Your 2 Cents' Worth

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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