William G. Wilkoff, MD

I would be very surprised if you were unfamiliar with Goodnight Moon. Either you have read it to a child or had it read to you when you were child. The dark tones of its illustrations and the gentle meter of its prose have made it a favorite with parents and children as a key ingredient of an effective bedtime ritual. But, reading doesn’t always have the same soporific effect on everyone.

From an early age, reading has always made me sleepy. When I was home in time to read my children a story at bedtime, they would often have to yell downstairs to my wife, "Mom, he’s falling asleep again." She would come up and finish the story for me. Now that I am working much less in the office, I have more stamina in the evening but my preference for dry plot-less nonfiction makes it unlikely that I will stay awake for more than a half a dozen pages.

It took me a few years before I accepted the fact that, for some of my patients, reading was keeping them awake instead of helping them fall asleep. Now, I am careful to ask children and adolescents who are having trouble falling asleep what it is they are reading. Often, the boys are reading fantasy and science fiction that they find very stimulating. The girls, on the other hand, are reading books about interpersonal relationships, but they find them just as stimulating.

While I cringe when I hear myself say the words, I find that I am suggesting to some parents that they discourage their children from reading for the hour before lights-out. But obviously, reading at bedtime is on the endangered activity list. In a recent Pediatrics, I found an article titled "Presleep Activities and Time of Sleep Onset in Children."(Pediatrics 2013;131:276-82). These New Zealand and Australian investigators found that television was the most common activity and that screen time accounted for about one-third of the 90 minutes prior to sleep onset. They also observed that children "with later sleep onset had significantly greater engagement in screen time than [did] those with earlier sleep onset."

The explanations for this observation run from the obvious stimulating effect of the content being watched to the disruptive effect that blue light emitted by the screens may have on melatonin levels. I don’t think we need to dig any deeper into the mechanisms. My anecdotal observations certainly agree with those of these researchers. But now what?

When I suggest that parents remove the television from their child’s room, I am sometimes met with answer, "He doesn’t really watch it." I reply "Well, then that should make it easy." Next, silence and a blank expression on the parents’ faces. I don’t recall any parent saying, "Hey, good idea. I’ll take it out tonight." It appears that for many families a television in a bedroom is as critical as a bed and light. I can’t imagine that they think they will need a master electrician to do the job.

Rarely, when a child’s misbehavior has been absolutely terrible, I have been able to convince parents to disconnect or remove a television from a bedroom as consequence. However, I think they agree only because they view it as a temporary measure to be undone when the child’s behavior improves. The concept of a permanent extirpation is too much to accept.

I’m not sure how we can do a better job of keeping televisions out of bedrooms. You could argue that if we just wait televisions will be pushed out by tablets and smartphones. But, it wouldn’t hurt to start by replacing every poster about the food pyramid with one about the dangers of televisions in bedrooms.

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

I would be very surprised if you were unfamiliar with Goodnight Moon. Either you have read it to a child or had it read to you when you were child. The dark tones of its illustrations and the gentle meter of its prose have made it a favorite with parents and children as a key ingredient of an effective bedtime ritual. But, reading doesn’t always have the same soporific effect on everyone.

From an early age, reading has always made me sleepy. When I was home in time to read my children a story at bedtime, they would often have to yell downstairs to my wife, "Mom, he’s falling asleep again." She would come up and finish the story for me. Now that I am working much less in the office, I have more stamina in the evening but my preference for dry plot-less nonfiction makes it unlikely that I will stay awake for more than a half a dozen pages.

It took me a few years before I accepted the fact that, for some of my patients, reading was keeping them awake instead of helping them fall asleep. Now, I am careful to ask children and adolescents who are having trouble falling asleep what it is they are reading. Often, the boys are reading fantasy and science fiction that they find very stimulating. The girls, on the other hand, are reading books about interpersonal relationships, but they find them just as stimulating.

While I cringe when I hear myself say the words, I find that I am suggesting to some parents that they discourage their children from reading for the hour before lights-out. But obviously, reading at bedtime is on the endangered activity list. In a recent Pediatrics, I found an article titled "Presleep Activities and Time of Sleep Onset in Children."(Pediatrics 2013;131:276-82). These New Zealand and Australian investigators found that television was the most common activity and that screen time accounted for about one-third of the 90 minutes prior to sleep onset. They also observed that children "with later sleep onset had significantly greater engagement in screen time than [did] those with earlier sleep onset."

The explanations for this observation run from the obvious stimulating effect of the content being watched to the disruptive effect that blue light emitted by the screens may have on melatonin levels. I don’t think we need to dig any deeper into the mechanisms. My anecdotal observations certainly agree with those of these researchers. But now what?

When I suggest that parents remove the television from their child’s room, I am sometimes met with answer, "He doesn’t really watch it." I reply "Well, then that should make it easy." Next, silence and a blank expression on the parents’ faces. I don’t recall any parent saying, "Hey, good idea. I’ll take it out tonight." It appears that for many families a television in a bedroom is as critical as a bed and light. I can’t imagine that they think they will need a master electrician to do the job.

Rarely, when a child’s misbehavior has been absolutely terrible, I have been able to convince parents to disconnect or remove a television from a bedroom as consequence. However, I think they agree only because they view it as a temporary measure to be undone when the child’s behavior improves. The concept of a permanent extirpation is too much to accept.

I’m not sure how we can do a better job of keeping televisions out of bedrooms. You could argue that if we just wait televisions will be pushed out by tablets and smartphones. But, it wouldn’t hurt to start by replacing every poster about the food pyramid with one about the dangers of televisions in bedrooms.

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

I would be very surprised if you were unfamiliar with Goodnight Moon. Either you have read it to a child or had it read to you when you were child. The dark tones of its illustrations and the gentle meter of its prose have made it a favorite with parents and children as a key ingredient of an effective bedtime ritual. But, reading doesn’t always have the same soporific effect on everyone.

From an early age, reading has always made me sleepy. When I was home in time to read my children a story at bedtime, they would often have to yell downstairs to my wife, "Mom, he’s falling asleep again." She would come up and finish the story for me. Now that I am working much less in the office, I have more stamina in the evening but my preference for dry plot-less nonfiction makes it unlikely that I will stay awake for more than a half a dozen pages.

It took me a few years before I accepted the fact that, for some of my patients, reading was keeping them awake instead of helping them fall asleep. Now, I am careful to ask children and adolescents who are having trouble falling asleep what it is they are reading. Often, the boys are reading fantasy and science fiction that they find very stimulating. The girls, on the other hand, are reading books about interpersonal relationships, but they find them just as stimulating.

While I cringe when I hear myself say the words, I find that I am suggesting to some parents that they discourage their children from reading for the hour before lights-out. But obviously, reading at bedtime is on the endangered activity list. In a recent Pediatrics, I found an article titled "Presleep Activities and Time of Sleep Onset in Children."(Pediatrics 2013;131:276-82). These New Zealand and Australian investigators found that television was the most common activity and that screen time accounted for about one-third of the 90 minutes prior to sleep onset. They also observed that children "with later sleep onset had significantly greater engagement in screen time than [did] those with earlier sleep onset."

The explanations for this observation run from the obvious stimulating effect of the content being watched to the disruptive effect that blue light emitted by the screens may have on melatonin levels. I don’t think we need to dig any deeper into the mechanisms. My anecdotal observations certainly agree with those of these researchers. But now what?

When I suggest that parents remove the television from their child’s room, I am sometimes met with answer, "He doesn’t really watch it." I reply "Well, then that should make it easy." Next, silence and a blank expression on the parents’ faces. I don’t recall any parent saying, "Hey, good idea. I’ll take it out tonight." It appears that for many families a television in a bedroom is as critical as a bed and light. I can’t imagine that they think they will need a master electrician to do the job.

Rarely, when a child’s misbehavior has been absolutely terrible, I have been able to convince parents to disconnect or remove a television from a bedroom as consequence. However, I think they agree only because they view it as a temporary measure to be undone when the child’s behavior improves. The concept of a permanent extirpation is too much to accept.

I’m not sure how we can do a better job of keeping televisions out of bedrooms. You could argue that if we just wait televisions will be pushed out by tablets and smartphones. But, it wouldn’t hurt to start by replacing every poster about the food pyramid with one about the dangers of televisions in bedrooms.

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

Gastroenteritis continues to be one of the primary presenting illnesses for children in North America and the rest of the world.

Rotavirus vaccine has diminished the disease burden from one virus, but I don’t think anyone is surprised that another infective agent has taken up the slack. A recent study provides a window into the behavior of clinicians when they are called to the bedside of a child who seems unable to keep up with his gastrointestinal fluid losses (Pediatrics 2012;130:e1504-11 [doi: 10.1542/peds.2012-1012]).

The researchers, from the Hospital for Sick Children in Toronto, looked at the emergency department experience of 435 children who presented with symptoms of gastroenteritis. They found that 10% of the caregivers and 14% of the clinicians would choose nasogastric rehydration if oral rehydration failed. Eighty percent of the caregivers were more familiar with the intravenous route. Fifteen percent of the children ended up having an IV. Zero had a nasogastric tube placed.

When the nurses tasked with intervention were surveyed, the researchers found that in the previous 6 months, the nurses had inserted 90 IVs and only 4 nasogastric tubes. "It appears that current practice begets current practice," the authors wrote.

We are all traveling in the ruts of the wagon wheels that have rolled ahead of us. And obviously, habituation stifles innovation. But in this case, is commitment to ritual causing any harm? The authors cite references that report a low complication rate of 3%-6% (intrapulmonary infusion) for nasogastric use. I haven’t been able to find a complication rate for intravenous rehydration, but I suspect it is in a comparable range.

These Canadian investigators raise an interesting concern. In a teaching hospital whose house staff has a strong international flavor, is the current practice of intravenous rehydration propagating an intervention that may not be the better choice in less developed countries?

I think they make a valid point, but for those of us who practice in communities without a teaching hospital, does nasogastric tube rehydration have a place?

In Australia and New Zealand, 82% of ED physicians prefer nasogastric tube placement. They must be good at it. But in our hospital, and I suspect in yours, the nurses are like those in Toronto: Most are much more comfortable with an intravenous needle than with a nasogastric tube. Having been a recipient of both interventions several times in my career as a patient, I can tell you that I am much more comfortable with an IV than a tube up my nose. But you can argue that my experience reflects the inexperience of my assailants, and not a discomfort inherent to the procedure itself.

What I do know is that if one of our nurses were to approach a parent and tell him the next thing she was going to do was to put a tube up his child’s nose, that parent’s response would more than likely be a negative one. Some of that response would be generated by surprise. In our community, even parents whose children have never been in the ED would be expecting an IV for dehydration that has failed oral rehydration, because "that’s just the way they do it. "

In the short term, I think the wagon wheel ruts here in Brunswick are just too deep. However, these Canadian authors report that after a brief educational intervention, they could create a shift in both caregiver and clinician attitudes toward nasogastric rehydration. I’m interested to hear whether your community leans toward IV or NG.

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

Gastroenteritis continues to be one of the primary presenting illnesses for children in North America and the rest of the world.

Rotavirus vaccine has diminished the disease burden from one virus, but I don’t think anyone is surprised that another infective agent has taken up the slack. A recent study provides a window into the behavior of clinicians when they are called to the bedside of a child who seems unable to keep up with his gastrointestinal fluid losses (Pediatrics 2012;130:e1504-11 [doi: 10.1542/peds.2012-1012]).

The researchers, from the Hospital for Sick Children in Toronto, looked at the emergency department experience of 435 children who presented with symptoms of gastroenteritis. They found that 10% of the caregivers and 14% of the clinicians would choose nasogastric rehydration if oral rehydration failed. Eighty percent of the caregivers were more familiar with the intravenous route. Fifteen percent of the children ended up having an IV. Zero had a nasogastric tube placed.

When the nurses tasked with intervention were surveyed, the researchers found that in the previous 6 months, the nurses had inserted 90 IVs and only 4 nasogastric tubes. "It appears that current practice begets current practice," the authors wrote.

We are all traveling in the ruts of the wagon wheels that have rolled ahead of us. And obviously, habituation stifles innovation. But in this case, is commitment to ritual causing any harm? The authors cite references that report a low complication rate of 3%-6% (intrapulmonary infusion) for nasogastric use. I haven’t been able to find a complication rate for intravenous rehydration, but I suspect it is in a comparable range.

These Canadian investigators raise an interesting concern. In a teaching hospital whose house staff has a strong international flavor, is the current practice of intravenous rehydration propagating an intervention that may not be the better choice in less developed countries?

I think they make a valid point, but for those of us who practice in communities without a teaching hospital, does nasogastric tube rehydration have a place?

In Australia and New Zealand, 82% of ED physicians prefer nasogastric tube placement. They must be good at it. But in our hospital, and I suspect in yours, the nurses are like those in Toronto: Most are much more comfortable with an intravenous needle than with a nasogastric tube. Having been a recipient of both interventions several times in my career as a patient, I can tell you that I am much more comfortable with an IV than a tube up my nose. But you can argue that my experience reflects the inexperience of my assailants, and not a discomfort inherent to the procedure itself.

What I do know is that if one of our nurses were to approach a parent and tell him the next thing she was going to do was to put a tube up his child’s nose, that parent’s response would more than likely be a negative one. Some of that response would be generated by surprise. In our community, even parents whose children have never been in the ED would be expecting an IV for dehydration that has failed oral rehydration, because "that’s just the way they do it. "

In the short term, I think the wagon wheel ruts here in Brunswick are just too deep. However, these Canadian authors report that after a brief educational intervention, they could create a shift in both caregiver and clinician attitudes toward nasogastric rehydration. I’m interested to hear whether your community leans toward IV or NG.

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

Gastroenteritis continues to be one of the primary presenting illnesses for children in North America and the rest of the world.

Rotavirus vaccine has diminished the disease burden from one virus, but I don’t think anyone is surprised that another infective agent has taken up the slack. A recent study provides a window into the behavior of clinicians when they are called to the bedside of a child who seems unable to keep up with his gastrointestinal fluid losses (Pediatrics 2012;130:e1504-11 [doi: 10.1542/peds.2012-1012]).

The researchers, from the Hospital for Sick Children in Toronto, looked at the emergency department experience of 435 children who presented with symptoms of gastroenteritis. They found that 10% of the caregivers and 14% of the clinicians would choose nasogastric rehydration if oral rehydration failed. Eighty percent of the caregivers were more familiar with the intravenous route. Fifteen percent of the children ended up having an IV. Zero had a nasogastric tube placed.

When the nurses tasked with intervention were surveyed, the researchers found that in the previous 6 months, the nurses had inserted 90 IVs and only 4 nasogastric tubes. "It appears that current practice begets current practice," the authors wrote.

We are all traveling in the ruts of the wagon wheels that have rolled ahead of us. And obviously, habituation stifles innovation. But in this case, is commitment to ritual causing any harm? The authors cite references that report a low complication rate of 3%-6% (intrapulmonary infusion) for nasogastric use. I haven’t been able to find a complication rate for intravenous rehydration, but I suspect it is in a comparable range.

These Canadian investigators raise an interesting concern. In a teaching hospital whose house staff has a strong international flavor, is the current practice of intravenous rehydration propagating an intervention that may not be the better choice in less developed countries?

I think they make a valid point, but for those of us who practice in communities without a teaching hospital, does nasogastric tube rehydration have a place?

In Australia and New Zealand, 82% of ED physicians prefer nasogastric tube placement. They must be good at it. But in our hospital, and I suspect in yours, the nurses are like those in Toronto: Most are much more comfortable with an intravenous needle than with a nasogastric tube. Having been a recipient of both interventions several times in my career as a patient, I can tell you that I am much more comfortable with an IV than a tube up my nose. But you can argue that my experience reflects the inexperience of my assailants, and not a discomfort inherent to the procedure itself.

What I do know is that if one of our nurses were to approach a parent and tell him the next thing she was going to do was to put a tube up his child’s nose, that parent’s response would more than likely be a negative one. Some of that response would be generated by surprise. In our community, even parents whose children have never been in the ED would be expecting an IV for dehydration that has failed oral rehydration, because "that’s just the way they do it. "

In the short term, I think the wagon wheel ruts here in Brunswick are just too deep. However, these Canadian authors report that after a brief educational intervention, they could create a shift in both caregiver and clinician attitudes toward nasogastric rehydration. I’m interested to hear whether your community leans toward IV or NG.

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

Despite having grown up in a home in which every room but one bathroom and the kitchen had at least one wall lined with books, I have never been much of a reader. In light of my relative unfamiliarity with books, I have been hesitant to include reading recommendations in this column. However, I have just finished a month and a half trek through the 700 pages (960 if one includes the notes and index) of a book that should be on every pediatrician’s bedside table.

Intrigued by a few reviews I had seen, I requested "Far from the Tree: Parents, Children and the Search for Identity" as a Christmas gift. Andrew Solomon, the author, has a master’s degree in psychology and is working on his Ph.D. He has written numerous magazine articles and several other books, including "The Noonday Demon: An Atlas of Depression," a popular treatise on depression that won the 2001 National Book Award for nonfiction.

"Far from the Tree" is an extensively researched exploration of parenting in families in which a child was born who shares very little of his or her parents’ identities. While most of the time the apple doesn’t fall far from the tree, every now and then an exceptional child is born. The examples Mr. Solomon has chosen are deafness, dwarfism, Down syndrome, autism, schizophrenia, multiple severe disabilities, children who are prodigies, children of rape, children who become criminals, and who are transgender.

During interviews with more than 300 families, often during several visits spaced over a number of years, he amassed more than 40,000 pages of notes. Each condition is covered in its own chapter, some more than 100 pages in length. Interspersed between individual scenarios, Mr. Solomon includes the history of the condition and a brief update on current therapies and management strategies. Each category presents its own suite of ethical and moral dilemmas, from cochlear implants to abortion based on prenatal testing.

During my career I have encountered numerous children with many of the conditions Mr. Solomon addresses; some of those professional relationships can be measured in decades. Typically the experiences are a collection of scores of 20 or 30 minutes of office or hospital encounters. Constrained by the reality of also being the pediatrician for several thousand other less exceptional children, I never felt I had the time to ask parents how they felt about parenting a child who clearly was in a different universe from what they had expected.

Of course, I often ask parents how they are doing. And, I think I usually have a general sense of how they are coping. I view it as my job to at least attempt to help them find solutions when crises arise. However, I have never taken the time to involve myself in the kind of extended and in-depth interviews Mr. Solomon has done.

Like me, you may have wondered how some families can endure the challenges that a child with multiple severe disabilities presents day after day, year after year, and still appear to have a positive worldview. In "Far from the Tree," you will get at least a glimpse of how that counterintuitive phenomenon can occur. But for many families. an exceptional child is more than they can manage, and Mr. Solomon does not shy away from illuminating this dark side of parenting.

Although well written, this was not an easy book for me to read because of the intensity of the issues it addresses. I had to set it aside for a day or so to digest what I had read, and then return for more. You may or may not find interesting the author’s own journey as a gay man and eventually a parent. However, the meat of the book offers the reader a perspective on parenting of exceptional children that also translates to parenting the child who has fallen closer to tree. I only wish it had been written in 1970 when I was embarking on my career.

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

Despite having grown up in a home in which every room but one bathroom and the kitchen had at least one wall lined with books, I have never been much of a reader. In light of my relative unfamiliarity with books, I have been hesitant to include reading recommendations in this column. However, I have just finished a month and a half trek through the 700 pages (960 if one includes the notes and index) of a book that should be on every pediatrician’s bedside table.

Intrigued by a few reviews I had seen, I requested "Far from the Tree: Parents, Children and the Search for Identity" as a Christmas gift. Andrew Solomon, the author, has a master’s degree in psychology and is working on his Ph.D. He has written numerous magazine articles and several other books, including "The Noonday Demon: An Atlas of Depression," a popular treatise on depression that won the 2001 National Book Award for nonfiction.

"Far from the Tree" is an extensively researched exploration of parenting in families in which a child was born who shares very little of his or her parents’ identities. While most of the time the apple doesn’t fall far from the tree, every now and then an exceptional child is born. The examples Mr. Solomon has chosen are deafness, dwarfism, Down syndrome, autism, schizophrenia, multiple severe disabilities, children who are prodigies, children of rape, children who become criminals, and who are transgender.

During interviews with more than 300 families, often during several visits spaced over a number of years, he amassed more than 40,000 pages of notes. Each condition is covered in its own chapter, some more than 100 pages in length. Interspersed between individual scenarios, Mr. Solomon includes the history of the condition and a brief update on current therapies and management strategies. Each category presents its own suite of ethical and moral dilemmas, from cochlear implants to abortion based on prenatal testing.

During my career I have encountered numerous children with many of the conditions Mr. Solomon addresses; some of those professional relationships can be measured in decades. Typically the experiences are a collection of scores of 20 or 30 minutes of office or hospital encounters. Constrained by the reality of also being the pediatrician for several thousand other less exceptional children, I never felt I had the time to ask parents how they felt about parenting a child who clearly was in a different universe from what they had expected.

Of course, I often ask parents how they are doing. And, I think I usually have a general sense of how they are coping. I view it as my job to at least attempt to help them find solutions when crises arise. However, I have never taken the time to involve myself in the kind of extended and in-depth interviews Mr. Solomon has done.

Like me, you may have wondered how some families can endure the challenges that a child with multiple severe disabilities presents day after day, year after year, and still appear to have a positive worldview. In "Far from the Tree," you will get at least a glimpse of how that counterintuitive phenomenon can occur. But for many families. an exceptional child is more than they can manage, and Mr. Solomon does not shy away from illuminating this dark side of parenting.

Although well written, this was not an easy book for me to read because of the intensity of the issues it addresses. I had to set it aside for a day or so to digest what I had read, and then return for more. You may or may not find interesting the author’s own journey as a gay man and eventually a parent. However, the meat of the book offers the reader a perspective on parenting of exceptional children that also translates to parenting the child who has fallen closer to tree. I only wish it had been written in 1970 when I was embarking on my career.

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

Despite having grown up in a home in which every room but one bathroom and the kitchen had at least one wall lined with books, I have never been much of a reader. In light of my relative unfamiliarity with books, I have been hesitant to include reading recommendations in this column. However, I have just finished a month and a half trek through the 700 pages (960 if one includes the notes and index) of a book that should be on every pediatrician’s bedside table.

Intrigued by a few reviews I had seen, I requested "Far from the Tree: Parents, Children and the Search for Identity" as a Christmas gift. Andrew Solomon, the author, has a master’s degree in psychology and is working on his Ph.D. He has written numerous magazine articles and several other books, including "The Noonday Demon: An Atlas of Depression," a popular treatise on depression that won the 2001 National Book Award for nonfiction.

"Far from the Tree" is an extensively researched exploration of parenting in families in which a child was born who shares very little of his or her parents’ identities. While most of the time the apple doesn’t fall far from the tree, every now and then an exceptional child is born. The examples Mr. Solomon has chosen are deafness, dwarfism, Down syndrome, autism, schizophrenia, multiple severe disabilities, children who are prodigies, children of rape, children who become criminals, and who are transgender.

During interviews with more than 300 families, often during several visits spaced over a number of years, he amassed more than 40,000 pages of notes. Each condition is covered in its own chapter, some more than 100 pages in length. Interspersed between individual scenarios, Mr. Solomon includes the history of the condition and a brief update on current therapies and management strategies. Each category presents its own suite of ethical and moral dilemmas, from cochlear implants to abortion based on prenatal testing.

During my career I have encountered numerous children with many of the conditions Mr. Solomon addresses; some of those professional relationships can be measured in decades. Typically the experiences are a collection of scores of 20 or 30 minutes of office or hospital encounters. Constrained by the reality of also being the pediatrician for several thousand other less exceptional children, I never felt I had the time to ask parents how they felt about parenting a child who clearly was in a different universe from what they had expected.

Of course, I often ask parents how they are doing. And, I think I usually have a general sense of how they are coping. I view it as my job to at least attempt to help them find solutions when crises arise. However, I have never taken the time to involve myself in the kind of extended and in-depth interviews Mr. Solomon has done.

Like me, you may have wondered how some families can endure the challenges that a child with multiple severe disabilities presents day after day, year after year, and still appear to have a positive worldview. In "Far from the Tree," you will get at least a glimpse of how that counterintuitive phenomenon can occur. But for many families. an exceptional child is more than they can manage, and Mr. Solomon does not shy away from illuminating this dark side of parenting.

Although well written, this was not an easy book for me to read because of the intensity of the issues it addresses. I had to set it aside for a day or so to digest what I had read, and then return for more. You may or may not find interesting the author’s own journey as a gay man and eventually a parent. However, the meat of the book offers the reader a perspective on parenting of exceptional children that also translates to parenting the child who has fallen closer to tree. I only wish it had been written in 1970 when I was embarking on my career.

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

As I write this, I’m sitting in a hotel lobby in Seville, Spain, waiting out a rain shower – one of many. Sunny Spain has chosen to replenish its sorely depleted aquifers during our 2-week holiday. Along with the tree-lined avenues and Moorish architectural motifs, one of the more striking images I will take home is that of Spanish toddlers, who are probably old enough to scribble their names, sucking on pacifiers ... at all hours of the day.

So while I’m waiting for a break in the weather, I’ve decided to share some of my observations on pacifiers. My family and I were all thumb suckers. In fact, I still have a shallow depression across the middle of my right thumbnail as evidence. If we had been asked prior to parenthood if we planned to offer our babies pacifiers, I’m sure Marilyn and I would have answered, "Definitely not! They don’t seem natural and we don’t like the looks of toddlers wandering around with plugs in their mouths." However, it doesn’t take long for pragmatic and sleep-deprived parents to alter their long-held and unrealistic principles.

For whatever reason, none of our three children could figure out how to keep the darned things in their mouths for longer than a few seconds. There may be some association with the fact that none of the Wilkoffs are particularly talented whistlers, either.

Despite my prior prejudices and our family’s experience with pacifiers, I have come to realize that, if used properly, they can be an effective parenting tool. Proper use, though, requires some anticipatory guidance by pediatricians and a little bit of discipline on the part of parents. Although I don’t think we should encourage parents to give their babies pacifiers, I do believe that how and when to use them should be a topic that is touched on at prenatal visits and 3-day weight checks.

First, with rare exception, a pacifier should not be offered to a neonate until her mother’s milk is established and regular weight gain has been demonstrated for several days. This may take a week or more. Hopefully, by then, parents will begin to have some inkling of when the baby is hungry and when she is just cranky (in other words, sleepy). In the interim, many mothers will be nursing much more often than they may have anticipated. They will need support and reassurance that getting their milk established is a temporary phase.

When the risk of nipple confusion and insufficient breast stimulation has passed and the baby is gaining weight, it’s safe to offer a pacifier to a fussy baby, with one important rule – only in the baby’s crib and only with her sleeping on her back. This makes the clear statement that a pacifier is first and foremost a sleep aid. It also emphasizes that a crib is the best and safest place for a child to sleep.

Of equal importance is the message this advice sends to parents: "If the baby is fussy and isn’t hungry and wants her pacifier, she is sleepy and needs to be put to bed." This is one lesson that will continue to pay dividends for years – provided the parents stick to the rule.

Used in this manner, pacifiers may decrease the risk of crib death and might even be associated with a smaller incidence of otitis media. When parents follow this simple only-in-the-crib rule for pacifier use, their child will never be seen wandering around with a plug in her mouth, interfering with her speech. It also means that, as the child gains more stamina, she will outgrow her need for the pacifier gradually, without the parents feeling the pressure to get rid of it by a certain age.

But any rule is meant to be bent. When the child is old enough to travel, the pacifier helps create a place to sleep when her crib isn’t handy. And, of course, for some children, pacifiers can be soothing in times of distress. When she falls and bumps her nose, the solution may be, "Let’s go to your room and you can sit on my lap with your pacifier until you feel better."

I see Marilyn beckoning me to grab my umbrella and head out for dinner. I can guarantee that, even though it’s almost 9 o’clock at night, we’ll encounter at least one Spanish toddler with a plug in his mouth.

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

As I write this, I’m sitting in a hotel lobby in Seville, Spain, waiting out a rain shower – one of many. Sunny Spain has chosen to replenish its sorely depleted aquifers during our 2-week holiday. Along with the tree-lined avenues and Moorish architectural motifs, one of the more striking images I will take home is that of Spanish toddlers, who are probably old enough to scribble their names, sucking on pacifiers ... at all hours of the day.

So while I’m waiting for a break in the weather, I’ve decided to share some of my observations on pacifiers. My family and I were all thumb suckers. In fact, I still have a shallow depression across the middle of my right thumbnail as evidence. If we had been asked prior to parenthood if we planned to offer our babies pacifiers, I’m sure Marilyn and I would have answered, "Definitely not! They don’t seem natural and we don’t like the looks of toddlers wandering around with plugs in their mouths." However, it doesn’t take long for pragmatic and sleep-deprived parents to alter their long-held and unrealistic principles.

For whatever reason, none of our three children could figure out how to keep the darned things in their mouths for longer than a few seconds. There may be some association with the fact that none of the Wilkoffs are particularly talented whistlers, either.

Despite my prior prejudices and our family’s experience with pacifiers, I have come to realize that, if used properly, they can be an effective parenting tool. Proper use, though, requires some anticipatory guidance by pediatricians and a little bit of discipline on the part of parents. Although I don’t think we should encourage parents to give their babies pacifiers, I do believe that how and when to use them should be a topic that is touched on at prenatal visits and 3-day weight checks.

First, with rare exception, a pacifier should not be offered to a neonate until her mother’s milk is established and regular weight gain has been demonstrated for several days. This may take a week or more. Hopefully, by then, parents will begin to have some inkling of when the baby is hungry and when she is just cranky (in other words, sleepy). In the interim, many mothers will be nursing much more often than they may have anticipated. They will need support and reassurance that getting their milk established is a temporary phase.

When the risk of nipple confusion and insufficient breast stimulation has passed and the baby is gaining weight, it’s safe to offer a pacifier to a fussy baby, with one important rule – only in the baby’s crib and only with her sleeping on her back. This makes the clear statement that a pacifier is first and foremost a sleep aid. It also emphasizes that a crib is the best and safest place for a child to sleep.

Of equal importance is the message this advice sends to parents: "If the baby is fussy and isn’t hungry and wants her pacifier, she is sleepy and needs to be put to bed." This is one lesson that will continue to pay dividends for years – provided the parents stick to the rule.

Used in this manner, pacifiers may decrease the risk of crib death and might even be associated with a smaller incidence of otitis media. When parents follow this simple only-in-the-crib rule for pacifier use, their child will never be seen wandering around with a plug in her mouth, interfering with her speech. It also means that, as the child gains more stamina, she will outgrow her need for the pacifier gradually, without the parents feeling the pressure to get rid of it by a certain age.

But any rule is meant to be bent. When the child is old enough to travel, the pacifier helps create a place to sleep when her crib isn’t handy. And, of course, for some children, pacifiers can be soothing in times of distress. When she falls and bumps her nose, the solution may be, "Let’s go to your room and you can sit on my lap with your pacifier until you feel better."

I see Marilyn beckoning me to grab my umbrella and head out for dinner. I can guarantee that, even though it’s almost 9 o’clock at night, we’ll encounter at least one Spanish toddler with a plug in his mouth.

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

As I write this, I’m sitting in a hotel lobby in Seville, Spain, waiting out a rain shower – one of many. Sunny Spain has chosen to replenish its sorely depleted aquifers during our 2-week holiday. Along with the tree-lined avenues and Moorish architectural motifs, one of the more striking images I will take home is that of Spanish toddlers, who are probably old enough to scribble their names, sucking on pacifiers ... at all hours of the day.

So while I’m waiting for a break in the weather, I’ve decided to share some of my observations on pacifiers. My family and I were all thumb suckers. In fact, I still have a shallow depression across the middle of my right thumbnail as evidence. If we had been asked prior to parenthood if we planned to offer our babies pacifiers, I’m sure Marilyn and I would have answered, "Definitely not! They don’t seem natural and we don’t like the looks of toddlers wandering around with plugs in their mouths." However, it doesn’t take long for pragmatic and sleep-deprived parents to alter their long-held and unrealistic principles.

For whatever reason, none of our three children could figure out how to keep the darned things in their mouths for longer than a few seconds. There may be some association with the fact that none of the Wilkoffs are particularly talented whistlers, either.

Despite my prior prejudices and our family’s experience with pacifiers, I have come to realize that, if used properly, they can be an effective parenting tool. Proper use, though, requires some anticipatory guidance by pediatricians and a little bit of discipline on the part of parents. Although I don’t think we should encourage parents to give their babies pacifiers, I do believe that how and when to use them should be a topic that is touched on at prenatal visits and 3-day weight checks.

First, with rare exception, a pacifier should not be offered to a neonate until her mother’s milk is established and regular weight gain has been demonstrated for several days. This may take a week or more. Hopefully, by then, parents will begin to have some inkling of when the baby is hungry and when she is just cranky (in other words, sleepy). In the interim, many mothers will be nursing much more often than they may have anticipated. They will need support and reassurance that getting their milk established is a temporary phase.

When the risk of nipple confusion and insufficient breast stimulation has passed and the baby is gaining weight, it’s safe to offer a pacifier to a fussy baby, with one important rule – only in the baby’s crib and only with her sleeping on her back. This makes the clear statement that a pacifier is first and foremost a sleep aid. It also emphasizes that a crib is the best and safest place for a child to sleep.

Of equal importance is the message this advice sends to parents: "If the baby is fussy and isn’t hungry and wants her pacifier, she is sleepy and needs to be put to bed." This is one lesson that will continue to pay dividends for years – provided the parents stick to the rule.

Used in this manner, pacifiers may decrease the risk of crib death and might even be associated with a smaller incidence of otitis media. When parents follow this simple only-in-the-crib rule for pacifier use, their child will never be seen wandering around with a plug in her mouth, interfering with her speech. It also means that, as the child gains more stamina, she will outgrow her need for the pacifier gradually, without the parents feeling the pressure to get rid of it by a certain age.

But any rule is meant to be bent. When the child is old enough to travel, the pacifier helps create a place to sleep when her crib isn’t handy. And, of course, for some children, pacifiers can be soothing in times of distress. When she falls and bumps her nose, the solution may be, "Let’s go to your room and you can sit on my lap with your pacifier until you feel better."

I see Marilyn beckoning me to grab my umbrella and head out for dinner. I can guarantee that, even though it’s almost 9 o’clock at night, we’ll encounter at least one Spanish toddler with a plug in his mouth.

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

According to the newspaper headlines, we are in the middle of an influenza epidemic that is worse than usual. After a closer reading of the reports, however, a more accurate description of the situation would be that there has been a recent surge in hospitalizations, visits to emergency departments and doctors’ offices, and school absenteeism. Since most people who are ill haven’t been tested for influenza, one can really only say that we know that there is influenza in the community and a lot of people are sick.

Regardless of whether there is influenza hip hopping around, winter is a sick time of year. Although public health officials seize the opportunity to encourage vaccination, the truth is that influenza has many fellow travelers. For the first time that I can remember, press releases have been more candid and referred to "flu-like illnesses." This season we have been seeing a large number of cases of gastroenteritis, possibly caused by norovirus. Here in Maine, this cohabitation is especially confusing because the natives refer to any illness in which vomiting predominates as "flu."

The bottom line, according to the collective mindset, is that everyone has the flu. This scares me more than the fact that there is influenza around. This is a busy time of year for a primary care physician, but I don’t mind being busy because I enjoy what I do. However, I find the flu-epidemic mentality to be anxiety provoking because, when there are more donkeys galloping through my office, it becomes that much more difficult to find the zebras hidden in the thundering herd.

Are our triage nurses adequately trained to deal with the surge? Do they have algorithms and templates that will allow them to identify the sickest people? Not every caller who has fever, headache, a slight cough, and "feels like crap" has an influenza-like illness that can be watched at home for a day or two.

One particularly busy Monday last week was typical. Most patients had simple upper respiratory infections. One or two had rapid test–positive influenza and a few had gastroenteritis. In the late afternoon, though, I saw an 8-year-old girl whom I had known since birth. Her routing sheet listed her chief complaints as "fever, achy neck and shoulders." I was surprised that she had slipped through the phone triage gauntlet.

When I walked into the exam room, it was difficult to tell that the child was the ill because she was sitting quietly on the exam table. However, as I began to examine her it was clear that an effort on her part to extend her neck created extreme discomfort. As I expanded my history, I discovered that, like most patients with influenza, she had some sore throat at the onset of the illness, but her neck pain had quickly become her major complaint.

Getting a good look at her oropharynx was out of the question, but I was able to gingerly obtain a throat swab sample that was rapid-strep positive. One or two calls later she was on her way to our tertiary care medical center, where my suspicion of a retropharyngeal abscess was confirmed and treated surgically.

Before she left for the hospital I quizzed her mother, whom I had always known to be concerned and observant. In the past she had never been afraid to come in and be told that nothing was seriously wrong. I was surprised that she had waited 2 days to call and bring her daughter in. I reminded her that we have always had weekend office hours.

She explained that there had been so much talk and media attention about the "flu epidemic" that her usual instincts had not penetrated the haze of information about influenza. Luckily, all’s well that ends well, but this young lady’s illness was a reminder to all of us that not everything that quacks is a duck.

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

According to the newspaper headlines, we are in the middle of an influenza epidemic that is worse than usual. After a closer reading of the reports, however, a more accurate description of the situation would be that there has been a recent surge in hospitalizations, visits to emergency departments and doctors’ offices, and school absenteeism. Since most people who are ill haven’t been tested for influenza, one can really only say that we know that there is influenza in the community and a lot of people are sick.

Regardless of whether there is influenza hip hopping around, winter is a sick time of year. Although public health officials seize the opportunity to encourage vaccination, the truth is that influenza has many fellow travelers. For the first time that I can remember, press releases have been more candid and referred to "flu-like illnesses." This season we have been seeing a large number of cases of gastroenteritis, possibly caused by norovirus. Here in Maine, this cohabitation is especially confusing because the natives refer to any illness in which vomiting predominates as "flu."

The bottom line, according to the collective mindset, is that everyone has the flu. This scares me more than the fact that there is influenza around. This is a busy time of year for a primary care physician, but I don’t mind being busy because I enjoy what I do. However, I find the flu-epidemic mentality to be anxiety provoking because, when there are more donkeys galloping through my office, it becomes that much more difficult to find the zebras hidden in the thundering herd.

Are our triage nurses adequately trained to deal with the surge? Do they have algorithms and templates that will allow them to identify the sickest people? Not every caller who has fever, headache, a slight cough, and "feels like crap" has an influenza-like illness that can be watched at home for a day or two.

One particularly busy Monday last week was typical. Most patients had simple upper respiratory infections. One or two had rapid test–positive influenza and a few had gastroenteritis. In the late afternoon, though, I saw an 8-year-old girl whom I had known since birth. Her routing sheet listed her chief complaints as "fever, achy neck and shoulders." I was surprised that she had slipped through the phone triage gauntlet.

When I walked into the exam room, it was difficult to tell that the child was the ill because she was sitting quietly on the exam table. However, as I began to examine her it was clear that an effort on her part to extend her neck created extreme discomfort. As I expanded my history, I discovered that, like most patients with influenza, she had some sore throat at the onset of the illness, but her neck pain had quickly become her major complaint.

Getting a good look at her oropharynx was out of the question, but I was able to gingerly obtain a throat swab sample that was rapid-strep positive. One or two calls later she was on her way to our tertiary care medical center, where my suspicion of a retropharyngeal abscess was confirmed and treated surgically.

Before she left for the hospital I quizzed her mother, whom I had always known to be concerned and observant. In the past she had never been afraid to come in and be told that nothing was seriously wrong. I was surprised that she had waited 2 days to call and bring her daughter in. I reminded her that we have always had weekend office hours.

She explained that there had been so much talk and media attention about the "flu epidemic" that her usual instincts had not penetrated the haze of information about influenza. Luckily, all’s well that ends well, but this young lady’s illness was a reminder to all of us that not everything that quacks is a duck.

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

According to the newspaper headlines, we are in the middle of an influenza epidemic that is worse than usual. After a closer reading of the reports, however, a more accurate description of the situation would be that there has been a recent surge in hospitalizations, visits to emergency departments and doctors’ offices, and school absenteeism. Since most people who are ill haven’t been tested for influenza, one can really only say that we know that there is influenza in the community and a lot of people are sick.

Regardless of whether there is influenza hip hopping around, winter is a sick time of year. Although public health officials seize the opportunity to encourage vaccination, the truth is that influenza has many fellow travelers. For the first time that I can remember, press releases have been more candid and referred to "flu-like illnesses." This season we have been seeing a large number of cases of gastroenteritis, possibly caused by norovirus. Here in Maine, this cohabitation is especially confusing because the natives refer to any illness in which vomiting predominates as "flu."

The bottom line, according to the collective mindset, is that everyone has the flu. This scares me more than the fact that there is influenza around. This is a busy time of year for a primary care physician, but I don’t mind being busy because I enjoy what I do. However, I find the flu-epidemic mentality to be anxiety provoking because, when there are more donkeys galloping through my office, it becomes that much more difficult to find the zebras hidden in the thundering herd.

Are our triage nurses adequately trained to deal with the surge? Do they have algorithms and templates that will allow them to identify the sickest people? Not every caller who has fever, headache, a slight cough, and "feels like crap" has an influenza-like illness that can be watched at home for a day or two.

One particularly busy Monday last week was typical. Most patients had simple upper respiratory infections. One or two had rapid test–positive influenza and a few had gastroenteritis. In the late afternoon, though, I saw an 8-year-old girl whom I had known since birth. Her routing sheet listed her chief complaints as "fever, achy neck and shoulders." I was surprised that she had slipped through the phone triage gauntlet.

When I walked into the exam room, it was difficult to tell that the child was the ill because she was sitting quietly on the exam table. However, as I began to examine her it was clear that an effort on her part to extend her neck created extreme discomfort. As I expanded my history, I discovered that, like most patients with influenza, she had some sore throat at the onset of the illness, but her neck pain had quickly become her major complaint.

Getting a good look at her oropharynx was out of the question, but I was able to gingerly obtain a throat swab sample that was rapid-strep positive. One or two calls later she was on her way to our tertiary care medical center, where my suspicion of a retropharyngeal abscess was confirmed and treated surgically.

Before she left for the hospital I quizzed her mother, whom I had always known to be concerned and observant. In the past she had never been afraid to come in and be told that nothing was seriously wrong. I was surprised that she had waited 2 days to call and bring her daughter in. I reminded her that we have always had weekend office hours.

She explained that there had been so much talk and media attention about the "flu epidemic" that her usual instincts had not penetrated the haze of information about influenza. Luckily, all’s well that ends well, but this young lady’s illness was a reminder to all of us that not everything that quacks is a duck.

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

Recently, I received an e-mail from a pediatrician who had decided to take a sharp turn off the fast lane and open his own micro practice. By rooming his own patients, giving injections, and cleaning the office himself he hoped to keep the overhead so low that he could see only six or seven patients a day and still turn a modest profit. He admitted that he was only a few months into the venture, but he sounded confident that he could make it work.

The downsizing movement seems to have begun in 2001 with Dr. L. Gordon Moore in Rochester, N.Y. His Ideal Medical Practice Model has attracted 500 doctors nationwide, and he suspects that the actual number is probably double that. Dr. Pamela Wible of Eugene, Ore., manages idealmedicalcare.org. Her website lists at least 200 physicians who are presumably enjoying success with micro practice. An article at theoptimist.com, "Ideal Medical Practices," by John Grossman, also addresses the rise of micro practices.

Are micro practices so far out on the fringe that they have no relevance to mainstream care delivery systems? Is slow medicine like the slow food and locavore movements? Does it appeal only to patients and physicians who aspire to live off the grid and grow their own food, and who prefer free-range asparagus? While micro practices are never going to meet the health care needs of the United States, their success should teach us all an important lesson. And that lesson is, "Watch your overhead!"

I practiced by myself for 10 years and enjoyed the satisfaction of being in control. It was certainly not a micro practice, as I often saw 40 or more patients a day. But, I vacuumed the office each morning and touched up the bathroom. I often roomed the patients and gave all the injections. My wife did the books and the billing. Our overhead was in the mid-30’s.

When I joined a group in hopes of recruiting a partner or two, the overhead jumped to well over 60%. However, there was no equivalent bump in the quality of the care. In fact, I suspect most of the families we served felt we had taken a step backwards.

While asking physicians to clean the bathrooms would cause a revolt in most groups I know, there are scores of other strategies for trimming overhead that are never considered. To determine the costs facing your practice, I suggest you begin by asking the practice administrator, "What is our overhead and where is that money going?" Then, follow up with a challenge: "I’ll see 5% more patients in the next 6 months if you lower the overhead by the same percentage."

Even if that sounds like tilting at windmills, the exercise should be instructive. The administrators who agree to accept the challenge will find it difficult to dismantle an overgrown top-heavy organization. The task for a physician in the slow medicine movement, however, should be much easier. He is starting from scratch and can add bits to his overhead only as the need arises.

Have you gone micro or succeeded in trimming excessive overhead in your group? I’m eager to hear what has worked for you, and for you to share that with the readers of Pediatric News.

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

Recently, I received an e-mail from a pediatrician who had decided to take a sharp turn off the fast lane and open his own micro practice. By rooming his own patients, giving injections, and cleaning the office himself he hoped to keep the overhead so low that he could see only six or seven patients a day and still turn a modest profit. He admitted that he was only a few months into the venture, but he sounded confident that he could make it work.

The downsizing movement seems to have begun in 2001 with Dr. L. Gordon Moore in Rochester, N.Y. His Ideal Medical Practice Model has attracted 500 doctors nationwide, and he suspects that the actual number is probably double that. Dr. Pamela Wible of Eugene, Ore., manages idealmedicalcare.org. Her website lists at least 200 physicians who are presumably enjoying success with micro practice. An article at theoptimist.com, "Ideal Medical Practices," by John Grossman, also addresses the rise of micro practices.

Are micro practices so far out on the fringe that they have no relevance to mainstream care delivery systems? Is slow medicine like the slow food and locavore movements? Does it appeal only to patients and physicians who aspire to live off the grid and grow their own food, and who prefer free-range asparagus? While micro practices are never going to meet the health care needs of the United States, their success should teach us all an important lesson. And that lesson is, "Watch your overhead!"

I practiced by myself for 10 years and enjoyed the satisfaction of being in control. It was certainly not a micro practice, as I often saw 40 or more patients a day. But, I vacuumed the office each morning and touched up the bathroom. I often roomed the patients and gave all the injections. My wife did the books and the billing. Our overhead was in the mid-30’s.

When I joined a group in hopes of recruiting a partner or two, the overhead jumped to well over 60%. However, there was no equivalent bump in the quality of the care. In fact, I suspect most of the families we served felt we had taken a step backwards.

While asking physicians to clean the bathrooms would cause a revolt in most groups I know, there are scores of other strategies for trimming overhead that are never considered. To determine the costs facing your practice, I suggest you begin by asking the practice administrator, "What is our overhead and where is that money going?" Then, follow up with a challenge: "I’ll see 5% more patients in the next 6 months if you lower the overhead by the same percentage."

Even if that sounds like tilting at windmills, the exercise should be instructive. The administrators who agree to accept the challenge will find it difficult to dismantle an overgrown top-heavy organization. The task for a physician in the slow medicine movement, however, should be much easier. He is starting from scratch and can add bits to his overhead only as the need arises.

Have you gone micro or succeeded in trimming excessive overhead in your group? I’m eager to hear what has worked for you, and for you to share that with the readers of Pediatric News.

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

Recently, I received an e-mail from a pediatrician who had decided to take a sharp turn off the fast lane and open his own micro practice. By rooming his own patients, giving injections, and cleaning the office himself he hoped to keep the overhead so low that he could see only six or seven patients a day and still turn a modest profit. He admitted that he was only a few months into the venture, but he sounded confident that he could make it work.

The downsizing movement seems to have begun in 2001 with Dr. L. Gordon Moore in Rochester, N.Y. His Ideal Medical Practice Model has attracted 500 doctors nationwide, and he suspects that the actual number is probably double that. Dr. Pamela Wible of Eugene, Ore., manages idealmedicalcare.org. Her website lists at least 200 physicians who are presumably enjoying success with micro practice. An article at theoptimist.com, "Ideal Medical Practices," by John Grossman, also addresses the rise of micro practices.

Are micro practices so far out on the fringe that they have no relevance to mainstream care delivery systems? Is slow medicine like the slow food and locavore movements? Does it appeal only to patients and physicians who aspire to live off the grid and grow their own food, and who prefer free-range asparagus? While micro practices are never going to meet the health care needs of the United States, their success should teach us all an important lesson. And that lesson is, "Watch your overhead!"

I practiced by myself for 10 years and enjoyed the satisfaction of being in control. It was certainly not a micro practice, as I often saw 40 or more patients a day. But, I vacuumed the office each morning and touched up the bathroom. I often roomed the patients and gave all the injections. My wife did the books and the billing. Our overhead was in the mid-30’s.

When I joined a group in hopes of recruiting a partner or two, the overhead jumped to well over 60%. However, there was no equivalent bump in the quality of the care. In fact, I suspect most of the families we served felt we had taken a step backwards.

While asking physicians to clean the bathrooms would cause a revolt in most groups I know, there are scores of other strategies for trimming overhead that are never considered. To determine the costs facing your practice, I suggest you begin by asking the practice administrator, "What is our overhead and where is that money going?" Then, follow up with a challenge: "I’ll see 5% more patients in the next 6 months if you lower the overhead by the same percentage."

Even if that sounds like tilting at windmills, the exercise should be instructive. The administrators who agree to accept the challenge will find it difficult to dismantle an overgrown top-heavy organization. The task for a physician in the slow medicine movement, however, should be much easier. He is starting from scratch and can add bits to his overhead only as the need arises.

Have you gone micro or succeeded in trimming excessive overhead in your group? I’m eager to hear what has worked for you, and for you to share that with the readers of Pediatric News.

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

I had a little unexpected time on my hands. A double well-child checkup turned into a no-show. (We are still fine-tuning our appointment reminder system.) Instead of going back to my office to check my e-mails, I decided to hang out next to the triage nurse’s desk while I waited for the next family to arrive.

I didn’t keep an exact tally but I am guessing that I listened to the nurse’s side of a half dozen phone calls. It sounded as though at least two (or a third) of the calls were call backs. Although I was interpreting conversations based on only half of the dialogues, my perception is that these two incoming calls could have been prevented if during the original encounter one additional fragment of anticipatory guidance had been provided.

I suspect if I had eavesdropped for the entire day, maybe a third of the calls could have been prevented with more complete advice during the initial office visit or phone call. However, I am sure that considering the volume of incoming calls we receive each day, the number of preventable ones is significant.

I know that most physicians are frustrated by the phone calls they must deal with after hours and in the course of a busy day in the office. The calls are more than a nuisance. They can create a significant drag on the bottom line. The physician must either sacrifice productive time when she could be seeing patients or pay someone else to field those calls – or in many cases both.

Years ago, I learned two phone-related strategies that helped me survive the years when I practiced solo and took call three or four nights a week. The first is to finish each unstable office encounter with a promise to call the next morning to check on how things are going. An unstable visit is one in which either the parents or I am not confident that the patient will be better the next day. The classic example of an unstable visit is one in which the presumed diagnosis is viral gastroenteritis. Otitis media in a child who doesn’t appear sick is an example of a stable encounter.

If parents are expecting a call from me, they are more likely to hold a question until I have called them, saving an incoming call. In some cases, the morning follow-up call might allow me to intervene early in a situation that seems to be worsening, preventing a call from the ED.

The second strategy is to give that extra bit of anticipatory guidance that I suspect had been forgotten in those calls on which I had eavesdropped. Here are just a few examples of some two- or three-liners that have helped keep my incoming calls more manageable:

• "While I was cleaning the wax out of Jason’s ear, I scratched his ear canal. You might notice a spot or two of blood later today. Call if there is more than that."

• "Swimmer’s ear takes a day or two longer to get better than the middle-ear infections you have been familiar with. So, she may not feel better tomorrow. But, she shouldn’t be worse."

• "When his umbilical cord falls off, there may be a spot or two of blood. Call if there is one bigger than a quarter."

• To the parent whose toddler has just run into the door jamb and sounds fine, you could say: "He may vomit once from the excitement, but if he vomits more than once or isn’t acting himself, call immediately.

• "Her temperature is a 102  F now. It may go up, even to 104  F, but as long as everything else is the same as it is now, you don’t have to call. Remember, I will be calling you in the morning."

Thirty seconds of anticipatory guidance at 3:00 o’clock in the afternoon may save you one 10-minute call at 3:00 in the morning. It sounds like a good investment to me.

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

I had a little unexpected time on my hands. A double well-child checkup turned into a no-show. (We are still fine-tuning our appointment reminder system.) Instead of going back to my office to check my e-mails, I decided to hang out next to the triage nurse’s desk while I waited for the next family to arrive.

I didn’t keep an exact tally but I am guessing that I listened to the nurse’s side of a half dozen phone calls. It sounded as though at least two (or a third) of the calls were call backs. Although I was interpreting conversations based on only half of the dialogues, my perception is that these two incoming calls could have been prevented if during the original encounter one additional fragment of anticipatory guidance had been provided.

I suspect if I had eavesdropped for the entire day, maybe a third of the calls could have been prevented with more complete advice during the initial office visit or phone call. However, I am sure that considering the volume of incoming calls we receive each day, the number of preventable ones is significant.

I know that most physicians are frustrated by the phone calls they must deal with after hours and in the course of a busy day in the office. The calls are more than a nuisance. They can create a significant drag on the bottom line. The physician must either sacrifice productive time when she could be seeing patients or pay someone else to field those calls – or in many cases both.

Years ago, I learned two phone-related strategies that helped me survive the years when I practiced solo and took call three or four nights a week. The first is to finish each unstable office encounter with a promise to call the next morning to check on how things are going. An unstable visit is one in which either the parents or I am not confident that the patient will be better the next day. The classic example of an unstable visit is one in which the presumed diagnosis is viral gastroenteritis. Otitis media in a child who doesn’t appear sick is an example of a stable encounter.

If parents are expecting a call from me, they are more likely to hold a question until I have called them, saving an incoming call. In some cases, the morning follow-up call might allow me to intervene early in a situation that seems to be worsening, preventing a call from the ED.

The second strategy is to give that extra bit of anticipatory guidance that I suspect had been forgotten in those calls on which I had eavesdropped. Here are just a few examples of some two- or three-liners that have helped keep my incoming calls more manageable:

• "While I was cleaning the wax out of Jason’s ear, I scratched his ear canal. You might notice a spot or two of blood later today. Call if there is more than that."

• "Swimmer’s ear takes a day or two longer to get better than the middle-ear infections you have been familiar with. So, she may not feel better tomorrow. But, she shouldn’t be worse."

• "When his umbilical cord falls off, there may be a spot or two of blood. Call if there is one bigger than a quarter."

• To the parent whose toddler has just run into the door jamb and sounds fine, you could say: "He may vomit once from the excitement, but if he vomits more than once or isn’t acting himself, call immediately.

• "Her temperature is a 102  F now. It may go up, even to 104  F, but as long as everything else is the same as it is now, you don’t have to call. Remember, I will be calling you in the morning."

Thirty seconds of anticipatory guidance at 3:00 o’clock in the afternoon may save you one 10-minute call at 3:00 in the morning. It sounds like a good investment to me.

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

I had a little unexpected time on my hands. A double well-child checkup turned into a no-show. (We are still fine-tuning our appointment reminder system.) Instead of going back to my office to check my e-mails, I decided to hang out next to the triage nurse’s desk while I waited for the next family to arrive.

I didn’t keep an exact tally but I am guessing that I listened to the nurse’s side of a half dozen phone calls. It sounded as though at least two (or a third) of the calls were call backs. Although I was interpreting conversations based on only half of the dialogues, my perception is that these two incoming calls could have been prevented if during the original encounter one additional fragment of anticipatory guidance had been provided.

I suspect if I had eavesdropped for the entire day, maybe a third of the calls could have been prevented with more complete advice during the initial office visit or phone call. However, I am sure that considering the volume of incoming calls we receive each day, the number of preventable ones is significant.

I know that most physicians are frustrated by the phone calls they must deal with after hours and in the course of a busy day in the office. The calls are more than a nuisance. They can create a significant drag on the bottom line. The physician must either sacrifice productive time when she could be seeing patients or pay someone else to field those calls – or in many cases both.

Years ago, I learned two phone-related strategies that helped me survive the years when I practiced solo and took call three or four nights a week. The first is to finish each unstable office encounter with a promise to call the next morning to check on how things are going. An unstable visit is one in which either the parents or I am not confident that the patient will be better the next day. The classic example of an unstable visit is one in which the presumed diagnosis is viral gastroenteritis. Otitis media in a child who doesn’t appear sick is an example of a stable encounter.

If parents are expecting a call from me, they are more likely to hold a question until I have called them, saving an incoming call. In some cases, the morning follow-up call might allow me to intervene early in a situation that seems to be worsening, preventing a call from the ED.

The second strategy is to give that extra bit of anticipatory guidance that I suspect had been forgotten in those calls on which I had eavesdropped. Here are just a few examples of some two- or three-liners that have helped keep my incoming calls more manageable:

• "While I was cleaning the wax out of Jason’s ear, I scratched his ear canal. You might notice a spot or two of blood later today. Call if there is more than that."

• "Swimmer’s ear takes a day or two longer to get better than the middle-ear infections you have been familiar with. So, she may not feel better tomorrow. But, she shouldn’t be worse."

• "When his umbilical cord falls off, there may be a spot or two of blood. Call if there is one bigger than a quarter."

• To the parent whose toddler has just run into the door jamb and sounds fine, you could say: "He may vomit once from the excitement, but if he vomits more than once or isn’t acting himself, call immediately.

• "Her temperature is a 102  F now. It may go up, even to 104  F, but as long as everything else is the same as it is now, you don’t have to call. Remember, I will be calling you in the morning."

Thirty seconds of anticipatory guidance at 3:00 o’clock in the afternoon may save you one 10-minute call at 3:00 in the morning. It sounds like a good investment to me.

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

We had run the gauntlet of TSA screening. Actually, it was more of a shuffle. We both had our shoes back on, and I rethreaded my belt as Marilyn and I walked toward our gate. Next, of course, was waiting and more waiting. Eventually, there was the call from the podium that boarding would start.

First were those obnoxious medallion people. You know, I never see any of them actually wearing their medallions. Then it was time to load by the letters. We were in D, which isn’t as bad as E or F. And I guess I wouldn’t want to be in A and risk sitting too close to the restrooms in the rear.

As I watched the A, B, and C folks troop by, I was impressed at the astounding variety of what they had self-proclaimed as carry-on luggage. It varied in size from large to enormous. I swear I saw something moving inside a duffle bag dragged by a college student. Some pieces had sharp pointy features. There were long tubes and plastic bags bulging with who knows what. Often, it was hard to tell what was a "personal item" and what was luggage.

Once seated on the plane, the entertainment continued as the E and F people struggled to stow their stuff. Clearly, some of them had no plan for what they would keep with them and what would go in the overhead. A small herd of passengers would back up in the aisle as minutes of indecision ticked by.

As the flight attendant began her seatbelt monologue, my mind floated back to last week’s all-provider meeting, at which one of the administrators announced that the long-promised patient Internet portal was on the launch pad. In concept, I’m a big fan of giving patients better access to their records and lab work. I think a portal will allow us to guide patients to health information sources we deem reliable, but I get a bit uncomfortable when I hear that patients will be able to make their own appointments.

Filling a physician’s schedule is a lot like loading a plane. Just like airline passengers, patients arrive at the doctor’s office with a wide variety of baggage. Some have a single issue that is troubling them. Others have been collecting complaints for months. Some have organized their questions on written lists. Many haven’t given much thought to prioritizing their issues and the physician is left to sort out what is the real problem. I suspect that most patients assume that all of their complaints will fit into a usual-length office visit, just as they assume their luggage will fit in the overhead bin or under the seat in front of them.

There are only so many hours in the day, and the physician and his staff must figure out how to get all that baggage stowed away safely in a reasonable time and with a minimum of unnecessary waiting for the other patients.

An experienced receptionist understands that different chief complaints require visits of different lengths. She or he also knows the patients well enough to realize that Mrs. Drifty’s visits are always twice as long as Mr. Organized’s, and that Dr. Speedy can see two patients in the time it takes Dr. Pokey to see one. A good receptionist/nurse team also can identify the patients who should be seen early in the day, regardless of what the schedule looks like.

It scares me to think of what might happen when patients are allowed freehand to make their own appointments. I fear that many will underestimate the amount of time their complaint takes to resolve. I dread the thought of what might happen if, at 8 a.m., the parent of a child with a fever and a purpuric rash clicks on a 4 p.m. slot instead of speaking to the nurse.

I can envision a few strategies that might avoid some of the potential scheduling disasters. The best option, I suspect, is going to be a carefully crafted hybrid that includes live receptionists. I’m sure some of you already have experience with patient-portal appointment schemes. I am interested to hear what’s working and what’s not. I’m afraid I’m going to have to buckle up because it’s probably going to be a bumpy ride.

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

We had run the gauntlet of TSA screening. Actually, it was more of a shuffle. We both had our shoes back on, and I rethreaded my belt as Marilyn and I walked toward our gate. Next, of course, was waiting and more waiting. Eventually, there was the call from the podium that boarding would start.

First were those obnoxious medallion people. You know, I never see any of them actually wearing their medallions. Then it was time to load by the letters. We were in D, which isn’t as bad as E or F. And I guess I wouldn’t want to be in A and risk sitting too close to the restrooms in the rear.

As I watched the A, B, and C folks troop by, I was impressed at the astounding variety of what they had self-proclaimed as carry-on luggage. It varied in size from large to enormous. I swear I saw something moving inside a duffle bag dragged by a college student. Some pieces had sharp pointy features. There were long tubes and plastic bags bulging with who knows what. Often, it was hard to tell what was a "personal item" and what was luggage.

Once seated on the plane, the entertainment continued as the E and F people struggled to stow their stuff. Clearly, some of them had no plan for what they would keep with them and what would go in the overhead. A small herd of passengers would back up in the aisle as minutes of indecision ticked by.

As the flight attendant began her seatbelt monologue, my mind floated back to last week’s all-provider meeting, at which one of the administrators announced that the long-promised patient Internet portal was on the launch pad. In concept, I’m a big fan of giving patients better access to their records and lab work. I think a portal will allow us to guide patients to health information sources we deem reliable, but I get a bit uncomfortable when I hear that patients will be able to make their own appointments.

Filling a physician’s schedule is a lot like loading a plane. Just like airline passengers, patients arrive at the doctor’s office with a wide variety of baggage. Some have a single issue that is troubling them. Others have been collecting complaints for months. Some have organized their questions on written lists. Many haven’t given much thought to prioritizing their issues and the physician is left to sort out what is the real problem. I suspect that most patients assume that all of their complaints will fit into a usual-length office visit, just as they assume their luggage will fit in the overhead bin or under the seat in front of them.

There are only so many hours in the day, and the physician and his staff must figure out how to get all that baggage stowed away safely in a reasonable time and with a minimum of unnecessary waiting for the other patients.

An experienced receptionist understands that different chief complaints require visits of different lengths. She or he also knows the patients well enough to realize that Mrs. Drifty’s visits are always twice as long as Mr. Organized’s, and that Dr. Speedy can see two patients in the time it takes Dr. Pokey to see one. A good receptionist/nurse team also can identify the patients who should be seen early in the day, regardless of what the schedule looks like.

It scares me to think of what might happen when patients are allowed freehand to make their own appointments. I fear that many will underestimate the amount of time their complaint takes to resolve. I dread the thought of what might happen if, at 8 a.m., the parent of a child with a fever and a purpuric rash clicks on a 4 p.m. slot instead of speaking to the nurse.

I can envision a few strategies that might avoid some of the potential scheduling disasters. The best option, I suspect, is going to be a carefully crafted hybrid that includes live receptionists. I’m sure some of you already have experience with patient-portal appointment schemes. I am interested to hear what’s working and what’s not. I’m afraid I’m going to have to buckle up because it’s probably going to be a bumpy ride.

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

We had run the gauntlet of TSA screening. Actually, it was more of a shuffle. We both had our shoes back on, and I rethreaded my belt as Marilyn and I walked toward our gate. Next, of course, was waiting and more waiting. Eventually, there was the call from the podium that boarding would start.

First were those obnoxious medallion people. You know, I never see any of them actually wearing their medallions. Then it was time to load by the letters. We were in D, which isn’t as bad as E or F. And I guess I wouldn’t want to be in A and risk sitting too close to the restrooms in the rear.

As I watched the A, B, and C folks troop by, I was impressed at the astounding variety of what they had self-proclaimed as carry-on luggage. It varied in size from large to enormous. I swear I saw something moving inside a duffle bag dragged by a college student. Some pieces had sharp pointy features. There were long tubes and plastic bags bulging with who knows what. Often, it was hard to tell what was a "personal item" and what was luggage.

Once seated on the plane, the entertainment continued as the E and F people struggled to stow their stuff. Clearly, some of them had no plan for what they would keep with them and what would go in the overhead. A small herd of passengers would back up in the aisle as minutes of indecision ticked by.

As the flight attendant began her seatbelt monologue, my mind floated back to last week’s all-provider meeting, at which one of the administrators announced that the long-promised patient Internet portal was on the launch pad. In concept, I’m a big fan of giving patients better access to their records and lab work. I think a portal will allow us to guide patients to health information sources we deem reliable, but I get a bit uncomfortable when I hear that patients will be able to make their own appointments.

Filling a physician’s schedule is a lot like loading a plane. Just like airline passengers, patients arrive at the doctor’s office with a wide variety of baggage. Some have a single issue that is troubling them. Others have been collecting complaints for months. Some have organized their questions on written lists. Many haven’t given much thought to prioritizing their issues and the physician is left to sort out what is the real problem. I suspect that most patients assume that all of their complaints will fit into a usual-length office visit, just as they assume their luggage will fit in the overhead bin or under the seat in front of them.

There are only so many hours in the day, and the physician and his staff must figure out how to get all that baggage stowed away safely in a reasonable time and with a minimum of unnecessary waiting for the other patients.

An experienced receptionist understands that different chief complaints require visits of different lengths. She or he also knows the patients well enough to realize that Mrs. Drifty’s visits are always twice as long as Mr. Organized’s, and that Dr. Speedy can see two patients in the time it takes Dr. Pokey to see one. A good receptionist/nurse team also can identify the patients who should be seen early in the day, regardless of what the schedule looks like.

It scares me to think of what might happen when patients are allowed freehand to make their own appointments. I fear that many will underestimate the amount of time their complaint takes to resolve. I dread the thought of what might happen if, at 8 a.m., the parent of a child with a fever and a purpuric rash clicks on a 4 p.m. slot instead of speaking to the nurse.

I can envision a few strategies that might avoid some of the potential scheduling disasters. The best option, I suspect, is going to be a carefully crafted hybrid that includes live receptionists. I’m sure some of you already have experience with patient-portal appointment schemes. I am interested to hear what’s working and what’s not. I’m afraid I’m going to have to buckle up because it’s probably going to be a bumpy ride.

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

Usually, once an idea enters my head these columns write themselves ... albeit with occasional and substantial help from the editor and the fact checkers. For the last month, however, I have been struggling with the notion that we need to include more physical activity in the school day. It’s not an original idea by any means. Michelle Obama has included making schools more active as one of the cornerstones of her program to stop the surge in obesity.

If we suspect that inactivity is a major contributor to the obesity epidemic, and if children spend a large part of their day in school, it just makes sense that we should inject more activity into the school day. The problem is that many schools have eliminated recesses for middle-school children and many high schools have just the skeleton of a physical education program. And, at least in the school systems that I am familiar with, gym class is as lame an exercise (maybe a poor word choice) as when I was in school 50-plus years ago.

The column I was going to write included a plea to increase recess and free playtime. I also was going to urge that, for the early grades, physical activity be woven into the academic curriculum. In fact, I had already found examples on the Internet of just such innovative curricula that could be downloaded free by any teacher who wanted to enhance his or her academic program.

I also was going to advocate for a whole new approach to physical education at the high school level by replacing traditional gym class with a smorgasbord of active opportunities. These could include small-group walks, jogs, or bike rides with a teacher. Or dance. Or tai chi, etc. It would take some creative thinking, and it would mean turning a deaf ear to the naysayers who can’t envision beyond their noses.

That is what I was going to write until I stumbled across a New York Times story that sent me to an article in the British Medical Journal entitled "Effectiveness of intervention on physical activity of children: systematic review and meta analysis of controlled trials with objectively measured outcomes" (BMJ 2012;345:e5888).

The authors looked at 30 studies involving over 14,000 subjects in which programs focused on increasing the physical activity of the children. Presumably most of these were school based. What they found was that, when one looked at the children’s total activity for the day, there was little or no increase. This observation could mean that the children had some exercise set point, so when it was exceeded at school they would compensate by being less active when they arrived home.

These results fit with other observations of weight loss programs in which success seems to require the total package. Just diet change or just exercise usually won’t work. If one wants to be a leaner, healthier person, then one must live like a leaner, healthier person ... all day long.

The data also could be interpreted to mean that we shouldn’t be wasting school time and energy on trying to keep children more active, but they also suggest that efforts at school are fruitless if there is no follow through at home. Families must play a significant role in the solution to obesity. It already seems pretty clear that they have played a big part in its creation.

There are days when I think that the solution to many of the problems facing our children would be to send them all to military school from 6th grade on. But those days are few. I remain hopeful that we can find better and more human solutions. Despite the discouraging findings by these researchers, I still believe that making the school day more active is a good idea. It can’t do the job alone, and it may take a while to see measurable results, but I think it won’t hurt.

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

Usually, once an idea enters my head these columns write themselves ... albeit with occasional and substantial help from the editor and the fact checkers. For the last month, however, I have been struggling with the notion that we need to include more physical activity in the school day. It’s not an original idea by any means. Michelle Obama has included making schools more active as one of the cornerstones of her program to stop the surge in obesity.

If we suspect that inactivity is a major contributor to the obesity epidemic, and if children spend a large part of their day in school, it just makes sense that we should inject more activity into the school day. The problem is that many schools have eliminated recesses for middle-school children and many high schools have just the skeleton of a physical education program. And, at least in the school systems that I am familiar with, gym class is as lame an exercise (maybe a poor word choice) as when I was in school 50-plus years ago.

The column I was going to write included a plea to increase recess and free playtime. I also was going to urge that, for the early grades, physical activity be woven into the academic curriculum. In fact, I had already found examples on the Internet of just such innovative curricula that could be downloaded free by any teacher who wanted to enhance his or her academic program.

I also was going to advocate for a whole new approach to physical education at the high school level by replacing traditional gym class with a smorgasbord of active opportunities. These could include small-group walks, jogs, or bike rides with a teacher. Or dance. Or tai chi, etc. It would take some creative thinking, and it would mean turning a deaf ear to the naysayers who can’t envision beyond their noses.

That is what I was going to write until I stumbled across a New York Times story that sent me to an article in the British Medical Journal entitled "Effectiveness of intervention on physical activity of children: systematic review and meta analysis of controlled trials with objectively measured outcomes" (BMJ 2012;345:e5888).

The authors looked at 30 studies involving over 14,000 subjects in which programs focused on increasing the physical activity of the children. Presumably most of these were school based. What they found was that, when one looked at the children’s total activity for the day, there was little or no increase. This observation could mean that the children had some exercise set point, so when it was exceeded at school they would compensate by being less active when they arrived home.

These results fit with other observations of weight loss programs in which success seems to require the total package. Just diet change or just exercise usually won’t work. If one wants to be a leaner, healthier person, then one must live like a leaner, healthier person ... all day long.

The data also could be interpreted to mean that we shouldn’t be wasting school time and energy on trying to keep children more active, but they also suggest that efforts at school are fruitless if there is no follow through at home. Families must play a significant role in the solution to obesity. It already seems pretty clear that they have played a big part in its creation.

There are days when I think that the solution to many of the problems facing our children would be to send them all to military school from 6th grade on. But those days are few. I remain hopeful that we can find better and more human solutions. Despite the discouraging findings by these researchers, I still believe that making the school day more active is a good idea. It can’t do the job alone, and it may take a while to see measurable results, but I think it won’t hurt.

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

Usually, once an idea enters my head these columns write themselves ... albeit with occasional and substantial help from the editor and the fact checkers. For the last month, however, I have been struggling with the notion that we need to include more physical activity in the school day. It’s not an original idea by any means. Michelle Obama has included making schools more active as one of the cornerstones of her program to stop the surge in obesity.

If we suspect that inactivity is a major contributor to the obesity epidemic, and if children spend a large part of their day in school, it just makes sense that we should inject more activity into the school day. The problem is that many schools have eliminated recesses for middle-school children and many high schools have just the skeleton of a physical education program. And, at least in the school systems that I am familiar with, gym class is as lame an exercise (maybe a poor word choice) as when I was in school 50-plus years ago.

The column I was going to write included a plea to increase recess and free playtime. I also was going to urge that, for the early grades, physical activity be woven into the academic curriculum. In fact, I had already found examples on the Internet of just such innovative curricula that could be downloaded free by any teacher who wanted to enhance his or her academic program.

I also was going to advocate for a whole new approach to physical education at the high school level by replacing traditional gym class with a smorgasbord of active opportunities. These could include small-group walks, jogs, or bike rides with a teacher. Or dance. Or tai chi, etc. It would take some creative thinking, and it would mean turning a deaf ear to the naysayers who can’t envision beyond their noses.

That is what I was going to write until I stumbled across a New York Times story that sent me to an article in the British Medical Journal entitled "Effectiveness of intervention on physical activity of children: systematic review and meta analysis of controlled trials with objectively measured outcomes" (BMJ 2012;345:e5888).

The authors looked at 30 studies involving over 14,000 subjects in which programs focused on increasing the physical activity of the children. Presumably most of these were school based. What they found was that, when one looked at the children’s total activity for the day, there was little or no increase. This observation could mean that the children had some exercise set point, so when it was exceeded at school they would compensate by being less active when they arrived home.

These results fit with other observations of weight loss programs in which success seems to require the total package. Just diet change or just exercise usually won’t work. If one wants to be a leaner, healthier person, then one must live like a leaner, healthier person ... all day long.

The data also could be interpreted to mean that we shouldn’t be wasting school time and energy on trying to keep children more active, but they also suggest that efforts at school are fruitless if there is no follow through at home. Families must play a significant role in the solution to obesity. It already seems pretty clear that they have played a big part in its creation.

There are days when I think that the solution to many of the problems facing our children would be to send them all to military school from 6th grade on. But those days are few. I remain hopeful that we can find better and more human solutions. Despite the discouraging findings by these researchers, I still believe that making the school day more active is a good idea. It can’t do the job alone, and it may take a while to see measurable results, but I think it won’t hurt.

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

A physician trying to follow the best practice path had better be prepared for a bumpy and tortuous ride. Years ago we were handed maps in the form of textbooks. New editions were updated every decade or so. But, the practitioner could reasonably rely on even a slightly outdated edition for guidance. As the pace of change in medicine increased, traditional hard copy texts lost much of their reliability.

More immediate electronic forms of information sharing have begun to replace hard copy books and supplement paper journals. The volume of information and the pace of change at times are so great that the busy physician may feel he doesn’t have the time to pull off on the shoulder to consult them. Instead, he speeds along looking for helpful road signs for direction. Unfortunately, the landscape is dominated by billboards erected by drug companies. Even the most conscientious physician can be distracted at times by these advertisements as he searches for the route to best practice.

Recently, I’ve been trying to remember how I arrived at my current strategy for managing asthma. It began when I learned in medical school that asthma was a disease characterized by "attacks." As a house officer, I was taught how to "break" these attacks with epinephrine injections (some older physicians were still using ipecac). We began using theophylline preparations and aminophylline drips. In my early days of practice I was prescribing oral albuterol and occasionally systemic steroids. At some point – but I don’t remember when or how – I began prescribing inhaled albuterol. Nebulizers, once reserved for the most seriously ill, became so common that if a family needed one in a pinch they could easily find a neighbor who had one in the closet. I now consider asthma a chronic disease and manage it with inhaled steroids and "rescue" inhalers.

How did I find my way? I can’t remember any sharp turns in the road. I guess it was a gradual process of talking with peers and former instructors, taking a rare CME course, and snatching a few moments to scan a journal here and there.

It feels as though most of the changes I’ve made in how I practice have been a collection of gentle turns. However, every now and then the route has taken a sharp 180-degree U-turn. The most dramatic example I can think of is the "Back to Sleep" initiative. It happened so many years ago that I suspect more than half the pediatricians practicing today have never told a mother to put her baby in the crib to sleep face down. This was not easy for those of us who had to change our tune in the blink of an eye.

The management of corneal abrasions is another clinical flip flop that has come recently. Now I’m left with a large box of eye patch pads that may never be used. I’m happy to have pivoted away from torturing toddlers who have fractured clavicles with figure-of-eight strapping. It always seemed like a bad idea.

However, I am a bit ambivalent about not casting simple buckle fractures. I accept the fact that a splint is not only just as good, but better. But I took great pride in crafting my own fiberglass sculptures, and then seeing them several weeks later cleverly decorated by the patient and his friends.

I guess the message is to not fall in love with one way of doing things, because more than likely time is going to make it obsolete. And, although most changes in the way we practice will be gradual, every now and then there comes a sharp 180 degree turn, and we need to keep our eyes on the road.

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

A physician trying to follow the best practice path had better be prepared for a bumpy and tortuous ride. Years ago we were handed maps in the form of textbooks. New editions were updated every decade or so. But, the practitioner could reasonably rely on even a slightly outdated edition for guidance. As the pace of change in medicine increased, traditional hard copy texts lost much of their reliability.

More immediate electronic forms of information sharing have begun to replace hard copy books and supplement paper journals. The volume of information and the pace of change at times are so great that the busy physician may feel he doesn’t have the time to pull off on the shoulder to consult them. Instead, he speeds along looking for helpful road signs for direction. Unfortunately, the landscape is dominated by billboards erected by drug companies. Even the most conscientious physician can be distracted at times by these advertisements as he searches for the route to best practice.

Recently, I’ve been trying to remember how I arrived at my current strategy for managing asthma. It began when I learned in medical school that asthma was a disease characterized by "attacks." As a house officer, I was taught how to "break" these attacks with epinephrine injections (some older physicians were still using ipecac). We began using theophylline preparations and aminophylline drips. In my early days of practice I was prescribing oral albuterol and occasionally systemic steroids. At some point – but I don’t remember when or how – I began prescribing inhaled albuterol. Nebulizers, once reserved for the most seriously ill, became so common that if a family needed one in a pinch they could easily find a neighbor who had one in the closet. I now consider asthma a chronic disease and manage it with inhaled steroids and "rescue" inhalers.

How did I find my way? I can’t remember any sharp turns in the road. I guess it was a gradual process of talking with peers and former instructors, taking a rare CME course, and snatching a few moments to scan a journal here and there.

It feels as though most of the changes I’ve made in how I practice have been a collection of gentle turns. However, every now and then the route has taken a sharp 180-degree U-turn. The most dramatic example I can think of is the "Back to Sleep" initiative. It happened so many years ago that I suspect more than half the pediatricians practicing today have never told a mother to put her baby in the crib to sleep face down. This was not easy for those of us who had to change our tune in the blink of an eye.

The management of corneal abrasions is another clinical flip flop that has come recently. Now I’m left with a large box of eye patch pads that may never be used. I’m happy to have pivoted away from torturing toddlers who have fractured clavicles with figure-of-eight strapping. It always seemed like a bad idea.

However, I am a bit ambivalent about not casting simple buckle fractures. I accept the fact that a splint is not only just as good, but better. But I took great pride in crafting my own fiberglass sculptures, and then seeing them several weeks later cleverly decorated by the patient and his friends.

I guess the message is to not fall in love with one way of doing things, because more than likely time is going to make it obsolete. And, although most changes in the way we practice will be gradual, every now and then there comes a sharp 180 degree turn, and we need to keep our eyes on the road.

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

A physician trying to follow the best practice path had better be prepared for a bumpy and tortuous ride. Years ago we were handed maps in the form of textbooks. New editions were updated every decade or so. But, the practitioner could reasonably rely on even a slightly outdated edition for guidance. As the pace of change in medicine increased, traditional hard copy texts lost much of their reliability.

More immediate electronic forms of information sharing have begun to replace hard copy books and supplement paper journals. The volume of information and the pace of change at times are so great that the busy physician may feel he doesn’t have the time to pull off on the shoulder to consult them. Instead, he speeds along looking for helpful road signs for direction. Unfortunately, the landscape is dominated by billboards erected by drug companies. Even the most conscientious physician can be distracted at times by these advertisements as he searches for the route to best practice.

Recently, I’ve been trying to remember how I arrived at my current strategy for managing asthma. It began when I learned in medical school that asthma was a disease characterized by "attacks." As a house officer, I was taught how to "break" these attacks with epinephrine injections (some older physicians were still using ipecac). We began using theophylline preparations and aminophylline drips. In my early days of practice I was prescribing oral albuterol and occasionally systemic steroids. At some point – but I don’t remember when or how – I began prescribing inhaled albuterol. Nebulizers, once reserved for the most seriously ill, became so common that if a family needed one in a pinch they could easily find a neighbor who had one in the closet. I now consider asthma a chronic disease and manage it with inhaled steroids and "rescue" inhalers.

How did I find my way? I can’t remember any sharp turns in the road. I guess it was a gradual process of talking with peers and former instructors, taking a rare CME course, and snatching a few moments to scan a journal here and there.

It feels as though most of the changes I’ve made in how I practice have been a collection of gentle turns. However, every now and then the route has taken a sharp 180-degree U-turn. The most dramatic example I can think of is the "Back to Sleep" initiative. It happened so many years ago that I suspect more than half the pediatricians practicing today have never told a mother to put her baby in the crib to sleep face down. This was not easy for those of us who had to change our tune in the blink of an eye.

The management of corneal abrasions is another clinical flip flop that has come recently. Now I’m left with a large box of eye patch pads that may never be used. I’m happy to have pivoted away from torturing toddlers who have fractured clavicles with figure-of-eight strapping. It always seemed like a bad idea.

However, I am a bit ambivalent about not casting simple buckle fractures. I accept the fact that a splint is not only just as good, but better. But I took great pride in crafting my own fiberglass sculptures, and then seeing them several weeks later cleverly decorated by the patient and his friends.

I guess the message is to not fall in love with one way of doing things, because more than likely time is going to make it obsolete. And, although most changes in the way we practice will be gradual, every now and then there comes a sharp 180 degree turn, and we need to keep our eyes on the road.

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