Letters

Another heretic

I could not agree more with Dr. William G. Wilkoff’s Letters From Maine column entitled "Heresy" (November 2013, p. 14) that suggests that pediatricians should drop doing well-child exams on healthy school-age children! Having been at this for about 30 years, I can well remember not seeing older kids for 3 or 4 years at a stretch. There were a number of reasons for this: 1) They were perfectly healthy; 2) The parents had to pay for the visit (i.e., there was some disincentive to unnecessary utilization of medical services); 3) Schools did not require a form for every sneeze, fever, or sports activity; 4) The insurance companies were not telling us how to practice medicine.

What I don’t remember is any major medical problems that I discovered on these episodic well visits.

Currently, our office is engaged in a major campaign to bring in every adolescent who is "behind" in his or her yearly physical, because we are not meeting the insurance companies’ "quality metrics" and are thus missing uncaptured revenue. It seems as if every time I have a break in my 10-minute per sick patient schedule, I am asked if I can "squeeze in" another physical.

Worse yet, we have just added 1-month and 2-1/2 year physicals (after deciding many years back that they really were unnecessary), again for the same reasons!

Alas, I must ask you not to use my name, as my employer does not like squeaky wheels, but I do feel much better after whining to someone other than my wife. (Just don’t ask me how I feel about the indignities I just endured taking my recertification exam at a secured and proctored testing center.)

Anyway, thanks for articulating so many issues that are relevant to we "real" pediatricians.

Anonymous

I disagree

With all due respect for Dr. Wilkoff’s emeritus status, I politely disagree that pediatricians should not do routine physical exams on healthy older children. Gestalt: An integrated entity where the sum is greater than the added individual parts. That is what regular annual physical exams for older children represent to me. After 29-plus years of pediatric practice, it is hard for me to believe that school-based health care alone can uniformly provide equivalent evaluations on older children and teens. Yes, they can do hypertension and body mass index screenings. Yes, school nurses are an integral part of pediatric care, identifying children who need further evaluations and treatments, but they have distinctive educational and experience-based limitations. We diminish our profession when we degrade the importance of the annual pediatric exam.

So you may ask me, what more can the pediatrician provide? How about:

• Providing age-based anticipatory guidance.

• Providing the most up-to-date immunization information and discussions in our immunization-adverse society.

• Clarifying for families the frequent misinformation presented by television, the Internet, and social media.

• Assessing teen, social, and behavioral issues for children and families. (Example: More than 50% of initial attention-deficit/hyperactivity disorder inquiries in my practice come at a routine well-child visit.)

• Assessing risk factors and counseling for cardiovascular and other adult diseases.

• Assessing psychological issues for at-risk children.

• Providing continuity of care and identifying family issues.

• Assisting families by accessing comprehensive community resources when needed.

• Providing transition counseling for older teens as they enter college or the workforce.

Of course, all of this cannot be done at one well visit, but over the course of multiple annual exams, pediatricians can provide superior continuity of care. Perhaps I am a glutton for punishment. While some may groan as the summer approaches, I look forward to physical exams and touching base with my older patients. Fully 40%-50% of older children or teens with no identifiable issues at initial intake for a physical exam will have additional diagnoses at checkout. This occurs based only on simple questions and conversations during the exam. This is the gestalt of good pediatric care. So no, Dr. Wilkoff, your suggestion is not heresy, it is just not smart!

Ivri K. Messinger, D.O.

San Marcos, Tex.

Count me in

Count me a fellow heretic! I completely agree that my healthy school-age patients would thrive just as well without their annual well-child visits with me! Of course, we all enjoy maintaining the relationship with our families, and the visits are well reimbursed, but is there really any medical benefit?

I think not.

Vaccines and appropriate screening could be performed by registered nurses, freeing up slots for the pediatricians to see kids currently running to the urgent care centers.

My partners may consider excommunicating me, but I agree with you!

Preston Herrington, M.D.

Farmington, N.M.

Annual checkup is essential

I am a pediatrician in Brookline, Mass., and have been in practice for 18 years. I am a huge fan of your column. While I completely agree that at first glance, the annual pediatric checkup doesn’t seem to add much to our patients’ health, I believe it is essential. It is part of the process of building a relationship so that when those angst-filled teen years come along, the patients feel as if you have known them forever. And perhaps they will tell you their concerns before they admit them to any other adult. Or that’s the hope, anyway.

I think if kids viewed their doctor only as "the strep throat person," it would diminish the role we play in their lives, and quite frankly, vice versa.

Susan Laster, M.D.

Brookline, Mass.

Fostering better relations

Let me start by saying I am a fan of your column, and have been for years. I am a (slightly) younger than you (based on your updated photo) general pediatrician, and I generally agree with your homespun, sensible advice regarding patients, practice, and pediatrics. I have to disagree with your column on reassessing the value of well visits for older well children.

I certainly don’t find a lot of earth-shattering exam findings at these visits (although there are some rare surprises that need to be dealt with). I think the benefit of these appointments is found in the myriad of questions and concerns a parent has about raising their child in this modern era. I think that gentle reassurance from me that a mother is handling behavioral/school/social media situations properly, or (hopefully) gentle prodding from me if mom is off base, is valuable, even to the parents of the healthiest child. I always have tried to maintain all well-child visits with my own patients – I practice in a midsize (nine-provider) group.

I think that over time, the better a family gets to know me as I help them with little problems, the more likely they are to follow my advice when bigger problems crop up. Time constraints will always be with us, but I don’t think giving up on the "well visits" is the right way to grease the wheel.

Tim Welby, M.D.

Dickson City, Pa.

Pediatrician as preventative

I usually agree with your Letters from Maine column, but I don’t agree with your latest one entitled "Heresy." I certainly agree with you that TV, the Internet, and social media sites are powerful communicators to children, and that is exactly why I strongly disagree with your position.

The pediatrician can and must be a source of correct advice and information, and is in the best position to counteract a lot of false information the child may be receiving. As pediatricians, we are in the prevention business, and the annual checkup is when we can best do our work, and is probably the only time.

Certainly the preteen and teen years must be carefully monitored. Doing away with the yearly visits would only lead to disaster.

Alvin N. Eden, M.D.

Forest Hills, N.Y.

Mostly agree

I truly appreciate your broaching this topic of "heresy," particularly in your neck of the woods where the stakes have been quite high.

That being said, I do agree with you for the most part. I have been doing my pediatric thing in Michigan for 38 years, and have probably come up with as many startling findings on a well-child exam after age 5 years as you have. It is also true (like it or not) that our newly acquired "business model" mentality drains significant time and energy out of all of us, and our lives can be much better spent not doing well exams in the well population.

However, I still worry about kids in their latency period, because I believe that still waters run deep. I hate it when someone shows up at age 15 with a significant drug problem who has not seen us for 5 years.

I strongly believe these kids should not be shelved. Their psychosocial development is important and can be addressed, as it is in just about every other country, by physician extenders. As issues of "turf" are well ingrained in us, who controls this (health department, practice) could be a topic for another Letter from Maine.

Arthur N. Feinberg, M.D.

Department of Pediatrics

Western Michigan University School of Medicine

Kalamazoo

Most schools not adequate

Dr. Wilkoff suggests in his column "Heresy" that we outsource well-check measurements and immunizations to schools. Implicit here is an assumption that all school-age children attend a well-funded public school system with adequate resources to take on this project. While Maine school nurses may be well versed in best practices regarding blood pressure cuff size and immunization protocols, our Tennessee school nurses (in my county, 1 registered nurse for 11 county schools) do not have the resources to, say, make sure their school’s vaccine refrigerators have VFC-compliant thermometry.

The nature of any well-designed screening program, by definition, is that the number of normals will substantially exceed the number of abnormals. Checkups are screening visits. "Targeted screening" implies that there is a simple, validated prescreen upon which to apply the second-tier targeted screen. Dr. Wilkoff suggests we use a nonexistent prescreen when he writes, "For the school-age child who is growing well and doesn’t have any chronic conditions or genetic predispositions, do annual physical exams make sense?" How, exactly, will I know which children are growing well and don’t have chronic conditions or genetic predispositions unless I’m doing checkups on them?

Suzanne Berman, M.D.

Crossville, Tenn.

Another heretic

I could not agree more with Dr. William G. Wilkoff’s Letters From Maine column entitled "Heresy" (November 2013, p. 14) that suggests that pediatricians should drop doing well-child exams on healthy school-age children! Having been at this for about 30 years, I can well remember not seeing older kids for 3 or 4 years at a stretch. There were a number of reasons for this: 1) They were perfectly healthy; 2) The parents had to pay for the visit (i.e., there was some disincentive to unnecessary utilization of medical services); 3) Schools did not require a form for every sneeze, fever, or sports activity; 4) The insurance companies were not telling us how to practice medicine.

What I don’t remember is any major medical problems that I discovered on these episodic well visits.

Currently, our office is engaged in a major campaign to bring in every adolescent who is "behind" in his or her yearly physical, because we are not meeting the insurance companies’ "quality metrics" and are thus missing uncaptured revenue. It seems as if every time I have a break in my 10-minute per sick patient schedule, I am asked if I can "squeeze in" another physical.

Worse yet, we have just added 1-month and 2-1/2 year physicals (after deciding many years back that they really were unnecessary), again for the same reasons!

Alas, I must ask you not to use my name, as my employer does not like squeaky wheels, but I do feel much better after whining to someone other than my wife. (Just don’t ask me how I feel about the indignities I just endured taking my recertification exam at a secured and proctored testing center.)

Anyway, thanks for articulating so many issues that are relevant to we "real" pediatricians.

Anonymous

I disagree

With all due respect for Dr. Wilkoff’s emeritus status, I politely disagree that pediatricians should not do routine physical exams on healthy older children. Gestalt: An integrated entity where the sum is greater than the added individual parts. That is what regular annual physical exams for older children represent to me. After 29-plus years of pediatric practice, it is hard for me to believe that school-based health care alone can uniformly provide equivalent evaluations on older children and teens. Yes, they can do hypertension and body mass index screenings. Yes, school nurses are an integral part of pediatric care, identifying children who need further evaluations and treatments, but they have distinctive educational and experience-based limitations. We diminish our profession when we degrade the importance of the annual pediatric exam.

So you may ask me, what more can the pediatrician provide? How about:

• Providing age-based anticipatory guidance.

• Providing the most up-to-date immunization information and discussions in our immunization-adverse society.

• Clarifying for families the frequent misinformation presented by television, the Internet, and social media.

• Assessing teen, social, and behavioral issues for children and families. (Example: More than 50% of initial attention-deficit/hyperactivity disorder inquiries in my practice come at a routine well-child visit.)

• Assessing risk factors and counseling for cardiovascular and other adult diseases.

• Assessing psychological issues for at-risk children.

• Providing continuity of care and identifying family issues.

• Assisting families by accessing comprehensive community resources when needed.

• Providing transition counseling for older teens as they enter college or the workforce.

Of course, all of this cannot be done at one well visit, but over the course of multiple annual exams, pediatricians can provide superior continuity of care. Perhaps I am a glutton for punishment. While some may groan as the summer approaches, I look forward to physical exams and touching base with my older patients. Fully 40%-50% of older children or teens with no identifiable issues at initial intake for a physical exam will have additional diagnoses at checkout. This occurs based only on simple questions and conversations during the exam. This is the gestalt of good pediatric care. So no, Dr. Wilkoff, your suggestion is not heresy, it is just not smart!

Ivri K. Messinger, D.O.

San Marcos, Tex.

Count me in

Count me a fellow heretic! I completely agree that my healthy school-age patients would thrive just as well without their annual well-child visits with me! Of course, we all enjoy maintaining the relationship with our families, and the visits are well reimbursed, but is there really any medical benefit?

I think not.

Vaccines and appropriate screening could be performed by registered nurses, freeing up slots for the pediatricians to see kids currently running to the urgent care centers.

My partners may consider excommunicating me, but I agree with you!

Preston Herrington, M.D.

Farmington, N.M.

Annual checkup is essential

I am a pediatrician in Brookline, Mass., and have been in practice for 18 years. I am a huge fan of your column. While I completely agree that at first glance, the annual pediatric checkup doesn’t seem to add much to our patients’ health, I believe it is essential. It is part of the process of building a relationship so that when those angst-filled teen years come along, the patients feel as if you have known them forever. And perhaps they will tell you their concerns before they admit them to any other adult. Or that’s the hope, anyway.

I think if kids viewed their doctor only as "the strep throat person," it would diminish the role we play in their lives, and quite frankly, vice versa.

Susan Laster, M.D.

Brookline, Mass.

Fostering better relations

Let me start by saying I am a fan of your column, and have been for years. I am a (slightly) younger than you (based on your updated photo) general pediatrician, and I generally agree with your homespun, sensible advice regarding patients, practice, and pediatrics. I have to disagree with your column on reassessing the value of well visits for older well children.

I certainly don’t find a lot of earth-shattering exam findings at these visits (although there are some rare surprises that need to be dealt with). I think the benefit of these appointments is found in the myriad of questions and concerns a parent has about raising their child in this modern era. I think that gentle reassurance from me that a mother is handling behavioral/school/social media situations properly, or (hopefully) gentle prodding from me if mom is off base, is valuable, even to the parents of the healthiest child. I always have tried to maintain all well-child visits with my own patients – I practice in a midsize (nine-provider) group.

I think that over time, the better a family gets to know me as I help them with little problems, the more likely they are to follow my advice when bigger problems crop up. Time constraints will always be with us, but I don’t think giving up on the "well visits" is the right way to grease the wheel.

Tim Welby, M.D.

Dickson City, Pa.

Pediatrician as preventative

I usually agree with your Letters from Maine column, but I don’t agree with your latest one entitled "Heresy." I certainly agree with you that TV, the Internet, and social media sites are powerful communicators to children, and that is exactly why I strongly disagree with your position.

The pediatrician can and must be a source of correct advice and information, and is in the best position to counteract a lot of false information the child may be receiving. As pediatricians, we are in the prevention business, and the annual checkup is when we can best do our work, and is probably the only time.

Certainly the preteen and teen years must be carefully monitored. Doing away with the yearly visits would only lead to disaster.

Alvin N. Eden, M.D.

Forest Hills, N.Y.

Mostly agree

I truly appreciate your broaching this topic of "heresy," particularly in your neck of the woods where the stakes have been quite high.

That being said, I do agree with you for the most part. I have been doing my pediatric thing in Michigan for 38 years, and have probably come up with as many startling findings on a well-child exam after age 5 years as you have. It is also true (like it or not) that our newly acquired "business model" mentality drains significant time and energy out of all of us, and our lives can be much better spent not doing well exams in the well population.

However, I still worry about kids in their latency period, because I believe that still waters run deep. I hate it when someone shows up at age 15 with a significant drug problem who has not seen us for 5 years.

I strongly believe these kids should not be shelved. Their psychosocial development is important and can be addressed, as it is in just about every other country, by physician extenders. As issues of "turf" are well ingrained in us, who controls this (health department, practice) could be a topic for another Letter from Maine.

Arthur N. Feinberg, M.D.

Department of Pediatrics

Western Michigan University School of Medicine

Kalamazoo

Most schools not adequate

Dr. Wilkoff suggests in his column "Heresy" that we outsource well-check measurements and immunizations to schools. Implicit here is an assumption that all school-age children attend a well-funded public school system with adequate resources to take on this project. While Maine school nurses may be well versed in best practices regarding blood pressure cuff size and immunization protocols, our Tennessee school nurses (in my county, 1 registered nurse for 11 county schools) do not have the resources to, say, make sure their school’s vaccine refrigerators have VFC-compliant thermometry.

The nature of any well-designed screening program, by definition, is that the number of normals will substantially exceed the number of abnormals. Checkups are screening visits. "Targeted screening" implies that there is a simple, validated prescreen upon which to apply the second-tier targeted screen. Dr. Wilkoff suggests we use a nonexistent prescreen when he writes, "For the school-age child who is growing well and doesn’t have any chronic conditions or genetic predispositions, do annual physical exams make sense?" How, exactly, will I know which children are growing well and don’t have chronic conditions or genetic predispositions unless I’m doing checkups on them?

Suzanne Berman, M.D.

Crossville, Tenn.

Another heretic

I could not agree more with Dr. William G. Wilkoff’s Letters From Maine column entitled "Heresy" (November 2013, p. 14) that suggests that pediatricians should drop doing well-child exams on healthy school-age children! Having been at this for about 30 years, I can well remember not seeing older kids for 3 or 4 years at a stretch. There were a number of reasons for this: 1) They were perfectly healthy; 2) The parents had to pay for the visit (i.e., there was some disincentive to unnecessary utilization of medical services); 3) Schools did not require a form for every sneeze, fever, or sports activity; 4) The insurance companies were not telling us how to practice medicine.

What I don’t remember is any major medical problems that I discovered on these episodic well visits.

Currently, our office is engaged in a major campaign to bring in every adolescent who is "behind" in his or her yearly physical, because we are not meeting the insurance companies’ "quality metrics" and are thus missing uncaptured revenue. It seems as if every time I have a break in my 10-minute per sick patient schedule, I am asked if I can "squeeze in" another physical.

Worse yet, we have just added 1-month and 2-1/2 year physicals (after deciding many years back that they really were unnecessary), again for the same reasons!

Alas, I must ask you not to use my name, as my employer does not like squeaky wheels, but I do feel much better after whining to someone other than my wife. (Just don’t ask me how I feel about the indignities I just endured taking my recertification exam at a secured and proctored testing center.)

Anyway, thanks for articulating so many issues that are relevant to we "real" pediatricians.

Anonymous

I disagree

With all due respect for Dr. Wilkoff’s emeritus status, I politely disagree that pediatricians should not do routine physical exams on healthy older children. Gestalt: An integrated entity where the sum is greater than the added individual parts. That is what regular annual physical exams for older children represent to me. After 29-plus years of pediatric practice, it is hard for me to believe that school-based health care alone can uniformly provide equivalent evaluations on older children and teens. Yes, they can do hypertension and body mass index screenings. Yes, school nurses are an integral part of pediatric care, identifying children who need further evaluations and treatments, but they have distinctive educational and experience-based limitations. We diminish our profession when we degrade the importance of the annual pediatric exam.

So you may ask me, what more can the pediatrician provide? How about:

• Providing age-based anticipatory guidance.

• Providing the most up-to-date immunization information and discussions in our immunization-adverse society.

• Clarifying for families the frequent misinformation presented by television, the Internet, and social media.

• Assessing teen, social, and behavioral issues for children and families. (Example: More than 50% of initial attention-deficit/hyperactivity disorder inquiries in my practice come at a routine well-child visit.)

• Assessing risk factors and counseling for cardiovascular and other adult diseases.

• Assessing psychological issues for at-risk children.

• Providing continuity of care and identifying family issues.

• Assisting families by accessing comprehensive community resources when needed.

• Providing transition counseling for older teens as they enter college or the workforce.

Of course, all of this cannot be done at one well visit, but over the course of multiple annual exams, pediatricians can provide superior continuity of care. Perhaps I am a glutton for punishment. While some may groan as the summer approaches, I look forward to physical exams and touching base with my older patients. Fully 40%-50% of older children or teens with no identifiable issues at initial intake for a physical exam will have additional diagnoses at checkout. This occurs based only on simple questions and conversations during the exam. This is the gestalt of good pediatric care. So no, Dr. Wilkoff, your suggestion is not heresy, it is just not smart!

Ivri K. Messinger, D.O.

San Marcos, Tex.

Count me in

Count me a fellow heretic! I completely agree that my healthy school-age patients would thrive just as well without their annual well-child visits with me! Of course, we all enjoy maintaining the relationship with our families, and the visits are well reimbursed, but is there really any medical benefit?

I think not.

Vaccines and appropriate screening could be performed by registered nurses, freeing up slots for the pediatricians to see kids currently running to the urgent care centers.

My partners may consider excommunicating me, but I agree with you!

Preston Herrington, M.D.

Farmington, N.M.

Annual checkup is essential

I am a pediatrician in Brookline, Mass., and have been in practice for 18 years. I am a huge fan of your column. While I completely agree that at first glance, the annual pediatric checkup doesn’t seem to add much to our patients’ health, I believe it is essential. It is part of the process of building a relationship so that when those angst-filled teen years come along, the patients feel as if you have known them forever. And perhaps they will tell you their concerns before they admit them to any other adult. Or that’s the hope, anyway.

I think if kids viewed their doctor only as "the strep throat person," it would diminish the role we play in their lives, and quite frankly, vice versa.

Susan Laster, M.D.

Brookline, Mass.

Fostering better relations

Let me start by saying I am a fan of your column, and have been for years. I am a (slightly) younger than you (based on your updated photo) general pediatrician, and I generally agree with your homespun, sensible advice regarding patients, practice, and pediatrics. I have to disagree with your column on reassessing the value of well visits for older well children.

I certainly don’t find a lot of earth-shattering exam findings at these visits (although there are some rare surprises that need to be dealt with). I think the benefit of these appointments is found in the myriad of questions and concerns a parent has about raising their child in this modern era. I think that gentle reassurance from me that a mother is handling behavioral/school/social media situations properly, or (hopefully) gentle prodding from me if mom is off base, is valuable, even to the parents of the healthiest child. I always have tried to maintain all well-child visits with my own patients – I practice in a midsize (nine-provider) group.

I think that over time, the better a family gets to know me as I help them with little problems, the more likely they are to follow my advice when bigger problems crop up. Time constraints will always be with us, but I don’t think giving up on the "well visits" is the right way to grease the wheel.

Tim Welby, M.D.

Dickson City, Pa.

Pediatrician as preventative

I usually agree with your Letters from Maine column, but I don’t agree with your latest one entitled "Heresy." I certainly agree with you that TV, the Internet, and social media sites are powerful communicators to children, and that is exactly why I strongly disagree with your position.

The pediatrician can and must be a source of correct advice and information, and is in the best position to counteract a lot of false information the child may be receiving. As pediatricians, we are in the prevention business, and the annual checkup is when we can best do our work, and is probably the only time.

Certainly the preteen and teen years must be carefully monitored. Doing away with the yearly visits would only lead to disaster.

Alvin N. Eden, M.D.

Forest Hills, N.Y.

Mostly agree

I truly appreciate your broaching this topic of "heresy," particularly in your neck of the woods where the stakes have been quite high.

That being said, I do agree with you for the most part. I have been doing my pediatric thing in Michigan for 38 years, and have probably come up with as many startling findings on a well-child exam after age 5 years as you have. It is also true (like it or not) that our newly acquired "business model" mentality drains significant time and energy out of all of us, and our lives can be much better spent not doing well exams in the well population.

However, I still worry about kids in their latency period, because I believe that still waters run deep. I hate it when someone shows up at age 15 with a significant drug problem who has not seen us for 5 years.

I strongly believe these kids should not be shelved. Their psychosocial development is important and can be addressed, as it is in just about every other country, by physician extenders. As issues of "turf" are well ingrained in us, who controls this (health department, practice) could be a topic for another Letter from Maine.

Arthur N. Feinberg, M.D.

Department of Pediatrics

Western Michigan University School of Medicine

Kalamazoo

Most schools not adequate

Dr. Wilkoff suggests in his column "Heresy" that we outsource well-check measurements and immunizations to schools. Implicit here is an assumption that all school-age children attend a well-funded public school system with adequate resources to take on this project. While Maine school nurses may be well versed in best practices regarding blood pressure cuff size and immunization protocols, our Tennessee school nurses (in my county, 1 registered nurse for 11 county schools) do not have the resources to, say, make sure their school’s vaccine refrigerators have VFC-compliant thermometry.

The nature of any well-designed screening program, by definition, is that the number of normals will substantially exceed the number of abnormals. Checkups are screening visits. "Targeted screening" implies that there is a simple, validated prescreen upon which to apply the second-tier targeted screen. Dr. Wilkoff suggests we use a nonexistent prescreen when he writes, "For the school-age child who is growing well and doesn’t have any chronic conditions or genetic predispositions, do annual physical exams make sense?" How, exactly, will I know which children are growing well and don’t have chronic conditions or genetic predispositions unless I’m doing checkups on them?

Suzanne Berman, M.D.

Crossville, Tenn.