William G. Wilkoff

[email protected]

I have always prided myself on being a business-savvy and efficient practitioner. In fact, I'm a little bummed that the editor didn't choose me to write the Efficient Pediatrician Practices column that you will find near the back of each issue.

But to be honest, I don't think I could do nearly as good a job at collecting and presenting tips about running a pediatric office as Dr. Charles A. Scott is doing. His advice has the ring of common sense and is realistically doable.

Nonetheless, I can't resist the urge to share a few of my thoughts on coding and the advantages of creating one's personal bite-sized menu of diagnoses. Being a “think small” kind of guy, I have always striven to keep my list of codes and hence diagnoses as short as possible. Six or eight pretty much cover it.

Regardless of how complex the patients' problems may sound when one listens to their parents, I try to distill things into something simple such as “viral illness” or “fever.”

Keeping my diagnostic list as short as possible makes it easier for our staff members, who are already working at the limits of their capabilities.

I notice that my partners who enjoy splitting hairs and dredging up unusual diagnoses spend way too much time with the front office people trying to get the coding correct.

If the physician has written the diagnosis legibly, he or she has probably misspelled it. Even if the physician is lucky enough to have spelled it correctly, the receptionist may not know in which organ system to begin her search for the appropriate code.

I know that some practices have an exhaustive and intimidating list of “common” diagnoses and codes printed on their billing sheets. This usually creates a document that looks something like a page out of the phone book and is even harder to navigate.

Another issue is that at least half of my patients reach the checkout desk before I have gathered enough information to render an accurate and specific diagnosis. Rarely, I may be waiting for some lab work, but more than likely I'm just plain waiting. I'm pretty sure I know what the child doesn't have, and I've asked the parents to join me in a friendly game of wait-and-see until I call the next day.

I suspect my short-list approach to coding creates the impression that my patient mix is of low complexity. My numbers may make it look as though my professional life is rather boring. And I'm sure it would make in-office research projects fruitless. But, you and I know that it's the patients and not the diagnoses that make pediatrics interesting.

However, there are days when I wonder if my life might be easier if I expanded my diagnostic list just a bit. If I included “teething,” then I could hustle those parents of fussy infants and low-grade fevers out of the office more quickly. No need to make those time-consuming follow-up calls the next day.

Imagine how easy things would be if I could sign out all the cranky 2-month-olds as having “colic.” No more extended interviews to find out whether a new mother is depressed or sleep-deprived or both.

If I could move “sinusitis” from my seldom-used list to my short list, then scores of toddlers with green and yellow snot would be on the fast track out of the office and off to the pharmacy for antibiotics. “Growing pains” could become another giant wastebasket into which I could efficiently toss those annoying and sometimes mysterious cases of extremity aches.

But, I know the grand old masters of pediatrics who trained me would be spinning in their graves. I'm sure they would prefer that I stick to my current game plan. I think they would approve of my philosophy that no diagnosis is always better than the wrong one.

[email protected]

I have always prided myself on being a business-savvy and efficient practitioner. In fact, I'm a little bummed that the editor didn't choose me to write the Efficient Pediatrician Practices column that you will find near the back of each issue.

But to be honest, I don't think I could do nearly as good a job at collecting and presenting tips about running a pediatric office as Dr. Charles A. Scott is doing. His advice has the ring of common sense and is realistically doable.

Nonetheless, I can't resist the urge to share a few of my thoughts on coding and the advantages of creating one's personal bite-sized menu of diagnoses. Being a “think small” kind of guy, I have always striven to keep my list of codes and hence diagnoses as short as possible. Six or eight pretty much cover it.

Regardless of how complex the patients' problems may sound when one listens to their parents, I try to distill things into something simple such as “viral illness” or “fever.”

Keeping my diagnostic list as short as possible makes it easier for our staff members, who are already working at the limits of their capabilities.

I notice that my partners who enjoy splitting hairs and dredging up unusual diagnoses spend way too much time with the front office people trying to get the coding correct.

If the physician has written the diagnosis legibly, he or she has probably misspelled it. Even if the physician is lucky enough to have spelled it correctly, the receptionist may not know in which organ system to begin her search for the appropriate code.

I know that some practices have an exhaustive and intimidating list of “common” diagnoses and codes printed on their billing sheets. This usually creates a document that looks something like a page out of the phone book and is even harder to navigate.

Another issue is that at least half of my patients reach the checkout desk before I have gathered enough information to render an accurate and specific diagnosis. Rarely, I may be waiting for some lab work, but more than likely I'm just plain waiting. I'm pretty sure I know what the child doesn't have, and I've asked the parents to join me in a friendly game of wait-and-see until I call the next day.

I suspect my short-list approach to coding creates the impression that my patient mix is of low complexity. My numbers may make it look as though my professional life is rather boring. And I'm sure it would make in-office research projects fruitless. But, you and I know that it's the patients and not the diagnoses that make pediatrics interesting.

However, there are days when I wonder if my life might be easier if I expanded my diagnostic list just a bit. If I included “teething,” then I could hustle those parents of fussy infants and low-grade fevers out of the office more quickly. No need to make those time-consuming follow-up calls the next day.

Imagine how easy things would be if I could sign out all the cranky 2-month-olds as having “colic.” No more extended interviews to find out whether a new mother is depressed or sleep-deprived or both.

If I could move “sinusitis” from my seldom-used list to my short list, then scores of toddlers with green and yellow snot would be on the fast track out of the office and off to the pharmacy for antibiotics. “Growing pains” could become another giant wastebasket into which I could efficiently toss those annoying and sometimes mysterious cases of extremity aches.

But, I know the grand old masters of pediatrics who trained me would be spinning in their graves. I'm sure they would prefer that I stick to my current game plan. I think they would approve of my philosophy that no diagnosis is always better than the wrong one.

[email protected]

I have always prided myself on being a business-savvy and efficient practitioner. In fact, I'm a little bummed that the editor didn't choose me to write the Efficient Pediatrician Practices column that you will find near the back of each issue.

But to be honest, I don't think I could do nearly as good a job at collecting and presenting tips about running a pediatric office as Dr. Charles A. Scott is doing. His advice has the ring of common sense and is realistically doable.

Nonetheless, I can't resist the urge to share a few of my thoughts on coding and the advantages of creating one's personal bite-sized menu of diagnoses. Being a “think small” kind of guy, I have always striven to keep my list of codes and hence diagnoses as short as possible. Six or eight pretty much cover it.

Regardless of how complex the patients' problems may sound when one listens to their parents, I try to distill things into something simple such as “viral illness” or “fever.”

Keeping my diagnostic list as short as possible makes it easier for our staff members, who are already working at the limits of their capabilities.

I notice that my partners who enjoy splitting hairs and dredging up unusual diagnoses spend way too much time with the front office people trying to get the coding correct.

If the physician has written the diagnosis legibly, he or she has probably misspelled it. Even if the physician is lucky enough to have spelled it correctly, the receptionist may not know in which organ system to begin her search for the appropriate code.

I know that some practices have an exhaustive and intimidating list of “common” diagnoses and codes printed on their billing sheets. This usually creates a document that looks something like a page out of the phone book and is even harder to navigate.

Another issue is that at least half of my patients reach the checkout desk before I have gathered enough information to render an accurate and specific diagnosis. Rarely, I may be waiting for some lab work, but more than likely I'm just plain waiting. I'm pretty sure I know what the child doesn't have, and I've asked the parents to join me in a friendly game of wait-and-see until I call the next day.

I suspect my short-list approach to coding creates the impression that my patient mix is of low complexity. My numbers may make it look as though my professional life is rather boring. And I'm sure it would make in-office research projects fruitless. But, you and I know that it's the patients and not the diagnoses that make pediatrics interesting.

However, there are days when I wonder if my life might be easier if I expanded my diagnostic list just a bit. If I included “teething,” then I could hustle those parents of fussy infants and low-grade fevers out of the office more quickly. No need to make those time-consuming follow-up calls the next day.

Imagine how easy things would be if I could sign out all the cranky 2-month-olds as having “colic.” No more extended interviews to find out whether a new mother is depressed or sleep-deprived or both.

If I could move “sinusitis” from my seldom-used list to my short list, then scores of toddlers with green and yellow snot would be on the fast track out of the office and off to the pharmacy for antibiotics. “Growing pains” could become another giant wastebasket into which I could efficiently toss those annoying and sometimes mysterious cases of extremity aches.

But, I know the grand old masters of pediatrics who trained me would be spinning in their graves. I'm sure they would prefer that I stick to my current game plan. I think they would approve of my philosophy that no diagnosis is always better than the wrong one.

[email protected]

Ask a group of primary care pediatricians who are old enough to have children in college and they will tell you that the mix of patients in their offices has changed significantly since they opened their practices. The increase in mental health complaints and the decrease in serious bacterial infections such as meningitis and epiglottitis have been striking.

A less talked-about shift in traffic flow has been the decrease in the number of victims of minor trauma who limp or are carried across the threshold of the average general pediatrician's office.

There are several reasons for this decline in the bumps, cuts, and bruises. One is the advent of emergency medicine as a specialty and the resulting ubiquity of fully staffed emergency departments. A related phenomenon is the realization by hospitals that minor trauma and walk-in illnesses can generate income that can help fund the overhead costs for more serious trauma treatments.

Aggressive marketing by these hungry hospitals has convinced many parents that the hospital “ER” is the place to go when one's child is injured, regardless of how minor the trauma. The marketing has been so successful in our community that parents are often surprised that we can, and occasionally still do, perform suture repairs and simple casting in our office.

Some recently trained pediatricians may be less comfortable seeing minor trauma victims in the office setting, particularly if they don't have access to the security blankets of lab and x-ray.

Experienced physicians have learned that even a simple three-suture repair can throw their busy offices into chaos, and some may instruct their staff to triage every injured child to the emergency department just to keep some semblance of calm in the waiting room. Not surprisingly, it doesn't take long for parents to catch on that their pediatricians aren't interested in seeing injured children, and they will self-refer to the emergency department the next time their child trips and falls.

I suspect that another and more troubling reason that we are seeing fewer injured children in our offices is that there are fewer children who are active enough to sustain even minor trauma. I don't have any statistics to support this observation, but the math is pretty simple. We know that more children are spending more of their time doing nothing but sitting in front of a video screen.

Couch potatoes can get bruised if they roll off onto the floor, but those injuries don't seem to generate enough discomfort to get the little video addicts to turn off the TV and come to the office. Even the hyperactive kids, a group that I could count on for a steady supply of cuts and dings, are being throttled down with amphetamines.

It is so unusual to see a child with grass stains on his knees that some parents feel the need to apologize for this once commonplace physical finding. Of course, I reassure them that these stains and lower extremity bruises are signs of good health. But, their rarity is troubling.

We adults must certainly shoulder a large part of the blame for this drought in minor trauma. We continue to “make poor choices,” which is new millennium-speak for “do stupid things,” when it comes to raising our children. For example, many of you have heard that a school system in Massachusetts recently decided to ban from its playgrounds the game of “tag” because it was deemed a dangerous activity.

The trend toward this low-impact style of parenting is so prevalent that I suggest you sell your stock in Johnson & Johnson and invest in bubble wrap! Because I'm sure my great-grandchildren won't know what a Band-Aid is for, and their parents will be swaddling them in protective layers of bubble wrap before allowing them to leave the house. If indeed they are even allowed to step outside!

[email protected]

Ask a group of primary care pediatricians who are old enough to have children in college and they will tell you that the mix of patients in their offices has changed significantly since they opened their practices. The increase in mental health complaints and the decrease in serious bacterial infections such as meningitis and epiglottitis have been striking.

A less talked-about shift in traffic flow has been the decrease in the number of victims of minor trauma who limp or are carried across the threshold of the average general pediatrician's office.

There are several reasons for this decline in the bumps, cuts, and bruises. One is the advent of emergency medicine as a specialty and the resulting ubiquity of fully staffed emergency departments. A related phenomenon is the realization by hospitals that minor trauma and walk-in illnesses can generate income that can help fund the overhead costs for more serious trauma treatments.

Aggressive marketing by these hungry hospitals has convinced many parents that the hospital “ER” is the place to go when one's child is injured, regardless of how minor the trauma. The marketing has been so successful in our community that parents are often surprised that we can, and occasionally still do, perform suture repairs and simple casting in our office.

Some recently trained pediatricians may be less comfortable seeing minor trauma victims in the office setting, particularly if they don't have access to the security blankets of lab and x-ray.

Experienced physicians have learned that even a simple three-suture repair can throw their busy offices into chaos, and some may instruct their staff to triage every injured child to the emergency department just to keep some semblance of calm in the waiting room. Not surprisingly, it doesn't take long for parents to catch on that their pediatricians aren't interested in seeing injured children, and they will self-refer to the emergency department the next time their child trips and falls.

I suspect that another and more troubling reason that we are seeing fewer injured children in our offices is that there are fewer children who are active enough to sustain even minor trauma. I don't have any statistics to support this observation, but the math is pretty simple. We know that more children are spending more of their time doing nothing but sitting in front of a video screen.

Couch potatoes can get bruised if they roll off onto the floor, but those injuries don't seem to generate enough discomfort to get the little video addicts to turn off the TV and come to the office. Even the hyperactive kids, a group that I could count on for a steady supply of cuts and dings, are being throttled down with amphetamines.

It is so unusual to see a child with grass stains on his knees that some parents feel the need to apologize for this once commonplace physical finding. Of course, I reassure them that these stains and lower extremity bruises are signs of good health. But, their rarity is troubling.

We adults must certainly shoulder a large part of the blame for this drought in minor trauma. We continue to “make poor choices,” which is new millennium-speak for “do stupid things,” when it comes to raising our children. For example, many of you have heard that a school system in Massachusetts recently decided to ban from its playgrounds the game of “tag” because it was deemed a dangerous activity.

The trend toward this low-impact style of parenting is so prevalent that I suggest you sell your stock in Johnson & Johnson and invest in bubble wrap! Because I'm sure my great-grandchildren won't know what a Band-Aid is for, and their parents will be swaddling them in protective layers of bubble wrap before allowing them to leave the house. If indeed they are even allowed to step outside!

[email protected]

Ask a group of primary care pediatricians who are old enough to have children in college and they will tell you that the mix of patients in their offices has changed significantly since they opened their practices. The increase in mental health complaints and the decrease in serious bacterial infections such as meningitis and epiglottitis have been striking.

A less talked-about shift in traffic flow has been the decrease in the number of victims of minor trauma who limp or are carried across the threshold of the average general pediatrician's office.

There are several reasons for this decline in the bumps, cuts, and bruises. One is the advent of emergency medicine as a specialty and the resulting ubiquity of fully staffed emergency departments. A related phenomenon is the realization by hospitals that minor trauma and walk-in illnesses can generate income that can help fund the overhead costs for more serious trauma treatments.

Aggressive marketing by these hungry hospitals has convinced many parents that the hospital “ER” is the place to go when one's child is injured, regardless of how minor the trauma. The marketing has been so successful in our community that parents are often surprised that we can, and occasionally still do, perform suture repairs and simple casting in our office.

Some recently trained pediatricians may be less comfortable seeing minor trauma victims in the office setting, particularly if they don't have access to the security blankets of lab and x-ray.

Experienced physicians have learned that even a simple three-suture repair can throw their busy offices into chaos, and some may instruct their staff to triage every injured child to the emergency department just to keep some semblance of calm in the waiting room. Not surprisingly, it doesn't take long for parents to catch on that their pediatricians aren't interested in seeing injured children, and they will self-refer to the emergency department the next time their child trips and falls.

I suspect that another and more troubling reason that we are seeing fewer injured children in our offices is that there are fewer children who are active enough to sustain even minor trauma. I don't have any statistics to support this observation, but the math is pretty simple. We know that more children are spending more of their time doing nothing but sitting in front of a video screen.

Couch potatoes can get bruised if they roll off onto the floor, but those injuries don't seem to generate enough discomfort to get the little video addicts to turn off the TV and come to the office. Even the hyperactive kids, a group that I could count on for a steady supply of cuts and dings, are being throttled down with amphetamines.

It is so unusual to see a child with grass stains on his knees that some parents feel the need to apologize for this once commonplace physical finding. Of course, I reassure them that these stains and lower extremity bruises are signs of good health. But, their rarity is troubling.

We adults must certainly shoulder a large part of the blame for this drought in minor trauma. We continue to “make poor choices,” which is new millennium-speak for “do stupid things,” when it comes to raising our children. For example, many of you have heard that a school system in Massachusetts recently decided to ban from its playgrounds the game of “tag” because it was deemed a dangerous activity.

The trend toward this low-impact style of parenting is so prevalent that I suggest you sell your stock in Johnson & Johnson and invest in bubble wrap! Because I'm sure my great-grandchildren won't know what a Band-Aid is for, and their parents will be swaddling them in protective layers of bubble wrap before allowing them to leave the house. If indeed they are even allowed to step outside!

[email protected]

After practicing for more than 30 years in the same small town, one finds oneself draped in a wide variety of perceptions—some well deserved and some not. Among the ones I wear most proudly is: “If you are injured, Dr. Wilkoff is the guy to see when you want a note to return to sports participation ASAP.”

For as long as I can remember, sports have been woven into the fabric of my life. Like many boys who grew up in the 1950s, I dreamed of being a college football player. Making the high school team and earning a varsity letter were goals that required devotion that bordered on obsession. Being an athlete was critical to establishing and strengthening my puberty-challenged ego. The memory of those adolescent days has left me with great sympathy for junior high and high school athletes who find their careers interrupted by an injury.

I hope that my reputation among young athletes is the result of a holistic and compassionate approach to sports injuries and not a result of my being perceived as a rubber stamp. That management style has several key components. First, one must possess the skills and comfort level to determine when it is safe for the injured athlete to return to the specific challenges of the sport. This doesn't mean that one must be board certified in sports medicine. I certainly don't remember the names of all the muscle groups, nor can I recite or even spell the sometimes tongue-twisting names of all the ligaments and tendons that hold us together. But, determining the strength, stability, and range of motion is usually pretty straightforward and doesn't require x-rays or MRIs.

Second, the practitioner must ask the right questions to understand how the injury fits into the bigger picture—that is, the picture from the perspective of the young athletes: What positions do they play? Are they on the first string? How many weeks are left in the season? Is the team going to make the playoffs? When do they play their traditional rivals? Is this current sport their favorite or is it merely a way to stay fit until their favorite sport's season?

The responses to these questions are almost as important as is the answer to “Where does it hurt?” They provide me a window into my young patient's mind and can help me understand how the young athlete will accept my rehab plan and prediction of the healing time.

We all know that few decisions in medicine are as easy as telling black from white and rehabilitation schedules are seldom chiseled in stone. Of course we should never allow ourselves to recommend or allow a patient to risk permanent or serious injury. But, can I err on the side of liberalism if a playoff birth hinges on the next game(s)? Is the patient willing to accept the risk of aggravating an injury and missing even more games or the tryouts for a sport he considers his favorite? Entering into a dialogue with the patient and his family can help clarify which shade of gray suits this injury.

Unfortunately for the patient with a head injury, a concussion is not a condition that allows for compromise or negotiation. I have found that sharing a printed copy of my favorite set of head injury management guidelines can return the discussion to the clarity of black and white.

Finally, successful and compassionate management of an athletic injury should include a rehab plan that incorporates a list of things the patient can do that is at least as long as the prohibitions. Very few injuries require total inactivity. Keeping the uninjured extremities in motion can help maintain the athlete's cardiovascular conditioning, but most importantly it can protect his fragile emotions while he is waiting impatiently to get back on the field.

When it's time to return to the action, he may remember that I was one of the people who were on his side.

[email protected]

After practicing for more than 30 years in the same small town, one finds oneself draped in a wide variety of perceptions—some well deserved and some not. Among the ones I wear most proudly is: “If you are injured, Dr. Wilkoff is the guy to see when you want a note to return to sports participation ASAP.”

For as long as I can remember, sports have been woven into the fabric of my life. Like many boys who grew up in the 1950s, I dreamed of being a college football player. Making the high school team and earning a varsity letter were goals that required devotion that bordered on obsession. Being an athlete was critical to establishing and strengthening my puberty-challenged ego. The memory of those adolescent days has left me with great sympathy for junior high and high school athletes who find their careers interrupted by an injury.

I hope that my reputation among young athletes is the result of a holistic and compassionate approach to sports injuries and not a result of my being perceived as a rubber stamp. That management style has several key components. First, one must possess the skills and comfort level to determine when it is safe for the injured athlete to return to the specific challenges of the sport. This doesn't mean that one must be board certified in sports medicine. I certainly don't remember the names of all the muscle groups, nor can I recite or even spell the sometimes tongue-twisting names of all the ligaments and tendons that hold us together. But, determining the strength, stability, and range of motion is usually pretty straightforward and doesn't require x-rays or MRIs.

Second, the practitioner must ask the right questions to understand how the injury fits into the bigger picture—that is, the picture from the perspective of the young athletes: What positions do they play? Are they on the first string? How many weeks are left in the season? Is the team going to make the playoffs? When do they play their traditional rivals? Is this current sport their favorite or is it merely a way to stay fit until their favorite sport's season?

The responses to these questions are almost as important as is the answer to “Where does it hurt?” They provide me a window into my young patient's mind and can help me understand how the young athlete will accept my rehab plan and prediction of the healing time.

We all know that few decisions in medicine are as easy as telling black from white and rehabilitation schedules are seldom chiseled in stone. Of course we should never allow ourselves to recommend or allow a patient to risk permanent or serious injury. But, can I err on the side of liberalism if a playoff birth hinges on the next game(s)? Is the patient willing to accept the risk of aggravating an injury and missing even more games or the tryouts for a sport he considers his favorite? Entering into a dialogue with the patient and his family can help clarify which shade of gray suits this injury.

Unfortunately for the patient with a head injury, a concussion is not a condition that allows for compromise or negotiation. I have found that sharing a printed copy of my favorite set of head injury management guidelines can return the discussion to the clarity of black and white.

Finally, successful and compassionate management of an athletic injury should include a rehab plan that incorporates a list of things the patient can do that is at least as long as the prohibitions. Very few injuries require total inactivity. Keeping the uninjured extremities in motion can help maintain the athlete's cardiovascular conditioning, but most importantly it can protect his fragile emotions while he is waiting impatiently to get back on the field.

When it's time to return to the action, he may remember that I was one of the people who were on his side.

[email protected]

After practicing for more than 30 years in the same small town, one finds oneself draped in a wide variety of perceptions—some well deserved and some not. Among the ones I wear most proudly is: “If you are injured, Dr. Wilkoff is the guy to see when you want a note to return to sports participation ASAP.”

For as long as I can remember, sports have been woven into the fabric of my life. Like many boys who grew up in the 1950s, I dreamed of being a college football player. Making the high school team and earning a varsity letter were goals that required devotion that bordered on obsession. Being an athlete was critical to establishing and strengthening my puberty-challenged ego. The memory of those adolescent days has left me with great sympathy for junior high and high school athletes who find their careers interrupted by an injury.

I hope that my reputation among young athletes is the result of a holistic and compassionate approach to sports injuries and not a result of my being perceived as a rubber stamp. That management style has several key components. First, one must possess the skills and comfort level to determine when it is safe for the injured athlete to return to the specific challenges of the sport. This doesn't mean that one must be board certified in sports medicine. I certainly don't remember the names of all the muscle groups, nor can I recite or even spell the sometimes tongue-twisting names of all the ligaments and tendons that hold us together. But, determining the strength, stability, and range of motion is usually pretty straightforward and doesn't require x-rays or MRIs.

Second, the practitioner must ask the right questions to understand how the injury fits into the bigger picture—that is, the picture from the perspective of the young athletes: What positions do they play? Are they on the first string? How many weeks are left in the season? Is the team going to make the playoffs? When do they play their traditional rivals? Is this current sport their favorite or is it merely a way to stay fit until their favorite sport's season?

The responses to these questions are almost as important as is the answer to “Where does it hurt?” They provide me a window into my young patient's mind and can help me understand how the young athlete will accept my rehab plan and prediction of the healing time.

We all know that few decisions in medicine are as easy as telling black from white and rehabilitation schedules are seldom chiseled in stone. Of course we should never allow ourselves to recommend or allow a patient to risk permanent or serious injury. But, can I err on the side of liberalism if a playoff birth hinges on the next game(s)? Is the patient willing to accept the risk of aggravating an injury and missing even more games or the tryouts for a sport he considers his favorite? Entering into a dialogue with the patient and his family can help clarify which shade of gray suits this injury.

Unfortunately for the patient with a head injury, a concussion is not a condition that allows for compromise or negotiation. I have found that sharing a printed copy of my favorite set of head injury management guidelines can return the discussion to the clarity of black and white.

Finally, successful and compassionate management of an athletic injury should include a rehab plan that incorporates a list of things the patient can do that is at least as long as the prohibitions. Very few injuries require total inactivity. Keeping the uninjured extremities in motion can help maintain the athlete's cardiovascular conditioning, but most importantly it can protect his fragile emotions while he is waiting impatiently to get back on the field.

When it's time to return to the action, he may remember that I was one of the people who were on his side.

[email protected]

Here on the coast of Maine, the clam diggers fear a “red tide.” This natural phenomenon is the result of a toxic algal bloom that doesn't harm the clams, but makes them dangerously inedible to humans. Some pediatricians seem to have a similar, but less rational, fear of a “yellow tide” known as neonatal jaundice.

Currently, this natural phenomenon has prompted a yellow alert. Some physicians are recommending baseline bilirubin sampling on all newborns prior to discharge from the nursery. Others are suggesting that we test every newborn who appears yellow, regardless of age or nutritional status. Nursery nurses are being encouraged to be proactive and order bilirubin tests whenever they have any suspicion of jaundice.

The result of this yellow phobia is that hundreds of new families must remain in the hospital waiting for lab results. Scores of already anxious parents are being made more anxious by informational chats about jaundice with well-meaning nurses and physicians. Focus shifts from breast-feeding to battling the dread yellow tide. Who knows how many breast-feeding experiences have been jeopardized or destroyed by this unfortunate shift in attention?

Maintaining close physical contact between mother and baby is difficult and ad lib breast-feeding is impossible if phototherapy is prescribed. Marginal results may be achieved with daily trips to the lab, which are not fun for new mothers with sore bottoms or healing abdominal wounds. Mothers and babies who should be home sleeping and nursing find themselves sitting in hard plastic chairs in laboratory waiting areas.

In the 1970s, the yellow tide of worry ebbed as some sensible neonatologists cautioned the rest of us about irrational “vigintiphobia” (fear of bilirubin levels greater than 20) and many of us relaxed. I began ordering fewer bilirubin tests and started paying more attention to learning how I could better support breast-feeding. The “bili lights” moved into the storage room behind the nursery and were wheeled out only on rare occasions.

However, when economic forces shrunk hospital stays and some physicians failed to adequately compensate with timely outpatient follow-up visits, there was an increase in the number of very yellow babies. The tide of concern turned from ebb to flow, and along with it came the new recommendations for more aggressive testing.

I have resisted the encouragement from the various committees that pontificate on such matters of color and have continued to ignore the color of all but the most pumpkin-colored newborns. I admit that I have had a small and lingering worry that my color blindness may have prevented some of my patients from doing as well as their peers on the college SATs. But I have trouble imagining that a phenomenon as common as neonatal jaundice is something to fear.

Galloping onto the stage in their white hats to rescue me from nagging worry are T. B. Newman et al. from the University of California in San Francisco (N. Engl. J. Med. 2006;354:1889–900). They have collected 140 neonates with bilirubins greater than 25 (10 had levels of 30 or greater). When these neonates were compared with the control group, the investigators could find no significant difference in their scores on a collection of cognitive tests. There also was no difference in either the proportion of children with neurologic findings or the documented diagnoses of neurologic findings.

So there you have it. Will the yellow tide begin to recede? Will physicians and nursery nurses begin to shift their focus away from jaundice onto more important issues, such as providing new mothers the technical and emotional support they often need to make breast-feeding succeed? It's time to give our jaundiced eyes a rest and begin to listen to what new mothers want.

[email protected]

Here on the coast of Maine, the clam diggers fear a “red tide.” This natural phenomenon is the result of a toxic algal bloom that doesn't harm the clams, but makes them dangerously inedible to humans. Some pediatricians seem to have a similar, but less rational, fear of a “yellow tide” known as neonatal jaundice.

Currently, this natural phenomenon has prompted a yellow alert. Some physicians are recommending baseline bilirubin sampling on all newborns prior to discharge from the nursery. Others are suggesting that we test every newborn who appears yellow, regardless of age or nutritional status. Nursery nurses are being encouraged to be proactive and order bilirubin tests whenever they have any suspicion of jaundice.

The result of this yellow phobia is that hundreds of new families must remain in the hospital waiting for lab results. Scores of already anxious parents are being made more anxious by informational chats about jaundice with well-meaning nurses and physicians. Focus shifts from breast-feeding to battling the dread yellow tide. Who knows how many breast-feeding experiences have been jeopardized or destroyed by this unfortunate shift in attention?

Maintaining close physical contact between mother and baby is difficult and ad lib breast-feeding is impossible if phototherapy is prescribed. Marginal results may be achieved with daily trips to the lab, which are not fun for new mothers with sore bottoms or healing abdominal wounds. Mothers and babies who should be home sleeping and nursing find themselves sitting in hard plastic chairs in laboratory waiting areas.

In the 1970s, the yellow tide of worry ebbed as some sensible neonatologists cautioned the rest of us about irrational “vigintiphobia” (fear of bilirubin levels greater than 20) and many of us relaxed. I began ordering fewer bilirubin tests and started paying more attention to learning how I could better support breast-feeding. The “bili lights” moved into the storage room behind the nursery and were wheeled out only on rare occasions.

However, when economic forces shrunk hospital stays and some physicians failed to adequately compensate with timely outpatient follow-up visits, there was an increase in the number of very yellow babies. The tide of concern turned from ebb to flow, and along with it came the new recommendations for more aggressive testing.

I have resisted the encouragement from the various committees that pontificate on such matters of color and have continued to ignore the color of all but the most pumpkin-colored newborns. I admit that I have had a small and lingering worry that my color blindness may have prevented some of my patients from doing as well as their peers on the college SATs. But I have trouble imagining that a phenomenon as common as neonatal jaundice is something to fear.

Galloping onto the stage in their white hats to rescue me from nagging worry are T. B. Newman et al. from the University of California in San Francisco (N. Engl. J. Med. 2006;354:1889–900). They have collected 140 neonates with bilirubins greater than 25 (10 had levels of 30 or greater). When these neonates were compared with the control group, the investigators could find no significant difference in their scores on a collection of cognitive tests. There also was no difference in either the proportion of children with neurologic findings or the documented diagnoses of neurologic findings.

So there you have it. Will the yellow tide begin to recede? Will physicians and nursery nurses begin to shift their focus away from jaundice onto more important issues, such as providing new mothers the technical and emotional support they often need to make breast-feeding succeed? It's time to give our jaundiced eyes a rest and begin to listen to what new mothers want.

[email protected]

Here on the coast of Maine, the clam diggers fear a “red tide.” This natural phenomenon is the result of a toxic algal bloom that doesn't harm the clams, but makes them dangerously inedible to humans. Some pediatricians seem to have a similar, but less rational, fear of a “yellow tide” known as neonatal jaundice.

Currently, this natural phenomenon has prompted a yellow alert. Some physicians are recommending baseline bilirubin sampling on all newborns prior to discharge from the nursery. Others are suggesting that we test every newborn who appears yellow, regardless of age or nutritional status. Nursery nurses are being encouraged to be proactive and order bilirubin tests whenever they have any suspicion of jaundice.

The result of this yellow phobia is that hundreds of new families must remain in the hospital waiting for lab results. Scores of already anxious parents are being made more anxious by informational chats about jaundice with well-meaning nurses and physicians. Focus shifts from breast-feeding to battling the dread yellow tide. Who knows how many breast-feeding experiences have been jeopardized or destroyed by this unfortunate shift in attention?

Maintaining close physical contact between mother and baby is difficult and ad lib breast-feeding is impossible if phototherapy is prescribed. Marginal results may be achieved with daily trips to the lab, which are not fun for new mothers with sore bottoms or healing abdominal wounds. Mothers and babies who should be home sleeping and nursing find themselves sitting in hard plastic chairs in laboratory waiting areas.

In the 1970s, the yellow tide of worry ebbed as some sensible neonatologists cautioned the rest of us about irrational “vigintiphobia” (fear of bilirubin levels greater than 20) and many of us relaxed. I began ordering fewer bilirubin tests and started paying more attention to learning how I could better support breast-feeding. The “bili lights” moved into the storage room behind the nursery and were wheeled out only on rare occasions.

However, when economic forces shrunk hospital stays and some physicians failed to adequately compensate with timely outpatient follow-up visits, there was an increase in the number of very yellow babies. The tide of concern turned from ebb to flow, and along with it came the new recommendations for more aggressive testing.

I have resisted the encouragement from the various committees that pontificate on such matters of color and have continued to ignore the color of all but the most pumpkin-colored newborns. I admit that I have had a small and lingering worry that my color blindness may have prevented some of my patients from doing as well as their peers on the college SATs. But I have trouble imagining that a phenomenon as common as neonatal jaundice is something to fear.

Galloping onto the stage in their white hats to rescue me from nagging worry are T. B. Newman et al. from the University of California in San Francisco (N. Engl. J. Med. 2006;354:1889–900). They have collected 140 neonates with bilirubins greater than 25 (10 had levels of 30 or greater). When these neonates were compared with the control group, the investigators could find no significant difference in their scores on a collection of cognitive tests. There also was no difference in either the proportion of children with neurologic findings or the documented diagnoses of neurologic findings.

So there you have it. Will the yellow tide begin to recede? Will physicians and nursery nurses begin to shift their focus away from jaundice onto more important issues, such as providing new mothers the technical and emotional support they often need to make breast-feeding succeed? It's time to give our jaundiced eyes a rest and begin to listen to what new mothers want.

[email protected]

Practicing pediatrics is a lot like baking brownies.

I've been to enough picnics and to enough potluck suppers to know that everyone likes brownies.

And it is clear that every parent wants quality health care for their children.

The problem is that there are lots of ways to make a brownie. Do you like yours more like cake or more like fudge? From scratch or a mix? Nuts? On top or mixed in? Is store-bought in a cellophane bag good enough?

Likewise, everyone seems to have his or her own definition of quality health care. Of course you want your child's condition accurately diagnosed and treated with the most appropriate remedy. Just as chocolate, flour, and sugar are to a brownie, those are the essential ingredients of quality health care. But the ratios between the ingredients and the special additions to the recipe are what make one provider's approach to health care delivery more or less appealing to the appetite of the patients and their families.

In our group of four pediatricians, each of us has his or her particular style of delivering quality health care. We talk frequently among ourselves and see each other's charts many times during a typical day. We use the same rationale for choosing antibiotics and asthma medications. And, although we try to speak with one voice, we each have our own distinct accent that can put a different spin on the same message.

As the senior member of the group, I tend to rely on my age and an aura of experience to convince the patient's family that I have chosen the diagnosis and treatment wisely. Instead of ordering much lab work or x-rays, I use the unstated “because-I-said-so” rationale. While it's a defense that may not stand up in court, it works more often than not with most families who have chosen me as their primary care provider. I'm sure I don't spend as much time as my partners do explaining anatomy and physiology in great detail … but I do draw a lot of pictures.

But, there are some families for whom lab work and x-rays are part of their definition of quality health care. Just as there are some parents who prefer their medical care with a liberal dose of worry sprinkled on top. They will tend to choose one of my partners who shares their preference for looking at worst-case scenarios.

Please don't hear this as a judgmental observation. I completely understand why some people are comforted by hearing about all the ugly and unlikely possibilities that have been ruled out. It's just not the way I like to bake my brownies.

My usual health care delivery style is the pop-in-the-microwave-ready-to-serve version. I contend that in a blindfolded taste test the consumer couldn't tell the difference between mine and the baked-from-scratch version. It's got the essential ingredients of the correct diagnosis and treatment. And, surprisingly, many working parents with busy lives and overscheduled children like the quick turnaround time in the office. But, not surprisingly, other parents feel more comfortable when they know a diagnosis and treatment plan has baked in the oven for 15 or 20 minutes.

With four pediatricians in our group, the families who choose us can select a primary care provider whose style best fits their preferences.

But occasionally families will ask to see someone other than their primary care provider because on a particular day or with a particular complaint, they feel that a different style would be a better fit for their schedule or their emotional needs.

The challenge for physicians comes when we are on call and the only package on the shelf. Obviously, if there is time, I would like all families to receive the style of care they are most comfortable with. I can still bake them from scratch, add nuts, or make them sweet and fudgy, and I will. The challenge is figuring out just how each family likes its brownies.

[email protected]

Practicing pediatrics is a lot like baking brownies.

I've been to enough picnics and to enough potluck suppers to know that everyone likes brownies.

And it is clear that every parent wants quality health care for their children.

The problem is that there are lots of ways to make a brownie. Do you like yours more like cake or more like fudge? From scratch or a mix? Nuts? On top or mixed in? Is store-bought in a cellophane bag good enough?

Likewise, everyone seems to have his or her own definition of quality health care. Of course you want your child's condition accurately diagnosed and treated with the most appropriate remedy. Just as chocolate, flour, and sugar are to a brownie, those are the essential ingredients of quality health care. But the ratios between the ingredients and the special additions to the recipe are what make one provider's approach to health care delivery more or less appealing to the appetite of the patients and their families.

In our group of four pediatricians, each of us has his or her particular style of delivering quality health care. We talk frequently among ourselves and see each other's charts many times during a typical day. We use the same rationale for choosing antibiotics and asthma medications. And, although we try to speak with one voice, we each have our own distinct accent that can put a different spin on the same message.

As the senior member of the group, I tend to rely on my age and an aura of experience to convince the patient's family that I have chosen the diagnosis and treatment wisely. Instead of ordering much lab work or x-rays, I use the unstated “because-I-said-so” rationale. While it's a defense that may not stand up in court, it works more often than not with most families who have chosen me as their primary care provider. I'm sure I don't spend as much time as my partners do explaining anatomy and physiology in great detail … but I do draw a lot of pictures.

But, there are some families for whom lab work and x-rays are part of their definition of quality health care. Just as there are some parents who prefer their medical care with a liberal dose of worry sprinkled on top. They will tend to choose one of my partners who shares their preference for looking at worst-case scenarios.

Please don't hear this as a judgmental observation. I completely understand why some people are comforted by hearing about all the ugly and unlikely possibilities that have been ruled out. It's just not the way I like to bake my brownies.

My usual health care delivery style is the pop-in-the-microwave-ready-to-serve version. I contend that in a blindfolded taste test the consumer couldn't tell the difference between mine and the baked-from-scratch version. It's got the essential ingredients of the correct diagnosis and treatment. And, surprisingly, many working parents with busy lives and overscheduled children like the quick turnaround time in the office. But, not surprisingly, other parents feel more comfortable when they know a diagnosis and treatment plan has baked in the oven for 15 or 20 minutes.

With four pediatricians in our group, the families who choose us can select a primary care provider whose style best fits their preferences.

But occasionally families will ask to see someone other than their primary care provider because on a particular day or with a particular complaint, they feel that a different style would be a better fit for their schedule or their emotional needs.

The challenge for physicians comes when we are on call and the only package on the shelf. Obviously, if there is time, I would like all families to receive the style of care they are most comfortable with. I can still bake them from scratch, add nuts, or make them sweet and fudgy, and I will. The challenge is figuring out just how each family likes its brownies.

[email protected]

Practicing pediatrics is a lot like baking brownies.

I've been to enough picnics and to enough potluck suppers to know that everyone likes brownies.

And it is clear that every parent wants quality health care for their children.

The problem is that there are lots of ways to make a brownie. Do you like yours more like cake or more like fudge? From scratch or a mix? Nuts? On top or mixed in? Is store-bought in a cellophane bag good enough?

Likewise, everyone seems to have his or her own definition of quality health care. Of course you want your child's condition accurately diagnosed and treated with the most appropriate remedy. Just as chocolate, flour, and sugar are to a brownie, those are the essential ingredients of quality health care. But the ratios between the ingredients and the special additions to the recipe are what make one provider's approach to health care delivery more or less appealing to the appetite of the patients and their families.

In our group of four pediatricians, each of us has his or her particular style of delivering quality health care. We talk frequently among ourselves and see each other's charts many times during a typical day. We use the same rationale for choosing antibiotics and asthma medications. And, although we try to speak with one voice, we each have our own distinct accent that can put a different spin on the same message.

As the senior member of the group, I tend to rely on my age and an aura of experience to convince the patient's family that I have chosen the diagnosis and treatment wisely. Instead of ordering much lab work or x-rays, I use the unstated “because-I-said-so” rationale. While it's a defense that may not stand up in court, it works more often than not with most families who have chosen me as their primary care provider. I'm sure I don't spend as much time as my partners do explaining anatomy and physiology in great detail … but I do draw a lot of pictures.

But, there are some families for whom lab work and x-rays are part of their definition of quality health care. Just as there are some parents who prefer their medical care with a liberal dose of worry sprinkled on top. They will tend to choose one of my partners who shares their preference for looking at worst-case scenarios.

Please don't hear this as a judgmental observation. I completely understand why some people are comforted by hearing about all the ugly and unlikely possibilities that have been ruled out. It's just not the way I like to bake my brownies.

My usual health care delivery style is the pop-in-the-microwave-ready-to-serve version. I contend that in a blindfolded taste test the consumer couldn't tell the difference between mine and the baked-from-scratch version. It's got the essential ingredients of the correct diagnosis and treatment. And, surprisingly, many working parents with busy lives and overscheduled children like the quick turnaround time in the office. But, not surprisingly, other parents feel more comfortable when they know a diagnosis and treatment plan has baked in the oven for 15 or 20 minutes.

With four pediatricians in our group, the families who choose us can select a primary care provider whose style best fits their preferences.

But occasionally families will ask to see someone other than their primary care provider because on a particular day or with a particular complaint, they feel that a different style would be a better fit for their schedule or their emotional needs.

The challenge for physicians comes when we are on call and the only package on the shelf. Obviously, if there is time, I would like all families to receive the style of care they are most comfortable with. I can still bake them from scratch, add nuts, or make them sweet and fudgy, and I will. The challenge is figuring out just how each family likes its brownies.

[email protected]

A couple of months ago I was invited to de-liver the commencement address at a small high school on Maryland's eastern shore. I was stumped for a topic, so my wife suggested that because I seem to be enjoying myself most of the time, I speak about happiness. Because I hear and read so much about burnout and professional dissatisfaction among physicians, I thought I would share with you what I discovered about happiness as I researched my address.

Of course, I would speak to the new graduates about the antidepressant effects of exercise, sunlight, and a good night's sleep. But because happiness is not merely the absence of depression, I needed more insight, so I aimed my computer mouse at Google and typed in “happiness.”

I quickly found that despite what the authors of our Declaration of Independence might have written, happiness is not something to pursue. Albert Camus has written, “You will never be happy if you continue to search for what happiness consists of.”

In the writing of the psychologist/physician Edward de Bono, I discovered his observation that “Unhappiness is best defined as a mismatch between our talents and expectations.” Every day, you and I see this phenomenon in new parents who have failed to accurately predict how much time and energy it takes to raise a child. Many of them think it will be just a tad more difficult than rearing a golden retriever.

But, how many of us realize that we may be suffering the unhappy consequences of similar miscalculations and choices? I have found it difficult to communicate to young would-be physicians how challenging it can be to see an economically profitable number of patients and still be the kind of physician they would like to be. If I did the math for them, I'm afraid I would discourage most of them from choosing outpatient pediatrics.

However, I learned from the Dalai Lama that being a pediatrician has great potential for providing happiness. He has said, “If you want others to be happy, practice compassion. If you want to be happy, practice compassion.” He also said, “It is hardly surprising that most of our happiness arises in the context of our relationship with others.” It is difficult to imagine many other professions that offer as many opportunities to interact with people and practice compassion as does pediatrics.

But even if you have discovered that pediatrics is the best fit between your talents and your expectations, doodoo happens. How you deal with these disappointments is a reflection of your happiness quotient. Helen Keller has written, “When one door of happiness closes, another one opens, but often we look so long at the door that is closed, we don't see the one that has opened for us.”

I read somewhere that happy people have a knack for always looking forward and not dwelling on the mistakes and misdeeds of others. Happy people tend to recall their successes and use them as a springboard to continue forward. I think this is what Albert Schweitzer was getting at when he said, “Happiness is nothing more than good health and a bad memory.” I would add that if we are smart we learn from our mistakes and the injustices we have received, but if we want to be happy, we quickly forget them and move on.

The last nugget about happiness that I discovered was from Matt Richey, who writes for the Motley Fool, a financial Web site. He has observed that “Contentment isn't a feeling or a mood, it is a decision. Only by choosing to be content with what you already have can you accomplish your goals. Without choosing happiness, you will be trapped by an ever-expanding appetite for money and all things it can purchase.”

That's more good news for us—I'm sure few of us have chosen pediatrics because we thought it would be a way to make a fast and easy buck.

[email protected]

A couple of months ago I was invited to de-liver the commencement address at a small high school on Maryland's eastern shore. I was stumped for a topic, so my wife suggested that because I seem to be enjoying myself most of the time, I speak about happiness. Because I hear and read so much about burnout and professional dissatisfaction among physicians, I thought I would share with you what I discovered about happiness as I researched my address.

Of course, I would speak to the new graduates about the antidepressant effects of exercise, sunlight, and a good night's sleep. But because happiness is not merely the absence of depression, I needed more insight, so I aimed my computer mouse at Google and typed in “happiness.”

I quickly found that despite what the authors of our Declaration of Independence might have written, happiness is not something to pursue. Albert Camus has written, “You will never be happy if you continue to search for what happiness consists of.”

In the writing of the psychologist/physician Edward de Bono, I discovered his observation that “Unhappiness is best defined as a mismatch between our talents and expectations.” Every day, you and I see this phenomenon in new parents who have failed to accurately predict how much time and energy it takes to raise a child. Many of them think it will be just a tad more difficult than rearing a golden retriever.

But, how many of us realize that we may be suffering the unhappy consequences of similar miscalculations and choices? I have found it difficult to communicate to young would-be physicians how challenging it can be to see an economically profitable number of patients and still be the kind of physician they would like to be. If I did the math for them, I'm afraid I would discourage most of them from choosing outpatient pediatrics.

However, I learned from the Dalai Lama that being a pediatrician has great potential for providing happiness. He has said, “If you want others to be happy, practice compassion. If you want to be happy, practice compassion.” He also said, “It is hardly surprising that most of our happiness arises in the context of our relationship with others.” It is difficult to imagine many other professions that offer as many opportunities to interact with people and practice compassion as does pediatrics.

But even if you have discovered that pediatrics is the best fit between your talents and your expectations, doodoo happens. How you deal with these disappointments is a reflection of your happiness quotient. Helen Keller has written, “When one door of happiness closes, another one opens, but often we look so long at the door that is closed, we don't see the one that has opened for us.”

I read somewhere that happy people have a knack for always looking forward and not dwelling on the mistakes and misdeeds of others. Happy people tend to recall their successes and use them as a springboard to continue forward. I think this is what Albert Schweitzer was getting at when he said, “Happiness is nothing more than good health and a bad memory.” I would add that if we are smart we learn from our mistakes and the injustices we have received, but if we want to be happy, we quickly forget them and move on.

The last nugget about happiness that I discovered was from Matt Richey, who writes for the Motley Fool, a financial Web site. He has observed that “Contentment isn't a feeling or a mood, it is a decision. Only by choosing to be content with what you already have can you accomplish your goals. Without choosing happiness, you will be trapped by an ever-expanding appetite for money and all things it can purchase.”

That's more good news for us—I'm sure few of us have chosen pediatrics because we thought it would be a way to make a fast and easy buck.

[email protected]

A couple of months ago I was invited to de-liver the commencement address at a small high school on Maryland's eastern shore. I was stumped for a topic, so my wife suggested that because I seem to be enjoying myself most of the time, I speak about happiness. Because I hear and read so much about burnout and professional dissatisfaction among physicians, I thought I would share with you what I discovered about happiness as I researched my address.

Of course, I would speak to the new graduates about the antidepressant effects of exercise, sunlight, and a good night's sleep. But because happiness is not merely the absence of depression, I needed more insight, so I aimed my computer mouse at Google and typed in “happiness.”

I quickly found that despite what the authors of our Declaration of Independence might have written, happiness is not something to pursue. Albert Camus has written, “You will never be happy if you continue to search for what happiness consists of.”

In the writing of the psychologist/physician Edward de Bono, I discovered his observation that “Unhappiness is best defined as a mismatch between our talents and expectations.” Every day, you and I see this phenomenon in new parents who have failed to accurately predict how much time and energy it takes to raise a child. Many of them think it will be just a tad more difficult than rearing a golden retriever.

But, how many of us realize that we may be suffering the unhappy consequences of similar miscalculations and choices? I have found it difficult to communicate to young would-be physicians how challenging it can be to see an economically profitable number of patients and still be the kind of physician they would like to be. If I did the math for them, I'm afraid I would discourage most of them from choosing outpatient pediatrics.

However, I learned from the Dalai Lama that being a pediatrician has great potential for providing happiness. He has said, “If you want others to be happy, practice compassion. If you want to be happy, practice compassion.” He also said, “It is hardly surprising that most of our happiness arises in the context of our relationship with others.” It is difficult to imagine many other professions that offer as many opportunities to interact with people and practice compassion as does pediatrics.

But even if you have discovered that pediatrics is the best fit between your talents and your expectations, doodoo happens. How you deal with these disappointments is a reflection of your happiness quotient. Helen Keller has written, “When one door of happiness closes, another one opens, but often we look so long at the door that is closed, we don't see the one that has opened for us.”

I read somewhere that happy people have a knack for always looking forward and not dwelling on the mistakes and misdeeds of others. Happy people tend to recall their successes and use them as a springboard to continue forward. I think this is what Albert Schweitzer was getting at when he said, “Happiness is nothing more than good health and a bad memory.” I would add that if we are smart we learn from our mistakes and the injustices we have received, but if we want to be happy, we quickly forget them and move on.

The last nugget about happiness that I discovered was from Matt Richey, who writes for the Motley Fool, a financial Web site. He has observed that “Contentment isn't a feeling or a mood, it is a decision. Only by choosing to be content with what you already have can you accomplish your goals. Without choosing happiness, you will be trapped by an ever-expanding appetite for money and all things it can purchase.”

That's more good news for us—I'm sure few of us have chosen pediatrics because we thought it would be a way to make a fast and easy buck.

Let me ask you a question. Your receptionist receives a call from the mother of a 7-month-old who has been feverish and irritable for 3 days. She is visiting from out of state and staying with a family whose three children have been your patients for 13 years. The mother is “pretty sure” that her insurance will cover an out-of-network visit.

Would your receptionist: (a) schedule an appointment, (b) ask you if it is okay to book the appointment and then warn the mother that she will have to pay at the time of the visit, or (c) suggest that the family take the child to the emergency department?

What would your answer be if the scenario included that this child from out of town also was the niece of one of your nurses?

I ask this question because the issue of how one manages visiting families comes up almost weekly in our office. Because our license plates here in Maine include the slogan “Vacationland” and because Brunswick sits on the shores of scenic Casco Bay, we have lots of visitors.

Our policy has always been to find an appointment slot for someone who tells us they are visiting from out of town regardless of whether they have been referred by a family that we know. I hope that the bulk of our motivation is just old-fashioned New England hospitality. But, a lot of it is just habit. In the not-so-good old days before there were such things as emergency department physicians, we were going to end up seeing the patients from out of town anyway. And it was usually more convenient for us to have them come to our office.

Even when staffed with well-trained physicians, an emergency department is usually not the optimal diagnostic or therapeutic setting for a moderately ill young child or infant. And most families who are accustomed to good office care at a medical home know this.

Although it's hard for me to imagine why anyone who lives in Vacationland would want to travel out of state, from time to time it does happen. And, when our patients' families return we occasionally hear horror stories of their attempts to find pediatric care. I recently had a mother tell me that a referral from a current patient and an offer to pay cash failed to unlock the tightly guarded pediatric office in the suburban community where she was visiting her parents.

I am sure that there are some communities with large transient populations in which our visitor-friendly office policy might be committing economic suicide. And, I suspect that many larger communities have emergency departments that can offer nonurgent pediatric care that would pass my “Is it good enough for my granddaughter?” test.

However, it troubles me to hear how shabbily some of our families are treated when they venture far from their children's medical home.

When we became fellows, the American Academy of Pediatrics didn't ask us to promise that we would see any patient who has a medical home supervised by one of our brother or sister pediatricians. Nor do any of us have written contracts with the families in our practices stating that we will agree to see any child who comes to visit them. But, if you have found yourself in a strange town with a sick child as I have, you know what you should do when a distraught mother visiting from out of town calls your office.

Let me ask you a question. Your receptionist receives a call from the mother of a 7-month-old who has been feverish and irritable for 3 days. She is visiting from out of state and staying with a family whose three children have been your patients for 13 years. The mother is “pretty sure” that her insurance will cover an out-of-network visit.

Would your receptionist: (a) schedule an appointment, (b) ask you if it is okay to book the appointment and then warn the mother that she will have to pay at the time of the visit, or (c) suggest that the family take the child to the emergency department?

What would your answer be if the scenario included that this child from out of town also was the niece of one of your nurses?

I ask this question because the issue of how one manages visiting families comes up almost weekly in our office. Because our license plates here in Maine include the slogan “Vacationland” and because Brunswick sits on the shores of scenic Casco Bay, we have lots of visitors.

Our policy has always been to find an appointment slot for someone who tells us they are visiting from out of town regardless of whether they have been referred by a family that we know. I hope that the bulk of our motivation is just old-fashioned New England hospitality. But, a lot of it is just habit. In the not-so-good old days before there were such things as emergency department physicians, we were going to end up seeing the patients from out of town anyway. And it was usually more convenient for us to have them come to our office.

Even when staffed with well-trained physicians, an emergency department is usually not the optimal diagnostic or therapeutic setting for a moderately ill young child or infant. And most families who are accustomed to good office care at a medical home know this.

Although it's hard for me to imagine why anyone who lives in Vacationland would want to travel out of state, from time to time it does happen. And, when our patients' families return we occasionally hear horror stories of their attempts to find pediatric care. I recently had a mother tell me that a referral from a current patient and an offer to pay cash failed to unlock the tightly guarded pediatric office in the suburban community where she was visiting her parents.

I am sure that there are some communities with large transient populations in which our visitor-friendly office policy might be committing economic suicide. And, I suspect that many larger communities have emergency departments that can offer nonurgent pediatric care that would pass my “Is it good enough for my granddaughter?” test.

However, it troubles me to hear how shabbily some of our families are treated when they venture far from their children's medical home.

When we became fellows, the American Academy of Pediatrics didn't ask us to promise that we would see any patient who has a medical home supervised by one of our brother or sister pediatricians. Nor do any of us have written contracts with the families in our practices stating that we will agree to see any child who comes to visit them. But, if you have found yourself in a strange town with a sick child as I have, you know what you should do when a distraught mother visiting from out of town calls your office.

Let me ask you a question. Your receptionist receives a call from the mother of a 7-month-old who has been feverish and irritable for 3 days. She is visiting from out of state and staying with a family whose three children have been your patients for 13 years. The mother is “pretty sure” that her insurance will cover an out-of-network visit.

Would your receptionist: (a) schedule an appointment, (b) ask you if it is okay to book the appointment and then warn the mother that she will have to pay at the time of the visit, or (c) suggest that the family take the child to the emergency department?

What would your answer be if the scenario included that this child from out of town also was the niece of one of your nurses?

I ask this question because the issue of how one manages visiting families comes up almost weekly in our office. Because our license plates here in Maine include the slogan “Vacationland” and because Brunswick sits on the shores of scenic Casco Bay, we have lots of visitors.

Our policy has always been to find an appointment slot for someone who tells us they are visiting from out of town regardless of whether they have been referred by a family that we know. I hope that the bulk of our motivation is just old-fashioned New England hospitality. But, a lot of it is just habit. In the not-so-good old days before there were such things as emergency department physicians, we were going to end up seeing the patients from out of town anyway. And it was usually more convenient for us to have them come to our office.

Even when staffed with well-trained physicians, an emergency department is usually not the optimal diagnostic or therapeutic setting for a moderately ill young child or infant. And most families who are accustomed to good office care at a medical home know this.

Although it's hard for me to imagine why anyone who lives in Vacationland would want to travel out of state, from time to time it does happen. And, when our patients' families return we occasionally hear horror stories of their attempts to find pediatric care. I recently had a mother tell me that a referral from a current patient and an offer to pay cash failed to unlock the tightly guarded pediatric office in the suburban community where she was visiting her parents.

I am sure that there are some communities with large transient populations in which our visitor-friendly office policy might be committing economic suicide. And, I suspect that many larger communities have emergency departments that can offer nonurgent pediatric care that would pass my “Is it good enough for my granddaughter?” test.

However, it troubles me to hear how shabbily some of our families are treated when they venture far from their children's medical home.

When we became fellows, the American Academy of Pediatrics didn't ask us to promise that we would see any patient who has a medical home supervised by one of our brother or sister pediatricians. Nor do any of us have written contracts with the families in our practices stating that we will agree to see any child who comes to visit them. But, if you have found yourself in a strange town with a sick child as I have, you know what you should do when a distraught mother visiting from out of town calls your office.

I recently stumbled across a reference to the fact that several colleges have felt the need to hire security guards to keep parents out of some freshman orientation activities. In a brief and unsuccessful attempt to find out exactly which colleges these were, I discovered that most other colleges offered flowery invitations to parents of incoming freshman to attend their own parent orientations. I suspect that in most cases these are attempts to distract the parents while the matriculating masses are hustled off to undisclosed locations for the real thing.

Regardless of whether they resort to uniformed guards or poorly disguised diversions, obviously college officials realize that one of their first challenges is to pry apart the Velcro attachments that bind many parents to their nearly adult children. This should not come as a surprise to those of us who practice general pediatrics. But it does represent a significant change in parenting styles over the last half century.

When I was in grade school there were no such things as parent-teacher conferences. Communication between my teacher and my parents consisted of a few handwritten phrases on the bottom of quarterly report cards. No one would have ever imagined that someday parents would receive weekly or even daily electronic reports on their children's activities.

Parents ventured inside schools only when summoned by the principal or the school nurse. If your parent was seen in the school, everyone knew that you had a big problem.

But that was back when a small-screen, black-and-white TV was a luxury few families could afford. Today, parental involvement has become an integral part of almost every school system. Fueled by budgetary shortfalls, volunteerism has been actively promoted and some parents play an important role as teachers' aides and classroom assistants. Many parents spend a half day or more every week in their children's classes.

Volunteering offers parents an opportunity to see exactly what and how their children are being taught. For some parents it is a step in the process of separating that may have been difficult, particularly if they had been practitioners of “attachment parenting.” Some parents have grown to see themselves as a friend and primary playmate for their child. I can imagine that for these parents the chance to spend a few hours in the child's classroom can be comforting.

But, parents volunteering in their children's classrooms can have a dark side. I suspect you have seen it in your own office. In some situations the presence of the child's parent inflames a preexisting classroom behavior problem. In other cases a usually well-behaved child will exhibit an uncharacteristic behavior when his parent is in the class. The child may appear unusually withdrawn and shy or may act out and misbehave.

Another more serious scenario occurs when a child is struggling with separation anxiety or school phobia. For these children, the goodbye at the bus stop in the morning has been a painful parting that they have mastered temporarily. Once in school with the support of a knowledgeable and compassionate teacher, the anxiety has abated. However, the arrival of the parent-volunteer in the classroom later in the morning is likely to fan the fading embers of uncertainty into a raging inferno of separation anxiety.

One of our newest and most difficult challenges as new-millennium pediatricians is to help parents learn to supervise without meddling. As soon as I e-mail this letter to the editor, I'm going to cc it to the school board and suggest that they continue to promote volunteerism. But, tactfully encourage parents to avoid regular assignments to their own children's classes. If I'm successful, maybe one less college will feel the need to call out the troops during freshman orientation.

I recently stumbled across a reference to the fact that several colleges have felt the need to hire security guards to keep parents out of some freshman orientation activities. In a brief and unsuccessful attempt to find out exactly which colleges these were, I discovered that most other colleges offered flowery invitations to parents of incoming freshman to attend their own parent orientations. I suspect that in most cases these are attempts to distract the parents while the matriculating masses are hustled off to undisclosed locations for the real thing.

Regardless of whether they resort to uniformed guards or poorly disguised diversions, obviously college officials realize that one of their first challenges is to pry apart the Velcro attachments that bind many parents to their nearly adult children. This should not come as a surprise to those of us who practice general pediatrics. But it does represent a significant change in parenting styles over the last half century.

When I was in grade school there were no such things as parent-teacher conferences. Communication between my teacher and my parents consisted of a few handwritten phrases on the bottom of quarterly report cards. No one would have ever imagined that someday parents would receive weekly or even daily electronic reports on their children's activities.

Parents ventured inside schools only when summoned by the principal or the school nurse. If your parent was seen in the school, everyone knew that you had a big problem.

But that was back when a small-screen, black-and-white TV was a luxury few families could afford. Today, parental involvement has become an integral part of almost every school system. Fueled by budgetary shortfalls, volunteerism has been actively promoted and some parents play an important role as teachers' aides and classroom assistants. Many parents spend a half day or more every week in their children's classes.

Volunteering offers parents an opportunity to see exactly what and how their children are being taught. For some parents it is a step in the process of separating that may have been difficult, particularly if they had been practitioners of “attachment parenting.” Some parents have grown to see themselves as a friend and primary playmate for their child. I can imagine that for these parents the chance to spend a few hours in the child's classroom can be comforting.

But, parents volunteering in their children's classrooms can have a dark side. I suspect you have seen it in your own office. In some situations the presence of the child's parent inflames a preexisting classroom behavior problem. In other cases a usually well-behaved child will exhibit an uncharacteristic behavior when his parent is in the class. The child may appear unusually withdrawn and shy or may act out and misbehave.

Another more serious scenario occurs when a child is struggling with separation anxiety or school phobia. For these children, the goodbye at the bus stop in the morning has been a painful parting that they have mastered temporarily. Once in school with the support of a knowledgeable and compassionate teacher, the anxiety has abated. However, the arrival of the parent-volunteer in the classroom later in the morning is likely to fan the fading embers of uncertainty into a raging inferno of separation anxiety.

One of our newest and most difficult challenges as new-millennium pediatricians is to help parents learn to supervise without meddling. As soon as I e-mail this letter to the editor, I'm going to cc it to the school board and suggest that they continue to promote volunteerism. But, tactfully encourage parents to avoid regular assignments to their own children's classes. If I'm successful, maybe one less college will feel the need to call out the troops during freshman orientation.

I recently stumbled across a reference to the fact that several colleges have felt the need to hire security guards to keep parents out of some freshman orientation activities. In a brief and unsuccessful attempt to find out exactly which colleges these were, I discovered that most other colleges offered flowery invitations to parents of incoming freshman to attend their own parent orientations. I suspect that in most cases these are attempts to distract the parents while the matriculating masses are hustled off to undisclosed locations for the real thing.

Regardless of whether they resort to uniformed guards or poorly disguised diversions, obviously college officials realize that one of their first challenges is to pry apart the Velcro attachments that bind many parents to their nearly adult children. This should not come as a surprise to those of us who practice general pediatrics. But it does represent a significant change in parenting styles over the last half century.

When I was in grade school there were no such things as parent-teacher conferences. Communication between my teacher and my parents consisted of a few handwritten phrases on the bottom of quarterly report cards. No one would have ever imagined that someday parents would receive weekly or even daily electronic reports on their children's activities.

Parents ventured inside schools only when summoned by the principal or the school nurse. If your parent was seen in the school, everyone knew that you had a big problem.

But that was back when a small-screen, black-and-white TV was a luxury few families could afford. Today, parental involvement has become an integral part of almost every school system. Fueled by budgetary shortfalls, volunteerism has been actively promoted and some parents play an important role as teachers' aides and classroom assistants. Many parents spend a half day or more every week in their children's classes.

Volunteering offers parents an opportunity to see exactly what and how their children are being taught. For some parents it is a step in the process of separating that may have been difficult, particularly if they had been practitioners of “attachment parenting.” Some parents have grown to see themselves as a friend and primary playmate for their child. I can imagine that for these parents the chance to spend a few hours in the child's classroom can be comforting.

But, parents volunteering in their children's classrooms can have a dark side. I suspect you have seen it in your own office. In some situations the presence of the child's parent inflames a preexisting classroom behavior problem. In other cases a usually well-behaved child will exhibit an uncharacteristic behavior when his parent is in the class. The child may appear unusually withdrawn and shy or may act out and misbehave.

Another more serious scenario occurs when a child is struggling with separation anxiety or school phobia. For these children, the goodbye at the bus stop in the morning has been a painful parting that they have mastered temporarily. Once in school with the support of a knowledgeable and compassionate teacher, the anxiety has abated. However, the arrival of the parent-volunteer in the classroom later in the morning is likely to fan the fading embers of uncertainty into a raging inferno of separation anxiety.

One of our newest and most difficult challenges as new-millennium pediatricians is to help parents learn to supervise without meddling. As soon as I e-mail this letter to the editor, I'm going to cc it to the school board and suggest that they continue to promote volunteerism. But, tactfully encourage parents to avoid regular assignments to their own children's classes. If I'm successful, maybe one less college will feel the need to call out the troops during freshman orientation.

Those of us practicing primary care pediatrics often refer to ourselves as “being in the trenches” or working on the “front lines.” But if one extends this battleground metaphor much further, it's clear that we are very poorly armed warriors indeed. The only standard-issue item we carry that could be construed as a weapon is a thin wooden stick only 6 inches long. It doesn't even have a sharp point. Despite its anemic appearance, a skilled practitioner can use it to pry open clenched teeth and reveal the deep recesses of the human body where lesser mortals fear to venture.

However, the longer I practice pediatrics the less I find that I need to use a tongue depressor as a pry bar. I suspect that my body language skills have improved so that more children are willing to open their mouths and utter a proper “aaahh.” Occasionally, I may need to use a throat stick to coax a tongue or buccal surface out of the way, but for the most part these little strips of birch just accumulate in my shirt pocket and eventually find their way into my sock drawer at home.

They seldom spend more than a few days slumbering in this miniature lumber yard in my bedroom, because tongue depressors have become my first choice for a wide variety of home projects. I use them to mix acrylic paints for my bird carvings, to blend body filler for my old World War II jeep restoration, to shim cranky kitchen drawers, and to scrape the mud off my work boots. Throat sticks are my default choice when my fingers can't do the job alone.

I have become so dependent on tongue depressors that I'm sure when I retire I will continue to make weekly trips back to the office to restock my sock drawer. Obviously, I'll pretend that I'm visiting to renew old acquaintances, but when I leave you can be sure that my pockets will be bulging with a few fistfuls of fresh throat sticks.

Of course, I could always drive up the road a couple of hours to Guilford, Maine, and buy direct from the Puritan Medical Products Company factory. Each year they produce approximately 268,000,000 tongue depressors, which is estimated to be about two-thirds of the American market and would fill quite a few sock drawers. The process requires about 1,400 cords of wood or 778,000 board feet of lumber.

I'm partial to our local Maine product. No wrapping, no flavoring, no logos. Just northern birch milled and sanded by solid men and women who don't need plastic bibs or instructions on a paper placemat when they eat “lobstah.”

But, for the foreseeable future, I'll still be getting my tongue depressors out of the drawers in my exam rooms. I also will continue to write phone numbers on them when I can't find a scrap of paper, and from time to time I will inadvertently insert one of these wooden mnemonics into a child's mouth and then cluelessly toss it into the trash.

Now that everyone from plumbers to drug dealers is carrying beepers and cell phones, a tongue depressor in my shirt pocket remains the only clear badge that identifies me as a physician. And, much to Marilyn's chagrin, I continue to wear one proudly at dinner parties, gallery openings, and concerts. Hey, you never know when you'll need to scrape something smelly off your shoes.

Those of us practicing primary care pediatrics often refer to ourselves as “being in the trenches” or working on the “front lines.” But if one extends this battleground metaphor much further, it's clear that we are very poorly armed warriors indeed. The only standard-issue item we carry that could be construed as a weapon is a thin wooden stick only 6 inches long. It doesn't even have a sharp point. Despite its anemic appearance, a skilled practitioner can use it to pry open clenched teeth and reveal the deep recesses of the human body where lesser mortals fear to venture.

However, the longer I practice pediatrics the less I find that I need to use a tongue depressor as a pry bar. I suspect that my body language skills have improved so that more children are willing to open their mouths and utter a proper “aaahh.” Occasionally, I may need to use a throat stick to coax a tongue or buccal surface out of the way, but for the most part these little strips of birch just accumulate in my shirt pocket and eventually find their way into my sock drawer at home.

They seldom spend more than a few days slumbering in this miniature lumber yard in my bedroom, because tongue depressors have become my first choice for a wide variety of home projects. I use them to mix acrylic paints for my bird carvings, to blend body filler for my old World War II jeep restoration, to shim cranky kitchen drawers, and to scrape the mud off my work boots. Throat sticks are my default choice when my fingers can't do the job alone.

I have become so dependent on tongue depressors that I'm sure when I retire I will continue to make weekly trips back to the office to restock my sock drawer. Obviously, I'll pretend that I'm visiting to renew old acquaintances, but when I leave you can be sure that my pockets will be bulging with a few fistfuls of fresh throat sticks.

Of course, I could always drive up the road a couple of hours to Guilford, Maine, and buy direct from the Puritan Medical Products Company factory. Each year they produce approximately 268,000,000 tongue depressors, which is estimated to be about two-thirds of the American market and would fill quite a few sock drawers. The process requires about 1,400 cords of wood or 778,000 board feet of lumber.

I'm partial to our local Maine product. No wrapping, no flavoring, no logos. Just northern birch milled and sanded by solid men and women who don't need plastic bibs or instructions on a paper placemat when they eat “lobstah.”

But, for the foreseeable future, I'll still be getting my tongue depressors out of the drawers in my exam rooms. I also will continue to write phone numbers on them when I can't find a scrap of paper, and from time to time I will inadvertently insert one of these wooden mnemonics into a child's mouth and then cluelessly toss it into the trash.

Now that everyone from plumbers to drug dealers is carrying beepers and cell phones, a tongue depressor in my shirt pocket remains the only clear badge that identifies me as a physician. And, much to Marilyn's chagrin, I continue to wear one proudly at dinner parties, gallery openings, and concerts. Hey, you never know when you'll need to scrape something smelly off your shoes.

Those of us practicing primary care pediatrics often refer to ourselves as “being in the trenches” or working on the “front lines.” But if one extends this battleground metaphor much further, it's clear that we are very poorly armed warriors indeed. The only standard-issue item we carry that could be construed as a weapon is a thin wooden stick only 6 inches long. It doesn't even have a sharp point. Despite its anemic appearance, a skilled practitioner can use it to pry open clenched teeth and reveal the deep recesses of the human body where lesser mortals fear to venture.

However, the longer I practice pediatrics the less I find that I need to use a tongue depressor as a pry bar. I suspect that my body language skills have improved so that more children are willing to open their mouths and utter a proper “aaahh.” Occasionally, I may need to use a throat stick to coax a tongue or buccal surface out of the way, but for the most part these little strips of birch just accumulate in my shirt pocket and eventually find their way into my sock drawer at home.

They seldom spend more than a few days slumbering in this miniature lumber yard in my bedroom, because tongue depressors have become my first choice for a wide variety of home projects. I use them to mix acrylic paints for my bird carvings, to blend body filler for my old World War II jeep restoration, to shim cranky kitchen drawers, and to scrape the mud off my work boots. Throat sticks are my default choice when my fingers can't do the job alone.

I have become so dependent on tongue depressors that I'm sure when I retire I will continue to make weekly trips back to the office to restock my sock drawer. Obviously, I'll pretend that I'm visiting to renew old acquaintances, but when I leave you can be sure that my pockets will be bulging with a few fistfuls of fresh throat sticks.

Of course, I could always drive up the road a couple of hours to Guilford, Maine, and buy direct from the Puritan Medical Products Company factory. Each year they produce approximately 268,000,000 tongue depressors, which is estimated to be about two-thirds of the American market and would fill quite a few sock drawers. The process requires about 1,400 cords of wood or 778,000 board feet of lumber.

I'm partial to our local Maine product. No wrapping, no flavoring, no logos. Just northern birch milled and sanded by solid men and women who don't need plastic bibs or instructions on a paper placemat when they eat “lobstah.”

But, for the foreseeable future, I'll still be getting my tongue depressors out of the drawers in my exam rooms. I also will continue to write phone numbers on them when I can't find a scrap of paper, and from time to time I will inadvertently insert one of these wooden mnemonics into a child's mouth and then cluelessly toss it into the trash.

Now that everyone from plumbers to drug dealers is carrying beepers and cell phones, a tongue depressor in my shirt pocket remains the only clear badge that identifies me as a physician. And, much to Marilyn's chagrin, I continue to wear one proudly at dinner parties, gallery openings, and concerts. Hey, you never know when you'll need to scrape something smelly off your shoes.

While in the past I have criticized the American Board of Pediatrics for adopting a proctored, closed-book exam format, I remain deeply appreciative of the board's decision to “grandfather” me and excuse me from the burden of recertification.

Although I suspect that the decision is based primarily on the old-dog-new-tricks myth, I hope the board also is giving me some partial credit for maturity. Maturity that might allow me to be trusted to keep my clinical skills current without the threat of recertification. Likewise, I hope that my choice of continuing education activities supports the wisdom of the board's decision.

Although the Bureau of Licensure here in Maine requires me to participate in 50 hours of category I educational experiences each year, it doesn't seem to care whether I am learning anything relevant to my practice. In fact, I am sure the bureau would be ecstatic if I went to Fiji and took a 2-week course in the Cosmetic Botoxification of Septuagenarians.

But, as a conscientious grandfather, I have tried to choose activities that are relevant to my daily clinical challenges. However, I am also a bit of a tightwad and hence don't want to invest much money or time in my continuing education activities. Expensive junkets to beautiful vacation spots to sit inside taking classes that may or may not be well taught have lost their appeal.

Being a rather distractible sort as well, I have learned that I can't tolerate the pain and frustration of being cooped up in a classroom (with or without windows) when I know there are recreational activities waiting outside just a few steps away. The odds that I won't stick around after the first coffee break are too high to make traveling for CME courses worth the time and expense.

The three CME activities I have chosen for myself are cheap, handy, and focused. The backbone of my curriculum is Pediatric Notes, the bimonthly letter founded by the late Dr. Sydney Gellis. In its well-chosen and smoothly written abstracts and commentary, I usually find one or two articles that are very relevant to my clinical situation. The open-book tests at the end of the year aren't painless, but at least I can work at my own pace in the comfort of my favorite rocker.

More painful and less relevant are my monthly copies of the American Academy of Pediatrics' Pediatrics in Review. I know that it is important to refresh the withering roots of my basic science education, but it hurts.

As soon as they arrive, I toss them in an old wooden bucket next to my rocker until it's time to subject myself to the torture of modern air travel. The accumulated Reviews give me something to read during those long airport layovers.

On one hand, I view reading them as a masochistic combination of more pain on top of pain. On the other, I see it as paying my dues for the privilege of bicycling on the quiet country roads of southern France.

The newest addition to my CME curriculum doesn't earn me any reportable credits. But, it is probably the most relevant and the most fun. The class meets once a week on Tuesday, when I have a standing invitation to visit my granddaughter, Hannah, who lives a short 10-minute walk away.

There also are numerous unscheduled seminar and lab sessions that meet throughout the week.

Although I see scores of little children each week in the office, it's been 30 years since I have had the chance to observe an infant in the relaxed atmosphere of a home environment.

Last month I relearned how infants learn to solve the problem of getting small bits of food into their mouths. This week's class is dealing with the advanced infantry crawl.

Because I am still struggling not to impose my parenting philosophy on my son and his wife, class participation is limited to tickling, knee-bouncing, and a wide variety of animal sound imitations. Each session is a wonderful opportunity to see if my timeworn advice to other parents still makes sense. And I've discovered some of it doesn't.

I don't know whether the American Board of Pediatrics would consider the changes I have made in my practice style as the result of my CME sessions with little Hannah to be “evidence based.” But then, I don't really care because I've truly been grandfathered.

While in the past I have criticized the American Board of Pediatrics for adopting a proctored, closed-book exam format, I remain deeply appreciative of the board's decision to “grandfather” me and excuse me from the burden of recertification.

Although I suspect that the decision is based primarily on the old-dog-new-tricks myth, I hope the board also is giving me some partial credit for maturity. Maturity that might allow me to be trusted to keep my clinical skills current without the threat of recertification. Likewise, I hope that my choice of continuing education activities supports the wisdom of the board's decision.

Although the Bureau of Licensure here in Maine requires me to participate in 50 hours of category I educational experiences each year, it doesn't seem to care whether I am learning anything relevant to my practice. In fact, I am sure the bureau would be ecstatic if I went to Fiji and took a 2-week course in the Cosmetic Botoxification of Septuagenarians.

But, as a conscientious grandfather, I have tried to choose activities that are relevant to my daily clinical challenges. However, I am also a bit of a tightwad and hence don't want to invest much money or time in my continuing education activities. Expensive junkets to beautiful vacation spots to sit inside taking classes that may or may not be well taught have lost their appeal.

Being a rather distractible sort as well, I have learned that I can't tolerate the pain and frustration of being cooped up in a classroom (with or without windows) when I know there are recreational activities waiting outside just a few steps away. The odds that I won't stick around after the first coffee break are too high to make traveling for CME courses worth the time and expense.

The three CME activities I have chosen for myself are cheap, handy, and focused. The backbone of my curriculum is Pediatric Notes, the bimonthly letter founded by the late Dr. Sydney Gellis. In its well-chosen and smoothly written abstracts and commentary, I usually find one or two articles that are very relevant to my clinical situation. The open-book tests at the end of the year aren't painless, but at least I can work at my own pace in the comfort of my favorite rocker.

More painful and less relevant are my monthly copies of the American Academy of Pediatrics' Pediatrics in Review. I know that it is important to refresh the withering roots of my basic science education, but it hurts.

As soon as they arrive, I toss them in an old wooden bucket next to my rocker until it's time to subject myself to the torture of modern air travel. The accumulated Reviews give me something to read during those long airport layovers.

On one hand, I view reading them as a masochistic combination of more pain on top of pain. On the other, I see it as paying my dues for the privilege of bicycling on the quiet country roads of southern France.

The newest addition to my CME curriculum doesn't earn me any reportable credits. But, it is probably the most relevant and the most fun. The class meets once a week on Tuesday, when I have a standing invitation to visit my granddaughter, Hannah, who lives a short 10-minute walk away.

There also are numerous unscheduled seminar and lab sessions that meet throughout the week.

Although I see scores of little children each week in the office, it's been 30 years since I have had the chance to observe an infant in the relaxed atmosphere of a home environment.

Last month I relearned how infants learn to solve the problem of getting small bits of food into their mouths. This week's class is dealing with the advanced infantry crawl.

Because I am still struggling not to impose my parenting philosophy on my son and his wife, class participation is limited to tickling, knee-bouncing, and a wide variety of animal sound imitations. Each session is a wonderful opportunity to see if my timeworn advice to other parents still makes sense. And I've discovered some of it doesn't.

I don't know whether the American Board of Pediatrics would consider the changes I have made in my practice style as the result of my CME sessions with little Hannah to be “evidence based.” But then, I don't really care because I've truly been grandfathered.

While in the past I have criticized the American Board of Pediatrics for adopting a proctored, closed-book exam format, I remain deeply appreciative of the board's decision to “grandfather” me and excuse me from the burden of recertification.

Although I suspect that the decision is based primarily on the old-dog-new-tricks myth, I hope the board also is giving me some partial credit for maturity. Maturity that might allow me to be trusted to keep my clinical skills current without the threat of recertification. Likewise, I hope that my choice of continuing education activities supports the wisdom of the board's decision.

Although the Bureau of Licensure here in Maine requires me to participate in 50 hours of category I educational experiences each year, it doesn't seem to care whether I am learning anything relevant to my practice. In fact, I am sure the bureau would be ecstatic if I went to Fiji and took a 2-week course in the Cosmetic Botoxification of Septuagenarians.

But, as a conscientious grandfather, I have tried to choose activities that are relevant to my daily clinical challenges. However, I am also a bit of a tightwad and hence don't want to invest much money or time in my continuing education activities. Expensive junkets to beautiful vacation spots to sit inside taking classes that may or may not be well taught have lost their appeal.

Being a rather distractible sort as well, I have learned that I can't tolerate the pain and frustration of being cooped up in a classroom (with or without windows) when I know there are recreational activities waiting outside just a few steps away. The odds that I won't stick around after the first coffee break are too high to make traveling for CME courses worth the time and expense.

The three CME activities I have chosen for myself are cheap, handy, and focused. The backbone of my curriculum is Pediatric Notes, the bimonthly letter founded by the late Dr. Sydney Gellis. In its well-chosen and smoothly written abstracts and commentary, I usually find one or two articles that are very relevant to my clinical situation. The open-book tests at the end of the year aren't painless, but at least I can work at my own pace in the comfort of my favorite rocker.

More painful and less relevant are my monthly copies of the American Academy of Pediatrics' Pediatrics in Review. I know that it is important to refresh the withering roots of my basic science education, but it hurts.

As soon as they arrive, I toss them in an old wooden bucket next to my rocker until it's time to subject myself to the torture of modern air travel. The accumulated Reviews give me something to read during those long airport layovers.

On one hand, I view reading them as a masochistic combination of more pain on top of pain. On the other, I see it as paying my dues for the privilege of bicycling on the quiet country roads of southern France.

The newest addition to my CME curriculum doesn't earn me any reportable credits. But, it is probably the most relevant and the most fun. The class meets once a week on Tuesday, when I have a standing invitation to visit my granddaughter, Hannah, who lives a short 10-minute walk away.

There also are numerous unscheduled seminar and lab sessions that meet throughout the week.

Although I see scores of little children each week in the office, it's been 30 years since I have had the chance to observe an infant in the relaxed atmosphere of a home environment.

Last month I relearned how infants learn to solve the problem of getting small bits of food into their mouths. This week's class is dealing with the advanced infantry crawl.

Because I am still struggling not to impose my parenting philosophy on my son and his wife, class participation is limited to tickling, knee-bouncing, and a wide variety of animal sound imitations. Each session is a wonderful opportunity to see if my timeworn advice to other parents still makes sense. And I've discovered some of it doesn't.

I don't know whether the American Board of Pediatrics would consider the changes I have made in my practice style as the result of my CME sessions with little Hannah to be “evidence based.” But then, I don't really care because I've truly been grandfathered.