Letters from Maine

 

My wife and I have dinner together almost every evening. There is a candle on the table regardless of the menu. And the meal begins with a toast, usually “To this chance to be together.” I can hear you muttering to yourself, “They must be one of those sappy, sweet hand-holding couples that appear to be joined at the hip.” Far from it, we lead very busy, active, but separate lives that only rarely intersect. But we make it a priority that one of those intersections occurs at a meal. For us, an evening dinner works best.

Listening to our friends, we have learned that an increasing number of them have drifted away from sharing a meal together. This phenomenon is surprising because most of them are retired, and time is not an issue. Of course, it is no secret that, for young overscheduled families, sitting down for a shared dining experience is becoming increasingly less frequent. Like some of you, I would like to claim that a return to family meal times would solve all of society’s ills. But some of the literature supporting this claim suggests shared family experiences in general, not particularly those associated with eating, may be just as important in supporting emotional health. But because everyone needs to eat, meals seem to me to be the easy target, low-hanging fruit if you will.

Yuki KONDO/Getty Images

I recently encountered some observations that suggest family meals may play an important role in the outcome of picky eating in the article “When New Means No: Picky Eating as a Normal Toddler Phase,” by Perri Klass, MD (New York Times, June 4, 2018). Dr. Klass describes a study presented as an abstract at the recent Pediatric Academic Societies meeting in Toronto in which Dr. Megan Pesch of the C.S. Mott Children’s Hospital, Ann Arbor, Mich., and her associates say that by 4 years of age, the children in their study were moving along “three stable trajectories” on a picky eating scale (high, medium, or low), and did not move out of their track for the next 4 and a half years. This finding suggests that we should reconsider our timeworn advice that picky eaters will outgrow this “stage.”

It is interesting that parents’ reports of their children’s eating patterns were validated by the behaviors videotaped by the researchers. But what is really interesting is that children who grew up in households where mealtimes followed a routine were more likely to be in the low–picky eating group. Routines included things like having a specific place times for eating, a habitual way of serving food, and other rituals such as saying grace.

In other words, meals were not so much about the food as they were about the event itself. This often means giving the concept of mealtime for the family a higher priority. In my experience, the successful management of picky eating often comes when parents can shift their focus away from what and how much their child is eating and onto the social and communal aspects of the meal.

Unfortunately, because this Michigan study began at age 4 years it doesn’t tell us if the worst picky eaters were that way from the beginning. I suspect that some were. But my hunch is that picky eaters who are managed in a home environment that includes mealtime rituals and puts dining together as a high priority are more likely to outgrow their pickiness.
 

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: A Guide for the Perplexed Parent.” Email him at [email protected].

 

My wife and I have dinner together almost every evening. There is a candle on the table regardless of the menu. And the meal begins with a toast, usually “To this chance to be together.” I can hear you muttering to yourself, “They must be one of those sappy, sweet hand-holding couples that appear to be joined at the hip.” Far from it, we lead very busy, active, but separate lives that only rarely intersect. But we make it a priority that one of those intersections occurs at a meal. For us, an evening dinner works best.

Listening to our friends, we have learned that an increasing number of them have drifted away from sharing a meal together. This phenomenon is surprising because most of them are retired, and time is not an issue. Of course, it is no secret that, for young overscheduled families, sitting down for a shared dining experience is becoming increasingly less frequent. Like some of you, I would like to claim that a return to family meal times would solve all of society’s ills. But some of the literature supporting this claim suggests shared family experiences in general, not particularly those associated with eating, may be just as important in supporting emotional health. But because everyone needs to eat, meals seem to me to be the easy target, low-hanging fruit if you will.

Yuki KONDO/Getty Images

I recently encountered some observations that suggest family meals may play an important role in the outcome of picky eating in the article “When New Means No: Picky Eating as a Normal Toddler Phase,” by Perri Klass, MD (New York Times, June 4, 2018). Dr. Klass describes a study presented as an abstract at the recent Pediatric Academic Societies meeting in Toronto in which Dr. Megan Pesch of the C.S. Mott Children’s Hospital, Ann Arbor, Mich., and her associates say that by 4 years of age, the children in their study were moving along “three stable trajectories” on a picky eating scale (high, medium, or low), and did not move out of their track for the next 4 and a half years. This finding suggests that we should reconsider our timeworn advice that picky eaters will outgrow this “stage.”

It is interesting that parents’ reports of their children’s eating patterns were validated by the behaviors videotaped by the researchers. But what is really interesting is that children who grew up in households where mealtimes followed a routine were more likely to be in the low–picky eating group. Routines included things like having a specific place times for eating, a habitual way of serving food, and other rituals such as saying grace.

In other words, meals were not so much about the food as they were about the event itself. This often means giving the concept of mealtime for the family a higher priority. In my experience, the successful management of picky eating often comes when parents can shift their focus away from what and how much their child is eating and onto the social and communal aspects of the meal.

Unfortunately, because this Michigan study began at age 4 years it doesn’t tell us if the worst picky eaters were that way from the beginning. I suspect that some were. But my hunch is that picky eaters who are managed in a home environment that includes mealtime rituals and puts dining together as a high priority are more likely to outgrow their pickiness.
 

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: A Guide for the Perplexed Parent.” Email him at [email protected].

 

My wife and I have dinner together almost every evening. There is a candle on the table regardless of the menu. And the meal begins with a toast, usually “To this chance to be together.” I can hear you muttering to yourself, “They must be one of those sappy, sweet hand-holding couples that appear to be joined at the hip.” Far from it, we lead very busy, active, but separate lives that only rarely intersect. But we make it a priority that one of those intersections occurs at a meal. For us, an evening dinner works best.

Listening to our friends, we have learned that an increasing number of them have drifted away from sharing a meal together. This phenomenon is surprising because most of them are retired, and time is not an issue. Of course, it is no secret that, for young overscheduled families, sitting down for a shared dining experience is becoming increasingly less frequent. Like some of you, I would like to claim that a return to family meal times would solve all of society’s ills. But some of the literature supporting this claim suggests shared family experiences in general, not particularly those associated with eating, may be just as important in supporting emotional health. But because everyone needs to eat, meals seem to me to be the easy target, low-hanging fruit if you will.

Yuki KONDO/Getty Images

I recently encountered some observations that suggest family meals may play an important role in the outcome of picky eating in the article “When New Means No: Picky Eating as a Normal Toddler Phase,” by Perri Klass, MD (New York Times, June 4, 2018). Dr. Klass describes a study presented as an abstract at the recent Pediatric Academic Societies meeting in Toronto in which Dr. Megan Pesch of the C.S. Mott Children’s Hospital, Ann Arbor, Mich., and her associates say that by 4 years of age, the children in their study were moving along “three stable trajectories” on a picky eating scale (high, medium, or low), and did not move out of their track for the next 4 and a half years. This finding suggests that we should reconsider our timeworn advice that picky eaters will outgrow this “stage.”

It is interesting that parents’ reports of their children’s eating patterns were validated by the behaviors videotaped by the researchers. But what is really interesting is that children who grew up in households where mealtimes followed a routine were more likely to be in the low–picky eating group. Routines included things like having a specific place times for eating, a habitual way of serving food, and other rituals such as saying grace.

In other words, meals were not so much about the food as they were about the event itself. This often means giving the concept of mealtime for the family a higher priority. In my experience, the successful management of picky eating often comes when parents can shift their focus away from what and how much their child is eating and onto the social and communal aspects of the meal.

Unfortunately, because this Michigan study began at age 4 years it doesn’t tell us if the worst picky eaters were that way from the beginning. I suspect that some were. But my hunch is that picky eaters who are managed in a home environment that includes mealtime rituals and puts dining together as a high priority are more likely to outgrow their pickiness.
 

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: A Guide for the Perplexed Parent.” Email him at [email protected].

 

Where did you learn about nutrition? Was it primarily at home supplemented by a few teachers as you navigated K through 12? Studies have shown that it probably wasn’t during medical school (“How much does your doctor actually know about nutrition?” American Heart Association News, April 30, 2018). A survey of one-third of medicals schools done in 1985 found “inadequate exposure to nutrition,” which prompted the National Academy of Sciences to recommend a minimum of 25 classroom hours. A more recent survey in 2013 discovered that 71% percent of medical schools fail to meet that benchmark.

A health advisory by the American Heart Association published in the May 15, 2018, issue of Circulation entitled “Medical nutrition education, training, and competencies to advance guideline-based diet counseling by physicians: A science advisory from the American Heart Association” (2018 Apr 30. pii: CIR.0000000000000563) claims that physicians are failing to be adequate and competent nutritional advisors to their patients because medical schools continue to undervalue the importance of nutritional education. The AHA urges medical schools to consider innovative programs such as one at Brown University, Providence, R.I., in which medical students are paired with culinary arts students in activities such as hands-on, in-kitchen experience cooking low-sodium meals.

I certainly don’t recall receiving any teaching in medical school that was specifically targeted at nutrition. And to be perfectly honest I never felt that I had missed anything. It’s not that I don’t believe nutrition is important. What we eat joins exercise and sleep at the core of a healthy lifestyle. The problem is that I was never confident that I or anyone else knew what a healthy diet should be. I learned what happened if child didn’t eat enough fruits and vegetables or consume enough vitamin D. But the tide seemed to keep going in and out on how much of each category of food was optimal. What was the perfect nutritional pyramid? And then there was the whole apparent flip-flop on eggs. For myself, I tried to follow the old dictum “everything in moderation ... including moderation.”

Don’t misunderstand me. I think dietitians have a critical role in health maintenance and disease management and should be on the forefront of our efforts to seek the causes of those medical conditions that have yet to be fully explained. It would be a mistake to recommend a low-salt diet to a patient without encouraging him or her (and the family) to consult with a dietitian. However, is having a medical students spend an afternoon in a kitchen preparing a low-salt diet a worthwhile investment of 4 precious hours of their educational time? It sounds cool, and at the end of the day, the student will certainly have a better understanding of how difficult his dietary recommendations will be to follow. But if the student ends up being a pediatrician, how often will he look back on the kitchen experience as a positive?

Giving specific and detailed instruction on how to shop for and prepare a medically prescribed diet can be very time consuming, and it can’t be done well without close follow-up that might even include a home visit or two. In some practices, the best option is to have a dietitian on the team. As a minimum, each physician should have a dietitian or two with whom he or she has a good working relationship.

However, when all is said and done, no matter how much training we or our favorite dietitian has accumulated, the tsunami of bogus nutritional advice spilling out of the television and the Internet every hour means that we are swimming up stream even when we have the best advice to give.

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].

 

Where did you learn about nutrition? Was it primarily at home supplemented by a few teachers as you navigated K through 12? Studies have shown that it probably wasn’t during medical school (“How much does your doctor actually know about nutrition?” American Heart Association News, April 30, 2018). A survey of one-third of medicals schools done in 1985 found “inadequate exposure to nutrition,” which prompted the National Academy of Sciences to recommend a minimum of 25 classroom hours. A more recent survey in 2013 discovered that 71% percent of medical schools fail to meet that benchmark.

A health advisory by the American Heart Association published in the May 15, 2018, issue of Circulation entitled “Medical nutrition education, training, and competencies to advance guideline-based diet counseling by physicians: A science advisory from the American Heart Association” (2018 Apr 30. pii: CIR.0000000000000563) claims that physicians are failing to be adequate and competent nutritional advisors to their patients because medical schools continue to undervalue the importance of nutritional education. The AHA urges medical schools to consider innovative programs such as one at Brown University, Providence, R.I., in which medical students are paired with culinary arts students in activities such as hands-on, in-kitchen experience cooking low-sodium meals.

I certainly don’t recall receiving any teaching in medical school that was specifically targeted at nutrition. And to be perfectly honest I never felt that I had missed anything. It’s not that I don’t believe nutrition is important. What we eat joins exercise and sleep at the core of a healthy lifestyle. The problem is that I was never confident that I or anyone else knew what a healthy diet should be. I learned what happened if child didn’t eat enough fruits and vegetables or consume enough vitamin D. But the tide seemed to keep going in and out on how much of each category of food was optimal. What was the perfect nutritional pyramid? And then there was the whole apparent flip-flop on eggs. For myself, I tried to follow the old dictum “everything in moderation ... including moderation.”

Don’t misunderstand me. I think dietitians have a critical role in health maintenance and disease management and should be on the forefront of our efforts to seek the causes of those medical conditions that have yet to be fully explained. It would be a mistake to recommend a low-salt diet to a patient without encouraging him or her (and the family) to consult with a dietitian. However, is having a medical students spend an afternoon in a kitchen preparing a low-salt diet a worthwhile investment of 4 precious hours of their educational time? It sounds cool, and at the end of the day, the student will certainly have a better understanding of how difficult his dietary recommendations will be to follow. But if the student ends up being a pediatrician, how often will he look back on the kitchen experience as a positive?

Giving specific and detailed instruction on how to shop for and prepare a medically prescribed diet can be very time consuming, and it can’t be done well without close follow-up that might even include a home visit or two. In some practices, the best option is to have a dietitian on the team. As a minimum, each physician should have a dietitian or two with whom he or she has a good working relationship.

However, when all is said and done, no matter how much training we or our favorite dietitian has accumulated, the tsunami of bogus nutritional advice spilling out of the television and the Internet every hour means that we are swimming up stream even when we have the best advice to give.

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].

 

Where did you learn about nutrition? Was it primarily at home supplemented by a few teachers as you navigated K through 12? Studies have shown that it probably wasn’t during medical school (“How much does your doctor actually know about nutrition?” American Heart Association News, April 30, 2018). A survey of one-third of medicals schools done in 1985 found “inadequate exposure to nutrition,” which prompted the National Academy of Sciences to recommend a minimum of 25 classroom hours. A more recent survey in 2013 discovered that 71% percent of medical schools fail to meet that benchmark.

A health advisory by the American Heart Association published in the May 15, 2018, issue of Circulation entitled “Medical nutrition education, training, and competencies to advance guideline-based diet counseling by physicians: A science advisory from the American Heart Association” (2018 Apr 30. pii: CIR.0000000000000563) claims that physicians are failing to be adequate and competent nutritional advisors to their patients because medical schools continue to undervalue the importance of nutritional education. The AHA urges medical schools to consider innovative programs such as one at Brown University, Providence, R.I., in which medical students are paired with culinary arts students in activities such as hands-on, in-kitchen experience cooking low-sodium meals.

I certainly don’t recall receiving any teaching in medical school that was specifically targeted at nutrition. And to be perfectly honest I never felt that I had missed anything. It’s not that I don’t believe nutrition is important. What we eat joins exercise and sleep at the core of a healthy lifestyle. The problem is that I was never confident that I or anyone else knew what a healthy diet should be. I learned what happened if child didn’t eat enough fruits and vegetables or consume enough vitamin D. But the tide seemed to keep going in and out on how much of each category of food was optimal. What was the perfect nutritional pyramid? And then there was the whole apparent flip-flop on eggs. For myself, I tried to follow the old dictum “everything in moderation ... including moderation.”

Don’t misunderstand me. I think dietitians have a critical role in health maintenance and disease management and should be on the forefront of our efforts to seek the causes of those medical conditions that have yet to be fully explained. It would be a mistake to recommend a low-salt diet to a patient without encouraging him or her (and the family) to consult with a dietitian. However, is having a medical students spend an afternoon in a kitchen preparing a low-salt diet a worthwhile investment of 4 precious hours of their educational time? It sounds cool, and at the end of the day, the student will certainly have a better understanding of how difficult his dietary recommendations will be to follow. But if the student ends up being a pediatrician, how often will he look back on the kitchen experience as a positive?

Giving specific and detailed instruction on how to shop for and prepare a medically prescribed diet can be very time consuming, and it can’t be done well without close follow-up that might even include a home visit or two. In some practices, the best option is to have a dietitian on the team. As a minimum, each physician should have a dietitian or two with whom he or she has a good working relationship.

However, when all is said and done, no matter how much training we or our favorite dietitian has accumulated, the tsunami of bogus nutritional advice spilling out of the television and the Internet every hour means that we are swimming up stream even when we have the best advice to give.

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].

 

Like most couples of retirement age, rituals dominate our breakfasts. I eat eggs. Marilyn leans toward baked goods. We each have a bowl of fruit and finish by working the New York Times mini-crossword on our electronic devices. Solving it usually takes somewhere between 40 seconds and 4 minutes. The challenge lies in how fast one can complete the puzzle. And, being who we are, Marilyn and I have ritualized this into a serious competition. She usually takes the first turn and then tries to psyche me out by announcing, “I did it in 2:34, but you should be able to solve it in less than 2 minutes.” This bit of gamesmanship often means that I am going to start the day with thin layer of nervous perspiration.

Antonio_Diaz/thinkstockphotos

Given that these puzzles are designed so that they can be easily solved by anyone with modest crossword experience, does the speed of completion have any importance beyond giving the septuagenarian winner bragging rights until the next morning? A recent Wall Street Journal article (“Colleges Bend the Rules for More Students, Give Them Extra Help,” by Douglas Belkin, May 25, 2018) reports that an increasing number of colleges are rethinking the value of timed exams. Driving this trend toward leniency is the recent increase in the number of students claiming a disability that puts them at a disadvantage when it comes to taking an exam, particularly when the test includes a time limit.

The claimed disabilities range from an anxiety disorder and ADHD to a problem with reading comprehension. The number of students requesting a test environment modification at Pomona College, Claremont, Calif., is 22% up from 5% in 2014. At Marlboro College in Vermont, one in three students asks for more time or a less distracting setting.

This phenomenon raises two obvious questions. First, what has happened to the bell-shaped curve? Was it too boring hanging out with all those people under the bell? Do folks feel safer and more secure in the tails? I guess we have to be happy that young people are less afraid to admit they are different. But it does make one wonder how we should go about defining a disability.

The second question is whether timed tests deserve a place in our educational toolbox? How often is processing speed important? I would like the woman piloting my flight to San Francisco to be quick-witted. But what about the research chemist working on a more durable tire compound? Is it a problem that it took him 30% longer than his classmates to successfully finish his college statistics final exam?

What about the lawyer who bills you $500 per hour to review the contract with your employer? It might have been helpful to know before you hired him that he routinely requested an extra hour and a half to complete his exams in law school. But I suspect that for the most part timed tests probably don’t produce better graduates. In the past they may have been used to thin oversubscribed disciplines, and certainly time limits have been the norm at every level of education I encountered. However, the best taught courses had exams with an abundance of time. Either you knew the information or you didn’t. An extra 2 hours wasn’t going to make a difference.

It is impractical to give every student an unlimited amount of time to take his or her exams. And it may be unfair to offer the extra time to some students and not to others. The best solution comes when the teacher and student can have a dialogue that begins, “This is what I want you to learn. What is the best way you can show me that you have learned it?”

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].

 

Like most couples of retirement age, rituals dominate our breakfasts. I eat eggs. Marilyn leans toward baked goods. We each have a bowl of fruit and finish by working the New York Times mini-crossword on our electronic devices. Solving it usually takes somewhere between 40 seconds and 4 minutes. The challenge lies in how fast one can complete the puzzle. And, being who we are, Marilyn and I have ritualized this into a serious competition. She usually takes the first turn and then tries to psyche me out by announcing, “I did it in 2:34, but you should be able to solve it in less than 2 minutes.” This bit of gamesmanship often means that I am going to start the day with thin layer of nervous perspiration.

Antonio_Diaz/thinkstockphotos

Given that these puzzles are designed so that they can be easily solved by anyone with modest crossword experience, does the speed of completion have any importance beyond giving the septuagenarian winner bragging rights until the next morning? A recent Wall Street Journal article (“Colleges Bend the Rules for More Students, Give Them Extra Help,” by Douglas Belkin, May 25, 2018) reports that an increasing number of colleges are rethinking the value of timed exams. Driving this trend toward leniency is the recent increase in the number of students claiming a disability that puts them at a disadvantage when it comes to taking an exam, particularly when the test includes a time limit.

The claimed disabilities range from an anxiety disorder and ADHD to a problem with reading comprehension. The number of students requesting a test environment modification at Pomona College, Claremont, Calif., is 22% up from 5% in 2014. At Marlboro College in Vermont, one in three students asks for more time or a less distracting setting.

This phenomenon raises two obvious questions. First, what has happened to the bell-shaped curve? Was it too boring hanging out with all those people under the bell? Do folks feel safer and more secure in the tails? I guess we have to be happy that young people are less afraid to admit they are different. But it does make one wonder how we should go about defining a disability.

The second question is whether timed tests deserve a place in our educational toolbox? How often is processing speed important? I would like the woman piloting my flight to San Francisco to be quick-witted. But what about the research chemist working on a more durable tire compound? Is it a problem that it took him 30% longer than his classmates to successfully finish his college statistics final exam?

What about the lawyer who bills you $500 per hour to review the contract with your employer? It might have been helpful to know before you hired him that he routinely requested an extra hour and a half to complete his exams in law school. But I suspect that for the most part timed tests probably don’t produce better graduates. In the past they may have been used to thin oversubscribed disciplines, and certainly time limits have been the norm at every level of education I encountered. However, the best taught courses had exams with an abundance of time. Either you knew the information or you didn’t. An extra 2 hours wasn’t going to make a difference.

It is impractical to give every student an unlimited amount of time to take his or her exams. And it may be unfair to offer the extra time to some students and not to others. The best solution comes when the teacher and student can have a dialogue that begins, “This is what I want you to learn. What is the best way you can show me that you have learned it?”

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].

 

Like most couples of retirement age, rituals dominate our breakfasts. I eat eggs. Marilyn leans toward baked goods. We each have a bowl of fruit and finish by working the New York Times mini-crossword on our electronic devices. Solving it usually takes somewhere between 40 seconds and 4 minutes. The challenge lies in how fast one can complete the puzzle. And, being who we are, Marilyn and I have ritualized this into a serious competition. She usually takes the first turn and then tries to psyche me out by announcing, “I did it in 2:34, but you should be able to solve it in less than 2 minutes.” This bit of gamesmanship often means that I am going to start the day with thin layer of nervous perspiration.

Antonio_Diaz/thinkstockphotos

Given that these puzzles are designed so that they can be easily solved by anyone with modest crossword experience, does the speed of completion have any importance beyond giving the septuagenarian winner bragging rights until the next morning? A recent Wall Street Journal article (“Colleges Bend the Rules for More Students, Give Them Extra Help,” by Douglas Belkin, May 25, 2018) reports that an increasing number of colleges are rethinking the value of timed exams. Driving this trend toward leniency is the recent increase in the number of students claiming a disability that puts them at a disadvantage when it comes to taking an exam, particularly when the test includes a time limit.

The claimed disabilities range from an anxiety disorder and ADHD to a problem with reading comprehension. The number of students requesting a test environment modification at Pomona College, Claremont, Calif., is 22% up from 5% in 2014. At Marlboro College in Vermont, one in three students asks for more time or a less distracting setting.

This phenomenon raises two obvious questions. First, what has happened to the bell-shaped curve? Was it too boring hanging out with all those people under the bell? Do folks feel safer and more secure in the tails? I guess we have to be happy that young people are less afraid to admit they are different. But it does make one wonder how we should go about defining a disability.

The second question is whether timed tests deserve a place in our educational toolbox? How often is processing speed important? I would like the woman piloting my flight to San Francisco to be quick-witted. But what about the research chemist working on a more durable tire compound? Is it a problem that it took him 30% longer than his classmates to successfully finish his college statistics final exam?

What about the lawyer who bills you $500 per hour to review the contract with your employer? It might have been helpful to know before you hired him that he routinely requested an extra hour and a half to complete his exams in law school. But I suspect that for the most part timed tests probably don’t produce better graduates. In the past they may have been used to thin oversubscribed disciplines, and certainly time limits have been the norm at every level of education I encountered. However, the best taught courses had exams with an abundance of time. Either you knew the information or you didn’t. An extra 2 hours wasn’t going to make a difference.

It is impractical to give every student an unlimited amount of time to take his or her exams. And it may be unfair to offer the extra time to some students and not to others. The best solution comes when the teacher and student can have a dialogue that begins, “This is what I want you to learn. What is the best way you can show me that you have learned it?”

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].

 

Veterinarians and farmers have known it for decades. If you give a herd or flock antibiotics, its members grow better and have a better survival rate than an equivalent group of unmedicated animals. The economic benefits of administering antibiotics are so great that until very recently the practice has been the norm. However, the “everything organic” movement has begun to turn the tide as more consumers have become aware of the hazards inherent in the agricultural use of antibiotics.

Grigorev_Vladimir/iStock Editorial/Getty Images

Physicians continually are reminded that we should use antibiotics only when we have determined that they are warranted to treat a specific condition. Prophylaxis is frowned upon and a practice to be applied only when there is a demonstrated benefit of significant magnitude. To do otherwise opens a Pandora’s box, thereby releasing a flock of miseries and unintended consequences, foremost of which is the emergence of resistant strains of bacteria that can threaten the population we are committed to protecting.

Following this conservative and prudent party line can be difficult, and few of us can claim to have never sinned and written a less-than-defensible prescription for an antibiotic. However, for physicians who work in places where the mortality rate for children under age 5 years can be as high as 25%, the temptation to treat the entire population with an antibiotic must be very real.

When decreased early-childhood mortality was observed in several populations that had been given prophylactic azithromycin for trachoma, a group of scientists from the University of California, San Francisco, were prompted to take a longer look at the phenomenon (“Azithromycin to Reduce Childhood Mortality in Sub-Saharan Africa,” N Engl J Med. 2018 Apr 26;378[17]:1583-92). Almost 200,000 children aged 1 month to 5 years in Niger, Malawi, and Tanzania were enrolled in the study. Half received a single dose of azithromycin every 6 months for 2 years. Overall, the mortality rate was 14% lower in the experimental group (P less than .001) and 25% lower in the children aged 1-5 months. Most of the effect was observed in Niger where only one in four children live until their fifth birthday.

Like any good experiment, this study raises more questions than it answers. Will the emergence of antibiotic resistance make broader application of the strategy impractical? Keenan et al. refer to previous trachoma treatment programs in which resistance occurred but seemed to recede when the programs were halted. What conditions were being treated successfully but blindly? Respiratory disease, diarrhea illness, and malaria are most prevalent and are the likely suspects. The authors acknowledge that more studies need to be done.

Giving prophylactic antibiotics to an entire population is clearly a double-edged sword. How does one develop criteria for choosing which populations will benefit enough to put its members and its neighbors at risk for antibiotic resistance? That the children of Niger benefited most suggests there might be some threshold effect that could be determined. Who should be making the decision about which populations to treat? Money wasn’t a problem in this study thanks to the Bill and Melinda Gates Foundation.

And of course, we must remember that, when it comes to antibiotic resistance, ultimately we are all neighbors.
 

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].

 

Veterinarians and farmers have known it for decades. If you give a herd or flock antibiotics, its members grow better and have a better survival rate than an equivalent group of unmedicated animals. The economic benefits of administering antibiotics are so great that until very recently the practice has been the norm. However, the “everything organic” movement has begun to turn the tide as more consumers have become aware of the hazards inherent in the agricultural use of antibiotics.

Grigorev_Vladimir/iStock Editorial/Getty Images

Physicians continually are reminded that we should use antibiotics only when we have determined that they are warranted to treat a specific condition. Prophylaxis is frowned upon and a practice to be applied only when there is a demonstrated benefit of significant magnitude. To do otherwise opens a Pandora’s box, thereby releasing a flock of miseries and unintended consequences, foremost of which is the emergence of resistant strains of bacteria that can threaten the population we are committed to protecting.

Following this conservative and prudent party line can be difficult, and few of us can claim to have never sinned and written a less-than-defensible prescription for an antibiotic. However, for physicians who work in places where the mortality rate for children under age 5 years can be as high as 25%, the temptation to treat the entire population with an antibiotic must be very real.

When decreased early-childhood mortality was observed in several populations that had been given prophylactic azithromycin for trachoma, a group of scientists from the University of California, San Francisco, were prompted to take a longer look at the phenomenon (“Azithromycin to Reduce Childhood Mortality in Sub-Saharan Africa,” N Engl J Med. 2018 Apr 26;378[17]:1583-92). Almost 200,000 children aged 1 month to 5 years in Niger, Malawi, and Tanzania were enrolled in the study. Half received a single dose of azithromycin every 6 months for 2 years. Overall, the mortality rate was 14% lower in the experimental group (P less than .001) and 25% lower in the children aged 1-5 months. Most of the effect was observed in Niger where only one in four children live until their fifth birthday.

Like any good experiment, this study raises more questions than it answers. Will the emergence of antibiotic resistance make broader application of the strategy impractical? Keenan et al. refer to previous trachoma treatment programs in which resistance occurred but seemed to recede when the programs were halted. What conditions were being treated successfully but blindly? Respiratory disease, diarrhea illness, and malaria are most prevalent and are the likely suspects. The authors acknowledge that more studies need to be done.

Giving prophylactic antibiotics to an entire population is clearly a double-edged sword. How does one develop criteria for choosing which populations will benefit enough to put its members and its neighbors at risk for antibiotic resistance? That the children of Niger benefited most suggests there might be some threshold effect that could be determined. Who should be making the decision about which populations to treat? Money wasn’t a problem in this study thanks to the Bill and Melinda Gates Foundation.

And of course, we must remember that, when it comes to antibiotic resistance, ultimately we are all neighbors.
 

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].

 

Veterinarians and farmers have known it for decades. If you give a herd or flock antibiotics, its members grow better and have a better survival rate than an equivalent group of unmedicated animals. The economic benefits of administering antibiotics are so great that until very recently the practice has been the norm. However, the “everything organic” movement has begun to turn the tide as more consumers have become aware of the hazards inherent in the agricultural use of antibiotics.

Grigorev_Vladimir/iStock Editorial/Getty Images

Physicians continually are reminded that we should use antibiotics only when we have determined that they are warranted to treat a specific condition. Prophylaxis is frowned upon and a practice to be applied only when there is a demonstrated benefit of significant magnitude. To do otherwise opens a Pandora’s box, thereby releasing a flock of miseries and unintended consequences, foremost of which is the emergence of resistant strains of bacteria that can threaten the population we are committed to protecting.

Following this conservative and prudent party line can be difficult, and few of us can claim to have never sinned and written a less-than-defensible prescription for an antibiotic. However, for physicians who work in places where the mortality rate for children under age 5 years can be as high as 25%, the temptation to treat the entire population with an antibiotic must be very real.

When decreased early-childhood mortality was observed in several populations that had been given prophylactic azithromycin for trachoma, a group of scientists from the University of California, San Francisco, were prompted to take a longer look at the phenomenon (“Azithromycin to Reduce Childhood Mortality in Sub-Saharan Africa,” N Engl J Med. 2018 Apr 26;378[17]:1583-92). Almost 200,000 children aged 1 month to 5 years in Niger, Malawi, and Tanzania were enrolled in the study. Half received a single dose of azithromycin every 6 months for 2 years. Overall, the mortality rate was 14% lower in the experimental group (P less than .001) and 25% lower in the children aged 1-5 months. Most of the effect was observed in Niger where only one in four children live until their fifth birthday.

Like any good experiment, this study raises more questions than it answers. Will the emergence of antibiotic resistance make broader application of the strategy impractical? Keenan et al. refer to previous trachoma treatment programs in which resistance occurred but seemed to recede when the programs were halted. What conditions were being treated successfully but blindly? Respiratory disease, diarrhea illness, and malaria are most prevalent and are the likely suspects. The authors acknowledge that more studies need to be done.

Giving prophylactic antibiotics to an entire population is clearly a double-edged sword. How does one develop criteria for choosing which populations will benefit enough to put its members and its neighbors at risk for antibiotic resistance? That the children of Niger benefited most suggests there might be some threshold effect that could be determined. Who should be making the decision about which populations to treat? Money wasn’t a problem in this study thanks to the Bill and Melinda Gates Foundation.

And of course, we must remember that, when it comes to antibiotic resistance, ultimately we are all neighbors.
 

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].

 

When a patient fails to show up for his appointment, your reaction may run the gamut from elation to anger or land somewhere on the spectrum between concern and self-doubt. If you are overbooked and running behind with a waiting room that looks like a bus station at rush hour, an unexpectedly unfilled appointment slot can provide a much needed but all too brief respite. However, if the patient who no-shows is someone whom you have been worried about, you may wonder if he has slipped further into a debilitating depression. Or maybe he found a physician that he prefers?

If you keep your finger on the economic pulse of your practice, you know that the empty slot created when a patient no-shows is valuable time that is not generating any income. Your practice administrator may have sent a practice-wide email expressing concern about what she feels is an unacceptably high and economically unsustainable no-show rate. She already may have replaced your antiquated system using postcards and personal phone call reminders with preprogrammed emails and robo-calls.

If despite these high tech targeted reminders your no-show rate continues to be unacceptably high, the problem may be with how and when your office schedules appointments. When a parent or older patient calls with what she feels is an urgent or time-sensitive complaint, is she offered an appointment that satisfies her sense of urgency? She may agree to make an appointment but as soon as she hangs up may begin searching for another source of care and neglect to cancel the appointment with you when she finds a more timely response.

On the other hand, the patient’s problem may have resolved itself. With this in mind, I asked our receptionists to not make next-day appointments for a child with ear pain if for whatever reason the child was unable to come in for a same-day appointment. I knew from experience that ear pain often resolved and appointments weren’t kept or parents would cancel at the last minute. However, we guaranteed that if the child’s pain persisted we would see them immediately in the morning.

You may be muttering to yourself that you can’t possibly give every patient an appointment as soon as they would like to be seen. True. But aren’t there some patients who could be well served by a quick same-day appointment to allay their fear and sketch out a starting point for diagnosis and management at a later visit? A skillful and calming appointment secretary or nurse may be able to provide the same level of reassurance. But sometimes a short office visit is a more effective and efficient way to depressurize the situation and avoid a longer appointment that has a high likelihood of being no-showed or canceled.

DenGuy/iStock/Getty Images

Finally, are you or other members of your group in the habit of making follow-up appointments for problems that probably don’t require follow up? Most patients have an excellent sense when a follow-up appointment is unnecessary and are likely to cancel at the last minute or no-show. They may have had more than one experience in which they took off time from work and traveled 20 miles for a 3-minute visit that didn’t seem worth the effort. A quick phone call or two from you or your staff may be a better way to make sure things are going in the right direction and avoid the cost and frustration of a no-show.

The bottom line is that no-shows happen but when appointments are thoughtfully made the patients are more likely to keep them.

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].

 

When a patient fails to show up for his appointment, your reaction may run the gamut from elation to anger or land somewhere on the spectrum between concern and self-doubt. If you are overbooked and running behind with a waiting room that looks like a bus station at rush hour, an unexpectedly unfilled appointment slot can provide a much needed but all too brief respite. However, if the patient who no-shows is someone whom you have been worried about, you may wonder if he has slipped further into a debilitating depression. Or maybe he found a physician that he prefers?

If you keep your finger on the economic pulse of your practice, you know that the empty slot created when a patient no-shows is valuable time that is not generating any income. Your practice administrator may have sent a practice-wide email expressing concern about what she feels is an unacceptably high and economically unsustainable no-show rate. She already may have replaced your antiquated system using postcards and personal phone call reminders with preprogrammed emails and robo-calls.

If despite these high tech targeted reminders your no-show rate continues to be unacceptably high, the problem may be with how and when your office schedules appointments. When a parent or older patient calls with what she feels is an urgent or time-sensitive complaint, is she offered an appointment that satisfies her sense of urgency? She may agree to make an appointment but as soon as she hangs up may begin searching for another source of care and neglect to cancel the appointment with you when she finds a more timely response.

On the other hand, the patient’s problem may have resolved itself. With this in mind, I asked our receptionists to not make next-day appointments for a child with ear pain if for whatever reason the child was unable to come in for a same-day appointment. I knew from experience that ear pain often resolved and appointments weren’t kept or parents would cancel at the last minute. However, we guaranteed that if the child’s pain persisted we would see them immediately in the morning.

You may be muttering to yourself that you can’t possibly give every patient an appointment as soon as they would like to be seen. True. But aren’t there some patients who could be well served by a quick same-day appointment to allay their fear and sketch out a starting point for diagnosis and management at a later visit? A skillful and calming appointment secretary or nurse may be able to provide the same level of reassurance. But sometimes a short office visit is a more effective and efficient way to depressurize the situation and avoid a longer appointment that has a high likelihood of being no-showed or canceled.

DenGuy/iStock/Getty Images

Finally, are you or other members of your group in the habit of making follow-up appointments for problems that probably don’t require follow up? Most patients have an excellent sense when a follow-up appointment is unnecessary and are likely to cancel at the last minute or no-show. They may have had more than one experience in which they took off time from work and traveled 20 miles for a 3-minute visit that didn’t seem worth the effort. A quick phone call or two from you or your staff may be a better way to make sure things are going in the right direction and avoid the cost and frustration of a no-show.

The bottom line is that no-shows happen but when appointments are thoughtfully made the patients are more likely to keep them.

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].

 

When a patient fails to show up for his appointment, your reaction may run the gamut from elation to anger or land somewhere on the spectrum between concern and self-doubt. If you are overbooked and running behind with a waiting room that looks like a bus station at rush hour, an unexpectedly unfilled appointment slot can provide a much needed but all too brief respite. However, if the patient who no-shows is someone whom you have been worried about, you may wonder if he has slipped further into a debilitating depression. Or maybe he found a physician that he prefers?

If you keep your finger on the economic pulse of your practice, you know that the empty slot created when a patient no-shows is valuable time that is not generating any income. Your practice administrator may have sent a practice-wide email expressing concern about what she feels is an unacceptably high and economically unsustainable no-show rate. She already may have replaced your antiquated system using postcards and personal phone call reminders with preprogrammed emails and robo-calls.

If despite these high tech targeted reminders your no-show rate continues to be unacceptably high, the problem may be with how and when your office schedules appointments. When a parent or older patient calls with what she feels is an urgent or time-sensitive complaint, is she offered an appointment that satisfies her sense of urgency? She may agree to make an appointment but as soon as she hangs up may begin searching for another source of care and neglect to cancel the appointment with you when she finds a more timely response.

On the other hand, the patient’s problem may have resolved itself. With this in mind, I asked our receptionists to not make next-day appointments for a child with ear pain if for whatever reason the child was unable to come in for a same-day appointment. I knew from experience that ear pain often resolved and appointments weren’t kept or parents would cancel at the last minute. However, we guaranteed that if the child’s pain persisted we would see them immediately in the morning.

You may be muttering to yourself that you can’t possibly give every patient an appointment as soon as they would like to be seen. True. But aren’t there some patients who could be well served by a quick same-day appointment to allay their fear and sketch out a starting point for diagnosis and management at a later visit? A skillful and calming appointment secretary or nurse may be able to provide the same level of reassurance. But sometimes a short office visit is a more effective and efficient way to depressurize the situation and avoid a longer appointment that has a high likelihood of being no-showed or canceled.

DenGuy/iStock/Getty Images

Finally, are you or other members of your group in the habit of making follow-up appointments for problems that probably don’t require follow up? Most patients have an excellent sense when a follow-up appointment is unnecessary and are likely to cancel at the last minute or no-show. They may have had more than one experience in which they took off time from work and traveled 20 miles for a 3-minute visit that didn’t seem worth the effort. A quick phone call or two from you or your staff may be a better way to make sure things are going in the right direction and avoid the cost and frustration of a no-show.

The bottom line is that no-shows happen but when appointments are thoughtfully made the patients are more likely to keep them.

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].

 

What percentage of your office visits are a response to an acute complaint? What percentage are prescheduled well-child visits? And how many are follow-ups to manage chronic conditions and behavioral problems?

You probably have a sense of how you are spending your time in the office, but do you really have the numbers to support your guesstimate of the patient mix? Does anyone in your organization have that data? You probably could come up with some numbers in a few hours with a pencil and your office schedule for the last 2 months. However, learning how much of your income is generated by each category of visit would be more difficult.

iStock

If you discover your patient mix is tilted toward acute visits, you may be making a mistake, according to one pediatric practice management consultant, Chip Hart, who claims that one of the five biggest mistakes independent pediatricians can make is failing to shift their focus toward preventive care and chronic disease management (“The 5 biggest business mistakes independent pediatricians make,” Contemporary Pediatrics, April 1, 2018). He argues that, “preventive care pays well; fills your schedule, is required by your payors; is a crucial part of being a patient-centered medical home; establishes your position as the trusted medical source for your families; and, most of all, is good for your patients.” He suggests that parents who take their children to quick-care walk-in clinics for earaches and sore throats are actually doing you a favor, at least as far as your bottom line is concerned.

Before you run out to the front desk and ask the receptionist to delete your same-day slots and replace them with a few preventive and chronic care visits, we should question a few of Mr. Hart’s assertions.

Of course, like you, I never spent the time to learn which categories of office visit were driving my income. However, I do know that I saw a stimulating mix of acute and chronic visits, and the most important number, the bottom line, was more than adequate for my needs. To achieve this profitable balance of visits meant that I needed to be as efficient as the patients’ complaints would allow. There is an often-repeated myth that there is a direct correlation between the length of time a physician spends with the patient and the quality of the visit. In my experience, patients are more impressed by the physician’s level of attention and concern than the amount of time he spends in the exam room.

What about Mr. Hart’s claim that preventive care visits represent “a crucial part of a patient-centered medical home?” Of course they are important, but suggesting that we distance ourselves from our patient’s acute complaints that they deem as emergent, he is ignoring a critical cornerstone of community pediatrics: accessibility. When you limped home from the playground with a scraped and bleeding knee, did you find a sign on the door suggesting you go next door to the neighbors because your parents were busy reading a book to your little sister? That strategy doesn’t fit with my image of a medical home. I think Mr. Hart seriously undervalues your patients’ acute concerns.

You might argue that you just don’t have the time to fit in all those acute visits. But have you had the courage to open up your schedule, maybe hire more staff, and give it a try? It takes a bit of shift in mindset and the acknowledgment that a large part of what we call preventive care has not proved effective. Immunizations? Yes, but the rest, not so much.

 

I know this is a heretical proposition but a mix of acute and chronic complaints keeps the practice of pediatrics stimulating and rewarding and is good for the patients. I found that I knew my patients better after seeing them when they were in need rather than in the less frequent but longer encounters of a health maintenance visit. It takes work, but there is room for both kinds of visit.

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].

 

What percentage of your office visits are a response to an acute complaint? What percentage are prescheduled well-child visits? And how many are follow-ups to manage chronic conditions and behavioral problems?

You probably have a sense of how you are spending your time in the office, but do you really have the numbers to support your guesstimate of the patient mix? Does anyone in your organization have that data? You probably could come up with some numbers in a few hours with a pencil and your office schedule for the last 2 months. However, learning how much of your income is generated by each category of visit would be more difficult.

iStock

If you discover your patient mix is tilted toward acute visits, you may be making a mistake, according to one pediatric practice management consultant, Chip Hart, who claims that one of the five biggest mistakes independent pediatricians can make is failing to shift their focus toward preventive care and chronic disease management (“The 5 biggest business mistakes independent pediatricians make,” Contemporary Pediatrics, April 1, 2018). He argues that, “preventive care pays well; fills your schedule, is required by your payors; is a crucial part of being a patient-centered medical home; establishes your position as the trusted medical source for your families; and, most of all, is good for your patients.” He suggests that parents who take their children to quick-care walk-in clinics for earaches and sore throats are actually doing you a favor, at least as far as your bottom line is concerned.

Before you run out to the front desk and ask the receptionist to delete your same-day slots and replace them with a few preventive and chronic care visits, we should question a few of Mr. Hart’s assertions.

Of course, like you, I never spent the time to learn which categories of office visit were driving my income. However, I do know that I saw a stimulating mix of acute and chronic visits, and the most important number, the bottom line, was more than adequate for my needs. To achieve this profitable balance of visits meant that I needed to be as efficient as the patients’ complaints would allow. There is an often-repeated myth that there is a direct correlation between the length of time a physician spends with the patient and the quality of the visit. In my experience, patients are more impressed by the physician’s level of attention and concern than the amount of time he spends in the exam room.

What about Mr. Hart’s claim that preventive care visits represent “a crucial part of a patient-centered medical home?” Of course they are important, but suggesting that we distance ourselves from our patient’s acute complaints that they deem as emergent, he is ignoring a critical cornerstone of community pediatrics: accessibility. When you limped home from the playground with a scraped and bleeding knee, did you find a sign on the door suggesting you go next door to the neighbors because your parents were busy reading a book to your little sister? That strategy doesn’t fit with my image of a medical home. I think Mr. Hart seriously undervalues your patients’ acute concerns.

You might argue that you just don’t have the time to fit in all those acute visits. But have you had the courage to open up your schedule, maybe hire more staff, and give it a try? It takes a bit of shift in mindset and the acknowledgment that a large part of what we call preventive care has not proved effective. Immunizations? Yes, but the rest, not so much.

 

I know this is a heretical proposition but a mix of acute and chronic complaints keeps the practice of pediatrics stimulating and rewarding and is good for the patients. I found that I knew my patients better after seeing them when they were in need rather than in the less frequent but longer encounters of a health maintenance visit. It takes work, but there is room for both kinds of visit.

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].

 

What percentage of your office visits are a response to an acute complaint? What percentage are prescheduled well-child visits? And how many are follow-ups to manage chronic conditions and behavioral problems?

You probably have a sense of how you are spending your time in the office, but do you really have the numbers to support your guesstimate of the patient mix? Does anyone in your organization have that data? You probably could come up with some numbers in a few hours with a pencil and your office schedule for the last 2 months. However, learning how much of your income is generated by each category of visit would be more difficult.

iStock

If you discover your patient mix is tilted toward acute visits, you may be making a mistake, according to one pediatric practice management consultant, Chip Hart, who claims that one of the five biggest mistakes independent pediatricians can make is failing to shift their focus toward preventive care and chronic disease management (“The 5 biggest business mistakes independent pediatricians make,” Contemporary Pediatrics, April 1, 2018). He argues that, “preventive care pays well; fills your schedule, is required by your payors; is a crucial part of being a patient-centered medical home; establishes your position as the trusted medical source for your families; and, most of all, is good for your patients.” He suggests that parents who take their children to quick-care walk-in clinics for earaches and sore throats are actually doing you a favor, at least as far as your bottom line is concerned.

Before you run out to the front desk and ask the receptionist to delete your same-day slots and replace them with a few preventive and chronic care visits, we should question a few of Mr. Hart’s assertions.

Of course, like you, I never spent the time to learn which categories of office visit were driving my income. However, I do know that I saw a stimulating mix of acute and chronic visits, and the most important number, the bottom line, was more than adequate for my needs. To achieve this profitable balance of visits meant that I needed to be as efficient as the patients’ complaints would allow. There is an often-repeated myth that there is a direct correlation between the length of time a physician spends with the patient and the quality of the visit. In my experience, patients are more impressed by the physician’s level of attention and concern than the amount of time he spends in the exam room.

What about Mr. Hart’s claim that preventive care visits represent “a crucial part of a patient-centered medical home?” Of course they are important, but suggesting that we distance ourselves from our patient’s acute complaints that they deem as emergent, he is ignoring a critical cornerstone of community pediatrics: accessibility. When you limped home from the playground with a scraped and bleeding knee, did you find a sign on the door suggesting you go next door to the neighbors because your parents were busy reading a book to your little sister? That strategy doesn’t fit with my image of a medical home. I think Mr. Hart seriously undervalues your patients’ acute concerns.

You might argue that you just don’t have the time to fit in all those acute visits. But have you had the courage to open up your schedule, maybe hire more staff, and give it a try? It takes a bit of shift in mindset and the acknowledgment that a large part of what we call preventive care has not proved effective. Immunizations? Yes, but the rest, not so much.

 

I know this is a heretical proposition but a mix of acute and chronic complaints keeps the practice of pediatrics stimulating and rewarding and is good for the patients. I found that I knew my patients better after seeing them when they were in need rather than in the less frequent but longer encounters of a health maintenance visit. It takes work, but there is room for both kinds of visit.

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].

A few weeks ago I visited my primary care physician in her new office. As the first patient of the day I was immediately ushered into the examining room by a woman I assume was a medical assistant. She didn’t introduce herself, but her name tag read “Marcy” (not her real name). Her demeanor could best be described as cheerless. She efficiently took my vital signs, asked me my height, and weighed me. She ran through the usual list of screening questions without the slightest hint of a smile despite my efforts to gently inject a bit of levity into my answers.

With her work completed, she left me to wait for “the doctor” without a clue about who I was. She knew that I had one beer and one glass of wine each evening, and that I always wore a seatbelt and didn’t have gun. But she hadn’t provided any outward evidence that she cared about the person who had been providing the answers.

There was a welcome lifting of the chill when my former colleague and current physician entered the exam room. After we had done some catching up about our families and before we started talking about my blood pressure I said, “Marcy really needs to lighten up a bit.”

My observation came as no surprise to my doctor. The transition to a new hospital-owned group practice still had some rough edges including the struggle to instill a more customer-friendly culture among the support staff that she had inherited. She thanked me for my unsolicited feedback.

When Marcy returned to administer my “pneumonia shot” she was wearing a smile. And she was more than willing to engage in the kind of banter that may not have much substance, but is the currency that most of us use to ease the tension in potentially uncomfortable situations. Obviously, while I was waiting she had been given a quick course in customer service.

Marcy and the receptionists are the face of that office, and it certainly wasn’t a welcoming or friendly face. No one was rude. On the other hand, no one was trying to treat the patients as they would like to be treated themselves. You could accuse me of being a nit picky curmudgeon. You could ask if the addition of a smiling face or two would have made a difference in the quality of care coming out of that office. It may not have, but it wouldn’t have hurt, and it would be the nice thing to do.

But I suspect that those initial impressions of interest and caring by the staff lessen the level of anxiety in anxious patients, and take some of the edge off the anger of patients who are unhappy about the care they have been receiving. There is some evidence that hospitalized patients in customer-friendly situations do better. And I bet that patients seen in customer-friendly offices staff get better more quickly.

 

Juanmonino/Getty Images

How friendly is the face of your office? You probably don’t have many patients who are as bold as I am to tell you that your assistant needs to smile more. But you may have seen or heard some exchanges between support staff and patients that make you cringe. Or, is your office organized like a fortress that isolates you from staff/patient interactions by doors and those customer-unfriendly sliding glass windows?

If you are aware of staff members whose behavior could be more customer friendly, have you said something to them? It can be touchy. You probably aren’t their supervisor. They may not being doing anything wrong. But their failure to make a pleasant and caring first impression may be making your job more difficult.

Maybe it is a systemic problem that goes beyond the support staff. Could it be time to hire a consultant to help facilitate an office-wide facelift?

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].

A few weeks ago I visited my primary care physician in her new office. As the first patient of the day I was immediately ushered into the examining room by a woman I assume was a medical assistant. She didn’t introduce herself, but her name tag read “Marcy” (not her real name). Her demeanor could best be described as cheerless. She efficiently took my vital signs, asked me my height, and weighed me. She ran through the usual list of screening questions without the slightest hint of a smile despite my efforts to gently inject a bit of levity into my answers.

With her work completed, she left me to wait for “the doctor” without a clue about who I was. She knew that I had one beer and one glass of wine each evening, and that I always wore a seatbelt and didn’t have gun. But she hadn’t provided any outward evidence that she cared about the person who had been providing the answers.

There was a welcome lifting of the chill when my former colleague and current physician entered the exam room. After we had done some catching up about our families and before we started talking about my blood pressure I said, “Marcy really needs to lighten up a bit.”

My observation came as no surprise to my doctor. The transition to a new hospital-owned group practice still had some rough edges including the struggle to instill a more customer-friendly culture among the support staff that she had inherited. She thanked me for my unsolicited feedback.

When Marcy returned to administer my “pneumonia shot” she was wearing a smile. And she was more than willing to engage in the kind of banter that may not have much substance, but is the currency that most of us use to ease the tension in potentially uncomfortable situations. Obviously, while I was waiting she had been given a quick course in customer service.

Marcy and the receptionists are the face of that office, and it certainly wasn’t a welcoming or friendly face. No one was rude. On the other hand, no one was trying to treat the patients as they would like to be treated themselves. You could accuse me of being a nit picky curmudgeon. You could ask if the addition of a smiling face or two would have made a difference in the quality of care coming out of that office. It may not have, but it wouldn’t have hurt, and it would be the nice thing to do.

But I suspect that those initial impressions of interest and caring by the staff lessen the level of anxiety in anxious patients, and take some of the edge off the anger of patients who are unhappy about the care they have been receiving. There is some evidence that hospitalized patients in customer-friendly situations do better. And I bet that patients seen in customer-friendly offices staff get better more quickly.

 

Juanmonino/Getty Images

How friendly is the face of your office? You probably don’t have many patients who are as bold as I am to tell you that your assistant needs to smile more. But you may have seen or heard some exchanges between support staff and patients that make you cringe. Or, is your office organized like a fortress that isolates you from staff/patient interactions by doors and those customer-unfriendly sliding glass windows?

If you are aware of staff members whose behavior could be more customer friendly, have you said something to them? It can be touchy. You probably aren’t their supervisor. They may not being doing anything wrong. But their failure to make a pleasant and caring first impression may be making your job more difficult.

Maybe it is a systemic problem that goes beyond the support staff. Could it be time to hire a consultant to help facilitate an office-wide facelift?

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].

A few weeks ago I visited my primary care physician in her new office. As the first patient of the day I was immediately ushered into the examining room by a woman I assume was a medical assistant. She didn’t introduce herself, but her name tag read “Marcy” (not her real name). Her demeanor could best be described as cheerless. She efficiently took my vital signs, asked me my height, and weighed me. She ran through the usual list of screening questions without the slightest hint of a smile despite my efforts to gently inject a bit of levity into my answers.

With her work completed, she left me to wait for “the doctor” without a clue about who I was. She knew that I had one beer and one glass of wine each evening, and that I always wore a seatbelt and didn’t have gun. But she hadn’t provided any outward evidence that she cared about the person who had been providing the answers.

There was a welcome lifting of the chill when my former colleague and current physician entered the exam room. After we had done some catching up about our families and before we started talking about my blood pressure I said, “Marcy really needs to lighten up a bit.”

My observation came as no surprise to my doctor. The transition to a new hospital-owned group practice still had some rough edges including the struggle to instill a more customer-friendly culture among the support staff that she had inherited. She thanked me for my unsolicited feedback.

When Marcy returned to administer my “pneumonia shot” she was wearing a smile. And she was more than willing to engage in the kind of banter that may not have much substance, but is the currency that most of us use to ease the tension in potentially uncomfortable situations. Obviously, while I was waiting she had been given a quick course in customer service.

Marcy and the receptionists are the face of that office, and it certainly wasn’t a welcoming or friendly face. No one was rude. On the other hand, no one was trying to treat the patients as they would like to be treated themselves. You could accuse me of being a nit picky curmudgeon. You could ask if the addition of a smiling face or two would have made a difference in the quality of care coming out of that office. It may not have, but it wouldn’t have hurt, and it would be the nice thing to do.

But I suspect that those initial impressions of interest and caring by the staff lessen the level of anxiety in anxious patients, and take some of the edge off the anger of patients who are unhappy about the care they have been receiving. There is some evidence that hospitalized patients in customer-friendly situations do better. And I bet that patients seen in customer-friendly offices staff get better more quickly.

 

Juanmonino/Getty Images

How friendly is the face of your office? You probably don’t have many patients who are as bold as I am to tell you that your assistant needs to smile more. But you may have seen or heard some exchanges between support staff and patients that make you cringe. Or, is your office organized like a fortress that isolates you from staff/patient interactions by doors and those customer-unfriendly sliding glass windows?

If you are aware of staff members whose behavior could be more customer friendly, have you said something to them? It can be touchy. You probably aren’t their supervisor. They may not being doing anything wrong. But their failure to make a pleasant and caring first impression may be making your job more difficult.

Maybe it is a systemic problem that goes beyond the support staff. Could it be time to hire a consultant to help facilitate an office-wide facelift?

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].

The odds are that you are an employee. In 2016, for the first time ever, fewer than half of physicians in this country owned their own practice. There are numerous explanations for this shift away from independent ownership. But the bottom line is that more physicians are employees than owners (“For the first time, physician practice owners are not the majority,” By Brendan Murphy, AMA Wire, May 31, 2017). The transition to employee status doesn’t always go well.

While an increasing number of physicians are uninterested in or maybe even intimidated by the challenges of practice ownership, they seem to be even less interested in accepting the uncomfortable realities that can be associated with being an employee.

Practice ownership comes with a host of worries including cash flow, staffing, and overhead. On the other hand, an employee has only one critical concern: Can she trust her employer? You may not have considered your relationship with your employer in terms of trust. But I urge you to look at a recent commentary in Clinician Reviews by Randy D. Danielson, PhD, PA, DAAPA, titled, “Do You Trust Your Employer? (2018 Apr;28[4]:6-8). Dr. Danielson relates the experiences of a colleague who complains that the organization for which he worked completely lacked transparency of its goals and failed to provide accurate financial data. This combination of deficiencies prevented “providers from making a positive impact on cost containment.” The colleague added that the organization’s complex compensation formulas did “not account for the vagaries and complexities of health care.”

Do any of these complaints sound familiar to you? Do you share the same lack of trust in your employer that this provider has voiced? The remainder of Dr. Danielson’s commentary is a discussion of the concept of organizational trust and includes this unsurprising observation: “Lack of trust, particularly between management and employers, creates a hostile work environment in which stress levels are high and productivity is reduced.” It makes one wonder how much of the burnout epidemic among physicians and other providers might be the result of organizational distrust.

 

At what point in your career did you begin to lose trust in your employer? In retrospect, should you have been more diligent in researching its financial history? How did its acquisitions and reorganizations affect its employees? Did they reflect a pattern that is consistent with your philosophy about how and to whom health care should be delivered?

How carefully did you interview the organization’s employees? Did you sense any distrust? This kind of information doesn’t usually seep out in a 1-day visit and meetings with handpicked employees. Did employees feel that there was sufficient transparency? It is likely that they sat on committees. But did those committees have a voice that was heard and acted upon?

I’m sure the organization’s administrators and executives told you that they were committed to delivering “quality care.” It may have been included in the organization’s logo and mission statement. But could you find evidence that the organization was consistently behaving in a manner that reflected its stated mission?

If you were going to purchase a practice you would have done hours, days, and weeks of due diligence before signing a purchase and sales agreement. Deciding whether or not to sign a contract with an employer demands an equivalent amount of research and investigation. You already may have discovered that being trapped by a noncompete clause with an organization you don’t trust can put you on the fast track to burnout.
 

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].

The odds are that you are an employee. In 2016, for the first time ever, fewer than half of physicians in this country owned their own practice. There are numerous explanations for this shift away from independent ownership. But the bottom line is that more physicians are employees than owners (“For the first time, physician practice owners are not the majority,” By Brendan Murphy, AMA Wire, May 31, 2017). The transition to employee status doesn’t always go well.

While an increasing number of physicians are uninterested in or maybe even intimidated by the challenges of practice ownership, they seem to be even less interested in accepting the uncomfortable realities that can be associated with being an employee.

Practice ownership comes with a host of worries including cash flow, staffing, and overhead. On the other hand, an employee has only one critical concern: Can she trust her employer? You may not have considered your relationship with your employer in terms of trust. But I urge you to look at a recent commentary in Clinician Reviews by Randy D. Danielson, PhD, PA, DAAPA, titled, “Do You Trust Your Employer? (2018 Apr;28[4]:6-8). Dr. Danielson relates the experiences of a colleague who complains that the organization for which he worked completely lacked transparency of its goals and failed to provide accurate financial data. This combination of deficiencies prevented “providers from making a positive impact on cost containment.” The colleague added that the organization’s complex compensation formulas did “not account for the vagaries and complexities of health care.”

Do any of these complaints sound familiar to you? Do you share the same lack of trust in your employer that this provider has voiced? The remainder of Dr. Danielson’s commentary is a discussion of the concept of organizational trust and includes this unsurprising observation: “Lack of trust, particularly between management and employers, creates a hostile work environment in which stress levels are high and productivity is reduced.” It makes one wonder how much of the burnout epidemic among physicians and other providers might be the result of organizational distrust.

 

At what point in your career did you begin to lose trust in your employer? In retrospect, should you have been more diligent in researching its financial history? How did its acquisitions and reorganizations affect its employees? Did they reflect a pattern that is consistent with your philosophy about how and to whom health care should be delivered?

How carefully did you interview the organization’s employees? Did you sense any distrust? This kind of information doesn’t usually seep out in a 1-day visit and meetings with handpicked employees. Did employees feel that there was sufficient transparency? It is likely that they sat on committees. But did those committees have a voice that was heard and acted upon?

I’m sure the organization’s administrators and executives told you that they were committed to delivering “quality care.” It may have been included in the organization’s logo and mission statement. But could you find evidence that the organization was consistently behaving in a manner that reflected its stated mission?

If you were going to purchase a practice you would have done hours, days, and weeks of due diligence before signing a purchase and sales agreement. Deciding whether or not to sign a contract with an employer demands an equivalent amount of research and investigation. You already may have discovered that being trapped by a noncompete clause with an organization you don’t trust can put you on the fast track to burnout.
 

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].

The odds are that you are an employee. In 2016, for the first time ever, fewer than half of physicians in this country owned their own practice. There are numerous explanations for this shift away from independent ownership. But the bottom line is that more physicians are employees than owners (“For the first time, physician practice owners are not the majority,” By Brendan Murphy, AMA Wire, May 31, 2017). The transition to employee status doesn’t always go well.

While an increasing number of physicians are uninterested in or maybe even intimidated by the challenges of practice ownership, they seem to be even less interested in accepting the uncomfortable realities that can be associated with being an employee.

Practice ownership comes with a host of worries including cash flow, staffing, and overhead. On the other hand, an employee has only one critical concern: Can she trust her employer? You may not have considered your relationship with your employer in terms of trust. But I urge you to look at a recent commentary in Clinician Reviews by Randy D. Danielson, PhD, PA, DAAPA, titled, “Do You Trust Your Employer? (2018 Apr;28[4]:6-8). Dr. Danielson relates the experiences of a colleague who complains that the organization for which he worked completely lacked transparency of its goals and failed to provide accurate financial data. This combination of deficiencies prevented “providers from making a positive impact on cost containment.” The colleague added that the organization’s complex compensation formulas did “not account for the vagaries and complexities of health care.”

Do any of these complaints sound familiar to you? Do you share the same lack of trust in your employer that this provider has voiced? The remainder of Dr. Danielson’s commentary is a discussion of the concept of organizational trust and includes this unsurprising observation: “Lack of trust, particularly between management and employers, creates a hostile work environment in which stress levels are high and productivity is reduced.” It makes one wonder how much of the burnout epidemic among physicians and other providers might be the result of organizational distrust.

 

At what point in your career did you begin to lose trust in your employer? In retrospect, should you have been more diligent in researching its financial history? How did its acquisitions and reorganizations affect its employees? Did they reflect a pattern that is consistent with your philosophy about how and to whom health care should be delivered?

How carefully did you interview the organization’s employees? Did you sense any distrust? This kind of information doesn’t usually seep out in a 1-day visit and meetings with handpicked employees. Did employees feel that there was sufficient transparency? It is likely that they sat on committees. But did those committees have a voice that was heard and acted upon?

I’m sure the organization’s administrators and executives told you that they were committed to delivering “quality care.” It may have been included in the organization’s logo and mission statement. But could you find evidence that the organization was consistently behaving in a manner that reflected its stated mission?

If you were going to purchase a practice you would have done hours, days, and weeks of due diligence before signing a purchase and sales agreement. Deciding whether or not to sign a contract with an employer demands an equivalent amount of research and investigation. You already may have discovered that being trapped by a noncompete clause with an organization you don’t trust can put you on the fast track to burnout.
 

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].

 

How do you feel about homework? Do you think your school-age patients are given too much homework? Would they be better off spending their after-school time at home in free play or exploring nonacademic interests? Or, do you feel the school day is too short to adequately cover what a well-educated child needs to know? Doesn’t homework foster good independent work habits and discipline?

Do you have fond memories of doing homework? Are you glad those days of bringing home an hour or 3 of extra work are behind you? Maybe they aren’t behind you. Are you still spending an hour or more getting stuff done at home you didn’t get done in the office?

aluxum/E+/Getty Images

If you are early in your career or even if you are a seasoned clinician, you are likely to still be doing homework. And you probably find it stressful. A recent survey of 1,200 early career pediatricians reported in an issue of AAP News (“What do early career pediatricians find stressful?”April 5, 2018) found that 52% of the respondents found “finishing/catching up with work from job at home” very or moderately stressful. Homework topped the list of stressors including staying current on medical knowledge (33%) and “providing care to children and adolescents (a reassuring 20%).

Primary care pediatrics has never promised its practitioners that they will arrive at home at the end of the workday free of unfinished business. If you have after-hours call responsibilities, there always have been phone calls, decisions to make, and trips to EDs and delivery rooms. Even if you are fortunate enough to not have after-hours call responsibilities, there are certainly evenings when you are nagged by second thoughts and worries about troublesome patients you have seen during the day. Did you make the correct diagnosis or forget to order a critical lab test?

This kind of homework is expected. It’s what you signed up for. But with experience, you learn how to provide better anticipatory guidance that can decrease the number of after-hours calls. You can minimize, but never eliminate, second-guessing by learning to make wiser diagnostic and therapeutic decisions.

However, arriving home with a laptop or notebook loaded with unfinished electronic health records and work-related emails is not what you thought primary care pediatrics was about ... and it didn’t used to be. For the first 35 years of practice, when I saw my last patient, my office work was over. If I wasn’t on call, I could enjoy the entire evening with my family uninterrupted.

But change happens. Coincident with the launch of a new computer system, my workday became an hour longer so that I could complete my electronic office notes before I went home. For some of my colleagues, this unwelcome addition ran more than an hour and a half or 2 hours, and many of them leapt at the practice administrator’s offer to link their home computers with our new office EHR. Buried in what sounded like a good deal to them, I could hear the creaky opening of a Pandora’s box.

 

Dealing with emergencies and reassuring parents after hours is at the core of pediatrics. However, spending hours at a home computer tidying up EHRs is a task devoid of meaning and reward. No wonder more than half of early-career pediatricians surveyed find it stressful. The time to revolt is long overdue. We need to stop playing the nice guy role and begin demanding that we be paid for those hours we spend at the computer. That would be a giant first step toward returning our homes to the sanctuaries of refreshment they once were and still should be.
 

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].

 

How do you feel about homework? Do you think your school-age patients are given too much homework? Would they be better off spending their after-school time at home in free play or exploring nonacademic interests? Or, do you feel the school day is too short to adequately cover what a well-educated child needs to know? Doesn’t homework foster good independent work habits and discipline?

Do you have fond memories of doing homework? Are you glad those days of bringing home an hour or 3 of extra work are behind you? Maybe they aren’t behind you. Are you still spending an hour or more getting stuff done at home you didn’t get done in the office?

aluxum/E+/Getty Images

If you are early in your career or even if you are a seasoned clinician, you are likely to still be doing homework. And you probably find it stressful. A recent survey of 1,200 early career pediatricians reported in an issue of AAP News (“What do early career pediatricians find stressful?”April 5, 2018) found that 52% of the respondents found “finishing/catching up with work from job at home” very or moderately stressful. Homework topped the list of stressors including staying current on medical knowledge (33%) and “providing care to children and adolescents (a reassuring 20%).

Primary care pediatrics has never promised its practitioners that they will arrive at home at the end of the workday free of unfinished business. If you have after-hours call responsibilities, there always have been phone calls, decisions to make, and trips to EDs and delivery rooms. Even if you are fortunate enough to not have after-hours call responsibilities, there are certainly evenings when you are nagged by second thoughts and worries about troublesome patients you have seen during the day. Did you make the correct diagnosis or forget to order a critical lab test?

This kind of homework is expected. It’s what you signed up for. But with experience, you learn how to provide better anticipatory guidance that can decrease the number of after-hours calls. You can minimize, but never eliminate, second-guessing by learning to make wiser diagnostic and therapeutic decisions.

However, arriving home with a laptop or notebook loaded with unfinished electronic health records and work-related emails is not what you thought primary care pediatrics was about ... and it didn’t used to be. For the first 35 years of practice, when I saw my last patient, my office work was over. If I wasn’t on call, I could enjoy the entire evening with my family uninterrupted.

But change happens. Coincident with the launch of a new computer system, my workday became an hour longer so that I could complete my electronic office notes before I went home. For some of my colleagues, this unwelcome addition ran more than an hour and a half or 2 hours, and many of them leapt at the practice administrator’s offer to link their home computers with our new office EHR. Buried in what sounded like a good deal to them, I could hear the creaky opening of a Pandora’s box.

 

Dealing with emergencies and reassuring parents after hours is at the core of pediatrics. However, spending hours at a home computer tidying up EHRs is a task devoid of meaning and reward. No wonder more than half of early-career pediatricians surveyed find it stressful. The time to revolt is long overdue. We need to stop playing the nice guy role and begin demanding that we be paid for those hours we spend at the computer. That would be a giant first step toward returning our homes to the sanctuaries of refreshment they once were and still should be.
 

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].

 

How do you feel about homework? Do you think your school-age patients are given too much homework? Would they be better off spending their after-school time at home in free play or exploring nonacademic interests? Or, do you feel the school day is too short to adequately cover what a well-educated child needs to know? Doesn’t homework foster good independent work habits and discipline?

Do you have fond memories of doing homework? Are you glad those days of bringing home an hour or 3 of extra work are behind you? Maybe they aren’t behind you. Are you still spending an hour or more getting stuff done at home you didn’t get done in the office?

aluxum/E+/Getty Images

If you are early in your career or even if you are a seasoned clinician, you are likely to still be doing homework. And you probably find it stressful. A recent survey of 1,200 early career pediatricians reported in an issue of AAP News (“What do early career pediatricians find stressful?”April 5, 2018) found that 52% of the respondents found “finishing/catching up with work from job at home” very or moderately stressful. Homework topped the list of stressors including staying current on medical knowledge (33%) and “providing care to children and adolescents (a reassuring 20%).

Primary care pediatrics has never promised its practitioners that they will arrive at home at the end of the workday free of unfinished business. If you have after-hours call responsibilities, there always have been phone calls, decisions to make, and trips to EDs and delivery rooms. Even if you are fortunate enough to not have after-hours call responsibilities, there are certainly evenings when you are nagged by second thoughts and worries about troublesome patients you have seen during the day. Did you make the correct diagnosis or forget to order a critical lab test?

This kind of homework is expected. It’s what you signed up for. But with experience, you learn how to provide better anticipatory guidance that can decrease the number of after-hours calls. You can minimize, but never eliminate, second-guessing by learning to make wiser diagnostic and therapeutic decisions.

However, arriving home with a laptop or notebook loaded with unfinished electronic health records and work-related emails is not what you thought primary care pediatrics was about ... and it didn’t used to be. For the first 35 years of practice, when I saw my last patient, my office work was over. If I wasn’t on call, I could enjoy the entire evening with my family uninterrupted.

But change happens. Coincident with the launch of a new computer system, my workday became an hour longer so that I could complete my electronic office notes before I went home. For some of my colleagues, this unwelcome addition ran more than an hour and a half or 2 hours, and many of them leapt at the practice administrator’s offer to link their home computers with our new office EHR. Buried in what sounded like a good deal to them, I could hear the creaky opening of a Pandora’s box.

 

Dealing with emergencies and reassuring parents after hours is at the core of pediatrics. However, spending hours at a home computer tidying up EHRs is a task devoid of meaning and reward. No wonder more than half of early-career pediatricians surveyed find it stressful. The time to revolt is long overdue. We need to stop playing the nice guy role and begin demanding that we be paid for those hours we spend at the computer. That would be a giant first step toward returning our homes to the sanctuaries of refreshment they once were and still should be.
 

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].

 

Do you have a creative diversion – a hobby for lack of a better word? One frequently hears of physicians who have creative skills not directly related to their professional careers. Furniture-building surgeons, fly-tying orthopedists, pediatrician poets, painting dermatologists ... I have even heard unsubstantiated claims that the traits that encourage individuals to become physicians make it more likely that they will have creative skills. Another one of those left brain/right brain things that probably doesn’t hold water.

If you do have a hobby or have the seed of a creative impulse you think could blossom into a hobby, I bet you wish that you could have an unlimited amount of time to invest in that activity. I am going to argue that this is another example of a situation in which you should be careful what you wish for.

SeventyFour/iStock/Getty Images

When I was 9 or 10 years old, I bought a small carving of a sandpiper in a gift shop on Cape Cod. I still have it with its chipped bill and yellowed paper label on its driftwood base. That little bird triggered my interest in carving, and with gaps sometimes measured in decades I have been a self-taught bird carver. Some are attempts at realism with burned in feathers that takes weeks to complete. Others are free form painted whimsically, and are created in a few hours. They aren’t for sale, but to keep my inventory in check I distribute them as birthday and hostess gifts.

Ten years ago, after decades of visiting art galleries and grumbling to my wife, “I could do that,” I decided to try my hand at two-dimensional landscape painting. It was a fun challenge, and after a year or 2, I was ready to see what other people thought of my work. The first show that I entered stipulated that all of the entries be for sale. With no intention of parting with my work, I priced mine several orders of magnitude above what I thought they were worth.

 

One sold, and with that began a 7-year period during which pretty much anything I painted with a maritime theme sold for hundreds of dollars. It was a nice ego trip, but it took me down a dark path in which I began to choose my subjects and style based on what I knew would sell. Creating was no longer something I did for a change of pace. I was now retired, but painting had become my job. I felt burdened by the obligation to paint enough to cover the walls of the restaurant that graciously hung my work.

Luckily, the epiphany that I had sacrificed my creative diversion, which began with that little sandpiper, coincided with the restaurant’s decision to redecorate and the loss of much of my hanging space. I was now free to paint subjects I was interested in, and return to the comfort of carving when I felt the need to create.

If you don’t have a hobby, I urge you open yourself to a wide range of possibilities and take your time experimenting. If you already have a creative diversion, remember that a large part of its appeal is that it plays counterpoint to your job. Even if you are retired, a hobby provides a change of pace from which we can all benefit.

You may or may not derive some of your inspiration from what you see and feel while you are at work. I never found that my hobby was escape because I enjoyed working. But having a creative diversion always has given me a chance to exercise parts of my mind and body simply because it wasn’t my job.
 

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].

 

Do you have a creative diversion – a hobby for lack of a better word? One frequently hears of physicians who have creative skills not directly related to their professional careers. Furniture-building surgeons, fly-tying orthopedists, pediatrician poets, painting dermatologists ... I have even heard unsubstantiated claims that the traits that encourage individuals to become physicians make it more likely that they will have creative skills. Another one of those left brain/right brain things that probably doesn’t hold water.

If you do have a hobby or have the seed of a creative impulse you think could blossom into a hobby, I bet you wish that you could have an unlimited amount of time to invest in that activity. I am going to argue that this is another example of a situation in which you should be careful what you wish for.

SeventyFour/iStock/Getty Images

When I was 9 or 10 years old, I bought a small carving of a sandpiper in a gift shop on Cape Cod. I still have it with its chipped bill and yellowed paper label on its driftwood base. That little bird triggered my interest in carving, and with gaps sometimes measured in decades I have been a self-taught bird carver. Some are attempts at realism with burned in feathers that takes weeks to complete. Others are free form painted whimsically, and are created in a few hours. They aren’t for sale, but to keep my inventory in check I distribute them as birthday and hostess gifts.

Ten years ago, after decades of visiting art galleries and grumbling to my wife, “I could do that,” I decided to try my hand at two-dimensional landscape painting. It was a fun challenge, and after a year or 2, I was ready to see what other people thought of my work. The first show that I entered stipulated that all of the entries be for sale. With no intention of parting with my work, I priced mine several orders of magnitude above what I thought they were worth.

 

One sold, and with that began a 7-year period during which pretty much anything I painted with a maritime theme sold for hundreds of dollars. It was a nice ego trip, but it took me down a dark path in which I began to choose my subjects and style based on what I knew would sell. Creating was no longer something I did for a change of pace. I was now retired, but painting had become my job. I felt burdened by the obligation to paint enough to cover the walls of the restaurant that graciously hung my work.

Luckily, the epiphany that I had sacrificed my creative diversion, which began with that little sandpiper, coincided with the restaurant’s decision to redecorate and the loss of much of my hanging space. I was now free to paint subjects I was interested in, and return to the comfort of carving when I felt the need to create.

If you don’t have a hobby, I urge you open yourself to a wide range of possibilities and take your time experimenting. If you already have a creative diversion, remember that a large part of its appeal is that it plays counterpoint to your job. Even if you are retired, a hobby provides a change of pace from which we can all benefit.

You may or may not derive some of your inspiration from what you see and feel while you are at work. I never found that my hobby was escape because I enjoyed working. But having a creative diversion always has given me a chance to exercise parts of my mind and body simply because it wasn’t my job.
 

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].

 

Do you have a creative diversion – a hobby for lack of a better word? One frequently hears of physicians who have creative skills not directly related to their professional careers. Furniture-building surgeons, fly-tying orthopedists, pediatrician poets, painting dermatologists ... I have even heard unsubstantiated claims that the traits that encourage individuals to become physicians make it more likely that they will have creative skills. Another one of those left brain/right brain things that probably doesn’t hold water.

If you do have a hobby or have the seed of a creative impulse you think could blossom into a hobby, I bet you wish that you could have an unlimited amount of time to invest in that activity. I am going to argue that this is another example of a situation in which you should be careful what you wish for.

SeventyFour/iStock/Getty Images

When I was 9 or 10 years old, I bought a small carving of a sandpiper in a gift shop on Cape Cod. I still have it with its chipped bill and yellowed paper label on its driftwood base. That little bird triggered my interest in carving, and with gaps sometimes measured in decades I have been a self-taught bird carver. Some are attempts at realism with burned in feathers that takes weeks to complete. Others are free form painted whimsically, and are created in a few hours. They aren’t for sale, but to keep my inventory in check I distribute them as birthday and hostess gifts.

Ten years ago, after decades of visiting art galleries and grumbling to my wife, “I could do that,” I decided to try my hand at two-dimensional landscape painting. It was a fun challenge, and after a year or 2, I was ready to see what other people thought of my work. The first show that I entered stipulated that all of the entries be for sale. With no intention of parting with my work, I priced mine several orders of magnitude above what I thought they were worth.

 

One sold, and with that began a 7-year period during which pretty much anything I painted with a maritime theme sold for hundreds of dollars. It was a nice ego trip, but it took me down a dark path in which I began to choose my subjects and style based on what I knew would sell. Creating was no longer something I did for a change of pace. I was now retired, but painting had become my job. I felt burdened by the obligation to paint enough to cover the walls of the restaurant that graciously hung my work.

Luckily, the epiphany that I had sacrificed my creative diversion, which began with that little sandpiper, coincided with the restaurant’s decision to redecorate and the loss of much of my hanging space. I was now free to paint subjects I was interested in, and return to the comfort of carving when I felt the need to create.

If you don’t have a hobby, I urge you open yourself to a wide range of possibilities and take your time experimenting. If you already have a creative diversion, remember that a large part of its appeal is that it plays counterpoint to your job. Even if you are retired, a hobby provides a change of pace from which we can all benefit.

You may or may not derive some of your inspiration from what you see and feel while you are at work. I never found that my hobby was escape because I enjoyed working. But having a creative diversion always has given me a chance to exercise parts of my mind and body simply because it wasn’t my job.
 

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].