William G. Wilkoff, MD

When things are going poorly, some of us grouse about them, and most of us keep our blinders on and just muddle along.

But every now and then, someone grabs the wheel and tries to get the ship back on course. Dr. Michael Pichichero seems to be among those saintly few. In a recent column, Dr. Pichichero reported the results of a longitudinal multiyear study.

The patients in the study group were begun on high-dose amoxicillin/clavunate, but the choice of antibiotics was adjusted using the results of bacterial testing on middle ear fluid obtained by tympanocentesis. The results were dramatic. Compared with a control group of patients in the same practice whose parents had declined tympanocentesis, the patients in the individualized care group had 250% fewer repeat ear infections. When compared to a broader community control group, the repeat ear infections were reduced by 460%. The reduction in the number of ear surgeries among these groups was even more dramatic.

Not surprisingly, these results have led Dr. Pichichero to recommend that tympanocentesis be in the curriculum of all pediatric residency training programs. He also encourages the rest of us to learn the skill or at least designate someone in our practices to become adept at ear taps.

In a perfect world, Dr. Pichichero’s findings and his recommendations make perfect sense. Why haven’t we been treating otitis media using the same principles we apply to most other infections? Define the organism, determine antibiotic sensitivities, and then adjust therapy to the narrowest and most effective drug.

Of course, the problem is that old this-is-the-real-world thing. I am sure I am the only physician in town and probably in the state of Maine who has done a tympanocentesis on an unanesthetized pediatric patient. As a house officer 4 decades ago, I participated in a small study of antibiotic sensitivities. The cohort of physicians who preceded me often "lanced" eardrums to provide prompt pain relief. But now we have indoor plumbing and central heating. Either for convenience or because of the fear of malpractice, outpatient pediatrics has become less procedure oriented. Few of us suture wounds or put on casts in our offices. Even removing cerumen with a curette seems to have become a procedure too edgy for many pediatricians.

To do a proper tympanocentesis or even diagnose otitis, the physician must have a good look at the eardrum and know what she or he is looking at. Sadly, we need to get ourselves back up to speed at removing cerumen and looking at tympanic membranes before we will be ready to do ear taps.

Dr. Pichichero observes that "the most common reason for children to receive ear tubes is repeated ear infections... ." I wonder if this is really true. I think it’s probably more correct to say that the most common reason for the placement of PE (pressure equalization) tubes is pressure from parents who think that their children have had too many ear infections. Sometimes this may be the result of overdiagnosis. Or it often occurs when the physician has failed to convince the family that a history of three or four episodes of otitis in a season is within an acceptable range and not a reason to do surgery.

Some of Dr. Pichichero’s dramatic results may be in part due to the fact that the parents of children in the individualized care groups were willing to listen to the physician and accept his or her plan to stick needles in their papoosed children’s ears. Parents this compliant would be less likely to ignore the physician’s conservative recommendations and seek surgery on their own.

While I don’t think I’m going to see scores of pediatricians signing up for tympanocentesis training in the near future, I think we owe Dr. Pichichero our gratitude for injecting some good science into the diagnosis of otitis. The fact that he was able to secure funding to expand and replicate the study in the Rochester, N.Y., area gives me great hope.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

When things are going poorly, some of us grouse about them, and most of us keep our blinders on and just muddle along.

But every now and then, someone grabs the wheel and tries to get the ship back on course. Dr. Michael Pichichero seems to be among those saintly few. In a recent column, Dr. Pichichero reported the results of a longitudinal multiyear study.

The patients in the study group were begun on high-dose amoxicillin/clavunate, but the choice of antibiotics was adjusted using the results of bacterial testing on middle ear fluid obtained by tympanocentesis. The results were dramatic. Compared with a control group of patients in the same practice whose parents had declined tympanocentesis, the patients in the individualized care group had 250% fewer repeat ear infections. When compared to a broader community control group, the repeat ear infections were reduced by 460%. The reduction in the number of ear surgeries among these groups was even more dramatic.

Not surprisingly, these results have led Dr. Pichichero to recommend that tympanocentesis be in the curriculum of all pediatric residency training programs. He also encourages the rest of us to learn the skill or at least designate someone in our practices to become adept at ear taps.

In a perfect world, Dr. Pichichero’s findings and his recommendations make perfect sense. Why haven’t we been treating otitis media using the same principles we apply to most other infections? Define the organism, determine antibiotic sensitivities, and then adjust therapy to the narrowest and most effective drug.

Of course, the problem is that old this-is-the-real-world thing. I am sure I am the only physician in town and probably in the state of Maine who has done a tympanocentesis on an unanesthetized pediatric patient. As a house officer 4 decades ago, I participated in a small study of antibiotic sensitivities. The cohort of physicians who preceded me often "lanced" eardrums to provide prompt pain relief. But now we have indoor plumbing and central heating. Either for convenience or because of the fear of malpractice, outpatient pediatrics has become less procedure oriented. Few of us suture wounds or put on casts in our offices. Even removing cerumen with a curette seems to have become a procedure too edgy for many pediatricians.

To do a proper tympanocentesis or even diagnose otitis, the physician must have a good look at the eardrum and know what she or he is looking at. Sadly, we need to get ourselves back up to speed at removing cerumen and looking at tympanic membranes before we will be ready to do ear taps.

Dr. Pichichero observes that "the most common reason for children to receive ear tubes is repeated ear infections... ." I wonder if this is really true. I think it’s probably more correct to say that the most common reason for the placement of PE (pressure equalization) tubes is pressure from parents who think that their children have had too many ear infections. Sometimes this may be the result of overdiagnosis. Or it often occurs when the physician has failed to convince the family that a history of three or four episodes of otitis in a season is within an acceptable range and not a reason to do surgery.

Some of Dr. Pichichero’s dramatic results may be in part due to the fact that the parents of children in the individualized care groups were willing to listen to the physician and accept his or her plan to stick needles in their papoosed children’s ears. Parents this compliant would be less likely to ignore the physician’s conservative recommendations and seek surgery on their own.

While I don’t think I’m going to see scores of pediatricians signing up for tympanocentesis training in the near future, I think we owe Dr. Pichichero our gratitude for injecting some good science into the diagnosis of otitis. The fact that he was able to secure funding to expand and replicate the study in the Rochester, N.Y., area gives me great hope.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

When things are going poorly, some of us grouse about them, and most of us keep our blinders on and just muddle along.

But every now and then, someone grabs the wheel and tries to get the ship back on course. Dr. Michael Pichichero seems to be among those saintly few. In a recent column, Dr. Pichichero reported the results of a longitudinal multiyear study.

The patients in the study group were begun on high-dose amoxicillin/clavunate, but the choice of antibiotics was adjusted using the results of bacterial testing on middle ear fluid obtained by tympanocentesis. The results were dramatic. Compared with a control group of patients in the same practice whose parents had declined tympanocentesis, the patients in the individualized care group had 250% fewer repeat ear infections. When compared to a broader community control group, the repeat ear infections were reduced by 460%. The reduction in the number of ear surgeries among these groups was even more dramatic.

Not surprisingly, these results have led Dr. Pichichero to recommend that tympanocentesis be in the curriculum of all pediatric residency training programs. He also encourages the rest of us to learn the skill or at least designate someone in our practices to become adept at ear taps.

In a perfect world, Dr. Pichichero’s findings and his recommendations make perfect sense. Why haven’t we been treating otitis media using the same principles we apply to most other infections? Define the organism, determine antibiotic sensitivities, and then adjust therapy to the narrowest and most effective drug.

Of course, the problem is that old this-is-the-real-world thing. I am sure I am the only physician in town and probably in the state of Maine who has done a tympanocentesis on an unanesthetized pediatric patient. As a house officer 4 decades ago, I participated in a small study of antibiotic sensitivities. The cohort of physicians who preceded me often "lanced" eardrums to provide prompt pain relief. But now we have indoor plumbing and central heating. Either for convenience or because of the fear of malpractice, outpatient pediatrics has become less procedure oriented. Few of us suture wounds or put on casts in our offices. Even removing cerumen with a curette seems to have become a procedure too edgy for many pediatricians.

To do a proper tympanocentesis or even diagnose otitis, the physician must have a good look at the eardrum and know what she or he is looking at. Sadly, we need to get ourselves back up to speed at removing cerumen and looking at tympanic membranes before we will be ready to do ear taps.

Dr. Pichichero observes that "the most common reason for children to receive ear tubes is repeated ear infections... ." I wonder if this is really true. I think it’s probably more correct to say that the most common reason for the placement of PE (pressure equalization) tubes is pressure from parents who think that their children have had too many ear infections. Sometimes this may be the result of overdiagnosis. Or it often occurs when the physician has failed to convince the family that a history of three or four episodes of otitis in a season is within an acceptable range and not a reason to do surgery.

Some of Dr. Pichichero’s dramatic results may be in part due to the fact that the parents of children in the individualized care groups were willing to listen to the physician and accept his or her plan to stick needles in their papoosed children’s ears. Parents this compliant would be less likely to ignore the physician’s conservative recommendations and seek surgery on their own.

While I don’t think I’m going to see scores of pediatricians signing up for tympanocentesis training in the near future, I think we owe Dr. Pichichero our gratitude for injecting some good science into the diagnosis of otitis. The fact that he was able to secure funding to expand and replicate the study in the Rochester, N.Y., area gives me great hope.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

A study in JAMA (2013;309:1607-12) found that children and adolescents seen in emergency departments and diagnosed with migraine were more than six times more likely to have had a history of colic than children seen in the ED for other reasons. The association with colic did not appear for other forms of headache, but was consistent for the patients diagnosed with migraine both with and without aura.

The authors of the study, which was done in three tertiary care hospitals in France and Italy, wonder if nerve endings in the gut and brain may be sensitized in a similar fashion. I have always suspected that there might be an association between migraine and colicky infants, and I find the investigators’ explanations interesting and plausible. But I think that there may be a simpler explanation that doesn’t involve as-yet-undiscovered neurochemical similarities between the infant gut and the brain of older children.

First, in my construct of infancy "Colic" with a capital "C" isn’t really a diagnosis, and attempts to treat it as a diagnosis only lead to confusion, misdiagnosis, and overtreatment. It is more helpful to describe young infants with episodic fussiness as being "colicky" or "having colicky pain."

In some cases the pain is obviously linked to a gastrointestinal cause. For example, the breast-fed infant with blood-streaked loose green stools has colicky pain. The infant who swallows more air than he can handle and is relieved by flatus or an improved burping technique has colicky pain. But, so may the child with an aberrant coronary artery or a urinary tract obstruction. Little babies can’t tell us where it hurts. They may grab their ears when their belly hurts or grab their belly when their ears hurt. In my experience, many colicky infants don’t have an abdominal cause for their pain. But, with centuries of old wives’ tales and anecdotal pseudoscience behind us, parents and physicians assume that babies with episodic spells of fussiness are having a gut problem.

Instead of postulating some undiscovered neurochemical relationships, doesn’t it make more sense to suspect that some colicky infants are actually having migraine headaches? We already know that sleep deprivation is a major trigger for childhood migraine. (Or, at least I do!) And we know that many infants don’t readily fall into a pattern that provides them with enough sleep.

In my experience, colicky infants who don’t have an obvious gastrointestinal cause for their episodes of discomfort are usually suffering because they find themselves in a poorly managed sleep environment. If I am successful in helping parents create more sleep-friendly schedules, the colicky pain often resolves.

For older children, migraine headaches usually resolve when the child falls asleep in a dark room. They wake up cured until the next episode of sleep deprivation starts the cycle over again. However, getting parents to put their obviously uncomfortable infant in a dark room and allowing sleep to take over isn’t always easy.

This study from the pages of JAMA should be a launching pad for some new thoughts about "Colic," but I fear that they will fall into the same old orbit that equates colicky pain with infant gastrointestinal tract problems.

This column, "Letters From Maine," regularly appears in Pediatric News, a publication of IMNG Medical Media. Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

A study in JAMA (2013;309:1607-12) found that children and adolescents seen in emergency departments and diagnosed with migraine were more than six times more likely to have had a history of colic than children seen in the ED for other reasons. The association with colic did not appear for other forms of headache, but was consistent for the patients diagnosed with migraine both with and without aura.

The authors of the study, which was done in three tertiary care hospitals in France and Italy, wonder if nerve endings in the gut and brain may be sensitized in a similar fashion. I have always suspected that there might be an association between migraine and colicky infants, and I find the investigators’ explanations interesting and plausible. But I think that there may be a simpler explanation that doesn’t involve as-yet-undiscovered neurochemical similarities between the infant gut and the brain of older children.

First, in my construct of infancy "Colic" with a capital "C" isn’t really a diagnosis, and attempts to treat it as a diagnosis only lead to confusion, misdiagnosis, and overtreatment. It is more helpful to describe young infants with episodic fussiness as being "colicky" or "having colicky pain."

In some cases the pain is obviously linked to a gastrointestinal cause. For example, the breast-fed infant with blood-streaked loose green stools has colicky pain. The infant who swallows more air than he can handle and is relieved by flatus or an improved burping technique has colicky pain. But, so may the child with an aberrant coronary artery or a urinary tract obstruction. Little babies can’t tell us where it hurts. They may grab their ears when their belly hurts or grab their belly when their ears hurt. In my experience, many colicky infants don’t have an abdominal cause for their pain. But, with centuries of old wives’ tales and anecdotal pseudoscience behind us, parents and physicians assume that babies with episodic spells of fussiness are having a gut problem.

Instead of postulating some undiscovered neurochemical relationships, doesn’t it make more sense to suspect that some colicky infants are actually having migraine headaches? We already know that sleep deprivation is a major trigger for childhood migraine. (Or, at least I do!) And we know that many infants don’t readily fall into a pattern that provides them with enough sleep.

In my experience, colicky infants who don’t have an obvious gastrointestinal cause for their episodes of discomfort are usually suffering because they find themselves in a poorly managed sleep environment. If I am successful in helping parents create more sleep-friendly schedules, the colicky pain often resolves.

For older children, migraine headaches usually resolve when the child falls asleep in a dark room. They wake up cured until the next episode of sleep deprivation starts the cycle over again. However, getting parents to put their obviously uncomfortable infant in a dark room and allowing sleep to take over isn’t always easy.

This study from the pages of JAMA should be a launching pad for some new thoughts about "Colic," but I fear that they will fall into the same old orbit that equates colicky pain with infant gastrointestinal tract problems.

This column, "Letters From Maine," regularly appears in Pediatric News, a publication of IMNG Medical Media. Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

A study in JAMA (2013;309:1607-12) found that children and adolescents seen in emergency departments and diagnosed with migraine were more than six times more likely to have had a history of colic than children seen in the ED for other reasons. The association with colic did not appear for other forms of headache, but was consistent for the patients diagnosed with migraine both with and without aura.

The authors of the study, which was done in three tertiary care hospitals in France and Italy, wonder if nerve endings in the gut and brain may be sensitized in a similar fashion. I have always suspected that there might be an association between migraine and colicky infants, and I find the investigators’ explanations interesting and plausible. But I think that there may be a simpler explanation that doesn’t involve as-yet-undiscovered neurochemical similarities between the infant gut and the brain of older children.

First, in my construct of infancy "Colic" with a capital "C" isn’t really a diagnosis, and attempts to treat it as a diagnosis only lead to confusion, misdiagnosis, and overtreatment. It is more helpful to describe young infants with episodic fussiness as being "colicky" or "having colicky pain."

In some cases the pain is obviously linked to a gastrointestinal cause. For example, the breast-fed infant with blood-streaked loose green stools has colicky pain. The infant who swallows more air than he can handle and is relieved by flatus or an improved burping technique has colicky pain. But, so may the child with an aberrant coronary artery or a urinary tract obstruction. Little babies can’t tell us where it hurts. They may grab their ears when their belly hurts or grab their belly when their ears hurt. In my experience, many colicky infants don’t have an abdominal cause for their pain. But, with centuries of old wives’ tales and anecdotal pseudoscience behind us, parents and physicians assume that babies with episodic spells of fussiness are having a gut problem.

Instead of postulating some undiscovered neurochemical relationships, doesn’t it make more sense to suspect that some colicky infants are actually having migraine headaches? We already know that sleep deprivation is a major trigger for childhood migraine. (Or, at least I do!) And we know that many infants don’t readily fall into a pattern that provides them with enough sleep.

In my experience, colicky infants who don’t have an obvious gastrointestinal cause for their episodes of discomfort are usually suffering because they find themselves in a poorly managed sleep environment. If I am successful in helping parents create more sleep-friendly schedules, the colicky pain often resolves.

For older children, migraine headaches usually resolve when the child falls asleep in a dark room. They wake up cured until the next episode of sleep deprivation starts the cycle over again. However, getting parents to put their obviously uncomfortable infant in a dark room and allowing sleep to take over isn’t always easy.

This study from the pages of JAMA should be a launching pad for some new thoughts about "Colic," but I fear that they will fall into the same old orbit that equates colicky pain with infant gastrointestinal tract problems.

This column, "Letters From Maine," regularly appears in Pediatric News, a publication of IMNG Medical Media. Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

Several years ago, someone asked me if I ever became bored at work. As I recall my inquisitor was an internist, and I assume that his question was based on the assumption that a general pediatrician sees only a limited varieties of illnesses ... runny noses, ear infections, sore throats, diarrhea, and a few others. And, of course, most of the problems involve only one organ system, and very few of them are life threatening. To someone who finds disease interesting and enjoys the complicated interplay that accompanies multiorgan system failure, I guess primary care pediatrics might appear rather ho-hum.

But, for several reasons, I have never found pediatric practice boring. There is always the threat that hidden in the forest of children with garden-variety illnesses, there are always a few who have serious life-threatening conditions. When it feels as though more than half of the patients I have seen in a morning have a viral sore throat, it is tempting to put one’s diagnostic machinery on cruise control and just sort of go through the motions. But, the next patient I see may be brewing a prevertebral abscess. It’s not very likely, but if I had allowed myself to doze off at the wheel and had sent the child home with inadequate or poorly understood instructions, both the child and I could be in big trouble. Obviously, my first concern is for the welfare of the patient. However, we all must admit that the threat of malpractice suit can be a potent motivator and strong deterrent against boredom.

I suspect that I have always enjoyed looking at what some might consider boringly repetitive patterns because I get some satisfaction searching for the outliers. As a teenager, I spent my summers as a lifeguard scanning a pool full of bobbing young bodies, all the while looking for that one child whose splashing wasn’t playful. Instead, it was a distress call.

The concern about missing serious illness can help a physician remain focused when the landscape of normalcy takes on a dull shade of monotony, but that level of engagement can only last so long if her focus is primarily disease. I recently learned that it was Hippocrates who is reported to have said, "It is more important to know what sort of person has a disease than what sort of disease the person has."

If that old Greek physician/philosopher followed his own advice, I’m sure he was never bored. A pediatrician, or any physician for that matter, whose focus is on disease is going to find out that after a year or 2 of practice, she has seen just about all the variety she is going to see. Of course, every now and then a zebra is going to wander into her exam room, but she had better have something else to keep herself engaged while she is waiting for the next zebra.

However, every patient with a sore throat is a unique individual. One may be very anxious. One may minimize his complaints. One may believe antibiotics cure everything, and the next may have an unvoiced concern that he has caught a sexually transmitted infection from oral sex. Each patient has her own way of manifesting a disease and her own unique story. It may be sitting there on the surface, but sometimes we have to scratch and dig to find what’s really causing patients to react as they do.

At times, there is no substitute for the correct diagnosis. But, if the physician fails to understand the patient, the correct diagnosis may not be accepted and even the appropriate therapy won’t be effective. Often, we don’t know the diagnosis, and then it is critical to understand the patient’s tolerance for uncertainty.

The list of potential diseases that one physician will see in her career is rather short. However, she will encounter thousands of patients, each one with his or her own unique way of dealing with those few illnesses. If she finds that boring, it’s time to find another career, preferably one that provides minimal exposure to people.

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

Several years ago, someone asked me if I ever became bored at work. As I recall my inquisitor was an internist, and I assume that his question was based on the assumption that a general pediatrician sees only a limited varieties of illnesses ... runny noses, ear infections, sore throats, diarrhea, and a few others. And, of course, most of the problems involve only one organ system, and very few of them are life threatening. To someone who finds disease interesting and enjoys the complicated interplay that accompanies multiorgan system failure, I guess primary care pediatrics might appear rather ho-hum.

But, for several reasons, I have never found pediatric practice boring. There is always the threat that hidden in the forest of children with garden-variety illnesses, there are always a few who have serious life-threatening conditions. When it feels as though more than half of the patients I have seen in a morning have a viral sore throat, it is tempting to put one’s diagnostic machinery on cruise control and just sort of go through the motions. But, the next patient I see may be brewing a prevertebral abscess. It’s not very likely, but if I had allowed myself to doze off at the wheel and had sent the child home with inadequate or poorly understood instructions, both the child and I could be in big trouble. Obviously, my first concern is for the welfare of the patient. However, we all must admit that the threat of malpractice suit can be a potent motivator and strong deterrent against boredom.

I suspect that I have always enjoyed looking at what some might consider boringly repetitive patterns because I get some satisfaction searching for the outliers. As a teenager, I spent my summers as a lifeguard scanning a pool full of bobbing young bodies, all the while looking for that one child whose splashing wasn’t playful. Instead, it was a distress call.

The concern about missing serious illness can help a physician remain focused when the landscape of normalcy takes on a dull shade of monotony, but that level of engagement can only last so long if her focus is primarily disease. I recently learned that it was Hippocrates who is reported to have said, "It is more important to know what sort of person has a disease than what sort of disease the person has."

If that old Greek physician/philosopher followed his own advice, I’m sure he was never bored. A pediatrician, or any physician for that matter, whose focus is on disease is going to find out that after a year or 2 of practice, she has seen just about all the variety she is going to see. Of course, every now and then a zebra is going to wander into her exam room, but she had better have something else to keep herself engaged while she is waiting for the next zebra.

However, every patient with a sore throat is a unique individual. One may be very anxious. One may minimize his complaints. One may believe antibiotics cure everything, and the next may have an unvoiced concern that he has caught a sexually transmitted infection from oral sex. Each patient has her own way of manifesting a disease and her own unique story. It may be sitting there on the surface, but sometimes we have to scratch and dig to find what’s really causing patients to react as they do.

At times, there is no substitute for the correct diagnosis. But, if the physician fails to understand the patient, the correct diagnosis may not be accepted and even the appropriate therapy won’t be effective. Often, we don’t know the diagnosis, and then it is critical to understand the patient’s tolerance for uncertainty.

The list of potential diseases that one physician will see in her career is rather short. However, she will encounter thousands of patients, each one with his or her own unique way of dealing with those few illnesses. If she finds that boring, it’s time to find another career, preferably one that provides minimal exposure to people.

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

Several years ago, someone asked me if I ever became bored at work. As I recall my inquisitor was an internist, and I assume that his question was based on the assumption that a general pediatrician sees only a limited varieties of illnesses ... runny noses, ear infections, sore throats, diarrhea, and a few others. And, of course, most of the problems involve only one organ system, and very few of them are life threatening. To someone who finds disease interesting and enjoys the complicated interplay that accompanies multiorgan system failure, I guess primary care pediatrics might appear rather ho-hum.

But, for several reasons, I have never found pediatric practice boring. There is always the threat that hidden in the forest of children with garden-variety illnesses, there are always a few who have serious life-threatening conditions. When it feels as though more than half of the patients I have seen in a morning have a viral sore throat, it is tempting to put one’s diagnostic machinery on cruise control and just sort of go through the motions. But, the next patient I see may be brewing a prevertebral abscess. It’s not very likely, but if I had allowed myself to doze off at the wheel and had sent the child home with inadequate or poorly understood instructions, both the child and I could be in big trouble. Obviously, my first concern is for the welfare of the patient. However, we all must admit that the threat of malpractice suit can be a potent motivator and strong deterrent against boredom.

I suspect that I have always enjoyed looking at what some might consider boringly repetitive patterns because I get some satisfaction searching for the outliers. As a teenager, I spent my summers as a lifeguard scanning a pool full of bobbing young bodies, all the while looking for that one child whose splashing wasn’t playful. Instead, it was a distress call.

The concern about missing serious illness can help a physician remain focused when the landscape of normalcy takes on a dull shade of monotony, but that level of engagement can only last so long if her focus is primarily disease. I recently learned that it was Hippocrates who is reported to have said, "It is more important to know what sort of person has a disease than what sort of disease the person has."

If that old Greek physician/philosopher followed his own advice, I’m sure he was never bored. A pediatrician, or any physician for that matter, whose focus is on disease is going to find out that after a year or 2 of practice, she has seen just about all the variety she is going to see. Of course, every now and then a zebra is going to wander into her exam room, but she had better have something else to keep herself engaged while she is waiting for the next zebra.

However, every patient with a sore throat is a unique individual. One may be very anxious. One may minimize his complaints. One may believe antibiotics cure everything, and the next may have an unvoiced concern that he has caught a sexually transmitted infection from oral sex. Each patient has her own way of manifesting a disease and her own unique story. It may be sitting there on the surface, but sometimes we have to scratch and dig to find what’s really causing patients to react as they do.

At times, there is no substitute for the correct diagnosis. But, if the physician fails to understand the patient, the correct diagnosis may not be accepted and even the appropriate therapy won’t be effective. Often, we don’t know the diagnosis, and then it is critical to understand the patient’s tolerance for uncertainty.

The list of potential diseases that one physician will see in her career is rather short. However, she will encounter thousands of patients, each one with his or her own unique way of dealing with those few illnesses. If she finds that boring, it’s time to find another career, preferably one that provides minimal exposure to people.

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

Over the last decade I have felt a growing kinship with teachers. We face challenges from the government and third-party payers to demonstrate the quality of our service by assessing the outcomes of our patients. Likewise, teachers are being rated by how well their students perform on "standardized" tests.

While theoretically the philosophy behind using outcomes to rate quality makes sense, it doesn’t as well with education and health care delivery as it does with automobile assembly plants. An overemphasis on outcomes fails to acknowledge the fact that some children arrive at our offices and schools so disadvantaged that even the most talented teacher or physician will not be able to make a measurable difference in their outcome.

Sean F. Reardon, professor of education and sociology at Stanford, has written in the New York Times about the widening gap between disadvantaged children and the privileged few ("No Rich Child Left Behind," April 27, 2013). It is no surprise that children from rich families get higher grades on standardized tests. And, Mr. Reardon writes, "family income is a better predictor of children’s success in school than race." He adds that the gap between rich and poor kids’ performance has increased by 40% in the last 30 years. It is interesting that this gap between the poor and middle-income levels is decreasing but the discrepancy between the middle class and the rich has grown.

Mr. Reardon provides some convincing evidence that "schools don’t seem to produce much of the disparity." Schools are unlikely to provide the route out of poverty for the disadvantaged child, he maintains, adding that "rising income inequality explains, at best, half of the increase in the rich-poor academic achievement gap."

One factor that might explain some of the disparity is that rich families have been increasing the time and money they spend on enriching activities for their children at a much faster rate than that of poor and middle class families. The rich seem to have taken our messages about the importance of early development more seriously and have bought Baby Einsteins, limited television exposure, and read "Goodnight Moon" until their eyes no longer focused. While not of all their investments have made a difference, the sheer volume of their efforts has paid off in better school success.

Mr. Reardon suggests that we rethink "our still-persistent notion that educational problems should be solved by schools alone." Instead he recommends that we emulate rich parents and "invest as a society in our children’s education from the day they are born." His recommendation clearly lobs at least one ball into our court, because as pediatricians we have an early and influential relationship with families during those critical first thousand days of a child’s life. We must redouble our efforts at encouraging parents to provide an enriching environment for their children, and we need to provide them with the strategies for creating that environment.

Because many parents can’t or don’t follow through with our recommendations, we must continue to advocate for government programs that provide early educational enrichment for their children. Recently, some politicians have suggested that we limit or eliminate Head Start, because there is a study or two that suggest it may not be effective. If these studies are valid (which I doubt), I suspect Mr. Reardon would say that by the time a child was old enough for Head Start the die would be cast.

We are in a position to do our colleagues in education a big favor by helping to provide more children who are ready to benefit from their skills. Their outcomes will look better, and in a generation we will be repaid with a cohort of better-educated parents who will make us look better when it comes time to judge our outcomes.

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

Over the last decade I have felt a growing kinship with teachers. We face challenges from the government and third-party payers to demonstrate the quality of our service by assessing the outcomes of our patients. Likewise, teachers are being rated by how well their students perform on "standardized" tests.

While theoretically the philosophy behind using outcomes to rate quality makes sense, it doesn’t as well with education and health care delivery as it does with automobile assembly plants. An overemphasis on outcomes fails to acknowledge the fact that some children arrive at our offices and schools so disadvantaged that even the most talented teacher or physician will not be able to make a measurable difference in their outcome.

Sean F. Reardon, professor of education and sociology at Stanford, has written in the New York Times about the widening gap between disadvantaged children and the privileged few ("No Rich Child Left Behind," April 27, 2013). It is no surprise that children from rich families get higher grades on standardized tests. And, Mr. Reardon writes, "family income is a better predictor of children’s success in school than race." He adds that the gap between rich and poor kids’ performance has increased by 40% in the last 30 years. It is interesting that this gap between the poor and middle-income levels is decreasing but the discrepancy between the middle class and the rich has grown.

Mr. Reardon provides some convincing evidence that "schools don’t seem to produce much of the disparity." Schools are unlikely to provide the route out of poverty for the disadvantaged child, he maintains, adding that "rising income inequality explains, at best, half of the increase in the rich-poor academic achievement gap."

One factor that might explain some of the disparity is that rich families have been increasing the time and money they spend on enriching activities for their children at a much faster rate than that of poor and middle class families. The rich seem to have taken our messages about the importance of early development more seriously and have bought Baby Einsteins, limited television exposure, and read "Goodnight Moon" until their eyes no longer focused. While not of all their investments have made a difference, the sheer volume of their efforts has paid off in better school success.

Mr. Reardon suggests that we rethink "our still-persistent notion that educational problems should be solved by schools alone." Instead he recommends that we emulate rich parents and "invest as a society in our children’s education from the day they are born." His recommendation clearly lobs at least one ball into our court, because as pediatricians we have an early and influential relationship with families during those critical first thousand days of a child’s life. We must redouble our efforts at encouraging parents to provide an enriching environment for their children, and we need to provide them with the strategies for creating that environment.

Because many parents can’t or don’t follow through with our recommendations, we must continue to advocate for government programs that provide early educational enrichment for their children. Recently, some politicians have suggested that we limit or eliminate Head Start, because there is a study or two that suggest it may not be effective. If these studies are valid (which I doubt), I suspect Mr. Reardon would say that by the time a child was old enough for Head Start the die would be cast.

We are in a position to do our colleagues in education a big favor by helping to provide more children who are ready to benefit from their skills. Their outcomes will look better, and in a generation we will be repaid with a cohort of better-educated parents who will make us look better when it comes time to judge our outcomes.

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

Over the last decade I have felt a growing kinship with teachers. We face challenges from the government and third-party payers to demonstrate the quality of our service by assessing the outcomes of our patients. Likewise, teachers are being rated by how well their students perform on "standardized" tests.

While theoretically the philosophy behind using outcomes to rate quality makes sense, it doesn’t as well with education and health care delivery as it does with automobile assembly plants. An overemphasis on outcomes fails to acknowledge the fact that some children arrive at our offices and schools so disadvantaged that even the most talented teacher or physician will not be able to make a measurable difference in their outcome.

Sean F. Reardon, professor of education and sociology at Stanford, has written in the New York Times about the widening gap between disadvantaged children and the privileged few ("No Rich Child Left Behind," April 27, 2013). It is no surprise that children from rich families get higher grades on standardized tests. And, Mr. Reardon writes, "family income is a better predictor of children’s success in school than race." He adds that the gap between rich and poor kids’ performance has increased by 40% in the last 30 years. It is interesting that this gap between the poor and middle-income levels is decreasing but the discrepancy between the middle class and the rich has grown.

Mr. Reardon provides some convincing evidence that "schools don’t seem to produce much of the disparity." Schools are unlikely to provide the route out of poverty for the disadvantaged child, he maintains, adding that "rising income inequality explains, at best, half of the increase in the rich-poor academic achievement gap."

One factor that might explain some of the disparity is that rich families have been increasing the time and money they spend on enriching activities for their children at a much faster rate than that of poor and middle class families. The rich seem to have taken our messages about the importance of early development more seriously and have bought Baby Einsteins, limited television exposure, and read "Goodnight Moon" until their eyes no longer focused. While not of all their investments have made a difference, the sheer volume of their efforts has paid off in better school success.

Mr. Reardon suggests that we rethink "our still-persistent notion that educational problems should be solved by schools alone." Instead he recommends that we emulate rich parents and "invest as a society in our children’s education from the day they are born." His recommendation clearly lobs at least one ball into our court, because as pediatricians we have an early and influential relationship with families during those critical first thousand days of a child’s life. We must redouble our efforts at encouraging parents to provide an enriching environment for their children, and we need to provide them with the strategies for creating that environment.

Because many parents can’t or don’t follow through with our recommendations, we must continue to advocate for government programs that provide early educational enrichment for their children. Recently, some politicians have suggested that we limit or eliminate Head Start, because there is a study or two that suggest it may not be effective. If these studies are valid (which I doubt), I suspect Mr. Reardon would say that by the time a child was old enough for Head Start the die would be cast.

We are in a position to do our colleagues in education a big favor by helping to provide more children who are ready to benefit from their skills. Their outcomes will look better, and in a generation we will be repaid with a cohort of better-educated parents who will make us look better when it comes time to judge our outcomes.

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

The introductions had been made and I had finished taking the history from this nervous 5-year-old and his mother, neither of whom I had met before. I was about to begin my exam when I noticed that the window on the head of my ophthalmoscope was loose. A simple tightening of the little screw should do the trick. I reached into my pocket, pulled out my 2½-inch penknife, and began to open it. The patient screamed and clung to his mother with a death grip.

It turns out that just as I was entering the exam room, the mother and son were finishing a discussion about doctors and knives. Somehow, the preschooler had heard about doctors doing amputations. I suspect an older brother or playmate had planted the seed of fear in the fertile soil of this young man’s imagination. The mother had reassured him that this new doctor didn’t do amputations and certainly didn’t have a knife. It took a few minutes of intense reassurance and a promise from me to leave the knife in the sink before I was able to gently pry the patient from his mother so that I could examine him.

I have carried a small single-blade penknife in my right front pants pocket for most of my adult life. Although I was only a Boy Scout for a couple of years, clearly those were formative years, and I have always tried to "be prepared." Letters must be opened, apples quartered, impenetrable blister packs penetrated, and loose screws tightened. Armed with a penknife, I am like MacGyver: ready for the next challenge to survive.

For those of us who have been habitual knife carriers, the Transportation Security Administration regulations in the wake of 9/11 have left us feeling naked and vulnerable when we travel. Some disarmed travelers have even taken the rash step of checking their carry-ons to avoid the insecurity of traveling knifeless. But I have learned to cope with my vulnerability and even believe the TSA is making a mistake with their recent plan to remove small penknives from their no-fly list.

I still carry a penknife when I’m at home and in the office and often use it to rescue myself and coworkers from minor catastrophes. But when the metal must meet the patient and sterility is important, my weaponry expands to include a No. 10 blade for shaving warts and a No. 11 blade for lancing large boils. I prefer to use these blades without their handles. While this does slightly increase the risk to my own skin, it has the advantage of making the weapon much less menacing to the patient.

However, my favorite sharp instrument is a lancet. You know, the ones that are usually encased in blue or white plastic and have a twist-off cap of matching color. They are the ultimate in stealth weaponry. They appear to be just innocuous little pieces of plastic. Even with the cap removed, the blade is difficult to see. One doesn’t have to be much of a magician to keep the business end of this little tool from the inquisitive eyes of nervous patients.

Actually, when it comes to sharps, all patients are nervous.

But lancets are excellent tools for incising small blisters. They are particularly effective for teasing out splinters. Although they were designed to puncture, lancets actually have a surprisingly useful cutting edge. Unfortunately, the development of mechanical spring-loaded lancets has made these little wonder tools difficult to find. I have hoarded all the ones I can put my hands on. We old Boy Scouts always want to be prepared.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

The introductions had been made and I had finished taking the history from this nervous 5-year-old and his mother, neither of whom I had met before. I was about to begin my exam when I noticed that the window on the head of my ophthalmoscope was loose. A simple tightening of the little screw should do the trick. I reached into my pocket, pulled out my 2½-inch penknife, and began to open it. The patient screamed and clung to his mother with a death grip.

It turns out that just as I was entering the exam room, the mother and son were finishing a discussion about doctors and knives. Somehow, the preschooler had heard about doctors doing amputations. I suspect an older brother or playmate had planted the seed of fear in the fertile soil of this young man’s imagination. The mother had reassured him that this new doctor didn’t do amputations and certainly didn’t have a knife. It took a few minutes of intense reassurance and a promise from me to leave the knife in the sink before I was able to gently pry the patient from his mother so that I could examine him.

I have carried a small single-blade penknife in my right front pants pocket for most of my adult life. Although I was only a Boy Scout for a couple of years, clearly those were formative years, and I have always tried to "be prepared." Letters must be opened, apples quartered, impenetrable blister packs penetrated, and loose screws tightened. Armed with a penknife, I am like MacGyver: ready for the next challenge to survive.

For those of us who have been habitual knife carriers, the Transportation Security Administration regulations in the wake of 9/11 have left us feeling naked and vulnerable when we travel. Some disarmed travelers have even taken the rash step of checking their carry-ons to avoid the insecurity of traveling knifeless. But I have learned to cope with my vulnerability and even believe the TSA is making a mistake with their recent plan to remove small penknives from their no-fly list.

I still carry a penknife when I’m at home and in the office and often use it to rescue myself and coworkers from minor catastrophes. But when the metal must meet the patient and sterility is important, my weaponry expands to include a No. 10 blade for shaving warts and a No. 11 blade for lancing large boils. I prefer to use these blades without their handles. While this does slightly increase the risk to my own skin, it has the advantage of making the weapon much less menacing to the patient.

However, my favorite sharp instrument is a lancet. You know, the ones that are usually encased in blue or white plastic and have a twist-off cap of matching color. They are the ultimate in stealth weaponry. They appear to be just innocuous little pieces of plastic. Even with the cap removed, the blade is difficult to see. One doesn’t have to be much of a magician to keep the business end of this little tool from the inquisitive eyes of nervous patients.

Actually, when it comes to sharps, all patients are nervous.

But lancets are excellent tools for incising small blisters. They are particularly effective for teasing out splinters. Although they were designed to puncture, lancets actually have a surprisingly useful cutting edge. Unfortunately, the development of mechanical spring-loaded lancets has made these little wonder tools difficult to find. I have hoarded all the ones I can put my hands on. We old Boy Scouts always want to be prepared.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

The introductions had been made and I had finished taking the history from this nervous 5-year-old and his mother, neither of whom I had met before. I was about to begin my exam when I noticed that the window on the head of my ophthalmoscope was loose. A simple tightening of the little screw should do the trick. I reached into my pocket, pulled out my 2½-inch penknife, and began to open it. The patient screamed and clung to his mother with a death grip.

It turns out that just as I was entering the exam room, the mother and son were finishing a discussion about doctors and knives. Somehow, the preschooler had heard about doctors doing amputations. I suspect an older brother or playmate had planted the seed of fear in the fertile soil of this young man’s imagination. The mother had reassured him that this new doctor didn’t do amputations and certainly didn’t have a knife. It took a few minutes of intense reassurance and a promise from me to leave the knife in the sink before I was able to gently pry the patient from his mother so that I could examine him.

I have carried a small single-blade penknife in my right front pants pocket for most of my adult life. Although I was only a Boy Scout for a couple of years, clearly those were formative years, and I have always tried to "be prepared." Letters must be opened, apples quartered, impenetrable blister packs penetrated, and loose screws tightened. Armed with a penknife, I am like MacGyver: ready for the next challenge to survive.

For those of us who have been habitual knife carriers, the Transportation Security Administration regulations in the wake of 9/11 have left us feeling naked and vulnerable when we travel. Some disarmed travelers have even taken the rash step of checking their carry-ons to avoid the insecurity of traveling knifeless. But I have learned to cope with my vulnerability and even believe the TSA is making a mistake with their recent plan to remove small penknives from their no-fly list.

I still carry a penknife when I’m at home and in the office and often use it to rescue myself and coworkers from minor catastrophes. But when the metal must meet the patient and sterility is important, my weaponry expands to include a No. 10 blade for shaving warts and a No. 11 blade for lancing large boils. I prefer to use these blades without their handles. While this does slightly increase the risk to my own skin, it has the advantage of making the weapon much less menacing to the patient.

However, my favorite sharp instrument is a lancet. You know, the ones that are usually encased in blue or white plastic and have a twist-off cap of matching color. They are the ultimate in stealth weaponry. They appear to be just innocuous little pieces of plastic. Even with the cap removed, the blade is difficult to see. One doesn’t have to be much of a magician to keep the business end of this little tool from the inquisitive eyes of nervous patients.

Actually, when it comes to sharps, all patients are nervous.

But lancets are excellent tools for incising small blisters. They are particularly effective for teasing out splinters. Although they were designed to puncture, lancets actually have a surprisingly useful cutting edge. Unfortunately, the development of mechanical spring-loaded lancets has made these little wonder tools difficult to find. I have hoarded all the ones I can put my hands on. We old Boy Scouts always want to be prepared.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

This spring, I met with the administrator of a nonprofit group that hopes to increase science literacy through an extensive outreach effort to Maine’s libraries. Its current project is based on the human body. I had been invited to share my experience as a pediatrician and suggest how a visit to the doctor might serve as a framework on which to hang hands-on activities for school-age children.

Our entire population’s science literacy is embarrassingly deficient, and this sounded like an interesting project. But, as I walked downtown for the meeting, I began to question how much of what I did in the office would qualify as science. The administrator introduced herself, and after she told me the history of the group and about its successes and challenges, it was my turn. I began with a disclaimer.

"I was an art-history major in college. And although at some points I was trained by scientists, I don’t consider myself one." Once she had digested what was to her a surprising revelation, we brainstormed for an hour that I hope will result in some stimulating activities that will further the group’s mission.

As I walked back home, I began to wonder whether my perspective on the role of science in my work would have been a surprise to other physicians. And, if I wasn’t a scientist, what was I?

My 1968 edition of Webster’s New World Dictionary defines science as "systematized knowledge derived from observations and experimentation to determine the nature or principles of what is being studied." While I try to be observant and learn from my observations, I don’t have a system. I’m certainly not doing any controlled and reproducible experiments. "Anecdotal" pretty much sums up my observations.

Although I know that some of you are involved with other physicians in small groups doing office-based research, most of us are not. And those of you who are members of very large groups such as Kaiser-Permanente are contributing data to large-scale inquiries that certainly qualify as science. However, I’m not sure that as data collectors, you would claim to be scientists.

While it may not qualify as true science, most of us have done our own little uncontrolled "experiments" in which we try a different therapy if the one we have used a few times doesn’t seem to have been successful. But the practice of medicine is becoming more centralized. Care maps, algorithms, templates, and checklists have reduced the practice of front-line medicine to little more than following evidence-based cookbooks. Many of these changes have resulted in better outcomes as measured by death and complication rates. Even if our little "experiments" were only yielding pseudoscience, this shift to standardization has eliminated them, and squeezed intellectual curiosity out of the professional lives of most physicians.

So if we can no longer claim to be scientists, what would we like to be called? I guess we can legitimately qualify as "practitioners," or one of my least favorite words, "providers." The term "doctor" doesn’t really do much for me anymore. The privilege of posting two or three extra letters after one’s name doesn’t imply much more than the person has had the stamina to stay in school longer than most people with good sense. And "doctor" unfairly excludes skilled nurse practitioners.I returned to Mr. Webster for my own answer. He says that an artist is "a person who does anything very well, with a feeling for form, effect, etc." While a medical education must include information that can be discovered only by scientists, armed with that knowledge, it is up to the individual to apply it with sensitivity. I can think of no greater praise for a physician than to say, "He was an artist."

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

This spring, I met with the administrator of a nonprofit group that hopes to increase science literacy through an extensive outreach effort to Maine’s libraries. Its current project is based on the human body. I had been invited to share my experience as a pediatrician and suggest how a visit to the doctor might serve as a framework on which to hang hands-on activities for school-age children.

Our entire population’s science literacy is embarrassingly deficient, and this sounded like an interesting project. But, as I walked downtown for the meeting, I began to question how much of what I did in the office would qualify as science. The administrator introduced herself, and after she told me the history of the group and about its successes and challenges, it was my turn. I began with a disclaimer.

"I was an art-history major in college. And although at some points I was trained by scientists, I don’t consider myself one." Once she had digested what was to her a surprising revelation, we brainstormed for an hour that I hope will result in some stimulating activities that will further the group’s mission.

As I walked back home, I began to wonder whether my perspective on the role of science in my work would have been a surprise to other physicians. And, if I wasn’t a scientist, what was I?

My 1968 edition of Webster’s New World Dictionary defines science as "systematized knowledge derived from observations and experimentation to determine the nature or principles of what is being studied." While I try to be observant and learn from my observations, I don’t have a system. I’m certainly not doing any controlled and reproducible experiments. "Anecdotal" pretty much sums up my observations.

Although I know that some of you are involved with other physicians in small groups doing office-based research, most of us are not. And those of you who are members of very large groups such as Kaiser-Permanente are contributing data to large-scale inquiries that certainly qualify as science. However, I’m not sure that as data collectors, you would claim to be scientists.

While it may not qualify as true science, most of us have done our own little uncontrolled "experiments" in which we try a different therapy if the one we have used a few times doesn’t seem to have been successful. But the practice of medicine is becoming more centralized. Care maps, algorithms, templates, and checklists have reduced the practice of front-line medicine to little more than following evidence-based cookbooks. Many of these changes have resulted in better outcomes as measured by death and complication rates. Even if our little "experiments" were only yielding pseudoscience, this shift to standardization has eliminated them, and squeezed intellectual curiosity out of the professional lives of most physicians.

So if we can no longer claim to be scientists, what would we like to be called? I guess we can legitimately qualify as "practitioners," or one of my least favorite words, "providers." The term "doctor" doesn’t really do much for me anymore. The privilege of posting two or three extra letters after one’s name doesn’t imply much more than the person has had the stamina to stay in school longer than most people with good sense. And "doctor" unfairly excludes skilled nurse practitioners.I returned to Mr. Webster for my own answer. He says that an artist is "a person who does anything very well, with a feeling for form, effect, etc." While a medical education must include information that can be discovered only by scientists, armed with that knowledge, it is up to the individual to apply it with sensitivity. I can think of no greater praise for a physician than to say, "He was an artist."

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

This spring, I met with the administrator of a nonprofit group that hopes to increase science literacy through an extensive outreach effort to Maine’s libraries. Its current project is based on the human body. I had been invited to share my experience as a pediatrician and suggest how a visit to the doctor might serve as a framework on which to hang hands-on activities for school-age children.

Our entire population’s science literacy is embarrassingly deficient, and this sounded like an interesting project. But, as I walked downtown for the meeting, I began to question how much of what I did in the office would qualify as science. The administrator introduced herself, and after she told me the history of the group and about its successes and challenges, it was my turn. I began with a disclaimer.

"I was an art-history major in college. And although at some points I was trained by scientists, I don’t consider myself one." Once she had digested what was to her a surprising revelation, we brainstormed for an hour that I hope will result in some stimulating activities that will further the group’s mission.

As I walked back home, I began to wonder whether my perspective on the role of science in my work would have been a surprise to other physicians. And, if I wasn’t a scientist, what was I?

My 1968 edition of Webster’s New World Dictionary defines science as "systematized knowledge derived from observations and experimentation to determine the nature or principles of what is being studied." While I try to be observant and learn from my observations, I don’t have a system. I’m certainly not doing any controlled and reproducible experiments. "Anecdotal" pretty much sums up my observations.

Although I know that some of you are involved with other physicians in small groups doing office-based research, most of us are not. And those of you who are members of very large groups such as Kaiser-Permanente are contributing data to large-scale inquiries that certainly qualify as science. However, I’m not sure that as data collectors, you would claim to be scientists.

While it may not qualify as true science, most of us have done our own little uncontrolled "experiments" in which we try a different therapy if the one we have used a few times doesn’t seem to have been successful. But the practice of medicine is becoming more centralized. Care maps, algorithms, templates, and checklists have reduced the practice of front-line medicine to little more than following evidence-based cookbooks. Many of these changes have resulted in better outcomes as measured by death and complication rates. Even if our little "experiments" were only yielding pseudoscience, this shift to standardization has eliminated them, and squeezed intellectual curiosity out of the professional lives of most physicians.

So if we can no longer claim to be scientists, what would we like to be called? I guess we can legitimately qualify as "practitioners," or one of my least favorite words, "providers." The term "doctor" doesn’t really do much for me anymore. The privilege of posting two or three extra letters after one’s name doesn’t imply much more than the person has had the stamina to stay in school longer than most people with good sense. And "doctor" unfairly excludes skilled nurse practitioners.I returned to Mr. Webster for my own answer. He says that an artist is "a person who does anything very well, with a feeling for form, effect, etc." While a medical education must include information that can be discovered only by scientists, armed with that knowledge, it is up to the individual to apply it with sensitivity. I can think of no greater praise for a physician than to say, "He was an artist."

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

"You’re my hero, doctor!" The comment came as quite a surprise because I had only just met the adulator and I was currently in the process of scooping some soft wax out of her 2-year-old’s ear with a curette.

It turns out that she and her family had recently moved to Brunswick from an extremely populous city on the East Coast. According to her, the pediatrician they had been seeing didn’t remove cerumen. Instead, she would have to take her son to an ear-nose-and-throat specialist for this procedure. She had always wondered why the pediatrician hadn’t been doing what she saw as a rather simple but critical task. This mother’s experience is unusual, but it represents the tip of what I suspect is a rather embarrassing iceberg.

In recent months we have seen another surge of suggestions/guidelines to help us improve our ability to accurately diagnose acute otitis media (AOM). One study suggests that bilaterality doesn’t necessarily indicate that the child needs to be treated. In February, the American Academy of Pediatrics published a new clinical practice guideline for AOM diagnosis and treatment (Pediatrics 2013;131:e964-e999 [doi:10.1542/peds.2012-3488]). This newspaper’s headline on the story about this read, "Tympanic membrane now is key to AOM diagnosis" (Pediatric News, March 2013, p. 1).

As I read and reread the headline, I kept asking myself, "What did the key used to be?" I always thought that I was supposed to be looking at the tympanic membranes to make a diagnosis of AOM. Over the last three and a half decades of looking in ears, however, I have come to realize that there must be a significant number of physicians who aren’t seeing tympanic membranes when they examine ears.

Now, I’m not talking about the situation in which one physician has seen a normal tympanic membrane at 4 in the afternoon and at 7 in the morning the same ear has drained. I know that infections can advance that rapidly – I’ve seen it myself scores of times. And no, I’m not talking about the situation when a small flake of wax can fall off the wall of the canal and obscure a clear view of the tympanic membrane that the previous observer reported. It happens.

What I’m talking about is a child has been diagnosed with an otitis on one day and on the next day I must remove a significant collection of cerumen to visualize what is often a normal tympanic membrane. I am at a loss to explain this phenomenon using accepted anatomic and physiologic principles. Cerumen doesn’t accumulate that rapidly, nor do tympanic membranes miraculously heal.

When it comes to the diagnosis and treatment of AOM, the elephant in the room is cerumen. We can talk about the appearance and the mobility of the drum until we are blue in the face, but a significant fact is that too many physicians are accepting a cerumen-obscured view of the tympanic membrane.

Removing cerumen isn’t always easy, and yes, from time to time it can be uncomfortable for the child. Rarely, there may be a small amount of bleeding. But if you want to make an accurate diagnosis, "ya gotta do it!"

Clearly, cerumen removal and insufflation have become lost skills. In many cases, they were never there to be lost, but it’s not too late to learn or relearn them. Find someone in the community who is skilled with a curette to show you his or her tricks. (I’d be happy to share some of mine.) Experiment with several different types to discover a style that works best for you. Practice the skill during well-child visits by removing insignificant collections of cerumen when there is less pressure. It takes time, "soft" hands, and plenty of patience. With time, though, families and patients become more accustomed to the process.

Acute bacterial rhinosinusitis has no objective physical findings, so making the diagnosis doesn’t require much skill, but if you truly want make an accurate diagnosis of AOM, you must see the tympanic membrane. And this is likely to mean removing some cerumen. "Ya gotta do it!"

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

"You’re my hero, doctor!" The comment came as quite a surprise because I had only just met the adulator and I was currently in the process of scooping some soft wax out of her 2-year-old’s ear with a curette.

It turns out that she and her family had recently moved to Brunswick from an extremely populous city on the East Coast. According to her, the pediatrician they had been seeing didn’t remove cerumen. Instead, she would have to take her son to an ear-nose-and-throat specialist for this procedure. She had always wondered why the pediatrician hadn’t been doing what she saw as a rather simple but critical task. This mother’s experience is unusual, but it represents the tip of what I suspect is a rather embarrassing iceberg.

In recent months we have seen another surge of suggestions/guidelines to help us improve our ability to accurately diagnose acute otitis media (AOM). One study suggests that bilaterality doesn’t necessarily indicate that the child needs to be treated. In February, the American Academy of Pediatrics published a new clinical practice guideline for AOM diagnosis and treatment (Pediatrics 2013;131:e964-e999 [doi:10.1542/peds.2012-3488]). This newspaper’s headline on the story about this read, "Tympanic membrane now is key to AOM diagnosis" (Pediatric News, March 2013, p. 1).

As I read and reread the headline, I kept asking myself, "What did the key used to be?" I always thought that I was supposed to be looking at the tympanic membranes to make a diagnosis of AOM. Over the last three and a half decades of looking in ears, however, I have come to realize that there must be a significant number of physicians who aren’t seeing tympanic membranes when they examine ears.

Now, I’m not talking about the situation in which one physician has seen a normal tympanic membrane at 4 in the afternoon and at 7 in the morning the same ear has drained. I know that infections can advance that rapidly – I’ve seen it myself scores of times. And no, I’m not talking about the situation when a small flake of wax can fall off the wall of the canal and obscure a clear view of the tympanic membrane that the previous observer reported. It happens.

What I’m talking about is a child has been diagnosed with an otitis on one day and on the next day I must remove a significant collection of cerumen to visualize what is often a normal tympanic membrane. I am at a loss to explain this phenomenon using accepted anatomic and physiologic principles. Cerumen doesn’t accumulate that rapidly, nor do tympanic membranes miraculously heal.

When it comes to the diagnosis and treatment of AOM, the elephant in the room is cerumen. We can talk about the appearance and the mobility of the drum until we are blue in the face, but a significant fact is that too many physicians are accepting a cerumen-obscured view of the tympanic membrane.

Removing cerumen isn’t always easy, and yes, from time to time it can be uncomfortable for the child. Rarely, there may be a small amount of bleeding. But if you want to make an accurate diagnosis, "ya gotta do it!"

Clearly, cerumen removal and insufflation have become lost skills. In many cases, they were never there to be lost, but it’s not too late to learn or relearn them. Find someone in the community who is skilled with a curette to show you his or her tricks. (I’d be happy to share some of mine.) Experiment with several different types to discover a style that works best for you. Practice the skill during well-child visits by removing insignificant collections of cerumen when there is less pressure. It takes time, "soft" hands, and plenty of patience. With time, though, families and patients become more accustomed to the process.

Acute bacterial rhinosinusitis has no objective physical findings, so making the diagnosis doesn’t require much skill, but if you truly want make an accurate diagnosis of AOM, you must see the tympanic membrane. And this is likely to mean removing some cerumen. "Ya gotta do it!"

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

"You’re my hero, doctor!" The comment came as quite a surprise because I had only just met the adulator and I was currently in the process of scooping some soft wax out of her 2-year-old’s ear with a curette.

It turns out that she and her family had recently moved to Brunswick from an extremely populous city on the East Coast. According to her, the pediatrician they had been seeing didn’t remove cerumen. Instead, she would have to take her son to an ear-nose-and-throat specialist for this procedure. She had always wondered why the pediatrician hadn’t been doing what she saw as a rather simple but critical task. This mother’s experience is unusual, but it represents the tip of what I suspect is a rather embarrassing iceberg.

In recent months we have seen another surge of suggestions/guidelines to help us improve our ability to accurately diagnose acute otitis media (AOM). One study suggests that bilaterality doesn’t necessarily indicate that the child needs to be treated. In February, the American Academy of Pediatrics published a new clinical practice guideline for AOM diagnosis and treatment (Pediatrics 2013;131:e964-e999 [doi:10.1542/peds.2012-3488]). This newspaper’s headline on the story about this read, "Tympanic membrane now is key to AOM diagnosis" (Pediatric News, March 2013, p. 1).

As I read and reread the headline, I kept asking myself, "What did the key used to be?" I always thought that I was supposed to be looking at the tympanic membranes to make a diagnosis of AOM. Over the last three and a half decades of looking in ears, however, I have come to realize that there must be a significant number of physicians who aren’t seeing tympanic membranes when they examine ears.

Now, I’m not talking about the situation in which one physician has seen a normal tympanic membrane at 4 in the afternoon and at 7 in the morning the same ear has drained. I know that infections can advance that rapidly – I’ve seen it myself scores of times. And no, I’m not talking about the situation when a small flake of wax can fall off the wall of the canal and obscure a clear view of the tympanic membrane that the previous observer reported. It happens.

What I’m talking about is a child has been diagnosed with an otitis on one day and on the next day I must remove a significant collection of cerumen to visualize what is often a normal tympanic membrane. I am at a loss to explain this phenomenon using accepted anatomic and physiologic principles. Cerumen doesn’t accumulate that rapidly, nor do tympanic membranes miraculously heal.

When it comes to the diagnosis and treatment of AOM, the elephant in the room is cerumen. We can talk about the appearance and the mobility of the drum until we are blue in the face, but a significant fact is that too many physicians are accepting a cerumen-obscured view of the tympanic membrane.

Removing cerumen isn’t always easy, and yes, from time to time it can be uncomfortable for the child. Rarely, there may be a small amount of bleeding. But if you want to make an accurate diagnosis, "ya gotta do it!"

Clearly, cerumen removal and insufflation have become lost skills. In many cases, they were never there to be lost, but it’s not too late to learn or relearn them. Find someone in the community who is skilled with a curette to show you his or her tricks. (I’d be happy to share some of mine.) Experiment with several different types to discover a style that works best for you. Practice the skill during well-child visits by removing insignificant collections of cerumen when there is less pressure. It takes time, "soft" hands, and plenty of patience. With time, though, families and patients become more accustomed to the process.

Acute bacterial rhinosinusitis has no objective physical findings, so making the diagnosis doesn’t require much skill, but if you truly want make an accurate diagnosis of AOM, you must see the tympanic membrane. And this is likely to mean removing some cerumen. "Ya gotta do it!"

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

Last week I found a story in the New York Times about a recent study by Centers for Disease Control and Prevention epidemiologists on the introduction of solid food to infants. Although the study was widely reported by other media outlets, it took me more than a week to discover the original journal article ("Prevalence and reasons for introducing infants early to solid food: Variations by milk feeding type [Pediatrics 2013;131:e1108]). The authors reported that 40% of the 1,334 mothers surveyed fed their babies solid food before 4 months of age, and 9% started as early as 4 weeks.

The mothers who introduced solids prior to 4 months were more likely to be young, less educated, and unmarried. The reasons that mothers gave were that they felt their baby was old enough, or seemed hungry, or they felt their infant would sleep longer if given solids. More than 50% of the mothers who introduced solids early replied affirmatively to the statement, "A doctor or health professional said my baby should begin eating solid food."

Like most surveys of this type, the results should come as no surprise to primary care pediatricians who see families from a broad mix of socioeconomic backgrounds. I also suspect that the investigators would have reported similar results had the study been performed 20 years ago. I think it’s risky to interpret their current results from such a small sample. What troubles me more is that some of the media reports I read as I hunted for the original article suggested that physicians and other health care providers aren’t doing a good job of educating and supporting young mothers. I suspect that there are few health care providers who have somehow navigated their training without hearing the good word about the introduction of solids. But the rest of us have gotten the message and are doing our best to see that our patients benefit from it. I wonder what the result would have been had the question been presented as two separate statements, one worded "should ..." and the other "was okay to start solids."

It is interesting that the mothers who were feeding only formula were more likely to report that a health care provider told them to start solids early than those who were solely breastfeeding (61.4% vs. 50.8%). This might suggest that the early introducers weren’t listening to the professional advice from the beginning.

Of course we could always do a better job, but I suspect the authors, who are epidemiologists, may be underestimating the strength of the current that primary care pediatricians are swimming against. They reported that just under 20% of the early introducers responded that relatives or friends told them that their babies should be eating solids. They did acknowledge that economics and lack of education are major contributors to the problem. But I think they are underestimating the strength of the grandmother factor. Even in stable, economically secure, two-parent families, grandparents, aunts, and uncles often provide unsolicited advice on feeding the newest buds on the family tree. But when a mother is unmarried and poor, it is very likely that a grandmother has significant influence over the food choices. It is difficult to contradict a grandmother’s advice, and even more difficult if she doesn’t attend the office visits.

For the better-educated mother who is nursing her baby, a dwindling milk supply that often comes with the return to work creates other pressures to add solids that must be considered. Given the choice between the expensive expletive (the f-word) and a few solids, the latter may seem to be (and arguably could be) the better choice. If I see a baby at his 4-month visit who had been offered a couple of spoonfuls of cereal the week before, am I going to climb on my soapbox? No, I am going to urge the family to take it slow and move on to other issues that are troubling them.

One of the best ways to avoid the whole situation is to make it very clear during the first few weeks of life that we feed our babies so they will grow, not so they will sleep better. By separating sleeping from eating, children are less likely to be overfed and their parents, sleep deprived.

Six months has always seemed to me to be an unreasonable target for us to set as a universal target for the introduction of solids. Common sense and individualization result in a better outcome. The recent evidence about late introduction of solids and the increased risk of allergy and celiac disease should make us all think more broadly as we craft our advice.

Last week I found a story in the New York Times about a recent study by Centers for Disease Control and Prevention epidemiologists on the introduction of solid food to infants. Although the study was widely reported by other media outlets, it took me more than a week to discover the original journal article ("Prevalence and reasons for introducing infants early to solid food: Variations by milk feeding type [Pediatrics 2013;131:e1108]). The authors reported that 40% of the 1,334 mothers surveyed fed their babies solid food before 4 months of age, and 9% started as early as 4 weeks.

The mothers who introduced solids prior to 4 months were more likely to be young, less educated, and unmarried. The reasons that mothers gave were that they felt their baby was old enough, or seemed hungry, or they felt their infant would sleep longer if given solids. More than 50% of the mothers who introduced solids early replied affirmatively to the statement, "A doctor or health professional said my baby should begin eating solid food."

Like most surveys of this type, the results should come as no surprise to primary care pediatricians who see families from a broad mix of socioeconomic backgrounds. I also suspect that the investigators would have reported similar results had the study been performed 20 years ago. I think it’s risky to interpret their current results from such a small sample. What troubles me more is that some of the media reports I read as I hunted for the original article suggested that physicians and other health care providers aren’t doing a good job of educating and supporting young mothers. I suspect that there are few health care providers who have somehow navigated their training without hearing the good word about the introduction of solids. But the rest of us have gotten the message and are doing our best to see that our patients benefit from it. I wonder what the result would have been had the question been presented as two separate statements, one worded "should ..." and the other "was okay to start solids."

It is interesting that the mothers who were feeding only formula were more likely to report that a health care provider told them to start solids early than those who were solely breastfeeding (61.4% vs. 50.8%). This might suggest that the early introducers weren’t listening to the professional advice from the beginning.

Of course we could always do a better job, but I suspect the authors, who are epidemiologists, may be underestimating the strength of the current that primary care pediatricians are swimming against. They reported that just under 20% of the early introducers responded that relatives or friends told them that their babies should be eating solids. They did acknowledge that economics and lack of education are major contributors to the problem. But I think they are underestimating the strength of the grandmother factor. Even in stable, economically secure, two-parent families, grandparents, aunts, and uncles often provide unsolicited advice on feeding the newest buds on the family tree. But when a mother is unmarried and poor, it is very likely that a grandmother has significant influence over the food choices. It is difficult to contradict a grandmother’s advice, and even more difficult if she doesn’t attend the office visits.

For the better-educated mother who is nursing her baby, a dwindling milk supply that often comes with the return to work creates other pressures to add solids that must be considered. Given the choice between the expensive expletive (the f-word) and a few solids, the latter may seem to be (and arguably could be) the better choice. If I see a baby at his 4-month visit who had been offered a couple of spoonfuls of cereal the week before, am I going to climb on my soapbox? No, I am going to urge the family to take it slow and move on to other issues that are troubling them.

One of the best ways to avoid the whole situation is to make it very clear during the first few weeks of life that we feed our babies so they will grow, not so they will sleep better. By separating sleeping from eating, children are less likely to be overfed and their parents, sleep deprived.

Six months has always seemed to me to be an unreasonable target for us to set as a universal target for the introduction of solids. Common sense and individualization result in a better outcome. The recent evidence about late introduction of solids and the increased risk of allergy and celiac disease should make us all think more broadly as we craft our advice.

Last week I found a story in the New York Times about a recent study by Centers for Disease Control and Prevention epidemiologists on the introduction of solid food to infants. Although the study was widely reported by other media outlets, it took me more than a week to discover the original journal article ("Prevalence and reasons for introducing infants early to solid food: Variations by milk feeding type [Pediatrics 2013;131:e1108]). The authors reported that 40% of the 1,334 mothers surveyed fed their babies solid food before 4 months of age, and 9% started as early as 4 weeks.

The mothers who introduced solids prior to 4 months were more likely to be young, less educated, and unmarried. The reasons that mothers gave were that they felt their baby was old enough, or seemed hungry, or they felt their infant would sleep longer if given solids. More than 50% of the mothers who introduced solids early replied affirmatively to the statement, "A doctor or health professional said my baby should begin eating solid food."

Like most surveys of this type, the results should come as no surprise to primary care pediatricians who see families from a broad mix of socioeconomic backgrounds. I also suspect that the investigators would have reported similar results had the study been performed 20 years ago. I think it’s risky to interpret their current results from such a small sample. What troubles me more is that some of the media reports I read as I hunted for the original article suggested that physicians and other health care providers aren’t doing a good job of educating and supporting young mothers. I suspect that there are few health care providers who have somehow navigated their training without hearing the good word about the introduction of solids. But the rest of us have gotten the message and are doing our best to see that our patients benefit from it. I wonder what the result would have been had the question been presented as two separate statements, one worded "should ..." and the other "was okay to start solids."

It is interesting that the mothers who were feeding only formula were more likely to report that a health care provider told them to start solids early than those who were solely breastfeeding (61.4% vs. 50.8%). This might suggest that the early introducers weren’t listening to the professional advice from the beginning.

Of course we could always do a better job, but I suspect the authors, who are epidemiologists, may be underestimating the strength of the current that primary care pediatricians are swimming against. They reported that just under 20% of the early introducers responded that relatives or friends told them that their babies should be eating solids. They did acknowledge that economics and lack of education are major contributors to the problem. But I think they are underestimating the strength of the grandmother factor. Even in stable, economically secure, two-parent families, grandparents, aunts, and uncles often provide unsolicited advice on feeding the newest buds on the family tree. But when a mother is unmarried and poor, it is very likely that a grandmother has significant influence over the food choices. It is difficult to contradict a grandmother’s advice, and even more difficult if she doesn’t attend the office visits.

For the better-educated mother who is nursing her baby, a dwindling milk supply that often comes with the return to work creates other pressures to add solids that must be considered. Given the choice between the expensive expletive (the f-word) and a few solids, the latter may seem to be (and arguably could be) the better choice. If I see a baby at his 4-month visit who had been offered a couple of spoonfuls of cereal the week before, am I going to climb on my soapbox? No, I am going to urge the family to take it slow and move on to other issues that are troubling them.

One of the best ways to avoid the whole situation is to make it very clear during the first few weeks of life that we feed our babies so they will grow, not so they will sleep better. By separating sleeping from eating, children are less likely to be overfed and their parents, sleep deprived.

Six months has always seemed to me to be an unreasonable target for us to set as a universal target for the introduction of solids. Common sense and individualization result in a better outcome. The recent evidence about late introduction of solids and the increased risk of allergy and celiac disease should make us all think more broadly as we craft our advice.

A century ago, when solo practitioners walked the earth and practiced in offices that often doubled as their homes, patients expected that when they called their doctor, they would talk to and see their doctor, not some stranger who claimed he or she was a physician. Doctors seldom took much time off nor did they keep terribly voluminous records. Vital signs, immunization dates, and demographic data were documented. Lab work was rarely ordered and therefore rarely recorded. They scribbled notes simply to jog their memory. Most isolated solo practitioners saw little reason to keep extensive notes. In the very rare circumstance that a physician might be away, the covering physician would see patients in his or her own home or office and not have access to the records.

But time has marched on. The population has grown and clumped together in cities and suburbs. Physicians banded together into groups to allow themselves more free time. Initially, these were merely coverage arrangements, but eventually, members of the group were housed under the same roof.

For the patients, this evolution meant trade-offs. Groups meant that there was always a physician on call and responsible for their care. However, it meant becoming accustomed to often seeing an unfamiliar face. As electronic health records have become more prevalent, the chances are greater that a covering physician is going to have instant access to a patient’s medical record. This availability should provide some comfort to the patient seeing a strange physician. But medical records are typically rather cold and impersonal documents that do little to warm up a new and temporary professional relationship.

In the hospital setting, this transition from primary to covering physician is often referred to as a "handoff," and is best done as a "warm handoff" in the presence of the patient with handshakes and introductions. Obviously, this kind of transition is neither practical nor possible for the run-of-the-mill outpatient. However, for the complex case or when the parents or I are more than a little concerned, it can be very comforting to all if I can walk them down the hall and briefly introduce them to the physician who will be covering until I return. It takes time, but it is time well spent.

However, most of the time a warm handoff isn’t possible. There are other options, and this is where I think many of us could do a better job in making our medical records into what might be called living documents. There is only so much information one can convey with check boxes and templates. This is particularly true in situations in which we have discussed a Plan B or C with the family. I find that too often a physician may have told the family "if this doesn’t work I’m going to prescribe antibiotics," or "order this test" ... and then neglects to document that discussion.

I think we must be careful not to present our Plans B’s as promises to the family because they can tie the hands of the covering physician should the situation change. However, in most cases the primary physician’s plans are appropriate, but it is discomforting for the family and embarrassing to the covering physician when these discussions haven’t been documented.

In situations in which a warm handoff can’t happen or there is some uncertainty whether the medical records will be available, I know it’s old fashioned, but a short phone call to the covering physician is courteous and good medicine. The family appreciates it when they can hear, "Dr. Primary called yesterday and told me that you might be calling today."

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

A century ago, when solo practitioners walked the earth and practiced in offices that often doubled as their homes, patients expected that when they called their doctor, they would talk to and see their doctor, not some stranger who claimed he or she was a physician. Doctors seldom took much time off nor did they keep terribly voluminous records. Vital signs, immunization dates, and demographic data were documented. Lab work was rarely ordered and therefore rarely recorded. They scribbled notes simply to jog their memory. Most isolated solo practitioners saw little reason to keep extensive notes. In the very rare circumstance that a physician might be away, the covering physician would see patients in his or her own home or office and not have access to the records.

But time has marched on. The population has grown and clumped together in cities and suburbs. Physicians banded together into groups to allow themselves more free time. Initially, these were merely coverage arrangements, but eventually, members of the group were housed under the same roof.

For the patients, this evolution meant trade-offs. Groups meant that there was always a physician on call and responsible for their care. However, it meant becoming accustomed to often seeing an unfamiliar face. As electronic health records have become more prevalent, the chances are greater that a covering physician is going to have instant access to a patient’s medical record. This availability should provide some comfort to the patient seeing a strange physician. But medical records are typically rather cold and impersonal documents that do little to warm up a new and temporary professional relationship.

In the hospital setting, this transition from primary to covering physician is often referred to as a "handoff," and is best done as a "warm handoff" in the presence of the patient with handshakes and introductions. Obviously, this kind of transition is neither practical nor possible for the run-of-the-mill outpatient. However, for the complex case or when the parents or I are more than a little concerned, it can be very comforting to all if I can walk them down the hall and briefly introduce them to the physician who will be covering until I return. It takes time, but it is time well spent.

However, most of the time a warm handoff isn’t possible. There are other options, and this is where I think many of us could do a better job in making our medical records into what might be called living documents. There is only so much information one can convey with check boxes and templates. This is particularly true in situations in which we have discussed a Plan B or C with the family. I find that too often a physician may have told the family "if this doesn’t work I’m going to prescribe antibiotics," or "order this test" ... and then neglects to document that discussion.

I think we must be careful not to present our Plans B’s as promises to the family because they can tie the hands of the covering physician should the situation change. However, in most cases the primary physician’s plans are appropriate, but it is discomforting for the family and embarrassing to the covering physician when these discussions haven’t been documented.

In situations in which a warm handoff can’t happen or there is some uncertainty whether the medical records will be available, I know it’s old fashioned, but a short phone call to the covering physician is courteous and good medicine. The family appreciates it when they can hear, "Dr. Primary called yesterday and told me that you might be calling today."

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

A century ago, when solo practitioners walked the earth and practiced in offices that often doubled as their homes, patients expected that when they called their doctor, they would talk to and see their doctor, not some stranger who claimed he or she was a physician. Doctors seldom took much time off nor did they keep terribly voluminous records. Vital signs, immunization dates, and demographic data were documented. Lab work was rarely ordered and therefore rarely recorded. They scribbled notes simply to jog their memory. Most isolated solo practitioners saw little reason to keep extensive notes. In the very rare circumstance that a physician might be away, the covering physician would see patients in his or her own home or office and not have access to the records.

But time has marched on. The population has grown and clumped together in cities and suburbs. Physicians banded together into groups to allow themselves more free time. Initially, these were merely coverage arrangements, but eventually, members of the group were housed under the same roof.

For the patients, this evolution meant trade-offs. Groups meant that there was always a physician on call and responsible for their care. However, it meant becoming accustomed to often seeing an unfamiliar face. As electronic health records have become more prevalent, the chances are greater that a covering physician is going to have instant access to a patient’s medical record. This availability should provide some comfort to the patient seeing a strange physician. But medical records are typically rather cold and impersonal documents that do little to warm up a new and temporary professional relationship.

In the hospital setting, this transition from primary to covering physician is often referred to as a "handoff," and is best done as a "warm handoff" in the presence of the patient with handshakes and introductions. Obviously, this kind of transition is neither practical nor possible for the run-of-the-mill outpatient. However, for the complex case or when the parents or I are more than a little concerned, it can be very comforting to all if I can walk them down the hall and briefly introduce them to the physician who will be covering until I return. It takes time, but it is time well spent.

However, most of the time a warm handoff isn’t possible. There are other options, and this is where I think many of us could do a better job in making our medical records into what might be called living documents. There is only so much information one can convey with check boxes and templates. This is particularly true in situations in which we have discussed a Plan B or C with the family. I find that too often a physician may have told the family "if this doesn’t work I’m going to prescribe antibiotics," or "order this test" ... and then neglects to document that discussion.

I think we must be careful not to present our Plans B’s as promises to the family because they can tie the hands of the covering physician should the situation change. However, in most cases the primary physician’s plans are appropriate, but it is discomforting for the family and embarrassing to the covering physician when these discussions haven’t been documented.

In situations in which a warm handoff can’t happen or there is some uncertainty whether the medical records will be available, I know it’s old fashioned, but a short phone call to the covering physician is courteous and good medicine. The family appreciates it when they can hear, "Dr. Primary called yesterday and told me that you might be calling today."

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