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Are we taught enough about behavior?
If you ask a primary care pediatrician who has been practicing for more than 2 decades, she will tell you that her practice has tilted steeply toward complaints with a more developmental and behavioral flavor. In the lead article of the April 2015 Pediatrics (“Are We on the Right Track? Examining the Role of Developmental Behavioral Pediatrics”) Dr. Ruth E.K. Stein, a recent recipient of the C. Anderson Aldrich Award given by the American Academy of Pediatrics section on children with developmental and behavioral pediatrics, questions whether we, both general pediatricians and specialists in developmental and behavioral pediatrics, are on the right path in addressing this shifting mix in our patient populations.
Dr. Stein observes that while she and other pioneers in the creation of her specialty began as general pediatricians, today physicians typically enter developmental and behavioral fellowship programs without the benefit of practicing the runny nose–earache–diaper rash kind of pediatrics that many of us enjoy. She worries that from this early branching point in training, developmental and behavioral specialists have become “sequestered and siloed – increasingly seen only as people who take care of children who have special needs.” The problem is that, as Dr. Stein wisely observes, developmental and behavioral issues “are the core constructs of pediatrics and its backbone and that they must be incorporated into every primary care and specialty encounter and included in every educational experience.”
Dr. Stein continues her essay by proposing a handful of strategies for bridging the gap between developmental and behavioral specialists and general pediatricians, and strengthening the training of house officers, which currently requires only a pitifully inadequate month devoted to developmental and behavioral issues. While it is hard to argue with Dr. Stein’s suggestions, they only nibble around the edges of the real problem.
If one really believes as she and I do, that behavior and development must be considered in every patient encounter and educational experience, then the solution lies in changing how we teach medicine from the very beginning instead of waiting until postgraduate education. Everyone mouths the importance of the mind-body connection, but it is often just so much hot air. The relationship between behavior and development, and what Dr. Stein refers to as “biomedical” conditions, exists in every patient. It is often said it is the fact that our patients are growing and developing that keeps pediatrics apart from the rest of medicine. But the same process of change over time occurs in adults as well; we call it aging instead of development. Understanding where our patients are positioned on this trajectory from birth to death is critical in helping us understand what is troubling them, and how best to help them manage their concerns.
For pediatricians, our preverbal patients’ behavior is often the only way we have of knowing there is a problem. Behavior can be their unspoken chief complaint. The failure by a physician to interpret her patient’s behavior as either a result or the cause of the problem can lead to an unfortunate outcome.
This means, as we teach aspiring doctors the art of medicine, we must make it clear that the patient’s behavior and stage of development must be considered equally with the more traditional biomedical etiologies, not as an afterthought. For example, any discussion of nonacute recurrent abdominal pain in children that fails to acknowledge from the outset that most of these patients will not have an abnormality detectable by lab work and imaging studies is doing the young physician and his patients a disservice. I am suggesting that we adopt a more patient-centered rather than a disease-centered approach to training all physicians.
While every patient must be viewed in the proper behavioral and developmental context, there are those in whom a behavior problem dominates. Given the patient mix that the new millennium pediatrician is going to face, 1 month in postgraduate training is clearly insufficient. One cannot begin to learn even the rudiments of managing common problems such as attention-deficit/hyperactivity disorder, disordered sleep, temper tantrums, and school refusal in 30 days. Finding room in a training program to give behavioral and developmental problems more than a quick nod is going to require some rethinking of how we train pediatricians. It may be that training programs will need to selectively trim back some programs that may be of only limited long-term use to most general office-based pediatricians and offer them as electives. For example, how many of us still practice the kind of neonatology we were exposed to in the special care nursery? These are not easy decisions, but as Dr. Reid has suggested, we need to reconsider whether we are on the right track.
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.” E-mail him at [email protected].
If you ask a primary care pediatrician who has been practicing for more than 2 decades, she will tell you that her practice has tilted steeply toward complaints with a more developmental and behavioral flavor. In the lead article of the April 2015 Pediatrics (“Are We on the Right Track? Examining the Role of Developmental Behavioral Pediatrics”) Dr. Ruth E.K. Stein, a recent recipient of the C. Anderson Aldrich Award given by the American Academy of Pediatrics section on children with developmental and behavioral pediatrics, questions whether we, both general pediatricians and specialists in developmental and behavioral pediatrics, are on the right path in addressing this shifting mix in our patient populations.
Dr. Stein observes that while she and other pioneers in the creation of her specialty began as general pediatricians, today physicians typically enter developmental and behavioral fellowship programs without the benefit of practicing the runny nose–earache–diaper rash kind of pediatrics that many of us enjoy. She worries that from this early branching point in training, developmental and behavioral specialists have become “sequestered and siloed – increasingly seen only as people who take care of children who have special needs.” The problem is that, as Dr. Stein wisely observes, developmental and behavioral issues “are the core constructs of pediatrics and its backbone and that they must be incorporated into every primary care and specialty encounter and included in every educational experience.”
Dr. Stein continues her essay by proposing a handful of strategies for bridging the gap between developmental and behavioral specialists and general pediatricians, and strengthening the training of house officers, which currently requires only a pitifully inadequate month devoted to developmental and behavioral issues. While it is hard to argue with Dr. Stein’s suggestions, they only nibble around the edges of the real problem.
If one really believes as she and I do, that behavior and development must be considered in every patient encounter and educational experience, then the solution lies in changing how we teach medicine from the very beginning instead of waiting until postgraduate education. Everyone mouths the importance of the mind-body connection, but it is often just so much hot air. The relationship between behavior and development, and what Dr. Stein refers to as “biomedical” conditions, exists in every patient. It is often said it is the fact that our patients are growing and developing that keeps pediatrics apart from the rest of medicine. But the same process of change over time occurs in adults as well; we call it aging instead of development. Understanding where our patients are positioned on this trajectory from birth to death is critical in helping us understand what is troubling them, and how best to help them manage their concerns.
For pediatricians, our preverbal patients’ behavior is often the only way we have of knowing there is a problem. Behavior can be their unspoken chief complaint. The failure by a physician to interpret her patient’s behavior as either a result or the cause of the problem can lead to an unfortunate outcome.
This means, as we teach aspiring doctors the art of medicine, we must make it clear that the patient’s behavior and stage of development must be considered equally with the more traditional biomedical etiologies, not as an afterthought. For example, any discussion of nonacute recurrent abdominal pain in children that fails to acknowledge from the outset that most of these patients will not have an abnormality detectable by lab work and imaging studies is doing the young physician and his patients a disservice. I am suggesting that we adopt a more patient-centered rather than a disease-centered approach to training all physicians.
While every patient must be viewed in the proper behavioral and developmental context, there are those in whom a behavior problem dominates. Given the patient mix that the new millennium pediatrician is going to face, 1 month in postgraduate training is clearly insufficient. One cannot begin to learn even the rudiments of managing common problems such as attention-deficit/hyperactivity disorder, disordered sleep, temper tantrums, and school refusal in 30 days. Finding room in a training program to give behavioral and developmental problems more than a quick nod is going to require some rethinking of how we train pediatricians. It may be that training programs will need to selectively trim back some programs that may be of only limited long-term use to most general office-based pediatricians and offer them as electives. For example, how many of us still practice the kind of neonatology we were exposed to in the special care nursery? These are not easy decisions, but as Dr. Reid has suggested, we need to reconsider whether we are on the right track.
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.” E-mail him at [email protected].
If you ask a primary care pediatrician who has been practicing for more than 2 decades, she will tell you that her practice has tilted steeply toward complaints with a more developmental and behavioral flavor. In the lead article of the April 2015 Pediatrics (“Are We on the Right Track? Examining the Role of Developmental Behavioral Pediatrics”) Dr. Ruth E.K. Stein, a recent recipient of the C. Anderson Aldrich Award given by the American Academy of Pediatrics section on children with developmental and behavioral pediatrics, questions whether we, both general pediatricians and specialists in developmental and behavioral pediatrics, are on the right path in addressing this shifting mix in our patient populations.
Dr. Stein observes that while she and other pioneers in the creation of her specialty began as general pediatricians, today physicians typically enter developmental and behavioral fellowship programs without the benefit of practicing the runny nose–earache–diaper rash kind of pediatrics that many of us enjoy. She worries that from this early branching point in training, developmental and behavioral specialists have become “sequestered and siloed – increasingly seen only as people who take care of children who have special needs.” The problem is that, as Dr. Stein wisely observes, developmental and behavioral issues “are the core constructs of pediatrics and its backbone and that they must be incorporated into every primary care and specialty encounter and included in every educational experience.”
Dr. Stein continues her essay by proposing a handful of strategies for bridging the gap between developmental and behavioral specialists and general pediatricians, and strengthening the training of house officers, which currently requires only a pitifully inadequate month devoted to developmental and behavioral issues. While it is hard to argue with Dr. Stein’s suggestions, they only nibble around the edges of the real problem.
If one really believes as she and I do, that behavior and development must be considered in every patient encounter and educational experience, then the solution lies in changing how we teach medicine from the very beginning instead of waiting until postgraduate education. Everyone mouths the importance of the mind-body connection, but it is often just so much hot air. The relationship between behavior and development, and what Dr. Stein refers to as “biomedical” conditions, exists in every patient. It is often said it is the fact that our patients are growing and developing that keeps pediatrics apart from the rest of medicine. But the same process of change over time occurs in adults as well; we call it aging instead of development. Understanding where our patients are positioned on this trajectory from birth to death is critical in helping us understand what is troubling them, and how best to help them manage their concerns.
For pediatricians, our preverbal patients’ behavior is often the only way we have of knowing there is a problem. Behavior can be their unspoken chief complaint. The failure by a physician to interpret her patient’s behavior as either a result or the cause of the problem can lead to an unfortunate outcome.
This means, as we teach aspiring doctors the art of medicine, we must make it clear that the patient’s behavior and stage of development must be considered equally with the more traditional biomedical etiologies, not as an afterthought. For example, any discussion of nonacute recurrent abdominal pain in children that fails to acknowledge from the outset that most of these patients will not have an abnormality detectable by lab work and imaging studies is doing the young physician and his patients a disservice. I am suggesting that we adopt a more patient-centered rather than a disease-centered approach to training all physicians.
While every patient must be viewed in the proper behavioral and developmental context, there are those in whom a behavior problem dominates. Given the patient mix that the new millennium pediatrician is going to face, 1 month in postgraduate training is clearly insufficient. One cannot begin to learn even the rudiments of managing common problems such as attention-deficit/hyperactivity disorder, disordered sleep, temper tantrums, and school refusal in 30 days. Finding room in a training program to give behavioral and developmental problems more than a quick nod is going to require some rethinking of how we train pediatricians. It may be that training programs will need to selectively trim back some programs that may be of only limited long-term use to most general office-based pediatricians and offer them as electives. For example, how many of us still practice the kind of neonatology we were exposed to in the special care nursery? These are not easy decisions, but as Dr. Reid has suggested, we need to reconsider whether we are on the right track.
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.” E-mail him at [email protected].
Letters from Maine: Defining quality
If you decided to read past the title of this column because you were expecting to hear me launch into a rant questioning how third-party payers or any credentialing group can honestly and fairly judge the quality of an individual physician by measuring the outcomes of his or her patients, I apologize. This column is about the quality of time, specifically the quality of time a parent spends with his or her child.
From an article in the Washington Post (“Making time for kids? Study says quality trumps quantity,” by Brigid Schulte, March 28, 2015), I learned of a study by Milkie et al. published in the Journal of Marriage and Family (“Does the Amount of Time Mothers Spend with Children or Adolescents Matter?” J. Marriage Family 2015;77:355-72) in which the researchers found that the amount of time a mother spent with her child was unrelated to the child’s behaviors, emotions, or academics. The only exception was during adolescence when more engaged maternal time was associated with better outcomes and fewer delinquent behaviors.
The sociologists who performed the study had observed in their previous research that working mothers today spend as much time with their children as did at-home mothers in the 1970s. This observation surprised them, but clearly fits with their current data that suggest that quantity doesn’t matter.
What did matter was quality. In fact, the authors found that if a mother was sleep deprived or felt guilty, anxious, or stressed, her time with her child could actually be “detrimental” to the child. The only factors that consistently had a positive impact on the child were maternal income and educational level.
Measuring the quantity of time a parent spends with his or her child is relatively easy. Assessing the quality of that time is much more difficult. The findings in this study won’t be of much help to a parent who wants to enhance the quality of time he or she spends with her child. Meeting the criteria of being mentally healthy, unstressed, well-slept, and economically stable is easier said than done. However, let’s say that you are a parent who is fortunate enough to be able to pull it off. Does this mean that just because you have your act together that your child is automatically going to get quality time?
I would answer, “No!” Because if we really want to know, let’s ask the child, because it is the child who should be defining the quality of time he spends with his parent. Unfortunately, many parents lose track of the child’s perspective when they are evaluating the time they spend together.
For example, you come home from a tough day at work and find that your 3½-year-old has been cooped up inside because the daycare provider didn’t want to take the kids out in the rain. It’s 40 degrees. It’s more than a light rain, but not a torrential downpour. Your son wants to go out and play in the puddles. Your plan for quality time had been to read one his favorite books to him for the umpteenth time before you start to fix dinner.
If we let the child define the quality of your time together, it means that both of you are going to get wet. Clothes will have to be changed, and the dinner that he wasn’t going to eat very much of anyway is going to be delayed a few minutes. But let’s face it – a few minutes out in the cold rain has the potential of being an event that one or both of you will remember for a long time. Is it going to have the educational value equivalent to the language skills your son will acquire from hearing multiple repetitions of the spoken word? Will it enhance his chances of being a competent reader? Probably not. But your son may learn that there is fun to be had outside on a rainy day. Or he may learn that 40 degrees is a little too cold be outside if it is raining. But he will certainly learn that you are someone who likes to share experiences with him and someone who is will to give him some say in what those experiences are.
A parent might argue that if I let my child choose the things we do together, it means we will always be watching cartoons. My response to that observation would be, “You’ve already made one mistake by letting him watch cartoons in the first place; let’s not make a second one. Give him healthier choices, and don’t impose your notion of quality on your time together.” Sometimes just standing by and watching your child enjoy himself is quality time for both of you.
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.”
If you decided to read past the title of this column because you were expecting to hear me launch into a rant questioning how third-party payers or any credentialing group can honestly and fairly judge the quality of an individual physician by measuring the outcomes of his or her patients, I apologize. This column is about the quality of time, specifically the quality of time a parent spends with his or her child.
From an article in the Washington Post (“Making time for kids? Study says quality trumps quantity,” by Brigid Schulte, March 28, 2015), I learned of a study by Milkie et al. published in the Journal of Marriage and Family (“Does the Amount of Time Mothers Spend with Children or Adolescents Matter?” J. Marriage Family 2015;77:355-72) in which the researchers found that the amount of time a mother spent with her child was unrelated to the child’s behaviors, emotions, or academics. The only exception was during adolescence when more engaged maternal time was associated with better outcomes and fewer delinquent behaviors.
The sociologists who performed the study had observed in their previous research that working mothers today spend as much time with their children as did at-home mothers in the 1970s. This observation surprised them, but clearly fits with their current data that suggest that quantity doesn’t matter.
What did matter was quality. In fact, the authors found that if a mother was sleep deprived or felt guilty, anxious, or stressed, her time with her child could actually be “detrimental” to the child. The only factors that consistently had a positive impact on the child were maternal income and educational level.
Measuring the quantity of time a parent spends with his or her child is relatively easy. Assessing the quality of that time is much more difficult. The findings in this study won’t be of much help to a parent who wants to enhance the quality of time he or she spends with her child. Meeting the criteria of being mentally healthy, unstressed, well-slept, and economically stable is easier said than done. However, let’s say that you are a parent who is fortunate enough to be able to pull it off. Does this mean that just because you have your act together that your child is automatically going to get quality time?
I would answer, “No!” Because if we really want to know, let’s ask the child, because it is the child who should be defining the quality of time he spends with his parent. Unfortunately, many parents lose track of the child’s perspective when they are evaluating the time they spend together.
For example, you come home from a tough day at work and find that your 3½-year-old has been cooped up inside because the daycare provider didn’t want to take the kids out in the rain. It’s 40 degrees. It’s more than a light rain, but not a torrential downpour. Your son wants to go out and play in the puddles. Your plan for quality time had been to read one his favorite books to him for the umpteenth time before you start to fix dinner.
If we let the child define the quality of your time together, it means that both of you are going to get wet. Clothes will have to be changed, and the dinner that he wasn’t going to eat very much of anyway is going to be delayed a few minutes. But let’s face it – a few minutes out in the cold rain has the potential of being an event that one or both of you will remember for a long time. Is it going to have the educational value equivalent to the language skills your son will acquire from hearing multiple repetitions of the spoken word? Will it enhance his chances of being a competent reader? Probably not. But your son may learn that there is fun to be had outside on a rainy day. Or he may learn that 40 degrees is a little too cold be outside if it is raining. But he will certainly learn that you are someone who likes to share experiences with him and someone who is will to give him some say in what those experiences are.
A parent might argue that if I let my child choose the things we do together, it means we will always be watching cartoons. My response to that observation would be, “You’ve already made one mistake by letting him watch cartoons in the first place; let’s not make a second one. Give him healthier choices, and don’t impose your notion of quality on your time together.” Sometimes just standing by and watching your child enjoy himself is quality time for both of you.
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.”
If you decided to read past the title of this column because you were expecting to hear me launch into a rant questioning how third-party payers or any credentialing group can honestly and fairly judge the quality of an individual physician by measuring the outcomes of his or her patients, I apologize. This column is about the quality of time, specifically the quality of time a parent spends with his or her child.
From an article in the Washington Post (“Making time for kids? Study says quality trumps quantity,” by Brigid Schulte, March 28, 2015), I learned of a study by Milkie et al. published in the Journal of Marriage and Family (“Does the Amount of Time Mothers Spend with Children or Adolescents Matter?” J. Marriage Family 2015;77:355-72) in which the researchers found that the amount of time a mother spent with her child was unrelated to the child’s behaviors, emotions, or academics. The only exception was during adolescence when more engaged maternal time was associated with better outcomes and fewer delinquent behaviors.
The sociologists who performed the study had observed in their previous research that working mothers today spend as much time with their children as did at-home mothers in the 1970s. This observation surprised them, but clearly fits with their current data that suggest that quantity doesn’t matter.
What did matter was quality. In fact, the authors found that if a mother was sleep deprived or felt guilty, anxious, or stressed, her time with her child could actually be “detrimental” to the child. The only factors that consistently had a positive impact on the child were maternal income and educational level.
Measuring the quantity of time a parent spends with his or her child is relatively easy. Assessing the quality of that time is much more difficult. The findings in this study won’t be of much help to a parent who wants to enhance the quality of time he or she spends with her child. Meeting the criteria of being mentally healthy, unstressed, well-slept, and economically stable is easier said than done. However, let’s say that you are a parent who is fortunate enough to be able to pull it off. Does this mean that just because you have your act together that your child is automatically going to get quality time?
I would answer, “No!” Because if we really want to know, let’s ask the child, because it is the child who should be defining the quality of time he spends with his parent. Unfortunately, many parents lose track of the child’s perspective when they are evaluating the time they spend together.
For example, you come home from a tough day at work and find that your 3½-year-old has been cooped up inside because the daycare provider didn’t want to take the kids out in the rain. It’s 40 degrees. It’s more than a light rain, but not a torrential downpour. Your son wants to go out and play in the puddles. Your plan for quality time had been to read one his favorite books to him for the umpteenth time before you start to fix dinner.
If we let the child define the quality of your time together, it means that both of you are going to get wet. Clothes will have to be changed, and the dinner that he wasn’t going to eat very much of anyway is going to be delayed a few minutes. But let’s face it – a few minutes out in the cold rain has the potential of being an event that one or both of you will remember for a long time. Is it going to have the educational value equivalent to the language skills your son will acquire from hearing multiple repetitions of the spoken word? Will it enhance his chances of being a competent reader? Probably not. But your son may learn that there is fun to be had outside on a rainy day. Or he may learn that 40 degrees is a little too cold be outside if it is raining. But he will certainly learn that you are someone who likes to share experiences with him and someone who is will to give him some say in what those experiences are.
A parent might argue that if I let my child choose the things we do together, it means we will always be watching cartoons. My response to that observation would be, “You’ve already made one mistake by letting him watch cartoons in the first place; let’s not make a second one. Give him healthier choices, and don’t impose your notion of quality on your time together.” Sometimes just standing by and watching your child enjoy himself is quality time for both of you.
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.”
Forget kids – get a dog instead
It’s no secret that young adult North Americans, especially those in more privileged socioeconomic strata, are delaying childbearing. They struggle with the notion of committing to one another and then take even longer to arrive at the decision to have children. On the other hand, they seem to have much less trouble deciding to get a dog. One wonders if the canine commitment is a subconscious test balloon launched to assess their aptitude for parenting. Of course, any parent who has raised both children and dogs will tell you that the coefficient of correlation between the two adventures is approaching zero.
It is often assumed that upwardly mobile young adults are choosing canine husbandry over parenting because they want to make sure their careers are solidly on track before they commit to the financial responsibilities and emotional challenges of raising a child. However, it may be that some of them have read the same studies I have recently encountered that suggest if you want to stay fit, you are better off getting a dog than having a child.
Dog owners are 34% more likely to squeeze 150 minutes of walking into their weeks than are those who don’t own a dog. And having a dog increases leisure time physical activity by 69%. Not surprising, walking a puppy increases one’s walking speed by 28% over a solitary pace. Compare this to walking with a human companion that only increases one’s speed 4% (“Dog Ownership and Physical Activity: A Review of the Evidence” [J. Phys. Act. Health 2013;10:750-9]).
On the other hand, having a child can really do a number on the fitness habits of a parent (“How to Get Your Spouse to Exercise,” Gretchen Reynolds, New York Times, March 28, 2015). For a father, becoming a parent of a single child usually has little effect on the amount of moderate to vigorous exercise he gets. However, when a woman becomes a mother, she can expect to see a significant drop in the time she can spend exercising. Fathers eventually pay the price in reduced vigorous activity if they father more than one child. Not surprisingly, having a child under 6 years in the house decreases moderate activity for both parents, while it increases their light activity as they attempt to stay one step ahead of a toddler.
So, if a young adult wants to stay healthy by maintaining even a moderate exercise regimen and he or she runs the numbers, the answer is pretty clear: Forget the kids and get a dog.
While children can have a negative impact on their parents’ physical activity, it turns out that parents can create downward pressure on their child’s physical activity if they adopt one of several parenting styles (“Hyper-parenting is negatively associated with physical activity among 7- to 12-year olds” [Prev. Med. 2015;73:55-9]). In a recently reported Canadian survey of more than 700 parents, a researcher has found that the children of parents whose style of parenting could be categorized as hyper-parenting got significantly less physical activity than did the children of parents with low hyper-parenting scores.
I learned from reviewing the paper that behavior specialists now split hyper-parents into categories: overprotective, helicopter, tiger mom, little emperor, and concerted cultivation (overscheduling). Only the children of helicopter parents were spared the negative impact of their parents’ style. It may be that while hovering may be annoying, it does allow for enough distance between parent and child for the child to follow his own urge to be active.
None of these studies that I reviewed was very robust, and while their results may not stand the test of repetition, intuition suggests having children can make it challenging for parents who want to maintain a healthy level of physical activity. And you and I know that children need physical and emotional space from their parents in which to play freely and actively.
Obviously I don’t think we should be encouraging all young adults to choose dog ownership over parenthood, but we should be helping parents choose strategies and parenting styles that leave enough time and space for everyone in the family to get a healthy amount of physical activity.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years, and is the author of “Coping With a Picky Eater.”
It’s no secret that young adult North Americans, especially those in more privileged socioeconomic strata, are delaying childbearing. They struggle with the notion of committing to one another and then take even longer to arrive at the decision to have children. On the other hand, they seem to have much less trouble deciding to get a dog. One wonders if the canine commitment is a subconscious test balloon launched to assess their aptitude for parenting. Of course, any parent who has raised both children and dogs will tell you that the coefficient of correlation between the two adventures is approaching zero.
It is often assumed that upwardly mobile young adults are choosing canine husbandry over parenting because they want to make sure their careers are solidly on track before they commit to the financial responsibilities and emotional challenges of raising a child. However, it may be that some of them have read the same studies I have recently encountered that suggest if you want to stay fit, you are better off getting a dog than having a child.
Dog owners are 34% more likely to squeeze 150 minutes of walking into their weeks than are those who don’t own a dog. And having a dog increases leisure time physical activity by 69%. Not surprising, walking a puppy increases one’s walking speed by 28% over a solitary pace. Compare this to walking with a human companion that only increases one’s speed 4% (“Dog Ownership and Physical Activity: A Review of the Evidence” [J. Phys. Act. Health 2013;10:750-9]).
On the other hand, having a child can really do a number on the fitness habits of a parent (“How to Get Your Spouse to Exercise,” Gretchen Reynolds, New York Times, March 28, 2015). For a father, becoming a parent of a single child usually has little effect on the amount of moderate to vigorous exercise he gets. However, when a woman becomes a mother, she can expect to see a significant drop in the time she can spend exercising. Fathers eventually pay the price in reduced vigorous activity if they father more than one child. Not surprisingly, having a child under 6 years in the house decreases moderate activity for both parents, while it increases their light activity as they attempt to stay one step ahead of a toddler.
So, if a young adult wants to stay healthy by maintaining even a moderate exercise regimen and he or she runs the numbers, the answer is pretty clear: Forget the kids and get a dog.
While children can have a negative impact on their parents’ physical activity, it turns out that parents can create downward pressure on their child’s physical activity if they adopt one of several parenting styles (“Hyper-parenting is negatively associated with physical activity among 7- to 12-year olds” [Prev. Med. 2015;73:55-9]). In a recently reported Canadian survey of more than 700 parents, a researcher has found that the children of parents whose style of parenting could be categorized as hyper-parenting got significantly less physical activity than did the children of parents with low hyper-parenting scores.
I learned from reviewing the paper that behavior specialists now split hyper-parents into categories: overprotective, helicopter, tiger mom, little emperor, and concerted cultivation (overscheduling). Only the children of helicopter parents were spared the negative impact of their parents’ style. It may be that while hovering may be annoying, it does allow for enough distance between parent and child for the child to follow his own urge to be active.
None of these studies that I reviewed was very robust, and while their results may not stand the test of repetition, intuition suggests having children can make it challenging for parents who want to maintain a healthy level of physical activity. And you and I know that children need physical and emotional space from their parents in which to play freely and actively.
Obviously I don’t think we should be encouraging all young adults to choose dog ownership over parenthood, but we should be helping parents choose strategies and parenting styles that leave enough time and space for everyone in the family to get a healthy amount of physical activity.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years, and is the author of “Coping With a Picky Eater.”
It’s no secret that young adult North Americans, especially those in more privileged socioeconomic strata, are delaying childbearing. They struggle with the notion of committing to one another and then take even longer to arrive at the decision to have children. On the other hand, they seem to have much less trouble deciding to get a dog. One wonders if the canine commitment is a subconscious test balloon launched to assess their aptitude for parenting. Of course, any parent who has raised both children and dogs will tell you that the coefficient of correlation between the two adventures is approaching zero.
It is often assumed that upwardly mobile young adults are choosing canine husbandry over parenting because they want to make sure their careers are solidly on track before they commit to the financial responsibilities and emotional challenges of raising a child. However, it may be that some of them have read the same studies I have recently encountered that suggest if you want to stay fit, you are better off getting a dog than having a child.
Dog owners are 34% more likely to squeeze 150 minutes of walking into their weeks than are those who don’t own a dog. And having a dog increases leisure time physical activity by 69%. Not surprising, walking a puppy increases one’s walking speed by 28% over a solitary pace. Compare this to walking with a human companion that only increases one’s speed 4% (“Dog Ownership and Physical Activity: A Review of the Evidence” [J. Phys. Act. Health 2013;10:750-9]).
On the other hand, having a child can really do a number on the fitness habits of a parent (“How to Get Your Spouse to Exercise,” Gretchen Reynolds, New York Times, March 28, 2015). For a father, becoming a parent of a single child usually has little effect on the amount of moderate to vigorous exercise he gets. However, when a woman becomes a mother, she can expect to see a significant drop in the time she can spend exercising. Fathers eventually pay the price in reduced vigorous activity if they father more than one child. Not surprisingly, having a child under 6 years in the house decreases moderate activity for both parents, while it increases their light activity as they attempt to stay one step ahead of a toddler.
So, if a young adult wants to stay healthy by maintaining even a moderate exercise regimen and he or she runs the numbers, the answer is pretty clear: Forget the kids and get a dog.
While children can have a negative impact on their parents’ physical activity, it turns out that parents can create downward pressure on their child’s physical activity if they adopt one of several parenting styles (“Hyper-parenting is negatively associated with physical activity among 7- to 12-year olds” [Prev. Med. 2015;73:55-9]). In a recently reported Canadian survey of more than 700 parents, a researcher has found that the children of parents whose style of parenting could be categorized as hyper-parenting got significantly less physical activity than did the children of parents with low hyper-parenting scores.
I learned from reviewing the paper that behavior specialists now split hyper-parents into categories: overprotective, helicopter, tiger mom, little emperor, and concerted cultivation (overscheduling). Only the children of helicopter parents were spared the negative impact of their parents’ style. It may be that while hovering may be annoying, it does allow for enough distance between parent and child for the child to follow his own urge to be active.
None of these studies that I reviewed was very robust, and while their results may not stand the test of repetition, intuition suggests having children can make it challenging for parents who want to maintain a healthy level of physical activity. And you and I know that children need physical and emotional space from their parents in which to play freely and actively.
Obviously I don’t think we should be encouraging all young adults to choose dog ownership over parenthood, but we should be helping parents choose strategies and parenting styles that leave enough time and space for everyone in the family to get a healthy amount of physical activity.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years, and is the author of “Coping With a Picky Eater.”
Give ’em a brrreak!
In some ways (my wife would say many), I haven’t grown up. As a child, I loved playing outside in the snow. If it was too powdery to make a snowman or build a fort, I was content just tromping through the drifts into the woods on my own arctic expeditions.
Four college winters in northern New Hampshire failed to dampen my enthusiasm for the cold. In fact, they probably influenced my decision to marry a girl from Maine and spend the last 45 winters in her home state. I enjoy cross-country skiing and snowshoeing, and the stack of books on my nightstand almost always contains one book about someone’s arctic adventure.
Two weeks ago on one of my crispy after-lunch refreshers, I walked past our neighborhood grade school. The playground was a mountainous landscape covered in pristine snow unsullied by the salt and sand the town has spread on the roads and sidewalks. Scores of 5- and 6-year-olds clad in a kaleidoscope of color swarmed over the giant mounds of snow, some of which were two and three times their height. Even my wool cap and fleece balaclava couldn’t muffle their shrieks of glee.
As I crunched along, I said to myself, those kids are experiencing an ecstasy that no child should be deprived of. Well, it turns out that in New York City, some thoughtless adults are doing just that (“A Casualty of a Frigid New York Winter: Outside School Recess,” by Ginia Bellafante, N.Y. Times, March 6, 2015). Although the official Department of Education policy cautions school administrators against using temperature alone as a criterion for canceling outside play, it does discourage sending children outside if wind chills will bring the effective temperature to less than zero degrees Fahrenheit, which sounds reasonable in a community unaccustomed to serious cold. However, it also discourages schools from allowing outside play if it is snowing or there is any ice on the playground.
Sadly, some cold-averse administrators have robbed hundreds of children of the chance to enjoy what has been an unusually snowy winter in the Northeast. In fact, no one can remember when the children in one unfortunate New York City grade school have been outside for recess. A conservative estimate is 40 consecutive days of incarceration.
This school is in the unenviable and unacceptable position of having no playground. Even in warmer weather, it relies on a nearby park that the parks department has chosen not to plow this winter. The tragic snow deprivation these children are suffering is just the tip of the iceberg. Despite ample evidence supporting the health and educational benefits of physical activity and recess, the New York City Department of Education does not mandate recess. Instead, it simply “encourages” schools to offer 20 minutes of outside activity.
I can understand why some school administrators are hesitant to send their young students out in the cold. It can take at least as long to bundle and unbundle a class of 5-year-olds as they will spend outside. But, at least teachers no longer have to contend with the thumb-lacerating metal buckles that made the old rubber galoshes such a painful challenge.
I am sure the list of willing volunteers to take playground duty on a frigid Friday afternoon is a short one. But, let’s remember that we are talking about young minds and bodies that need fresh air, even if it is cold fresh air, to keep them healthy and engaged in the learning process. For goodness sake, put on another layer, or three, and let them go out to enjoy the winter wonderland.
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.” E-mail him at [email protected].
In some ways (my wife would say many), I haven’t grown up. As a child, I loved playing outside in the snow. If it was too powdery to make a snowman or build a fort, I was content just tromping through the drifts into the woods on my own arctic expeditions.
Four college winters in northern New Hampshire failed to dampen my enthusiasm for the cold. In fact, they probably influenced my decision to marry a girl from Maine and spend the last 45 winters in her home state. I enjoy cross-country skiing and snowshoeing, and the stack of books on my nightstand almost always contains one book about someone’s arctic adventure.
Two weeks ago on one of my crispy after-lunch refreshers, I walked past our neighborhood grade school. The playground was a mountainous landscape covered in pristine snow unsullied by the salt and sand the town has spread on the roads and sidewalks. Scores of 5- and 6-year-olds clad in a kaleidoscope of color swarmed over the giant mounds of snow, some of which were two and three times their height. Even my wool cap and fleece balaclava couldn’t muffle their shrieks of glee.
As I crunched along, I said to myself, those kids are experiencing an ecstasy that no child should be deprived of. Well, it turns out that in New York City, some thoughtless adults are doing just that (“A Casualty of a Frigid New York Winter: Outside School Recess,” by Ginia Bellafante, N.Y. Times, March 6, 2015). Although the official Department of Education policy cautions school administrators against using temperature alone as a criterion for canceling outside play, it does discourage sending children outside if wind chills will bring the effective temperature to less than zero degrees Fahrenheit, which sounds reasonable in a community unaccustomed to serious cold. However, it also discourages schools from allowing outside play if it is snowing or there is any ice on the playground.
Sadly, some cold-averse administrators have robbed hundreds of children of the chance to enjoy what has been an unusually snowy winter in the Northeast. In fact, no one can remember when the children in one unfortunate New York City grade school have been outside for recess. A conservative estimate is 40 consecutive days of incarceration.
This school is in the unenviable and unacceptable position of having no playground. Even in warmer weather, it relies on a nearby park that the parks department has chosen not to plow this winter. The tragic snow deprivation these children are suffering is just the tip of the iceberg. Despite ample evidence supporting the health and educational benefits of physical activity and recess, the New York City Department of Education does not mandate recess. Instead, it simply “encourages” schools to offer 20 minutes of outside activity.
I can understand why some school administrators are hesitant to send their young students out in the cold. It can take at least as long to bundle and unbundle a class of 5-year-olds as they will spend outside. But, at least teachers no longer have to contend with the thumb-lacerating metal buckles that made the old rubber galoshes such a painful challenge.
I am sure the list of willing volunteers to take playground duty on a frigid Friday afternoon is a short one. But, let’s remember that we are talking about young minds and bodies that need fresh air, even if it is cold fresh air, to keep them healthy and engaged in the learning process. For goodness sake, put on another layer, or three, and let them go out to enjoy the winter wonderland.
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.” E-mail him at [email protected].
In some ways (my wife would say many), I haven’t grown up. As a child, I loved playing outside in the snow. If it was too powdery to make a snowman or build a fort, I was content just tromping through the drifts into the woods on my own arctic expeditions.
Four college winters in northern New Hampshire failed to dampen my enthusiasm for the cold. In fact, they probably influenced my decision to marry a girl from Maine and spend the last 45 winters in her home state. I enjoy cross-country skiing and snowshoeing, and the stack of books on my nightstand almost always contains one book about someone’s arctic adventure.
Two weeks ago on one of my crispy after-lunch refreshers, I walked past our neighborhood grade school. The playground was a mountainous landscape covered in pristine snow unsullied by the salt and sand the town has spread on the roads and sidewalks. Scores of 5- and 6-year-olds clad in a kaleidoscope of color swarmed over the giant mounds of snow, some of which were two and three times their height. Even my wool cap and fleece balaclava couldn’t muffle their shrieks of glee.
As I crunched along, I said to myself, those kids are experiencing an ecstasy that no child should be deprived of. Well, it turns out that in New York City, some thoughtless adults are doing just that (“A Casualty of a Frigid New York Winter: Outside School Recess,” by Ginia Bellafante, N.Y. Times, March 6, 2015). Although the official Department of Education policy cautions school administrators against using temperature alone as a criterion for canceling outside play, it does discourage sending children outside if wind chills will bring the effective temperature to less than zero degrees Fahrenheit, which sounds reasonable in a community unaccustomed to serious cold. However, it also discourages schools from allowing outside play if it is snowing or there is any ice on the playground.
Sadly, some cold-averse administrators have robbed hundreds of children of the chance to enjoy what has been an unusually snowy winter in the Northeast. In fact, no one can remember when the children in one unfortunate New York City grade school have been outside for recess. A conservative estimate is 40 consecutive days of incarceration.
This school is in the unenviable and unacceptable position of having no playground. Even in warmer weather, it relies on a nearby park that the parks department has chosen not to plow this winter. The tragic snow deprivation these children are suffering is just the tip of the iceberg. Despite ample evidence supporting the health and educational benefits of physical activity and recess, the New York City Department of Education does not mandate recess. Instead, it simply “encourages” schools to offer 20 minutes of outside activity.
I can understand why some school administrators are hesitant to send their young students out in the cold. It can take at least as long to bundle and unbundle a class of 5-year-olds as they will spend outside. But, at least teachers no longer have to contend with the thumb-lacerating metal buckles that made the old rubber galoshes such a painful challenge.
I am sure the list of willing volunteers to take playground duty on a frigid Friday afternoon is a short one. But, let’s remember that we are talking about young minds and bodies that need fresh air, even if it is cold fresh air, to keep them healthy and engaged in the learning process. For goodness sake, put on another layer, or three, and let them go out to enjoy the winter wonderland.
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.” E-mail him at [email protected].
Patience, my dear
When I am trying to help parents deal with their picky eaters, the most frustrating challenge is getting the parents to sit back and silently watch their child not eating. Despite their claims that they want their child to eat a healthy and varied diet, many parents can’t muster up either the patience or the fortitude to watch their child ignore a plate of healthy but unpreferred food. Going to bed “hungry” just doesn’t seem to happen. Before the pajamas are even out of the bottom drawer, the child is offered an alternative serving of something on the child’s short list of nutritionally sketchy “will eats.”
Parents will dredge up any excuse they can find, including the eco-conscious claim that throwing the uneaten food will swamp the town landfill. Neither the reality that the amount thrown out is minuscule nor the concept of composting seems to convince them not to worry. The more prevalent excuse is that if their child doesn’t eat something he will become malnourished or lose weight – a strange claim in a country plagued by obesity. Or heaven forbid, the child will be sentenced to suffer the pangs of “hunger” until morning.
As part of an epidemic loss of common sense, North American parents seem to also have lost their ability to be patient. It takes time to break old habits and develop new ones. They fail to appreciate that the process of change will grind to a halt if they continue to offer alternatives that enable an old habit to persist.
The challenge facing the parent of a 3-year-old picky eater is no different than the one facing our nation’s school lunch program. It is just a matter of scale. In an attempt to stop our epidemic of child obesity, the Congress passed the Healthy, Hunger-Free Kids Act in 2010. The nutritional standards it mandated were finalized by the Department of Agriculture in 2012 and put into effect in the 2012-2013 school year.
Before the first tray of healthier alternatives could slide down the polished stainless steel of a cafeteria line, there were complaints from the “lunch ladies,” aka the School Nutrition Association, a group with support from some food industry giants. Like the parent of a picky eater, the “lunch ladies” predicted that kids wouldn’t eat that healthy stuff and food would be wasted. Healthy less processed food would be more expensive (and of course less profitable for industries that process). And surprise, surprise, they were correct. Some grade school kids even organized their own protests.
However, common sense suggests that with time behavior would change if the standards were maintained. A recently released study by the Rudd Center for Food Policy and Obesity at the University of Connecticut, Hartford, “New School Meal Regulations Increase Fruit Consumption and Do Not Increase Total Plate Waste” (Child Obesity 2015 [doi:10.1089/chi.2015.0019]), has found that in the three urban school districts sampled that the percentage of students choosing fruit for lunch rose from 54% in 2012 to 66% 2014. There also was less wasted because 84% of the students ate their entrées, including fruit, in 2014. This was up from 71% at the beginning of the 3-year survey. There was a significant increase in vegetable consumption, from 45.6% in 2012 to 63.6% in 2014.
The study was far from robust in that it compared data from only 1 day in each school year over the study period. The authors noted that each year fewer children in the cohort were eating school lunches, a phenomenon they suspect may be due to the tendency of older children to take less advantage of school lunches.
Regardless of its deficiencies, the study seems to support the basic principle that giving children better choices and waiting patiently will result in more nutritionally sound eating patterns. There is no question that in the short term that providing healthier school meals is more costly. However, this gap should narrow as the lunch ladies learn more cost-effective strategies for food procurement and preparation. The Department of Agriculture is already providing funds for the school departments who are struggling financially to comply with the new standards.
Unfortunately, some impatient members of Congress are like many parents of picky eaters and are trying to roll back the nutritional standards rather than wait for the inevitable change. None of us likes the thought of wasting food or money. But when managing unhealthy eating behaviors, sometimes waste has to happen.
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.” E-mail him at [email protected].
When I am trying to help parents deal with their picky eaters, the most frustrating challenge is getting the parents to sit back and silently watch their child not eating. Despite their claims that they want their child to eat a healthy and varied diet, many parents can’t muster up either the patience or the fortitude to watch their child ignore a plate of healthy but unpreferred food. Going to bed “hungry” just doesn’t seem to happen. Before the pajamas are even out of the bottom drawer, the child is offered an alternative serving of something on the child’s short list of nutritionally sketchy “will eats.”
Parents will dredge up any excuse they can find, including the eco-conscious claim that throwing the uneaten food will swamp the town landfill. Neither the reality that the amount thrown out is minuscule nor the concept of composting seems to convince them not to worry. The more prevalent excuse is that if their child doesn’t eat something he will become malnourished or lose weight – a strange claim in a country plagued by obesity. Or heaven forbid, the child will be sentenced to suffer the pangs of “hunger” until morning.
As part of an epidemic loss of common sense, North American parents seem to also have lost their ability to be patient. It takes time to break old habits and develop new ones. They fail to appreciate that the process of change will grind to a halt if they continue to offer alternatives that enable an old habit to persist.
The challenge facing the parent of a 3-year-old picky eater is no different than the one facing our nation’s school lunch program. It is just a matter of scale. In an attempt to stop our epidemic of child obesity, the Congress passed the Healthy, Hunger-Free Kids Act in 2010. The nutritional standards it mandated were finalized by the Department of Agriculture in 2012 and put into effect in the 2012-2013 school year.
Before the first tray of healthier alternatives could slide down the polished stainless steel of a cafeteria line, there were complaints from the “lunch ladies,” aka the School Nutrition Association, a group with support from some food industry giants. Like the parent of a picky eater, the “lunch ladies” predicted that kids wouldn’t eat that healthy stuff and food would be wasted. Healthy less processed food would be more expensive (and of course less profitable for industries that process). And surprise, surprise, they were correct. Some grade school kids even organized their own protests.
However, common sense suggests that with time behavior would change if the standards were maintained. A recently released study by the Rudd Center for Food Policy and Obesity at the University of Connecticut, Hartford, “New School Meal Regulations Increase Fruit Consumption and Do Not Increase Total Plate Waste” (Child Obesity 2015 [doi:10.1089/chi.2015.0019]), has found that in the three urban school districts sampled that the percentage of students choosing fruit for lunch rose from 54% in 2012 to 66% 2014. There also was less wasted because 84% of the students ate their entrées, including fruit, in 2014. This was up from 71% at the beginning of the 3-year survey. There was a significant increase in vegetable consumption, from 45.6% in 2012 to 63.6% in 2014.
The study was far from robust in that it compared data from only 1 day in each school year over the study period. The authors noted that each year fewer children in the cohort were eating school lunches, a phenomenon they suspect may be due to the tendency of older children to take less advantage of school lunches.
Regardless of its deficiencies, the study seems to support the basic principle that giving children better choices and waiting patiently will result in more nutritionally sound eating patterns. There is no question that in the short term that providing healthier school meals is more costly. However, this gap should narrow as the lunch ladies learn more cost-effective strategies for food procurement and preparation. The Department of Agriculture is already providing funds for the school departments who are struggling financially to comply with the new standards.
Unfortunately, some impatient members of Congress are like many parents of picky eaters and are trying to roll back the nutritional standards rather than wait for the inevitable change. None of us likes the thought of wasting food or money. But when managing unhealthy eating behaviors, sometimes waste has to happen.
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.” E-mail him at [email protected].
When I am trying to help parents deal with their picky eaters, the most frustrating challenge is getting the parents to sit back and silently watch their child not eating. Despite their claims that they want their child to eat a healthy and varied diet, many parents can’t muster up either the patience or the fortitude to watch their child ignore a plate of healthy but unpreferred food. Going to bed “hungry” just doesn’t seem to happen. Before the pajamas are even out of the bottom drawer, the child is offered an alternative serving of something on the child’s short list of nutritionally sketchy “will eats.”
Parents will dredge up any excuse they can find, including the eco-conscious claim that throwing the uneaten food will swamp the town landfill. Neither the reality that the amount thrown out is minuscule nor the concept of composting seems to convince them not to worry. The more prevalent excuse is that if their child doesn’t eat something he will become malnourished or lose weight – a strange claim in a country plagued by obesity. Or heaven forbid, the child will be sentenced to suffer the pangs of “hunger” until morning.
As part of an epidemic loss of common sense, North American parents seem to also have lost their ability to be patient. It takes time to break old habits and develop new ones. They fail to appreciate that the process of change will grind to a halt if they continue to offer alternatives that enable an old habit to persist.
The challenge facing the parent of a 3-year-old picky eater is no different than the one facing our nation’s school lunch program. It is just a matter of scale. In an attempt to stop our epidemic of child obesity, the Congress passed the Healthy, Hunger-Free Kids Act in 2010. The nutritional standards it mandated were finalized by the Department of Agriculture in 2012 and put into effect in the 2012-2013 school year.
Before the first tray of healthier alternatives could slide down the polished stainless steel of a cafeteria line, there were complaints from the “lunch ladies,” aka the School Nutrition Association, a group with support from some food industry giants. Like the parent of a picky eater, the “lunch ladies” predicted that kids wouldn’t eat that healthy stuff and food would be wasted. Healthy less processed food would be more expensive (and of course less profitable for industries that process). And surprise, surprise, they were correct. Some grade school kids even organized their own protests.
However, common sense suggests that with time behavior would change if the standards were maintained. A recently released study by the Rudd Center for Food Policy and Obesity at the University of Connecticut, Hartford, “New School Meal Regulations Increase Fruit Consumption and Do Not Increase Total Plate Waste” (Child Obesity 2015 [doi:10.1089/chi.2015.0019]), has found that in the three urban school districts sampled that the percentage of students choosing fruit for lunch rose from 54% in 2012 to 66% 2014. There also was less wasted because 84% of the students ate their entrées, including fruit, in 2014. This was up from 71% at the beginning of the 3-year survey. There was a significant increase in vegetable consumption, from 45.6% in 2012 to 63.6% in 2014.
The study was far from robust in that it compared data from only 1 day in each school year over the study period. The authors noted that each year fewer children in the cohort were eating school lunches, a phenomenon they suspect may be due to the tendency of older children to take less advantage of school lunches.
Regardless of its deficiencies, the study seems to support the basic principle that giving children better choices and waiting patiently will result in more nutritionally sound eating patterns. There is no question that in the short term that providing healthier school meals is more costly. However, this gap should narrow as the lunch ladies learn more cost-effective strategies for food procurement and preparation. The Department of Agriculture is already providing funds for the school departments who are struggling financially to comply with the new standards.
Unfortunately, some impatient members of Congress are like many parents of picky eaters and are trying to roll back the nutritional standards rather than wait for the inevitable change. None of us likes the thought of wasting food or money. But when managing unhealthy eating behaviors, sometimes waste has to happen.
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.” E-mail him at [email protected].
Family telemedicine
Yesterday, I took a very long, slow walk to the mailbox at the end of our driveway. Regardless of my emotional state, it was going to be a difficult trip. A fresh 6 inches of snow on top of the several feet we already had received meant that I had to choose my footsteps carefully and climb the Continental Divide that the town plow guys had thrown up. Before I fired up the snowblower, I wanted to get this letter mailed, lest I have a change of heart.
It was time to renew my license to practice medicine, and my choices were to pay a hefty fee and scramble to collect enough Category I CME credits or check the box that said “withdraw reapplication.” It wasn’t a drop-dead decision because withdrawal would put me in limbo for another 5 years during which I could reapply. But I hadn’t seen a patient in the office for 2 years. I make frequent social visits to chat up the staff and bathe in the glow of having someone tell me how much they miss me. Apparently, they assign this task to different employees on a rotating basis. They seem to enjoy telling me how the place has gone in the toilet since I left. Of course, this observation has nothing to do with the fact that my departure coincided with the adoption of a new electronic health records system that they all hate with a passion.
Other than writing a prescription for amoxicillin on one of my social visits when they couldn’t find the doctor who had forgotten to do it, I hadn’t practiced office medicine in 2 years. I missed the patients and the camaraderie badly for the first 6 months, but I had crossed over the bridge. Well almost, this trip to the mailbox would complete the crossing.
But I was pretty sure that even without a license I would still be able to practice the kind of pediatrics that was keeping me busy. For the last 9 years, I have been practicing family telemedicine. You may have a similar practice. The requirements are simple. The basic requirement is at least one grandchild (a niece or nephew will do); having four grandchildren spices up the variety of the practice. They can live around the corner, but it is helpful if one family lives on the opposite coast. Each family must have a computer with a camera or a smartphone, and of course, a Skype or FaceTime contract.
The next ingredient is critical. Each grandchild’s medical home must be served by a phone tree and a triage system that guarantees that calls about acute problems will be returned in no less than 2 hours. And the chances of speaking directly to the child’s primary care physician before the following day’s afternoon should be slim to none. The child’s family should have the alternative of going to an emergency room that is at least a 45-minute drive away and may involve a copay that is on the order of a down payment on a small car.
Given these options, the parents (a.k.a., my children) have little choice but to call Dr. Grampy for an opinion. Needless to say, my family telemedicine practice is booming ... and I love it. When my wife’s smartphone rings (I have a dumb phone), it might be a hastily e-mailed picture from California of a molluscum lesion. “Dad, is this infected or is it just one of those that is dying.”
“She just fell in the bath tub. Does that front tooth look okay?” On two consecutive Thursday afternoons at exactly the same point in a doubles-tennis match, I had the opportunity to consult on a lacerated chin ... the same chin and the same child. “Band-Aid or a trip to the ED?”
There has been a bit of a learning curve for the photographers. But, once they understood how helpful it was to give me some frame of reference as to size of the lesion/wound and a hint as to what part of the body I was being consulted about, a picture or two has been worth a thousand words. And more than a thousand dollars that would have been wasted on copays for unnecessary visits.
As I trudged back up the driveway – still not convinced that giving up my license was the right idea – the family room door swung open and my wife yelled, her breath forming a frosty cloud, “Jenn is on the computer. Ada woke up with a rash, and she wants you to take a look!” No license is required.
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.” E-mail him at [email protected].
Yesterday, I took a very long, slow walk to the mailbox at the end of our driveway. Regardless of my emotional state, it was going to be a difficult trip. A fresh 6 inches of snow on top of the several feet we already had received meant that I had to choose my footsteps carefully and climb the Continental Divide that the town plow guys had thrown up. Before I fired up the snowblower, I wanted to get this letter mailed, lest I have a change of heart.
It was time to renew my license to practice medicine, and my choices were to pay a hefty fee and scramble to collect enough Category I CME credits or check the box that said “withdraw reapplication.” It wasn’t a drop-dead decision because withdrawal would put me in limbo for another 5 years during which I could reapply. But I hadn’t seen a patient in the office for 2 years. I make frequent social visits to chat up the staff and bathe in the glow of having someone tell me how much they miss me. Apparently, they assign this task to different employees on a rotating basis. They seem to enjoy telling me how the place has gone in the toilet since I left. Of course, this observation has nothing to do with the fact that my departure coincided with the adoption of a new electronic health records system that they all hate with a passion.
Other than writing a prescription for amoxicillin on one of my social visits when they couldn’t find the doctor who had forgotten to do it, I hadn’t practiced office medicine in 2 years. I missed the patients and the camaraderie badly for the first 6 months, but I had crossed over the bridge. Well almost, this trip to the mailbox would complete the crossing.
But I was pretty sure that even without a license I would still be able to practice the kind of pediatrics that was keeping me busy. For the last 9 years, I have been practicing family telemedicine. You may have a similar practice. The requirements are simple. The basic requirement is at least one grandchild (a niece or nephew will do); having four grandchildren spices up the variety of the practice. They can live around the corner, but it is helpful if one family lives on the opposite coast. Each family must have a computer with a camera or a smartphone, and of course, a Skype or FaceTime contract.
The next ingredient is critical. Each grandchild’s medical home must be served by a phone tree and a triage system that guarantees that calls about acute problems will be returned in no less than 2 hours. And the chances of speaking directly to the child’s primary care physician before the following day’s afternoon should be slim to none. The child’s family should have the alternative of going to an emergency room that is at least a 45-minute drive away and may involve a copay that is on the order of a down payment on a small car.
Given these options, the parents (a.k.a., my children) have little choice but to call Dr. Grampy for an opinion. Needless to say, my family telemedicine practice is booming ... and I love it. When my wife’s smartphone rings (I have a dumb phone), it might be a hastily e-mailed picture from California of a molluscum lesion. “Dad, is this infected or is it just one of those that is dying.”
“She just fell in the bath tub. Does that front tooth look okay?” On two consecutive Thursday afternoons at exactly the same point in a doubles-tennis match, I had the opportunity to consult on a lacerated chin ... the same chin and the same child. “Band-Aid or a trip to the ED?”
There has been a bit of a learning curve for the photographers. But, once they understood how helpful it was to give me some frame of reference as to size of the lesion/wound and a hint as to what part of the body I was being consulted about, a picture or two has been worth a thousand words. And more than a thousand dollars that would have been wasted on copays for unnecessary visits.
As I trudged back up the driveway – still not convinced that giving up my license was the right idea – the family room door swung open and my wife yelled, her breath forming a frosty cloud, “Jenn is on the computer. Ada woke up with a rash, and she wants you to take a look!” No license is required.
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.” E-mail him at [email protected].
Yesterday, I took a very long, slow walk to the mailbox at the end of our driveway. Regardless of my emotional state, it was going to be a difficult trip. A fresh 6 inches of snow on top of the several feet we already had received meant that I had to choose my footsteps carefully and climb the Continental Divide that the town plow guys had thrown up. Before I fired up the snowblower, I wanted to get this letter mailed, lest I have a change of heart.
It was time to renew my license to practice medicine, and my choices were to pay a hefty fee and scramble to collect enough Category I CME credits or check the box that said “withdraw reapplication.” It wasn’t a drop-dead decision because withdrawal would put me in limbo for another 5 years during which I could reapply. But I hadn’t seen a patient in the office for 2 years. I make frequent social visits to chat up the staff and bathe in the glow of having someone tell me how much they miss me. Apparently, they assign this task to different employees on a rotating basis. They seem to enjoy telling me how the place has gone in the toilet since I left. Of course, this observation has nothing to do with the fact that my departure coincided with the adoption of a new electronic health records system that they all hate with a passion.
Other than writing a prescription for amoxicillin on one of my social visits when they couldn’t find the doctor who had forgotten to do it, I hadn’t practiced office medicine in 2 years. I missed the patients and the camaraderie badly for the first 6 months, but I had crossed over the bridge. Well almost, this trip to the mailbox would complete the crossing.
But I was pretty sure that even without a license I would still be able to practice the kind of pediatrics that was keeping me busy. For the last 9 years, I have been practicing family telemedicine. You may have a similar practice. The requirements are simple. The basic requirement is at least one grandchild (a niece or nephew will do); having four grandchildren spices up the variety of the practice. They can live around the corner, but it is helpful if one family lives on the opposite coast. Each family must have a computer with a camera or a smartphone, and of course, a Skype or FaceTime contract.
The next ingredient is critical. Each grandchild’s medical home must be served by a phone tree and a triage system that guarantees that calls about acute problems will be returned in no less than 2 hours. And the chances of speaking directly to the child’s primary care physician before the following day’s afternoon should be slim to none. The child’s family should have the alternative of going to an emergency room that is at least a 45-minute drive away and may involve a copay that is on the order of a down payment on a small car.
Given these options, the parents (a.k.a., my children) have little choice but to call Dr. Grampy for an opinion. Needless to say, my family telemedicine practice is booming ... and I love it. When my wife’s smartphone rings (I have a dumb phone), it might be a hastily e-mailed picture from California of a molluscum lesion. “Dad, is this infected or is it just one of those that is dying.”
“She just fell in the bath tub. Does that front tooth look okay?” On two consecutive Thursday afternoons at exactly the same point in a doubles-tennis match, I had the opportunity to consult on a lacerated chin ... the same chin and the same child. “Band-Aid or a trip to the ED?”
There has been a bit of a learning curve for the photographers. But, once they understood how helpful it was to give me some frame of reference as to size of the lesion/wound and a hint as to what part of the body I was being consulted about, a picture or two has been worth a thousand words. And more than a thousand dollars that would have been wasted on copays for unnecessary visits.
As I trudged back up the driveway – still not convinced that giving up my license was the right idea – the family room door swung open and my wife yelled, her breath forming a frosty cloud, “Jenn is on the computer. Ada woke up with a rash, and she wants you to take a look!” No license is required.
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.” E-mail him at [email protected].
Playing with fire
Hoping to learn a bit more about the apparently healthy 8-year-old who has been deposited in your exam room for his biannual checkup, you take the opportunity to ask him a few questions with his mother in the waiting room. “So, Jason, what do you like to do for fun?”
“Well, yesterday I started a fire with my buddy Rudy, and we burned a whole bunch of sticks and stuff.”
“Does your mother know about this?”
“She wasn’t around, but I think so. We’ve done it a bunch of times before.”
Okay, here you are with an 8-year-old pyromaniac whose parents are clearly under-supervising him. Who do you call first? The folks at Child Protective Services or the State Fire Marshall’s Office? Clearly, he and your community are at significant risk.
If you were practicing in Wrexham, a town in North Wales, you would continue your questioning with, “So you like to go to The Land after school? I’ve heard it’s a fun place?”
The Land is 3-year-old adventure playground that I learned about in a thought-provoking article in The Atlantic (The Overprotected Kid, by Hanna Rosin, April 2014). The nearly acre-sized site would look like a junkyard to any adult whose imagination has atrophied with age. Strewn with used tires, wooden palettes, dirty old mattresses, and decrepit lawn furniture, it provides endless opportunities for children to create their own places for play and adventure. By stacking, rolling, hammering together, and rearranging the loose detritus of society, children can transform the junk into an ever-changing landscape for fun. A fire pit and an old oil drum – among the most popular items – are often smoldering with fires the children have started. The filthy mattresses become trampolines. The children are observed by professionally trained “playworkers” who are continually updating the risk assessments of the activities that were begun prior to the opening of the facility. The observers seldom have to intervene. Other than a few scraped knees, no children have been injured.
Although adventure playgrounds were relatively common in the U.K. during the 1940’s, their popularity faded until the last few years when they have enjoyed a modest resurgence. In the article in The Atlantic, author Hanna Rosin chronicles the de-riskification of playgrounds in America that began in the 1970’s. The process was fueled by an unfortunate incident in which a toddler supervised by his mother fell off a 12-foot playground slide in a Chicago playground. The child sustained a significant and permanent brain injury and received a multimillion dollar award in the suit that followed.
A commentary in Pediatrics entitled “X-rated playgrounds?” (Pediatrics 1979;64:961) and a crusade by its author, Theodora Briggs Sweeney culminated in the release of the Handbook for Public Playground Safety (U.S. Consumer Product Safety Commission, 1981) which listed in minute detail guidelines for dimensions and materials for playground equipment and play surfaces. Although these were only “guidelines,” only the most foolish manufacturer would ignore them. Little thought was given to the validity of the alarming statistics that had prompted these changes. What were the denominators? Can you compare 1970’s hospital data with those from the 1950’s when injured children were managed at home or in their doctors’ offices?
Regardless of the validity of the data, the result was that these redesigned playgrounds offered so little sense of risk that they were abandoned by all but the youngest children. Numerous studies suggest that by eliminating risk or at least the appearance of risk, we are robbing children of important learning experiences on which they can build fuller, more creative, successful, and less anxiety-dominated lives. I urge you to look at that Atlantic article for a more robust description of the evidence.
I suspect that you may be a bit uncomfortable with 8-year-old boys playing with fire, but do you agree that we need to seriously rethink our attempts to protect children from the ordinary risks of an active life? Or do you think those of us who believe children will benefit from more perceived risk are just a bunch of fogys who begin every other sentence, “When I was your age ... .”
Do you encourage parents to allow their children to walk to school unattended? Do you caution parents about being overprotective? Have I ignited a spark of concern in you, or am I just playing with fire?
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.” E-mail him at [email protected].
Hoping to learn a bit more about the apparently healthy 8-year-old who has been deposited in your exam room for his biannual checkup, you take the opportunity to ask him a few questions with his mother in the waiting room. “So, Jason, what do you like to do for fun?”
“Well, yesterday I started a fire with my buddy Rudy, and we burned a whole bunch of sticks and stuff.”
“Does your mother know about this?”
“She wasn’t around, but I think so. We’ve done it a bunch of times before.”
Okay, here you are with an 8-year-old pyromaniac whose parents are clearly under-supervising him. Who do you call first? The folks at Child Protective Services or the State Fire Marshall’s Office? Clearly, he and your community are at significant risk.
If you were practicing in Wrexham, a town in North Wales, you would continue your questioning with, “So you like to go to The Land after school? I’ve heard it’s a fun place?”
The Land is 3-year-old adventure playground that I learned about in a thought-provoking article in The Atlantic (The Overprotected Kid, by Hanna Rosin, April 2014). The nearly acre-sized site would look like a junkyard to any adult whose imagination has atrophied with age. Strewn with used tires, wooden palettes, dirty old mattresses, and decrepit lawn furniture, it provides endless opportunities for children to create their own places for play and adventure. By stacking, rolling, hammering together, and rearranging the loose detritus of society, children can transform the junk into an ever-changing landscape for fun. A fire pit and an old oil drum – among the most popular items – are often smoldering with fires the children have started. The filthy mattresses become trampolines. The children are observed by professionally trained “playworkers” who are continually updating the risk assessments of the activities that were begun prior to the opening of the facility. The observers seldom have to intervene. Other than a few scraped knees, no children have been injured.
Although adventure playgrounds were relatively common in the U.K. during the 1940’s, their popularity faded until the last few years when they have enjoyed a modest resurgence. In the article in The Atlantic, author Hanna Rosin chronicles the de-riskification of playgrounds in America that began in the 1970’s. The process was fueled by an unfortunate incident in which a toddler supervised by his mother fell off a 12-foot playground slide in a Chicago playground. The child sustained a significant and permanent brain injury and received a multimillion dollar award in the suit that followed.
A commentary in Pediatrics entitled “X-rated playgrounds?” (Pediatrics 1979;64:961) and a crusade by its author, Theodora Briggs Sweeney culminated in the release of the Handbook for Public Playground Safety (U.S. Consumer Product Safety Commission, 1981) which listed in minute detail guidelines for dimensions and materials for playground equipment and play surfaces. Although these were only “guidelines,” only the most foolish manufacturer would ignore them. Little thought was given to the validity of the alarming statistics that had prompted these changes. What were the denominators? Can you compare 1970’s hospital data with those from the 1950’s when injured children were managed at home or in their doctors’ offices?
Regardless of the validity of the data, the result was that these redesigned playgrounds offered so little sense of risk that they were abandoned by all but the youngest children. Numerous studies suggest that by eliminating risk or at least the appearance of risk, we are robbing children of important learning experiences on which they can build fuller, more creative, successful, and less anxiety-dominated lives. I urge you to look at that Atlantic article for a more robust description of the evidence.
I suspect that you may be a bit uncomfortable with 8-year-old boys playing with fire, but do you agree that we need to seriously rethink our attempts to protect children from the ordinary risks of an active life? Or do you think those of us who believe children will benefit from more perceived risk are just a bunch of fogys who begin every other sentence, “When I was your age ... .”
Do you encourage parents to allow their children to walk to school unattended? Do you caution parents about being overprotective? Have I ignited a spark of concern in you, or am I just playing with fire?
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.” E-mail him at [email protected].
Hoping to learn a bit more about the apparently healthy 8-year-old who has been deposited in your exam room for his biannual checkup, you take the opportunity to ask him a few questions with his mother in the waiting room. “So, Jason, what do you like to do for fun?”
“Well, yesterday I started a fire with my buddy Rudy, and we burned a whole bunch of sticks and stuff.”
“Does your mother know about this?”
“She wasn’t around, but I think so. We’ve done it a bunch of times before.”
Okay, here you are with an 8-year-old pyromaniac whose parents are clearly under-supervising him. Who do you call first? The folks at Child Protective Services or the State Fire Marshall’s Office? Clearly, he and your community are at significant risk.
If you were practicing in Wrexham, a town in North Wales, you would continue your questioning with, “So you like to go to The Land after school? I’ve heard it’s a fun place?”
The Land is 3-year-old adventure playground that I learned about in a thought-provoking article in The Atlantic (The Overprotected Kid, by Hanna Rosin, April 2014). The nearly acre-sized site would look like a junkyard to any adult whose imagination has atrophied with age. Strewn with used tires, wooden palettes, dirty old mattresses, and decrepit lawn furniture, it provides endless opportunities for children to create their own places for play and adventure. By stacking, rolling, hammering together, and rearranging the loose detritus of society, children can transform the junk into an ever-changing landscape for fun. A fire pit and an old oil drum – among the most popular items – are often smoldering with fires the children have started. The filthy mattresses become trampolines. The children are observed by professionally trained “playworkers” who are continually updating the risk assessments of the activities that were begun prior to the opening of the facility. The observers seldom have to intervene. Other than a few scraped knees, no children have been injured.
Although adventure playgrounds were relatively common in the U.K. during the 1940’s, their popularity faded until the last few years when they have enjoyed a modest resurgence. In the article in The Atlantic, author Hanna Rosin chronicles the de-riskification of playgrounds in America that began in the 1970’s. The process was fueled by an unfortunate incident in which a toddler supervised by his mother fell off a 12-foot playground slide in a Chicago playground. The child sustained a significant and permanent brain injury and received a multimillion dollar award in the suit that followed.
A commentary in Pediatrics entitled “X-rated playgrounds?” (Pediatrics 1979;64:961) and a crusade by its author, Theodora Briggs Sweeney culminated in the release of the Handbook for Public Playground Safety (U.S. Consumer Product Safety Commission, 1981) which listed in minute detail guidelines for dimensions and materials for playground equipment and play surfaces. Although these were only “guidelines,” only the most foolish manufacturer would ignore them. Little thought was given to the validity of the alarming statistics that had prompted these changes. What were the denominators? Can you compare 1970’s hospital data with those from the 1950’s when injured children were managed at home or in their doctors’ offices?
Regardless of the validity of the data, the result was that these redesigned playgrounds offered so little sense of risk that they were abandoned by all but the youngest children. Numerous studies suggest that by eliminating risk or at least the appearance of risk, we are robbing children of important learning experiences on which they can build fuller, more creative, successful, and less anxiety-dominated lives. I urge you to look at that Atlantic article for a more robust description of the evidence.
I suspect that you may be a bit uncomfortable with 8-year-old boys playing with fire, but do you agree that we need to seriously rethink our attempts to protect children from the ordinary risks of an active life? Or do you think those of us who believe children will benefit from more perceived risk are just a bunch of fogys who begin every other sentence, “When I was your age ... .”
Do you encourage parents to allow their children to walk to school unattended? Do you caution parents about being overprotective? Have I ignited a spark of concern in you, or am I just playing with fire?
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.” E-mail him at [email protected].
Too sick to work?
By yesterday at lunch time, you knew you were sick. The sniffly nose and scratchy throat of the previous 2 days were maturing into a full-blown cold or worse. You woke this morning feeling achy and a bit feverish. The only thermometer in the house is a scary looking thing in the cutlery drawer next to the kitchen stove. There have been no cases of influenza reported in the country or even the state.
It is Thursday, and it is your partner’s traditional day off. You think you remember him saying that he was planning on driving out of state to visit his daughter who was struggling in her freshman year in college. Your new associate is in St. Louis taking her boards. The questions that need to be answered by 7:30 this morning are: Do I see if I can reach my partner before he leaves town and ask him if can work for me? If he is already on the road, do I call the office and tell them to cancel the day’s schedule because I am too sick to work?
This is the kind of scenario that most have us have faced more than once in our working lives. Who will I be putting at risk by going to work when I am sick? Of course, there are my patients. Is my patient population particularly fragile because of their age or immunological vulnerabilities? And there are my coworkers. Last of all, will going to work make me even sicker so that I will miss more work?
Where do you go for help in answering the question of whether you are too sick to go to work? Should you try to find a thermometer at an all-night convenience store? If you find one, exactly what temperature is the threshold that will prompt you to call in sick? How many sneezes per hour will render you too contagious to work? How many coughs? If your illness is primarily gastrointestinal, are you still a threat to your patients if your trips to the bathroom are spaced far enough apart to allow you to spend 15 minutes trapped in an examining room?
Would wearing a mask be of any benefit? My sense is that it wouldn’t help and may make you more of a threat if you keeping fiddling with it to readjust it for comfort. And a mask will certainly alarm some parents.
There are situations in which you look or sound worse than you are. I seem to develop laryngitis several days after the worst of my cold has passed. Unfortunately, this scenario is not one of those situations. If you show up in the office, you are going to sound and maybe look like you are as sick as you feel.
What are you going to do? I am embarrassed to admit that I was one of those masochists who would have gone to work regardless of my state of health. You would have had to tether me to an IV bottle to keep me at home. As a recovering workaholic, I have had to accept the fact that I may have jeopardized the health of some of my patients by my pigheaded and at times selfish devotion to showing up in the office come hell or high fever. But, on days when I was the only show in town, it was easy to fall into the trap of believing that I was indispensable. Although full-time emergency room physicians and hospitalists hadn’t been invented yet, there were a few other primary care physicians. I guess it was pride that prevented me from admitting that I could have called on them for help, even though they weren’t board certified pediatricians.
On the other hand, I still wonder how much harm I did by dragging myself to work when I was sick. Because Brunswick is a small town, I know my overly intense devotion to work didn’t result in any deaths. But how great was the collateral damage in the form of lost days from school and work for my patients, their parents, and my coworkers? There is no way to know, but I am sure there was some.
It is unreasonable to say, “I won’t ever go to work if I am ill.” I may have set the bar too high, but I am interested to hear how you decide when you are too sick to go to work.
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.” E-mail him at [email protected].
By yesterday at lunch time, you knew you were sick. The sniffly nose and scratchy throat of the previous 2 days were maturing into a full-blown cold or worse. You woke this morning feeling achy and a bit feverish. The only thermometer in the house is a scary looking thing in the cutlery drawer next to the kitchen stove. There have been no cases of influenza reported in the country or even the state.
It is Thursday, and it is your partner’s traditional day off. You think you remember him saying that he was planning on driving out of state to visit his daughter who was struggling in her freshman year in college. Your new associate is in St. Louis taking her boards. The questions that need to be answered by 7:30 this morning are: Do I see if I can reach my partner before he leaves town and ask him if can work for me? If he is already on the road, do I call the office and tell them to cancel the day’s schedule because I am too sick to work?
This is the kind of scenario that most have us have faced more than once in our working lives. Who will I be putting at risk by going to work when I am sick? Of course, there are my patients. Is my patient population particularly fragile because of their age or immunological vulnerabilities? And there are my coworkers. Last of all, will going to work make me even sicker so that I will miss more work?
Where do you go for help in answering the question of whether you are too sick to go to work? Should you try to find a thermometer at an all-night convenience store? If you find one, exactly what temperature is the threshold that will prompt you to call in sick? How many sneezes per hour will render you too contagious to work? How many coughs? If your illness is primarily gastrointestinal, are you still a threat to your patients if your trips to the bathroom are spaced far enough apart to allow you to spend 15 minutes trapped in an examining room?
Would wearing a mask be of any benefit? My sense is that it wouldn’t help and may make you more of a threat if you keeping fiddling with it to readjust it for comfort. And a mask will certainly alarm some parents.
There are situations in which you look or sound worse than you are. I seem to develop laryngitis several days after the worst of my cold has passed. Unfortunately, this scenario is not one of those situations. If you show up in the office, you are going to sound and maybe look like you are as sick as you feel.
What are you going to do? I am embarrassed to admit that I was one of those masochists who would have gone to work regardless of my state of health. You would have had to tether me to an IV bottle to keep me at home. As a recovering workaholic, I have had to accept the fact that I may have jeopardized the health of some of my patients by my pigheaded and at times selfish devotion to showing up in the office come hell or high fever. But, on days when I was the only show in town, it was easy to fall into the trap of believing that I was indispensable. Although full-time emergency room physicians and hospitalists hadn’t been invented yet, there were a few other primary care physicians. I guess it was pride that prevented me from admitting that I could have called on them for help, even though they weren’t board certified pediatricians.
On the other hand, I still wonder how much harm I did by dragging myself to work when I was sick. Because Brunswick is a small town, I know my overly intense devotion to work didn’t result in any deaths. But how great was the collateral damage in the form of lost days from school and work for my patients, their parents, and my coworkers? There is no way to know, but I am sure there was some.
It is unreasonable to say, “I won’t ever go to work if I am ill.” I may have set the bar too high, but I am interested to hear how you decide when you are too sick to go to work.
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.” E-mail him at [email protected].
By yesterday at lunch time, you knew you were sick. The sniffly nose and scratchy throat of the previous 2 days were maturing into a full-blown cold or worse. You woke this morning feeling achy and a bit feverish. The only thermometer in the house is a scary looking thing in the cutlery drawer next to the kitchen stove. There have been no cases of influenza reported in the country or even the state.
It is Thursday, and it is your partner’s traditional day off. You think you remember him saying that he was planning on driving out of state to visit his daughter who was struggling in her freshman year in college. Your new associate is in St. Louis taking her boards. The questions that need to be answered by 7:30 this morning are: Do I see if I can reach my partner before he leaves town and ask him if can work for me? If he is already on the road, do I call the office and tell them to cancel the day’s schedule because I am too sick to work?
This is the kind of scenario that most have us have faced more than once in our working lives. Who will I be putting at risk by going to work when I am sick? Of course, there are my patients. Is my patient population particularly fragile because of their age or immunological vulnerabilities? And there are my coworkers. Last of all, will going to work make me even sicker so that I will miss more work?
Where do you go for help in answering the question of whether you are too sick to go to work? Should you try to find a thermometer at an all-night convenience store? If you find one, exactly what temperature is the threshold that will prompt you to call in sick? How many sneezes per hour will render you too contagious to work? How many coughs? If your illness is primarily gastrointestinal, are you still a threat to your patients if your trips to the bathroom are spaced far enough apart to allow you to spend 15 minutes trapped in an examining room?
Would wearing a mask be of any benefit? My sense is that it wouldn’t help and may make you more of a threat if you keeping fiddling with it to readjust it for comfort. And a mask will certainly alarm some parents.
There are situations in which you look or sound worse than you are. I seem to develop laryngitis several days after the worst of my cold has passed. Unfortunately, this scenario is not one of those situations. If you show up in the office, you are going to sound and maybe look like you are as sick as you feel.
What are you going to do? I am embarrassed to admit that I was one of those masochists who would have gone to work regardless of my state of health. You would have had to tether me to an IV bottle to keep me at home. As a recovering workaholic, I have had to accept the fact that I may have jeopardized the health of some of my patients by my pigheaded and at times selfish devotion to showing up in the office come hell or high fever. But, on days when I was the only show in town, it was easy to fall into the trap of believing that I was indispensable. Although full-time emergency room physicians and hospitalists hadn’t been invented yet, there were a few other primary care physicians. I guess it was pride that prevented me from admitting that I could have called on them for help, even though they weren’t board certified pediatricians.
On the other hand, I still wonder how much harm I did by dragging myself to work when I was sick. Because Brunswick is a small town, I know my overly intense devotion to work didn’t result in any deaths. But how great was the collateral damage in the form of lost days from school and work for my patients, their parents, and my coworkers? There is no way to know, but I am sure there was some.
It is unreasonable to say, “I won’t ever go to work if I am ill.” I may have set the bar too high, but I am interested to hear how you decide when you are too sick to go to work.
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.” E-mail him at [email protected].
Time-dependent decisions
Let’s talk about your average workday. Is it a long day? Or is it a half-day that feels like a two-thirds day? Does it start with early morning rounds or taking your daughter to day care … or both? Breakfast? Eaten at home or behind the wheel? Do you have a break at lunchtime? How do you invest that time? Or has someone invested it for you by scheduling a #$@%&*! department meeting?
When does your day end? After the last patient is seen? Or do you stay until your charting is done? Do you make end-of-the-day rounds? Does your office scheduling reasonably approximate the reality of when you would like to leave?
Even more importantly, how does your day end? Are you wasted physically and mentally? Is the last hour and a half a stress packed, clock-watching ordeal because you have to pick up your daughter from day care? And/or be home in time to prepare dinner? Or even just eat? Have you given up on sharing the meal with your family but have promised your son that you will be home to tuck him in and give him a good-night kiss? Did you stop promising to read him a story months ago because you were never there in time?
I suspect that once you have had a cup of coffee, negotiated your commute, and settled into your office routine, the mornings are less taxing than your afternoons. Particularly if your routine includes a drop-dead time commitment when you must leave to do after school pickups and make or join the family for dinner. Do you think the quality of your doctoring is as good in the afternoon as it was in the morning? Be honest! Because I have some data that shouldn’t surprise you.
In a study entitled “Time of day and the decision to prescribe antibiotics (JAMA Intern. Med. 2014;174:2029-31), a group of physicians at Brigham and Women’s Hospital in Boston analyzed the billing and electronic health records of 21,000 clinic visits of adults diagnosed with an acute respiratory illness. The investigators found that the likelihood that a patient would be prescribed antibiotics increased throughout both the morning and afternoon office visit sessions. By the end of each 4-hour session, 5% more patients received antibiotics than at the beginning of the session.
You could argue that, for some, an as-yet-undiscovered quirk of pulmonary bacterial pathogens prompts their victims to schedule appointments later in the day. The authors of the study, however, suggest that the physicians were suffering from “decision fatigue,” a phenomenon that has apparently been described in other professionals, including judges.
But what is decision fatigue? Isn’t it really just a description of one of the things that can happen when we get tired? Everyone with a job is making decisions. “Should I mop behind the toilet or just make a quick swipe where it’s obvious?” Or, “Is it really that important to make sure I have correctly tightened that bolt on that carburetor?”
If you are physically tired or squeezed by commitment to be out of the office at a specific time for another obligation, priority lists can reshuffle as the end of the day approaches. And the quality of care can suffer. Taking the extra time to explain to a patient why antibiotics aren’t appropriate for his or her situation may drop behind the speedier alternative of simply writing a prescription.
I’m sure that this study from a Harvard-affiliated hospital could be repeated using any one of a variety of quality of care measures. It should prompt all of us to rethink how we are structuring our lives. Are you staying up too late watching television or whatever? Has your decision of where to live locked you into a time-gobbling commute? Do you invest your lunch break in a restorative activity, such as a brisk walk outside? Is your office schedule realistic? Have you accepted inflexible commitments at the end of the day that make it impossible for you to spend extra time with a patient when it would probably improve the quality of his care?
Practicing good medicine boils down to making sure that we are in good physical and mental health and have fostered a work environment that fosters good decisions. Fatigue happens, but our patients shouldn’t have to suffer the consequences when it happens to us.
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.” E-mail him at [email protected].
Let’s talk about your average workday. Is it a long day? Or is it a half-day that feels like a two-thirds day? Does it start with early morning rounds or taking your daughter to day care … or both? Breakfast? Eaten at home or behind the wheel? Do you have a break at lunchtime? How do you invest that time? Or has someone invested it for you by scheduling a #$@%&*! department meeting?
When does your day end? After the last patient is seen? Or do you stay until your charting is done? Do you make end-of-the-day rounds? Does your office scheduling reasonably approximate the reality of when you would like to leave?
Even more importantly, how does your day end? Are you wasted physically and mentally? Is the last hour and a half a stress packed, clock-watching ordeal because you have to pick up your daughter from day care? And/or be home in time to prepare dinner? Or even just eat? Have you given up on sharing the meal with your family but have promised your son that you will be home to tuck him in and give him a good-night kiss? Did you stop promising to read him a story months ago because you were never there in time?
I suspect that once you have had a cup of coffee, negotiated your commute, and settled into your office routine, the mornings are less taxing than your afternoons. Particularly if your routine includes a drop-dead time commitment when you must leave to do after school pickups and make or join the family for dinner. Do you think the quality of your doctoring is as good in the afternoon as it was in the morning? Be honest! Because I have some data that shouldn’t surprise you.
In a study entitled “Time of day and the decision to prescribe antibiotics (JAMA Intern. Med. 2014;174:2029-31), a group of physicians at Brigham and Women’s Hospital in Boston analyzed the billing and electronic health records of 21,000 clinic visits of adults diagnosed with an acute respiratory illness. The investigators found that the likelihood that a patient would be prescribed antibiotics increased throughout both the morning and afternoon office visit sessions. By the end of each 4-hour session, 5% more patients received antibiotics than at the beginning of the session.
You could argue that, for some, an as-yet-undiscovered quirk of pulmonary bacterial pathogens prompts their victims to schedule appointments later in the day. The authors of the study, however, suggest that the physicians were suffering from “decision fatigue,” a phenomenon that has apparently been described in other professionals, including judges.
But what is decision fatigue? Isn’t it really just a description of one of the things that can happen when we get tired? Everyone with a job is making decisions. “Should I mop behind the toilet or just make a quick swipe where it’s obvious?” Or, “Is it really that important to make sure I have correctly tightened that bolt on that carburetor?”
If you are physically tired or squeezed by commitment to be out of the office at a specific time for another obligation, priority lists can reshuffle as the end of the day approaches. And the quality of care can suffer. Taking the extra time to explain to a patient why antibiotics aren’t appropriate for his or her situation may drop behind the speedier alternative of simply writing a prescription.
I’m sure that this study from a Harvard-affiliated hospital could be repeated using any one of a variety of quality of care measures. It should prompt all of us to rethink how we are structuring our lives. Are you staying up too late watching television or whatever? Has your decision of where to live locked you into a time-gobbling commute? Do you invest your lunch break in a restorative activity, such as a brisk walk outside? Is your office schedule realistic? Have you accepted inflexible commitments at the end of the day that make it impossible for you to spend extra time with a patient when it would probably improve the quality of his care?
Practicing good medicine boils down to making sure that we are in good physical and mental health and have fostered a work environment that fosters good decisions. Fatigue happens, but our patients shouldn’t have to suffer the consequences when it happens to us.
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.” E-mail him at [email protected].
Let’s talk about your average workday. Is it a long day? Or is it a half-day that feels like a two-thirds day? Does it start with early morning rounds or taking your daughter to day care … or both? Breakfast? Eaten at home or behind the wheel? Do you have a break at lunchtime? How do you invest that time? Or has someone invested it for you by scheduling a #$@%&*! department meeting?
When does your day end? After the last patient is seen? Or do you stay until your charting is done? Do you make end-of-the-day rounds? Does your office scheduling reasonably approximate the reality of when you would like to leave?
Even more importantly, how does your day end? Are you wasted physically and mentally? Is the last hour and a half a stress packed, clock-watching ordeal because you have to pick up your daughter from day care? And/or be home in time to prepare dinner? Or even just eat? Have you given up on sharing the meal with your family but have promised your son that you will be home to tuck him in and give him a good-night kiss? Did you stop promising to read him a story months ago because you were never there in time?
I suspect that once you have had a cup of coffee, negotiated your commute, and settled into your office routine, the mornings are less taxing than your afternoons. Particularly if your routine includes a drop-dead time commitment when you must leave to do after school pickups and make or join the family for dinner. Do you think the quality of your doctoring is as good in the afternoon as it was in the morning? Be honest! Because I have some data that shouldn’t surprise you.
In a study entitled “Time of day and the decision to prescribe antibiotics (JAMA Intern. Med. 2014;174:2029-31), a group of physicians at Brigham and Women’s Hospital in Boston analyzed the billing and electronic health records of 21,000 clinic visits of adults diagnosed with an acute respiratory illness. The investigators found that the likelihood that a patient would be prescribed antibiotics increased throughout both the morning and afternoon office visit sessions. By the end of each 4-hour session, 5% more patients received antibiotics than at the beginning of the session.
You could argue that, for some, an as-yet-undiscovered quirk of pulmonary bacterial pathogens prompts their victims to schedule appointments later in the day. The authors of the study, however, suggest that the physicians were suffering from “decision fatigue,” a phenomenon that has apparently been described in other professionals, including judges.
But what is decision fatigue? Isn’t it really just a description of one of the things that can happen when we get tired? Everyone with a job is making decisions. “Should I mop behind the toilet or just make a quick swipe where it’s obvious?” Or, “Is it really that important to make sure I have correctly tightened that bolt on that carburetor?”
If you are physically tired or squeezed by commitment to be out of the office at a specific time for another obligation, priority lists can reshuffle as the end of the day approaches. And the quality of care can suffer. Taking the extra time to explain to a patient why antibiotics aren’t appropriate for his or her situation may drop behind the speedier alternative of simply writing a prescription.
I’m sure that this study from a Harvard-affiliated hospital could be repeated using any one of a variety of quality of care measures. It should prompt all of us to rethink how we are structuring our lives. Are you staying up too late watching television or whatever? Has your decision of where to live locked you into a time-gobbling commute? Do you invest your lunch break in a restorative activity, such as a brisk walk outside? Is your office schedule realistic? Have you accepted inflexible commitments at the end of the day that make it impossible for you to spend extra time with a patient when it would probably improve the quality of his care?
Practicing good medicine boils down to making sure that we are in good physical and mental health and have fostered a work environment that fosters good decisions. Fatigue happens, but our patients shouldn’t have to suffer the consequences when it happens to us.
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.” E-mail him at [email protected].
Fearful pictures
As the recent measles outbreak spreads out from its apparent epicenter at Disneyland Resorts in California, the media spotlights have again swung to the problem of underimmunization and the effect of vaccine refusal by parents. Because the statistics that are so alarming to us as pediatricians have little audience-grabbing appeal for print and electronic journalists, nearly every story about immunizations includes a picture of a young child screaming in pain and/or horror as he or she is receiving or is about to receive an injection.
In the Wall Street Journal, I was assaulted by one of the more egregious examples of this kind of inflammatory and fear-mongering photojournalism. The four-column-wide image depicts a cute 10- to 12-month old boy sitting in his mother’s lap encircled by her ample arms. He is grimacing, eyes puffed from crying as he is receives an injection in his left upper arm. You know he is about to shriek and the pacifier will fall out of his mouth. His mother is also grimacing, her teeth bared. Her eyes are clenched closed as she turns away from the horror.
The villain in this scene could be the young woman clothed in a lab coat and wearing blue plastic gloves. Of course, it isn’t much of a leap to believe that the real villain is the syringe and the vaccine it contains. A closer look at the image reveals the thumb of a gloved hand that is holding the little victim’s left leg. His puffy eyes suggest that this moment is the culmination of a long and unpleasant preamble.
Of course, the first and most important question we must ask is why does the media persist in using these anxiety-provoking images to embellish otherwise evenhanded and well-written stories about vaccine refusal? You might defend the journalists by pointing out that kids often cry when they get shots and that it is hard to find images of a contented child receiving an injection. Baloney!
I have just done a quick Google image search of “children receiving immunizations,” and what I found in scrolling down the first 45 photos of children receiving injections was that only five were crying – seven, in fact, were smiling! The rest had neutral facial expressions and body postures.
I saw a picture of the same white-coated injector in the New York Times. This time, the victim was girl about age 2 years, in full scream, sitting on her mother’s lap, her right arm pinned by her mother and an ungloved fully visible pink-printed grandmotherly assistant. The injector’s face revealed more than a trace of anxiety. Both these images were attributed to Getty Images and were probably from the same photo shoot. Obviously, the editors responsible for these stories hadn’t looked very hard for a photograph that might portray immunizations in a more-positive light.
Much has been written lately about religious and antiscience (or at least junk science) aspects of vaccine refusal. I don’t recall seeing much, if anything, said about just plain old needle fear. I suspect that many vaccine decliners are hiding (consciously or unconsciously) their fear of injections under the cloak of “intellectual” or religious choice. By continuing to use the kinds of fear-mongering images I have described, journalists are fueling the vaccine refusal debate.
How about you and I who provide immunizations on a regular basis adopt a policy of refusing to allow pictures from our offices to be taken immunizing uncooperative or terrified children? Or at least journalists should be forced publish three images of contented vaccine recipients for every photograph of a screaming child. Or, even better, how about a one-for-one arrangement that shows one child in the intensive care unit as the result of a vaccine-preventable illness for every crying injection recipient?
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.” E-mail him at [email protected].
As the recent measles outbreak spreads out from its apparent epicenter at Disneyland Resorts in California, the media spotlights have again swung to the problem of underimmunization and the effect of vaccine refusal by parents. Because the statistics that are so alarming to us as pediatricians have little audience-grabbing appeal for print and electronic journalists, nearly every story about immunizations includes a picture of a young child screaming in pain and/or horror as he or she is receiving or is about to receive an injection.
In the Wall Street Journal, I was assaulted by one of the more egregious examples of this kind of inflammatory and fear-mongering photojournalism. The four-column-wide image depicts a cute 10- to 12-month old boy sitting in his mother’s lap encircled by her ample arms. He is grimacing, eyes puffed from crying as he is receives an injection in his left upper arm. You know he is about to shriek and the pacifier will fall out of his mouth. His mother is also grimacing, her teeth bared. Her eyes are clenched closed as she turns away from the horror.
The villain in this scene could be the young woman clothed in a lab coat and wearing blue plastic gloves. Of course, it isn’t much of a leap to believe that the real villain is the syringe and the vaccine it contains. A closer look at the image reveals the thumb of a gloved hand that is holding the little victim’s left leg. His puffy eyes suggest that this moment is the culmination of a long and unpleasant preamble.
Of course, the first and most important question we must ask is why does the media persist in using these anxiety-provoking images to embellish otherwise evenhanded and well-written stories about vaccine refusal? You might defend the journalists by pointing out that kids often cry when they get shots and that it is hard to find images of a contented child receiving an injection. Baloney!
I have just done a quick Google image search of “children receiving immunizations,” and what I found in scrolling down the first 45 photos of children receiving injections was that only five were crying – seven, in fact, were smiling! The rest had neutral facial expressions and body postures.
I saw a picture of the same white-coated injector in the New York Times. This time, the victim was girl about age 2 years, in full scream, sitting on her mother’s lap, her right arm pinned by her mother and an ungloved fully visible pink-printed grandmotherly assistant. The injector’s face revealed more than a trace of anxiety. Both these images were attributed to Getty Images and were probably from the same photo shoot. Obviously, the editors responsible for these stories hadn’t looked very hard for a photograph that might portray immunizations in a more-positive light.
Much has been written lately about religious and antiscience (or at least junk science) aspects of vaccine refusal. I don’t recall seeing much, if anything, said about just plain old needle fear. I suspect that many vaccine decliners are hiding (consciously or unconsciously) their fear of injections under the cloak of “intellectual” or religious choice. By continuing to use the kinds of fear-mongering images I have described, journalists are fueling the vaccine refusal debate.
How about you and I who provide immunizations on a regular basis adopt a policy of refusing to allow pictures from our offices to be taken immunizing uncooperative or terrified children? Or at least journalists should be forced publish three images of contented vaccine recipients for every photograph of a screaming child. Or, even better, how about a one-for-one arrangement that shows one child in the intensive care unit as the result of a vaccine-preventable illness for every crying injection recipient?
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.” E-mail him at [email protected].
As the recent measles outbreak spreads out from its apparent epicenter at Disneyland Resorts in California, the media spotlights have again swung to the problem of underimmunization and the effect of vaccine refusal by parents. Because the statistics that are so alarming to us as pediatricians have little audience-grabbing appeal for print and electronic journalists, nearly every story about immunizations includes a picture of a young child screaming in pain and/or horror as he or she is receiving or is about to receive an injection.
In the Wall Street Journal, I was assaulted by one of the more egregious examples of this kind of inflammatory and fear-mongering photojournalism. The four-column-wide image depicts a cute 10- to 12-month old boy sitting in his mother’s lap encircled by her ample arms. He is grimacing, eyes puffed from crying as he is receives an injection in his left upper arm. You know he is about to shriek and the pacifier will fall out of his mouth. His mother is also grimacing, her teeth bared. Her eyes are clenched closed as she turns away from the horror.
The villain in this scene could be the young woman clothed in a lab coat and wearing blue plastic gloves. Of course, it isn’t much of a leap to believe that the real villain is the syringe and the vaccine it contains. A closer look at the image reveals the thumb of a gloved hand that is holding the little victim’s left leg. His puffy eyes suggest that this moment is the culmination of a long and unpleasant preamble.
Of course, the first and most important question we must ask is why does the media persist in using these anxiety-provoking images to embellish otherwise evenhanded and well-written stories about vaccine refusal? You might defend the journalists by pointing out that kids often cry when they get shots and that it is hard to find images of a contented child receiving an injection. Baloney!
I have just done a quick Google image search of “children receiving immunizations,” and what I found in scrolling down the first 45 photos of children receiving injections was that only five were crying – seven, in fact, were smiling! The rest had neutral facial expressions and body postures.
I saw a picture of the same white-coated injector in the New York Times. This time, the victim was girl about age 2 years, in full scream, sitting on her mother’s lap, her right arm pinned by her mother and an ungloved fully visible pink-printed grandmotherly assistant. The injector’s face revealed more than a trace of anxiety. Both these images were attributed to Getty Images and were probably from the same photo shoot. Obviously, the editors responsible for these stories hadn’t looked very hard for a photograph that might portray immunizations in a more-positive light.
Much has been written lately about religious and antiscience (or at least junk science) aspects of vaccine refusal. I don’t recall seeing much, if anything, said about just plain old needle fear. I suspect that many vaccine decliners are hiding (consciously or unconsciously) their fear of injections under the cloak of “intellectual” or religious choice. By continuing to use the kinds of fear-mongering images I have described, journalists are fueling the vaccine refusal debate.
How about you and I who provide immunizations on a regular basis adopt a policy of refusing to allow pictures from our offices to be taken immunizing uncooperative or terrified children? Or at least journalists should be forced publish three images of contented vaccine recipients for every photograph of a screaming child. Or, even better, how about a one-for-one arrangement that shows one child in the intensive care unit as the result of a vaccine-preventable illness for every crying injection recipient?
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.” E-mail him at [email protected].
