William G. Wilkoff, MD

Every so often I have been offered an opportunity to donate a week or 2 of my pediatric skills in an underdeveloped country, mostly in Central and South America, but occasionally in Africa. The offers sound exciting, but the din from a chaotic waiting room and exam rooms overflowing with sick children made it difficult to imagine extracting myself long enough to take advantage of those opportunities to practice abroad. With weekends off in short supply, I would always fall back on the flimsy excuse that charity begins at home. I am embarrassed to admit that in those preretirement days, time was money. The lost income during my time away and the cost of the airfare left me feeling a bit uneasy. But now, I have been made redundant, and time and money have been disconnected. Time is just time, and I have enough to share.

So, when I received an e-mail a few days ago, offering me the chance to work with children in Central America, I had time to consider it seriously. I would be expected to pay about $700 in room and board and, of course, purchase my own plane ticket. I would be working with a group of other North American physicians and a few translators to supplement a full-time physician.

It sounded appealing. By March, I would have had enough cross-country skiing and snow shoveling and would be ready to enjoy some warm weather. And, of course, the chance to work with children again would make it a real feel-good experience.

I began to envision what my days in the tropics would be like. Shorts and a loose-fitting flowered shirt, I could wear those new sandals I bought at that end-of-summer sale last year. But, what exactly would I be doing? I doubt there would be many, "Does my child have attention-deficit/hyperactivity disorder?" discussions. Was I going to see any children with functional abdominal pain? I’m good at that, particularly if it is triggered by school anxiety. Although I’m pretty skillful with an otoscope and a stethoscope, the skills that have become the sharpest over the last 4 decades are those of taking a targeted history and then sorting out the red herrings. Most of the time, I have arrived at the diagnosis before I even put the stethoscope in my ears.

As I considered what I have become, I realized that my skills are primarily language based, and I don’t speak Spanish. Of course, there would be translators, but in the short space of a week, would the translator and I understand each other well to make sure that my questions and the patients’ answers were properly nuanced. Like all experienced physicians, I also read body language, but I have noticed that different cultures speak body language with accents that I sometimes don’t understand. I’m comfortable diagnosing the common dermatologic problems in North America, but I fear that just as I wouldn’t recognize the tropical birds, I would need a serious field guide to the rashes of Central America.

Having listened to other physicians who have been on similar missions, I am sure that I would enjoy myself. I would see new flora and fauna, eat some different foods, and meet some wonderful people. I have no doubt that everyone would make me feel appreciated.

But, then my thoughts drifted back to money, the damn money. I now have enough time and money so that I can easily afford the adventure. But, if my primary goal was to improve the health of disadvantaged children, would my thousand dollars do more good if I wrote a check for a refrigerator to store vaccines or a pump and filter to make safe water more available? How valuable a gift is a week of my language-challenged skills going to be?

I have time to decide, and I will talk to some physicians who have made the trip before. If I decide to go, I’ll send you all a note from the tropics to let you know how it went.

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 pdnews@ frontlinemedcom.com.

Every so often I have been offered an opportunity to donate a week or 2 of my pediatric skills in an underdeveloped country, mostly in Central and South America, but occasionally in Africa. The offers sound exciting, but the din from a chaotic waiting room and exam rooms overflowing with sick children made it difficult to imagine extracting myself long enough to take advantage of those opportunities to practice abroad. With weekends off in short supply, I would always fall back on the flimsy excuse that charity begins at home. I am embarrassed to admit that in those preretirement days, time was money. The lost income during my time away and the cost of the airfare left me feeling a bit uneasy. But now, I have been made redundant, and time and money have been disconnected. Time is just time, and I have enough to share.

So, when I received an e-mail a few days ago, offering me the chance to work with children in Central America, I had time to consider it seriously. I would be expected to pay about $700 in room and board and, of course, purchase my own plane ticket. I would be working with a group of other North American physicians and a few translators to supplement a full-time physician.

It sounded appealing. By March, I would have had enough cross-country skiing and snow shoveling and would be ready to enjoy some warm weather. And, of course, the chance to work with children again would make it a real feel-good experience.

I began to envision what my days in the tropics would be like. Shorts and a loose-fitting flowered shirt, I could wear those new sandals I bought at that end-of-summer sale last year. But, what exactly would I be doing? I doubt there would be many, "Does my child have attention-deficit/hyperactivity disorder?" discussions. Was I going to see any children with functional abdominal pain? I’m good at that, particularly if it is triggered by school anxiety. Although I’m pretty skillful with an otoscope and a stethoscope, the skills that have become the sharpest over the last 4 decades are those of taking a targeted history and then sorting out the red herrings. Most of the time, I have arrived at the diagnosis before I even put the stethoscope in my ears.

As I considered what I have become, I realized that my skills are primarily language based, and I don’t speak Spanish. Of course, there would be translators, but in the short space of a week, would the translator and I understand each other well to make sure that my questions and the patients’ answers were properly nuanced. Like all experienced physicians, I also read body language, but I have noticed that different cultures speak body language with accents that I sometimes don’t understand. I’m comfortable diagnosing the common dermatologic problems in North America, but I fear that just as I wouldn’t recognize the tropical birds, I would need a serious field guide to the rashes of Central America.

Having listened to other physicians who have been on similar missions, I am sure that I would enjoy myself. I would see new flora and fauna, eat some different foods, and meet some wonderful people. I have no doubt that everyone would make me feel appreciated.

But, then my thoughts drifted back to money, the damn money. I now have enough time and money so that I can easily afford the adventure. But, if my primary goal was to improve the health of disadvantaged children, would my thousand dollars do more good if I wrote a check for a refrigerator to store vaccines or a pump and filter to make safe water more available? How valuable a gift is a week of my language-challenged skills going to be?

I have time to decide, and I will talk to some physicians who have made the trip before. If I decide to go, I’ll send you all a note from the tropics to let you know how it went.

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 pdnews@ frontlinemedcom.com.

Every so often I have been offered an opportunity to donate a week or 2 of my pediatric skills in an underdeveloped country, mostly in Central and South America, but occasionally in Africa. The offers sound exciting, but the din from a chaotic waiting room and exam rooms overflowing with sick children made it difficult to imagine extracting myself long enough to take advantage of those opportunities to practice abroad. With weekends off in short supply, I would always fall back on the flimsy excuse that charity begins at home. I am embarrassed to admit that in those preretirement days, time was money. The lost income during my time away and the cost of the airfare left me feeling a bit uneasy. But now, I have been made redundant, and time and money have been disconnected. Time is just time, and I have enough to share.

So, when I received an e-mail a few days ago, offering me the chance to work with children in Central America, I had time to consider it seriously. I would be expected to pay about $700 in room and board and, of course, purchase my own plane ticket. I would be working with a group of other North American physicians and a few translators to supplement a full-time physician.

It sounded appealing. By March, I would have had enough cross-country skiing and snow shoveling and would be ready to enjoy some warm weather. And, of course, the chance to work with children again would make it a real feel-good experience.

I began to envision what my days in the tropics would be like. Shorts and a loose-fitting flowered shirt, I could wear those new sandals I bought at that end-of-summer sale last year. But, what exactly would I be doing? I doubt there would be many, "Does my child have attention-deficit/hyperactivity disorder?" discussions. Was I going to see any children with functional abdominal pain? I’m good at that, particularly if it is triggered by school anxiety. Although I’m pretty skillful with an otoscope and a stethoscope, the skills that have become the sharpest over the last 4 decades are those of taking a targeted history and then sorting out the red herrings. Most of the time, I have arrived at the diagnosis before I even put the stethoscope in my ears.

As I considered what I have become, I realized that my skills are primarily language based, and I don’t speak Spanish. Of course, there would be translators, but in the short space of a week, would the translator and I understand each other well to make sure that my questions and the patients’ answers were properly nuanced. Like all experienced physicians, I also read body language, but I have noticed that different cultures speak body language with accents that I sometimes don’t understand. I’m comfortable diagnosing the common dermatologic problems in North America, but I fear that just as I wouldn’t recognize the tropical birds, I would need a serious field guide to the rashes of Central America.

Having listened to other physicians who have been on similar missions, I am sure that I would enjoy myself. I would see new flora and fauna, eat some different foods, and meet some wonderful people. I have no doubt that everyone would make me feel appreciated.

But, then my thoughts drifted back to money, the damn money. I now have enough time and money so that I can easily afford the adventure. But, if my primary goal was to improve the health of disadvantaged children, would my thousand dollars do more good if I wrote a check for a refrigerator to store vaccines or a pump and filter to make safe water more available? How valuable a gift is a week of my language-challenged skills going to be?

I have time to decide, and I will talk to some physicians who have made the trip before. If I decide to go, I’ll send you all a note from the tropics to let you know how it went.

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 pdnews@ frontlinemedcom.com.

In the flurry of responses I received in response to my column, "Heresy," about annual checkups on older children (November 2013, p. 14) was an e-mail from a pediatrician who observed that while she doesn’t advocate annual checkups on older children, she tries to see her patients for as many of their visits as she can. I suspect that whether we are believers in annual checkups or not, we all share her goal.

And why is that? It’s because we feel that if a family has chosen us to be their pediatrician, availability is something we owe them as part of that unwritten contract. But it’s also because we realize a doctor-patient relationship is not created in a day and certainly not in a half-hour well-child visit. It is an evolving process that is the summation of multiple, sometimes very brief, encounters: a sore throat here, a sprained ankle there, maybe even a chance encounter in the express checkout line at the grocery store. Over time, repeated visits foster a familiarity that allows the physician to make more accurate diagnoses and suggest the most effective therapies.

Hopefully, familiarity also breeds confidence and comfort in the patient and family. One occasionally hears the complaint that "in a small town everyone knows your business," but most people prefer the comfort that comes from repeated encounters with the same cashier, hairdresser, and crossing guard, whether these frequent meetings occur here on the rural coast of Maine or in a four-square block neighborhood in a large city.

But let’s be honest, how good are we at providing that kind of continuity in our offices? During the 10 years I was in solo practice, it was easy. My patients could count on seeing me 94% of the time. However, for a variety of good and bad reasons, solo practice is no longer sustainable. It certainly wasn’t for me. Group practice is the reality, and groups are growing larger.

The shared coverage group model by definition means that sometimes our patients will not be seeing their chosen physician as often as they would in the solo practice model. But I worry that many practices aren’t doing enough to preserve continuity. How often do you hear people complain, "I never get to see my own doctor" or "Every time I go in, I see someone different?"

How continuity-friendly is your group and your appointment schedule? Do you leave enough same-day slots to maximize the chances that your patients will get to see you when they call with problems? Is the mix of sick and well visits seasonally adjusted to match the ebb and flow of illness in the community? Are the receptionists and nurses committed to having patients see their own physicians?

Another trend that has challenged the limits of continuity is the shift toward more physicians working less than full time. Driven by the struggle to balance our personal and professional lives, many of us put in fewer hours in the office, making it more likely that our patients will be seeing another provider. I suspect that some part-time work schedules are more continuity friendly than others. For example, do we know whether a pediatrician who works four 5-hour days is more available to his or her patients than one who works three 7-hour days? If we believe that continuity is important (and the patients certainly do) then that is the kind of question we should be asking ourselves.

With the more widespread adoption of electronic medical records, there may come the day when we will be able to promise our patients, "We are all on the same page." However, I suspect the patients will continue to complain: "Great, but I would feel much better if I could see the same face more often when I come into the office."

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 flurry of responses I received in response to my column, "Heresy," about annual checkups on older children (November 2013, p. 14) was an e-mail from a pediatrician who observed that while she doesn’t advocate annual checkups on older children, she tries to see her patients for as many of their visits as she can. I suspect that whether we are believers in annual checkups or not, we all share her goal.

And why is that? It’s because we feel that if a family has chosen us to be their pediatrician, availability is something we owe them as part of that unwritten contract. But it’s also because we realize a doctor-patient relationship is not created in a day and certainly not in a half-hour well-child visit. It is an evolving process that is the summation of multiple, sometimes very brief, encounters: a sore throat here, a sprained ankle there, maybe even a chance encounter in the express checkout line at the grocery store. Over time, repeated visits foster a familiarity that allows the physician to make more accurate diagnoses and suggest the most effective therapies.

Hopefully, familiarity also breeds confidence and comfort in the patient and family. One occasionally hears the complaint that "in a small town everyone knows your business," but most people prefer the comfort that comes from repeated encounters with the same cashier, hairdresser, and crossing guard, whether these frequent meetings occur here on the rural coast of Maine or in a four-square block neighborhood in a large city.

But let’s be honest, how good are we at providing that kind of continuity in our offices? During the 10 years I was in solo practice, it was easy. My patients could count on seeing me 94% of the time. However, for a variety of good and bad reasons, solo practice is no longer sustainable. It certainly wasn’t for me. Group practice is the reality, and groups are growing larger.

The shared coverage group model by definition means that sometimes our patients will not be seeing their chosen physician as often as they would in the solo practice model. But I worry that many practices aren’t doing enough to preserve continuity. How often do you hear people complain, "I never get to see my own doctor" or "Every time I go in, I see someone different?"

How continuity-friendly is your group and your appointment schedule? Do you leave enough same-day slots to maximize the chances that your patients will get to see you when they call with problems? Is the mix of sick and well visits seasonally adjusted to match the ebb and flow of illness in the community? Are the receptionists and nurses committed to having patients see their own physicians?

Another trend that has challenged the limits of continuity is the shift toward more physicians working less than full time. Driven by the struggle to balance our personal and professional lives, many of us put in fewer hours in the office, making it more likely that our patients will be seeing another provider. I suspect that some part-time work schedules are more continuity friendly than others. For example, do we know whether a pediatrician who works four 5-hour days is more available to his or her patients than one who works three 7-hour days? If we believe that continuity is important (and the patients certainly do) then that is the kind of question we should be asking ourselves.

With the more widespread adoption of electronic medical records, there may come the day when we will be able to promise our patients, "We are all on the same page." However, I suspect the patients will continue to complain: "Great, but I would feel much better if I could see the same face more often when I come into the office."

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 flurry of responses I received in response to my column, "Heresy," about annual checkups on older children (November 2013, p. 14) was an e-mail from a pediatrician who observed that while she doesn’t advocate annual checkups on older children, she tries to see her patients for as many of their visits as she can. I suspect that whether we are believers in annual checkups or not, we all share her goal.

And why is that? It’s because we feel that if a family has chosen us to be their pediatrician, availability is something we owe them as part of that unwritten contract. But it’s also because we realize a doctor-patient relationship is not created in a day and certainly not in a half-hour well-child visit. It is an evolving process that is the summation of multiple, sometimes very brief, encounters: a sore throat here, a sprained ankle there, maybe even a chance encounter in the express checkout line at the grocery store. Over time, repeated visits foster a familiarity that allows the physician to make more accurate diagnoses and suggest the most effective therapies.

Hopefully, familiarity also breeds confidence and comfort in the patient and family. One occasionally hears the complaint that "in a small town everyone knows your business," but most people prefer the comfort that comes from repeated encounters with the same cashier, hairdresser, and crossing guard, whether these frequent meetings occur here on the rural coast of Maine or in a four-square block neighborhood in a large city.

But let’s be honest, how good are we at providing that kind of continuity in our offices? During the 10 years I was in solo practice, it was easy. My patients could count on seeing me 94% of the time. However, for a variety of good and bad reasons, solo practice is no longer sustainable. It certainly wasn’t for me. Group practice is the reality, and groups are growing larger.

The shared coverage group model by definition means that sometimes our patients will not be seeing their chosen physician as often as they would in the solo practice model. But I worry that many practices aren’t doing enough to preserve continuity. How often do you hear people complain, "I never get to see my own doctor" or "Every time I go in, I see someone different?"

How continuity-friendly is your group and your appointment schedule? Do you leave enough same-day slots to maximize the chances that your patients will get to see you when they call with problems? Is the mix of sick and well visits seasonally adjusted to match the ebb and flow of illness in the community? Are the receptionists and nurses committed to having patients see their own physicians?

Another trend that has challenged the limits of continuity is the shift toward more physicians working less than full time. Driven by the struggle to balance our personal and professional lives, many of us put in fewer hours in the office, making it more likely that our patients will be seeing another provider. I suspect that some part-time work schedules are more continuity friendly than others. For example, do we know whether a pediatrician who works four 5-hour days is more available to his or her patients than one who works three 7-hour days? If we believe that continuity is important (and the patients certainly do) then that is the kind of question we should be asking ourselves.

With the more widespread adoption of electronic medical records, there may come the day when we will be able to promise our patients, "We are all on the same page." However, I suspect the patients will continue to complain: "Great, but I would feel much better if I could see the same face more often when I come into the office."

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].

For the last decade or two, a higher percentage of my patients were adequately immunized than were my younger partners’ patients. The gap wasn’t always dramatic, but it was consistent. We all thought this phenomenon was primarily based on a physician selection bias. My age and gender seemed to attract families who tended to be more traditional in their parenting style and predisposed to accepting the party line on immunizations. The families who were more liberal and skeptical about immunization sought out my younger female partners.

Although our suspicions of causation were for the most part correct, an article in the December 2013 issue of Pediatrics (132:1037-46) suggests that how I presented the immunization opportunities may have contributed to my relative success. These investigators observed more than 100 vaccine discussions by 16 providers in nine practices. They categorized the providers’ formats as being presumptive ("Well, we have to do some shots") or participatory ("What do you want to do about shots?").

The researchers found that parents had a "significantly higher odds of resisting vaccine recommendations if the provider used a participatory rather than a presumptive format." We shouldn’t be surprised at this observation. If you present an issue as a "can do" instead of a "will do" situation, hesitant parents are more likely to say, "Won’t do."

However, I am surprised how many providers presented the issue of immunization in what might be called a shared-decision format. But I guess it is just another example of how the role of physicians has changed in the past few generations. For the first half of the last century, most physicians could be characterized as paternalistic. They were accustomed to telling patients what to do. The patient brought the doctor a complaint. The doctor would provide a diagnosis and dictate what the patient should do to get better. End of discussion.

I’m not exactly sure of all the forces that have created the shift, but it became clear that although medical knowledge was expanding exponentially, doctors still didn’t have all the answers. And, in many situations, the outcome was better when the patient participated in the decisions about his or her care.

In pediatrics, the use of a shared-decision, participatory format for managing otitis media has been successful in reducing the amount of antibiotics prescribed. However, this new study makes it clear that welcoming the patient or parents into the decision-making process may not always be the best strategy. My direct, no-nonsense let’s-get-it-done style helped me to achieve a better immunization record than the softer tell-me-what-you-think approach of my partners.

The problem is that one style doesn’t fit every clinical situation. To be a successful physician, one must be able to adjust one’s style to match the diagnosis, personality, and emotional needs of the patient and the myriad of societal and economic features that make up the landscape of the real world. I admit that I haven’t always achieved the perfect match. Although my basic inclination is to use a presumptive approach, I found over the years that I tended to lean more toward a participatory format. It just seemed to work better. But, when it came to immunizations, I wanted to give families the best chance of avoiding a bad decision.

Although most of us would feel uncomfortable with having our clinical encounters videotaped, the results of this study suggest that we should be examining more closely what we say to patients and how we say it. Our success as physicians depends on it.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He continues to monitor and comment on anything pediatric. E-mail him at [email protected].

For the last decade or two, a higher percentage of my patients were adequately immunized than were my younger partners’ patients. The gap wasn’t always dramatic, but it was consistent. We all thought this phenomenon was primarily based on a physician selection bias. My age and gender seemed to attract families who tended to be more traditional in their parenting style and predisposed to accepting the party line on immunizations. The families who were more liberal and skeptical about immunization sought out my younger female partners.

Although our suspicions of causation were for the most part correct, an article in the December 2013 issue of Pediatrics (132:1037-46) suggests that how I presented the immunization opportunities may have contributed to my relative success. These investigators observed more than 100 vaccine discussions by 16 providers in nine practices. They categorized the providers’ formats as being presumptive ("Well, we have to do some shots") or participatory ("What do you want to do about shots?").

The researchers found that parents had a "significantly higher odds of resisting vaccine recommendations if the provider used a participatory rather than a presumptive format." We shouldn’t be surprised at this observation. If you present an issue as a "can do" instead of a "will do" situation, hesitant parents are more likely to say, "Won’t do."

However, I am surprised how many providers presented the issue of immunization in what might be called a shared-decision format. But I guess it is just another example of how the role of physicians has changed in the past few generations. For the first half of the last century, most physicians could be characterized as paternalistic. They were accustomed to telling patients what to do. The patient brought the doctor a complaint. The doctor would provide a diagnosis and dictate what the patient should do to get better. End of discussion.

I’m not exactly sure of all the forces that have created the shift, but it became clear that although medical knowledge was expanding exponentially, doctors still didn’t have all the answers. And, in many situations, the outcome was better when the patient participated in the decisions about his or her care.

In pediatrics, the use of a shared-decision, participatory format for managing otitis media has been successful in reducing the amount of antibiotics prescribed. However, this new study makes it clear that welcoming the patient or parents into the decision-making process may not always be the best strategy. My direct, no-nonsense let’s-get-it-done style helped me to achieve a better immunization record than the softer tell-me-what-you-think approach of my partners.

The problem is that one style doesn’t fit every clinical situation. To be a successful physician, one must be able to adjust one’s style to match the diagnosis, personality, and emotional needs of the patient and the myriad of societal and economic features that make up the landscape of the real world. I admit that I haven’t always achieved the perfect match. Although my basic inclination is to use a presumptive approach, I found over the years that I tended to lean more toward a participatory format. It just seemed to work better. But, when it came to immunizations, I wanted to give families the best chance of avoiding a bad decision.

Although most of us would feel uncomfortable with having our clinical encounters videotaped, the results of this study suggest that we should be examining more closely what we say to patients and how we say it. Our success as physicians depends on it.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He continues to monitor and comment on anything pediatric. E-mail him at [email protected].

For the last decade or two, a higher percentage of my patients were adequately immunized than were my younger partners’ patients. The gap wasn’t always dramatic, but it was consistent. We all thought this phenomenon was primarily based on a physician selection bias. My age and gender seemed to attract families who tended to be more traditional in their parenting style and predisposed to accepting the party line on immunizations. The families who were more liberal and skeptical about immunization sought out my younger female partners.

Although our suspicions of causation were for the most part correct, an article in the December 2013 issue of Pediatrics (132:1037-46) suggests that how I presented the immunization opportunities may have contributed to my relative success. These investigators observed more than 100 vaccine discussions by 16 providers in nine practices. They categorized the providers’ formats as being presumptive ("Well, we have to do some shots") or participatory ("What do you want to do about shots?").

The researchers found that parents had a "significantly higher odds of resisting vaccine recommendations if the provider used a participatory rather than a presumptive format." We shouldn’t be surprised at this observation. If you present an issue as a "can do" instead of a "will do" situation, hesitant parents are more likely to say, "Won’t do."

However, I am surprised how many providers presented the issue of immunization in what might be called a shared-decision format. But I guess it is just another example of how the role of physicians has changed in the past few generations. For the first half of the last century, most physicians could be characterized as paternalistic. They were accustomed to telling patients what to do. The patient brought the doctor a complaint. The doctor would provide a diagnosis and dictate what the patient should do to get better. End of discussion.

I’m not exactly sure of all the forces that have created the shift, but it became clear that although medical knowledge was expanding exponentially, doctors still didn’t have all the answers. And, in many situations, the outcome was better when the patient participated in the decisions about his or her care.

In pediatrics, the use of a shared-decision, participatory format for managing otitis media has been successful in reducing the amount of antibiotics prescribed. However, this new study makes it clear that welcoming the patient or parents into the decision-making process may not always be the best strategy. My direct, no-nonsense let’s-get-it-done style helped me to achieve a better immunization record than the softer tell-me-what-you-think approach of my partners.

The problem is that one style doesn’t fit every clinical situation. To be a successful physician, one must be able to adjust one’s style to match the diagnosis, personality, and emotional needs of the patient and the myriad of societal and economic features that make up the landscape of the real world. I admit that I haven’t always achieved the perfect match. Although my basic inclination is to use a presumptive approach, I found over the years that I tended to lean more toward a participatory format. It just seemed to work better. But, when it came to immunizations, I wanted to give families the best chance of avoiding a bad decision.

Although most of us would feel uncomfortable with having our clinical encounters videotaped, the results of this study suggest that we should be examining more closely what we say to patients and how we say it. Our success as physicians depends on it.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He continues to monitor and comment on anything pediatric. E-mail him at [email protected].

There were days when I really didn’t like doing annual checkups, in fact, sometimes I hated it. I always enjoyed talking with the kids who wanted to engage, but I would wonder if the whole preventive care thing was just a bunch of bunk. There, I said it.

Stand back because at any moment lightning may strike me for coming out as a heretic. We pediatricians are supposed to be the preventive care standard-bearers. We are the immunizers. We are the growth-chart plotters. We are the ones toiling at ground zero, hoping to steer our little patients toward the paths of a healthy adulthood.

But, are annual checkups on well children really making a difference? The Society of General Internal Medicine has recently released a list of Five Things Physicians and Patients Should Question (Choose Wisely, an initiative of the ABIM Foundation). No. 2 on the list is "Don’t perform routine general health checks on asymptomatic adults." The authors observe that "annual visit have not shown to be effective in reducing morbidity, mortality, or hospitalization." Could the same claim be made for annual checkups on asymptomatic older children? Has anyone had the courage to ask the question?

Take a deep breath. Please don’t call the American Academy of Pediatrics and demand that they revoke my emeritus membership. Let me do some quick backpedaling. Yes, there were days when doing checkups on apparently healthy tight-lipped 10-year-olds who would rather be elsewhere made me feel worthless. But, children aren’t adults. Preverbal children can’t really be said to have "no complaints." Up to the point that a child has successfully negotiated kindergarten and first grade, they are dependent on us to find out if there is anything wrong with them. Annual or more often checkups makes sense.

But, for the school-age child who is growing well and doesn’t have any chronic conditions or genetic predispositions, do annual physical exams make sense? Let’s be honest. How many novel physical findings did you make last year in the course of doing hundreds of well-child exams on children without complaints. Of course, you found some concerning growth curves and a few elevated blood pressures. But wouldn’t a complete set of vital signs done at school been just as effective a screening device?

You might ask, "What about immunizations?" Couldn’t the school be a more efficient place to administer them? You might also question whether curtailing annual checkups might remove the office as a critical venue for health education. I think we have to be realistic here and admit that television, the Internet, and social medial sites are probably more powerful communicators.

Wouldn’t being more selective about doing annual exams narrow an important income stream for physicians? Just listen to the receptionists and nurse triage specialists in the average office struggle to deflect calls from concerned parents who would like to have their children seen promptly. Pediatricians could easily fill the appointment slots vacated by older children having needless checkups with the sick and the worried well who need and/or want to be seen. Two of the most frequent complaints we hear about physicians is that it’s "impossible" to get in for an appointment, and we don’t spend enough time with the patients.

As the ill conceived and poorly administered push to adopt electronic health records gobbles up more and more of the time physicians can spend with patients, we are going to have to be smarter and thoughtful about who we see. When there is a shortage of lubricant, the squeaky wheel should get the grease. The other three wheels are rolling along just fine.

If any of you have harbored the same heretical thoughts, please share them, anonymously if you choose.

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].

There were days when I really didn’t like doing annual checkups, in fact, sometimes I hated it. I always enjoyed talking with the kids who wanted to engage, but I would wonder if the whole preventive care thing was just a bunch of bunk. There, I said it.

Stand back because at any moment lightning may strike me for coming out as a heretic. We pediatricians are supposed to be the preventive care standard-bearers. We are the immunizers. We are the growth-chart plotters. We are the ones toiling at ground zero, hoping to steer our little patients toward the paths of a healthy adulthood.

But, are annual checkups on well children really making a difference? The Society of General Internal Medicine has recently released a list of Five Things Physicians and Patients Should Question (Choose Wisely, an initiative of the ABIM Foundation). No. 2 on the list is "Don’t perform routine general health checks on asymptomatic adults." The authors observe that "annual visit have not shown to be effective in reducing morbidity, mortality, or hospitalization." Could the same claim be made for annual checkups on asymptomatic older children? Has anyone had the courage to ask the question?

Take a deep breath. Please don’t call the American Academy of Pediatrics and demand that they revoke my emeritus membership. Let me do some quick backpedaling. Yes, there were days when doing checkups on apparently healthy tight-lipped 10-year-olds who would rather be elsewhere made me feel worthless. But, children aren’t adults. Preverbal children can’t really be said to have "no complaints." Up to the point that a child has successfully negotiated kindergarten and first grade, they are dependent on us to find out if there is anything wrong with them. Annual or more often checkups makes sense.

But, for the school-age child who is growing well and doesn’t have any chronic conditions or genetic predispositions, do annual physical exams make sense? Let’s be honest. How many novel physical findings did you make last year in the course of doing hundreds of well-child exams on children without complaints. Of course, you found some concerning growth curves and a few elevated blood pressures. But wouldn’t a complete set of vital signs done at school been just as effective a screening device?

You might ask, "What about immunizations?" Couldn’t the school be a more efficient place to administer them? You might also question whether curtailing annual checkups might remove the office as a critical venue for health education. I think we have to be realistic here and admit that television, the Internet, and social medial sites are probably more powerful communicators.

Wouldn’t being more selective about doing annual exams narrow an important income stream for physicians? Just listen to the receptionists and nurse triage specialists in the average office struggle to deflect calls from concerned parents who would like to have their children seen promptly. Pediatricians could easily fill the appointment slots vacated by older children having needless checkups with the sick and the worried well who need and/or want to be seen. Two of the most frequent complaints we hear about physicians is that it’s "impossible" to get in for an appointment, and we don’t spend enough time with the patients.

As the ill conceived and poorly administered push to adopt electronic health records gobbles up more and more of the time physicians can spend with patients, we are going to have to be smarter and thoughtful about who we see. When there is a shortage of lubricant, the squeaky wheel should get the grease. The other three wheels are rolling along just fine.

If any of you have harbored the same heretical thoughts, please share them, anonymously if you choose.

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].

There were days when I really didn’t like doing annual checkups, in fact, sometimes I hated it. I always enjoyed talking with the kids who wanted to engage, but I would wonder if the whole preventive care thing was just a bunch of bunk. There, I said it.

Stand back because at any moment lightning may strike me for coming out as a heretic. We pediatricians are supposed to be the preventive care standard-bearers. We are the immunizers. We are the growth-chart plotters. We are the ones toiling at ground zero, hoping to steer our little patients toward the paths of a healthy adulthood.

But, are annual checkups on well children really making a difference? The Society of General Internal Medicine has recently released a list of Five Things Physicians and Patients Should Question (Choose Wisely, an initiative of the ABIM Foundation). No. 2 on the list is "Don’t perform routine general health checks on asymptomatic adults." The authors observe that "annual visit have not shown to be effective in reducing morbidity, mortality, or hospitalization." Could the same claim be made for annual checkups on asymptomatic older children? Has anyone had the courage to ask the question?

Take a deep breath. Please don’t call the American Academy of Pediatrics and demand that they revoke my emeritus membership. Let me do some quick backpedaling. Yes, there were days when doing checkups on apparently healthy tight-lipped 10-year-olds who would rather be elsewhere made me feel worthless. But, children aren’t adults. Preverbal children can’t really be said to have "no complaints." Up to the point that a child has successfully negotiated kindergarten and first grade, they are dependent on us to find out if there is anything wrong with them. Annual or more often checkups makes sense.

But, for the school-age child who is growing well and doesn’t have any chronic conditions or genetic predispositions, do annual physical exams make sense? Let’s be honest. How many novel physical findings did you make last year in the course of doing hundreds of well-child exams on children without complaints. Of course, you found some concerning growth curves and a few elevated blood pressures. But wouldn’t a complete set of vital signs done at school been just as effective a screening device?

You might ask, "What about immunizations?" Couldn’t the school be a more efficient place to administer them? You might also question whether curtailing annual checkups might remove the office as a critical venue for health education. I think we have to be realistic here and admit that television, the Internet, and social medial sites are probably more powerful communicators.

Wouldn’t being more selective about doing annual exams narrow an important income stream for physicians? Just listen to the receptionists and nurse triage specialists in the average office struggle to deflect calls from concerned parents who would like to have their children seen promptly. Pediatricians could easily fill the appointment slots vacated by older children having needless checkups with the sick and the worried well who need and/or want to be seen. Two of the most frequent complaints we hear about physicians is that it’s "impossible" to get in for an appointment, and we don’t spend enough time with the patients.

As the ill conceived and poorly administered push to adopt electronic health records gobbles up more and more of the time physicians can spend with patients, we are going to have to be smarter and thoughtful about who we see. When there is a shortage of lubricant, the squeaky wheel should get the grease. The other three wheels are rolling along just fine.

If any of you have harbored the same heretical thoughts, please share them, anonymously if you choose.

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].

On Aug. 27, Dr. John Kennell died at the age of 91. I learned from his obituary in the New York Times that he was the guy who put maternal-infant bonding on the map. It was his observations as a neonatologist, when neonatology was in its infancy, that ended the common and unnatural practice of separating mother and infants for hours and in some sad cases even days, so that each could recover from the ordeal of an uncomplicated hospital childbirth.

In a book coauthored with Dr. Marshall Klaus in 1976 titled "Maternal-Infant Bonding," Dr. Kennell claimed that there was a critical period in the first few hours after delivery during which mothers were biochemically primed to form bonds with their infants. And, that these bonds were crucial for normal development. Over the next few decades, he nuanced his position. In fact, his most recent efforts were in support of doula care, which if poorly done could conceivably interfere with the bonding he had pioneered.

But, the damage was already done. At least two generations of parents still live in dread fear that they didn’t spend enough of the right kind of time with their newborns. For example, 2 years ago, I received a call from a friend whose daughter had recently delivered her second child by C-section. The baby was fine, but the mother nearly died of intrapartum group A beta-hemolytic sepsis. The ordeal included DIC [disseminated intravascular coagulation],multiorgan failure, and the partial amputation of a couple of digits.

Not surprisingly, this young woman was in no condition to interact with anyone for more than 2 weeks. The new grandmother’s call was prompted by the observation that now in the third week postpartum when her daughter was awake she seemed to have little interest in holding or nurturing the baby. And, she was more than willing to have nurses and family members do the hugging and cuddling.

I asked, "Is this about that bonding thing? If your daughter really wanted to have this baby, we could send her to Cleveland for 3 months and the two of them would still form a normal mother-daughter relationship." I could have added, "Let’s remember, we aren’t geese who will imprint on the first adult figure they see after hatching. Even if it is a 6-foot-tall researcher with a beard." This summer I got to meet this young woman and her daughter and could tell that the two made a beautifully adjusted dyad.

It is unfortunate that Dr. Kennell’s early work that was so critical to creating a more humane birthing experience had a dark side that sent a ripple of needless anxiety that still shakes parents 3 decades later. Tragically, there are cases of seriously disordered maternal-infant bonding so severe that they result in infanticide. But, in my experience these incidents are the result of a long or deep mental illness and are not caused by a few hours or days of separation immediately after birth.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected].

Updated: 10/8/2013

On Aug. 27, Dr. John Kennell died at the age of 91. I learned from his obituary in the New York Times that he was the guy who put maternal-infant bonding on the map. It was his observations as a neonatologist, when neonatology was in its infancy, that ended the common and unnatural practice of separating mother and infants for hours and in some sad cases even days, so that each could recover from the ordeal of an uncomplicated hospital childbirth.

In a book coauthored with Dr. Marshall Klaus in 1976 titled "Maternal-Infant Bonding," Dr. Kennell claimed that there was a critical period in the first few hours after delivery during which mothers were biochemically primed to form bonds with their infants. And, that these bonds were crucial for normal development. Over the next few decades, he nuanced his position. In fact, his most recent efforts were in support of doula care, which if poorly done could conceivably interfere with the bonding he had pioneered.

But, the damage was already done. At least two generations of parents still live in dread fear that they didn’t spend enough of the right kind of time with their newborns. For example, 2 years ago, I received a call from a friend whose daughter had recently delivered her second child by C-section. The baby was fine, but the mother nearly died of intrapartum group A beta-hemolytic sepsis. The ordeal included DIC [disseminated intravascular coagulation],multiorgan failure, and the partial amputation of a couple of digits.

Not surprisingly, this young woman was in no condition to interact with anyone for more than 2 weeks. The new grandmother’s call was prompted by the observation that now in the third week postpartum when her daughter was awake she seemed to have little interest in holding or nurturing the baby. And, she was more than willing to have nurses and family members do the hugging and cuddling.

I asked, "Is this about that bonding thing? If your daughter really wanted to have this baby, we could send her to Cleveland for 3 months and the two of them would still form a normal mother-daughter relationship." I could have added, "Let’s remember, we aren’t geese who will imprint on the first adult figure they see after hatching. Even if it is a 6-foot-tall researcher with a beard." This summer I got to meet this young woman and her daughter and could tell that the two made a beautifully adjusted dyad.

It is unfortunate that Dr. Kennell’s early work that was so critical to creating a more humane birthing experience had a dark side that sent a ripple of needless anxiety that still shakes parents 3 decades later. Tragically, there are cases of seriously disordered maternal-infant bonding so severe that they result in infanticide. But, in my experience these incidents are the result of a long or deep mental illness and are not caused by a few hours or days of separation immediately after birth.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected].

Updated: 10/8/2013

On Aug. 27, Dr. John Kennell died at the age of 91. I learned from his obituary in the New York Times that he was the guy who put maternal-infant bonding on the map. It was his observations as a neonatologist, when neonatology was in its infancy, that ended the common and unnatural practice of separating mother and infants for hours and in some sad cases even days, so that each could recover from the ordeal of an uncomplicated hospital childbirth.

In a book coauthored with Dr. Marshall Klaus in 1976 titled "Maternal-Infant Bonding," Dr. Kennell claimed that there was a critical period in the first few hours after delivery during which mothers were biochemically primed to form bonds with their infants. And, that these bonds were crucial for normal development. Over the next few decades, he nuanced his position. In fact, his most recent efforts were in support of doula care, which if poorly done could conceivably interfere with the bonding he had pioneered.

But, the damage was already done. At least two generations of parents still live in dread fear that they didn’t spend enough of the right kind of time with their newborns. For example, 2 years ago, I received a call from a friend whose daughter had recently delivered her second child by C-section. The baby was fine, but the mother nearly died of intrapartum group A beta-hemolytic sepsis. The ordeal included DIC [disseminated intravascular coagulation],multiorgan failure, and the partial amputation of a couple of digits.

Not surprisingly, this young woman was in no condition to interact with anyone for more than 2 weeks. The new grandmother’s call was prompted by the observation that now in the third week postpartum when her daughter was awake she seemed to have little interest in holding or nurturing the baby. And, she was more than willing to have nurses and family members do the hugging and cuddling.

I asked, "Is this about that bonding thing? If your daughter really wanted to have this baby, we could send her to Cleveland for 3 months and the two of them would still form a normal mother-daughter relationship." I could have added, "Let’s remember, we aren’t geese who will imprint on the first adult figure they see after hatching. Even if it is a 6-foot-tall researcher with a beard." This summer I got to meet this young woman and her daughter and could tell that the two made a beautifully adjusted dyad.

It is unfortunate that Dr. Kennell’s early work that was so critical to creating a more humane birthing experience had a dark side that sent a ripple of needless anxiety that still shakes parents 3 decades later. Tragically, there are cases of seriously disordered maternal-infant bonding so severe that they result in infanticide. But, in my experience these incidents are the result of a long or deep mental illness and are not caused by a few hours or days of separation immediately after birth.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected].

Updated: 10/8/2013

Most days, I feel that the Affordable Care Act’s negatives outweigh its positives, but I’m not quite ready to throw out the baby with the bathwater. For example, I recently discovered that the ACA requires that all insurance companies pay for breast pumps and lactation counseling. Great idea! But, then I learned that the law neither specifies the type of breast pump nor defines who qualifies as a trained provider of lactation counseling services (Breast-Feeding Services Lag Behind the Law, Catherine Saint Louis, New York Times, Sept. 30, 2013). It turns out that with rare exceptions, finding a lactation consultant who is approved by the insurance company and then securing payment are fraught with delays that are measured in days or weeks. Of course, these delays and snafus come during a critical window for breastfeeding success.

A recent study by Wagner et al. (Breastfeeding Concerns at 3 and 7 Days Postpartum and Feeding Status at 2 Months; Pediatrics 2013;132:e865-e75) reports the obvious. Maternal concerns about their infant’s feeding difficulties, breastfeeding pain, and milk quantity were associated with early cessation of breastfeeding, with peaks at 3 and 7 days postpartum. The fact is that even mothers who had a solid intent to nurse their babies for at least 2 months worry. They become upset if they perceive that their babies are struggling to feed, or if they suspect that the babies aren’t getting enough to eat. And, they are just as vulnerable to pain as everyone else.

These concerns and worries occur in a compressed time frame of very few days and are magnified by the sleep deprivation that accompanies most deliveries. The correct advice provided by compassionate lactation consultants (and here I include pediatricians) can be critical to breastfeeding success. But, it must be provided on a time scale that matches the tempo of the lactation process. Here I am talking about hours, not days.

Interestingly and sadly, the hospital where Ms. Wagner and her colleagues collected their data doesn’t seem to understand that time-sensitive urgency. The investigators report that lactation consultants are "generally available on the maternity unit 6 days per week." Heaven help the poor mother and infant who are struggling with a poor latch on that 7th day. And, what does "generally available" mean? Folks, a new mother’s breastfeeding concerns require intensive care. The nurses and doctors in an ICU just aren’t "generally available."

The researchers also postulate that the increase in adverse outcomes later in the first week postpartum may be because "there is often a gap between hospital and community lactation services." Really? There’s the problem in a nutshell. If we want more babies to be breastfed, we have to treat the support services as critical and time sensitive. We have done a pretty good job of convincing mothers that breastfeeding is the best way to feed their newborns. Now we have to acknowledge their concerns and support them with quality advice 24/7.

Medical homes must function like homes. Your parents may have turned the lights out at 10:00 p.m., but they didn’t leave you alone and go to a motel for the night. To achieve the kind of seamless support net that new mothers need and deserve, pediatricians need to learn more about giving lactation advice themselves. They need to join with lactation consultants with whom they feel comfortable to provide 24/7 phone support and face-to-face visits on a 365/365 schedule.

The ACA appears to be offering us the opportunity to take breastfeeding support seriously. Obviously, it has some rough edges at this point. But, let’s take advantage of this chance by seeing that the support for our patients is provided in a time frame that matches the biology of breastfeeding.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected].

Updated: 10/8/2013

Most days, I feel that the Affordable Care Act’s negatives outweigh its positives, but I’m not quite ready to throw out the baby with the bathwater. For example, I recently discovered that the ACA requires that all insurance companies pay for breast pumps and lactation counseling. Great idea! But, then I learned that the law neither specifies the type of breast pump nor defines who qualifies as a trained provider of lactation counseling services (Breast-Feeding Services Lag Behind the Law, Catherine Saint Louis, New York Times, Sept. 30, 2013). It turns out that with rare exceptions, finding a lactation consultant who is approved by the insurance company and then securing payment are fraught with delays that are measured in days or weeks. Of course, these delays and snafus come during a critical window for breastfeeding success.

A recent study by Wagner et al. (Breastfeeding Concerns at 3 and 7 Days Postpartum and Feeding Status at 2 Months; Pediatrics 2013;132:e865-e75) reports the obvious. Maternal concerns about their infant’s feeding difficulties, breastfeeding pain, and milk quantity were associated with early cessation of breastfeeding, with peaks at 3 and 7 days postpartum. The fact is that even mothers who had a solid intent to nurse their babies for at least 2 months worry. They become upset if they perceive that their babies are struggling to feed, or if they suspect that the babies aren’t getting enough to eat. And, they are just as vulnerable to pain as everyone else.

These concerns and worries occur in a compressed time frame of very few days and are magnified by the sleep deprivation that accompanies most deliveries. The correct advice provided by compassionate lactation consultants (and here I include pediatricians) can be critical to breastfeeding success. But, it must be provided on a time scale that matches the tempo of the lactation process. Here I am talking about hours, not days.

Interestingly and sadly, the hospital where Ms. Wagner and her colleagues collected their data doesn’t seem to understand that time-sensitive urgency. The investigators report that lactation consultants are "generally available on the maternity unit 6 days per week." Heaven help the poor mother and infant who are struggling with a poor latch on that 7th day. And, what does "generally available" mean? Folks, a new mother’s breastfeeding concerns require intensive care. The nurses and doctors in an ICU just aren’t "generally available."

The researchers also postulate that the increase in adverse outcomes later in the first week postpartum may be because "there is often a gap between hospital and community lactation services." Really? There’s the problem in a nutshell. If we want more babies to be breastfed, we have to treat the support services as critical and time sensitive. We have done a pretty good job of convincing mothers that breastfeeding is the best way to feed their newborns. Now we have to acknowledge their concerns and support them with quality advice 24/7.

Medical homes must function like homes. Your parents may have turned the lights out at 10:00 p.m., but they didn’t leave you alone and go to a motel for the night. To achieve the kind of seamless support net that new mothers need and deserve, pediatricians need to learn more about giving lactation advice themselves. They need to join with lactation consultants with whom they feel comfortable to provide 24/7 phone support and face-to-face visits on a 365/365 schedule.

The ACA appears to be offering us the opportunity to take breastfeeding support seriously. Obviously, it has some rough edges at this point. But, let’s take advantage of this chance by seeing that the support for our patients is provided in a time frame that matches the biology of breastfeeding.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected].

Updated: 10/8/2013

Most days, I feel that the Affordable Care Act’s negatives outweigh its positives, but I’m not quite ready to throw out the baby with the bathwater. For example, I recently discovered that the ACA requires that all insurance companies pay for breast pumps and lactation counseling. Great idea! But, then I learned that the law neither specifies the type of breast pump nor defines who qualifies as a trained provider of lactation counseling services (Breast-Feeding Services Lag Behind the Law, Catherine Saint Louis, New York Times, Sept. 30, 2013). It turns out that with rare exceptions, finding a lactation consultant who is approved by the insurance company and then securing payment are fraught with delays that are measured in days or weeks. Of course, these delays and snafus come during a critical window for breastfeeding success.

A recent study by Wagner et al. (Breastfeeding Concerns at 3 and 7 Days Postpartum and Feeding Status at 2 Months; Pediatrics 2013;132:e865-e75) reports the obvious. Maternal concerns about their infant’s feeding difficulties, breastfeeding pain, and milk quantity were associated with early cessation of breastfeeding, with peaks at 3 and 7 days postpartum. The fact is that even mothers who had a solid intent to nurse their babies for at least 2 months worry. They become upset if they perceive that their babies are struggling to feed, or if they suspect that the babies aren’t getting enough to eat. And, they are just as vulnerable to pain as everyone else.

These concerns and worries occur in a compressed time frame of very few days and are magnified by the sleep deprivation that accompanies most deliveries. The correct advice provided by compassionate lactation consultants (and here I include pediatricians) can be critical to breastfeeding success. But, it must be provided on a time scale that matches the tempo of the lactation process. Here I am talking about hours, not days.

Interestingly and sadly, the hospital where Ms. Wagner and her colleagues collected their data doesn’t seem to understand that time-sensitive urgency. The investigators report that lactation consultants are "generally available on the maternity unit 6 days per week." Heaven help the poor mother and infant who are struggling with a poor latch on that 7th day. And, what does "generally available" mean? Folks, a new mother’s breastfeeding concerns require intensive care. The nurses and doctors in an ICU just aren’t "generally available."

The researchers also postulate that the increase in adverse outcomes later in the first week postpartum may be because "there is often a gap between hospital and community lactation services." Really? There’s the problem in a nutshell. If we want more babies to be breastfed, we have to treat the support services as critical and time sensitive. We have done a pretty good job of convincing mothers that breastfeeding is the best way to feed their newborns. Now we have to acknowledge their concerns and support them with quality advice 24/7.

Medical homes must function like homes. Your parents may have turned the lights out at 10:00 p.m., but they didn’t leave you alone and go to a motel for the night. To achieve the kind of seamless support net that new mothers need and deserve, pediatricians need to learn more about giving lactation advice themselves. They need to join with lactation consultants with whom they feel comfortable to provide 24/7 phone support and face-to-face visits on a 365/365 schedule.

The ACA appears to be offering us the opportunity to take breastfeeding support seriously. Obviously, it has some rough edges at this point. But, let’s take advantage of this chance by seeing that the support for our patients is provided in a time frame that matches the biology of breastfeeding.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected].

Updated: 10/8/2013

Two of my physician friends recently had knee surgery. Both have had good outcomes, but during their hospital stays they struggled to defend themselves against the troops of the no-pain-goes-untreated army. They have been paying attention, and realize that every medication and intervention carries a downside. So when they were badgered into taking something for pain in the immediate postop period, their inclination was to decline.

Weakened by preop fatigue, each eventually relented and "took the damn pills." The result was for each of them the worst experience of their surgical adventure. One vomited and wisely declined anything more than acetaminophen. The other became so loopy and disoriented that his hospital stay was extended by a day as the physicians and nurses struggled to make sure he hadn’t suffered a stroke.

If you had asked each of my friends whether they were having pain, they would have answered, "Sure." But, if you had asked them to rate their pain on a scale of 1-10, they would have screwed up their faces and asked, "What are you talking about?" If you rephrased the question and asked, "How does this compare to the worst pain you have ever had?" they would reply, "I’m sorry, are we talking apples or oranges?"

Pain is one of those things that doesn’t fit into any definable category. Because of their commitment to helping patients be as comfortable as they can, nurses are eager to use the tools at their disposal. They have been taught that in most cases, early mobility results in a better outcome, and that pain can discourage patients from wanting to move or even participate in their own recovery.

In the last several decades, there has been a well-intentioned but misguided movement toward asking patients to quantify their pain. I wonder whether there is much good evidence to support this effort. But it sounds oh so terribly scientific to put a number on something. Suffering is such a personal experience that pain can’t really be distilled down to a number or a smiley face emoticon. Although it requires more time and skill, a better approach for caregivers is to engage the patient in a dialogue about his or her discomfort. I suspect that most of the best nurses do just that.

Some well-crafted questions delivered with an empathetic tone will detect confounding issues, such as anxiety. From my observations and personal experience, anxiety is a powerful multiplier of pain. The more the patient understands about what is causing his pain and the more realistic his expectations are about how long it will last, the more tolerable the pain can be. But finding out what is making the patient anxious, and explaining the management options, including likely side effects, take time. My physician friends who initially declined pain medications (and certainly will again) did so because they have seen scores of their own patients suffer similar side effects. I’m sure that they share my suspicion that reports of side effects seriously underestimate reality.

When it comes to very young children and unconscious adults, we are limited in our ability to have a dialogue about discomfort. In those cases, we are obligated to treat and accept the risk of side effects. We must make inferences from vital signs and other biophysical measurements that the patient is uncomfortable. However, for the patient who can communicate, I think we should put more stock in what the patient tells us about what is bothering him, and why, than in the tracings on a monitor or some sketchy number.

While dictionaries usually make little distinction between "pain" and "suffering," it may be time for those of us who treat patients to consider assigning each word its own working definition. Pain could be reserved for the neurophysiologists and described in terms of spike potentials and neurotransmitter levels. Suffering, on the other hand, would be a much broader term that is unique to each patient’s experience and takes into account factors such as anxiety and depression. We may find with this redefinition that we are using less medication and that patients are more comfortable.

Dr. Wilkoff practiced general pediatrics in Brunswick, Maine, for nearly forty years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected]. 

 Updated 9/4/13, 10/8/2013

Two of my physician friends recently had knee surgery. Both have had good outcomes, but during their hospital stays they struggled to defend themselves against the troops of the no-pain-goes-untreated army. They have been paying attention, and realize that every medication and intervention carries a downside. So when they were badgered into taking something for pain in the immediate postop period, their inclination was to decline.

Weakened by preop fatigue, each eventually relented and "took the damn pills." The result was for each of them the worst experience of their surgical adventure. One vomited and wisely declined anything more than acetaminophen. The other became so loopy and disoriented that his hospital stay was extended by a day as the physicians and nurses struggled to make sure he hadn’t suffered a stroke.

If you had asked each of my friends whether they were having pain, they would have answered, "Sure." But, if you had asked them to rate their pain on a scale of 1-10, they would have screwed up their faces and asked, "What are you talking about?" If you rephrased the question and asked, "How does this compare to the worst pain you have ever had?" they would reply, "I’m sorry, are we talking apples or oranges?"

Pain is one of those things that doesn’t fit into any definable category. Because of their commitment to helping patients be as comfortable as they can, nurses are eager to use the tools at their disposal. They have been taught that in most cases, early mobility results in a better outcome, and that pain can discourage patients from wanting to move or even participate in their own recovery.

In the last several decades, there has been a well-intentioned but misguided movement toward asking patients to quantify their pain. I wonder whether there is much good evidence to support this effort. But it sounds oh so terribly scientific to put a number on something. Suffering is such a personal experience that pain can’t really be distilled down to a number or a smiley face emoticon. Although it requires more time and skill, a better approach for caregivers is to engage the patient in a dialogue about his or her discomfort. I suspect that most of the best nurses do just that.

Some well-crafted questions delivered with an empathetic tone will detect confounding issues, such as anxiety. From my observations and personal experience, anxiety is a powerful multiplier of pain. The more the patient understands about what is causing his pain and the more realistic his expectations are about how long it will last, the more tolerable the pain can be. But finding out what is making the patient anxious, and explaining the management options, including likely side effects, take time. My physician friends who initially declined pain medications (and certainly will again) did so because they have seen scores of their own patients suffer similar side effects. I’m sure that they share my suspicion that reports of side effects seriously underestimate reality.

When it comes to very young children and unconscious adults, we are limited in our ability to have a dialogue about discomfort. In those cases, we are obligated to treat and accept the risk of side effects. We must make inferences from vital signs and other biophysical measurements that the patient is uncomfortable. However, for the patient who can communicate, I think we should put more stock in what the patient tells us about what is bothering him, and why, than in the tracings on a monitor or some sketchy number.

While dictionaries usually make little distinction between "pain" and "suffering," it may be time for those of us who treat patients to consider assigning each word its own working definition. Pain could be reserved for the neurophysiologists and described in terms of spike potentials and neurotransmitter levels. Suffering, on the other hand, would be a much broader term that is unique to each patient’s experience and takes into account factors such as anxiety and depression. We may find with this redefinition that we are using less medication and that patients are more comfortable.

Dr. Wilkoff practiced general pediatrics in Brunswick, Maine, for nearly forty years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected]. 

 Updated 9/4/13, 10/8/2013

Two of my physician friends recently had knee surgery. Both have had good outcomes, but during their hospital stays they struggled to defend themselves against the troops of the no-pain-goes-untreated army. They have been paying attention, and realize that every medication and intervention carries a downside. So when they were badgered into taking something for pain in the immediate postop period, their inclination was to decline.

Weakened by preop fatigue, each eventually relented and "took the damn pills." The result was for each of them the worst experience of their surgical adventure. One vomited and wisely declined anything more than acetaminophen. The other became so loopy and disoriented that his hospital stay was extended by a day as the physicians and nurses struggled to make sure he hadn’t suffered a stroke.

If you had asked each of my friends whether they were having pain, they would have answered, "Sure." But, if you had asked them to rate their pain on a scale of 1-10, they would have screwed up their faces and asked, "What are you talking about?" If you rephrased the question and asked, "How does this compare to the worst pain you have ever had?" they would reply, "I’m sorry, are we talking apples or oranges?"

Pain is one of those things that doesn’t fit into any definable category. Because of their commitment to helping patients be as comfortable as they can, nurses are eager to use the tools at their disposal. They have been taught that in most cases, early mobility results in a better outcome, and that pain can discourage patients from wanting to move or even participate in their own recovery.

In the last several decades, there has been a well-intentioned but misguided movement toward asking patients to quantify their pain. I wonder whether there is much good evidence to support this effort. But it sounds oh so terribly scientific to put a number on something. Suffering is such a personal experience that pain can’t really be distilled down to a number or a smiley face emoticon. Although it requires more time and skill, a better approach for caregivers is to engage the patient in a dialogue about his or her discomfort. I suspect that most of the best nurses do just that.

Some well-crafted questions delivered with an empathetic tone will detect confounding issues, such as anxiety. From my observations and personal experience, anxiety is a powerful multiplier of pain. The more the patient understands about what is causing his pain and the more realistic his expectations are about how long it will last, the more tolerable the pain can be. But finding out what is making the patient anxious, and explaining the management options, including likely side effects, take time. My physician friends who initially declined pain medications (and certainly will again) did so because they have seen scores of their own patients suffer similar side effects. I’m sure that they share my suspicion that reports of side effects seriously underestimate reality.

When it comes to very young children and unconscious adults, we are limited in our ability to have a dialogue about discomfort. In those cases, we are obligated to treat and accept the risk of side effects. We must make inferences from vital signs and other biophysical measurements that the patient is uncomfortable. However, for the patient who can communicate, I think we should put more stock in what the patient tells us about what is bothering him, and why, than in the tracings on a monitor or some sketchy number.

While dictionaries usually make little distinction between "pain" and "suffering," it may be time for those of us who treat patients to consider assigning each word its own working definition. Pain could be reserved for the neurophysiologists and described in terms of spike potentials and neurotransmitter levels. Suffering, on the other hand, would be a much broader term that is unique to each patient’s experience and takes into account factors such as anxiety and depression. We may find with this redefinition that we are using less medication and that patients are more comfortable.

Dr. Wilkoff practiced general pediatrics in Brunswick, Maine, for nearly forty years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected]. 

 Updated 9/4/13, 10/8/2013

I grew up in a small town about 30 miles north of New York City. Back then, it was a quiet, semirural community proud of its excellent school system. It was a wonderful place for raising children and still affordable for families with modest means.

Like half of the other men in town, my father commuted into the city for his job. As a result, he spent more than 2 hours of his day travelling. My memories of how he looked and what he said when he arrived home in the evening convinced me that I would never allow commuting to gobble up a large chunk of my life. As commutes go, I guess his was relatively benign. Most nights he had a seat on the train and could read the newspaper and do the crossword.

My sister and I will be forever grateful for those sacrifices he made by commuting so that we could grow up in a safe and supportive community. But as I considered my options for work, I ruled out the subspecialties of pediatric dermatology and radiology, which suited my visual skills, because they would have required me to live in a city of several hundred thousand people. My preference for small town life and an aversion to commuting meant that happiness would be more likely if I worked and resided in the same town.

Until one of our hospitals moved 4 miles to the other side of town a few years ago, my commute consisted of a 5-minute bike ride or a 12-minute walk. When our children were young, it meant that, even though I might not be able to make it home for dinner or tuck-in time, we could have lunch and play ball in the yard before their afternoon naps.

As I have watched other parents struggle to fabricate quality time with their children, I wish that more of them could have made the decision my wife and I made when we chose to live and work in the same community. I know that this will never be a viable option for many families, particularly for those saintly folks who have chosen to provide health care to underserved inner city populations. However, I fear that too many families underestimate the toll that commuting can take on the fabric of their lives.

A parent exhausted by a long drive in rush-hour traffic is generally not the best parent he or she could be. Young children have trouble understanding why they need to wait for the weekend to spend time with their parents. Workdays inflated by lengthy commutes may nudge parents into making the unwise decision of delaying their children’s bedtimes to an unhealthy hour so that they can be part of the process.

I suspect that most of you have long ago made the big decisions about location and have either endured the consequences or made creative adjustments that have allowed you to comfortably bridge the gap between where you work and where you live. But for those of you who are on the threshold of your professional career or who are facing burnout fueled by too-few-hours-in-a-day, do the math. Imagine what you could do with the time you will be or have been investing in your commute. Are there things you could be doing to make the community where you work a place where you would also like to live? If you eliminate your commute you may have the time to do all sorts of wonderful things.

Dr. Wilkoff practiced general pediatrics in Brunswick, Maine, for nearly forty years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected]. 

Updated 9/4/13, 10/8/13

I grew up in a small town about 30 miles north of New York City. Back then, it was a quiet, semirural community proud of its excellent school system. It was a wonderful place for raising children and still affordable for families with modest means.

Like half of the other men in town, my father commuted into the city for his job. As a result, he spent more than 2 hours of his day travelling. My memories of how he looked and what he said when he arrived home in the evening convinced me that I would never allow commuting to gobble up a large chunk of my life. As commutes go, I guess his was relatively benign. Most nights he had a seat on the train and could read the newspaper and do the crossword.

My sister and I will be forever grateful for those sacrifices he made by commuting so that we could grow up in a safe and supportive community. But as I considered my options for work, I ruled out the subspecialties of pediatric dermatology and radiology, which suited my visual skills, because they would have required me to live in a city of several hundred thousand people. My preference for small town life and an aversion to commuting meant that happiness would be more likely if I worked and resided in the same town.

Until one of our hospitals moved 4 miles to the other side of town a few years ago, my commute consisted of a 5-minute bike ride or a 12-minute walk. When our children were young, it meant that, even though I might not be able to make it home for dinner or tuck-in time, we could have lunch and play ball in the yard before their afternoon naps.

As I have watched other parents struggle to fabricate quality time with their children, I wish that more of them could have made the decision my wife and I made when we chose to live and work in the same community. I know that this will never be a viable option for many families, particularly for those saintly folks who have chosen to provide health care to underserved inner city populations. However, I fear that too many families underestimate the toll that commuting can take on the fabric of their lives.

A parent exhausted by a long drive in rush-hour traffic is generally not the best parent he or she could be. Young children have trouble understanding why they need to wait for the weekend to spend time with their parents. Workdays inflated by lengthy commutes may nudge parents into making the unwise decision of delaying their children’s bedtimes to an unhealthy hour so that they can be part of the process.

I suspect that most of you have long ago made the big decisions about location and have either endured the consequences or made creative adjustments that have allowed you to comfortably bridge the gap between where you work and where you live. But for those of you who are on the threshold of your professional career or who are facing burnout fueled by too-few-hours-in-a-day, do the math. Imagine what you could do with the time you will be or have been investing in your commute. Are there things you could be doing to make the community where you work a place where you would also like to live? If you eliminate your commute you may have the time to do all sorts of wonderful things.

Dr. Wilkoff practiced general pediatrics in Brunswick, Maine, for nearly forty years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected]. 

Updated 9/4/13, 10/8/13

I grew up in a small town about 30 miles north of New York City. Back then, it was a quiet, semirural community proud of its excellent school system. It was a wonderful place for raising children and still affordable for families with modest means.

Like half of the other men in town, my father commuted into the city for his job. As a result, he spent more than 2 hours of his day travelling. My memories of how he looked and what he said when he arrived home in the evening convinced me that I would never allow commuting to gobble up a large chunk of my life. As commutes go, I guess his was relatively benign. Most nights he had a seat on the train and could read the newspaper and do the crossword.

My sister and I will be forever grateful for those sacrifices he made by commuting so that we could grow up in a safe and supportive community. But as I considered my options for work, I ruled out the subspecialties of pediatric dermatology and radiology, which suited my visual skills, because they would have required me to live in a city of several hundred thousand people. My preference for small town life and an aversion to commuting meant that happiness would be more likely if I worked and resided in the same town.

Until one of our hospitals moved 4 miles to the other side of town a few years ago, my commute consisted of a 5-minute bike ride or a 12-minute walk. When our children were young, it meant that, even though I might not be able to make it home for dinner or tuck-in time, we could have lunch and play ball in the yard before their afternoon naps.

As I have watched other parents struggle to fabricate quality time with their children, I wish that more of them could have made the decision my wife and I made when we chose to live and work in the same community. I know that this will never be a viable option for many families, particularly for those saintly folks who have chosen to provide health care to underserved inner city populations. However, I fear that too many families underestimate the toll that commuting can take on the fabric of their lives.

A parent exhausted by a long drive in rush-hour traffic is generally not the best parent he or she could be. Young children have trouble understanding why they need to wait for the weekend to spend time with their parents. Workdays inflated by lengthy commutes may nudge parents into making the unwise decision of delaying their children’s bedtimes to an unhealthy hour so that they can be part of the process.

I suspect that most of you have long ago made the big decisions about location and have either endured the consequences or made creative adjustments that have allowed you to comfortably bridge the gap between where you work and where you live. But for those of you who are on the threshold of your professional career or who are facing burnout fueled by too-few-hours-in-a-day, do the math. Imagine what you could do with the time you will be or have been investing in your commute. Are there things you could be doing to make the community where you work a place where you would also like to live? If you eliminate your commute you may have the time to do all sorts of wonderful things.

Dr. Wilkoff practiced general pediatrics in Brunswick, Maine, for nearly forty years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected]. 

Updated 9/4/13, 10/8/13

Thirty years ago, I was transitioning from a two-doctor partnership to solo practice. I was desperately seeking advice about how to run a small business when I stumbled across a letter to the editor written by an older physician. He wrote that for 20 years he had pegged his office visit charge to the price of a first-class stamp ... a dollar for each penny of postage. He claimed that over 2 decades, it had allowed him to stay ahead of inflation and provided him a level of reimbursement that he felt was fair and equitable.

While at the time it seemed like a reasonable strategy, it obviously wouldn’t work now. Today, at $0.47 a stamp the United States Postal Service is losing money hand over fist. And, I don’t think there are many physicians today who are billing $47 dollars for a 99213. Although if the price of stamp reflected the real costs, that old guy’s formula might still hold up.

As long as I practiced by myself, I was acutely aware of my expenses and my charges. While most families I saw had some level of third-party coverage, there were plenty of lobsterman, carpenters, and other small business owners who were paying out of pocket. Often, on the weekend, I was the only one in the office. I had to be comfortable with saying, as I looked a parent in the eye, "If you want to pay for the visit today, it’ll be $23." Many of the families were friends and all of them were neighbors because Brunswick was and still is a small town.

Although I was very aware of my own office visit and in-house lab charges, I was never quite sure about what the hospitals were billing for tests and x-rays that I ordered. But, I got enough "Doctor, do you know what that test cost?" calls to want to be better informed.

Many years later, when I joined a small physician-owned group, we were all still directly involved in the fee-setting process. But, as the group was engulfed by larger and larger entities, the fee schedule disappeared behind a corporate smoke screen. An article in the June 2013 Pediatrics makes it pretty clear that I was not alone in my state of ignorance. T. A. Rock et al. from the Children’s Hospital of Philadelphia reported that 71% of the general pediatric attending physicians and 75% of the pediatric residents would describe themselves as "minimally knowledgeable" or "completely unaware" of the costs, charges, and reimbursements at the hospital (Pediatrics 2013:131;1072-80).

One might argue that hospitals and large group practices are such complex entities with a variety of contractual arrangements with multiple payers that it is unreasonable for a physician to be informed about what is being charged of his or her services. Rubbish! It is unreasonable to expect a physician to become an investigative reporter in his or her spare time. But, it is time that hospitals and large groups lift the smoke screen that hangs over health care charges in this country. Everyone – patients, tax payers and not least of all providers – need to know what health care costs.

One might also argue that a physician should not consider the cost of a diagnostic test that he or she is ordering. That may have been a valid argument when malpractice suits were infrequent and inconsequential. But, now an unreasonable number of tests are ordered simply as defensive medicine. We physicians have not been good stewards of the health care dollar. Cost should not discourage us from ordering a test that is truly necessary. But, each time we click a box on the order screen we should be asking ourselves, "How much of somebody else’s money am I spending to cover my behind?"

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine.

Thirty years ago, I was transitioning from a two-doctor partnership to solo practice. I was desperately seeking advice about how to run a small business when I stumbled across a letter to the editor written by an older physician. He wrote that for 20 years he had pegged his office visit charge to the price of a first-class stamp ... a dollar for each penny of postage. He claimed that over 2 decades, it had allowed him to stay ahead of inflation and provided him a level of reimbursement that he felt was fair and equitable.

While at the time it seemed like a reasonable strategy, it obviously wouldn’t work now. Today, at $0.47 a stamp the United States Postal Service is losing money hand over fist. And, I don’t think there are many physicians today who are billing $47 dollars for a 99213. Although if the price of stamp reflected the real costs, that old guy’s formula might still hold up.

As long as I practiced by myself, I was acutely aware of my expenses and my charges. While most families I saw had some level of third-party coverage, there were plenty of lobsterman, carpenters, and other small business owners who were paying out of pocket. Often, on the weekend, I was the only one in the office. I had to be comfortable with saying, as I looked a parent in the eye, "If you want to pay for the visit today, it’ll be $23." Many of the families were friends and all of them were neighbors because Brunswick was and still is a small town.

Although I was very aware of my own office visit and in-house lab charges, I was never quite sure about what the hospitals were billing for tests and x-rays that I ordered. But, I got enough "Doctor, do you know what that test cost?" calls to want to be better informed.

Many years later, when I joined a small physician-owned group, we were all still directly involved in the fee-setting process. But, as the group was engulfed by larger and larger entities, the fee schedule disappeared behind a corporate smoke screen. An article in the June 2013 Pediatrics makes it pretty clear that I was not alone in my state of ignorance. T. A. Rock et al. from the Children’s Hospital of Philadelphia reported that 71% of the general pediatric attending physicians and 75% of the pediatric residents would describe themselves as "minimally knowledgeable" or "completely unaware" of the costs, charges, and reimbursements at the hospital (Pediatrics 2013:131;1072-80).

One might argue that hospitals and large group practices are such complex entities with a variety of contractual arrangements with multiple payers that it is unreasonable for a physician to be informed about what is being charged of his or her services. Rubbish! It is unreasonable to expect a physician to become an investigative reporter in his or her spare time. But, it is time that hospitals and large groups lift the smoke screen that hangs over health care charges in this country. Everyone – patients, tax payers and not least of all providers – need to know what health care costs.

One might also argue that a physician should not consider the cost of a diagnostic test that he or she is ordering. That may have been a valid argument when malpractice suits were infrequent and inconsequential. But, now an unreasonable number of tests are ordered simply as defensive medicine. We physicians have not been good stewards of the health care dollar. Cost should not discourage us from ordering a test that is truly necessary. But, each time we click a box on the order screen we should be asking ourselves, "How much of somebody else’s money am I spending to cover my behind?"

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine.

Thirty years ago, I was transitioning from a two-doctor partnership to solo practice. I was desperately seeking advice about how to run a small business when I stumbled across a letter to the editor written by an older physician. He wrote that for 20 years he had pegged his office visit charge to the price of a first-class stamp ... a dollar for each penny of postage. He claimed that over 2 decades, it had allowed him to stay ahead of inflation and provided him a level of reimbursement that he felt was fair and equitable.

While at the time it seemed like a reasonable strategy, it obviously wouldn’t work now. Today, at $0.47 a stamp the United States Postal Service is losing money hand over fist. And, I don’t think there are many physicians today who are billing $47 dollars for a 99213. Although if the price of stamp reflected the real costs, that old guy’s formula might still hold up.

As long as I practiced by myself, I was acutely aware of my expenses and my charges. While most families I saw had some level of third-party coverage, there were plenty of lobsterman, carpenters, and other small business owners who were paying out of pocket. Often, on the weekend, I was the only one in the office. I had to be comfortable with saying, as I looked a parent in the eye, "If you want to pay for the visit today, it’ll be $23." Many of the families were friends and all of them were neighbors because Brunswick was and still is a small town.

Although I was very aware of my own office visit and in-house lab charges, I was never quite sure about what the hospitals were billing for tests and x-rays that I ordered. But, I got enough "Doctor, do you know what that test cost?" calls to want to be better informed.

Many years later, when I joined a small physician-owned group, we were all still directly involved in the fee-setting process. But, as the group was engulfed by larger and larger entities, the fee schedule disappeared behind a corporate smoke screen. An article in the June 2013 Pediatrics makes it pretty clear that I was not alone in my state of ignorance. T. A. Rock et al. from the Children’s Hospital of Philadelphia reported that 71% of the general pediatric attending physicians and 75% of the pediatric residents would describe themselves as "minimally knowledgeable" or "completely unaware" of the costs, charges, and reimbursements at the hospital (Pediatrics 2013:131;1072-80).

One might argue that hospitals and large group practices are such complex entities with a variety of contractual arrangements with multiple payers that it is unreasonable for a physician to be informed about what is being charged of his or her services. Rubbish! It is unreasonable to expect a physician to become an investigative reporter in his or her spare time. But, it is time that hospitals and large groups lift the smoke screen that hangs over health care charges in this country. Everyone – patients, tax payers and not least of all providers – need to know what health care costs.

One might also argue that a physician should not consider the cost of a diagnostic test that he or she is ordering. That may have been a valid argument when malpractice suits were infrequent and inconsequential. But, now an unreasonable number of tests are ordered simply as defensive medicine. We physicians have not been good stewards of the health care dollar. Cost should not discourage us from ordering a test that is truly necessary. But, each time we click a box on the order screen we should be asking ourselves, "How much of somebody else’s money am I spending to cover my behind?"

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine.

When I was 8 and my sister was 10 months old, we were playing on the living room carpet when, suddenly and without provocation, the little creeper hit me in the mouth with a Kiwi shoe polish bottle.

I have no idea why we were playing with a shoe polish bottle, but of all the potential disasters that could have occurred, I guess a chipped central incisor was a relatively minor result. That was my first wake-up call to the destructive power lurking in the lightning-quick hands of infants and toddlers.

Unfortunately, many adults are unaware or have forgotten that their own faces can be enticing targets for babies eager to engage in tactile exploration of the environment. Scratched corneas, torn ear lobes, and mangled spectacles are the most common occurrences when relatives and strangers attempt an in-your-face style of getting acquainted. I recall meeting one grandmother who nearly lost her vision in one eye as the result of an infected infant fingernail scratch of her cornea.

We pediatricians should understand better than most people that infants can lash out without warning, but stuff happens. We might be distracted by a could-it-be-a-murmur sound coming through the stethoscope tubing. Or we may be suffering from some postlunch drowsiness and "Oops," there goes a new pair of glasses.

Given the frequency of our close encounters with infants and toddlers, one would expect that patient-inflicted injuries are quite common, but I’m not aware of any data on this kind of work-related hazard. I suspect that most of us fret more about the risk of contracting an infection from our patients than about being injured in the line of duty.

Looking back on a career that spans 4 decades, I can recall a few incidents in which I took a direct snot shot to the eye and developed conjunctivitis. I don’t remember being injured. Have I just been lucky or is there something about how I approach little patients that has protected me?

Like most of you, I have unconsciously learned some self-defense strategies along the way. For example, I got peed on quite a bit as resident, but now I always keep one eye on the penis and one hand on the flap of a diaper. I haven’t been hit in the last 30 years.

I examine patients under the age of 4 in their parents’ laps. I hold the child’s left elbow with my right hand, adjusting the grip depending on the child’s behavior. I ask the parent to hold the other elbow. When it’s time to get into the child’s face, I show the parents how to encircle the patient in a bear hug. Some parents don’t seem to realize that their role is critical to my safety, and so I must remain on alert for the first sign of a Houdini escape.

As infants become toddlers, innocent pokes of curiosity can become intentional jabs and swats. Hopefully, a low-key, gentle approach can keep these challenges to a minimum, but you know as well as I do that, when language fails them, children have few ways to respond but to strike out when they are afraid.

Have patients tried to bite me? Yes! Have they succeeded? Thankfully not.

Nowadays, my biggest safety concern when I enter an exam room is tripping as I navigate the minefield of toys scattered on the floor. I would like to hear from you about patient-inflicted injuries that you have experienced or heard about, and what strategies you may use to keep yourself intact while you examine these deceptively passive cuties.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine.

When I was 8 and my sister was 10 months old, we were playing on the living room carpet when, suddenly and without provocation, the little creeper hit me in the mouth with a Kiwi shoe polish bottle.

I have no idea why we were playing with a shoe polish bottle, but of all the potential disasters that could have occurred, I guess a chipped central incisor was a relatively minor result. That was my first wake-up call to the destructive power lurking in the lightning-quick hands of infants and toddlers.

Unfortunately, many adults are unaware or have forgotten that their own faces can be enticing targets for babies eager to engage in tactile exploration of the environment. Scratched corneas, torn ear lobes, and mangled spectacles are the most common occurrences when relatives and strangers attempt an in-your-face style of getting acquainted. I recall meeting one grandmother who nearly lost her vision in one eye as the result of an infected infant fingernail scratch of her cornea.

We pediatricians should understand better than most people that infants can lash out without warning, but stuff happens. We might be distracted by a could-it-be-a-murmur sound coming through the stethoscope tubing. Or we may be suffering from some postlunch drowsiness and "Oops," there goes a new pair of glasses.

Given the frequency of our close encounters with infants and toddlers, one would expect that patient-inflicted injuries are quite common, but I’m not aware of any data on this kind of work-related hazard. I suspect that most of us fret more about the risk of contracting an infection from our patients than about being injured in the line of duty.

Looking back on a career that spans 4 decades, I can recall a few incidents in which I took a direct snot shot to the eye and developed conjunctivitis. I don’t remember being injured. Have I just been lucky or is there something about how I approach little patients that has protected me?

Like most of you, I have unconsciously learned some self-defense strategies along the way. For example, I got peed on quite a bit as resident, but now I always keep one eye on the penis and one hand on the flap of a diaper. I haven’t been hit in the last 30 years.

I examine patients under the age of 4 in their parents’ laps. I hold the child’s left elbow with my right hand, adjusting the grip depending on the child’s behavior. I ask the parent to hold the other elbow. When it’s time to get into the child’s face, I show the parents how to encircle the patient in a bear hug. Some parents don’t seem to realize that their role is critical to my safety, and so I must remain on alert for the first sign of a Houdini escape.

As infants become toddlers, innocent pokes of curiosity can become intentional jabs and swats. Hopefully, a low-key, gentle approach can keep these challenges to a minimum, but you know as well as I do that, when language fails them, children have few ways to respond but to strike out when they are afraid.

Have patients tried to bite me? Yes! Have they succeeded? Thankfully not.

Nowadays, my biggest safety concern when I enter an exam room is tripping as I navigate the minefield of toys scattered on the floor. I would like to hear from you about patient-inflicted injuries that you have experienced or heard about, and what strategies you may use to keep yourself intact while you examine these deceptively passive cuties.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine.

When I was 8 and my sister was 10 months old, we were playing on the living room carpet when, suddenly and without provocation, the little creeper hit me in the mouth with a Kiwi shoe polish bottle.

I have no idea why we were playing with a shoe polish bottle, but of all the potential disasters that could have occurred, I guess a chipped central incisor was a relatively minor result. That was my first wake-up call to the destructive power lurking in the lightning-quick hands of infants and toddlers.

Unfortunately, many adults are unaware or have forgotten that their own faces can be enticing targets for babies eager to engage in tactile exploration of the environment. Scratched corneas, torn ear lobes, and mangled spectacles are the most common occurrences when relatives and strangers attempt an in-your-face style of getting acquainted. I recall meeting one grandmother who nearly lost her vision in one eye as the result of an infected infant fingernail scratch of her cornea.

We pediatricians should understand better than most people that infants can lash out without warning, but stuff happens. We might be distracted by a could-it-be-a-murmur sound coming through the stethoscope tubing. Or we may be suffering from some postlunch drowsiness and "Oops," there goes a new pair of glasses.

Given the frequency of our close encounters with infants and toddlers, one would expect that patient-inflicted injuries are quite common, but I’m not aware of any data on this kind of work-related hazard. I suspect that most of us fret more about the risk of contracting an infection from our patients than about being injured in the line of duty.

Looking back on a career that spans 4 decades, I can recall a few incidents in which I took a direct snot shot to the eye and developed conjunctivitis. I don’t remember being injured. Have I just been lucky or is there something about how I approach little patients that has protected me?

Like most of you, I have unconsciously learned some self-defense strategies along the way. For example, I got peed on quite a bit as resident, but now I always keep one eye on the penis and one hand on the flap of a diaper. I haven’t been hit in the last 30 years.

I examine patients under the age of 4 in their parents’ laps. I hold the child’s left elbow with my right hand, adjusting the grip depending on the child’s behavior. I ask the parent to hold the other elbow. When it’s time to get into the child’s face, I show the parents how to encircle the patient in a bear hug. Some parents don’t seem to realize that their role is critical to my safety, and so I must remain on alert for the first sign of a Houdini escape.

As infants become toddlers, innocent pokes of curiosity can become intentional jabs and swats. Hopefully, a low-key, gentle approach can keep these challenges to a minimum, but you know as well as I do that, when language fails them, children have few ways to respond but to strike out when they are afraid.

Have patients tried to bite me? Yes! Have they succeeded? Thankfully not.

Nowadays, my biggest safety concern when I enter an exam room is tripping as I navigate the minefield of toys scattered on the floor. I would like to hear from you about patient-inflicted injuries that you have experienced or heard about, and what strategies you may use to keep yourself intact while you examine these deceptively passive cuties.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine.