William G. Wilkoff, MD

If Maine conjures up images of pine-covered mountains and rocky coastlines, then Fort Kent won’t fit into your construct. Slumbering on the broad flat valley of the Saint John River that forms Maine’s border with Canada, the rolling farmland around this town of 4,000 would remind you more of Iowa. Aroostook County is potato country and is so unique that most Mainers refer to it simply as “The County.”

Fort Kent was originally built as a defense outpost but was seldom used. Today it is an unlikely spot for what could be one of the pivotal battles in a war that could decide our country’s future. But who in 1800 would have guessed that the small town of Gettysburg would have such a crucial role to play in American history.

And, who would imagine that a pixy-faced young woman with strawberry ringlets would be one of the heroes? But, on Halloween Day, 2014, the chief judge of the Maine District Courts ruled that Kaci Hickox was no longer to be quarantined in her home. As a nurse who had recently returned from West Africa where she had been caring for patients with Ebola, she certainly was at a higher risk for contracting the disease. But, there has been no clinical evidence that she had the disease or was contagious.

However, the governor of New Jersey, Chris Christie, ignored the facts and responded to irrational fear and isolated Ms. Hickox when she arrived from Africa in an unheated tent with little regard for her psychological comfort. With the help of her lawyer, she was allowed to travel back to Fort Kent where she had been living with her boyfriend, a nursing student. The governor of Maine, Paul LePage, reacted only slightly less irrationally than his New Jersey counterpart, and Kaci was ordered not leave her home. Negotiations for a more reasonable evidence-based arrangement broke down. And, in a brave and clever show of defiance, Kaci and her boyfriend went for a bike ride, heading away from town on the rural roads around Fort Kent. Were the state troopers following in two squad cars going to don hazmat suits to arrest the couple? Not likely, and the ride ended uneventfully. The next day Judge Charles C. Laverdiere lifted the quarantine and in his decision said that we all owed the nurse “a debt of gratitude” for her decision to treat Ebola patients.

Much of the buzz surrounding this decision has focused on the issue of Ms. Hickox’s personal freedom and even the constitutionality of her quarantine. But, more importantly, her case represents a rare victory in a key battle in a bigger war, the war between science and fear-based irrational thought. It is a war in which we have incurred too many losses. Hundreds of children have died of illnesses from which they could have been protected by immunization because their parents failed to trust the science.

Scientific thought is on the defensive. It is being poorly taught in school, and sadly a few who claim to be scientists have allowed their egos and greed to taint the results of their experiments. In the vacuum created when science has been ignored, fear and emotionally based decisions dominate.

In the case of Ebola, we all have suffered from the absence of a single voice of authority armed with evidence. It could have been the U.S. Surgeon General if the Senate hadn’t declined to confirm President Barack Obama’s appointment because of his position on gun-related issues.

However, even if we had a surgeon general, the most obvious choice for the role of defender and promoter of evidence-based decisions in a case that is so highly charged should have been the president himself. The country deserved a straight talking, look-em-in-the-eye delineation of the facts, a presentation that acknowledged that there are seldom situations in which the risk is zero, but one that reminded us that the only thing we have to fear is fear itself. However, this president’s style seems to be to step back and delegate when we need someone who will step forward and lead. The result of his abdication has been the confusing and conflicting attempts at leadership by three governors who may have been well intended, but lacked the skills and resources to address the scientific evidence.

In a battle with no general and a commander-in-chief who chose to stay in his tent, science has been rescued temporarily by a courageous young nurse and sage judge from Maine where our state motto is “Dirigo” – I lead.

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].

If Maine conjures up images of pine-covered mountains and rocky coastlines, then Fort Kent won’t fit into your construct. Slumbering on the broad flat valley of the Saint John River that forms Maine’s border with Canada, the rolling farmland around this town of 4,000 would remind you more of Iowa. Aroostook County is potato country and is so unique that most Mainers refer to it simply as “The County.”

Fort Kent was originally built as a defense outpost but was seldom used. Today it is an unlikely spot for what could be one of the pivotal battles in a war that could decide our country’s future. But who in 1800 would have guessed that the small town of Gettysburg would have such a crucial role to play in American history.

And, who would imagine that a pixy-faced young woman with strawberry ringlets would be one of the heroes? But, on Halloween Day, 2014, the chief judge of the Maine District Courts ruled that Kaci Hickox was no longer to be quarantined in her home. As a nurse who had recently returned from West Africa where she had been caring for patients with Ebola, she certainly was at a higher risk for contracting the disease. But, there has been no clinical evidence that she had the disease or was contagious.

However, the governor of New Jersey, Chris Christie, ignored the facts and responded to irrational fear and isolated Ms. Hickox when she arrived from Africa in an unheated tent with little regard for her psychological comfort. With the help of her lawyer, she was allowed to travel back to Fort Kent where she had been living with her boyfriend, a nursing student. The governor of Maine, Paul LePage, reacted only slightly less irrationally than his New Jersey counterpart, and Kaci was ordered not leave her home. Negotiations for a more reasonable evidence-based arrangement broke down. And, in a brave and clever show of defiance, Kaci and her boyfriend went for a bike ride, heading away from town on the rural roads around Fort Kent. Were the state troopers following in two squad cars going to don hazmat suits to arrest the couple? Not likely, and the ride ended uneventfully. The next day Judge Charles C. Laverdiere lifted the quarantine and in his decision said that we all owed the nurse “a debt of gratitude” for her decision to treat Ebola patients.

Much of the buzz surrounding this decision has focused on the issue of Ms. Hickox’s personal freedom and even the constitutionality of her quarantine. But, more importantly, her case represents a rare victory in a key battle in a bigger war, the war between science and fear-based irrational thought. It is a war in which we have incurred too many losses. Hundreds of children have died of illnesses from which they could have been protected by immunization because their parents failed to trust the science.

Scientific thought is on the defensive. It is being poorly taught in school, and sadly a few who claim to be scientists have allowed their egos and greed to taint the results of their experiments. In the vacuum created when science has been ignored, fear and emotionally based decisions dominate.

In the case of Ebola, we all have suffered from the absence of a single voice of authority armed with evidence. It could have been the U.S. Surgeon General if the Senate hadn’t declined to confirm President Barack Obama’s appointment because of his position on gun-related issues.

However, even if we had a surgeon general, the most obvious choice for the role of defender and promoter of evidence-based decisions in a case that is so highly charged should have been the president himself. The country deserved a straight talking, look-em-in-the-eye delineation of the facts, a presentation that acknowledged that there are seldom situations in which the risk is zero, but one that reminded us that the only thing we have to fear is fear itself. However, this president’s style seems to be to step back and delegate when we need someone who will step forward and lead. The result of his abdication has been the confusing and conflicting attempts at leadership by three governors who may have been well intended, but lacked the skills and resources to address the scientific evidence.

In a battle with no general and a commander-in-chief who chose to stay in his tent, science has been rescued temporarily by a courageous young nurse and sage judge from Maine where our state motto is “Dirigo” – I lead.

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].

If Maine conjures up images of pine-covered mountains and rocky coastlines, then Fort Kent won’t fit into your construct. Slumbering on the broad flat valley of the Saint John River that forms Maine’s border with Canada, the rolling farmland around this town of 4,000 would remind you more of Iowa. Aroostook County is potato country and is so unique that most Mainers refer to it simply as “The County.”

Fort Kent was originally built as a defense outpost but was seldom used. Today it is an unlikely spot for what could be one of the pivotal battles in a war that could decide our country’s future. But who in 1800 would have guessed that the small town of Gettysburg would have such a crucial role to play in American history.

And, who would imagine that a pixy-faced young woman with strawberry ringlets would be one of the heroes? But, on Halloween Day, 2014, the chief judge of the Maine District Courts ruled that Kaci Hickox was no longer to be quarantined in her home. As a nurse who had recently returned from West Africa where she had been caring for patients with Ebola, she certainly was at a higher risk for contracting the disease. But, there has been no clinical evidence that she had the disease or was contagious.

However, the governor of New Jersey, Chris Christie, ignored the facts and responded to irrational fear and isolated Ms. Hickox when she arrived from Africa in an unheated tent with little regard for her psychological comfort. With the help of her lawyer, she was allowed to travel back to Fort Kent where she had been living with her boyfriend, a nursing student. The governor of Maine, Paul LePage, reacted only slightly less irrationally than his New Jersey counterpart, and Kaci was ordered not leave her home. Negotiations for a more reasonable evidence-based arrangement broke down. And, in a brave and clever show of defiance, Kaci and her boyfriend went for a bike ride, heading away from town on the rural roads around Fort Kent. Were the state troopers following in two squad cars going to don hazmat suits to arrest the couple? Not likely, and the ride ended uneventfully. The next day Judge Charles C. Laverdiere lifted the quarantine and in his decision said that we all owed the nurse “a debt of gratitude” for her decision to treat Ebola patients.

Much of the buzz surrounding this decision has focused on the issue of Ms. Hickox’s personal freedom and even the constitutionality of her quarantine. But, more importantly, her case represents a rare victory in a key battle in a bigger war, the war between science and fear-based irrational thought. It is a war in which we have incurred too many losses. Hundreds of children have died of illnesses from which they could have been protected by immunization because their parents failed to trust the science.

Scientific thought is on the defensive. It is being poorly taught in school, and sadly a few who claim to be scientists have allowed their egos and greed to taint the results of their experiments. In the vacuum created when science has been ignored, fear and emotionally based decisions dominate.

In the case of Ebola, we all have suffered from the absence of a single voice of authority armed with evidence. It could have been the U.S. Surgeon General if the Senate hadn’t declined to confirm President Barack Obama’s appointment because of his position on gun-related issues.

However, even if we had a surgeon general, the most obvious choice for the role of defender and promoter of evidence-based decisions in a case that is so highly charged should have been the president himself. The country deserved a straight talking, look-em-in-the-eye delineation of the facts, a presentation that acknowledged that there are seldom situations in which the risk is zero, but one that reminded us that the only thing we have to fear is fear itself. However, this president’s style seems to be to step back and delegate when we need someone who will step forward and lead. The result of his abdication has been the confusing and conflicting attempts at leadership by three governors who may have been well intended, but lacked the skills and resources to address the scientific evidence.

In a battle with no general and a commander-in-chief who chose to stay in his tent, science has been rescued temporarily by a courageous young nurse and sage judge from Maine where our state motto is “Dirigo” – I lead.

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].

Fear of the unknown is driving many pediatricians to refer out their patients with simple and easily managed orthopedic and dermatologic complaints. From several perspectives, this tendency to dump and run is unfortunate. For the patients and their families, a trip to the specialist may be expensive, certainly time consuming, and often comes after a long anxiety provoking and frustrating delay.

For the physician worried about her bottom line or who is being told by her practice administrator to see more patients, sending away a patient with a skin rash that can be diagnosed in 30 seconds (10 seconds in many cases) and explained in 5 minutes is a poor business decision. The office time required to make the referral could be as much as $20 while the 10-minute visit probably generates twice that in revenue.

But, the real tragedy is that, by referring out patients with simple dermatologic and orthopedic complaints, the physician is depriving herself of a source of intellectually stimulating variety. Parents appreciate the effort when their child’s doctor demonstrates that she is a more complete physician.

At least when it comes to gap in the dermatology training of pediatricians, there is a glimmer of a solution on the horizon. As reported by this news organization (“What should pediatricians know about dermatology?” Sept. 2014, page 1) the Society of Pediatric Dermatologists convened a committee of pediatricians, family practitioners, and pediatric dermatologists to determine what a pediatrician’s training in dermatology should include with the goal of creating an online pediatric dermatologic curricular for primary care providers.

Exactly how this training should be structured is yet to be determined. However, while we are waiting, I’m going to offer a few suggestions on what a pediatricians’ training in dermatology should look like. I would divide the training into three segments. The first would be a couple of hours of a one-on-one or small-group session with a dermatologist (not necessarily a pediatric dermatologist) in which the students were shown and participated in the Sherlock Holmes deductive reasoning approach that a good diagnostician uses as he approaches an unfamiliar skin lesion. Does it seem to be an “inside” or and “outside” job? Is there a sun exposure distribution? Raised or flat? Does it itch? At a minimum, the doctor in training should learn the language used to describe the lesion.

Second, there should be an hour or two of lectures on the diagnosis and management of common dermatologic conditions that require management, with atopic dermatitis and acne leading the short list. This should include a demonstration on how to do skin scraping for fungus, a simple skill that the select committee rejected based on the complaints of its pediatric members.

Finally, there is what one of my instructors called the “Aunt Millie” diagnoses. The scores of common skin findings that one learns by repeated exposure. “If it looks like Aunt Millie, it’s probably Aunt Millie.” This requires abundant exposure to the scores of patients that fill any busy outpatient setting, some of whom who did not even present with a skin complaint. I am sure that technology exists that would allow each student to keep a list of “must-see” findings on his smartphone. This list is updated as he progresses through his training. The program would keep a live data bank of each trainee’s list. When an instructor (not necessarily a dermatologist, could even be a fellow trainee) encounters a common finding, a quick entry in to his or her smartphone could summon for a quick look some or all the trainees whose data bases reflect that they haven’t seen this finding before. Parents and patients are usually impressed when their skin rash gets the special attention of several doctors. If time allows, there may even be a quick 3-minute explanation of the finding. This kind of sharing has been the hallmark of a good training program for years, but now is the time to let our smartphones and computers expand it to fill an embarrassing gap in our education of pediatricians.

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].

Fear of the unknown is driving many pediatricians to refer out their patients with simple and easily managed orthopedic and dermatologic complaints. From several perspectives, this tendency to dump and run is unfortunate. For the patients and their families, a trip to the specialist may be expensive, certainly time consuming, and often comes after a long anxiety provoking and frustrating delay.

For the physician worried about her bottom line or who is being told by her practice administrator to see more patients, sending away a patient with a skin rash that can be diagnosed in 30 seconds (10 seconds in many cases) and explained in 5 minutes is a poor business decision. The office time required to make the referral could be as much as $20 while the 10-minute visit probably generates twice that in revenue.

But, the real tragedy is that, by referring out patients with simple dermatologic and orthopedic complaints, the physician is depriving herself of a source of intellectually stimulating variety. Parents appreciate the effort when their child’s doctor demonstrates that she is a more complete physician.

At least when it comes to gap in the dermatology training of pediatricians, there is a glimmer of a solution on the horizon. As reported by this news organization (“What should pediatricians know about dermatology?” Sept. 2014, page 1) the Society of Pediatric Dermatologists convened a committee of pediatricians, family practitioners, and pediatric dermatologists to determine what a pediatrician’s training in dermatology should include with the goal of creating an online pediatric dermatologic curricular for primary care providers.

Exactly how this training should be structured is yet to be determined. However, while we are waiting, I’m going to offer a few suggestions on what a pediatricians’ training in dermatology should look like. I would divide the training into three segments. The first would be a couple of hours of a one-on-one or small-group session with a dermatologist (not necessarily a pediatric dermatologist) in which the students were shown and participated in the Sherlock Holmes deductive reasoning approach that a good diagnostician uses as he approaches an unfamiliar skin lesion. Does it seem to be an “inside” or and “outside” job? Is there a sun exposure distribution? Raised or flat? Does it itch? At a minimum, the doctor in training should learn the language used to describe the lesion.

Second, there should be an hour or two of lectures on the diagnosis and management of common dermatologic conditions that require management, with atopic dermatitis and acne leading the short list. This should include a demonstration on how to do skin scraping for fungus, a simple skill that the select committee rejected based on the complaints of its pediatric members.

Finally, there is what one of my instructors called the “Aunt Millie” diagnoses. The scores of common skin findings that one learns by repeated exposure. “If it looks like Aunt Millie, it’s probably Aunt Millie.” This requires abundant exposure to the scores of patients that fill any busy outpatient setting, some of whom who did not even present with a skin complaint. I am sure that technology exists that would allow each student to keep a list of “must-see” findings on his smartphone. This list is updated as he progresses through his training. The program would keep a live data bank of each trainee’s list. When an instructor (not necessarily a dermatologist, could even be a fellow trainee) encounters a common finding, a quick entry in to his or her smartphone could summon for a quick look some or all the trainees whose data bases reflect that they haven’t seen this finding before. Parents and patients are usually impressed when their skin rash gets the special attention of several doctors. If time allows, there may even be a quick 3-minute explanation of the finding. This kind of sharing has been the hallmark of a good training program for years, but now is the time to let our smartphones and computers expand it to fill an embarrassing gap in our education of pediatricians.

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].

Fear of the unknown is driving many pediatricians to refer out their patients with simple and easily managed orthopedic and dermatologic complaints. From several perspectives, this tendency to dump and run is unfortunate. For the patients and their families, a trip to the specialist may be expensive, certainly time consuming, and often comes after a long anxiety provoking and frustrating delay.

For the physician worried about her bottom line or who is being told by her practice administrator to see more patients, sending away a patient with a skin rash that can be diagnosed in 30 seconds (10 seconds in many cases) and explained in 5 minutes is a poor business decision. The office time required to make the referral could be as much as $20 while the 10-minute visit probably generates twice that in revenue.

But, the real tragedy is that, by referring out patients with simple dermatologic and orthopedic complaints, the physician is depriving herself of a source of intellectually stimulating variety. Parents appreciate the effort when their child’s doctor demonstrates that she is a more complete physician.

At least when it comes to gap in the dermatology training of pediatricians, there is a glimmer of a solution on the horizon. As reported by this news organization (“What should pediatricians know about dermatology?” Sept. 2014, page 1) the Society of Pediatric Dermatologists convened a committee of pediatricians, family practitioners, and pediatric dermatologists to determine what a pediatrician’s training in dermatology should include with the goal of creating an online pediatric dermatologic curricular for primary care providers.

Exactly how this training should be structured is yet to be determined. However, while we are waiting, I’m going to offer a few suggestions on what a pediatricians’ training in dermatology should look like. I would divide the training into three segments. The first would be a couple of hours of a one-on-one or small-group session with a dermatologist (not necessarily a pediatric dermatologist) in which the students were shown and participated in the Sherlock Holmes deductive reasoning approach that a good diagnostician uses as he approaches an unfamiliar skin lesion. Does it seem to be an “inside” or and “outside” job? Is there a sun exposure distribution? Raised or flat? Does it itch? At a minimum, the doctor in training should learn the language used to describe the lesion.

Second, there should be an hour or two of lectures on the diagnosis and management of common dermatologic conditions that require management, with atopic dermatitis and acne leading the short list. This should include a demonstration on how to do skin scraping for fungus, a simple skill that the select committee rejected based on the complaints of its pediatric members.

Finally, there is what one of my instructors called the “Aunt Millie” diagnoses. The scores of common skin findings that one learns by repeated exposure. “If it looks like Aunt Millie, it’s probably Aunt Millie.” This requires abundant exposure to the scores of patients that fill any busy outpatient setting, some of whom who did not even present with a skin complaint. I am sure that technology exists that would allow each student to keep a list of “must-see” findings on his smartphone. This list is updated as he progresses through his training. The program would keep a live data bank of each trainee’s list. When an instructor (not necessarily a dermatologist, could even be a fellow trainee) encounters a common finding, a quick entry in to his or her smartphone could summon for a quick look some or all the trainees whose data bases reflect that they haven’t seen this finding before. Parents and patients are usually impressed when their skin rash gets the special attention of several doctors. If time allows, there may even be a quick 3-minute explanation of the finding. This kind of sharing has been the hallmark of a good training program for years, but now is the time to let our smartphones and computers expand it to fill an embarrassing gap in our education of pediatricians.

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].

It’s a “Little House on the Prairie” tableau. The whole family is seated around the dinner table enjoying locally grown food that includes an abundance of fruit and vegetables. Animated conversation flows easily around the table, with every family member sharing his or her experiences and opinions. The younger children sit patiently waiting their turn to contribute.

It’s a scenario we all would like to emulate in our own homes because we instinctively assume that a family that dines together produces happy and well-adjusted children. We and many other parents have heard about the studies that suggest children in families that eat together do better in school and are less likely to smoke and drink, become depressed, or develop an eating disorder. And we probably recommend family meals to the families in our practices. The information has become so widely disseminated that family meals have become a gold standard against which parents measure themselves.

But one doesn’t have to scratch the surface too deeply to discover that dining together isn’t all it’s cracked up to be. Other studies that have controlled for a few more variables have shown that family dining is just one of several markers that can identify a well-functioning family. Although a family may eat together only infrequently, if they share other activities together the outcomes for their children are similar to those of families that dine together regularly.

However, the “Little House on the Prairie” image is so indelibly etched into our society’s consciousness that parents (particularly mothers) feel guilty if they can’t have everyone in the family sitting at the dinner table eating a healthy meal, preferably one they have cooked themselves from scratch. A recent ethnographic study by a team of sociologists at North Carolina State University, Raleigh, suggests that attempts by families to have meals together creates enough stress and tension to threaten the alleged benefits the parents had hoped for (“The Joy of Cooking?”, Sarah Bowen, Sinikka Elliot, and Joslyn Brenton, Contexts, Summer 2014, Vol. 13, No. 3, 20-25). The investigators visited 12 working class and poor families and observed their meals. They also interviewed 150 mothers from other families representing a broad range of socioeconomic categories.

The economically challenged mothers felt that cooking healthy meals at home required more time and money than they could afford. Across the board, mothers from all economic strata complained that planning and preparing healthy meals for the family were stressful, particularly when what they had prepared was rejected by some of those at the table. The investigators reported, “We rarely observed a meal in which at least one family member didn’t complain about the food they were served.” It’s not surprising, without immediate positive feedback, that mothers may struggle to see any long-term value.

While eating dinner together may be only one of the markers of a functional family and in spite of this evidence that it can be stressful, it is still an activity worth promoting. However, it must be recast in a more realistic light. Pediatricians can play a role in this transformation from stressful to achievable.

First, we must make it clear that we don’t expect families to eat every evening meal together. Some is better than none. For some families, a big Sunday breakfast may be all that they can work out. Second, we must counter the easy-as-pie attitude pervasive in magazines than anyone should be able to make quick, easy, and healthy meals at home. Again, one bag of chips isn’t going to trash an otherwise reasonably healthy meal. It’s a skill we should have learned as we attempted to ease the minds of the unfortunate women who couldn’t meet the American Academy of Pediatrics’ guidelines of only breast milk for the first 6 months.

Finally, we must help parents learn how to prevent and cope with picky eating. If properly managed, the initial rejection of green beans by a 6-month-old need not be the first step in a downward spiral of “he-won’t-eat-it-so-I-won’t-serve-it.” We must help parents learn to be comfortable with watching their children not eat. And this means helping mothers accept the transition from being a feeder to being merely a presenter of food. It also may mean encouraging parents to adopt a policy that says anyone complaining about what is being served is banished from the room until the meal is over. Initially, this may create a few more stressful meals, but eventually it will result in meals that have become family-building shared experiences.

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].

It’s a “Little House on the Prairie” tableau. The whole family is seated around the dinner table enjoying locally grown food that includes an abundance of fruit and vegetables. Animated conversation flows easily around the table, with every family member sharing his or her experiences and opinions. The younger children sit patiently waiting their turn to contribute.

It’s a scenario we all would like to emulate in our own homes because we instinctively assume that a family that dines together produces happy and well-adjusted children. We and many other parents have heard about the studies that suggest children in families that eat together do better in school and are less likely to smoke and drink, become depressed, or develop an eating disorder. And we probably recommend family meals to the families in our practices. The information has become so widely disseminated that family meals have become a gold standard against which parents measure themselves.

But one doesn’t have to scratch the surface too deeply to discover that dining together isn’t all it’s cracked up to be. Other studies that have controlled for a few more variables have shown that family dining is just one of several markers that can identify a well-functioning family. Although a family may eat together only infrequently, if they share other activities together the outcomes for their children are similar to those of families that dine together regularly.

However, the “Little House on the Prairie” image is so indelibly etched into our society’s consciousness that parents (particularly mothers) feel guilty if they can’t have everyone in the family sitting at the dinner table eating a healthy meal, preferably one they have cooked themselves from scratch. A recent ethnographic study by a team of sociologists at North Carolina State University, Raleigh, suggests that attempts by families to have meals together creates enough stress and tension to threaten the alleged benefits the parents had hoped for (“The Joy of Cooking?”, Sarah Bowen, Sinikka Elliot, and Joslyn Brenton, Contexts, Summer 2014, Vol. 13, No. 3, 20-25). The investigators visited 12 working class and poor families and observed their meals. They also interviewed 150 mothers from other families representing a broad range of socioeconomic categories.

The economically challenged mothers felt that cooking healthy meals at home required more time and money than they could afford. Across the board, mothers from all economic strata complained that planning and preparing healthy meals for the family were stressful, particularly when what they had prepared was rejected by some of those at the table. The investigators reported, “We rarely observed a meal in which at least one family member didn’t complain about the food they were served.” It’s not surprising, without immediate positive feedback, that mothers may struggle to see any long-term value.

While eating dinner together may be only one of the markers of a functional family and in spite of this evidence that it can be stressful, it is still an activity worth promoting. However, it must be recast in a more realistic light. Pediatricians can play a role in this transformation from stressful to achievable.

First, we must make it clear that we don’t expect families to eat every evening meal together. Some is better than none. For some families, a big Sunday breakfast may be all that they can work out. Second, we must counter the easy-as-pie attitude pervasive in magazines than anyone should be able to make quick, easy, and healthy meals at home. Again, one bag of chips isn’t going to trash an otherwise reasonably healthy meal. It’s a skill we should have learned as we attempted to ease the minds of the unfortunate women who couldn’t meet the American Academy of Pediatrics’ guidelines of only breast milk for the first 6 months.

Finally, we must help parents learn how to prevent and cope with picky eating. If properly managed, the initial rejection of green beans by a 6-month-old need not be the first step in a downward spiral of “he-won’t-eat-it-so-I-won’t-serve-it.” We must help parents learn to be comfortable with watching their children not eat. And this means helping mothers accept the transition from being a feeder to being merely a presenter of food. It also may mean encouraging parents to adopt a policy that says anyone complaining about what is being served is banished from the room until the meal is over. Initially, this may create a few more stressful meals, but eventually it will result in meals that have become family-building shared experiences.

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].

It’s a “Little House on the Prairie” tableau. The whole family is seated around the dinner table enjoying locally grown food that includes an abundance of fruit and vegetables. Animated conversation flows easily around the table, with every family member sharing his or her experiences and opinions. The younger children sit patiently waiting their turn to contribute.

It’s a scenario we all would like to emulate in our own homes because we instinctively assume that a family that dines together produces happy and well-adjusted children. We and many other parents have heard about the studies that suggest children in families that eat together do better in school and are less likely to smoke and drink, become depressed, or develop an eating disorder. And we probably recommend family meals to the families in our practices. The information has become so widely disseminated that family meals have become a gold standard against which parents measure themselves.

But one doesn’t have to scratch the surface too deeply to discover that dining together isn’t all it’s cracked up to be. Other studies that have controlled for a few more variables have shown that family dining is just one of several markers that can identify a well-functioning family. Although a family may eat together only infrequently, if they share other activities together the outcomes for their children are similar to those of families that dine together regularly.

However, the “Little House on the Prairie” image is so indelibly etched into our society’s consciousness that parents (particularly mothers) feel guilty if they can’t have everyone in the family sitting at the dinner table eating a healthy meal, preferably one they have cooked themselves from scratch. A recent ethnographic study by a team of sociologists at North Carolina State University, Raleigh, suggests that attempts by families to have meals together creates enough stress and tension to threaten the alleged benefits the parents had hoped for (“The Joy of Cooking?”, Sarah Bowen, Sinikka Elliot, and Joslyn Brenton, Contexts, Summer 2014, Vol. 13, No. 3, 20-25). The investigators visited 12 working class and poor families and observed their meals. They also interviewed 150 mothers from other families representing a broad range of socioeconomic categories.

The economically challenged mothers felt that cooking healthy meals at home required more time and money than they could afford. Across the board, mothers from all economic strata complained that planning and preparing healthy meals for the family were stressful, particularly when what they had prepared was rejected by some of those at the table. The investigators reported, “We rarely observed a meal in which at least one family member didn’t complain about the food they were served.” It’s not surprising, without immediate positive feedback, that mothers may struggle to see any long-term value.

While eating dinner together may be only one of the markers of a functional family and in spite of this evidence that it can be stressful, it is still an activity worth promoting. However, it must be recast in a more realistic light. Pediatricians can play a role in this transformation from stressful to achievable.

First, we must make it clear that we don’t expect families to eat every evening meal together. Some is better than none. For some families, a big Sunday breakfast may be all that they can work out. Second, we must counter the easy-as-pie attitude pervasive in magazines than anyone should be able to make quick, easy, and healthy meals at home. Again, one bag of chips isn’t going to trash an otherwise reasonably healthy meal. It’s a skill we should have learned as we attempted to ease the minds of the unfortunate women who couldn’t meet the American Academy of Pediatrics’ guidelines of only breast milk for the first 6 months.

Finally, we must help parents learn how to prevent and cope with picky eating. If properly managed, the initial rejection of green beans by a 6-month-old need not be the first step in a downward spiral of “he-won’t-eat-it-so-I-won’t-serve-it.” We must help parents learn to be comfortable with watching their children not eat. And this means helping mothers accept the transition from being a feeder to being merely a presenter of food. It also may mean encouraging parents to adopt a policy that says anyone complaining about what is being served is banished from the room until the meal is over. Initially, this may create a few more stressful meals, but eventually it will result in meals that have become family-building shared experiences.

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].

It’s far too early to begin a comprehensive list of the lessons to be learned from the ongoing Ebola situation. Each day brings a new revelation of another misstep or oversight that this frighteningly virulent virus has taken as an opportunity to spread its lethality. However, at the very beginning of the unfortunate debacle in Dallas, the question of who knew what and when became a focus. It is interesting, and not surprising, that the hospital where the index case presented was quick to blame a failure of its electronic health record (EHR) to allow various members of its health team to share information about the patient’s history.

Within days, the hospital retracted this explanation. But, the fact that EHRs were the first scapegoat demonstrates how dissatisfied and distrustful the medical profession is of computerized medical records. Many of us who practice medicine at the first interface with patients feel that we have been sold a bill of goods by the software vendors. Or, at the very least, we see ourselves as lab rats in a nationwide experiment in health information management, a beta-test that is not going well.

One revelation from the Dallas hospital was that the intake nurse took a history to which the doctor had access, but that the doctor took his or her own history during the 10-minute visit. If we ever hear more about the details of this unfortunate clinical encounter, we may discover that it was simply a case of physician seeing the dots but failing to make the correct connections. However, I am going to seize the opportunity to question a situation in health care delivery that troubles me.

If you have ever been a patient anywhere in this country in the last 20 years, you know to expect that you will be asked scores of questions by several people with varying amounts of training and experience. Your interrogation may begin with a clipboard you are handed in the waiting room. It will likely continue with an assistant – someone in a costume that suggests some medical training. Many of the questions will be repeated and repeated and seldom will be used to initiate a dialogue.

If you are lucky, the next person you see will be the “provider,” who may or may not look at the clipboard or computer screen. He or she may ask you some of the same questions again and, if you are very lucky, your answers may result in a conversation during which the provider will learn more about you and what is troubling you. If you are very unlucky, you may be referred to another provider or testing facility where this scenario will be repeated again.

Some of the questions provide necessary demographic information; others are intended to create a distant past history (such as how old you were when your parents misguidedly sent you to have your tonsils and adenoids out) that is unlikely to be of much clinical significance. I accept that this minutiae that has little clinical value is best collected by someone other than the provider. But, I submit that the patient’s chief complaint and the review of systems need only be gathered by one person, the provider. For most simple encounters, certainly those involving pediatric patients and most folks under the age of 50 years, the patient’s description of the present illness should unfold as part of a conversation during which the provider learns more about the patient and why he or she is sitting there in the office.

The notion that having an assistant obtain an extensive review of systems and history of the present illness saves the provider time is flawed. If it does save any time, it is often at the expense of not offering the provider a rich, full-color picture of the patient. Many patients complain that it appears the provider hasn’t read the answers to the questions that they have been asked several times. In cases in which the provider has taken the time to look at the answers, he or she may appear to have “always had his nose in the computer and never looked me in the eye.”

It’s time to reinject a little bit of D.I.Y. (do it yourself) doctoring into our practices. We may never know, but it may be that if one physician in Dallas had been solely responsible for obtaining the patient’s history and review of systems, disaster may have been averted.

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].

It’s far too early to begin a comprehensive list of the lessons to be learned from the ongoing Ebola situation. Each day brings a new revelation of another misstep or oversight that this frighteningly virulent virus has taken as an opportunity to spread its lethality. However, at the very beginning of the unfortunate debacle in Dallas, the question of who knew what and when became a focus. It is interesting, and not surprising, that the hospital where the index case presented was quick to blame a failure of its electronic health record (EHR) to allow various members of its health team to share information about the patient’s history.

Within days, the hospital retracted this explanation. But, the fact that EHRs were the first scapegoat demonstrates how dissatisfied and distrustful the medical profession is of computerized medical records. Many of us who practice medicine at the first interface with patients feel that we have been sold a bill of goods by the software vendors. Or, at the very least, we see ourselves as lab rats in a nationwide experiment in health information management, a beta-test that is not going well.

One revelation from the Dallas hospital was that the intake nurse took a history to which the doctor had access, but that the doctor took his or her own history during the 10-minute visit. If we ever hear more about the details of this unfortunate clinical encounter, we may discover that it was simply a case of physician seeing the dots but failing to make the correct connections. However, I am going to seize the opportunity to question a situation in health care delivery that troubles me.

If you have ever been a patient anywhere in this country in the last 20 years, you know to expect that you will be asked scores of questions by several people with varying amounts of training and experience. Your interrogation may begin with a clipboard you are handed in the waiting room. It will likely continue with an assistant – someone in a costume that suggests some medical training. Many of the questions will be repeated and repeated and seldom will be used to initiate a dialogue.

If you are lucky, the next person you see will be the “provider,” who may or may not look at the clipboard or computer screen. He or she may ask you some of the same questions again and, if you are very lucky, your answers may result in a conversation during which the provider will learn more about you and what is troubling you. If you are very unlucky, you may be referred to another provider or testing facility where this scenario will be repeated again.

Some of the questions provide necessary demographic information; others are intended to create a distant past history (such as how old you were when your parents misguidedly sent you to have your tonsils and adenoids out) that is unlikely to be of much clinical significance. I accept that this minutiae that has little clinical value is best collected by someone other than the provider. But, I submit that the patient’s chief complaint and the review of systems need only be gathered by one person, the provider. For most simple encounters, certainly those involving pediatric patients and most folks under the age of 50 years, the patient’s description of the present illness should unfold as part of a conversation during which the provider learns more about the patient and why he or she is sitting there in the office.

The notion that having an assistant obtain an extensive review of systems and history of the present illness saves the provider time is flawed. If it does save any time, it is often at the expense of not offering the provider a rich, full-color picture of the patient. Many patients complain that it appears the provider hasn’t read the answers to the questions that they have been asked several times. In cases in which the provider has taken the time to look at the answers, he or she may appear to have “always had his nose in the computer and never looked me in the eye.”

It’s time to reinject a little bit of D.I.Y. (do it yourself) doctoring into our practices. We may never know, but it may be that if one physician in Dallas had been solely responsible for obtaining the patient’s history and review of systems, disaster may have been averted.

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].

It’s far too early to begin a comprehensive list of the lessons to be learned from the ongoing Ebola situation. Each day brings a new revelation of another misstep or oversight that this frighteningly virulent virus has taken as an opportunity to spread its lethality. However, at the very beginning of the unfortunate debacle in Dallas, the question of who knew what and when became a focus. It is interesting, and not surprising, that the hospital where the index case presented was quick to blame a failure of its electronic health record (EHR) to allow various members of its health team to share information about the patient’s history.

Within days, the hospital retracted this explanation. But, the fact that EHRs were the first scapegoat demonstrates how dissatisfied and distrustful the medical profession is of computerized medical records. Many of us who practice medicine at the first interface with patients feel that we have been sold a bill of goods by the software vendors. Or, at the very least, we see ourselves as lab rats in a nationwide experiment in health information management, a beta-test that is not going well.

One revelation from the Dallas hospital was that the intake nurse took a history to which the doctor had access, but that the doctor took his or her own history during the 10-minute visit. If we ever hear more about the details of this unfortunate clinical encounter, we may discover that it was simply a case of physician seeing the dots but failing to make the correct connections. However, I am going to seize the opportunity to question a situation in health care delivery that troubles me.

If you have ever been a patient anywhere in this country in the last 20 years, you know to expect that you will be asked scores of questions by several people with varying amounts of training and experience. Your interrogation may begin with a clipboard you are handed in the waiting room. It will likely continue with an assistant – someone in a costume that suggests some medical training. Many of the questions will be repeated and repeated and seldom will be used to initiate a dialogue.

If you are lucky, the next person you see will be the “provider,” who may or may not look at the clipboard or computer screen. He or she may ask you some of the same questions again and, if you are very lucky, your answers may result in a conversation during which the provider will learn more about you and what is troubling you. If you are very unlucky, you may be referred to another provider or testing facility where this scenario will be repeated again.

Some of the questions provide necessary demographic information; others are intended to create a distant past history (such as how old you were when your parents misguidedly sent you to have your tonsils and adenoids out) that is unlikely to be of much clinical significance. I accept that this minutiae that has little clinical value is best collected by someone other than the provider. But, I submit that the patient’s chief complaint and the review of systems need only be gathered by one person, the provider. For most simple encounters, certainly those involving pediatric patients and most folks under the age of 50 years, the patient’s description of the present illness should unfold as part of a conversation during which the provider learns more about the patient and why he or she is sitting there in the office.

The notion that having an assistant obtain an extensive review of systems and history of the present illness saves the provider time is flawed. If it does save any time, it is often at the expense of not offering the provider a rich, full-color picture of the patient. Many patients complain that it appears the provider hasn’t read the answers to the questions that they have been asked several times. In cases in which the provider has taken the time to look at the answers, he or she may appear to have “always had his nose in the computer and never looked me in the eye.”

It’s time to reinject a little bit of D.I.Y. (do it yourself) doctoring into our practices. We may never know, but it may be that if one physician in Dallas had been solely responsible for obtaining the patient’s history and review of systems, disaster may have been averted.

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 the wake of the allegations that a star NFL running back abused his 4-year-old son by hitting him with a switch, the debate about spanking and other forms of corporal punishment has reignited. It’s not much of a debate. It’s really just a cacophony of “experts” condemning the act. There are a few dissenting voices who find fault with this particular high-profile event, but still hold the opinion that there are certain situations in which spanking may be an acceptable option. My mother taught me to never say never. But, the occasions in which an open-handed spank on a well-padded bottom are so rare that for all practical purposes, striking a child should not appear on any list of discipline strategies.

However, I’m not sure that spanking should automatically be equated with child abuse. It is seldom effective and should raise a red flag that we are dealing with a parent who needs help in managing his or her child’s behavior, but it’s generally not abuse.

In this recent case, the father has talked about the long lineage of corporal punishment that runs through his family. However, I think that most parents in this country instinctively know that hitting their child is not the best option. They may have learned from experience that it is ineffective and has a very narrow safety margin. But, parents aren’t sure what they should have done.

They may have read magazine articles or heard talking heads on television encouraging parents to engage their misbehaving children in a dialogue to explore their motives. Or, how to condemn the misdeeds without damaging the child’s self-image. To many parents, this kind of advice fells like just so much talk. They have already discovered that one can’t have a meaningful discussion with a child in the throes of a tantrum.

In many cases, the failure of words alone is the natural result of an uncountable number of threats that have never been followed by a consistent consequence. It’s not surprising that parents often fail to follow up on their threats because they lack even the smallest arsenal of safe and effective consequences. They know that corporal punishment is wrong. But, does that mean that discipline must be completely hands off? Is any physical restraint such as a bear hug of a toddler or preschooler in the throes of a tantrum so close to spanking that it could be interpreted as child abuse? Unfortunately, I suspect that there are a few child behavior experts who might say that it is.

What about putting a child in his room for time-out? If he won’t go willingly and has to be carried, is that corporal punishment? If he won’t stay in his room for even 30 seconds unless the door is held shut or latched, is that same as a penal institution’s use of solitary confinement? Although they have a physical component, these restrictions – if done sensibly – are far safer and more effective than hitting a child.

Of course, prevention should be the keystone of any behavior-management strategy. Does the parent understand the spectrum of age-appropriate behavior for his child? Does he accept that his child’s temperament may force him to modify his expectations? Have family dynamics and schedules created situations in which the child feels underappreciated? Is the parent himself in good physical and mental health?

As pediatricians, we must make it clear that we are prepared to help parents to deal with the challenges inherent in setting limits for their children and assist them in creating a strategies of safe consequences to assure that these limits are effective.

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].

In the wake of the allegations that a star NFL running back abused his 4-year-old son by hitting him with a switch, the debate about spanking and other forms of corporal punishment has reignited. It’s not much of a debate. It’s really just a cacophony of “experts” condemning the act. There are a few dissenting voices who find fault with this particular high-profile event, but still hold the opinion that there are certain situations in which spanking may be an acceptable option. My mother taught me to never say never. But, the occasions in which an open-handed spank on a well-padded bottom are so rare that for all practical purposes, striking a child should not appear on any list of discipline strategies.

However, I’m not sure that spanking should automatically be equated with child abuse. It is seldom effective and should raise a red flag that we are dealing with a parent who needs help in managing his or her child’s behavior, but it’s generally not abuse.

In this recent case, the father has talked about the long lineage of corporal punishment that runs through his family. However, I think that most parents in this country instinctively know that hitting their child is not the best option. They may have learned from experience that it is ineffective and has a very narrow safety margin. But, parents aren’t sure what they should have done.

They may have read magazine articles or heard talking heads on television encouraging parents to engage their misbehaving children in a dialogue to explore their motives. Or, how to condemn the misdeeds without damaging the child’s self-image. To many parents, this kind of advice fells like just so much talk. They have already discovered that one can’t have a meaningful discussion with a child in the throes of a tantrum.

In many cases, the failure of words alone is the natural result of an uncountable number of threats that have never been followed by a consistent consequence. It’s not surprising that parents often fail to follow up on their threats because they lack even the smallest arsenal of safe and effective consequences. They know that corporal punishment is wrong. But, does that mean that discipline must be completely hands off? Is any physical restraint such as a bear hug of a toddler or preschooler in the throes of a tantrum so close to spanking that it could be interpreted as child abuse? Unfortunately, I suspect that there are a few child behavior experts who might say that it is.

What about putting a child in his room for time-out? If he won’t go willingly and has to be carried, is that corporal punishment? If he won’t stay in his room for even 30 seconds unless the door is held shut or latched, is that same as a penal institution’s use of solitary confinement? Although they have a physical component, these restrictions – if done sensibly – are far safer and more effective than hitting a child.

Of course, prevention should be the keystone of any behavior-management strategy. Does the parent understand the spectrum of age-appropriate behavior for his child? Does he accept that his child’s temperament may force him to modify his expectations? Have family dynamics and schedules created situations in which the child feels underappreciated? Is the parent himself in good physical and mental health?

As pediatricians, we must make it clear that we are prepared to help parents to deal with the challenges inherent in setting limits for their children and assist them in creating a strategies of safe consequences to assure that these limits are effective.

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].

In the wake of the allegations that a star NFL running back abused his 4-year-old son by hitting him with a switch, the debate about spanking and other forms of corporal punishment has reignited. It’s not much of a debate. It’s really just a cacophony of “experts” condemning the act. There are a few dissenting voices who find fault with this particular high-profile event, but still hold the opinion that there are certain situations in which spanking may be an acceptable option. My mother taught me to never say never. But, the occasions in which an open-handed spank on a well-padded bottom are so rare that for all practical purposes, striking a child should not appear on any list of discipline strategies.

However, I’m not sure that spanking should automatically be equated with child abuse. It is seldom effective and should raise a red flag that we are dealing with a parent who needs help in managing his or her child’s behavior, but it’s generally not abuse.

In this recent case, the father has talked about the long lineage of corporal punishment that runs through his family. However, I think that most parents in this country instinctively know that hitting their child is not the best option. They may have learned from experience that it is ineffective and has a very narrow safety margin. But, parents aren’t sure what they should have done.

They may have read magazine articles or heard talking heads on television encouraging parents to engage their misbehaving children in a dialogue to explore their motives. Or, how to condemn the misdeeds without damaging the child’s self-image. To many parents, this kind of advice fells like just so much talk. They have already discovered that one can’t have a meaningful discussion with a child in the throes of a tantrum.

In many cases, the failure of words alone is the natural result of an uncountable number of threats that have never been followed by a consistent consequence. It’s not surprising that parents often fail to follow up on their threats because they lack even the smallest arsenal of safe and effective consequences. They know that corporal punishment is wrong. But, does that mean that discipline must be completely hands off? Is any physical restraint such as a bear hug of a toddler or preschooler in the throes of a tantrum so close to spanking that it could be interpreted as child abuse? Unfortunately, I suspect that there are a few child behavior experts who might say that it is.

What about putting a child in his room for time-out? If he won’t go willingly and has to be carried, is that corporal punishment? If he won’t stay in his room for even 30 seconds unless the door is held shut or latched, is that same as a penal institution’s use of solitary confinement? Although they have a physical component, these restrictions – if done sensibly – are far safer and more effective than hitting a child.

Of course, prevention should be the keystone of any behavior-management strategy. Does the parent understand the spectrum of age-appropriate behavior for his child? Does he accept that his child’s temperament may force him to modify his expectations? Have family dynamics and schedules created situations in which the child feels underappreciated? Is the parent himself in good physical and mental health?

As pediatricians, we must make it clear that we are prepared to help parents to deal with the challenges inherent in setting limits for their children and assist them in creating a strategies of safe consequences to assure that these limits are effective.

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].

I didn’t have a piggy bank when I was a child. But, I did have a bank. Instead of a porcelain porcine, my coin repository was a fiendishly designed miniature cash register. It would accept pennies, but it only acknowledged the receipt of nickels, dimes, and quarters by revealing the total amount in a window next to the register arm. It was surprisingly complex given that this was many decades prior to the invention of computer chips.

The contents only could be retrieved through a spring-loaded cash drawer that opened when the devilish instrument of torture perceived that it had been fully fed with $10 worth of silver coins. The spring that held the door tight was one tough spring. Trust me, I tried every tool on my dad’s workbench to try to open the door before it was ready. This bank demanded patience, and as a 5-year-old without an allowance, it was painful to wait and then wait and then wait some more until I had accumulated $10.

Once I was in grade school, my classmates and I opened our own accounts with a bank that provided the service to the school. I assume the bank hoped they would harvest a bountiful crop of future customers to whom they could offer mortgages and auto loans. On Wednesdays, we all arrived with our handful of coins, and the teacher recorded the amounts in our little bankbooks. I can’t recall how the interest was calculated, but we all understood that in some mysterious fashion our money was making money.

My diabolical cash register bank and my grade school bank account provided me with an introduction to the concept of saving for the future that has stayed with me to this day. It turns out that those two exercises in financial health may have contributed to my physical health.

In a recent New York Times article ("Your 401(k) Is Healthy. So Maybe You Are, Too." Aug. 16, 2014), I learned about a study published in the journal Psychological Science that found that regular contributors to their 401(k)’s were more likely to take steps to improve their health. Two business school professors at Washington University, St. Louis, studied 200 workers at an industrial laundry business. The subjects were given a baseline health evaluation that included blood tests. When the workers were informed of the results of the evaluation, they also were offered suggestions on how they could address any concerning findings. In follow-up, the regular 401(k) contributors as a group had a 27% improvement in their lab results, while noncontributors continued to suffer health declines (Psychol. Sci. 2014 June 27 [doi: 10.1177/0956797614540467]).

As a pediatrician, wouldn’t you like to know if these healthier investors were born that way? Or, were there factors in their childhood that molded them into adults who will choose to invest in the future, of both their finances and their health? We didn’t talk about money in my family as I was growing up, nor have my wife and I raised the topic with our children. But, we all fund our IRAs and try to lead healthy lifestyles. Were there subliminal messages that my parents conveyed to me and then I passed on to my children?

This country is going through a spell in which saving has slipped out of fashion. This study from St. Louis suggests that it may be linked to our difficulty in getting patients to take better care of themselves. Most of you know that we ask pediatricians to address too many issues at well-child visits. But, maybe we should begin asking every 4-year-old if he or she has a piggy bank. Maybe we even should be giving out piggy banks the way we give out children’s books, and take a moment to discuss the concept of saving. If we can convince this next generation that the future is something worth investing in now, then maybe they will be more receptive to advice about their health when they are adults.

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

I didn’t have a piggy bank when I was a child. But, I did have a bank. Instead of a porcelain porcine, my coin repository was a fiendishly designed miniature cash register. It would accept pennies, but it only acknowledged the receipt of nickels, dimes, and quarters by revealing the total amount in a window next to the register arm. It was surprisingly complex given that this was many decades prior to the invention of computer chips.

The contents only could be retrieved through a spring-loaded cash drawer that opened when the devilish instrument of torture perceived that it had been fully fed with $10 worth of silver coins. The spring that held the door tight was one tough spring. Trust me, I tried every tool on my dad’s workbench to try to open the door before it was ready. This bank demanded patience, and as a 5-year-old without an allowance, it was painful to wait and then wait and then wait some more until I had accumulated $10.

Once I was in grade school, my classmates and I opened our own accounts with a bank that provided the service to the school. I assume the bank hoped they would harvest a bountiful crop of future customers to whom they could offer mortgages and auto loans. On Wednesdays, we all arrived with our handful of coins, and the teacher recorded the amounts in our little bankbooks. I can’t recall how the interest was calculated, but we all understood that in some mysterious fashion our money was making money.

My diabolical cash register bank and my grade school bank account provided me with an introduction to the concept of saving for the future that has stayed with me to this day. It turns out that those two exercises in financial health may have contributed to my physical health.

In a recent New York Times article ("Your 401(k) Is Healthy. So Maybe You Are, Too." Aug. 16, 2014), I learned about a study published in the journal Psychological Science that found that regular contributors to their 401(k)’s were more likely to take steps to improve their health. Two business school professors at Washington University, St. Louis, studied 200 workers at an industrial laundry business. The subjects were given a baseline health evaluation that included blood tests. When the workers were informed of the results of the evaluation, they also were offered suggestions on how they could address any concerning findings. In follow-up, the regular 401(k) contributors as a group had a 27% improvement in their lab results, while noncontributors continued to suffer health declines (Psychol. Sci. 2014 June 27 [doi: 10.1177/0956797614540467]).

As a pediatrician, wouldn’t you like to know if these healthier investors were born that way? Or, were there factors in their childhood that molded them into adults who will choose to invest in the future, of both their finances and their health? We didn’t talk about money in my family as I was growing up, nor have my wife and I raised the topic with our children. But, we all fund our IRAs and try to lead healthy lifestyles. Were there subliminal messages that my parents conveyed to me and then I passed on to my children?

This country is going through a spell in which saving has slipped out of fashion. This study from St. Louis suggests that it may be linked to our difficulty in getting patients to take better care of themselves. Most of you know that we ask pediatricians to address too many issues at well-child visits. But, maybe we should begin asking every 4-year-old if he or she has a piggy bank. Maybe we even should be giving out piggy banks the way we give out children’s books, and take a moment to discuss the concept of saving. If we can convince this next generation that the future is something worth investing in now, then maybe they will be more receptive to advice about their health when they are adults.

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

I didn’t have a piggy bank when I was a child. But, I did have a bank. Instead of a porcelain porcine, my coin repository was a fiendishly designed miniature cash register. It would accept pennies, but it only acknowledged the receipt of nickels, dimes, and quarters by revealing the total amount in a window next to the register arm. It was surprisingly complex given that this was many decades prior to the invention of computer chips.

The contents only could be retrieved through a spring-loaded cash drawer that opened when the devilish instrument of torture perceived that it had been fully fed with $10 worth of silver coins. The spring that held the door tight was one tough spring. Trust me, I tried every tool on my dad’s workbench to try to open the door before it was ready. This bank demanded patience, and as a 5-year-old without an allowance, it was painful to wait and then wait and then wait some more until I had accumulated $10.

Once I was in grade school, my classmates and I opened our own accounts with a bank that provided the service to the school. I assume the bank hoped they would harvest a bountiful crop of future customers to whom they could offer mortgages and auto loans. On Wednesdays, we all arrived with our handful of coins, and the teacher recorded the amounts in our little bankbooks. I can’t recall how the interest was calculated, but we all understood that in some mysterious fashion our money was making money.

My diabolical cash register bank and my grade school bank account provided me with an introduction to the concept of saving for the future that has stayed with me to this day. It turns out that those two exercises in financial health may have contributed to my physical health.

In a recent New York Times article ("Your 401(k) Is Healthy. So Maybe You Are, Too." Aug. 16, 2014), I learned about a study published in the journal Psychological Science that found that regular contributors to their 401(k)’s were more likely to take steps to improve their health. Two business school professors at Washington University, St. Louis, studied 200 workers at an industrial laundry business. The subjects were given a baseline health evaluation that included blood tests. When the workers were informed of the results of the evaluation, they also were offered suggestions on how they could address any concerning findings. In follow-up, the regular 401(k) contributors as a group had a 27% improvement in their lab results, while noncontributors continued to suffer health declines (Psychol. Sci. 2014 June 27 [doi: 10.1177/0956797614540467]).

As a pediatrician, wouldn’t you like to know if these healthier investors were born that way? Or, were there factors in their childhood that molded them into adults who will choose to invest in the future, of both their finances and their health? We didn’t talk about money in my family as I was growing up, nor have my wife and I raised the topic with our children. But, we all fund our IRAs and try to lead healthy lifestyles. Were there subliminal messages that my parents conveyed to me and then I passed on to my children?

This country is going through a spell in which saving has slipped out of fashion. This study from St. Louis suggests that it may be linked to our difficulty in getting patients to take better care of themselves. Most of you know that we ask pediatricians to address too many issues at well-child visits. But, maybe we should begin asking every 4-year-old if he or she has a piggy bank. Maybe we even should be giving out piggy banks the way we give out children’s books, and take a moment to discuss the concept of saving. If we can convince this next generation that the future is something worth investing in now, then maybe they will be more receptive to advice about their health when they are adults.

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

Being on call means different things to different people, but it is safe to say that on call is a state that most physicians would avoid if they could. On call obligations are almost always included in advertisements in search of primary care physicians because both recent graduates of training programs and older physicians with their eyes on a retirement horizon put less-taxing call rotations high on their priority lists.

What makes on call so onerous? There is the obvious fact of life that the on call person is working at times when everyone else would rather not work ... nights, weekends, holidays, etc. Being on call can mess with your mind. It smacks of martyrdom for those of us who weren’t cut out to be saints. In places like Maine where warm sunny days are a rarity, being on call can tempt even the most altruistic among us to silently harbor hopes for rain so that we won’t be missing out on as much fun.

Being on call means that you will be fielding questions and interacting with patients and families who haven’t chosen you to be their primary care physician and with whom you are unfamiliar. This mutual unfamiliarity can breed discontent. It certainly doesn’t foster confidence. As on call physicians, you may be forced to invest extra time and effort to establish a therapeutic relationship with patients to whom you are a stranger. The failure to accept this challenge makes you more vulnerable to lawsuit should there be an unexpected outcome.

The physician who has made an effort to educate his patients and families is usually rewarded with fewer calls from them after hours. But, he will be frustrated by calls from patients of physicians who haven’t been as diligent at providing anticipatory guidance.

And, of course, there is always the problem of "But, Doctor Otherguy always just calls in a prescription for eye drops." There isn’t a perfect solution to this problem because physicians don’t all pop out of the same mold. However, discussions at group or hospital meetings, even if just informal chats in front of a chafing dish of overcooked vegetables, can help create some semblance of uniformity and minimize on call friction.

In some ways, a busy on call day that involves scores of calls and patient encounters can be more tolerable than a quiet day sitting at home waiting for the occasional call or beep. When it’s busy, the time passes more quickly, and encounters may generate some income (but never enough to justify the inconvenience and discomfort of being on call). However, when it’s quiet, you can slip into denial that you are on call. You may be tempted to make plans and begin activities that if interrupted could tip you into a cauldron of anger and self-pity.

There is an art to crafting an on call lifestyle that is compatible with a quiet on call. Choosing activities that one enjoys, but can be easily interrupted is a skill that comes after years of painful trial and error. When I was carving birds, I could drop my knives and head out to the office or hospital without a whimper. However, if I was in the middle of painting a project, the process of cleaning up and preserving the mixed color was too frustrating. So I only painted when I was off call.

Choosing which social invitations to accept also can be a challenge. Backyard cookouts are usually easier to exit by disappearing into the foliage. However, a small dinner party is a bad choice when one is on call. Several years ago, I discussed the issue of drinking on call in this column, and clearly, this is a personal decision that we all must make after a period of honest introspection.

Finally, communicating to one’s family the reality of on call and the inevitability of interruptions is of critical importance. Spouses and children can learn that "it-is-what-it-is" as long as we don’t allow ourselves to dip into denial and communicate our frustrations to them. They can learn to build their own lives while we are in that onerous other world of being on call.

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].

Being on call means different things to different people, but it is safe to say that on call is a state that most physicians would avoid if they could. On call obligations are almost always included in advertisements in search of primary care physicians because both recent graduates of training programs and older physicians with their eyes on a retirement horizon put less-taxing call rotations high on their priority lists.

What makes on call so onerous? There is the obvious fact of life that the on call person is working at times when everyone else would rather not work ... nights, weekends, holidays, etc. Being on call can mess with your mind. It smacks of martyrdom for those of us who weren’t cut out to be saints. In places like Maine where warm sunny days are a rarity, being on call can tempt even the most altruistic among us to silently harbor hopes for rain so that we won’t be missing out on as much fun.

Being on call means that you will be fielding questions and interacting with patients and families who haven’t chosen you to be their primary care physician and with whom you are unfamiliar. This mutual unfamiliarity can breed discontent. It certainly doesn’t foster confidence. As on call physicians, you may be forced to invest extra time and effort to establish a therapeutic relationship with patients to whom you are a stranger. The failure to accept this challenge makes you more vulnerable to lawsuit should there be an unexpected outcome.

The physician who has made an effort to educate his patients and families is usually rewarded with fewer calls from them after hours. But, he will be frustrated by calls from patients of physicians who haven’t been as diligent at providing anticipatory guidance.

And, of course, there is always the problem of "But, Doctor Otherguy always just calls in a prescription for eye drops." There isn’t a perfect solution to this problem because physicians don’t all pop out of the same mold. However, discussions at group or hospital meetings, even if just informal chats in front of a chafing dish of overcooked vegetables, can help create some semblance of uniformity and minimize on call friction.

In some ways, a busy on call day that involves scores of calls and patient encounters can be more tolerable than a quiet day sitting at home waiting for the occasional call or beep. When it’s busy, the time passes more quickly, and encounters may generate some income (but never enough to justify the inconvenience and discomfort of being on call). However, when it’s quiet, you can slip into denial that you are on call. You may be tempted to make plans and begin activities that if interrupted could tip you into a cauldron of anger and self-pity.

There is an art to crafting an on call lifestyle that is compatible with a quiet on call. Choosing activities that one enjoys, but can be easily interrupted is a skill that comes after years of painful trial and error. When I was carving birds, I could drop my knives and head out to the office or hospital without a whimper. However, if I was in the middle of painting a project, the process of cleaning up and preserving the mixed color was too frustrating. So I only painted when I was off call.

Choosing which social invitations to accept also can be a challenge. Backyard cookouts are usually easier to exit by disappearing into the foliage. However, a small dinner party is a bad choice when one is on call. Several years ago, I discussed the issue of drinking on call in this column, and clearly, this is a personal decision that we all must make after a period of honest introspection.

Finally, communicating to one’s family the reality of on call and the inevitability of interruptions is of critical importance. Spouses and children can learn that "it-is-what-it-is" as long as we don’t allow ourselves to dip into denial and communicate our frustrations to them. They can learn to build their own lives while we are in that onerous other world of being on call.

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].

Being on call means different things to different people, but it is safe to say that on call is a state that most physicians would avoid if they could. On call obligations are almost always included in advertisements in search of primary care physicians because both recent graduates of training programs and older physicians with their eyes on a retirement horizon put less-taxing call rotations high on their priority lists.

What makes on call so onerous? There is the obvious fact of life that the on call person is working at times when everyone else would rather not work ... nights, weekends, holidays, etc. Being on call can mess with your mind. It smacks of martyrdom for those of us who weren’t cut out to be saints. In places like Maine where warm sunny days are a rarity, being on call can tempt even the most altruistic among us to silently harbor hopes for rain so that we won’t be missing out on as much fun.

Being on call means that you will be fielding questions and interacting with patients and families who haven’t chosen you to be their primary care physician and with whom you are unfamiliar. This mutual unfamiliarity can breed discontent. It certainly doesn’t foster confidence. As on call physicians, you may be forced to invest extra time and effort to establish a therapeutic relationship with patients to whom you are a stranger. The failure to accept this challenge makes you more vulnerable to lawsuit should there be an unexpected outcome.

The physician who has made an effort to educate his patients and families is usually rewarded with fewer calls from them after hours. But, he will be frustrated by calls from patients of physicians who haven’t been as diligent at providing anticipatory guidance.

And, of course, there is always the problem of "But, Doctor Otherguy always just calls in a prescription for eye drops." There isn’t a perfect solution to this problem because physicians don’t all pop out of the same mold. However, discussions at group or hospital meetings, even if just informal chats in front of a chafing dish of overcooked vegetables, can help create some semblance of uniformity and minimize on call friction.

In some ways, a busy on call day that involves scores of calls and patient encounters can be more tolerable than a quiet day sitting at home waiting for the occasional call or beep. When it’s busy, the time passes more quickly, and encounters may generate some income (but never enough to justify the inconvenience and discomfort of being on call). However, when it’s quiet, you can slip into denial that you are on call. You may be tempted to make plans and begin activities that if interrupted could tip you into a cauldron of anger and self-pity.

There is an art to crafting an on call lifestyle that is compatible with a quiet on call. Choosing activities that one enjoys, but can be easily interrupted is a skill that comes after years of painful trial and error. When I was carving birds, I could drop my knives and head out to the office or hospital without a whimper. However, if I was in the middle of painting a project, the process of cleaning up and preserving the mixed color was too frustrating. So I only painted when I was off call.

Choosing which social invitations to accept also can be a challenge. Backyard cookouts are usually easier to exit by disappearing into the foliage. However, a small dinner party is a bad choice when one is on call. Several years ago, I discussed the issue of drinking on call in this column, and clearly, this is a personal decision that we all must make after a period of honest introspection.

Finally, communicating to one’s family the reality of on call and the inevitability of interruptions is of critical importance. Spouses and children can learn that "it-is-what-it-is" as long as we don’t allow ourselves to dip into denial and communicate our frustrations to them. They can learn to build their own lives while we are in that onerous other world of being on call.

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].

Doctors once received a free pass when it came to penmanship. We wrote our prescriptions in Latin. So, it was okay that everything else we scribbled looked like Greek. Referrals and consultations occurred in hospital corridors or doctors’ lounges. Documentation was spotty if it happened at all. Our handwriting was a joke. As long as we could sort of decipher our own scribbling, that was okay. But, the laughing stopped when third-party payers began to ask for proof that they were getting their money’s worth for our services – a proof that they could read.

Dictation with transcription was the obvious solution. It was efficient and produced a legible result. Whatever was lost in transcription resulted in humorous and usually harmless errors. As a card-carrying cheapskate, I typed my own letters. My typos added a kind of homey touch to my communications, and they were certainly more readable than my scrawl.

Dictated and transcribed reports seemed to be a relatively accurate reflection of what had occurred at an office visit, and it kept the payers happy for a while. Most physicians continued to handwrite their office notes. But, it was clear that handwriting was coming off the walls. Insurance companies, the government, quality control folks, and risk assessment managers all wanted more documentation. Computerization seemed to offer a reasonable compromise. The payers got the data, and physicians could take advantage of the efficiencies that electronic records promised.

The software vendors’ sales pitch went like this, "Doc, aren’t most of your visits pretty much the same? History, physical, lab, diagnosis, plan? And, you do pretty much the same exam on everyone? And most of the stuff is normal, right? We’ll show you how to make some templates that will save you a ton of time without all that repetition – done in just a couple of mouse clicks."

So, the templates were made, sometimes with the physician’s help, but often without. And accuracy was sacrificed in the name of legibility and efficiency. The problem is that patients with the same diagnosis aren’t all the same. Their examinations are as different as snowflakes.

What makes a normal ENT exam normal? Is the absence of tonsils worth noting? A bifid uvula? It depends. What does the template include in its definition of normal? More importantly, does the physician remember or did he ever know what his computer considers normal? With a single mouse click, he can create a crisp, laser-printable document that because of its legibility and level of detail appears to be the gospel truth.

But of course, sometimes and certainly too often, it’s not the truth. I recently received an e-mail from a pediatrician who said that he files the EHR records from specialists, emergency departments, and urgent care centers in the "fiction section." He cited an example of a report from a neurologist about a 10-month-old that included a "normal sense of smell" and a warning against driving while taking the medicine prescribed. I can’t top that; maybe you can. But I certainly have received numerous reports that clearly bore little relationship to what had transpired in the clinic or specialist’s office – complete neurologic exams that would have taken 30 minutes to perform, normal tympanic membranes in children with PE (pressure equalization) tubes or cavernous perforations.

Although I frequently complain about the sad state of the physical examination, a bigger problem may be the reliance on the EHR to document the result of the exam. I fear there is little incentive to correct the problem because of the malpractice lawyers’ mantra, "if you didn’t document it, it wasn’t done." Unfortunately, that has come to mean that if it’s legible and detailed, it must be the truth. I would enjoy hearing from you some examples in which you know this clearly wasn’t the case.

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].

Doctors once received a free pass when it came to penmanship. We wrote our prescriptions in Latin. So, it was okay that everything else we scribbled looked like Greek. Referrals and consultations occurred in hospital corridors or doctors’ lounges. Documentation was spotty if it happened at all. Our handwriting was a joke. As long as we could sort of decipher our own scribbling, that was okay. But, the laughing stopped when third-party payers began to ask for proof that they were getting their money’s worth for our services – a proof that they could read.

Dictation with transcription was the obvious solution. It was efficient and produced a legible result. Whatever was lost in transcription resulted in humorous and usually harmless errors. As a card-carrying cheapskate, I typed my own letters. My typos added a kind of homey touch to my communications, and they were certainly more readable than my scrawl.

Dictated and transcribed reports seemed to be a relatively accurate reflection of what had occurred at an office visit, and it kept the payers happy for a while. Most physicians continued to handwrite their office notes. But, it was clear that handwriting was coming off the walls. Insurance companies, the government, quality control folks, and risk assessment managers all wanted more documentation. Computerization seemed to offer a reasonable compromise. The payers got the data, and physicians could take advantage of the efficiencies that electronic records promised.

The software vendors’ sales pitch went like this, "Doc, aren’t most of your visits pretty much the same? History, physical, lab, diagnosis, plan? And, you do pretty much the same exam on everyone? And most of the stuff is normal, right? We’ll show you how to make some templates that will save you a ton of time without all that repetition – done in just a couple of mouse clicks."

So, the templates were made, sometimes with the physician’s help, but often without. And accuracy was sacrificed in the name of legibility and efficiency. The problem is that patients with the same diagnosis aren’t all the same. Their examinations are as different as snowflakes.

What makes a normal ENT exam normal? Is the absence of tonsils worth noting? A bifid uvula? It depends. What does the template include in its definition of normal? More importantly, does the physician remember or did he ever know what his computer considers normal? With a single mouse click, he can create a crisp, laser-printable document that because of its legibility and level of detail appears to be the gospel truth.

But of course, sometimes and certainly too often, it’s not the truth. I recently received an e-mail from a pediatrician who said that he files the EHR records from specialists, emergency departments, and urgent care centers in the "fiction section." He cited an example of a report from a neurologist about a 10-month-old that included a "normal sense of smell" and a warning against driving while taking the medicine prescribed. I can’t top that; maybe you can. But I certainly have received numerous reports that clearly bore little relationship to what had transpired in the clinic or specialist’s office – complete neurologic exams that would have taken 30 minutes to perform, normal tympanic membranes in children with PE (pressure equalization) tubes or cavernous perforations.

Although I frequently complain about the sad state of the physical examination, a bigger problem may be the reliance on the EHR to document the result of the exam. I fear there is little incentive to correct the problem because of the malpractice lawyers’ mantra, "if you didn’t document it, it wasn’t done." Unfortunately, that has come to mean that if it’s legible and detailed, it must be the truth. I would enjoy hearing from you some examples in which you know this clearly wasn’t the case.

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].

Doctors once received a free pass when it came to penmanship. We wrote our prescriptions in Latin. So, it was okay that everything else we scribbled looked like Greek. Referrals and consultations occurred in hospital corridors or doctors’ lounges. Documentation was spotty if it happened at all. Our handwriting was a joke. As long as we could sort of decipher our own scribbling, that was okay. But, the laughing stopped when third-party payers began to ask for proof that they were getting their money’s worth for our services – a proof that they could read.

Dictation with transcription was the obvious solution. It was efficient and produced a legible result. Whatever was lost in transcription resulted in humorous and usually harmless errors. As a card-carrying cheapskate, I typed my own letters. My typos added a kind of homey touch to my communications, and they were certainly more readable than my scrawl.

Dictated and transcribed reports seemed to be a relatively accurate reflection of what had occurred at an office visit, and it kept the payers happy for a while. Most physicians continued to handwrite their office notes. But, it was clear that handwriting was coming off the walls. Insurance companies, the government, quality control folks, and risk assessment managers all wanted more documentation. Computerization seemed to offer a reasonable compromise. The payers got the data, and physicians could take advantage of the efficiencies that electronic records promised.

The software vendors’ sales pitch went like this, "Doc, aren’t most of your visits pretty much the same? History, physical, lab, diagnosis, plan? And, you do pretty much the same exam on everyone? And most of the stuff is normal, right? We’ll show you how to make some templates that will save you a ton of time without all that repetition – done in just a couple of mouse clicks."

So, the templates were made, sometimes with the physician’s help, but often without. And accuracy was sacrificed in the name of legibility and efficiency. The problem is that patients with the same diagnosis aren’t all the same. Their examinations are as different as snowflakes.

What makes a normal ENT exam normal? Is the absence of tonsils worth noting? A bifid uvula? It depends. What does the template include in its definition of normal? More importantly, does the physician remember or did he ever know what his computer considers normal? With a single mouse click, he can create a crisp, laser-printable document that because of its legibility and level of detail appears to be the gospel truth.

But of course, sometimes and certainly too often, it’s not the truth. I recently received an e-mail from a pediatrician who said that he files the EHR records from specialists, emergency departments, and urgent care centers in the "fiction section." He cited an example of a report from a neurologist about a 10-month-old that included a "normal sense of smell" and a warning against driving while taking the medicine prescribed. I can’t top that; maybe you can. But I certainly have received numerous reports that clearly bore little relationship to what had transpired in the clinic or specialist’s office – complete neurologic exams that would have taken 30 minutes to perform, normal tympanic membranes in children with PE (pressure equalization) tubes or cavernous perforations.

Although I frequently complain about the sad state of the physical examination, a bigger problem may be the reliance on the EHR to document the result of the exam. I fear there is little incentive to correct the problem because of the malpractice lawyers’ mantra, "if you didn’t document it, it wasn’t done." Unfortunately, that has come to mean that if it’s legible and detailed, it must be the truth. I would enjoy hearing from you some examples in which you know this clearly wasn’t the case.

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].

During a recent interview on public radio, the CEO of one of Maine’s small hospitals (we have only one hospital that might qualify as not small) observed that the implementation of the Affordable Care Act had already resulted in a decrease in the length of hospital stay and shifted some of the health care utilization away from his hospital. These changes have been reflected in decreased revenue for his institution. This in turn was making it difficult for it to subsidize the outpatient practices it had purchased. He added that over the last several years, outpatient medicine was not sustainable without subsidies.

We hear a lot these days about sustainability, but I had never considered outpatient pediatrics in terms of sustainability. But as I thought more about it, I realized that on several levels that primary care pediatrics had frequently had to adjust when its resources had been unable to keep up with demand.

Fifty years ago, outpatient pediatrics was comfortably sustainable, at least from the profit and loss perspective. Most practices were solo, owner-operated enterprises. Real estate was cheap, and many physicians practiced out of their homes. Overhead costs were low. There were no expensive immunizations to stockpile and then, as now, most pediatricians didn’t require much in the way of high tech equipment to make diagnoses. And certainly there were no costly computer systems to purchase and invest valuable time in learning to operate.

If there was something unsustainable about solo practice, it was the issue of coverage. A surprising number of physicians were able to find a balance between being available to their patients and having enough time and energy for personal restoration and a family. However, over time, an increasing number of physicians found solo practice unsustainable. They simply ran out of emotional capital. The solution was to join together in groups. This provided an answer to the on-call issue and offered the promise of an improved financial balance sheet. Business consultants preached the economy of scale. A group could buy things like toilet paper at a discount, and group members could share support staff, saving on payroll.

But it turns out that seeing patients in an outpatient setting doesn’t follow the rules of economy of scale that apply to a factory cranking out widgets. Physicians practice with different levels of efficiency. They are often independent-minded individuals for whom sharing overhead is a difficult concept to grasp. Sometimes, the result is an unsustainable dynamic in which the overhead of the less-efficient members dictates the overhead for the group. As groups grow bigger, even the physicians who understood how to run an office efficiently surrender control to business managers who may not understand medicine. The overhead continues to rise.

The result can be a tense and unsustainable atmosphere with the business manager saying, "You need to bring in more money by doing more studies and/or seeing more patients." The physicians respond, "But doing more procedures doesn’t translate into good medicine. And neither does seeing too many patients."

Even groups that had been able to craft a sustainable model began to face threat from third-party payers whose preferred provider lists that could change year to year might exclude them. This threat of instability created an unsustainable situation in which a practice could no longer count on having a panel of patients large enough to be profitable. The result was often selling out to an even larger entity.

On top of these scenarios consider the rising cost of college and medical school, and the reality that even the best electronic medical record systems adds at least 5 minutes to the physician’s time investment in each office visit. It is surprising that young people still choose primary care.

Is there hope for this bleak picture of unsustainability? I’m not sure, but there is clearly enough fat and waste in our health care system that a redistribution of resources toward primary care could make it sustainable and improve the quality.

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].

During a recent interview on public radio, the CEO of one of Maine’s small hospitals (we have only one hospital that might qualify as not small) observed that the implementation of the Affordable Care Act had already resulted in a decrease in the length of hospital stay and shifted some of the health care utilization away from his hospital. These changes have been reflected in decreased revenue for his institution. This in turn was making it difficult for it to subsidize the outpatient practices it had purchased. He added that over the last several years, outpatient medicine was not sustainable without subsidies.

We hear a lot these days about sustainability, but I had never considered outpatient pediatrics in terms of sustainability. But as I thought more about it, I realized that on several levels that primary care pediatrics had frequently had to adjust when its resources had been unable to keep up with demand.

Fifty years ago, outpatient pediatrics was comfortably sustainable, at least from the profit and loss perspective. Most practices were solo, owner-operated enterprises. Real estate was cheap, and many physicians practiced out of their homes. Overhead costs were low. There were no expensive immunizations to stockpile and then, as now, most pediatricians didn’t require much in the way of high tech equipment to make diagnoses. And certainly there were no costly computer systems to purchase and invest valuable time in learning to operate.

If there was something unsustainable about solo practice, it was the issue of coverage. A surprising number of physicians were able to find a balance between being available to their patients and having enough time and energy for personal restoration and a family. However, over time, an increasing number of physicians found solo practice unsustainable. They simply ran out of emotional capital. The solution was to join together in groups. This provided an answer to the on-call issue and offered the promise of an improved financial balance sheet. Business consultants preached the economy of scale. A group could buy things like toilet paper at a discount, and group members could share support staff, saving on payroll.

But it turns out that seeing patients in an outpatient setting doesn’t follow the rules of economy of scale that apply to a factory cranking out widgets. Physicians practice with different levels of efficiency. They are often independent-minded individuals for whom sharing overhead is a difficult concept to grasp. Sometimes, the result is an unsustainable dynamic in which the overhead of the less-efficient members dictates the overhead for the group. As groups grow bigger, even the physicians who understood how to run an office efficiently surrender control to business managers who may not understand medicine. The overhead continues to rise.

The result can be a tense and unsustainable atmosphere with the business manager saying, "You need to bring in more money by doing more studies and/or seeing more patients." The physicians respond, "But doing more procedures doesn’t translate into good medicine. And neither does seeing too many patients."

Even groups that had been able to craft a sustainable model began to face threat from third-party payers whose preferred provider lists that could change year to year might exclude them. This threat of instability created an unsustainable situation in which a practice could no longer count on having a panel of patients large enough to be profitable. The result was often selling out to an even larger entity.

On top of these scenarios consider the rising cost of college and medical school, and the reality that even the best electronic medical record systems adds at least 5 minutes to the physician’s time investment in each office visit. It is surprising that young people still choose primary care.

Is there hope for this bleak picture of unsustainability? I’m not sure, but there is clearly enough fat and waste in our health care system that a redistribution of resources toward primary care could make it sustainable and improve the quality.

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].

During a recent interview on public radio, the CEO of one of Maine’s small hospitals (we have only one hospital that might qualify as not small) observed that the implementation of the Affordable Care Act had already resulted in a decrease in the length of hospital stay and shifted some of the health care utilization away from his hospital. These changes have been reflected in decreased revenue for his institution. This in turn was making it difficult for it to subsidize the outpatient practices it had purchased. He added that over the last several years, outpatient medicine was not sustainable without subsidies.

We hear a lot these days about sustainability, but I had never considered outpatient pediatrics in terms of sustainability. But as I thought more about it, I realized that on several levels that primary care pediatrics had frequently had to adjust when its resources had been unable to keep up with demand.

Fifty years ago, outpatient pediatrics was comfortably sustainable, at least from the profit and loss perspective. Most practices were solo, owner-operated enterprises. Real estate was cheap, and many physicians practiced out of their homes. Overhead costs were low. There were no expensive immunizations to stockpile and then, as now, most pediatricians didn’t require much in the way of high tech equipment to make diagnoses. And certainly there were no costly computer systems to purchase and invest valuable time in learning to operate.

If there was something unsustainable about solo practice, it was the issue of coverage. A surprising number of physicians were able to find a balance between being available to their patients and having enough time and energy for personal restoration and a family. However, over time, an increasing number of physicians found solo practice unsustainable. They simply ran out of emotional capital. The solution was to join together in groups. This provided an answer to the on-call issue and offered the promise of an improved financial balance sheet. Business consultants preached the economy of scale. A group could buy things like toilet paper at a discount, and group members could share support staff, saving on payroll.

But it turns out that seeing patients in an outpatient setting doesn’t follow the rules of economy of scale that apply to a factory cranking out widgets. Physicians practice with different levels of efficiency. They are often independent-minded individuals for whom sharing overhead is a difficult concept to grasp. Sometimes, the result is an unsustainable dynamic in which the overhead of the less-efficient members dictates the overhead for the group. As groups grow bigger, even the physicians who understood how to run an office efficiently surrender control to business managers who may not understand medicine. The overhead continues to rise.

The result can be a tense and unsustainable atmosphere with the business manager saying, "You need to bring in more money by doing more studies and/or seeing more patients." The physicians respond, "But doing more procedures doesn’t translate into good medicine. And neither does seeing too many patients."

Even groups that had been able to craft a sustainable model began to face threat from third-party payers whose preferred provider lists that could change year to year might exclude them. This threat of instability created an unsustainable situation in which a practice could no longer count on having a panel of patients large enough to be profitable. The result was often selling out to an even larger entity.

On top of these scenarios consider the rising cost of college and medical school, and the reality that even the best electronic medical record systems adds at least 5 minutes to the physician’s time investment in each office visit. It is surprising that young people still choose primary care.

Is there hope for this bleak picture of unsustainability? I’m not sure, but there is clearly enough fat and waste in our health care system that a redistribution of resources toward primary care could make it sustainable and improve the quality.

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].

Pediatricians tend to be rather easygoing or at least to survive they must learn to appear calm. It is our job to keep our heads when all about us are losing theirs. However, there are certain words that can rattle even the most apparently unflappable pediatrician. For example, when a parent or nurse says a child is "grunting," I begin to get twitchy. I drop everything I’m doing, and that child receives all of my professional attention.

"Lethargic" used to be one of those pulse-quickening words for me, but over the years, it began to lose some of its coronary-tightening qualities. I had always considered "lethargic" to be a rather ominous descriptor. But, people seem to apply the term to children who were merely sleepy, listless, or just plain unmotivated. It took me a decade or two of rushing to bedsides or opening the office in the middle of the night to see a "lethargic" child who turned out, in my vocabulary, to be just a bit "droopy" or unusually quiet but not seriously ill.

I found that to minimize the number of false alarms, I just needed to ask more questions to flesh out the child’s appearance and determine what had prompted the caller to use the "L" word. "Lethargy" seemed to mean too many different things to too many people to be of much use as a descriptor. Nonetheless, I still feel twinges of fear when I hear the word. When I encounter it in a nurse’s progress note, I always feel the need to counter it in my own note by providing a more specific description of the child’s condition.

A recent study in Pediatric Emergency Care (Webb, T. et al. 2014;30: 151-6) mirrors my experience with "lethargy." In a retrospective chart review of 272 patients aged 0-6 months, the investigators found that only 12.5% of the children who were described as having poor feeding or lethargy had a condition that required intervention. Infants who were feverish, hypothermic, or less than 35 weeks’ gestation were excluded from the study. However, infants that were described as appearing "ill" were much more likely to require intervention.

So what does a pediatrician mean when she or he describes a child as "ill looking" or "sick looking?" That is the $64,000 question (actually $560,000 in today’s dollars). We could generate a list that include abnormal vital signs, a spectrum of colors from pale to blue, and some neurologic observations, but a child looking sick or ill (and here I mean sick at level of needing immediate attention and probably intervention) is a gestalt.

Knowing when a child is seriously ill is a skill that is difficult to teach and can only come with seeing scores, and scores, and scores of children with a variety of conditions. The physician in training may not necessarily be directly involved with the care of those children, but she or he should have been close enough long enough to feel, see, smell, and hear what is going on. House officers and students should be encouraged to seek out as many of these chances to see sick and well children as they can to sharpen this skill. A mentor may help by pointing out a certain finding or collection of findings that are useful in forming the impression that this is a seriously ill child. But, it is a mistake to focus on one or two observations and not to emphasize the total picture. The ability to correctly determine that a child is desperately ill requires that the physician be able to see the trees, but not ignore the forest.

While most parents have that special sense when things are terribly wrong, we have all witnessed tragic situations when a focus on the thermometer has blurred the bigger picture that the child is desperately ill. Unfortunately, I have seen cases when a physician or nurse has been similarly deceived by a normal vital sign or laboratory result and failed to step back, look at the child, and say to themselves, "But, this child looks sick."

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].

Pediatricians tend to be rather easygoing or at least to survive they must learn to appear calm. It is our job to keep our heads when all about us are losing theirs. However, there are certain words that can rattle even the most apparently unflappable pediatrician. For example, when a parent or nurse says a child is "grunting," I begin to get twitchy. I drop everything I’m doing, and that child receives all of my professional attention.

"Lethargic" used to be one of those pulse-quickening words for me, but over the years, it began to lose some of its coronary-tightening qualities. I had always considered "lethargic" to be a rather ominous descriptor. But, people seem to apply the term to children who were merely sleepy, listless, or just plain unmotivated. It took me a decade or two of rushing to bedsides or opening the office in the middle of the night to see a "lethargic" child who turned out, in my vocabulary, to be just a bit "droopy" or unusually quiet but not seriously ill.

I found that to minimize the number of false alarms, I just needed to ask more questions to flesh out the child’s appearance and determine what had prompted the caller to use the "L" word. "Lethargy" seemed to mean too many different things to too many people to be of much use as a descriptor. Nonetheless, I still feel twinges of fear when I hear the word. When I encounter it in a nurse’s progress note, I always feel the need to counter it in my own note by providing a more specific description of the child’s condition.

A recent study in Pediatric Emergency Care (Webb, T. et al. 2014;30: 151-6) mirrors my experience with "lethargy." In a retrospective chart review of 272 patients aged 0-6 months, the investigators found that only 12.5% of the children who were described as having poor feeding or lethargy had a condition that required intervention. Infants who were feverish, hypothermic, or less than 35 weeks’ gestation were excluded from the study. However, infants that were described as appearing "ill" were much more likely to require intervention.

So what does a pediatrician mean when she or he describes a child as "ill looking" or "sick looking?" That is the $64,000 question (actually $560,000 in today’s dollars). We could generate a list that include abnormal vital signs, a spectrum of colors from pale to blue, and some neurologic observations, but a child looking sick or ill (and here I mean sick at level of needing immediate attention and probably intervention) is a gestalt.

Knowing when a child is seriously ill is a skill that is difficult to teach and can only come with seeing scores, and scores, and scores of children with a variety of conditions. The physician in training may not necessarily be directly involved with the care of those children, but she or he should have been close enough long enough to feel, see, smell, and hear what is going on. House officers and students should be encouraged to seek out as many of these chances to see sick and well children as they can to sharpen this skill. A mentor may help by pointing out a certain finding or collection of findings that are useful in forming the impression that this is a seriously ill child. But, it is a mistake to focus on one or two observations and not to emphasize the total picture. The ability to correctly determine that a child is desperately ill requires that the physician be able to see the trees, but not ignore the forest.

While most parents have that special sense when things are terribly wrong, we have all witnessed tragic situations when a focus on the thermometer has blurred the bigger picture that the child is desperately ill. Unfortunately, I have seen cases when a physician or nurse has been similarly deceived by a normal vital sign or laboratory result and failed to step back, look at the child, and say to themselves, "But, this child looks sick."

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].

Pediatricians tend to be rather easygoing or at least to survive they must learn to appear calm. It is our job to keep our heads when all about us are losing theirs. However, there are certain words that can rattle even the most apparently unflappable pediatrician. For example, when a parent or nurse says a child is "grunting," I begin to get twitchy. I drop everything I’m doing, and that child receives all of my professional attention.

"Lethargic" used to be one of those pulse-quickening words for me, but over the years, it began to lose some of its coronary-tightening qualities. I had always considered "lethargic" to be a rather ominous descriptor. But, people seem to apply the term to children who were merely sleepy, listless, or just plain unmotivated. It took me a decade or two of rushing to bedsides or opening the office in the middle of the night to see a "lethargic" child who turned out, in my vocabulary, to be just a bit "droopy" or unusually quiet but not seriously ill.

I found that to minimize the number of false alarms, I just needed to ask more questions to flesh out the child’s appearance and determine what had prompted the caller to use the "L" word. "Lethargy" seemed to mean too many different things to too many people to be of much use as a descriptor. Nonetheless, I still feel twinges of fear when I hear the word. When I encounter it in a nurse’s progress note, I always feel the need to counter it in my own note by providing a more specific description of the child’s condition.

A recent study in Pediatric Emergency Care (Webb, T. et al. 2014;30: 151-6) mirrors my experience with "lethargy." In a retrospective chart review of 272 patients aged 0-6 months, the investigators found that only 12.5% of the children who were described as having poor feeding or lethargy had a condition that required intervention. Infants who were feverish, hypothermic, or less than 35 weeks’ gestation were excluded from the study. However, infants that were described as appearing "ill" were much more likely to require intervention.

So what does a pediatrician mean when she or he describes a child as "ill looking" or "sick looking?" That is the $64,000 question (actually $560,000 in today’s dollars). We could generate a list that include abnormal vital signs, a spectrum of colors from pale to blue, and some neurologic observations, but a child looking sick or ill (and here I mean sick at level of needing immediate attention and probably intervention) is a gestalt.

Knowing when a child is seriously ill is a skill that is difficult to teach and can only come with seeing scores, and scores, and scores of children with a variety of conditions. The physician in training may not necessarily be directly involved with the care of those children, but she or he should have been close enough long enough to feel, see, smell, and hear what is going on. House officers and students should be encouraged to seek out as many of these chances to see sick and well children as they can to sharpen this skill. A mentor may help by pointing out a certain finding or collection of findings that are useful in forming the impression that this is a seriously ill child. But, it is a mistake to focus on one or two observations and not to emphasize the total picture. The ability to correctly determine that a child is desperately ill requires that the physician be able to see the trees, but not ignore the forest.

While most parents have that special sense when things are terribly wrong, we have all witnessed tragic situations when a focus on the thermometer has blurred the bigger picture that the child is desperately ill. Unfortunately, I have seen cases when a physician or nurse has been similarly deceived by a normal vital sign or laboratory result and failed to step back, look at the child, and say to themselves, "But, this child looks sick."

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].