatrics convened an invitation-only symposium titled Growing Up Digital. Its goal was to reconsider the Academy’s advice on “screen time” and make sure that its policies were “science-driven, not based merely on the precautionary principle.” (“Beyond ‘turn it off’: How to advice families on media use,” Brown et al. AAP News, October 2015). Driven by the concern that the current AAP advice was becoming obsolete and as a result likely to be ignored by parents faced with the realities of our digital culture, the participants investigated the available data on “early learning, game-based learning, social/emotional and developmental concerns, and strategies to foster digital citizenship.”

Their findings have been distilled into a collection of “key messages” for parents published in the October, 2015 AAP News. It’s hard to argue with most of the common sense advice that includes “Role modeling is critical; playtime is important; co-engagement counts; set limits; and create tech-free zones.” A set of formal recommendations is in the works and will be published at a later date.

It is comforting to learn of the academy’s concern to keep its advice current and evidence-based. It is frustrating for those of us expected to deliver the party line when we suspect that parents are muttering to themselves, “Really?” I assume that most pediatricians at the parent/doctor interface will join me in welcoming much of the more nuanced advice in the final recommendations, particularly those for older children and adolescents.

However, if the new document is not carefully worded and promoted, I fear that the potent message of “no screen time under age 2” will be lost or diluted. While the symposium participants may have uncovered some evidence of benefit or at least no serious harm from some digital platforms, does this warrant softening the catchy and clear advice of “no screen time under 2?” I have to ask myself when would a child under the age of 2 being raised in a healthy environment have time for electronic distraction?

As Dr. Ari Brown, Dr. Donald L. Shifrin, and Dr. David L. Hill ask parents in their AAP News piece, “Does your child’s technology use help or hinder participation in other activities?” Just doing a little quick math: Wake up at 7 a.m., breakfast, playground time, maybe a midmorning nap, snack, lunch, afternoon nap, afternoon playground time, maybe another snack, dinner, bedtime story and lights out at 7 p.m. I don’t see a spot to shoehorn in some screen time without eliminating a developmentally and socially important activity. You could replace the hard cover book at bedtime with an electronic one on a tablet, but in my experience that runs the risk of replacing a soporific activity with one that is too visually stimulating.

One could argue that depriving a young child of screen time is going to put him behind his peers who have become masterful web navigators by the time they are 18 months. Rubbish. The learning curve for most electronic devices is so short that the “deprived” child will catch up in a couple of dozen clicks. However, screens require little more than a moving and tapping index finger. What about those other manipulative skills and the strength and coordination of the muscles sitting unused during screen time?

Unfortunately, the crafters of these new guidelines have repeated the same mistake the academy has made before when they observe, “The quality of the content is more important than the platform or time spent with media.” In my opinion, if the time spent on a screen is kept sufficiently short, children won’t squander it on bad stuff for very long nor will what they see be that harmful. Burdening parents with the task of determining quality is unrealistic. However, setting a time limit is far more workable and enforceable.

Finally, when it comes to parents enforcing no screen time under 2, everyone knows that Skyping with Grandma and Grandpa gets a free pass.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.” Email him at [email protected].

You probably first heard the acronym EDC in medical school, and it replaced what you had been referring to as a “due date.” Of course, you remember the “C” is the first letter of “confinement.” Or is it? You would be forgiven if you thought EDC stood for Estimated Date of Cesarean.

While the practice of keeping new mothers cooped up in their homes for month and placed on dietary, activity, and even hygienic restrictions has all but disappeared in this country, the tradition persists in China. Believing that the process of even a normal delivery renders a woman vulnerable to all sorts of maladies, for 2,000 years Chinese grandmothers have been confining their daughters at home for the first month post partum.

In a recent article in the New York Times, I learned that while confinement continues post partum in China, it has changed among some affluent families so that it is more like spending a month in a high-end spa (“A Tradition for New Mothers in China, Now $27,000 a month” By Dan Levin, Oct. 1, 2015). The new confinement includes breastfeeding instruction, and dietary and activity choices that purport to be more scientifically based than the traditional restrictions. It has become popular with women who can afford it, while in the past confinement could be a month filled with tension between grandmothers and their daughters taking care of their new babies.

I can’t see the new Chinese version of confinement catching on here in North America, but the New York Times article did get me thinking about how we could do a better job helping mothers navigate the choppy waters of those first 30 days post partum. The Chinese are correct that a delivery is an assault on the body of even a previously healthy young woman. Even as one who hasn’t had the experience, I can only imagine it is like pulling an all-nighter (or two) and then running a marathon. Oh, and along the way losing a pint or two of blood.

There are a few families in North America who can afford to hire trained personnel (doulas), but for the most part we aren’t doing a very good job of helping women transition into motherhood. Of course, universal and more liberal family leave policies could make things easier. But simply lessening some of the tension associated with the inevitable return to the workplace isn’t enough. It is unlikely that we have the political will to make the changes to see those policies enacted.

However, there are things that we as pediatricians can do to make the postpartum period safer, healthier, and more comfortable for struggling families. First, we can encourage expectant mothers to make prenatal visits in our offices. While these visits are often little more than doctor shopping, we can ask the families who have committed to our practices to make a second appointment with more educational content. Would we get paid for it? Maybe not, but these second visits could pay for themselves in fewer after-hours calls.

We should do a better job of getting to know a new mother before she goes home from the hospital. What is her discharge hemoglobin? Does she have a history of depression and/or anxiety? Anemia and psychiatric issues can dramatically increase the risk that breastfeeding won’t go well and that post partum depression is more likely to ensue.

Are our offices and lactation consultants really available 24/7? Are we all on the same page when it comes to post partum advice? Do we return calls promptly and make follow-up calls? Are our offices and schedules truly new-mother friendly? Have we made use of all the available home health services that might be required?

The first postpartum month is critical, and new mothers need to be treated as our highest priority, but not confined.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.” Email him at [email protected].

You probably first heard the acronym EDC in medical school, and it replaced what you had been referring to as a “due date.” Of course, you remember the “C” is the first letter of “confinement.” Or is it? You would be forgiven if you thought EDC stood for Estimated Date of Cesarean.

While the practice of keeping new mothers cooped up in their homes for month and placed on dietary, activity, and even hygienic restrictions has all but disappeared in this country, the tradition persists in China. Believing that the process of even a normal delivery renders a woman vulnerable to all sorts of maladies, for 2,000 years Chinese grandmothers have been confining their daughters at home for the first month post partum.

In a recent article in the New York Times, I learned that while confinement continues post partum in China, it has changed among some affluent families so that it is more like spending a month in a high-end spa (“A Tradition for New Mothers in China, Now $27,000 a month” By Dan Levin, Oct. 1, 2015). The new confinement includes breastfeeding instruction, and dietary and activity choices that purport to be more scientifically based than the traditional restrictions. It has become popular with women who can afford it, while in the past confinement could be a month filled with tension between grandmothers and their daughters taking care of their new babies.

I can’t see the new Chinese version of confinement catching on here in North America, but the New York Times article did get me thinking about how we could do a better job helping mothers navigate the choppy waters of those first 30 days post partum. The Chinese are correct that a delivery is an assault on the body of even a previously healthy young woman. Even as one who hasn’t had the experience, I can only imagine it is like pulling an all-nighter (or two) and then running a marathon. Oh, and along the way losing a pint or two of blood.

There are a few families in North America who can afford to hire trained personnel (doulas), but for the most part we aren’t doing a very good job of helping women transition into motherhood. Of course, universal and more liberal family leave policies could make things easier. But simply lessening some of the tension associated with the inevitable return to the workplace isn’t enough. It is unlikely that we have the political will to make the changes to see those policies enacted.

However, there are things that we as pediatricians can do to make the postpartum period safer, healthier, and more comfortable for struggling families. First, we can encourage expectant mothers to make prenatal visits in our offices. While these visits are often little more than doctor shopping, we can ask the families who have committed to our practices to make a second appointment with more educational content. Would we get paid for it? Maybe not, but these second visits could pay for themselves in fewer after-hours calls.

We should do a better job of getting to know a new mother before she goes home from the hospital. What is her discharge hemoglobin? Does she have a history of depression and/or anxiety? Anemia and psychiatric issues can dramatically increase the risk that breastfeeding won’t go well and that post partum depression is more likely to ensue.

Are our offices and lactation consultants really available 24/7? Are we all on the same page when it comes to post partum advice? Do we return calls promptly and make follow-up calls? Are our offices and schedules truly new-mother friendly? Have we made use of all the available home health services that might be required?

The first postpartum month is critical, and new mothers need to be treated as our highest priority, but not confined.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.” Email him at [email protected].

You probably first heard the acronym EDC in medical school, and it replaced what you had been referring to as a “due date.” Of course, you remember the “C” is the first letter of “confinement.” Or is it? You would be forgiven if you thought EDC stood for Estimated Date of Cesarean.

While the practice of keeping new mothers cooped up in their homes for month and placed on dietary, activity, and even hygienic restrictions has all but disappeared in this country, the tradition persists in China. Believing that the process of even a normal delivery renders a woman vulnerable to all sorts of maladies, for 2,000 years Chinese grandmothers have been confining their daughters at home for the first month post partum.

In a recent article in the New York Times, I learned that while confinement continues post partum in China, it has changed among some affluent families so that it is more like spending a month in a high-end spa (“A Tradition for New Mothers in China, Now $27,000 a month” By Dan Levin, Oct. 1, 2015). The new confinement includes breastfeeding instruction, and dietary and activity choices that purport to be more scientifically based than the traditional restrictions. It has become popular with women who can afford it, while in the past confinement could be a month filled with tension between grandmothers and their daughters taking care of their new babies.

I can’t see the new Chinese version of confinement catching on here in North America, but the New York Times article did get me thinking about how we could do a better job helping mothers navigate the choppy waters of those first 30 days post partum. The Chinese are correct that a delivery is an assault on the body of even a previously healthy young woman. Even as one who hasn’t had the experience, I can only imagine it is like pulling an all-nighter (or two) and then running a marathon. Oh, and along the way losing a pint or two of blood.

There are a few families in North America who can afford to hire trained personnel (doulas), but for the most part we aren’t doing a very good job of helping women transition into motherhood. Of course, universal and more liberal family leave policies could make things easier. But simply lessening some of the tension associated with the inevitable return to the workplace isn’t enough. It is unlikely that we have the political will to make the changes to see those policies enacted.

However, there are things that we as pediatricians can do to make the postpartum period safer, healthier, and more comfortable for struggling families. First, we can encourage expectant mothers to make prenatal visits in our offices. While these visits are often little more than doctor shopping, we can ask the families who have committed to our practices to make a second appointment with more educational content. Would we get paid for it? Maybe not, but these second visits could pay for themselves in fewer after-hours calls.

We should do a better job of getting to know a new mother before she goes home from the hospital. What is her discharge hemoglobin? Does she have a history of depression and/or anxiety? Anemia and psychiatric issues can dramatically increase the risk that breastfeeding won’t go well and that post partum depression is more likely to ensue.

Are our offices and lactation consultants really available 24/7? Are we all on the same page when it comes to post partum advice? Do we return calls promptly and make follow-up calls? Are our offices and schedules truly new-mother friendly? Have we made use of all the available home health services that might be required?

The first postpartum month is critical, and new mothers need to be treated as our highest priority, but not confined.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.” Email him at [email protected].

Apparently, it is well known among canine behavior specialists that under similar situations dogs will look at human faces while wolves continue about their business – usually eating (“Why Is That Dog Looking at Me?” by James Gorman, New York Times, Sept. 15, 2015).

It also has been shown that when presented with the challenge of opening a food container that has been sealed shut, dogs will give up quickly and look to a nearby human, presumably for help. On the other hand, wolves raised by humans don’t look for help, suggesting that this looking to humans for help behavior may have a genetic component.

If the container of food has been altered so that it can be opened, but only with significant effort, the wolves will persist until they succeed. The adult dogs give up too quickly to succeed and instead look to humans. But, it is very interesting that in some preexperiment trials, at least one 8-month-old puppy kept at it until he was able to open the container, suggesting that in addition to some genetic influence, hanging around humans may foster what we might consider learned helplessness.

This observation wouldn’t surprise the product engineers tasked with developing child-resistant closures that can be easily opened by an adult. And I’m sure this evidence of learned helplessness in an animal wouldn’t surprise those who believe that welfare in any form is an abomination. As a card-carrying centrist, I will leave that argument to the polarizers on both ends of the political spectrum.

But I think this observation is most interesting because it raises the question of how often today’s parents are contributing to their children’s sense of helplessness. You only have to watch a child or grandchild tackle and construct a Lego project to realize that children are natural problem solvers. They get the trial-and-error thing. The problem is that too often we adults intervene at the first hint of failure, and in doing so, screw up the beautiful simplicity of the trial-and-error method of learning.

Watching someone struggle with a challenge for which you know the solution is difficult, particularly difficult if the struggler is your child or spouse. It is tempting to step forward and offer, “Here, let me show you how to do it.” Or, even worse, “Let me do it for you.”

To return to the canine world, consider the dog that brings a ball or stick to his/her master and then sits patiently waiting for the object to be tossed. If nothing is thrown, the dog will eventually give up and curl up for a nap. Puppies, on the other hand, don’t expect someone to initiate the game. They will paw at the ball until it moves or chase some unsuspecting insect playmate.

While offering children the chance to participate in organized sports is preferable to having them sit inside watching television or glued to a computer screen, the pendulum has swung a little too far toward the “organized” side of things. Too many parents seem unaware that if children are placed in an environment with room to run, a ball or two, and a few older children from whom they can model behavior, the children will organize themselves. They will figure out how to choose teams, make rules, and settle disputes.

The sad thing is that too many children have been offered so few opportunities to exercise their own powers of invention that they believe they are helpless to organize themselves. To them a sport is just a miniature version of what they see on television and comes complete with full uniforms, organized teams, sidelines lined with adoring fans ... and – of course – team pictures and trophies for everyone at the end of the season.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” Email him at [email protected].

Apparently, it is well known among canine behavior specialists that under similar situations dogs will look at human faces while wolves continue about their business – usually eating (“Why Is That Dog Looking at Me?” by James Gorman, New York Times, Sept. 15, 2015).

It also has been shown that when presented with the challenge of opening a food container that has been sealed shut, dogs will give up quickly and look to a nearby human, presumably for help. On the other hand, wolves raised by humans don’t look for help, suggesting that this looking to humans for help behavior may have a genetic component.

If the container of food has been altered so that it can be opened, but only with significant effort, the wolves will persist until they succeed. The adult dogs give up too quickly to succeed and instead look to humans. But, it is very interesting that in some preexperiment trials, at least one 8-month-old puppy kept at it until he was able to open the container, suggesting that in addition to some genetic influence, hanging around humans may foster what we might consider learned helplessness.

This observation wouldn’t surprise the product engineers tasked with developing child-resistant closures that can be easily opened by an adult. And I’m sure this evidence of learned helplessness in an animal wouldn’t surprise those who believe that welfare in any form is an abomination. As a card-carrying centrist, I will leave that argument to the polarizers on both ends of the political spectrum.

But I think this observation is most interesting because it raises the question of how often today’s parents are contributing to their children’s sense of helplessness. You only have to watch a child or grandchild tackle and construct a Lego project to realize that children are natural problem solvers. They get the trial-and-error thing. The problem is that too often we adults intervene at the first hint of failure, and in doing so, screw up the beautiful simplicity of the trial-and-error method of learning.

Watching someone struggle with a challenge for which you know the solution is difficult, particularly difficult if the struggler is your child or spouse. It is tempting to step forward and offer, “Here, let me show you how to do it.” Or, even worse, “Let me do it for you.”

To return to the canine world, consider the dog that brings a ball or stick to his/her master and then sits patiently waiting for the object to be tossed. If nothing is thrown, the dog will eventually give up and curl up for a nap. Puppies, on the other hand, don’t expect someone to initiate the game. They will paw at the ball until it moves or chase some unsuspecting insect playmate.

While offering children the chance to participate in organized sports is preferable to having them sit inside watching television or glued to a computer screen, the pendulum has swung a little too far toward the “organized” side of things. Too many parents seem unaware that if children are placed in an environment with room to run, a ball or two, and a few older children from whom they can model behavior, the children will organize themselves. They will figure out how to choose teams, make rules, and settle disputes.

The sad thing is that too many children have been offered so few opportunities to exercise their own powers of invention that they believe they are helpless to organize themselves. To them a sport is just a miniature version of what they see on television and comes complete with full uniforms, organized teams, sidelines lined with adoring fans ... and – of course – team pictures and trophies for everyone at the end of the season.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” Email him at [email protected].

Apparently, it is well known among canine behavior specialists that under similar situations dogs will look at human faces while wolves continue about their business – usually eating (“Why Is That Dog Looking at Me?” by James Gorman, New York Times, Sept. 15, 2015).

It also has been shown that when presented with the challenge of opening a food container that has been sealed shut, dogs will give up quickly and look to a nearby human, presumably for help. On the other hand, wolves raised by humans don’t look for help, suggesting that this looking to humans for help behavior may have a genetic component.

If the container of food has been altered so that it can be opened, but only with significant effort, the wolves will persist until they succeed. The adult dogs give up too quickly to succeed and instead look to humans. But, it is very interesting that in some preexperiment trials, at least one 8-month-old puppy kept at it until he was able to open the container, suggesting that in addition to some genetic influence, hanging around humans may foster what we might consider learned helplessness.

This observation wouldn’t surprise the product engineers tasked with developing child-resistant closures that can be easily opened by an adult. And I’m sure this evidence of learned helplessness in an animal wouldn’t surprise those who believe that welfare in any form is an abomination. As a card-carrying centrist, I will leave that argument to the polarizers on both ends of the political spectrum.

But I think this observation is most interesting because it raises the question of how often today’s parents are contributing to their children’s sense of helplessness. You only have to watch a child or grandchild tackle and construct a Lego project to realize that children are natural problem solvers. They get the trial-and-error thing. The problem is that too often we adults intervene at the first hint of failure, and in doing so, screw up the beautiful simplicity of the trial-and-error method of learning.

Watching someone struggle with a challenge for which you know the solution is difficult, particularly difficult if the struggler is your child or spouse. It is tempting to step forward and offer, “Here, let me show you how to do it.” Or, even worse, “Let me do it for you.”

To return to the canine world, consider the dog that brings a ball or stick to his/her master and then sits patiently waiting for the object to be tossed. If nothing is thrown, the dog will eventually give up and curl up for a nap. Puppies, on the other hand, don’t expect someone to initiate the game. They will paw at the ball until it moves or chase some unsuspecting insect playmate.

While offering children the chance to participate in organized sports is preferable to having them sit inside watching television or glued to a computer screen, the pendulum has swung a little too far toward the “organized” side of things. Too many parents seem unaware that if children are placed in an environment with room to run, a ball or two, and a few older children from whom they can model behavior, the children will organize themselves. They will figure out how to choose teams, make rules, and settle disputes.

The sad thing is that too many children have been offered so few opportunities to exercise their own powers of invention that they believe they are helpless to organize themselves. To them a sport is just a miniature version of what they see on television and comes complete with full uniforms, organized teams, sidelines lined with adoring fans ... and – of course – team pictures and trophies for everyone at the end of the season.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” Email him at [email protected].

A recent study released by the Association of State Correctional Administrators and researchers from Yale Law School has found that federal and state prisons are holding as many as 100,000 inmates in solitary confinement or isolated housing (“Large Number of Inmates in Solitary Poses Problem for Justice System, Study Says,” by Jess Bravin, Wall Street Journal, Sept. 2, 2015). This new data has turned up the volume of voices calling for abolishment of solitary confinement on the grounds that not only is it inhumane but also counterproductive.

Do you agree with abolitionists or are you sympathetic to some prison workers and administrators who say that there are situations in which social isolation is the best and maybe the only solution when a prisoner is a serious threat to the safety of his fellow inmates and staff?

While you are mulling over your answer, here is a related question more relevant to your own situation. How do you feel about solitary confinement (a.k.a., time-out) as a consequence for a misbehaving preschooler?

Do you think it is cruel and inhumane? Do you recommend it to parents as part of a comprehensive behavior-management strategy? Will many parents try it? Or, do they recoil and wonder why you would suggest that they become prison wardens in their own homes? If parents try it, is it effective?

In my experience, if done correctly in the right circumstances, time-out for a young child in his room – even if it requires latching the door – can be a safe, humane, and effective consequence for misbehavior. Sometimes, it is the only thing that works. But the devil is in the “ifs.”

First, time-out should be the last step in a comprehensive behavior-management strategy that begins with prevention – by assuring that the child is getting enough sleep and the right kind of attention from his parents who have expectations for their child that are appropriate for his age and temperament. The child’s environment and schedule should be structured to minimize the temptation to misbehave. Other less-drastic-sounding consequences must have been tried unsuccessfully. And ... both parent and child must be psychologically and developmentally normal.

Will brief episodes of solitary confinement make a young child feel insecure or unloved? Not if his parents make it clear by their behavior that she is loved and living in a stable environment, regardless of whether she is in time-out or not. Will time-out make a child hate her room? I’ve never seen it happen. If the child plays happily in her room during her sentence, does this render time-out ineffective? No, that’s a win-win situation. The misbehavior has stopped and the child is happy. Does this mean that time-out may not be a good deterrent? It might. But I have found that the only effective deterrent is consistent follow-up of every threat with the promised consequence – regardless of the consequence.

What if the child “destroys” his room during time-out? And is it safe to leave a child alone in his room? The solutions to these challenges can be found in Lowes or Home Depot.

I’m not going to take up any more of your recreational reading time describing the details of how time-out can be made more effective and palatable for parents. But it can be done and may require purchasing a latch or some kind of child-resistant door closure device. It will most likely be used briefly – if at all – but it can remain as a tangible reminder to the child that his parent follows up on his threats.

I won’t be surprised if some of you are shocked that I would advocate solitary confinement for young children. I am interested to hear what you recommend to parents who are struggling to keep their child’s behavior in bounds.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.”

A recent study released by the Association of State Correctional Administrators and researchers from Yale Law School has found that federal and state prisons are holding as many as 100,000 inmates in solitary confinement or isolated housing (“Large Number of Inmates in Solitary Poses Problem for Justice System, Study Says,” by Jess Bravin, Wall Street Journal, Sept. 2, 2015). This new data has turned up the volume of voices calling for abolishment of solitary confinement on the grounds that not only is it inhumane but also counterproductive.

Do you agree with abolitionists or are you sympathetic to some prison workers and administrators who say that there are situations in which social isolation is the best and maybe the only solution when a prisoner is a serious threat to the safety of his fellow inmates and staff?

While you are mulling over your answer, here is a related question more relevant to your own situation. How do you feel about solitary confinement (a.k.a., time-out) as a consequence for a misbehaving preschooler?

Do you think it is cruel and inhumane? Do you recommend it to parents as part of a comprehensive behavior-management strategy? Will many parents try it? Or, do they recoil and wonder why you would suggest that they become prison wardens in their own homes? If parents try it, is it effective?

In my experience, if done correctly in the right circumstances, time-out for a young child in his room – even if it requires latching the door – can be a safe, humane, and effective consequence for misbehavior. Sometimes, it is the only thing that works. But the devil is in the “ifs.”

First, time-out should be the last step in a comprehensive behavior-management strategy that begins with prevention – by assuring that the child is getting enough sleep and the right kind of attention from his parents who have expectations for their child that are appropriate for his age and temperament. The child’s environment and schedule should be structured to minimize the temptation to misbehave. Other less-drastic-sounding consequences must have been tried unsuccessfully. And ... both parent and child must be psychologically and developmentally normal.

Will brief episodes of solitary confinement make a young child feel insecure or unloved? Not if his parents make it clear by their behavior that she is loved and living in a stable environment, regardless of whether she is in time-out or not. Will time-out make a child hate her room? I’ve never seen it happen. If the child plays happily in her room during her sentence, does this render time-out ineffective? No, that’s a win-win situation. The misbehavior has stopped and the child is happy. Does this mean that time-out may not be a good deterrent? It might. But I have found that the only effective deterrent is consistent follow-up of every threat with the promised consequence – regardless of the consequence.

What if the child “destroys” his room during time-out? And is it safe to leave a child alone in his room? The solutions to these challenges can be found in Lowes or Home Depot.

I’m not going to take up any more of your recreational reading time describing the details of how time-out can be made more effective and palatable for parents. But it can be done and may require purchasing a latch or some kind of child-resistant door closure device. It will most likely be used briefly – if at all – but it can remain as a tangible reminder to the child that his parent follows up on his threats.

I won’t be surprised if some of you are shocked that I would advocate solitary confinement for young children. I am interested to hear what you recommend to parents who are struggling to keep their child’s behavior in bounds.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.”

A recent study released by the Association of State Correctional Administrators and researchers from Yale Law School has found that federal and state prisons are holding as many as 100,000 inmates in solitary confinement or isolated housing (“Large Number of Inmates in Solitary Poses Problem for Justice System, Study Says,” by Jess Bravin, Wall Street Journal, Sept. 2, 2015). This new data has turned up the volume of voices calling for abolishment of solitary confinement on the grounds that not only is it inhumane but also counterproductive.

Do you agree with abolitionists or are you sympathetic to some prison workers and administrators who say that there are situations in which social isolation is the best and maybe the only solution when a prisoner is a serious threat to the safety of his fellow inmates and staff?

While you are mulling over your answer, here is a related question more relevant to your own situation. How do you feel about solitary confinement (a.k.a., time-out) as a consequence for a misbehaving preschooler?

Do you think it is cruel and inhumane? Do you recommend it to parents as part of a comprehensive behavior-management strategy? Will many parents try it? Or, do they recoil and wonder why you would suggest that they become prison wardens in their own homes? If parents try it, is it effective?

In my experience, if done correctly in the right circumstances, time-out for a young child in his room – even if it requires latching the door – can be a safe, humane, and effective consequence for misbehavior. Sometimes, it is the only thing that works. But the devil is in the “ifs.”

First, time-out should be the last step in a comprehensive behavior-management strategy that begins with prevention – by assuring that the child is getting enough sleep and the right kind of attention from his parents who have expectations for their child that are appropriate for his age and temperament. The child’s environment and schedule should be structured to minimize the temptation to misbehave. Other less-drastic-sounding consequences must have been tried unsuccessfully. And ... both parent and child must be psychologically and developmentally normal.

Will brief episodes of solitary confinement make a young child feel insecure or unloved? Not if his parents make it clear by their behavior that she is loved and living in a stable environment, regardless of whether she is in time-out or not. Will time-out make a child hate her room? I’ve never seen it happen. If the child plays happily in her room during her sentence, does this render time-out ineffective? No, that’s a win-win situation. The misbehavior has stopped and the child is happy. Does this mean that time-out may not be a good deterrent? It might. But I have found that the only effective deterrent is consistent follow-up of every threat with the promised consequence – regardless of the consequence.

What if the child “destroys” his room during time-out? And is it safe to leave a child alone in his room? The solutions to these challenges can be found in Lowes or Home Depot.

I’m not going to take up any more of your recreational reading time describing the details of how time-out can be made more effective and palatable for parents. But it can be done and may require purchasing a latch or some kind of child-resistant door closure device. It will most likely be used briefly – if at all – but it can remain as a tangible reminder to the child that his parent follows up on his threats.

I won’t be surprised if some of you are shocked that I would advocate solitary confinement for young children. I am interested to hear what you recommend to parents who are struggling to keep their child’s behavior in bounds.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.”