Letters from Maine

Are you happy with your current situation? Do you enjoy your job and look forward to getting home at the end of the day? Or, do you find your work unrewarding? Do you consider your home simply a place to wait impatiently until you can hop on a plane for your next getaway vacation?

wellesenterprises/Getty Images

Maybe you should consider relocating to Montana. According to the headline in an article by Richard Franki in Pediatric News (“Montana named ‘best state to practice medicine’ in 2019,” Mar. 28, 2019) the Treasure State is currently the best state to practice medicine. Big Sky Country earned this distinction by outdistancing 49 states and Washington, D.C., in a ranking by WalletHub. The personal finance website used 18 metrics ranging from average annual wage adjusted for cost of living to malpractice award payment per capita. One category of metrics grouped data related to “competition and opportunity” and the other “medical environment.”

I suspect that you are as skeptical as I am of surveys that claim to rank complex entities across broad geographic landscapes. I hope you are neither depressed or elated when your alma mater moves three positions on U.S. News and World Report’s ranking of colleges and universities. However, there are a few pearls hidden in this WalletHub attempt at choosing the most physician-friendly states.

New York was again ranked the worst state to practice medicine, a distinction it had “earned” in 2017 with a highest cost of malpractice insurance. This consistency suggests that there is a litigious atmosphere, at least in some parts of New York, that could make forging a trusting doctor-patient relationship difficult. Heading off to work each morning under the dark cloud of malpractice must take a lot of the fun out of practicing medicine.

The other interesting association buried in the ranking is that Montana is at the top of the list because it also was the state with the highest percentage of “medical residents retained.” This concurrence suggests that living and working in Big Sky Country provided a balance that young physicians found not just tolerable but so enjoyable they wanted to stay. I have been unable to find a complete listing of the raw data, but I suspect that Maine also could boast a high percentage of medical residents who choose to remain at the end of their training. It has been and continues to be a wonderful place to live and raise a family.

While there may be days when you feel as though the practice of medicine has consumed your every waking moment, the truth is that there is more to life than being a physician. Of course, one must be able to earn enough to support oneself and family, but this survey that purports to rank the best place to practice is too heavily weighted to the financial side of the equation and ignores the more difficult to quantify lifestyle qualities.

You may have found a position that pays well enough but requires a time-gobbling and stress-inducing commute to a place you feel comfortable living. Or, you may like your work, but find the community where you have settled lacks the suite of recreational and/or cultural opportunities you enjoy. Finding a place that offers the best mix of lifestyle and professional rewards that fits your wants and needs can be a matter of luck. Not everyone gets it right the first time. Sometimes it is a matter of making compromises and then continuing to reassess whether these compromises have been the best ones.

Regardless of its ranking on any survey, every state has multiple communities in which a physician can have a satisfying career and a lifestyle he or she enjoys. However, achieving this balanced mix may require the physician to invest something of him or herself into making that community one that feels like home.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Are you happy with your current situation? Do you enjoy your job and look forward to getting home at the end of the day? Or, do you find your work unrewarding? Do you consider your home simply a place to wait impatiently until you can hop on a plane for your next getaway vacation?

wellesenterprises/Getty Images

Maybe you should consider relocating to Montana. According to the headline in an article by Richard Franki in Pediatric News (“Montana named ‘best state to practice medicine’ in 2019,” Mar. 28, 2019) the Treasure State is currently the best state to practice medicine. Big Sky Country earned this distinction by outdistancing 49 states and Washington, D.C., in a ranking by WalletHub. The personal finance website used 18 metrics ranging from average annual wage adjusted for cost of living to malpractice award payment per capita. One category of metrics grouped data related to “competition and opportunity” and the other “medical environment.”

I suspect that you are as skeptical as I am of surveys that claim to rank complex entities across broad geographic landscapes. I hope you are neither depressed or elated when your alma mater moves three positions on U.S. News and World Report’s ranking of colleges and universities. However, there are a few pearls hidden in this WalletHub attempt at choosing the most physician-friendly states.

New York was again ranked the worst state to practice medicine, a distinction it had “earned” in 2017 with a highest cost of malpractice insurance. This consistency suggests that there is a litigious atmosphere, at least in some parts of New York, that could make forging a trusting doctor-patient relationship difficult. Heading off to work each morning under the dark cloud of malpractice must take a lot of the fun out of practicing medicine.

The other interesting association buried in the ranking is that Montana is at the top of the list because it also was the state with the highest percentage of “medical residents retained.” This concurrence suggests that living and working in Big Sky Country provided a balance that young physicians found not just tolerable but so enjoyable they wanted to stay. I have been unable to find a complete listing of the raw data, but I suspect that Maine also could boast a high percentage of medical residents who choose to remain at the end of their training. It has been and continues to be a wonderful place to live and raise a family.

While there may be days when you feel as though the practice of medicine has consumed your every waking moment, the truth is that there is more to life than being a physician. Of course, one must be able to earn enough to support oneself and family, but this survey that purports to rank the best place to practice is too heavily weighted to the financial side of the equation and ignores the more difficult to quantify lifestyle qualities.

You may have found a position that pays well enough but requires a time-gobbling and stress-inducing commute to a place you feel comfortable living. Or, you may like your work, but find the community where you have settled lacks the suite of recreational and/or cultural opportunities you enjoy. Finding a place that offers the best mix of lifestyle and professional rewards that fits your wants and needs can be a matter of luck. Not everyone gets it right the first time. Sometimes it is a matter of making compromises and then continuing to reassess whether these compromises have been the best ones.

Regardless of its ranking on any survey, every state has multiple communities in which a physician can have a satisfying career and a lifestyle he or she enjoys. However, achieving this balanced mix may require the physician to invest something of him or herself into making that community one that feels like home.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Are you happy with your current situation? Do you enjoy your job and look forward to getting home at the end of the day? Or, do you find your work unrewarding? Do you consider your home simply a place to wait impatiently until you can hop on a plane for your next getaway vacation?

wellesenterprises/Getty Images

Maybe you should consider relocating to Montana. According to the headline in an article by Richard Franki in Pediatric News (“Montana named ‘best state to practice medicine’ in 2019,” Mar. 28, 2019) the Treasure State is currently the best state to practice medicine. Big Sky Country earned this distinction by outdistancing 49 states and Washington, D.C., in a ranking by WalletHub. The personal finance website used 18 metrics ranging from average annual wage adjusted for cost of living to malpractice award payment per capita. One category of metrics grouped data related to “competition and opportunity” and the other “medical environment.”

I suspect that you are as skeptical as I am of surveys that claim to rank complex entities across broad geographic landscapes. I hope you are neither depressed or elated when your alma mater moves three positions on U.S. News and World Report’s ranking of colleges and universities. However, there are a few pearls hidden in this WalletHub attempt at choosing the most physician-friendly states.

New York was again ranked the worst state to practice medicine, a distinction it had “earned” in 2017 with a highest cost of malpractice insurance. This consistency suggests that there is a litigious atmosphere, at least in some parts of New York, that could make forging a trusting doctor-patient relationship difficult. Heading off to work each morning under the dark cloud of malpractice must take a lot of the fun out of practicing medicine.

The other interesting association buried in the ranking is that Montana is at the top of the list because it also was the state with the highest percentage of “medical residents retained.” This concurrence suggests that living and working in Big Sky Country provided a balance that young physicians found not just tolerable but so enjoyable they wanted to stay. I have been unable to find a complete listing of the raw data, but I suspect that Maine also could boast a high percentage of medical residents who choose to remain at the end of their training. It has been and continues to be a wonderful place to live and raise a family.

While there may be days when you feel as though the practice of medicine has consumed your every waking moment, the truth is that there is more to life than being a physician. Of course, one must be able to earn enough to support oneself and family, but this survey that purports to rank the best place to practice is too heavily weighted to the financial side of the equation and ignores the more difficult to quantify lifestyle qualities.

You may have found a position that pays well enough but requires a time-gobbling and stress-inducing commute to a place you feel comfortable living. Or, you may like your work, but find the community where you have settled lacks the suite of recreational and/or cultural opportunities you enjoy. Finding a place that offers the best mix of lifestyle and professional rewards that fits your wants and needs can be a matter of luck. Not everyone gets it right the first time. Sometimes it is a matter of making compromises and then continuing to reassess whether these compromises have been the best ones.

Regardless of its ranking on any survey, every state has multiple communities in which a physician can have a satisfying career and a lifestyle he or she enjoys. However, achieving this balanced mix may require the physician to invest something of him or herself into making that community one that feels like home.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

In a previous Letter from Maine I wrote about a study performed in China in which more than half a million patients were diagnosed by an artificial intelligence (A.I.) system that was able to extract and analyze information from their electronic medical records. The system was at least as accurate as physicians who had access to the same data (“A.I. Shows Promise Assisting Physicians,” by Cade Metz, The New York Times, Feb. 11, 2019). I ended my column with the hopeful assumption that despite incredible advances in A.I., the practice of medicine always would include a human element. However, I left unexplained exactly how physicians would fit into the post-A.I. revolution. In the weeks since I submitted that column, I have been searching for roles that might remain for physicians after A.I. has snatched their bread and butter of diagnosis and management.

gpointstudio/Thinkstock

I discovered there always will be a need be someone in the health care delivery system to serve as a communicator and translator for the patient. I easily can envision a system in which the patient enters her chief complaint and current symptoms into her smartphone or tablet. Using its database of the patient’s past, family, and social history, the system generates a list of laboratory and imaging studies, some of which the patient may be able to submit directly from her handheld device. For example, the system may be able to use the patient’s phone to “examine” her. The A.I. system then generates a diagnosis.

If the diagnosed condition and management is simple and straightforward, such as a rash, the information could be communicated to the patient directly, with a short paragraph of explanation and list of persistent symptoms that would indicate that the condition was not improving as expected. A contact dermatitis comes to mind here.

However, suppose the A.I. system determines that the patient has a 90% chance of having stage IV pancreatic cancer, with a life expectancy of 6 months. Is this the kind of information you would like to learn about yourself by clicking “Your Diagnosis” box on your phone while you were having lunch with a friend? Obviously, a diagnosis of this severity should be communicated human to human, even though it was generated by a highly accurate computer system. And this communication would best be done in the form of a dialogue with someone who knows the patient and has some understanding of how she might understand and cope with the information. In the absence of a prior relationship, the dialogue should occur in real time and face to face at a minimum. I guess we have to acknowledge that FaceTime or Skype might be acceptable here.

Fortunately, stage IV cancers are rare, but there are a bazillion other conditions that, while not serious, require a nuanced explanation as part of a successful management plan that takes into account the patient’s level of anxiety and cognitive abilities. A boilerplate paragraph or two spit out by an A.I. system isn’t good health care. Although I know many physicians do rely on printed handouts for conditions they feel is a no-brainer.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

In a previous Letter from Maine I wrote about a study performed in China in which more than half a million patients were diagnosed by an artificial intelligence (A.I.) system that was able to extract and analyze information from their electronic medical records. The system was at least as accurate as physicians who had access to the same data (“A.I. Shows Promise Assisting Physicians,” by Cade Metz, The New York Times, Feb. 11, 2019). I ended my column with the hopeful assumption that despite incredible advances in A.I., the practice of medicine always would include a human element. However, I left unexplained exactly how physicians would fit into the post-A.I. revolution. In the weeks since I submitted that column, I have been searching for roles that might remain for physicians after A.I. has snatched their bread and butter of diagnosis and management.

gpointstudio/Thinkstock

I discovered there always will be a need be someone in the health care delivery system to serve as a communicator and translator for the patient. I easily can envision a system in which the patient enters her chief complaint and current symptoms into her smartphone or tablet. Using its database of the patient’s past, family, and social history, the system generates a list of laboratory and imaging studies, some of which the patient may be able to submit directly from her handheld device. For example, the system may be able to use the patient’s phone to “examine” her. The A.I. system then generates a diagnosis.

If the diagnosed condition and management is simple and straightforward, such as a rash, the information could be communicated to the patient directly, with a short paragraph of explanation and list of persistent symptoms that would indicate that the condition was not improving as expected. A contact dermatitis comes to mind here.

However, suppose the A.I. system determines that the patient has a 90% chance of having stage IV pancreatic cancer, with a life expectancy of 6 months. Is this the kind of information you would like to learn about yourself by clicking “Your Diagnosis” box on your phone while you were having lunch with a friend? Obviously, a diagnosis of this severity should be communicated human to human, even though it was generated by a highly accurate computer system. And this communication would best be done in the form of a dialogue with someone who knows the patient and has some understanding of how she might understand and cope with the information. In the absence of a prior relationship, the dialogue should occur in real time and face to face at a minimum. I guess we have to acknowledge that FaceTime or Skype might be acceptable here.

Fortunately, stage IV cancers are rare, but there are a bazillion other conditions that, while not serious, require a nuanced explanation as part of a successful management plan that takes into account the patient’s level of anxiety and cognitive abilities. A boilerplate paragraph or two spit out by an A.I. system isn’t good health care. Although I know many physicians do rely on printed handouts for conditions they feel is a no-brainer.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

In a previous Letter from Maine I wrote about a study performed in China in which more than half a million patients were diagnosed by an artificial intelligence (A.I.) system that was able to extract and analyze information from their electronic medical records. The system was at least as accurate as physicians who had access to the same data (“A.I. Shows Promise Assisting Physicians,” by Cade Metz, The New York Times, Feb. 11, 2019). I ended my column with the hopeful assumption that despite incredible advances in A.I., the practice of medicine always would include a human element. However, I left unexplained exactly how physicians would fit into the post-A.I. revolution. In the weeks since I submitted that column, I have been searching for roles that might remain for physicians after A.I. has snatched their bread and butter of diagnosis and management.

gpointstudio/Thinkstock

I discovered there always will be a need be someone in the health care delivery system to serve as a communicator and translator for the patient. I easily can envision a system in which the patient enters her chief complaint and current symptoms into her smartphone or tablet. Using its database of the patient’s past, family, and social history, the system generates a list of laboratory and imaging studies, some of which the patient may be able to submit directly from her handheld device. For example, the system may be able to use the patient’s phone to “examine” her. The A.I. system then generates a diagnosis.

If the diagnosed condition and management is simple and straightforward, such as a rash, the information could be communicated to the patient directly, with a short paragraph of explanation and list of persistent symptoms that would indicate that the condition was not improving as expected. A contact dermatitis comes to mind here.

However, suppose the A.I. system determines that the patient has a 90% chance of having stage IV pancreatic cancer, with a life expectancy of 6 months. Is this the kind of information you would like to learn about yourself by clicking “Your Diagnosis” box on your phone while you were having lunch with a friend? Obviously, a diagnosis of this severity should be communicated human to human, even though it was generated by a highly accurate computer system. And this communication would best be done in the form of a dialogue with someone who knows the patient and has some understanding of how she might understand and cope with the information. In the absence of a prior relationship, the dialogue should occur in real time and face to face at a minimum. I guess we have to acknowledge that FaceTime or Skype might be acceptable here.

Fortunately, stage IV cancers are rare, but there are a bazillion other conditions that, while not serious, require a nuanced explanation as part of a successful management plan that takes into account the patient’s level of anxiety and cognitive abilities. A boilerplate paragraph or two spit out by an A.I. system isn’t good health care. Although I know many physicians do rely on printed handouts for conditions they feel is a no-brainer.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Study results showing an association between active atopic dermatitis (AD) and poor sleep quality were published in JAMA Pediatrics by a group of dermatologists at the University of California, San Francisco (JAMA Pediatr. 2019 Mar 4. doi: 10.1001/jamapediatrics.2019.0025). The data on the sleep quality and quantity of nearly 14,000 children were collected over span of 11 years. Of these children, slightly fewer than 5,000 met the researchers’ definition of atopic dermatitis.

deyangeorgiev/thinkstockphotos.com

Although the sleep duration of children with and without AD was not statistically different, the reports of poor sleep quality and sleep disturbances by children with AD were dramatically more frequent – a nearly 50% higher chance of having more sleep-quality disturbances. In addition, children with more severe active disease were even more likely to report poor sleep quality – almost 80%.

I suspect that you’re not surprised by these findings. You have probably heard numerous tales of poor sleep from families who have children with AD. It just makes sense that a child whose skin is dry and itchy will have trouble sleeping. I’m sure you have struggled to help parents be more diligent about applying moisturizing creams and lotions, and have been aggressive with steroid creams during flare-ups. You may have added sleep onset-promoting antihistamines when topical treatments haven’t been as effective as you had hoped.

Has your working assumption always been that if you can get the child’s skin settled down, the itching will improve and the child will have an easier time falling asleep? But have you ever considered flipping the equation over and tried to be more aggressive in managing the child’s sleep problems? Maybe if the child had healthier sleep habits and ended his day with a smaller sleep debt, he could more successfully resist the urge to scratch.

Like many other folks with psoriasis, I have noticed that my itching is worse when I am tired, and particularly worse in that evil interval between crawling into bed and falling asleep. As the grandparent of a child with AD, I have observed a similar phenomenon. While I am not going to claim that sleep deprivation causes psoriasis or AD, I think that we need to consider the association between poor sleep quality and itching as a feedback loop that must be interrupted. This means that in addition to recommending topicals and moisturizing strategies, we must learn more about our patients’ sleep habits and suggest appropriate sleep hygiene practices.

Many parents aren’t aware of the cruel paradox that an overtired child is more likely to have trouble falling asleep. Has the child been allowed to give up his nap prematurely? Is bedtime at an appropriate hour, and does it consist of a limited number of sleep-promoting rituals? Is the bedroom dark enough, cool enough, and free of electronic distractions?

Providing effective counseling on sleep hygiene is time consuming and requires that you have first convinced the parents that the child’s itching is being aggravated by his sleep deprivation and not just the other way around. Successful management may require a close working relationship between the child’s pediatrician and his dermatologist, with both physicians reinforcing each other’s message that atopic dermatitis isn’t just skin deep.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Is My Child Overtired?: The Sleep Solution for Raising Happier, Healthier Children.” Email him at [email protected].

Study results showing an association between active atopic dermatitis (AD) and poor sleep quality were published in JAMA Pediatrics by a group of dermatologists at the University of California, San Francisco (JAMA Pediatr. 2019 Mar 4. doi: 10.1001/jamapediatrics.2019.0025). The data on the sleep quality and quantity of nearly 14,000 children were collected over span of 11 years. Of these children, slightly fewer than 5,000 met the researchers’ definition of atopic dermatitis.

deyangeorgiev/thinkstockphotos.com

Although the sleep duration of children with and without AD was not statistically different, the reports of poor sleep quality and sleep disturbances by children with AD were dramatically more frequent – a nearly 50% higher chance of having more sleep-quality disturbances. In addition, children with more severe active disease were even more likely to report poor sleep quality – almost 80%.

I suspect that you’re not surprised by these findings. You have probably heard numerous tales of poor sleep from families who have children with AD. It just makes sense that a child whose skin is dry and itchy will have trouble sleeping. I’m sure you have struggled to help parents be more diligent about applying moisturizing creams and lotions, and have been aggressive with steroid creams during flare-ups. You may have added sleep onset-promoting antihistamines when topical treatments haven’t been as effective as you had hoped.

Has your working assumption always been that if you can get the child’s skin settled down, the itching will improve and the child will have an easier time falling asleep? But have you ever considered flipping the equation over and tried to be more aggressive in managing the child’s sleep problems? Maybe if the child had healthier sleep habits and ended his day with a smaller sleep debt, he could more successfully resist the urge to scratch.

Like many other folks with psoriasis, I have noticed that my itching is worse when I am tired, and particularly worse in that evil interval between crawling into bed and falling asleep. As the grandparent of a child with AD, I have observed a similar phenomenon. While I am not going to claim that sleep deprivation causes psoriasis or AD, I think that we need to consider the association between poor sleep quality and itching as a feedback loop that must be interrupted. This means that in addition to recommending topicals and moisturizing strategies, we must learn more about our patients’ sleep habits and suggest appropriate sleep hygiene practices.

Many parents aren’t aware of the cruel paradox that an overtired child is more likely to have trouble falling asleep. Has the child been allowed to give up his nap prematurely? Is bedtime at an appropriate hour, and does it consist of a limited number of sleep-promoting rituals? Is the bedroom dark enough, cool enough, and free of electronic distractions?

Providing effective counseling on sleep hygiene is time consuming and requires that you have first convinced the parents that the child’s itching is being aggravated by his sleep deprivation and not just the other way around. Successful management may require a close working relationship between the child’s pediatrician and his dermatologist, with both physicians reinforcing each other’s message that atopic dermatitis isn’t just skin deep.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Is My Child Overtired?: The Sleep Solution for Raising Happier, Healthier Children.” Email him at [email protected].

Study results showing an association between active atopic dermatitis (AD) and poor sleep quality were published in JAMA Pediatrics by a group of dermatologists at the University of California, San Francisco (JAMA Pediatr. 2019 Mar 4. doi: 10.1001/jamapediatrics.2019.0025). The data on the sleep quality and quantity of nearly 14,000 children were collected over span of 11 years. Of these children, slightly fewer than 5,000 met the researchers’ definition of atopic dermatitis.

deyangeorgiev/thinkstockphotos.com

Although the sleep duration of children with and without AD was not statistically different, the reports of poor sleep quality and sleep disturbances by children with AD were dramatically more frequent – a nearly 50% higher chance of having more sleep-quality disturbances. In addition, children with more severe active disease were even more likely to report poor sleep quality – almost 80%.

I suspect that you’re not surprised by these findings. You have probably heard numerous tales of poor sleep from families who have children with AD. It just makes sense that a child whose skin is dry and itchy will have trouble sleeping. I’m sure you have struggled to help parents be more diligent about applying moisturizing creams and lotions, and have been aggressive with steroid creams during flare-ups. You may have added sleep onset-promoting antihistamines when topical treatments haven’t been as effective as you had hoped.

Has your working assumption always been that if you can get the child’s skin settled down, the itching will improve and the child will have an easier time falling asleep? But have you ever considered flipping the equation over and tried to be more aggressive in managing the child’s sleep problems? Maybe if the child had healthier sleep habits and ended his day with a smaller sleep debt, he could more successfully resist the urge to scratch.

Like many other folks with psoriasis, I have noticed that my itching is worse when I am tired, and particularly worse in that evil interval between crawling into bed and falling asleep. As the grandparent of a child with AD, I have observed a similar phenomenon. While I am not going to claim that sleep deprivation causes psoriasis or AD, I think that we need to consider the association between poor sleep quality and itching as a feedback loop that must be interrupted. This means that in addition to recommending topicals and moisturizing strategies, we must learn more about our patients’ sleep habits and suggest appropriate sleep hygiene practices.

Many parents aren’t aware of the cruel paradox that an overtired child is more likely to have trouble falling asleep. Has the child been allowed to give up his nap prematurely? Is bedtime at an appropriate hour, and does it consist of a limited number of sleep-promoting rituals? Is the bedroom dark enough, cool enough, and free of electronic distractions?

Providing effective counseling on sleep hygiene is time consuming and requires that you have first convinced the parents that the child’s itching is being aggravated by his sleep deprivation and not just the other way around. Successful management may require a close working relationship between the child’s pediatrician and his dermatologist, with both physicians reinforcing each other’s message that atopic dermatitis isn’t just skin deep.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Is My Child Overtired?: The Sleep Solution for Raising Happier, Healthier Children.” Email him at [email protected].

There is a good chance that your car is equipped with a backup camera. It also may have sensors that alert you when there is another vehicle in one of your blind spots. These wonders of modern technology simply are vision enhancers much like an x-ray or an ultrasound. The sensors merely collect visual data, but the decision of what should be done with this additional information is up to you, just as you decide how to respond to your patient’s lab work and imaging studies.

Andrea Danti/Thinkstock

If you have more disposable income than I do, you may have a vehicle that not only gathers information but also makes decisions based on what it senses by slowing down, applying the brakes, or adjusting the steering. My friends who own these semi-autonomous cars generally have given these control systems positive grades once they have experienced a few events in which the vehicle took over in what it considered a dangerous situation. However, even my friends who are fans of their semi-autonomous cars are uncomfortable about the widespread introduction of fully autonomous vehicles.

The practice of medicine is riding the crest of this same wave of artificial intelligence that promises, or some might say threatens, to remove humans from the driver’s seat (“A.I. Shows Promise Assisting Physicians,” by Cade Metz, The New York Times, Feb. 11, 2019). As reported in the New York Times, a team of physicians has created a system capable of making diagnoses based on a “neural network” that uses complex computer algorithms to learn by analyzing extremely large amounts of data. Once this system had been “taught” to identify certain medical conditions in EMRs, the team tasked the system with analyzing the records of nearly 600,000 patients at a women and children’s hospital in southern China. The investigators claim that the system was able to diagnose asthma with more than 90% accuracy, while physicians can diagnose with an accuracy of 80%-94%, and the system diagnosed gastrointestinal disease with 87% accuracy, well within the physicians’ accuracy range of 82%-90%.

Does this apparent success for A.I. mean that not only will you be vacating your place behind the wheel of your car, but also taking down your shingle and hanging up your stethoscope? Before you rush out and sign up for a federally-funded retraining program, you should remember that this study was done in China, where the privacy laws are somewhat skimpy and the data more voluminous by several scales of magnitude than here. Replicating their results and scaling a similar A.I. neural network to the United States health care system will be difficult in the short term. However, this report should serve as wake-up call to those of you who believe that making diagnoses is at the core of what makes you a physician. If sorting through pages of data to arrive at an explanation for your patients’ complaints is the intellectual challenge that keeps the practice of medicine fresh and exciting, you may want to start looking for other sources of mental stimulation.

A.I. isn’t going to replace the primary care physician. There still will need to be someone available at the initial point of contact who can do a physical exam, take, or at least review, the patient’s history, and then order the lab work and imaging studies that the A.I. system will use to make the diagnosis. In other words, the physician will be primarily responsible for data collection. You may feel that you are almost there already. 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

There is a good chance that your car is equipped with a backup camera. It also may have sensors that alert you when there is another vehicle in one of your blind spots. These wonders of modern technology simply are vision enhancers much like an x-ray or an ultrasound. The sensors merely collect visual data, but the decision of what should be done with this additional information is up to you, just as you decide how to respond to your patient’s lab work and imaging studies.

Andrea Danti/Thinkstock

If you have more disposable income than I do, you may have a vehicle that not only gathers information but also makes decisions based on what it senses by slowing down, applying the brakes, or adjusting the steering. My friends who own these semi-autonomous cars generally have given these control systems positive grades once they have experienced a few events in which the vehicle took over in what it considered a dangerous situation. However, even my friends who are fans of their semi-autonomous cars are uncomfortable about the widespread introduction of fully autonomous vehicles.

The practice of medicine is riding the crest of this same wave of artificial intelligence that promises, or some might say threatens, to remove humans from the driver’s seat (“A.I. Shows Promise Assisting Physicians,” by Cade Metz, The New York Times, Feb. 11, 2019). As reported in the New York Times, a team of physicians has created a system capable of making diagnoses based on a “neural network” that uses complex computer algorithms to learn by analyzing extremely large amounts of data. Once this system had been “taught” to identify certain medical conditions in EMRs, the team tasked the system with analyzing the records of nearly 600,000 patients at a women and children’s hospital in southern China. The investigators claim that the system was able to diagnose asthma with more than 90% accuracy, while physicians can diagnose with an accuracy of 80%-94%, and the system diagnosed gastrointestinal disease with 87% accuracy, well within the physicians’ accuracy range of 82%-90%.

Does this apparent success for A.I. mean that not only will you be vacating your place behind the wheel of your car, but also taking down your shingle and hanging up your stethoscope? Before you rush out and sign up for a federally-funded retraining program, you should remember that this study was done in China, where the privacy laws are somewhat skimpy and the data more voluminous by several scales of magnitude than here. Replicating their results and scaling a similar A.I. neural network to the United States health care system will be difficult in the short term. However, this report should serve as wake-up call to those of you who believe that making diagnoses is at the core of what makes you a physician. If sorting through pages of data to arrive at an explanation for your patients’ complaints is the intellectual challenge that keeps the practice of medicine fresh and exciting, you may want to start looking for other sources of mental stimulation.

A.I. isn’t going to replace the primary care physician. There still will need to be someone available at the initial point of contact who can do a physical exam, take, or at least review, the patient’s history, and then order the lab work and imaging studies that the A.I. system will use to make the diagnosis. In other words, the physician will be primarily responsible for data collection. You may feel that you are almost there already. 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

There is a good chance that your car is equipped with a backup camera. It also may have sensors that alert you when there is another vehicle in one of your blind spots. These wonders of modern technology simply are vision enhancers much like an x-ray or an ultrasound. The sensors merely collect visual data, but the decision of what should be done with this additional information is up to you, just as you decide how to respond to your patient’s lab work and imaging studies.

Andrea Danti/Thinkstock

If you have more disposable income than I do, you may have a vehicle that not only gathers information but also makes decisions based on what it senses by slowing down, applying the brakes, or adjusting the steering. My friends who own these semi-autonomous cars generally have given these control systems positive grades once they have experienced a few events in which the vehicle took over in what it considered a dangerous situation. However, even my friends who are fans of their semi-autonomous cars are uncomfortable about the widespread introduction of fully autonomous vehicles.

The practice of medicine is riding the crest of this same wave of artificial intelligence that promises, or some might say threatens, to remove humans from the driver’s seat (“A.I. Shows Promise Assisting Physicians,” by Cade Metz, The New York Times, Feb. 11, 2019). As reported in the New York Times, a team of physicians has created a system capable of making diagnoses based on a “neural network” that uses complex computer algorithms to learn by analyzing extremely large amounts of data. Once this system had been “taught” to identify certain medical conditions in EMRs, the team tasked the system with analyzing the records of nearly 600,000 patients at a women and children’s hospital in southern China. The investigators claim that the system was able to diagnose asthma with more than 90% accuracy, while physicians can diagnose with an accuracy of 80%-94%, and the system diagnosed gastrointestinal disease with 87% accuracy, well within the physicians’ accuracy range of 82%-90%.

Does this apparent success for A.I. mean that not only will you be vacating your place behind the wheel of your car, but also taking down your shingle and hanging up your stethoscope? Before you rush out and sign up for a federally-funded retraining program, you should remember that this study was done in China, where the privacy laws are somewhat skimpy and the data more voluminous by several scales of magnitude than here. Replicating their results and scaling a similar A.I. neural network to the United States health care system will be difficult in the short term. However, this report should serve as wake-up call to those of you who believe that making diagnoses is at the core of what makes you a physician. If sorting through pages of data to arrive at an explanation for your patients’ complaints is the intellectual challenge that keeps the practice of medicine fresh and exciting, you may want to start looking for other sources of mental stimulation.

A.I. isn’t going to replace the primary care physician. There still will need to be someone available at the initial point of contact who can do a physical exam, take, or at least review, the patient’s history, and then order the lab work and imaging studies that the A.I. system will use to make the diagnosis. In other words, the physician will be primarily responsible for data collection. You may feel that you are almost there already. 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

As reported in the Wall Street Journal, the current administration has proposed a suite of initiatives that could improve patients’ access to their health data, including doctors’ and hospitals’ electronic records as well as insurance claim information (“Rules to Ease Patient Access to Health Data Are Proposed,” by Anna Wilde Mathews, Feb. 11, 2019). One of the draft rules would mandate new technology standards that allow health information data to flow seamlessly between providers and hospitals using different electronic systems, a step that should have been taken well before the federal government began cajoling physicians into adopting not-ready-for-prime-time EMR systems and rewarding their “meaningful use.” Other rules are aimed at discouraging the patient-unfriendly practice of delaying and charging for the transfer of medical records.

pandpstock001/ThinkStock.com

Apple already has begun research and development on systems and tools that would allow patients to receive and store their health information on their smart phones and tablets. Arriving at the ED or a consulting physician, the patient would need only unlock his or her device to share his or her medical record.

These proposals are long overdue and in the long run should save providers and patients time and expense. As long as they also include rules mandating true transparency in hospital billing, these initiatives appear to be heading us in the right direction.

Are you prepared to deal with transparency when it comes to your medical records? Do you create your office notes with the assumption that your patient will be reading them? Seventy-five years ago, physicians, many of whom were in solo practice, scrawled their notes as simple mnemonics. They could barely decipher their own scribbles. If they needed to share information with a consultant, it was with a phone call or dictated letter. You probably are more aware of creating a readable note because you rely on covering physicians ... and you know that the folks who pay you will be auditing your charts.

Depending on your patient mix, most of the notes you generate probably don’t contain many observations that you are hesitant to share with the patient. If you haven’t already discussed his body mass index with the patient you have described as “obese,” you aren’t doing your job. However, occasionally there are topics that have arisen in the family and social history that may not be pertinent to the patient’s current problem, but provide a more nuanced picture of her and serve as a mnemonic at a later visit. Will the patient mind if you include these tidbits in an electronic record that may be shared by a wide audience outside the confines of your exam room?

How do you deal with situations like this when the threat of transparency could interfere with our relationship with our patients? You could ask the patient, “ Do you mind if I include that event you just told me, in your EMR?” You could create a “shadow record” that includes information the patient prefers not to be shared and your own observations that you don’t feel comfortable sharing with the patient. Is this “shadow record” something electronic that could be redacted by simply toggling a clickable box? Or is it an old-fashioned paper note you keep in a separate file in a locked drawer in a file cabinet (if you even have a file cabinet)? I fear the lawyers would have something to say about both those options. The best solution may simply be to rely on your memory. If you have so many patients that you can’t remember those occasional sensitive issues that have been shared with you, then maybe you have too many patients.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” Email him at [email protected].

As reported in the Wall Street Journal, the current administration has proposed a suite of initiatives that could improve patients’ access to their health data, including doctors’ and hospitals’ electronic records as well as insurance claim information (“Rules to Ease Patient Access to Health Data Are Proposed,” by Anna Wilde Mathews, Feb. 11, 2019). One of the draft rules would mandate new technology standards that allow health information data to flow seamlessly between providers and hospitals using different electronic systems, a step that should have been taken well before the federal government began cajoling physicians into adopting not-ready-for-prime-time EMR systems and rewarding their “meaningful use.” Other rules are aimed at discouraging the patient-unfriendly practice of delaying and charging for the transfer of medical records.

pandpstock001/ThinkStock.com

Apple already has begun research and development on systems and tools that would allow patients to receive and store their health information on their smart phones and tablets. Arriving at the ED or a consulting physician, the patient would need only unlock his or her device to share his or her medical record.

These proposals are long overdue and in the long run should save providers and patients time and expense. As long as they also include rules mandating true transparency in hospital billing, these initiatives appear to be heading us in the right direction.

Are you prepared to deal with transparency when it comes to your medical records? Do you create your office notes with the assumption that your patient will be reading them? Seventy-five years ago, physicians, many of whom were in solo practice, scrawled their notes as simple mnemonics. They could barely decipher their own scribbles. If they needed to share information with a consultant, it was with a phone call or dictated letter. You probably are more aware of creating a readable note because you rely on covering physicians ... and you know that the folks who pay you will be auditing your charts.

Depending on your patient mix, most of the notes you generate probably don’t contain many observations that you are hesitant to share with the patient. If you haven’t already discussed his body mass index with the patient you have described as “obese,” you aren’t doing your job. However, occasionally there are topics that have arisen in the family and social history that may not be pertinent to the patient’s current problem, but provide a more nuanced picture of her and serve as a mnemonic at a later visit. Will the patient mind if you include these tidbits in an electronic record that may be shared by a wide audience outside the confines of your exam room?

How do you deal with situations like this when the threat of transparency could interfere with our relationship with our patients? You could ask the patient, “ Do you mind if I include that event you just told me, in your EMR?” You could create a “shadow record” that includes information the patient prefers not to be shared and your own observations that you don’t feel comfortable sharing with the patient. Is this “shadow record” something electronic that could be redacted by simply toggling a clickable box? Or is it an old-fashioned paper note you keep in a separate file in a locked drawer in a file cabinet (if you even have a file cabinet)? I fear the lawyers would have something to say about both those options. The best solution may simply be to rely on your memory. If you have so many patients that you can’t remember those occasional sensitive issues that have been shared with you, then maybe you have too many patients.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” Email him at [email protected].

As reported in the Wall Street Journal, the current administration has proposed a suite of initiatives that could improve patients’ access to their health data, including doctors’ and hospitals’ electronic records as well as insurance claim information (“Rules to Ease Patient Access to Health Data Are Proposed,” by Anna Wilde Mathews, Feb. 11, 2019). One of the draft rules would mandate new technology standards that allow health information data to flow seamlessly between providers and hospitals using different electronic systems, a step that should have been taken well before the federal government began cajoling physicians into adopting not-ready-for-prime-time EMR systems and rewarding their “meaningful use.” Other rules are aimed at discouraging the patient-unfriendly practice of delaying and charging for the transfer of medical records.

pandpstock001/ThinkStock.com

Apple already has begun research and development on systems and tools that would allow patients to receive and store their health information on their smart phones and tablets. Arriving at the ED or a consulting physician, the patient would need only unlock his or her device to share his or her medical record.

These proposals are long overdue and in the long run should save providers and patients time and expense. As long as they also include rules mandating true transparency in hospital billing, these initiatives appear to be heading us in the right direction.

Are you prepared to deal with transparency when it comes to your medical records? Do you create your office notes with the assumption that your patient will be reading them? Seventy-five years ago, physicians, many of whom were in solo practice, scrawled their notes as simple mnemonics. They could barely decipher their own scribbles. If they needed to share information with a consultant, it was with a phone call or dictated letter. You probably are more aware of creating a readable note because you rely on covering physicians ... and you know that the folks who pay you will be auditing your charts.

Depending on your patient mix, most of the notes you generate probably don’t contain many observations that you are hesitant to share with the patient. If you haven’t already discussed his body mass index with the patient you have described as “obese,” you aren’t doing your job. However, occasionally there are topics that have arisen in the family and social history that may not be pertinent to the patient’s current problem, but provide a more nuanced picture of her and serve as a mnemonic at a later visit. Will the patient mind if you include these tidbits in an electronic record that may be shared by a wide audience outside the confines of your exam room?

How do you deal with situations like this when the threat of transparency could interfere with our relationship with our patients? You could ask the patient, “ Do you mind if I include that event you just told me, in your EMR?” You could create a “shadow record” that includes information the patient prefers not to be shared and your own observations that you don’t feel comfortable sharing with the patient. Is this “shadow record” something electronic that could be redacted by simply toggling a clickable box? Or is it an old-fashioned paper note you keep in a separate file in a locked drawer in a file cabinet (if you even have a file cabinet)? I fear the lawyers would have something to say about both those options. The best solution may simply be to rely on your memory. If you have so many patients that you can’t remember those occasional sensitive issues that have been shared with you, then maybe you have too many patients.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” Email him at [email protected].

On our way up north to go backcountry skiing with another couple, we stopped at a roadside restaurant/tavern for lunch. We seated ourselves and, after a long 10 minutes, our waitperson arrived like a tornado, looking frazzled. She offered an apology and the first installment of her tale of woe. Before taking our order, she explained it all began when her car wouldn’t start, and then her day care provider called to say that she was sick and our server would have to find some other arrangement for the day. When our meal finally arrived, it looked appetizing but didn’t quite match our order. Again, our waitperson apologized, adding that it has been a particularly hard week because her husband was out of town and not around to help with her three children.

track5/Getty Images

Had we been dining at a high-end restaurant with a white tablecloth and a candle, we would have considered our server’s behavior unprofessional and off-putting. However, we were in no hurry as the light snow had turned to a ski-unfriendly drizzle. While our original intent had been to simply have lunch, we accepted our role as a sympathetic audience for this unfortunate woman. In fact, we asked a few open-ended questions to help the cathartic process along.

The need to share one’s troubles seems to be a universal human trait. Our server had no illusions that we were going to provide any solutions to her problems. Nor was she seeking any expression of sympathy beyond our patience. However, I’m sure that unburdening herself by telling the story made her feel better, at least temporarily. Hopefully, there would be additional understanding diners to help her through the day.

For many people, the workplace serves as a therapeutic outlet where they can share their troubles and concerns. At times, the whining can be annoying to coworkers but in general, woe sharing is a harmless and valuable perk of having a job. Unless, of course, one’s job is primarily serving the public.

As physicians we are accustomed listening to our patients’ troubles. However, our job is not one of those that affords much opportunity to unburden ourselves of our own concerns. The patients assume that we are the problem solvers and don’t have any of our own. Or, if we do have some troubles, their office visit is not the time for us to share them.

The occasional sharing, such as that we are running late because we’ve had a flat on the way to the office, is harmless and can remind patients that we are human. But one must be careful stay off the slippery slope that leads to unprofessional oversharing.

Without that luxury of a workplace that allows for occasional catharsis, physicians have an additional risk for burnout. There are no easy solutions. Sharing with patients is unprofessional. Our peers are as busy as we are and probably don’t have the time to listen. Or at least they don’t seem to have the time. And then there is that ego-vulnerability issue where we are hesitant to reveal to anyone, be they staff or peers, that we have a soft underbelly.

I don’t have any easy answers to the problem beyond the usual suggestion that, when your troubles seem overwhelming, find someone with whom you can share your story, such as clergy, counselor, or mental health worker. Personally, I have to admit that, when my bad day was the result of an accumulation of minor bumps, I would follow our waitperson’s example and share them selectively with patients whom I deluded myself into believing had the time and concern to listen. It probably was unprofessional, but it made me feel better.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

On our way up north to go backcountry skiing with another couple, we stopped at a roadside restaurant/tavern for lunch. We seated ourselves and, after a long 10 minutes, our waitperson arrived like a tornado, looking frazzled. She offered an apology and the first installment of her tale of woe. Before taking our order, she explained it all began when her car wouldn’t start, and then her day care provider called to say that she was sick and our server would have to find some other arrangement for the day. When our meal finally arrived, it looked appetizing but didn’t quite match our order. Again, our waitperson apologized, adding that it has been a particularly hard week because her husband was out of town and not around to help with her three children.

track5/Getty Images

Had we been dining at a high-end restaurant with a white tablecloth and a candle, we would have considered our server’s behavior unprofessional and off-putting. However, we were in no hurry as the light snow had turned to a ski-unfriendly drizzle. While our original intent had been to simply have lunch, we accepted our role as a sympathetic audience for this unfortunate woman. In fact, we asked a few open-ended questions to help the cathartic process along.

The need to share one’s troubles seems to be a universal human trait. Our server had no illusions that we were going to provide any solutions to her problems. Nor was she seeking any expression of sympathy beyond our patience. However, I’m sure that unburdening herself by telling the story made her feel better, at least temporarily. Hopefully, there would be additional understanding diners to help her through the day.

For many people, the workplace serves as a therapeutic outlet where they can share their troubles and concerns. At times, the whining can be annoying to coworkers but in general, woe sharing is a harmless and valuable perk of having a job. Unless, of course, one’s job is primarily serving the public.

As physicians we are accustomed listening to our patients’ troubles. However, our job is not one of those that affords much opportunity to unburden ourselves of our own concerns. The patients assume that we are the problem solvers and don’t have any of our own. Or, if we do have some troubles, their office visit is not the time for us to share them.

The occasional sharing, such as that we are running late because we’ve had a flat on the way to the office, is harmless and can remind patients that we are human. But one must be careful stay off the slippery slope that leads to unprofessional oversharing.

Without that luxury of a workplace that allows for occasional catharsis, physicians have an additional risk for burnout. There are no easy solutions. Sharing with patients is unprofessional. Our peers are as busy as we are and probably don’t have the time to listen. Or at least they don’t seem to have the time. And then there is that ego-vulnerability issue where we are hesitant to reveal to anyone, be they staff or peers, that we have a soft underbelly.

I don’t have any easy answers to the problem beyond the usual suggestion that, when your troubles seem overwhelming, find someone with whom you can share your story, such as clergy, counselor, or mental health worker. Personally, I have to admit that, when my bad day was the result of an accumulation of minor bumps, I would follow our waitperson’s example and share them selectively with patients whom I deluded myself into believing had the time and concern to listen. It probably was unprofessional, but it made me feel better.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

On our way up north to go backcountry skiing with another couple, we stopped at a roadside restaurant/tavern for lunch. We seated ourselves and, after a long 10 minutes, our waitperson arrived like a tornado, looking frazzled. She offered an apology and the first installment of her tale of woe. Before taking our order, she explained it all began when her car wouldn’t start, and then her day care provider called to say that she was sick and our server would have to find some other arrangement for the day. When our meal finally arrived, it looked appetizing but didn’t quite match our order. Again, our waitperson apologized, adding that it has been a particularly hard week because her husband was out of town and not around to help with her three children.

track5/Getty Images

Had we been dining at a high-end restaurant with a white tablecloth and a candle, we would have considered our server’s behavior unprofessional and off-putting. However, we were in no hurry as the light snow had turned to a ski-unfriendly drizzle. While our original intent had been to simply have lunch, we accepted our role as a sympathetic audience for this unfortunate woman. In fact, we asked a few open-ended questions to help the cathartic process along.

The need to share one’s troubles seems to be a universal human trait. Our server had no illusions that we were going to provide any solutions to her problems. Nor was she seeking any expression of sympathy beyond our patience. However, I’m sure that unburdening herself by telling the story made her feel better, at least temporarily. Hopefully, there would be additional understanding diners to help her through the day.

For many people, the workplace serves as a therapeutic outlet where they can share their troubles and concerns. At times, the whining can be annoying to coworkers but in general, woe sharing is a harmless and valuable perk of having a job. Unless, of course, one’s job is primarily serving the public.

As physicians we are accustomed listening to our patients’ troubles. However, our job is not one of those that affords much opportunity to unburden ourselves of our own concerns. The patients assume that we are the problem solvers and don’t have any of our own. Or, if we do have some troubles, their office visit is not the time for us to share them.

The occasional sharing, such as that we are running late because we’ve had a flat on the way to the office, is harmless and can remind patients that we are human. But one must be careful stay off the slippery slope that leads to unprofessional oversharing.

Without that luxury of a workplace that allows for occasional catharsis, physicians have an additional risk for burnout. There are no easy solutions. Sharing with patients is unprofessional. Our peers are as busy as we are and probably don’t have the time to listen. Or at least they don’t seem to have the time. And then there is that ego-vulnerability issue where we are hesitant to reveal to anyone, be they staff or peers, that we have a soft underbelly.

I don’t have any easy answers to the problem beyond the usual suggestion that, when your troubles seem overwhelming, find someone with whom you can share your story, such as clergy, counselor, or mental health worker. Personally, I have to admit that, when my bad day was the result of an accumulation of minor bumps, I would follow our waitperson’s example and share them selectively with patients whom I deluded myself into believing had the time and concern to listen. It probably was unprofessional, but it made me feel better.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

If you live in Spokane, Wash., 99213 and 99214 are important numbers. Interchanging the last two digits can send your mail into the Twilight Zone. Otherwise those five digit sequences have little significance to most Americans ... unless of course you are a physician. You have been told multiple times by practice administrators and business consultants that the failure to attach the proper sequence to your bill for services can threaten the sustainability of your practice’s bottom line or put you at risk for a costly fine.

utah778/Thinkstock

Numerical codes for office visits were not handed down on stone tablets. There was a time when a physician simply charged for something he called an “office visit” and about half that for a “short” office visit that took less time and probably nothing for a “quick recheck.” He chose the fees based on what he felt was reasonable. I remember reading of one physician who pegged his charges at a dollar per penny of the cost of a regular postage stamp. For a variety of obvious and some unfortunate reasons, these loosely structured fee structures have disappeared.

Now a physician is asked to justify his or her charges by documenting what transpired during the office visit. The patient always has been the best witness, and at least has some sense of how much work the physician has had to do to arrive at diagnosis and suggest a treatment plan. Because the patient usually was paying the bill and had a personal stake in the value of the services provided, this system seemed to make sense.

However, now some large corporate entity or government agency probably is paying the bill and would like some idea of what it is being billed for. Justifying the service provided now falls on the physician. When the billing codes were first introduced and before the payers became more curious, it was easy. I simply applied 99213 to all my office visits and once or twice a day I would code out a visit that seemed more complex as a 99214. I wasn’t keeping track of how many minutes I spent in each visit, how many questions I asked, or how many body parts I examined. Except for patients with injured extremities, everyone was pretty much getting the same exam. My coding was based on my perception of value and effort. If it took more time than usual to remove a bit of cerumen or reassure an unusually concerned parent I chalked that up as my misfortune, not a reason to code the visit as a 99214. If I felt I needed more money, I assumed that my best option was to see more patients. Neither the patients nor the payers seemed to be complaining.

But obviously somewhere someone felt that there were too many providers gaming the system and there needed to be a better way to assign value to what a physician was doing in his or her examining room. Not surprisingly, the current coding system is flawed. I don’t have a workable alternative. However, I always have felt that if the folks who were paying the bills would come visit my office (unannounced if they wish) and spend a morning watching me see patients, they could more accurately assign a value to my work. I’m not sure how many of you would be comfortable with that degree of transparency. But for me it would be worth it if it freed me from the burden of coding to justify my effort.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

If you live in Spokane, Wash., 99213 and 99214 are important numbers. Interchanging the last two digits can send your mail into the Twilight Zone. Otherwise those five digit sequences have little significance to most Americans ... unless of course you are a physician. You have been told multiple times by practice administrators and business consultants that the failure to attach the proper sequence to your bill for services can threaten the sustainability of your practice’s bottom line or put you at risk for a costly fine.

utah778/Thinkstock

Numerical codes for office visits were not handed down on stone tablets. There was a time when a physician simply charged for something he called an “office visit” and about half that for a “short” office visit that took less time and probably nothing for a “quick recheck.” He chose the fees based on what he felt was reasonable. I remember reading of one physician who pegged his charges at a dollar per penny of the cost of a regular postage stamp. For a variety of obvious and some unfortunate reasons, these loosely structured fee structures have disappeared.

Now a physician is asked to justify his or her charges by documenting what transpired during the office visit. The patient always has been the best witness, and at least has some sense of how much work the physician has had to do to arrive at diagnosis and suggest a treatment plan. Because the patient usually was paying the bill and had a personal stake in the value of the services provided, this system seemed to make sense.

However, now some large corporate entity or government agency probably is paying the bill and would like some idea of what it is being billed for. Justifying the service provided now falls on the physician. When the billing codes were first introduced and before the payers became more curious, it was easy. I simply applied 99213 to all my office visits and once or twice a day I would code out a visit that seemed more complex as a 99214. I wasn’t keeping track of how many minutes I spent in each visit, how many questions I asked, or how many body parts I examined. Except for patients with injured extremities, everyone was pretty much getting the same exam. My coding was based on my perception of value and effort. If it took more time than usual to remove a bit of cerumen or reassure an unusually concerned parent I chalked that up as my misfortune, not a reason to code the visit as a 99214. If I felt I needed more money, I assumed that my best option was to see more patients. Neither the patients nor the payers seemed to be complaining.

But obviously somewhere someone felt that there were too many providers gaming the system and there needed to be a better way to assign value to what a physician was doing in his or her examining room. Not surprisingly, the current coding system is flawed. I don’t have a workable alternative. However, I always have felt that if the folks who were paying the bills would come visit my office (unannounced if they wish) and spend a morning watching me see patients, they could more accurately assign a value to my work. I’m not sure how many of you would be comfortable with that degree of transparency. But for me it would be worth it if it freed me from the burden of coding to justify my effort.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

If you live in Spokane, Wash., 99213 and 99214 are important numbers. Interchanging the last two digits can send your mail into the Twilight Zone. Otherwise those five digit sequences have little significance to most Americans ... unless of course you are a physician. You have been told multiple times by practice administrators and business consultants that the failure to attach the proper sequence to your bill for services can threaten the sustainability of your practice’s bottom line or put you at risk for a costly fine.

utah778/Thinkstock

Numerical codes for office visits were not handed down on stone tablets. There was a time when a physician simply charged for something he called an “office visit” and about half that for a “short” office visit that took less time and probably nothing for a “quick recheck.” He chose the fees based on what he felt was reasonable. I remember reading of one physician who pegged his charges at a dollar per penny of the cost of a regular postage stamp. For a variety of obvious and some unfortunate reasons, these loosely structured fee structures have disappeared.

Now a physician is asked to justify his or her charges by documenting what transpired during the office visit. The patient always has been the best witness, and at least has some sense of how much work the physician has had to do to arrive at diagnosis and suggest a treatment plan. Because the patient usually was paying the bill and had a personal stake in the value of the services provided, this system seemed to make sense.

However, now some large corporate entity or government agency probably is paying the bill and would like some idea of what it is being billed for. Justifying the service provided now falls on the physician. When the billing codes were first introduced and before the payers became more curious, it was easy. I simply applied 99213 to all my office visits and once or twice a day I would code out a visit that seemed more complex as a 99214. I wasn’t keeping track of how many minutes I spent in each visit, how many questions I asked, or how many body parts I examined. Except for patients with injured extremities, everyone was pretty much getting the same exam. My coding was based on my perception of value and effort. If it took more time than usual to remove a bit of cerumen or reassure an unusually concerned parent I chalked that up as my misfortune, not a reason to code the visit as a 99214. If I felt I needed more money, I assumed that my best option was to see more patients. Neither the patients nor the payers seemed to be complaining.

But obviously somewhere someone felt that there were too many providers gaming the system and there needed to be a better way to assign value to what a physician was doing in his or her examining room. Not surprisingly, the current coding system is flawed. I don’t have a workable alternative. However, I always have felt that if the folks who were paying the bills would come visit my office (unannounced if they wish) and spend a morning watching me see patients, they could more accurately assign a value to my work. I’m not sure how many of you would be comfortable with that degree of transparency. But for me it would be worth it if it freed me from the burden of coding to justify my effort.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

One of the common symptoms described by postconcussion patients is that their heads feel a bit foggy. It may not be simply by chance that “foggy” is the best word to describe the atmosphere surrounding the entire field of concussion diagnosis and management.

KatarzynaBialasiewicz/Thinkstock

Back in the Dark Ages, when the diagnosis of concussion was a simpler binary call, the issue of management seldom created much discussion. If the patient lost consciousness or was amnesic, he (it was less frequently she) could return to activity when his headache was gone and he could remember what he was supposed to do when the quarterback called for a “Red 34, Drive Right Smash” play. That may have even been during the second half of the game in which he was injured.

As it became more widely understood that the diagnosis of concussion didn’t require loss of consciousness and that repeated concussions could have serious sequelae, management became a bit fuzzier. No one had thought much about the recuperative process. Into this vacuum came a wide variety of researchers and providers. Concussion management blossomed into a cottage industry, populated by neurologists, orthopedists, trainers, sports medicine specialists, and physical therapists. Not surprisingly, much of their advice was based on unproven assumptions, including the concept of “brain rest.”

It has taken time, but fortunately, folks with patience and wisdom have questioned these assumptions and begun collecting data. The result of these investigations and others has prompted the American Academy of Pediatrics to publish an updated set of guidelines on concussion management that includes the observation that extended school absence may slow the rehabilitation process (Pediatrics. 2018 Dec. doi: 10.1542/peds.2018-3074).

It is becoming clear that management of concussion can be rather complex and must be individualized to each patient. In my experience, the postconcussion period can unmask behavioral, cognitive, and emotional problems that were preexisting but had received little or no attention. For example, the trauma of the event may trigger anxiety about further injury or exacerbate depression that had been building for years. The student who “couldn’t do algebra” following a head injury may have had a lifelong learning disability that had gone unnoticed. The student athlete with prolonged postconcussion symptoms may indeed have another more serious problem. Hopefully, the new guidelines from the AAP will be a first step toward a more thoughtful and scientifically driven approach to concussion management.

It would be nice if that approach could filter down to the management of the more common but less dramatic pediatric injuries. There is hope. Choosing Wisely – a patient/parent–targeted initiative by the American Board of Internal Medicine Foundation in cooperation with the AAP – points out that, although half of the pediatric head injury patients seen in emergency departments received CT scan, only a third of those studies were indicated. Parents are encouraged to learn more about the risks of CT scans and question the physician when one is recommended.

But, doctors’ habits and old wives’ tales die slowly. I hope that you no longer recommend that parents keep their children awake after a head injury, or wake them every hour to check their pupils. Those counterproductive recommendations make about as much sense as staying out of the swimming pool for an hour after eating a chocolate chip cookie.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

One of the common symptoms described by postconcussion patients is that their heads feel a bit foggy. It may not be simply by chance that “foggy” is the best word to describe the atmosphere surrounding the entire field of concussion diagnosis and management.

KatarzynaBialasiewicz/Thinkstock

Back in the Dark Ages, when the diagnosis of concussion was a simpler binary call, the issue of management seldom created much discussion. If the patient lost consciousness or was amnesic, he (it was less frequently she) could return to activity when his headache was gone and he could remember what he was supposed to do when the quarterback called for a “Red 34, Drive Right Smash” play. That may have even been during the second half of the game in which he was injured.

As it became more widely understood that the diagnosis of concussion didn’t require loss of consciousness and that repeated concussions could have serious sequelae, management became a bit fuzzier. No one had thought much about the recuperative process. Into this vacuum came a wide variety of researchers and providers. Concussion management blossomed into a cottage industry, populated by neurologists, orthopedists, trainers, sports medicine specialists, and physical therapists. Not surprisingly, much of their advice was based on unproven assumptions, including the concept of “brain rest.”

It has taken time, but fortunately, folks with patience and wisdom have questioned these assumptions and begun collecting data. The result of these investigations and others has prompted the American Academy of Pediatrics to publish an updated set of guidelines on concussion management that includes the observation that extended school absence may slow the rehabilitation process (Pediatrics. 2018 Dec. doi: 10.1542/peds.2018-3074).

It is becoming clear that management of concussion can be rather complex and must be individualized to each patient. In my experience, the postconcussion period can unmask behavioral, cognitive, and emotional problems that were preexisting but had received little or no attention. For example, the trauma of the event may trigger anxiety about further injury or exacerbate depression that had been building for years. The student who “couldn’t do algebra” following a head injury may have had a lifelong learning disability that had gone unnoticed. The student athlete with prolonged postconcussion symptoms may indeed have another more serious problem. Hopefully, the new guidelines from the AAP will be a first step toward a more thoughtful and scientifically driven approach to concussion management.

It would be nice if that approach could filter down to the management of the more common but less dramatic pediatric injuries. There is hope. Choosing Wisely – a patient/parent–targeted initiative by the American Board of Internal Medicine Foundation in cooperation with the AAP – points out that, although half of the pediatric head injury patients seen in emergency departments received CT scan, only a third of those studies were indicated. Parents are encouraged to learn more about the risks of CT scans and question the physician when one is recommended.

But, doctors’ habits and old wives’ tales die slowly. I hope that you no longer recommend that parents keep their children awake after a head injury, or wake them every hour to check their pupils. Those counterproductive recommendations make about as much sense as staying out of the swimming pool for an hour after eating a chocolate chip cookie.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

One of the common symptoms described by postconcussion patients is that their heads feel a bit foggy. It may not be simply by chance that “foggy” is the best word to describe the atmosphere surrounding the entire field of concussion diagnosis and management.

KatarzynaBialasiewicz/Thinkstock

Back in the Dark Ages, when the diagnosis of concussion was a simpler binary call, the issue of management seldom created much discussion. If the patient lost consciousness or was amnesic, he (it was less frequently she) could return to activity when his headache was gone and he could remember what he was supposed to do when the quarterback called for a “Red 34, Drive Right Smash” play. That may have even been during the second half of the game in which he was injured.

As it became more widely understood that the diagnosis of concussion didn’t require loss of consciousness and that repeated concussions could have serious sequelae, management became a bit fuzzier. No one had thought much about the recuperative process. Into this vacuum came a wide variety of researchers and providers. Concussion management blossomed into a cottage industry, populated by neurologists, orthopedists, trainers, sports medicine specialists, and physical therapists. Not surprisingly, much of their advice was based on unproven assumptions, including the concept of “brain rest.”

It has taken time, but fortunately, folks with patience and wisdom have questioned these assumptions and begun collecting data. The result of these investigations and others has prompted the American Academy of Pediatrics to publish an updated set of guidelines on concussion management that includes the observation that extended school absence may slow the rehabilitation process (Pediatrics. 2018 Dec. doi: 10.1542/peds.2018-3074).

It is becoming clear that management of concussion can be rather complex and must be individualized to each patient. In my experience, the postconcussion period can unmask behavioral, cognitive, and emotional problems that were preexisting but had received little or no attention. For example, the trauma of the event may trigger anxiety about further injury or exacerbate depression that had been building for years. The student who “couldn’t do algebra” following a head injury may have had a lifelong learning disability that had gone unnoticed. The student athlete with prolonged postconcussion symptoms may indeed have another more serious problem. Hopefully, the new guidelines from the AAP will be a first step toward a more thoughtful and scientifically driven approach to concussion management.

It would be nice if that approach could filter down to the management of the more common but less dramatic pediatric injuries. There is hope. Choosing Wisely – a patient/parent–targeted initiative by the American Board of Internal Medicine Foundation in cooperation with the AAP – points out that, although half of the pediatric head injury patients seen in emergency departments received CT scan, only a third of those studies were indicated. Parents are encouraged to learn more about the risks of CT scans and question the physician when one is recommended.

But, doctors’ habits and old wives’ tales die slowly. I hope that you no longer recommend that parents keep their children awake after a head injury, or wake them every hour to check their pupils. Those counterproductive recommendations make about as much sense as staying out of the swimming pool for an hour after eating a chocolate chip cookie.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

While the increasing prevalence of obesity has been obvious for nearly half a century, it is only in the last decade or two that the focus has broadened to include the associated decline in physical activity.

iStockphoto.com

A recent paper attempts to sharpen that focus by examining the timeline of that decline (Pediatrics 2019 Jan. doi: 10.1542/peds.2018-0994.). Using a device incorporating five sensors, one of which was an accelerometer, the investigators collected data from 600 children from five European countries accumulating more than 1,200 observations. What they discovered was that their subjects’ physical activity declined by 75 minutes per day from ages 6 to 11 years of age while sedentary behavior increased more than 100 minutes over that same interval. This observation is concerning because previous attention has focused intervention on adolescents assuming that the erosion of physical activity was occurring primarily during the teen years.

Not surprisingly the authors suggest that more studies should be performed to aid in the design of more sharply targeted interventions. While more information may be helpful, their current findings and an abundance of anecdotal observations suggest that to be effective that intervention must begin well before children reach school age.

What should this intervention look like? Currently, the emphasis seems to have been on programs that encourage activity. The National Football League is promoting its NFL Play 60 initiative. The Afterschool Alliance has its Kids on the Move programs. Former First Lady Michelle Obama has been the spokesperson and driving force behind Let’s Move. And, the American Academy of Pediatrics has recently been encouraging both parents and pediatricians to appreciate The Power of Play to encourage children to get into more physical activity. All of these initiatives are well meaning, but I suspect their effectiveness is usually limited to the public awareness they generate.

We seem to have forgotten that there are two sides to the equation. The accelerometer study from Europe should remind us that our initiatives should also be addressing the problem of epidemic inactivity with equal vigor. The investigators have shown that, while on one hand, activity decreased by 75 minutes, the subjects’ sedentary behaviors increased by more than 100 minutes. Creating programs that focus on increasing activity can be expensive. There may be costs for equipment, spaces to be maintained, and staff to be paid. On the other hand, curbing sedentary behavior requires only an adult with the courage to say, “No.” “No, we will have the television for only an hour today.” “No, you can’t play your video game until after dinner.”

While addressing the disciplinary side of the activity-inactivity dichotomy may be relatively inexpensive, it does seem to have a cost on parents. It requires them to buy into the idea that, given even the most-limited supply of objects and infrastructure, most children can keep themselves entertained and active. There does seem to be a small subset of children who enter the world with a sedentary mindset, possibly inherited from their parents. This unfortunate minority will require some creative intervention to achieve a healthy level of activity.

However, most young children who have become accustomed to being amused by sedentary “activities” such as television and video games still retain their innate creativity and natural inclination to be physically active. Unfortunately, unmasking these health-sustaining attributes may require a long and unpleasant weaning period that many parents don’t seem to have the patience to endure. The longer the child has been allowed to engage in sedentary behaviors, the longer this adjustment period will be, yet another argument for early intervention.

Encouraging physical activity is something we should be doing every day in our offices, but it must go hand in hand with an equivalent emphasis on helping parents create a discipline framework that discourages sedentary behavior.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

While the increasing prevalence of obesity has been obvious for nearly half a century, it is only in the last decade or two that the focus has broadened to include the associated decline in physical activity.

iStockphoto.com

A recent paper attempts to sharpen that focus by examining the timeline of that decline (Pediatrics 2019 Jan. doi: 10.1542/peds.2018-0994.). Using a device incorporating five sensors, one of which was an accelerometer, the investigators collected data from 600 children from five European countries accumulating more than 1,200 observations. What they discovered was that their subjects’ physical activity declined by 75 minutes per day from ages 6 to 11 years of age while sedentary behavior increased more than 100 minutes over that same interval. This observation is concerning because previous attention has focused intervention on adolescents assuming that the erosion of physical activity was occurring primarily during the teen years.

Not surprisingly the authors suggest that more studies should be performed to aid in the design of more sharply targeted interventions. While more information may be helpful, their current findings and an abundance of anecdotal observations suggest that to be effective that intervention must begin well before children reach school age.

What should this intervention look like? Currently, the emphasis seems to have been on programs that encourage activity. The National Football League is promoting its NFL Play 60 initiative. The Afterschool Alliance has its Kids on the Move programs. Former First Lady Michelle Obama has been the spokesperson and driving force behind Let’s Move. And, the American Academy of Pediatrics has recently been encouraging both parents and pediatricians to appreciate The Power of Play to encourage children to get into more physical activity. All of these initiatives are well meaning, but I suspect their effectiveness is usually limited to the public awareness they generate.

We seem to have forgotten that there are two sides to the equation. The accelerometer study from Europe should remind us that our initiatives should also be addressing the problem of epidemic inactivity with equal vigor. The investigators have shown that, while on one hand, activity decreased by 75 minutes, the subjects’ sedentary behaviors increased by more than 100 minutes. Creating programs that focus on increasing activity can be expensive. There may be costs for equipment, spaces to be maintained, and staff to be paid. On the other hand, curbing sedentary behavior requires only an adult with the courage to say, “No.” “No, we will have the television for only an hour today.” “No, you can’t play your video game until after dinner.”

While addressing the disciplinary side of the activity-inactivity dichotomy may be relatively inexpensive, it does seem to have a cost on parents. It requires them to buy into the idea that, given even the most-limited supply of objects and infrastructure, most children can keep themselves entertained and active. There does seem to be a small subset of children who enter the world with a sedentary mindset, possibly inherited from their parents. This unfortunate minority will require some creative intervention to achieve a healthy level of activity.

However, most young children who have become accustomed to being amused by sedentary “activities” such as television and video games still retain their innate creativity and natural inclination to be physically active. Unfortunately, unmasking these health-sustaining attributes may require a long and unpleasant weaning period that many parents don’t seem to have the patience to endure. The longer the child has been allowed to engage in sedentary behaviors, the longer this adjustment period will be, yet another argument for early intervention.

Encouraging physical activity is something we should be doing every day in our offices, but it must go hand in hand with an equivalent emphasis on helping parents create a discipline framework that discourages sedentary behavior.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

While the increasing prevalence of obesity has been obvious for nearly half a century, it is only in the last decade or two that the focus has broadened to include the associated decline in physical activity.

iStockphoto.com

A recent paper attempts to sharpen that focus by examining the timeline of that decline (Pediatrics 2019 Jan. doi: 10.1542/peds.2018-0994.). Using a device incorporating five sensors, one of which was an accelerometer, the investigators collected data from 600 children from five European countries accumulating more than 1,200 observations. What they discovered was that their subjects’ physical activity declined by 75 minutes per day from ages 6 to 11 years of age while sedentary behavior increased more than 100 minutes over that same interval. This observation is concerning because previous attention has focused intervention on adolescents assuming that the erosion of physical activity was occurring primarily during the teen years.

Not surprisingly the authors suggest that more studies should be performed to aid in the design of more sharply targeted interventions. While more information may be helpful, their current findings and an abundance of anecdotal observations suggest that to be effective that intervention must begin well before children reach school age.

What should this intervention look like? Currently, the emphasis seems to have been on programs that encourage activity. The National Football League is promoting its NFL Play 60 initiative. The Afterschool Alliance has its Kids on the Move programs. Former First Lady Michelle Obama has been the spokesperson and driving force behind Let’s Move. And, the American Academy of Pediatrics has recently been encouraging both parents and pediatricians to appreciate The Power of Play to encourage children to get into more physical activity. All of these initiatives are well meaning, but I suspect their effectiveness is usually limited to the public awareness they generate.

We seem to have forgotten that there are two sides to the equation. The accelerometer study from Europe should remind us that our initiatives should also be addressing the problem of epidemic inactivity with equal vigor. The investigators have shown that, while on one hand, activity decreased by 75 minutes, the subjects’ sedentary behaviors increased by more than 100 minutes. Creating programs that focus on increasing activity can be expensive. There may be costs for equipment, spaces to be maintained, and staff to be paid. On the other hand, curbing sedentary behavior requires only an adult with the courage to say, “No.” “No, we will have the television for only an hour today.” “No, you can’t play your video game until after dinner.”

While addressing the disciplinary side of the activity-inactivity dichotomy may be relatively inexpensive, it does seem to have a cost on parents. It requires them to buy into the idea that, given even the most-limited supply of objects and infrastructure, most children can keep themselves entertained and active. There does seem to be a small subset of children who enter the world with a sedentary mindset, possibly inherited from their parents. This unfortunate minority will require some creative intervention to achieve a healthy level of activity.

However, most young children who have become accustomed to being amused by sedentary “activities” such as television and video games still retain their innate creativity and natural inclination to be physically active. Unfortunately, unmasking these health-sustaining attributes may require a long and unpleasant weaning period that many parents don’t seem to have the patience to endure. The longer the child has been allowed to engage in sedentary behaviors, the longer this adjustment period will be, yet another argument for early intervention.

Encouraging physical activity is something we should be doing every day in our offices, but it must go hand in hand with an equivalent emphasis on helping parents create a discipline framework that discourages sedentary behavior.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Although many families still resort to spanking when “No!” isn’t working, pediatricians and child psychologists are unified in their condemnation of physical discipline. However, when it comes to timeout, child behavior specialists have failed to reach consensus. In a recent Washington Post article, Claire Gillespie quotes several experts who feel that timeout is ineffective at best and damaging and dangerous at its worst. (Timeouts are a dated and ineffective parenting strategy. So what’s a good alternative? Washington Post, Nov. 29, 2019.)

Comstock/Thinkstock

How do you feel about timeouts? Do you think they are effective? Do you think that brief periods of isolation in a home setting will increase a child’s anxiety? Will the threat of isolation create long-lasting psychological harm? Or do you believe that properly done timeout can be a safe consequence when a child misbehaves?

The disagreement seems to be another one of those issues of apples and oranges. Do I believe that solitary confinement in a prison or chained to a metal cot in the basement of mentally deranged and obsessive parent will leave psychological scars? Of course I do. But, do I believe that a few minutes alone in a child’s own room in a home in which her parents frequently express their affection will cause any harm? Not for a moment. It’s not so much where the child is. It’s where she isn’t. Of course, she doesn’t want to be isolated from the family and that sends a powerful but not harmful message. A big hug and a kiss at the end of the timeout wipes the slate clear.

Some critics believe that timeout should be condemned because it is a punishment. Here again, it’s a case of semantics. Punishments in my mind are inhumane, “a pound of flesh” or “an eye for an eye” response. A well-done timeout is a harmless consequence and one that particularly makes sense when the misbehavior has been or is creating an unpleasant atmosphere in the family.

Other critics will claim that timeouts aren’t an effective deterrent. Correct! They aren’t meant to be a deterrent. A detailed discussion, more likely a lecture, about the misbehavior before and even immediately after a timeout is a waste of time. If timeouts are a deterrent it is because of their safety. Parents will be more likely to use them as a consequence, and most importantly to follow up on their threats. A parent whose words can be believed is his or her own best deterrent.

Finally, many parents who have tried timeouts will claim that they don’t work. This is true if they were talking about deterrent value. Maybe the timeouts have been too long or too short. About 30-60 seconds after the child stops crying may be enough. However, if the parents mean that the child wouldn’t stay in timeout in his room, then they have not taken the difficult final step. If the parent doesn’t have the stamina to keep walking the child back into his room, then it is time to put a latch on the door. Whoops. ... I may have lost some of you who up to this point have been nodding agreement along with my rationale. I know, I know it smacks of prison. It may be used only once or twice, but it will remain as a tangible reminder that sometimes enough is enough. Frequent trips into the room to help the child self-calm make it clear he hasn’t been abandoned.

It’s hard to provide a fully nuanced argument for including timeout in the consequence arsenal in 500 words. I’m eager to hear how you feel on the subject. I can take the heat.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Although many families still resort to spanking when “No!” isn’t working, pediatricians and child psychologists are unified in their condemnation of physical discipline. However, when it comes to timeout, child behavior specialists have failed to reach consensus. In a recent Washington Post article, Claire Gillespie quotes several experts who feel that timeout is ineffective at best and damaging and dangerous at its worst. (Timeouts are a dated and ineffective parenting strategy. So what’s a good alternative? Washington Post, Nov. 29, 2019.)

Comstock/Thinkstock

How do you feel about timeouts? Do you think they are effective? Do you think that brief periods of isolation in a home setting will increase a child’s anxiety? Will the threat of isolation create long-lasting psychological harm? Or do you believe that properly done timeout can be a safe consequence when a child misbehaves?

The disagreement seems to be another one of those issues of apples and oranges. Do I believe that solitary confinement in a prison or chained to a metal cot in the basement of mentally deranged and obsessive parent will leave psychological scars? Of course I do. But, do I believe that a few minutes alone in a child’s own room in a home in which her parents frequently express their affection will cause any harm? Not for a moment. It’s not so much where the child is. It’s where she isn’t. Of course, she doesn’t want to be isolated from the family and that sends a powerful but not harmful message. A big hug and a kiss at the end of the timeout wipes the slate clear.

Some critics believe that timeout should be condemned because it is a punishment. Here again, it’s a case of semantics. Punishments in my mind are inhumane, “a pound of flesh” or “an eye for an eye” response. A well-done timeout is a harmless consequence and one that particularly makes sense when the misbehavior has been or is creating an unpleasant atmosphere in the family.

Other critics will claim that timeouts aren’t an effective deterrent. Correct! They aren’t meant to be a deterrent. A detailed discussion, more likely a lecture, about the misbehavior before and even immediately after a timeout is a waste of time. If timeouts are a deterrent it is because of their safety. Parents will be more likely to use them as a consequence, and most importantly to follow up on their threats. A parent whose words can be believed is his or her own best deterrent.

Finally, many parents who have tried timeouts will claim that they don’t work. This is true if they were talking about deterrent value. Maybe the timeouts have been too long or too short. About 30-60 seconds after the child stops crying may be enough. However, if the parents mean that the child wouldn’t stay in timeout in his room, then they have not taken the difficult final step. If the parent doesn’t have the stamina to keep walking the child back into his room, then it is time to put a latch on the door. Whoops. ... I may have lost some of you who up to this point have been nodding agreement along with my rationale. I know, I know it smacks of prison. It may be used only once or twice, but it will remain as a tangible reminder that sometimes enough is enough. Frequent trips into the room to help the child self-calm make it clear he hasn’t been abandoned.

It’s hard to provide a fully nuanced argument for including timeout in the consequence arsenal in 500 words. I’m eager to hear how you feel on the subject. I can take the heat.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Although many families still resort to spanking when “No!” isn’t working, pediatricians and child psychologists are unified in their condemnation of physical discipline. However, when it comes to timeout, child behavior specialists have failed to reach consensus. In a recent Washington Post article, Claire Gillespie quotes several experts who feel that timeout is ineffective at best and damaging and dangerous at its worst. (Timeouts are a dated and ineffective parenting strategy. So what’s a good alternative? Washington Post, Nov. 29, 2019.)

Comstock/Thinkstock

How do you feel about timeouts? Do you think they are effective? Do you think that brief periods of isolation in a home setting will increase a child’s anxiety? Will the threat of isolation create long-lasting psychological harm? Or do you believe that properly done timeout can be a safe consequence when a child misbehaves?

The disagreement seems to be another one of those issues of apples and oranges. Do I believe that solitary confinement in a prison or chained to a metal cot in the basement of mentally deranged and obsessive parent will leave psychological scars? Of course I do. But, do I believe that a few minutes alone in a child’s own room in a home in which her parents frequently express their affection will cause any harm? Not for a moment. It’s not so much where the child is. It’s where she isn’t. Of course, she doesn’t want to be isolated from the family and that sends a powerful but not harmful message. A big hug and a kiss at the end of the timeout wipes the slate clear.

Some critics believe that timeout should be condemned because it is a punishment. Here again, it’s a case of semantics. Punishments in my mind are inhumane, “a pound of flesh” or “an eye for an eye” response. A well-done timeout is a harmless consequence and one that particularly makes sense when the misbehavior has been or is creating an unpleasant atmosphere in the family.

Other critics will claim that timeouts aren’t an effective deterrent. Correct! They aren’t meant to be a deterrent. A detailed discussion, more likely a lecture, about the misbehavior before and even immediately after a timeout is a waste of time. If timeouts are a deterrent it is because of their safety. Parents will be more likely to use them as a consequence, and most importantly to follow up on their threats. A parent whose words can be believed is his or her own best deterrent.

Finally, many parents who have tried timeouts will claim that they don’t work. This is true if they were talking about deterrent value. Maybe the timeouts have been too long or too short. About 30-60 seconds after the child stops crying may be enough. However, if the parents mean that the child wouldn’t stay in timeout in his room, then they have not taken the difficult final step. If the parent doesn’t have the stamina to keep walking the child back into his room, then it is time to put a latch on the door. Whoops. ... I may have lost some of you who up to this point have been nodding agreement along with my rationale. I know, I know it smacks of prison. It may be used only once or twice, but it will remain as a tangible reminder that sometimes enough is enough. Frequent trips into the room to help the child self-calm make it clear he hasn’t been abandoned.

It’s hard to provide a fully nuanced argument for including timeout in the consequence arsenal in 500 words. I’m eager to hear how you feel on the subject. I can take the heat.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].