William G. Wilkoff, MD

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 But, the practitioner could reasonably rely on even a slightly outdated edition for guidance.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].

Like most pediatricians I’m not accustomed to giving bad news, and I try to keep these columns balanced and hope to avoid sounding too curmudgeonly. But, this week I am compelled to share two troubling reports that slithered across my desk. Neither came as a surprise to me, because as a card-carrying optimist I have continued to hope that my unfortunate experiences with electronic medical records were not the norm.

The first is an opinion piece that appeared in the Wall Street Journal of Sept. 17, 2012, titled "A Major Glitch for Digitized Health-Care Records" by Stephen Soumerai and Ross Koppel, Ph.D. Mr. Soumerai is a professor of population medicine at Harvard Medical School, Boston, and Dr. Koppel is a professor of sociology and medicine at the University of Pennsylvania, Philadelphia. Their conclusion is that there is little evidence to support the promises of the federal government and information technology vendors that the widespread adoption of electronic medical records will save money and lives. They observe that health IT software "is generally clunky, frustrating, user-unfriendly, and inefficient."

They cite a study done by faculty at McMaster University in Hamilton, Ont., titled "The Economics of Health Information Technology in Medication Management: A Systematic Review of Economic Evaluations" (J. Am. Med. Inform. Assoc. 2011 [doi: 10.1136/amiajnl-2011-000310]). Of the 36,000 studies evaluated, the researchers found 31 that examined claims of cost-savings. With some isolated exceptions, IT systems had neither saved money nor improved health care. For example, several studies found that doctors overrode drug interaction alerts between 50% and 97% of the time. That pretty much covers my average rate for overrides.

Mr. Soumerai and Dr. Koppel also cite studies from the Indiana University School of Medicine that found no savings and an increase in cost of $2,200 per physician with the introduction of electronic health records (EHRs). One study did show a "small but statistically questionable savings of $22 per patient per year."

On a smaller and more personal scale is Medscape’s "EHR Report 2012 - Physicians Rank Top EHRs" that a colleague e-mailed me. This survey was performed in June 2012 and included more than 20,000 physicians representing 25 specialties. One of the most striking findings was that although in a 2009 survey more than a third of respondents said they had no plans to include an EHR system in their practices, in 2012 more than 80% of physicians were using or in the process of installing EHRs.

Do you think that the government’s financial incentives have had anything to do with this dramatic shift in attitude? If we look back at the evidence that Mr. Soumerai and Dr. Koppel have accumulated, this sudden shift in plans couldn’t possibly result from testimonies by EHR users who are thrilled with their financial experiences.

In the Medscape survey of current users, 26% reported that EHRs decreased their productivity and only 6% said it increase their revenues. Nearly a third of the respondents thought that their EHR system had a negative impact on the doctor-patient relationship. Of this subgroup, 82% reported that the EHR resulted in less eye contact, and 75% thought it resulted in less conversation time.

What do these numbers tell us? First, physicians tend to be rather poor business people. When offered a subsidy, they don’t ask the obvious question, "What will this do to my bottom line?" Second, many of the people who design software (even those who may have an MD after their names) don’t understand the nuts and bolts of day-to-day clinical practice.

The tragic thread through this whole EHR mess is that if properly conceived and implemented, EHRs have the potential to save both money and lives. However, the federal government made a serious error in failing to demand unified standards. Left to their own devices, the vendors haven’t cooperated with each other, and chaos is the result.

I remain hopeful that if Apple can do what it has done with the iPhone and the iPad, then we have the people and smarts to make EHRs fulfill the promises that are currently missing in action.

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

Like most pediatricians I’m not accustomed to giving bad news, and I try to keep these columns balanced and hope to avoid sounding too curmudgeonly. But, this week I am compelled to share two troubling reports that slithered across my desk. Neither came as a surprise to me, because as a card-carrying optimist I have continued to hope that my unfortunate experiences with electronic medical records were not the norm.

The first is an opinion piece that appeared in the Wall Street Journal of Sept. 17, 2012, titled "A Major Glitch for Digitized Health-Care Records" by Stephen Soumerai and Ross Koppel, Ph.D. Mr. Soumerai is a professor of population medicine at Harvard Medical School, Boston, and Dr. Koppel is a professor of sociology and medicine at the University of Pennsylvania, Philadelphia. Their conclusion is that there is little evidence to support the promises of the federal government and information technology vendors that the widespread adoption of electronic medical records will save money and lives. They observe that health IT software "is generally clunky, frustrating, user-unfriendly, and inefficient."

They cite a study done by faculty at McMaster University in Hamilton, Ont., titled "The Economics of Health Information Technology in Medication Management: A Systematic Review of Economic Evaluations" (J. Am. Med. Inform. Assoc. 2011 [doi: 10.1136/amiajnl-2011-000310]). Of the 36,000 studies evaluated, the researchers found 31 that examined claims of cost-savings. With some isolated exceptions, IT systems had neither saved money nor improved health care. For example, several studies found that doctors overrode drug interaction alerts between 50% and 97% of the time. That pretty much covers my average rate for overrides.

Mr. Soumerai and Dr. Koppel also cite studies from the Indiana University School of Medicine that found no savings and an increase in cost of $2,200 per physician with the introduction of electronic health records (EHRs). One study did show a "small but statistically questionable savings of $22 per patient per year."

On a smaller and more personal scale is Medscape’s "EHR Report 2012 - Physicians Rank Top EHRs" that a colleague e-mailed me. This survey was performed in June 2012 and included more than 20,000 physicians representing 25 specialties. One of the most striking findings was that although in a 2009 survey more than a third of respondents said they had no plans to include an EHR system in their practices, in 2012 more than 80% of physicians were using or in the process of installing EHRs.

Do you think that the government’s financial incentives have had anything to do with this dramatic shift in attitude? If we look back at the evidence that Mr. Soumerai and Dr. Koppel have accumulated, this sudden shift in plans couldn’t possibly result from testimonies by EHR users who are thrilled with their financial experiences.

In the Medscape survey of current users, 26% reported that EHRs decreased their productivity and only 6% said it increase their revenues. Nearly a third of the respondents thought that their EHR system had a negative impact on the doctor-patient relationship. Of this subgroup, 82% reported that the EHR resulted in less eye contact, and 75% thought it resulted in less conversation time.

What do these numbers tell us? First, physicians tend to be rather poor business people. When offered a subsidy, they don’t ask the obvious question, "What will this do to my bottom line?" Second, many of the people who design software (even those who may have an MD after their names) don’t understand the nuts and bolts of day-to-day clinical practice.

The tragic thread through this whole EHR mess is that if properly conceived and implemented, EHRs have the potential to save both money and lives. However, the federal government made a serious error in failing to demand unified standards. Left to their own devices, the vendors haven’t cooperated with each other, and chaos is the result.

I remain hopeful that if Apple can do what it has done with the iPhone and the iPad, then we have the people and smarts to make EHRs fulfill the promises that are currently missing in action.

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

Like most pediatricians I’m not accustomed to giving bad news, and I try to keep these columns balanced and hope to avoid sounding too curmudgeonly. But, this week I am compelled to share two troubling reports that slithered across my desk. Neither came as a surprise to me, because as a card-carrying optimist I have continued to hope that my unfortunate experiences with electronic medical records were not the norm.

The first is an opinion piece that appeared in the Wall Street Journal of Sept. 17, 2012, titled "A Major Glitch for Digitized Health-Care Records" by Stephen Soumerai and Ross Koppel, Ph.D. Mr. Soumerai is a professor of population medicine at Harvard Medical School, Boston, and Dr. Koppel is a professor of sociology and medicine at the University of Pennsylvania, Philadelphia. Their conclusion is that there is little evidence to support the promises of the federal government and information technology vendors that the widespread adoption of electronic medical records will save money and lives. They observe that health IT software "is generally clunky, frustrating, user-unfriendly, and inefficient."

They cite a study done by faculty at McMaster University in Hamilton, Ont., titled "The Economics of Health Information Technology in Medication Management: A Systematic Review of Economic Evaluations" (J. Am. Med. Inform. Assoc. 2011 [doi: 10.1136/amiajnl-2011-000310]). Of the 36,000 studies evaluated, the researchers found 31 that examined claims of cost-savings. With some isolated exceptions, IT systems had neither saved money nor improved health care. For example, several studies found that doctors overrode drug interaction alerts between 50% and 97% of the time. That pretty much covers my average rate for overrides.

Mr. Soumerai and Dr. Koppel also cite studies from the Indiana University School of Medicine that found no savings and an increase in cost of $2,200 per physician with the introduction of electronic health records (EHRs). One study did show a "small but statistically questionable savings of $22 per patient per year."

On a smaller and more personal scale is Medscape’s "EHR Report 2012 - Physicians Rank Top EHRs" that a colleague e-mailed me. This survey was performed in June 2012 and included more than 20,000 physicians representing 25 specialties. One of the most striking findings was that although in a 2009 survey more than a third of respondents said they had no plans to include an EHR system in their practices, in 2012 more than 80% of physicians were using or in the process of installing EHRs.

Do you think that the government’s financial incentives have had anything to do with this dramatic shift in attitude? If we look back at the evidence that Mr. Soumerai and Dr. Koppel have accumulated, this sudden shift in plans couldn’t possibly result from testimonies by EHR users who are thrilled with their financial experiences.

In the Medscape survey of current users, 26% reported that EHRs decreased their productivity and only 6% said it increase their revenues. Nearly a third of the respondents thought that their EHR system had a negative impact on the doctor-patient relationship. Of this subgroup, 82% reported that the EHR resulted in less eye contact, and 75% thought it resulted in less conversation time.

What do these numbers tell us? First, physicians tend to be rather poor business people. When offered a subsidy, they don’t ask the obvious question, "What will this do to my bottom line?" Second, many of the people who design software (even those who may have an MD after their names) don’t understand the nuts and bolts of day-to-day clinical practice.

The tragic thread through this whole EHR mess is that if properly conceived and implemented, EHRs have the potential to save both money and lives. However, the federal government made a serious error in failing to demand unified standards. Left to their own devices, the vendors haven’t cooperated with each other, and chaos is the result.

I remain hopeful that if Apple can do what it has done with the iPhone and the iPad, then we have the people and smarts to make EHRs fulfill the promises that are currently missing in action.

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

The American Academy of Pediatrics has just published its policy statement, "Trampoline Safety in Childhood and Adolescence" (Pediatrics 2012;130:774-9). It cites the most recent injury figures in 2009 of 70 per 100,000 for children aged 0 to 4 years and 160 per 100,000 for 5- to 14-year-olds. The statement also raises concerns about the quality of the equipment as lower-priced backyard models have entered the market. Padding on the frames of the higher-priced trampolines still seems to be ineffective in preventing injuries.

When there are multiple jumpers on the trampoline, the risk of injury increases dramatically. And, while the safety of most recreational activities seems to significantly improve with adult supervision, this doesn’t seem to be the case with trampolines. Between a third and a half of all trampoline injuries occurred during adult supervision.

The AAP’s statement stops short of suggesting that all trampolines be dismantled and recycled into lawn furniture. But it does leave the impression that allowing a child to play on a trampoline is a bad idea.

My personal relationship with trampolines ended with high school. Because I had some competitive diving experience, I was asked to do a demonstration during halftime of the faculty-varsity basketball game. My final trick was a backward somersault that ended poorly with me cradled in the arms of one of the spotters. The announcer, who was also the football coach, bellowed, "Bill (I now go by Will) is going to climb back up and do it again." Although this wasn’t my plan, I desperately wanted to make the starting 11 in the fall. While I can’t say I stuck the landing, at least I ended up closer to the center of the trampoline.

My professional experience with trampolines has been even more limited and certainly less exciting. I have seen very few trampoline-related injuries in children, and fortunately none have been serious or memorable. I suspect there are several factors at play here. Our geographic isolation in Maine means that most fads arrive here late or not at all. I can’t recall seeing a single outdoor trampoline park. Our long cold winters discourage the purchase of trampolines and swimming pools. However, we do have them.

While trampolines may not generate an alarming number of injuries here in Brunswick, I can tell you that mattresses do. At least once a month we see a child who was injured bouncing on (or often off) a bed. Most of these injuries are of the superficial hematoma, split lip, chipped tooth variety. But a significant number are not so trivial. My personal list includes one ruptured spleen, one fractured femur, a couple of tibial fractures, a few handfuls of broken clavicles, and a dozen or more mild concussions.

A quick Internet search yielded no studies of the incidence and severity of bed-bouncing injuries. But I’m sure my experience is not unique. I inspected the tag on my mattress (the one that if you tear it off you go to federal prison), and it does not include a warning about bed jumping.

While I applaud the AAP for making its current statement on trampoline safety, it may be time to form a working group tasked with addressing the issue of bed bouncing. Currently, the sum total of our prevention effort on this risky behavior comes in the form of a nursery rhyme.

Recite along with me:

One little monkey jumping on the bed.

He fell off and bumped his head.

Mama called the doctor and the doctor said,

"No more monkeys jumping on the bed!"

As a start, we should include this admonition on every mattress tag.

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

The American Academy of Pediatrics has just published its policy statement, "Trampoline Safety in Childhood and Adolescence" (Pediatrics 2012;130:774-9). It cites the most recent injury figures in 2009 of 70 per 100,000 for children aged 0 to 4 years and 160 per 100,000 for 5- to 14-year-olds. The statement also raises concerns about the quality of the equipment as lower-priced backyard models have entered the market. Padding on the frames of the higher-priced trampolines still seems to be ineffective in preventing injuries.

When there are multiple jumpers on the trampoline, the risk of injury increases dramatically. And, while the safety of most recreational activities seems to significantly improve with adult supervision, this doesn’t seem to be the case with trampolines. Between a third and a half of all trampoline injuries occurred during adult supervision.

The AAP’s statement stops short of suggesting that all trampolines be dismantled and recycled into lawn furniture. But it does leave the impression that allowing a child to play on a trampoline is a bad idea.

My personal relationship with trampolines ended with high school. Because I had some competitive diving experience, I was asked to do a demonstration during halftime of the faculty-varsity basketball game. My final trick was a backward somersault that ended poorly with me cradled in the arms of one of the spotters. The announcer, who was also the football coach, bellowed, "Bill (I now go by Will) is going to climb back up and do it again." Although this wasn’t my plan, I desperately wanted to make the starting 11 in the fall. While I can’t say I stuck the landing, at least I ended up closer to the center of the trampoline.

My professional experience with trampolines has been even more limited and certainly less exciting. I have seen very few trampoline-related injuries in children, and fortunately none have been serious or memorable. I suspect there are several factors at play here. Our geographic isolation in Maine means that most fads arrive here late or not at all. I can’t recall seeing a single outdoor trampoline park. Our long cold winters discourage the purchase of trampolines and swimming pools. However, we do have them.

While trampolines may not generate an alarming number of injuries here in Brunswick, I can tell you that mattresses do. At least once a month we see a child who was injured bouncing on (or often off) a bed. Most of these injuries are of the superficial hematoma, split lip, chipped tooth variety. But a significant number are not so trivial. My personal list includes one ruptured spleen, one fractured femur, a couple of tibial fractures, a few handfuls of broken clavicles, and a dozen or more mild concussions.

A quick Internet search yielded no studies of the incidence and severity of bed-bouncing injuries. But I’m sure my experience is not unique. I inspected the tag on my mattress (the one that if you tear it off you go to federal prison), and it does not include a warning about bed jumping.

While I applaud the AAP for making its current statement on trampoline safety, it may be time to form a working group tasked with addressing the issue of bed bouncing. Currently, the sum total of our prevention effort on this risky behavior comes in the form of a nursery rhyme.

Recite along with me:

One little monkey jumping on the bed.

He fell off and bumped his head.

Mama called the doctor and the doctor said,

"No more monkeys jumping on the bed!"

As a start, we should include this admonition on every mattress tag.

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

The American Academy of Pediatrics has just published its policy statement, "Trampoline Safety in Childhood and Adolescence" (Pediatrics 2012;130:774-9). It cites the most recent injury figures in 2009 of 70 per 100,000 for children aged 0 to 4 years and 160 per 100,000 for 5- to 14-year-olds. The statement also raises concerns about the quality of the equipment as lower-priced backyard models have entered the market. Padding on the frames of the higher-priced trampolines still seems to be ineffective in preventing injuries.

When there are multiple jumpers on the trampoline, the risk of injury increases dramatically. And, while the safety of most recreational activities seems to significantly improve with adult supervision, this doesn’t seem to be the case with trampolines. Between a third and a half of all trampoline injuries occurred during adult supervision.

The AAP’s statement stops short of suggesting that all trampolines be dismantled and recycled into lawn furniture. But it does leave the impression that allowing a child to play on a trampoline is a bad idea.

My personal relationship with trampolines ended with high school. Because I had some competitive diving experience, I was asked to do a demonstration during halftime of the faculty-varsity basketball game. My final trick was a backward somersault that ended poorly with me cradled in the arms of one of the spotters. The announcer, who was also the football coach, bellowed, "Bill (I now go by Will) is going to climb back up and do it again." Although this wasn’t my plan, I desperately wanted to make the starting 11 in the fall. While I can’t say I stuck the landing, at least I ended up closer to the center of the trampoline.

My professional experience with trampolines has been even more limited and certainly less exciting. I have seen very few trampoline-related injuries in children, and fortunately none have been serious or memorable. I suspect there are several factors at play here. Our geographic isolation in Maine means that most fads arrive here late or not at all. I can’t recall seeing a single outdoor trampoline park. Our long cold winters discourage the purchase of trampolines and swimming pools. However, we do have them.

While trampolines may not generate an alarming number of injuries here in Brunswick, I can tell you that mattresses do. At least once a month we see a child who was injured bouncing on (or often off) a bed. Most of these injuries are of the superficial hematoma, split lip, chipped tooth variety. But a significant number are not so trivial. My personal list includes one ruptured spleen, one fractured femur, a couple of tibial fractures, a few handfuls of broken clavicles, and a dozen or more mild concussions.

A quick Internet search yielded no studies of the incidence and severity of bed-bouncing injuries. But I’m sure my experience is not unique. I inspected the tag on my mattress (the one that if you tear it off you go to federal prison), and it does not include a warning about bed jumping.

While I applaud the AAP for making its current statement on trampoline safety, it may be time to form a working group tasked with addressing the issue of bed bouncing. Currently, the sum total of our prevention effort on this risky behavior comes in the form of a nursery rhyme.

Recite along with me:

One little monkey jumping on the bed.

He fell off and bumped his head.

Mama called the doctor and the doctor said,

"No more monkeys jumping on the bed!"

As a start, we should include this admonition on every mattress tag.

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

Most of us don’t do much healing. We pride ourselves as being ace preventionists. But the truth is that pediatricians are primarily advice dispensers. In his commentary in the September 2012 Pediatrics, Dr. Robert Needleman asks, "What Do We Do With Our 15 Minutes?" (Pediatrics 2012;130:e683-4). He is talking about our face-to-face time during a well child visit. Of course you could ask for more time, but unless you or your spouse is living off the income stream from a large family trust fund, you can’t afford more time. And maybe more time wouldn’t be better.

Dr. Needleman questions the assumption that "when pediatricians cover more, parents come away knowing more and are able to translate that into action." But no one knows because, as Dr. Needleman writes, "little guidance is grounded in studies done in primary care settings." His commentary closes with a plea for more research to help us make the most of our 15 minutes of guidance giving.

But what should we primary care folks do with our quarter hour while we are waiting for the wheels of office-based research to grind out a few answers? I suggest that we start with a simple triage scheme. The first and maybe the only agenda we address should be the one that the parents/patients bring with them. In other words, the well child visit should be parent/patient driven, not the end product of a checklist generated by a committee whose members have contributed their own favorite health or safety issues.

I am flattered that so many groups think so highly of my persuasive powers that they want me to devote 15 minutes of my patient’s visit addressing the issues that they are focused on. I’m happy to provide wall space for posters and shelf space for pamphlet racks, but someone has to choose how to allot the face-to-face time. And from my perspective, the patients/parents get to choose first.

However, some parents/patients don’t come with an agenda. Or they may be too timid to verbalize their concerns. Here we are at the second level of triage, and the one that takes the most clinical skill because the physician must know enough to anticipate the specific needs of the parent/patient. It helps to be familiar with the family or at least the demographic. But still, the physician is playing a guessing game. What are the concerns that are most likely to be troubling these parents/patients that they aren’t voicing? What pitfalls will they encounter before the next time we meet? The result should be truly focused anticipatory guidance. To succeed, it is critical that the physician present himself as someone who cares and is willing and prepared to talk about a range of topics far beyond ear infections and diarrhea. Or the best questions won’t surface.

It is rare for parents/patients to slip past these first two triage groups. But sometimes, just sometimes, they won’t come with an agenda nor will I be able to elicit their unspoken concerns. I am happy to fill the void by talking about issues I think are important. In other words, Triage III is my soapbox time. That is, if there is any time left.

When I get to drive the bus, we’re usually going to talk about sleep. In my view, sleep deprivation is at the heart of most maladies. It warmed the cockles of my sleep-obsessed heart to read that the only study cited by Dr. Needleman as an example of proven anticipatory guidance was one by Adair and colleagues (Pediatrics 1992;89(4pt 1):585-8). In this study, the investigators found that when parents were given advice about putting their children to bed drowsy but not asleep at 4 months of age, the infants experienced 36% less night waking at 9 months of age.

So that’s how I manage my 15 minutes. But I am interested to hear how you budget your precious quarter of an hour during a well child visit.

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

Most of us don’t do much healing. We pride ourselves as being ace preventionists. But the truth is that pediatricians are primarily advice dispensers. In his commentary in the September 2012 Pediatrics, Dr. Robert Needleman asks, "What Do We Do With Our 15 Minutes?" (Pediatrics 2012;130:e683-4). He is talking about our face-to-face time during a well child visit. Of course you could ask for more time, but unless you or your spouse is living off the income stream from a large family trust fund, you can’t afford more time. And maybe more time wouldn’t be better.

Dr. Needleman questions the assumption that "when pediatricians cover more, parents come away knowing more and are able to translate that into action." But no one knows because, as Dr. Needleman writes, "little guidance is grounded in studies done in primary care settings." His commentary closes with a plea for more research to help us make the most of our 15 minutes of guidance giving.

But what should we primary care folks do with our quarter hour while we are waiting for the wheels of office-based research to grind out a few answers? I suggest that we start with a simple triage scheme. The first and maybe the only agenda we address should be the one that the parents/patients bring with them. In other words, the well child visit should be parent/patient driven, not the end product of a checklist generated by a committee whose members have contributed their own favorite health or safety issues.

I am flattered that so many groups think so highly of my persuasive powers that they want me to devote 15 minutes of my patient’s visit addressing the issues that they are focused on. I’m happy to provide wall space for posters and shelf space for pamphlet racks, but someone has to choose how to allot the face-to-face time. And from my perspective, the patients/parents get to choose first.

However, some parents/patients don’t come with an agenda. Or they may be too timid to verbalize their concerns. Here we are at the second level of triage, and the one that takes the most clinical skill because the physician must know enough to anticipate the specific needs of the parent/patient. It helps to be familiar with the family or at least the demographic. But still, the physician is playing a guessing game. What are the concerns that are most likely to be troubling these parents/patients that they aren’t voicing? What pitfalls will they encounter before the next time we meet? The result should be truly focused anticipatory guidance. To succeed, it is critical that the physician present himself as someone who cares and is willing and prepared to talk about a range of topics far beyond ear infections and diarrhea. Or the best questions won’t surface.

It is rare for parents/patients to slip past these first two triage groups. But sometimes, just sometimes, they won’t come with an agenda nor will I be able to elicit their unspoken concerns. I am happy to fill the void by talking about issues I think are important. In other words, Triage III is my soapbox time. That is, if there is any time left.

When I get to drive the bus, we’re usually going to talk about sleep. In my view, sleep deprivation is at the heart of most maladies. It warmed the cockles of my sleep-obsessed heart to read that the only study cited by Dr. Needleman as an example of proven anticipatory guidance was one by Adair and colleagues (Pediatrics 1992;89(4pt 1):585-8). In this study, the investigators found that when parents were given advice about putting their children to bed drowsy but not asleep at 4 months of age, the infants experienced 36% less night waking at 9 months of age.

So that’s how I manage my 15 minutes. But I am interested to hear how you budget your precious quarter of an hour during a well child visit.

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

Most of us don’t do much healing. We pride ourselves as being ace preventionists. But the truth is that pediatricians are primarily advice dispensers. In his commentary in the September 2012 Pediatrics, Dr. Robert Needleman asks, "What Do We Do With Our 15 Minutes?" (Pediatrics 2012;130:e683-4). He is talking about our face-to-face time during a well child visit. Of course you could ask for more time, but unless you or your spouse is living off the income stream from a large family trust fund, you can’t afford more time. And maybe more time wouldn’t be better.

Dr. Needleman questions the assumption that "when pediatricians cover more, parents come away knowing more and are able to translate that into action." But no one knows because, as Dr. Needleman writes, "little guidance is grounded in studies done in primary care settings." His commentary closes with a plea for more research to help us make the most of our 15 minutes of guidance giving.

But what should we primary care folks do with our quarter hour while we are waiting for the wheels of office-based research to grind out a few answers? I suggest that we start with a simple triage scheme. The first and maybe the only agenda we address should be the one that the parents/patients bring with them. In other words, the well child visit should be parent/patient driven, not the end product of a checklist generated by a committee whose members have contributed their own favorite health or safety issues.

I am flattered that so many groups think so highly of my persuasive powers that they want me to devote 15 minutes of my patient’s visit addressing the issues that they are focused on. I’m happy to provide wall space for posters and shelf space for pamphlet racks, but someone has to choose how to allot the face-to-face time. And from my perspective, the patients/parents get to choose first.

However, some parents/patients don’t come with an agenda. Or they may be too timid to verbalize their concerns. Here we are at the second level of triage, and the one that takes the most clinical skill because the physician must know enough to anticipate the specific needs of the parent/patient. It helps to be familiar with the family or at least the demographic. But still, the physician is playing a guessing game. What are the concerns that are most likely to be troubling these parents/patients that they aren’t voicing? What pitfalls will they encounter before the next time we meet? The result should be truly focused anticipatory guidance. To succeed, it is critical that the physician present himself as someone who cares and is willing and prepared to talk about a range of topics far beyond ear infections and diarrhea. Or the best questions won’t surface.

It is rare for parents/patients to slip past these first two triage groups. But sometimes, just sometimes, they won’t come with an agenda nor will I be able to elicit their unspoken concerns. I am happy to fill the void by talking about issues I think are important. In other words, Triage III is my soapbox time. That is, if there is any time left.

When I get to drive the bus, we’re usually going to talk about sleep. In my view, sleep deprivation is at the heart of most maladies. It warmed the cockles of my sleep-obsessed heart to read that the only study cited by Dr. Needleman as an example of proven anticipatory guidance was one by Adair and colleagues (Pediatrics 1992;89(4pt 1):585-8). In this study, the investigators found that when parents were given advice about putting their children to bed drowsy but not asleep at 4 months of age, the infants experienced 36% less night waking at 9 months of age.

So that’s how I manage my 15 minutes. But I am interested to hear how you budget your precious quarter of an hour during a well child visit.

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

I inherited a bunch of stuff from my mother. Among them are a strong aversion to confrontation and amateur theatrical performances, comfortable relationships with sketching pencils and paint brushes, and a mouthful of dental caries. In fact, I have enough amalgam in my teeth to tune in National Public Radio if I open my mouth just enough and face northeast.

For years, I thought my plethora of dental cavities was because my mom was always generous with the chewing gum she habitually carried in her purse. Whenever my sister and I were out and about with my mom and seeming a bit bored or devilish, she would unwrap a couple of sticks to keep us amused.

Well, it turns out that although bathing my teeth with sugar-containing saliva wasn’t helping the situation, the suite of bacteria that my mother shared with me when I was a neonate was a coconspirator in rotting my teeth. Thriving on the nutrient-rich saliva, Streptococcus mutans gobbled away at my enamel.

While I was still processing this new assault on my mother’s reputation, I discovered that, had she lived into the 21st century, her free gifting of chewing gum would be considered on the cutting edge of oral health. I recently discovered that some dentists are encouraging their young patients to chew gum to help prevent dental caries. Of course, not just any gum, but gum that contains xylitol, a sweetener found in some fruits and vegetables.

It turns out that chewing gum increases saliva production, which is a good thing as long as the saliva is not sugar rich. When sugar is replaced with xylitol, the saliva is less acidic. The combination of more saliva and a higher pH seems to encourage remineralization of teeth, even those that have already begun to degrade. The effect is apparently most effective when xylitol-containing gum is chewed regularly before adult teeth have erupted.

If we accept the studies that support these findings, then it means that most communities should be making a fast 180 shift in their policies about chewing gum in school. Having spent most of one summer as school custodian laying on my back scraping petrified gum off the undersides of desks with a putty knife, I can understand why school administrators would be resistant to a change in policy.

However, there might be another reason to encourage gum chewing in school that might get the administrators’ attention. It turns out that a handful of researchers have observed that gum chewing can help cognition and improve attention. One explanation for this phenomenon is that for many of us, repetitive physical actions such as pencil tapping helps us concentrate. Bouncing my legs to the throbbing beat of the Rolling Stones helped me get through medical school. It may simply be that the music kept me awake, but for whatever reason, it worked.

But, to be fair, there is a study from the Netherlands that found that not only did chewing gum not help with attention, but that it was detrimental to task execution and vigilance in both healthy children and those with attention-deficit/hyperactivity disorder (Appetite 2010;55:679-84).

I hope that others will try to repeat this study and find that my mother was on the right track in keeping my sister and I focused with a stick of gum. If the detrimental effects on learning stand up, this information will present an interesting dilemma for pediatricians. Rotten teeth or distracted students?

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

I inherited a bunch of stuff from my mother. Among them are a strong aversion to confrontation and amateur theatrical performances, comfortable relationships with sketching pencils and paint brushes, and a mouthful of dental caries. In fact, I have enough amalgam in my teeth to tune in National Public Radio if I open my mouth just enough and face northeast.

For years, I thought my plethora of dental cavities was because my mom was always generous with the chewing gum she habitually carried in her purse. Whenever my sister and I were out and about with my mom and seeming a bit bored or devilish, she would unwrap a couple of sticks to keep us amused.

Well, it turns out that although bathing my teeth with sugar-containing saliva wasn’t helping the situation, the suite of bacteria that my mother shared with me when I was a neonate was a coconspirator in rotting my teeth. Thriving on the nutrient-rich saliva, Streptococcus mutans gobbled away at my enamel.

While I was still processing this new assault on my mother’s reputation, I discovered that, had she lived into the 21st century, her free gifting of chewing gum would be considered on the cutting edge of oral health. I recently discovered that some dentists are encouraging their young patients to chew gum to help prevent dental caries. Of course, not just any gum, but gum that contains xylitol, a sweetener found in some fruits and vegetables.

It turns out that chewing gum increases saliva production, which is a good thing as long as the saliva is not sugar rich. When sugar is replaced with xylitol, the saliva is less acidic. The combination of more saliva and a higher pH seems to encourage remineralization of teeth, even those that have already begun to degrade. The effect is apparently most effective when xylitol-containing gum is chewed regularly before adult teeth have erupted.

If we accept the studies that support these findings, then it means that most communities should be making a fast 180 shift in their policies about chewing gum in school. Having spent most of one summer as school custodian laying on my back scraping petrified gum off the undersides of desks with a putty knife, I can understand why school administrators would be resistant to a change in policy.

However, there might be another reason to encourage gum chewing in school that might get the administrators’ attention. It turns out that a handful of researchers have observed that gum chewing can help cognition and improve attention. One explanation for this phenomenon is that for many of us, repetitive physical actions such as pencil tapping helps us concentrate. Bouncing my legs to the throbbing beat of the Rolling Stones helped me get through medical school. It may simply be that the music kept me awake, but for whatever reason, it worked.

But, to be fair, there is a study from the Netherlands that found that not only did chewing gum not help with attention, but that it was detrimental to task execution and vigilance in both healthy children and those with attention-deficit/hyperactivity disorder (Appetite 2010;55:679-84).

I hope that others will try to repeat this study and find that my mother was on the right track in keeping my sister and I focused with a stick of gum. If the detrimental effects on learning stand up, this information will present an interesting dilemma for pediatricians. Rotten teeth or distracted students?

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

I inherited a bunch of stuff from my mother. Among them are a strong aversion to confrontation and amateur theatrical performances, comfortable relationships with sketching pencils and paint brushes, and a mouthful of dental caries. In fact, I have enough amalgam in my teeth to tune in National Public Radio if I open my mouth just enough and face northeast.

For years, I thought my plethora of dental cavities was because my mom was always generous with the chewing gum she habitually carried in her purse. Whenever my sister and I were out and about with my mom and seeming a bit bored or devilish, she would unwrap a couple of sticks to keep us amused.

Well, it turns out that although bathing my teeth with sugar-containing saliva wasn’t helping the situation, the suite of bacteria that my mother shared with me when I was a neonate was a coconspirator in rotting my teeth. Thriving on the nutrient-rich saliva, Streptococcus mutans gobbled away at my enamel.

While I was still processing this new assault on my mother’s reputation, I discovered that, had she lived into the 21st century, her free gifting of chewing gum would be considered on the cutting edge of oral health. I recently discovered that some dentists are encouraging their young patients to chew gum to help prevent dental caries. Of course, not just any gum, but gum that contains xylitol, a sweetener found in some fruits and vegetables.

It turns out that chewing gum increases saliva production, which is a good thing as long as the saliva is not sugar rich. When sugar is replaced with xylitol, the saliva is less acidic. The combination of more saliva and a higher pH seems to encourage remineralization of teeth, even those that have already begun to degrade. The effect is apparently most effective when xylitol-containing gum is chewed regularly before adult teeth have erupted.

If we accept the studies that support these findings, then it means that most communities should be making a fast 180 shift in their policies about chewing gum in school. Having spent most of one summer as school custodian laying on my back scraping petrified gum off the undersides of desks with a putty knife, I can understand why school administrators would be resistant to a change in policy.

However, there might be another reason to encourage gum chewing in school that might get the administrators’ attention. It turns out that a handful of researchers have observed that gum chewing can help cognition and improve attention. One explanation for this phenomenon is that for many of us, repetitive physical actions such as pencil tapping helps us concentrate. Bouncing my legs to the throbbing beat of the Rolling Stones helped me get through medical school. It may simply be that the music kept me awake, but for whatever reason, it worked.

But, to be fair, there is a study from the Netherlands that found that not only did chewing gum not help with attention, but that it was detrimental to task execution and vigilance in both healthy children and those with attention-deficit/hyperactivity disorder (Appetite 2010;55:679-84).

I hope that others will try to repeat this study and find that my mother was on the right track in keeping my sister and I focused with a stick of gum. If the detrimental effects on learning stand up, this information will present an interesting dilemma for pediatricians. Rotten teeth or distracted students?

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

"What’s that thing in your mouth for?"

"It’s so I can blow on his eardrum to see if it moves. It’s the same idea as one of these." I fumble in a drawer to find a more traditional hand-operated bulb insufflator. The surprised parent replies, "I haven’t seen one of those either." I stifle the urge to climb on my soapbox labeled, "Every pediatrician should be using one" and begin to explain what I understand about middle ear anatomy and the importance of tympanic membrane mobility in the diagnosis and management of otitis media.

It’s a scenario I’ve participated in hundreds, no probably thousands, of times. Recently, I was being trailed by a third-year medical student who had already completed 3 months of a pediatric and family medicine experience. And, sadly, he had never seen, let alone heard about, tympanic membrane insufflation.

I must admit that my style of insufflation, which involves a length of latex tubing and a plastic mouthpiece, is a bit untraditional, and I don’t recall where I learned it. But its great advantage is that it allows me much more freedom with my hands to stabilize squirmy or uncooperative patients. You might think that putting an object in my mouth that is occasionally accessible to the drool-covered hands of toddlers puts me at risk for a cornucopia of infections. But my theory is that the more germs there are lined up waiting on the surface of my body, the more likely it is that by the time one gets to the front of the line, it will have lost its enthusiasm for pathogenicity.

It is clear that otitis media is at or near the top of pediatric diagnoses and certainly a leading trigger for antibiotic prescriptions. It is also clear that physicians are not terribly skillful at examining ears. This sad irony results in an unacceptable level of misdiagnosis, usually of the overdiagnosis variety. In an attempt to correct this situation, the September 2012 edition of AAP News has included a snippet from a new study, "Development of an Algorithm for the Diagnosis of Otitis Media" (33:2 [doi:10.1542/aapnews.2012339-2]).

It’s a pretty simple algorithm that hinges on the presence of a bulging tympanic membrane (TM). If the TM is bulging, it’s acute otitis media (AOM), although 8% of the AOMs did not have a bulging drum. If the nonbulging TM was opacified or had an air fluid level, then the diagnosis was otitis media with effusion (OME).

In a note accompanying the algorithm, there is an observation: "All of the children with no effusion had normal mobility, compared with 32% of those with OME and none of those with AOM [my emphasis]." Why has tympanic membrane mobility fallen out of the decision tree? It appears that the investigators have thrown in the towel and given up on getting clinicians to insufflate TMs.

To my eye, it is much easier to detect TM mobility than to accurately perceive bulging. To see bulging, one must see all or almost all of the eardrum. And, let’s be honest, how often do you get to see the entire tympanic membrane? (The dying art of cerumen removal is another sad story of atrophying clinical skills.) However, if I see only a third of the TM and it’s moving, I know I’m not dealing with AOM. And I know that the child has no effusion, an important finding if I am following up on a previous AOM.

If you are a techie, you might ask, "Why not a use a tympanometer?" My first answer is I trust my eyes more. My second answer is that the machine doesn’t excuse you from having a good look in the ear. What is the tympanometer tracing of an insect in the ear? Not every earache is an infection. In my mind, a tympanometer is a shaky crutch you can bill for.

I urge you to find your insufflator in the back of that spare parts drawer, make sure the head of your otoscope seals properly, and give a few little magic puffs. They will help you clear up that murky diagnosis of otitis media.

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

"What’s that thing in your mouth for?"

"It’s so I can blow on his eardrum to see if it moves. It’s the same idea as one of these." I fumble in a drawer to find a more traditional hand-operated bulb insufflator. The surprised parent replies, "I haven’t seen one of those either." I stifle the urge to climb on my soapbox labeled, "Every pediatrician should be using one" and begin to explain what I understand about middle ear anatomy and the importance of tympanic membrane mobility in the diagnosis and management of otitis media.

It’s a scenario I’ve participated in hundreds, no probably thousands, of times. Recently, I was being trailed by a third-year medical student who had already completed 3 months of a pediatric and family medicine experience. And, sadly, he had never seen, let alone heard about, tympanic membrane insufflation.

I must admit that my style of insufflation, which involves a length of latex tubing and a plastic mouthpiece, is a bit untraditional, and I don’t recall where I learned it. But its great advantage is that it allows me much more freedom with my hands to stabilize squirmy or uncooperative patients. You might think that putting an object in my mouth that is occasionally accessible to the drool-covered hands of toddlers puts me at risk for a cornucopia of infections. But my theory is that the more germs there are lined up waiting on the surface of my body, the more likely it is that by the time one gets to the front of the line, it will have lost its enthusiasm for pathogenicity.

It is clear that otitis media is at or near the top of pediatric diagnoses and certainly a leading trigger for antibiotic prescriptions. It is also clear that physicians are not terribly skillful at examining ears. This sad irony results in an unacceptable level of misdiagnosis, usually of the overdiagnosis variety. In an attempt to correct this situation, the September 2012 edition of AAP News has included a snippet from a new study, "Development of an Algorithm for the Diagnosis of Otitis Media" (33:2 [doi:10.1542/aapnews.2012339-2]).

It’s a pretty simple algorithm that hinges on the presence of a bulging tympanic membrane (TM). If the TM is bulging, it’s acute otitis media (AOM), although 8% of the AOMs did not have a bulging drum. If the nonbulging TM was opacified or had an air fluid level, then the diagnosis was otitis media with effusion (OME).

In a note accompanying the algorithm, there is an observation: "All of the children with no effusion had normal mobility, compared with 32% of those with OME and none of those with AOM [my emphasis]." Why has tympanic membrane mobility fallen out of the decision tree? It appears that the investigators have thrown in the towel and given up on getting clinicians to insufflate TMs.

To my eye, it is much easier to detect TM mobility than to accurately perceive bulging. To see bulging, one must see all or almost all of the eardrum. And, let’s be honest, how often do you get to see the entire tympanic membrane? (The dying art of cerumen removal is another sad story of atrophying clinical skills.) However, if I see only a third of the TM and it’s moving, I know I’m not dealing with AOM. And I know that the child has no effusion, an important finding if I am following up on a previous AOM.

If you are a techie, you might ask, "Why not a use a tympanometer?" My first answer is I trust my eyes more. My second answer is that the machine doesn’t excuse you from having a good look in the ear. What is the tympanometer tracing of an insect in the ear? Not every earache is an infection. In my mind, a tympanometer is a shaky crutch you can bill for.

I urge you to find your insufflator in the back of that spare parts drawer, make sure the head of your otoscope seals properly, and give a few little magic puffs. They will help you clear up that murky diagnosis of otitis media.

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

"What’s that thing in your mouth for?"

"It’s so I can blow on his eardrum to see if it moves. It’s the same idea as one of these." I fumble in a drawer to find a more traditional hand-operated bulb insufflator. The surprised parent replies, "I haven’t seen one of those either." I stifle the urge to climb on my soapbox labeled, "Every pediatrician should be using one" and begin to explain what I understand about middle ear anatomy and the importance of tympanic membrane mobility in the diagnosis and management of otitis media.

It’s a scenario I’ve participated in hundreds, no probably thousands, of times. Recently, I was being trailed by a third-year medical student who had already completed 3 months of a pediatric and family medicine experience. And, sadly, he had never seen, let alone heard about, tympanic membrane insufflation.

I must admit that my style of insufflation, which involves a length of latex tubing and a plastic mouthpiece, is a bit untraditional, and I don’t recall where I learned it. But its great advantage is that it allows me much more freedom with my hands to stabilize squirmy or uncooperative patients. You might think that putting an object in my mouth that is occasionally accessible to the drool-covered hands of toddlers puts me at risk for a cornucopia of infections. But my theory is that the more germs there are lined up waiting on the surface of my body, the more likely it is that by the time one gets to the front of the line, it will have lost its enthusiasm for pathogenicity.

It is clear that otitis media is at or near the top of pediatric diagnoses and certainly a leading trigger for antibiotic prescriptions. It is also clear that physicians are not terribly skillful at examining ears. This sad irony results in an unacceptable level of misdiagnosis, usually of the overdiagnosis variety. In an attempt to correct this situation, the September 2012 edition of AAP News has included a snippet from a new study, "Development of an Algorithm for the Diagnosis of Otitis Media" (33:2 [doi:10.1542/aapnews.2012339-2]).

It’s a pretty simple algorithm that hinges on the presence of a bulging tympanic membrane (TM). If the TM is bulging, it’s acute otitis media (AOM), although 8% of the AOMs did not have a bulging drum. If the nonbulging TM was opacified or had an air fluid level, then the diagnosis was otitis media with effusion (OME).

In a note accompanying the algorithm, there is an observation: "All of the children with no effusion had normal mobility, compared with 32% of those with OME and none of those with AOM [my emphasis]." Why has tympanic membrane mobility fallen out of the decision tree? It appears that the investigators have thrown in the towel and given up on getting clinicians to insufflate TMs.

To my eye, it is much easier to detect TM mobility than to accurately perceive bulging. To see bulging, one must see all or almost all of the eardrum. And, let’s be honest, how often do you get to see the entire tympanic membrane? (The dying art of cerumen removal is another sad story of atrophying clinical skills.) However, if I see only a third of the TM and it’s moving, I know I’m not dealing with AOM. And I know that the child has no effusion, an important finding if I am following up on a previous AOM.

If you are a techie, you might ask, "Why not a use a tympanometer?" My first answer is I trust my eyes more. My second answer is that the machine doesn’t excuse you from having a good look in the ear. What is the tympanometer tracing of an insect in the ear? Not every earache is an infection. In my mind, a tympanometer is a shaky crutch you can bill for.

I urge you to find your insufflator in the back of that spare parts drawer, make sure the head of your otoscope seals properly, and give a few little magic puffs. They will help you clear up that murky diagnosis of otitis media.

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

Yesterday, the last patient of the morning’s routing sheet listed "needs orthotics" as the chief complaint. This meant that I would probably be seeing one of my physically challenged patients who had been wearing orthotics to achieve some reasonable facsimile of ambulation. They had either outgrown or lost the inserts, and now my reapproval and signature was needed so a third party payor might cover at least some of the cost.

Or, the patient may have had flat feet and although not having any pain someone had told his parents, "My brother’s feet look like that and the doctor prescribed orthotics." While I have found that orthotics can be helpful for some children with severe flat feet, usually good supportive shoes are sufficient. If the child is actively growing (most are), I encourage parents to go with over-the-counter orthotics to avoid the cost of custom made inserts that will be outgrown in 6 months.

This 8-year-old was one of my partner’s patients whom I had seen once or twice years ago. His mother told me that she was concerned because her son’s shoes were wearing unevenly. And, she had heard that this might point to a problem that could be managed with orthotics. She had also heard that these untreated asymmetries might lead to hip, knee, or ankle problems later in life.

As I began my exam, the child was sitting on the table in shorts. The most striking finding was the appearance of his legs. Each was covered with a mosaic of dirt and grass stains, bug bites, and bruises of various shapes and sizes. When I had him stand down on the floor, he had the mildest pronation I had seen all day. I could easily get a finger tip under each arch. His gait and hopping were confident and athletic.

His shoes were well made by a prominent athletic footwear manufacturer. They had a good solid heel counter that extended well forward on the medial side. However, the soles were worn down three layers in some places and at least two all over. The wear was slightly more prominent on the lateral aspect of both heels. These shoes had not spent much time sitting idly on some mud room floor.

As I shared my findings with his mother, I told her that seeing her son’s legs and shoes was a refreshing oasis in my day of looking at underutilized bodies. I told her not to be embarrassed by the grass and dirt stains but to exhibit them with pride. I told her that her son had an insignificant amount of pronation and that she had chosen his shoes wisely. The condition of his shoes was a tribute to the active lifestyle that her parenting style had fostered. He child didn’t need orthotics. He just needed a new pair of the good shoes he had worn out.

It was then that I realized that she and her husband were the farmers of our largest Community Supported Agriculture (CSA) Farms. I knew they didn’t have a TV and I didn’t have to ask the patient how often he played video games. "Never" would have been his answer.

This encounter triggered a flashback to my medical school days when I interviewed the mother of a 6-year-old who was 6 months past a congenital cardiac defect repair. She tearfully told me how that week was the first time she had ever had to buy her daughter shoes because the old ones had been worn out. Prior to that, the child had been too weak to be active.

Maybe it’s because my uncle owned a shoe store, but I always include at least a glance at the patient’s footwear as part of my exam. It may just give me an "ice breaker" opportunity, such as, "Those are cool fire truck sneakers." But, sometimes what the child is wearing on his feet can tell me something about his family and how he spends his day.

Sadly, the most common finding is that while the uppers may be stained with a collection of soda and ice cream drippings, the soles are scarcely worn. Shoes can last forever if you spend your days on the couch.

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

Yesterday, the last patient of the morning’s routing sheet listed "needs orthotics" as the chief complaint. This meant that I would probably be seeing one of my physically challenged patients who had been wearing orthotics to achieve some reasonable facsimile of ambulation. They had either outgrown or lost the inserts, and now my reapproval and signature was needed so a third party payor might cover at least some of the cost.

Or, the patient may have had flat feet and although not having any pain someone had told his parents, "My brother’s feet look like that and the doctor prescribed orthotics." While I have found that orthotics can be helpful for some children with severe flat feet, usually good supportive shoes are sufficient. If the child is actively growing (most are), I encourage parents to go with over-the-counter orthotics to avoid the cost of custom made inserts that will be outgrown in 6 months.

This 8-year-old was one of my partner’s patients whom I had seen once or twice years ago. His mother told me that she was concerned because her son’s shoes were wearing unevenly. And, she had heard that this might point to a problem that could be managed with orthotics. She had also heard that these untreated asymmetries might lead to hip, knee, or ankle problems later in life.

As I began my exam, the child was sitting on the table in shorts. The most striking finding was the appearance of his legs. Each was covered with a mosaic of dirt and grass stains, bug bites, and bruises of various shapes and sizes. When I had him stand down on the floor, he had the mildest pronation I had seen all day. I could easily get a finger tip under each arch. His gait and hopping were confident and athletic.

His shoes were well made by a prominent athletic footwear manufacturer. They had a good solid heel counter that extended well forward on the medial side. However, the soles were worn down three layers in some places and at least two all over. The wear was slightly more prominent on the lateral aspect of both heels. These shoes had not spent much time sitting idly on some mud room floor.

As I shared my findings with his mother, I told her that seeing her son’s legs and shoes was a refreshing oasis in my day of looking at underutilized bodies. I told her not to be embarrassed by the grass and dirt stains but to exhibit them with pride. I told her that her son had an insignificant amount of pronation and that she had chosen his shoes wisely. The condition of his shoes was a tribute to the active lifestyle that her parenting style had fostered. He child didn’t need orthotics. He just needed a new pair of the good shoes he had worn out.

It was then that I realized that she and her husband were the farmers of our largest Community Supported Agriculture (CSA) Farms. I knew they didn’t have a TV and I didn’t have to ask the patient how often he played video games. "Never" would have been his answer.

This encounter triggered a flashback to my medical school days when I interviewed the mother of a 6-year-old who was 6 months past a congenital cardiac defect repair. She tearfully told me how that week was the first time she had ever had to buy her daughter shoes because the old ones had been worn out. Prior to that, the child had been too weak to be active.

Maybe it’s because my uncle owned a shoe store, but I always include at least a glance at the patient’s footwear as part of my exam. It may just give me an "ice breaker" opportunity, such as, "Those are cool fire truck sneakers." But, sometimes what the child is wearing on his feet can tell me something about his family and how he spends his day.

Sadly, the most common finding is that while the uppers may be stained with a collection of soda and ice cream drippings, the soles are scarcely worn. Shoes can last forever if you spend your days on the couch.

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

Yesterday, the last patient of the morning’s routing sheet listed "needs orthotics" as the chief complaint. This meant that I would probably be seeing one of my physically challenged patients who had been wearing orthotics to achieve some reasonable facsimile of ambulation. They had either outgrown or lost the inserts, and now my reapproval and signature was needed so a third party payor might cover at least some of the cost.

Or, the patient may have had flat feet and although not having any pain someone had told his parents, "My brother’s feet look like that and the doctor prescribed orthotics." While I have found that orthotics can be helpful for some children with severe flat feet, usually good supportive shoes are sufficient. If the child is actively growing (most are), I encourage parents to go with over-the-counter orthotics to avoid the cost of custom made inserts that will be outgrown in 6 months.

This 8-year-old was one of my partner’s patients whom I had seen once or twice years ago. His mother told me that she was concerned because her son’s shoes were wearing unevenly. And, she had heard that this might point to a problem that could be managed with orthotics. She had also heard that these untreated asymmetries might lead to hip, knee, or ankle problems later in life.

As I began my exam, the child was sitting on the table in shorts. The most striking finding was the appearance of his legs. Each was covered with a mosaic of dirt and grass stains, bug bites, and bruises of various shapes and sizes. When I had him stand down on the floor, he had the mildest pronation I had seen all day. I could easily get a finger tip under each arch. His gait and hopping were confident and athletic.

His shoes were well made by a prominent athletic footwear manufacturer. They had a good solid heel counter that extended well forward on the medial side. However, the soles were worn down three layers in some places and at least two all over. The wear was slightly more prominent on the lateral aspect of both heels. These shoes had not spent much time sitting idly on some mud room floor.

As I shared my findings with his mother, I told her that seeing her son’s legs and shoes was a refreshing oasis in my day of looking at underutilized bodies. I told her not to be embarrassed by the grass and dirt stains but to exhibit them with pride. I told her that her son had an insignificant amount of pronation and that she had chosen his shoes wisely. The condition of his shoes was a tribute to the active lifestyle that her parenting style had fostered. He child didn’t need orthotics. He just needed a new pair of the good shoes he had worn out.

It was then that I realized that she and her husband were the farmers of our largest Community Supported Agriculture (CSA) Farms. I knew they didn’t have a TV and I didn’t have to ask the patient how often he played video games. "Never" would have been his answer.

This encounter triggered a flashback to my medical school days when I interviewed the mother of a 6-year-old who was 6 months past a congenital cardiac defect repair. She tearfully told me how that week was the first time she had ever had to buy her daughter shoes because the old ones had been worn out. Prior to that, the child had been too weak to be active.

Maybe it’s because my uncle owned a shoe store, but I always include at least a glance at the patient’s footwear as part of my exam. It may just give me an "ice breaker" opportunity, such as, "Those are cool fire truck sneakers." But, sometimes what the child is wearing on his feet can tell me something about his family and how he spends his day.

Sadly, the most common finding is that while the uppers may be stained with a collection of soda and ice cream drippings, the soles are scarcely worn. Shoes can last forever if you spend your days on the couch.

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

Have you lost some of your enthusiasm for work? Do you find yourself becoming more cynical? At the end of the day, do you wonder if you have really accomplished anything? If you answered "yes" to any of these questions, some studies suggest that you are at significant risk of burnout. In fact, it may have already happened.

In a recent study, "Burnout and Satisfaction With Work-Life Balance Among U.S. Physicians Relative to the General U.S. Population," investigators found that more than 45% of physicians in the United States are at risk for burnout (Arch. Intern. Med. 2012 Aug. 20 [doi:10.1001/archinternmed.2012.3199]). People with MD or DO degrees are at higher risk than are high school graduates. On the other hand, graduates with bachelor’s degrees, master’s degrees, or doctorates in disciplines other than medicine are less likely to burn out than are those with high school diplomas.

This is bad news not only for physicians but for their patients as well, because other studies have suggested that physician burnout erodes professionalism, negatively influences the quality of care, and increases the risk of medical errors.

The study authors also found that those physicians in what they labeled the "frontline" medical disciplines are most vulnerable; emergency physicians experience the greatest level of stress (about 65%), with general medicine and family medicine scoring slightly less. If you are a general pediatrician, the good news is that we are at the bottom of the list, along with dermatologists and the preventive medicine folks. Conversely, these same three specialties are at the top of the list when the respondents were asked if they were content with their life-work balance; almost 60% of us admitted that we were.

Why are pediatricians at less risk of burnout? The authors emphasized that the groups at most risk are frontline specialties. Well, excuse me, but I don’t think one can get much closer to the battlefield than pediatrics. We’re in the trenches as much as anyone, and our trenches are often littered with dirty diapers.

I think the answer to this discrepancy with their interpretation can be summed up in one word: children. Most pediatricians do what they do because they like children. We grew up liking children. Not everyone shares the intensity with which we enjoy being around children, but you have to be a world-class curmudgeon not to feel even a little pang of goodness when you see a cute child smile. Pediatricians don’t have to be coached into feeling sympathy for their patients.

Furthermore, children are resilient. Most of their illnesses are self-limited. So, even if we don’t provide the cure, they get better anyway. Children often outgrow things, and we seldom have to be the bearer of bad news.

However, despite the fact that working with children helps protect us from burnout, why are more than a third of us still at risk? The study authors proposed some reasons.

First on their list is excessive workload. I disagree. If we consider the number of patients we see in a day as a measure of workload, it appears to me that most pediatricians are seeing fewer patients now than they were a few decades ago. If I am enjoying what I am doing, I can easily tolerate days when I’m having too much of a good thing.

Also on the list of contributors is loss of autonomy. When you talk with people (not just physicians) who have spent some of their career self-employed, most will tell you that it was a time when they never worked harder nor felt more fulfilled. Group practice certainly has its advantages, particularly when it comes to offering more-humane call schedules. However, as group practices have spread, autonomy has evaporated.

Not surprisingly, the struggle for balance that most people face when they try to integrate their personal and professional lives appears on the researchers’ list. Words such as discipline and compartmentalization come to mind, but they are just words. The reality of weaving the professional and personal is far more challenging.

Finally, the authors mentioned "inefficiency due to excessive administrative burdens." For me, this phrase translates into "electronic medical records." If anything drives me to the brink of burnout, it is spending an additional 6-7 minutes per patient using an EMR. This means that on a modestly busy day, I am spending as much as 120 minutes doing something that provides me no sense of personal accomplishment. And to make matters worse, it has robbed me of 2 hours with the most potent burnout deterrent I know: children.

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

Have you lost some of your enthusiasm for work? Do you find yourself becoming more cynical? At the end of the day, do you wonder if you have really accomplished anything? If you answered "yes" to any of these questions, some studies suggest that you are at significant risk of burnout. In fact, it may have already happened.

In a recent study, "Burnout and Satisfaction With Work-Life Balance Among U.S. Physicians Relative to the General U.S. Population," investigators found that more than 45% of physicians in the United States are at risk for burnout (Arch. Intern. Med. 2012 Aug. 20 [doi:10.1001/archinternmed.2012.3199]). People with MD or DO degrees are at higher risk than are high school graduates. On the other hand, graduates with bachelor’s degrees, master’s degrees, or doctorates in disciplines other than medicine are less likely to burn out than are those with high school diplomas.

This is bad news not only for physicians but for their patients as well, because other studies have suggested that physician burnout erodes professionalism, negatively influences the quality of care, and increases the risk of medical errors.

The study authors also found that those physicians in what they labeled the "frontline" medical disciplines are most vulnerable; emergency physicians experience the greatest level of stress (about 65%), with general medicine and family medicine scoring slightly less. If you are a general pediatrician, the good news is that we are at the bottom of the list, along with dermatologists and the preventive medicine folks. Conversely, these same three specialties are at the top of the list when the respondents were asked if they were content with their life-work balance; almost 60% of us admitted that we were.

Why are pediatricians at less risk of burnout? The authors emphasized that the groups at most risk are frontline specialties. Well, excuse me, but I don’t think one can get much closer to the battlefield than pediatrics. We’re in the trenches as much as anyone, and our trenches are often littered with dirty diapers.

I think the answer to this discrepancy with their interpretation can be summed up in one word: children. Most pediatricians do what they do because they like children. We grew up liking children. Not everyone shares the intensity with which we enjoy being around children, but you have to be a world-class curmudgeon not to feel even a little pang of goodness when you see a cute child smile. Pediatricians don’t have to be coached into feeling sympathy for their patients.

Furthermore, children are resilient. Most of their illnesses are self-limited. So, even if we don’t provide the cure, they get better anyway. Children often outgrow things, and we seldom have to be the bearer of bad news.

However, despite the fact that working with children helps protect us from burnout, why are more than a third of us still at risk? The study authors proposed some reasons.

First on their list is excessive workload. I disagree. If we consider the number of patients we see in a day as a measure of workload, it appears to me that most pediatricians are seeing fewer patients now than they were a few decades ago. If I am enjoying what I am doing, I can easily tolerate days when I’m having too much of a good thing.

Also on the list of contributors is loss of autonomy. When you talk with people (not just physicians) who have spent some of their career self-employed, most will tell you that it was a time when they never worked harder nor felt more fulfilled. Group practice certainly has its advantages, particularly when it comes to offering more-humane call schedules. However, as group practices have spread, autonomy has evaporated.

Not surprisingly, the struggle for balance that most people face when they try to integrate their personal and professional lives appears on the researchers’ list. Words such as discipline and compartmentalization come to mind, but they are just words. The reality of weaving the professional and personal is far more challenging.

Finally, the authors mentioned "inefficiency due to excessive administrative burdens." For me, this phrase translates into "electronic medical records." If anything drives me to the brink of burnout, it is spending an additional 6-7 minutes per patient using an EMR. This means that on a modestly busy day, I am spending as much as 120 minutes doing something that provides me no sense of personal accomplishment. And to make matters worse, it has robbed me of 2 hours with the most potent burnout deterrent I know: children.

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

Have you lost some of your enthusiasm for work? Do you find yourself becoming more cynical? At the end of the day, do you wonder if you have really accomplished anything? If you answered "yes" to any of these questions, some studies suggest that you are at significant risk of burnout. In fact, it may have already happened.

In a recent study, "Burnout and Satisfaction With Work-Life Balance Among U.S. Physicians Relative to the General U.S. Population," investigators found that more than 45% of physicians in the United States are at risk for burnout (Arch. Intern. Med. 2012 Aug. 20 [doi:10.1001/archinternmed.2012.3199]). People with MD or DO degrees are at higher risk than are high school graduates. On the other hand, graduates with bachelor’s degrees, master’s degrees, or doctorates in disciplines other than medicine are less likely to burn out than are those with high school diplomas.

This is bad news not only for physicians but for their patients as well, because other studies have suggested that physician burnout erodes professionalism, negatively influences the quality of care, and increases the risk of medical errors.

The study authors also found that those physicians in what they labeled the "frontline" medical disciplines are most vulnerable; emergency physicians experience the greatest level of stress (about 65%), with general medicine and family medicine scoring slightly less. If you are a general pediatrician, the good news is that we are at the bottom of the list, along with dermatologists and the preventive medicine folks. Conversely, these same three specialties are at the top of the list when the respondents were asked if they were content with their life-work balance; almost 60% of us admitted that we were.

Why are pediatricians at less risk of burnout? The authors emphasized that the groups at most risk are frontline specialties. Well, excuse me, but I don’t think one can get much closer to the battlefield than pediatrics. We’re in the trenches as much as anyone, and our trenches are often littered with dirty diapers.

I think the answer to this discrepancy with their interpretation can be summed up in one word: children. Most pediatricians do what they do because they like children. We grew up liking children. Not everyone shares the intensity with which we enjoy being around children, but you have to be a world-class curmudgeon not to feel even a little pang of goodness when you see a cute child smile. Pediatricians don’t have to be coached into feeling sympathy for their patients.

Furthermore, children are resilient. Most of their illnesses are self-limited. So, even if we don’t provide the cure, they get better anyway. Children often outgrow things, and we seldom have to be the bearer of bad news.

However, despite the fact that working with children helps protect us from burnout, why are more than a third of us still at risk? The study authors proposed some reasons.

First on their list is excessive workload. I disagree. If we consider the number of patients we see in a day as a measure of workload, it appears to me that most pediatricians are seeing fewer patients now than they were a few decades ago. If I am enjoying what I am doing, I can easily tolerate days when I’m having too much of a good thing.

Also on the list of contributors is loss of autonomy. When you talk with people (not just physicians) who have spent some of their career self-employed, most will tell you that it was a time when they never worked harder nor felt more fulfilled. Group practice certainly has its advantages, particularly when it comes to offering more-humane call schedules. However, as group practices have spread, autonomy has evaporated.

Not surprisingly, the struggle for balance that most people face when they try to integrate their personal and professional lives appears on the researchers’ list. Words such as discipline and compartmentalization come to mind, but they are just words. The reality of weaving the professional and personal is far more challenging.

Finally, the authors mentioned "inefficiency due to excessive administrative burdens." For me, this phrase translates into "electronic medical records." If anything drives me to the brink of burnout, it is spending an additional 6-7 minutes per patient using an EMR. This means that on a modestly busy day, I am spending as much as 120 minutes doing something that provides me no sense of personal accomplishment. And to make matters worse, it has robbed me of 2 hours with the most potent burnout deterrent I know: children.

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

It’s been too long in coming, and it’s still moving at a snail’s pace, but there is a low-amplitude groundswell of recognition that sleep is a critical factor in our physical and mental health. Sleep deprivation has been implicated in problems as far-reaching as attention deficit–like symptoms and obesity. Students who don’t get enough sleep are more likely to be depressed and to do poorly on exams.

If there were an award for the least sleep friendly environment, American colleges and universities would win, hands down. Many parents also deserve special recognition for allowing children to have televisions in their bedrooms and failing to set even a vague approximation of a healthy bedtime. But the ivory towers of education remain the places least likely to offer a good night’s sleep.

One of the reasons for this unfortunate situation is the predictable response of young people who suddenly find themselves without parental oversight. Combined with that phenomenon is what some sleep scientists believe is a normal physiological adjustment in sleep cycles during adolescence. I agree that a shift does occur with puberty, but I wonder how much of the late-to-bed, late-to-rise habit is inflated by enabling societal responses.

An attitude that sleep deprivation is a necessary part of college life blankets every campus. Students often brag about how little they have slept or how many all-nighters they have endured. The schools have done their share of enabling, as sleep-promoting rules that once were part of dormitory life have been allowed to evaporate. A student must now ask for a "quiet dorm" assignment to get even a poor approximation of a good night’s sleep. One college has even scheduled its freshman orientation activities to begin after 10 or 11 a.m. to match the entering students’ sleep habits.

It has always seemed strange to me that what for many young people is the last stop on their way to the "real world" fosters a sleep schedule incompatible with most "real world" jobs. But there are some feeble winds of change rustling the ivy on the walls of several American colleges.

An Associated Press story by Justin Pope, "Colleges Open Their Eyes: ZZZs Are Key to GPA" (Portland Press Herald, Aug. 31, 2012) includes several examples of colleges that have taken an interest in their students’ sleep habits. At Hastings (Neb.) College, campus health officials installed a bed in the student union, donned pajamas, and engaged students in discussions about sleep. The officials were motivated by their observations that sleep deprivation and mental health problems are often related. Macalaster College in St. Paul, Minn., publishes a "nap map" describing various campus locations where students might take a restorative snooze. The University of Louisville (Ky.) has planned a campus-wide "flash nap" to highlight the importance of sleep.

But these somewhat gimmicky efforts are the exception. The National College Health Assessment includes the troubling observation that although three-fourths of the students report having a sleep problem, the same percentage can’t recall receiving any information about sleep, according to Mr. Pope’s report.

The only example in which an institution has made substantive changes to address sleep deprivation comes from a prep school. Deerfield (Mass.) Academy advanced its morning class start time from 7:55 a.m. to 8:30 a.m., and decreased its sports practices and homework expectations by 10%. These changes were followed by a 20% decrease in infirmary visits, a significant increase in grade point average, and an improvement in the athletic teams’ end-of-the-year records, according to the article.

Of course, prep school students are more malleable than are near-adult college students. But the point is that if a school commits itself to sleep-promoting structural and procedural changes, the quality of the students’ lives and learning experiences will improve. Colleges have a long way to go to move beyond promotional stunts and a handful of quiet dorms.

It will be interesting to see whether colleges and universities begin to take meaningful steps to protect and promote healthy sleep habits now that the medical community has finally awakened to the health hazards of sleep deprivation.

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

It’s been too long in coming, and it’s still moving at a snail’s pace, but there is a low-amplitude groundswell of recognition that sleep is a critical factor in our physical and mental health. Sleep deprivation has been implicated in problems as far-reaching as attention deficit–like symptoms and obesity. Students who don’t get enough sleep are more likely to be depressed and to do poorly on exams.

If there were an award for the least sleep friendly environment, American colleges and universities would win, hands down. Many parents also deserve special recognition for allowing children to have televisions in their bedrooms and failing to set even a vague approximation of a healthy bedtime. But the ivory towers of education remain the places least likely to offer a good night’s sleep.

One of the reasons for this unfortunate situation is the predictable response of young people who suddenly find themselves without parental oversight. Combined with that phenomenon is what some sleep scientists believe is a normal physiological adjustment in sleep cycles during adolescence. I agree that a shift does occur with puberty, but I wonder how much of the late-to-bed, late-to-rise habit is inflated by enabling societal responses.

An attitude that sleep deprivation is a necessary part of college life blankets every campus. Students often brag about how little they have slept or how many all-nighters they have endured. The schools have done their share of enabling, as sleep-promoting rules that once were part of dormitory life have been allowed to evaporate. A student must now ask for a "quiet dorm" assignment to get even a poor approximation of a good night’s sleep. One college has even scheduled its freshman orientation activities to begin after 10 or 11 a.m. to match the entering students’ sleep habits.

It has always seemed strange to me that what for many young people is the last stop on their way to the "real world" fosters a sleep schedule incompatible with most "real world" jobs. But there are some feeble winds of change rustling the ivy on the walls of several American colleges.

An Associated Press story by Justin Pope, "Colleges Open Their Eyes: ZZZs Are Key to GPA" (Portland Press Herald, Aug. 31, 2012) includes several examples of colleges that have taken an interest in their students’ sleep habits. At Hastings (Neb.) College, campus health officials installed a bed in the student union, donned pajamas, and engaged students in discussions about sleep. The officials were motivated by their observations that sleep deprivation and mental health problems are often related. Macalaster College in St. Paul, Minn., publishes a "nap map" describing various campus locations where students might take a restorative snooze. The University of Louisville (Ky.) has planned a campus-wide "flash nap" to highlight the importance of sleep.

But these somewhat gimmicky efforts are the exception. The National College Health Assessment includes the troubling observation that although three-fourths of the students report having a sleep problem, the same percentage can’t recall receiving any information about sleep, according to Mr. Pope’s report.

The only example in which an institution has made substantive changes to address sleep deprivation comes from a prep school. Deerfield (Mass.) Academy advanced its morning class start time from 7:55 a.m. to 8:30 a.m., and decreased its sports practices and homework expectations by 10%. These changes were followed by a 20% decrease in infirmary visits, a significant increase in grade point average, and an improvement in the athletic teams’ end-of-the-year records, according to the article.

Of course, prep school students are more malleable than are near-adult college students. But the point is that if a school commits itself to sleep-promoting structural and procedural changes, the quality of the students’ lives and learning experiences will improve. Colleges have a long way to go to move beyond promotional stunts and a handful of quiet dorms.

It will be interesting to see whether colleges and universities begin to take meaningful steps to protect and promote healthy sleep habits now that the medical community has finally awakened to the health hazards of sleep deprivation.

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

It’s been too long in coming, and it’s still moving at a snail’s pace, but there is a low-amplitude groundswell of recognition that sleep is a critical factor in our physical and mental health. Sleep deprivation has been implicated in problems as far-reaching as attention deficit–like symptoms and obesity. Students who don’t get enough sleep are more likely to be depressed and to do poorly on exams.

If there were an award for the least sleep friendly environment, American colleges and universities would win, hands down. Many parents also deserve special recognition for allowing children to have televisions in their bedrooms and failing to set even a vague approximation of a healthy bedtime. But the ivory towers of education remain the places least likely to offer a good night’s sleep.

One of the reasons for this unfortunate situation is the predictable response of young people who suddenly find themselves without parental oversight. Combined with that phenomenon is what some sleep scientists believe is a normal physiological adjustment in sleep cycles during adolescence. I agree that a shift does occur with puberty, but I wonder how much of the late-to-bed, late-to-rise habit is inflated by enabling societal responses.

An attitude that sleep deprivation is a necessary part of college life blankets every campus. Students often brag about how little they have slept or how many all-nighters they have endured. The schools have done their share of enabling, as sleep-promoting rules that once were part of dormitory life have been allowed to evaporate. A student must now ask for a "quiet dorm" assignment to get even a poor approximation of a good night’s sleep. One college has even scheduled its freshman orientation activities to begin after 10 or 11 a.m. to match the entering students’ sleep habits.

It has always seemed strange to me that what for many young people is the last stop on their way to the "real world" fosters a sleep schedule incompatible with most "real world" jobs. But there are some feeble winds of change rustling the ivy on the walls of several American colleges.

An Associated Press story by Justin Pope, "Colleges Open Their Eyes: ZZZs Are Key to GPA" (Portland Press Herald, Aug. 31, 2012) includes several examples of colleges that have taken an interest in their students’ sleep habits. At Hastings (Neb.) College, campus health officials installed a bed in the student union, donned pajamas, and engaged students in discussions about sleep. The officials were motivated by their observations that sleep deprivation and mental health problems are often related. Macalaster College in St. Paul, Minn., publishes a "nap map" describing various campus locations where students might take a restorative snooze. The University of Louisville (Ky.) has planned a campus-wide "flash nap" to highlight the importance of sleep.

But these somewhat gimmicky efforts are the exception. The National College Health Assessment includes the troubling observation that although three-fourths of the students report having a sleep problem, the same percentage can’t recall receiving any information about sleep, according to Mr. Pope’s report.

The only example in which an institution has made substantive changes to address sleep deprivation comes from a prep school. Deerfield (Mass.) Academy advanced its morning class start time from 7:55 a.m. to 8:30 a.m., and decreased its sports practices and homework expectations by 10%. These changes were followed by a 20% decrease in infirmary visits, a significant increase in grade point average, and an improvement in the athletic teams’ end-of-the-year records, according to the article.

Of course, prep school students are more malleable than are near-adult college students. But the point is that if a school commits itself to sleep-promoting structural and procedural changes, the quality of the students’ lives and learning experiences will improve. Colleges have a long way to go to move beyond promotional stunts and a handful of quiet dorms.

It will be interesting to see whether colleges and universities begin to take meaningful steps to protect and promote healthy sleep habits now that the medical community has finally awakened to the health hazards of sleep deprivation.

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

Ada Winchester is a 15-month-old girl I had never met before. All I knew about this first patient of the day was that her chart listed "abdominal pain" as the chief complaint. As I approached the exam room door, I was already rehearsing my constipation speech. But when I entered the room I quickly put my timeworn pooping monologue back on the shelf.

Ada (the name is fictitious) was sitting comfortably on her mother’s lap. Her sparse, wispy hair framed a cute but slightly pale face. She was lean but not scrawny, and I could see why her usual pediatrician had at times been concerned about her weight. She was breathing easily and interacted with her mother in a relaxed manner. Although I couldn’t put my finger on the reason, my first impression was that she was a sick child.

She had not seemed herself for about 3 days, she had had no measurable fever, her appetite was down, and she seemed uncomfortable, her mother told me. Although the discomfort waxed and waned, it had never completely abated. She had not vomited. The most consistent observation by her family was abdominal tenderness. She had no prior history of constipation. And, although she had not had a bowel movement since the illness began, her mother said that this could be explained by her lack of intake. The morning of this visit, she had a large, loose bowel movement that did not seem to relieve her discomfort.

On my exam, I found that her chest was clear, and her ears and pharynx were normal. Despite her pallor, her palpebral conjunctiva were a robust red. When she cried, her skin color turned a reassuring pink. Her abdomen was not distended, but was strikingly tender to palpation. Her bowel sounds were normal and she did not complain when I asked her mother to bounce Ada on her knee.

I explained to Rhonda Winchester (not her real name) that her daughter presented a fairly common diagnostic dilemma. Did she have stomach flu? Or was she constipated? Each condition required a completely different management plan. What I didn’t tell her was that my overwhelming concern was that her daughter looked sick in a subtle way that I couldn’t square with either constipation of gastroenteritis.

I sent them down the hall for an abdominal x-ray on the slim hope that Ada was more constipated than her history suggested. The image showed a few dilated loops of bowel and a nearly airless left lower quadrant. (Later in the day, it was officially read as normal.)

When she returned from x-ray, Ada was happily exploring the room, but I was still uncomfortable with her appearance. I now shared my discomfort with her mother, but I told her she could take her daughter home. I asked her to call promptly if anything changed and that I would call her in a few hours to check on her and report the official x-ray interpretation.

Just 2 hours later, Mrs. Winchester called back to report that Ada was much more uncomfortable. Suspecting that she might have a problem requiring intervention by a pediatric surgeon, I told her to go to the tertiary medical center in Portland rather than our local emergency department. By late the next day Ada, was finally diagnosed with an infected urachal remnant, a condition that was not even at the bottom of my diagnostic list.

As I discussed this scenario with a couple of my partners, we agreed that it demonstrated the two most important critical skills that a pediatrician must possess.

The first is the ability to identify a sick child. A lay person might ask, "Almost every child who is brought to you for anything other than a checkup is sick. What’s the big deal?" Well, there is sick, and there is scary sick. And sometimes vital signs and lab work aren’t going to separate the two. In Ada’s case, her vital signs and blood work (obtained at the tertiary hospital) were normal. Identifying the scary sick patient is a difficult skill to teach. It requires that the student see a large volume of patients and compare the outcomes with their first impressions.

The second skill that must accompany this critical exercise in pattern recognition is the ability to know when you don’t know what is going on ... and then ask for help.

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

Ada Winchester is a 15-month-old girl I had never met before. All I knew about this first patient of the day was that her chart listed "abdominal pain" as the chief complaint. As I approached the exam room door, I was already rehearsing my constipation speech. But when I entered the room I quickly put my timeworn pooping monologue back on the shelf.

Ada (the name is fictitious) was sitting comfortably on her mother’s lap. Her sparse, wispy hair framed a cute but slightly pale face. She was lean but not scrawny, and I could see why her usual pediatrician had at times been concerned about her weight. She was breathing easily and interacted with her mother in a relaxed manner. Although I couldn’t put my finger on the reason, my first impression was that she was a sick child.

She had not seemed herself for about 3 days, she had had no measurable fever, her appetite was down, and she seemed uncomfortable, her mother told me. Although the discomfort waxed and waned, it had never completely abated. She had not vomited. The most consistent observation by her family was abdominal tenderness. She had no prior history of constipation. And, although she had not had a bowel movement since the illness began, her mother said that this could be explained by her lack of intake. The morning of this visit, she had a large, loose bowel movement that did not seem to relieve her discomfort.

On my exam, I found that her chest was clear, and her ears and pharynx were normal. Despite her pallor, her palpebral conjunctiva were a robust red. When she cried, her skin color turned a reassuring pink. Her abdomen was not distended, but was strikingly tender to palpation. Her bowel sounds were normal and she did not complain when I asked her mother to bounce Ada on her knee.

I explained to Rhonda Winchester (not her real name) that her daughter presented a fairly common diagnostic dilemma. Did she have stomach flu? Or was she constipated? Each condition required a completely different management plan. What I didn’t tell her was that my overwhelming concern was that her daughter looked sick in a subtle way that I couldn’t square with either constipation of gastroenteritis.

I sent them down the hall for an abdominal x-ray on the slim hope that Ada was more constipated than her history suggested. The image showed a few dilated loops of bowel and a nearly airless left lower quadrant. (Later in the day, it was officially read as normal.)

When she returned from x-ray, Ada was happily exploring the room, but I was still uncomfortable with her appearance. I now shared my discomfort with her mother, but I told her she could take her daughter home. I asked her to call promptly if anything changed and that I would call her in a few hours to check on her and report the official x-ray interpretation.

Just 2 hours later, Mrs. Winchester called back to report that Ada was much more uncomfortable. Suspecting that she might have a problem requiring intervention by a pediatric surgeon, I told her to go to the tertiary medical center in Portland rather than our local emergency department. By late the next day Ada, was finally diagnosed with an infected urachal remnant, a condition that was not even at the bottom of my diagnostic list.

As I discussed this scenario with a couple of my partners, we agreed that it demonstrated the two most important critical skills that a pediatrician must possess.

The first is the ability to identify a sick child. A lay person might ask, "Almost every child who is brought to you for anything other than a checkup is sick. What’s the big deal?" Well, there is sick, and there is scary sick. And sometimes vital signs and lab work aren’t going to separate the two. In Ada’s case, her vital signs and blood work (obtained at the tertiary hospital) were normal. Identifying the scary sick patient is a difficult skill to teach. It requires that the student see a large volume of patients and compare the outcomes with their first impressions.

The second skill that must accompany this critical exercise in pattern recognition is the ability to know when you don’t know what is going on ... and then ask for help.

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

Ada Winchester is a 15-month-old girl I had never met before. All I knew about this first patient of the day was that her chart listed "abdominal pain" as the chief complaint. As I approached the exam room door, I was already rehearsing my constipation speech. But when I entered the room I quickly put my timeworn pooping monologue back on the shelf.

Ada (the name is fictitious) was sitting comfortably on her mother’s lap. Her sparse, wispy hair framed a cute but slightly pale face. She was lean but not scrawny, and I could see why her usual pediatrician had at times been concerned about her weight. She was breathing easily and interacted with her mother in a relaxed manner. Although I couldn’t put my finger on the reason, my first impression was that she was a sick child.

She had not seemed herself for about 3 days, she had had no measurable fever, her appetite was down, and she seemed uncomfortable, her mother told me. Although the discomfort waxed and waned, it had never completely abated. She had not vomited. The most consistent observation by her family was abdominal tenderness. She had no prior history of constipation. And, although she had not had a bowel movement since the illness began, her mother said that this could be explained by her lack of intake. The morning of this visit, she had a large, loose bowel movement that did not seem to relieve her discomfort.

On my exam, I found that her chest was clear, and her ears and pharynx were normal. Despite her pallor, her palpebral conjunctiva were a robust red. When she cried, her skin color turned a reassuring pink. Her abdomen was not distended, but was strikingly tender to palpation. Her bowel sounds were normal and she did not complain when I asked her mother to bounce Ada on her knee.

I explained to Rhonda Winchester (not her real name) that her daughter presented a fairly common diagnostic dilemma. Did she have stomach flu? Or was she constipated? Each condition required a completely different management plan. What I didn’t tell her was that my overwhelming concern was that her daughter looked sick in a subtle way that I couldn’t square with either constipation of gastroenteritis.

I sent them down the hall for an abdominal x-ray on the slim hope that Ada was more constipated than her history suggested. The image showed a few dilated loops of bowel and a nearly airless left lower quadrant. (Later in the day, it was officially read as normal.)

When she returned from x-ray, Ada was happily exploring the room, but I was still uncomfortable with her appearance. I now shared my discomfort with her mother, but I told her she could take her daughter home. I asked her to call promptly if anything changed and that I would call her in a few hours to check on her and report the official x-ray interpretation.

Just 2 hours later, Mrs. Winchester called back to report that Ada was much more uncomfortable. Suspecting that she might have a problem requiring intervention by a pediatric surgeon, I told her to go to the tertiary medical center in Portland rather than our local emergency department. By late the next day Ada, was finally diagnosed with an infected urachal remnant, a condition that was not even at the bottom of my diagnostic list.

As I discussed this scenario with a couple of my partners, we agreed that it demonstrated the two most important critical skills that a pediatrician must possess.

The first is the ability to identify a sick child. A lay person might ask, "Almost every child who is brought to you for anything other than a checkup is sick. What’s the big deal?" Well, there is sick, and there is scary sick. And sometimes vital signs and lab work aren’t going to separate the two. In Ada’s case, her vital signs and blood work (obtained at the tertiary hospital) were normal. Identifying the scary sick patient is a difficult skill to teach. It requires that the student see a large volume of patients and compare the outcomes with their first impressions.

The second skill that must accompany this critical exercise in pattern recognition is the ability to know when you don’t know what is going on ... and then ask for help.

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