Letters from Maine

 

It’s very likely that you have at least one or two female patients who play lacrosse. The sport has been reported to be the fastest-growing high school sport in the United States. (“Lacrosse is Actually America’s Fastest-Growing Sport,” by John Templon, BuzzFeed News, June 30, 2014). When I played in college, most of my teammates were products of prep schools in the Northeast or one of the few local hotbeds in Baltimore, Long Island, or the Finger Lakes Region of New York. But pickings were slim, and there was room for walk-ons like me looking to learn a new sport and stay in shape for football. Now hundreds of high schools in all parts of the country offer the sport for both boys and girls.

Although the two versions of the sport use similar-appearing sticks, the same ball and goal, confrontations between the players and their sticks are forbidden in the girls’ game. Women are not even allowed to windup and fire the hard rubber ball with maximum force because it might injure an opponent. Surrounded by a surplus of rules governing body contact and stick control, female lacrosse players have traditionally played without protective equipment other than a lightweight eye cage. The goalies, however, are amply padded and helmeted.

With growing awareness of the long-term effects of repeated head trauma, there has been a call from some parents and organizers of women’s lacrosse to require helmets on all players (“As Concussion Worries Rise, Girls’ Lacrosse Turns to Headgear,” by Bill Pennington, The New York Times, Nov 23, 2017). To those of us who have committed our professional lives to the health of children, the inclusion of helmets to the standard equipment for a female lacrosse player sounds like a good idea.

However, the proposed mandate has its critics, including several college coaches. Karen Corbett, women’s lacrosse coach at the University of Pennsylvania, has said that, players “will start to lead with their head because they feel protected, and that causes more injuries. We’ll become a more physical sport and a very different sport than we are today.”

kjuniper/Thinkstock

This is not some old-school traditionalist, no-change-is-good blather. One only has to look at the evolution men’s ice hockey to validate her concern. In 1977, Dr. Daniel Hanley, the chief physician of the United States Olympic Team, told me he was sure that, in the wake of the National Collegiate Athletic Association’s upcoming mandate of full face masks for college hockey players, the character of the game would change, and not for the better. He felt that sticks would come up off the ice more often and be wielded more carelessly. Of greater concern to him was that players, emboldened by their false sense of invulnerability from behind their masks, would begin to take more risks with their head and neck.

Although I’m afraid that there are few data to support the validity of Dr. Hanley’s prediction, any observer of college hockey over the last 3 or 4 decades will tell you that he was unfortunately correct. There have been certainly fewer lacerations and eye injuries since face masks were introduced, but the game has become far more violent, and head, neck, and spine injuries have become more frequent. I think part of the problem is that game officials have been duped by the same false assumption as the players that more protection would make the game safer, and enforcement of the rules has not kept up with the technological changes.

There will always be injuries in any sport, but before we as physicians lend our support to a proposed change in protective equipment, we should step back and look at the broader picture. While the loss of an eye for an individual player is a tragedy, did we put several dozen more players at greater risk for spinal injury in college hockey with more protective gear? If adding headgear protects female lacrosse players from concussions, what might be the result if play becomes more physical? Protection can come with a price.


 

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].

 

It’s very likely that you have at least one or two female patients who play lacrosse. The sport has been reported to be the fastest-growing high school sport in the United States. (“Lacrosse is Actually America’s Fastest-Growing Sport,” by John Templon, BuzzFeed News, June 30, 2014). When I played in college, most of my teammates were products of prep schools in the Northeast or one of the few local hotbeds in Baltimore, Long Island, or the Finger Lakes Region of New York. But pickings were slim, and there was room for walk-ons like me looking to learn a new sport and stay in shape for football. Now hundreds of high schools in all parts of the country offer the sport for both boys and girls.

Although the two versions of the sport use similar-appearing sticks, the same ball and goal, confrontations between the players and their sticks are forbidden in the girls’ game. Women are not even allowed to windup and fire the hard rubber ball with maximum force because it might injure an opponent. Surrounded by a surplus of rules governing body contact and stick control, female lacrosse players have traditionally played without protective equipment other than a lightweight eye cage. The goalies, however, are amply padded and helmeted.

With growing awareness of the long-term effects of repeated head trauma, there has been a call from some parents and organizers of women’s lacrosse to require helmets on all players (“As Concussion Worries Rise, Girls’ Lacrosse Turns to Headgear,” by Bill Pennington, The New York Times, Nov 23, 2017). To those of us who have committed our professional lives to the health of children, the inclusion of helmets to the standard equipment for a female lacrosse player sounds like a good idea.

However, the proposed mandate has its critics, including several college coaches. Karen Corbett, women’s lacrosse coach at the University of Pennsylvania, has said that, players “will start to lead with their head because they feel protected, and that causes more injuries. We’ll become a more physical sport and a very different sport than we are today.”

kjuniper/Thinkstock

This is not some old-school traditionalist, no-change-is-good blather. One only has to look at the evolution men’s ice hockey to validate her concern. In 1977, Dr. Daniel Hanley, the chief physician of the United States Olympic Team, told me he was sure that, in the wake of the National Collegiate Athletic Association’s upcoming mandate of full face masks for college hockey players, the character of the game would change, and not for the better. He felt that sticks would come up off the ice more often and be wielded more carelessly. Of greater concern to him was that players, emboldened by their false sense of invulnerability from behind their masks, would begin to take more risks with their head and neck.

Although I’m afraid that there are few data to support the validity of Dr. Hanley’s prediction, any observer of college hockey over the last 3 or 4 decades will tell you that he was unfortunately correct. There have been certainly fewer lacerations and eye injuries since face masks were introduced, but the game has become far more violent, and head, neck, and spine injuries have become more frequent. I think part of the problem is that game officials have been duped by the same false assumption as the players that more protection would make the game safer, and enforcement of the rules has not kept up with the technological changes.

There will always be injuries in any sport, but before we as physicians lend our support to a proposed change in protective equipment, we should step back and look at the broader picture. While the loss of an eye for an individual player is a tragedy, did we put several dozen more players at greater risk for spinal injury in college hockey with more protective gear? If adding headgear protects female lacrosse players from concussions, what might be the result if play becomes more physical? Protection can come with a price.


 

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].

 

It’s very likely that you have at least one or two female patients who play lacrosse. The sport has been reported to be the fastest-growing high school sport in the United States. (“Lacrosse is Actually America’s Fastest-Growing Sport,” by John Templon, BuzzFeed News, June 30, 2014). When I played in college, most of my teammates were products of prep schools in the Northeast or one of the few local hotbeds in Baltimore, Long Island, or the Finger Lakes Region of New York. But pickings were slim, and there was room for walk-ons like me looking to learn a new sport and stay in shape for football. Now hundreds of high schools in all parts of the country offer the sport for both boys and girls.

Although the two versions of the sport use similar-appearing sticks, the same ball and goal, confrontations between the players and their sticks are forbidden in the girls’ game. Women are not even allowed to windup and fire the hard rubber ball with maximum force because it might injure an opponent. Surrounded by a surplus of rules governing body contact and stick control, female lacrosse players have traditionally played without protective equipment other than a lightweight eye cage. The goalies, however, are amply padded and helmeted.

With growing awareness of the long-term effects of repeated head trauma, there has been a call from some parents and organizers of women’s lacrosse to require helmets on all players (“As Concussion Worries Rise, Girls’ Lacrosse Turns to Headgear,” by Bill Pennington, The New York Times, Nov 23, 2017). To those of us who have committed our professional lives to the health of children, the inclusion of helmets to the standard equipment for a female lacrosse player sounds like a good idea.

However, the proposed mandate has its critics, including several college coaches. Karen Corbett, women’s lacrosse coach at the University of Pennsylvania, has said that, players “will start to lead with their head because they feel protected, and that causes more injuries. We’ll become a more physical sport and a very different sport than we are today.”

kjuniper/Thinkstock

This is not some old-school traditionalist, no-change-is-good blather. One only has to look at the evolution men’s ice hockey to validate her concern. In 1977, Dr. Daniel Hanley, the chief physician of the United States Olympic Team, told me he was sure that, in the wake of the National Collegiate Athletic Association’s upcoming mandate of full face masks for college hockey players, the character of the game would change, and not for the better. He felt that sticks would come up off the ice more often and be wielded more carelessly. Of greater concern to him was that players, emboldened by their false sense of invulnerability from behind their masks, would begin to take more risks with their head and neck.

Although I’m afraid that there are few data to support the validity of Dr. Hanley’s prediction, any observer of college hockey over the last 3 or 4 decades will tell you that he was unfortunately correct. There have been certainly fewer lacerations and eye injuries since face masks were introduced, but the game has become far more violent, and head, neck, and spine injuries have become more frequent. I think part of the problem is that game officials have been duped by the same false assumption as the players that more protection would make the game safer, and enforcement of the rules has not kept up with the technological changes.

There will always be injuries in any sport, but before we as physicians lend our support to a proposed change in protective equipment, we should step back and look at the broader picture. While the loss of an eye for an individual player is a tragedy, did we put several dozen more players at greater risk for spinal injury in college hockey with more protective gear? If adding headgear protects female lacrosse players from concussions, what might be the result if play becomes more physical? Protection can come with a price.


 

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].

 

Within the academic pediatric community, there is little argument that the concepts “evidence based” and “early intervention” are gold standards against which we must measure our efforts.

It should be obvious to everyone that if we can intervene early in a child’s developmental trajectory, our chances of affecting his/her outcome are improved. And the earlier the better. If we aren’t supremely committed to prevention, then what sets pediatrics apart from the other specialties?

Likewise, if we aren’t willing to systematically measure our efforts at improving the health of our patients, we run the risk of simply spinning our wheels and even worse, squandering our patients’ time and their parents’ energies. However, a recent article in Pediatrics and a companion commentary suggest that we need to be more careful as we interpret the buzz that surrounds the terms “early intervention” and “evidence based.”

In their one-sentence conclusion of a paper reviewing 48 studies of early intervention in early childhood development, the authors observe, “Although several interventions resulted in improved child development outcomes age 0 to 3 years, comparison across studies and interventions is limited by the use of different outcome measures, time of evaluation, and variability of results” (“Primary Care Interventions for Early Childhood Development: A Systematic Review,” Peacock-Chambers et al. Pediatrics. 2017, Nov 14. doi: 10.1542/peds.2017-1661). Unless you are looking for another reason to slip further into an abyss of despair, I urge that you skip reading the details of the Peacock-Chambers paper and turn instead to Dr. Jack P. Shonkoff’s excellent commentary (“Rethinking the Definition of Evidence-Based Interventions to Promote Early Child Development,” Pediatrics. 2017, Dec. doi: 10.1542/peds.2017-3136).

Dr. Shonkoff observes that there is ample evidence to support the general concept of early intervention as it relates to childhood development. However, he acknowledges that the improvements observed generally have been small. And there has been little success in scaling these few successes to larger populations. It would seem that the sacred cow of early intervention remains standing, albeit on somewhat shaky legs.

However, when it comes to the usefulness of an evidence-based yardstick, Dr. Shonkoff is understandably less reassuring. The results of the Peacock-Chambers paper alone should give us pause rather than our blindly accepting results of a trial just because it has appeared in a peer-reviewed journal. As Peacock-Cambers et al. remind us, comparing interventions that differ in outcomes measured and time sequences is difficult, if not impossible.

Dr. Shonkoff points out that an obsession with statistical significance often has blinded some of us to the importance of the magnitude of (or the lack of) impact when interpreting studies of early intervention. As a result, we may have failed to realize how far research in early childhood development has fallen behind the other fields of biomedical research such as cancer, HIV, and AIDS. His plea is that we begin to leverage our successes in fields such as molecular biology, epigenetics, and neuroscience when designing future studies of early childhood development. He asserts that this kind of basic science – in concert with “on-the-ground experience” (that’s you and me) and “authentic parental engagement” – is more likely to result in greater scalable impact for our patients threatened by developmental delays.

It is refreshing and encouraging reading a critical consideration of the evidence-based sacred cow. Evidence can be viewed from a variety of perspectives. If we continue to filter all of our observations through a statistical significance filter, we run the risk of missing both the forest and the trees.
 

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].

 

Within the academic pediatric community, there is little argument that the concepts “evidence based” and “early intervention” are gold standards against which we must measure our efforts.

It should be obvious to everyone that if we can intervene early in a child’s developmental trajectory, our chances of affecting his/her outcome are improved. And the earlier the better. If we aren’t supremely committed to prevention, then what sets pediatrics apart from the other specialties?

Likewise, if we aren’t willing to systematically measure our efforts at improving the health of our patients, we run the risk of simply spinning our wheels and even worse, squandering our patients’ time and their parents’ energies. However, a recent article in Pediatrics and a companion commentary suggest that we need to be more careful as we interpret the buzz that surrounds the terms “early intervention” and “evidence based.”

In their one-sentence conclusion of a paper reviewing 48 studies of early intervention in early childhood development, the authors observe, “Although several interventions resulted in improved child development outcomes age 0 to 3 years, comparison across studies and interventions is limited by the use of different outcome measures, time of evaluation, and variability of results” (“Primary Care Interventions for Early Childhood Development: A Systematic Review,” Peacock-Chambers et al. Pediatrics. 2017, Nov 14. doi: 10.1542/peds.2017-1661). Unless you are looking for another reason to slip further into an abyss of despair, I urge that you skip reading the details of the Peacock-Chambers paper and turn instead to Dr. Jack P. Shonkoff’s excellent commentary (“Rethinking the Definition of Evidence-Based Interventions to Promote Early Child Development,” Pediatrics. 2017, Dec. doi: 10.1542/peds.2017-3136).

Dr. Shonkoff observes that there is ample evidence to support the general concept of early intervention as it relates to childhood development. However, he acknowledges that the improvements observed generally have been small. And there has been little success in scaling these few successes to larger populations. It would seem that the sacred cow of early intervention remains standing, albeit on somewhat shaky legs.

However, when it comes to the usefulness of an evidence-based yardstick, Dr. Shonkoff is understandably less reassuring. The results of the Peacock-Chambers paper alone should give us pause rather than our blindly accepting results of a trial just because it has appeared in a peer-reviewed journal. As Peacock-Cambers et al. remind us, comparing interventions that differ in outcomes measured and time sequences is difficult, if not impossible.

Dr. Shonkoff points out that an obsession with statistical significance often has blinded some of us to the importance of the magnitude of (or the lack of) impact when interpreting studies of early intervention. As a result, we may have failed to realize how far research in early childhood development has fallen behind the other fields of biomedical research such as cancer, HIV, and AIDS. His plea is that we begin to leverage our successes in fields such as molecular biology, epigenetics, and neuroscience when designing future studies of early childhood development. He asserts that this kind of basic science – in concert with “on-the-ground experience” (that’s you and me) and “authentic parental engagement” – is more likely to result in greater scalable impact for our patients threatened by developmental delays.

It is refreshing and encouraging reading a critical consideration of the evidence-based sacred cow. Evidence can be viewed from a variety of perspectives. If we continue to filter all of our observations through a statistical significance filter, we run the risk of missing both the forest and the trees.
 

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].

 

Within the academic pediatric community, there is little argument that the concepts “evidence based” and “early intervention” are gold standards against which we must measure our efforts.

It should be obvious to everyone that if we can intervene early in a child’s developmental trajectory, our chances of affecting his/her outcome are improved. And the earlier the better. If we aren’t supremely committed to prevention, then what sets pediatrics apart from the other specialties?

Likewise, if we aren’t willing to systematically measure our efforts at improving the health of our patients, we run the risk of simply spinning our wheels and even worse, squandering our patients’ time and their parents’ energies. However, a recent article in Pediatrics and a companion commentary suggest that we need to be more careful as we interpret the buzz that surrounds the terms “early intervention” and “evidence based.”

In their one-sentence conclusion of a paper reviewing 48 studies of early intervention in early childhood development, the authors observe, “Although several interventions resulted in improved child development outcomes age 0 to 3 years, comparison across studies and interventions is limited by the use of different outcome measures, time of evaluation, and variability of results” (“Primary Care Interventions for Early Childhood Development: A Systematic Review,” Peacock-Chambers et al. Pediatrics. 2017, Nov 14. doi: 10.1542/peds.2017-1661). Unless you are looking for another reason to slip further into an abyss of despair, I urge that you skip reading the details of the Peacock-Chambers paper and turn instead to Dr. Jack P. Shonkoff’s excellent commentary (“Rethinking the Definition of Evidence-Based Interventions to Promote Early Child Development,” Pediatrics. 2017, Dec. doi: 10.1542/peds.2017-3136).

Dr. Shonkoff observes that there is ample evidence to support the general concept of early intervention as it relates to childhood development. However, he acknowledges that the improvements observed generally have been small. And there has been little success in scaling these few successes to larger populations. It would seem that the sacred cow of early intervention remains standing, albeit on somewhat shaky legs.

However, when it comes to the usefulness of an evidence-based yardstick, Dr. Shonkoff is understandably less reassuring. The results of the Peacock-Chambers paper alone should give us pause rather than our blindly accepting results of a trial just because it has appeared in a peer-reviewed journal. As Peacock-Cambers et al. remind us, comparing interventions that differ in outcomes measured and time sequences is difficult, if not impossible.

Dr. Shonkoff points out that an obsession with statistical significance often has blinded some of us to the importance of the magnitude of (or the lack of) impact when interpreting studies of early intervention. As a result, we may have failed to realize how far research in early childhood development has fallen behind the other fields of biomedical research such as cancer, HIV, and AIDS. His plea is that we begin to leverage our successes in fields such as molecular biology, epigenetics, and neuroscience when designing future studies of early childhood development. He asserts that this kind of basic science – in concert with “on-the-ground experience” (that’s you and me) and “authentic parental engagement” – is more likely to result in greater scalable impact for our patients threatened by developmental delays.

It is refreshing and encouraging reading a critical consideration of the evidence-based sacred cow. Evidence can be viewed from a variety of perspectives. If we continue to filter all of our observations through a statistical significance filter, we run the risk of missing both the forest and the trees.
 

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].

 

About 800 million radiology exams were performed in this country in the past year, and they generated approximately 60 billion images, according to an article published in 2017 in the Wall Street Journal (“No need for radiologists to be negative on AI,” by Greg Ip, Nov. 24, 2017). How many of those millions of radiology studies did you order? And how many of the scores of images you requested did you see with your own two eyes? In fact, how many of the radiologists’ reports that were sent to you did you read in their entirety? How often did you just skip over the radiologist’s CYA disclaimers and simply read the final summary, “exam negative”?

XiXinXing/Thinkstock

Can you sense that I’m warming up for a when-I-was-your-age lecture? Good! You won’t be disappointed when I tell you that, when I was a house officer, we were expected to shuffle off to the darkened bowels of the hospital (the radiology department had no need for windows) and take a look at any x-ray we had ordered on our patients. During the day, this exercise was intended to be an educational field trip. But, at night, when the radiologists were sleeping comfortably at home in the suburbs, this trip to the basement was a fact-finding mission in which we were asked to rely on our memory bank of images we had seen during our brief training. Of course, we could call in the radiologist if we felt the patient’s situation was so critical that we needed an official interpretation of the study we had ordered. But often, house officer machismo kept us from reaching for the phone. To some extent, this rule of if-you-order-it-you-look-at-it functioned as a healthy deterrent against frivolous ordering of marginally valuable studies.

I enjoy the challenge of interpreting x-ray images. In fact, I toyed with becoming a pediatric radiologist, but that career path would have meant settling in or near a large city, a compromise my wife and I were unwilling to make. I hoped to continue my habit of looking at all my patients’ x-rays, but because my practice was not in or near the hospital, I reluctantly had to bend my rules and admit I didn’t see every image I had ordered. But, I did read every report in its entirety. In one case, an offhand comment buried in the middle of the radiologist’s report referring to the “residual barium from a previous study” caught my eye, because I knew the patient hadn’t had a previous contrast study. Unfortunately, the neuroblastoma that the radiologist had missed initially, and I had seen the next day, never responded to treatment.

Toward the end of my career, digital imagery allowed me to view my patients’ x-rays without having to leave my desk, which got me closer to my goal of seeing all my patients’ studies. However, the advent of computerized axial tomography and magnetic resonance imaging meant that an increasing number of studies pushed my anatomic knowledge beyond its limits.

I suspect that many of you benefited from the if-you-order-it-look-at-it mantra during your training. How many of you have continued to follow the dictum? With the advent of digitized imagery, there is really little excuse for not taking a minute or 2 to pull up your patients’ images on your desktop. One could argue that looking inside your patient is part of a complete exam. Forcing yourself to take that extra step and look at the study may nudge you into thinking twice about whether you really needed the information the imaging study might add to the diagnostic process. Was your click to order the study just a reflex subliminally related to the fear of a lawsuit? Was it important enough to deserve a firsthand look?

At the very least, being able to say, “I’ve looked at your x-rays myself, and they look fine” may be more comforting to your patient than a third-hand relay of a “negative reading” performed by someone whom they have likely never met.

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.”

 

About 800 million radiology exams were performed in this country in the past year, and they generated approximately 60 billion images, according to an article published in 2017 in the Wall Street Journal (“No need for radiologists to be negative on AI,” by Greg Ip, Nov. 24, 2017). How many of those millions of radiology studies did you order? And how many of the scores of images you requested did you see with your own two eyes? In fact, how many of the radiologists’ reports that were sent to you did you read in their entirety? How often did you just skip over the radiologist’s CYA disclaimers and simply read the final summary, “exam negative”?

XiXinXing/Thinkstock

Can you sense that I’m warming up for a when-I-was-your-age lecture? Good! You won’t be disappointed when I tell you that, when I was a house officer, we were expected to shuffle off to the darkened bowels of the hospital (the radiology department had no need for windows) and take a look at any x-ray we had ordered on our patients. During the day, this exercise was intended to be an educational field trip. But, at night, when the radiologists were sleeping comfortably at home in the suburbs, this trip to the basement was a fact-finding mission in which we were asked to rely on our memory bank of images we had seen during our brief training. Of course, we could call in the radiologist if we felt the patient’s situation was so critical that we needed an official interpretation of the study we had ordered. But often, house officer machismo kept us from reaching for the phone. To some extent, this rule of if-you-order-it-you-look-at-it functioned as a healthy deterrent against frivolous ordering of marginally valuable studies.

I enjoy the challenge of interpreting x-ray images. In fact, I toyed with becoming a pediatric radiologist, but that career path would have meant settling in or near a large city, a compromise my wife and I were unwilling to make. I hoped to continue my habit of looking at all my patients’ x-rays, but because my practice was not in or near the hospital, I reluctantly had to bend my rules and admit I didn’t see every image I had ordered. But, I did read every report in its entirety. In one case, an offhand comment buried in the middle of the radiologist’s report referring to the “residual barium from a previous study” caught my eye, because I knew the patient hadn’t had a previous contrast study. Unfortunately, the neuroblastoma that the radiologist had missed initially, and I had seen the next day, never responded to treatment.

Toward the end of my career, digital imagery allowed me to view my patients’ x-rays without having to leave my desk, which got me closer to my goal of seeing all my patients’ studies. However, the advent of computerized axial tomography and magnetic resonance imaging meant that an increasing number of studies pushed my anatomic knowledge beyond its limits.

I suspect that many of you benefited from the if-you-order-it-look-at-it mantra during your training. How many of you have continued to follow the dictum? With the advent of digitized imagery, there is really little excuse for not taking a minute or 2 to pull up your patients’ images on your desktop. One could argue that looking inside your patient is part of a complete exam. Forcing yourself to take that extra step and look at the study may nudge you into thinking twice about whether you really needed the information the imaging study might add to the diagnostic process. Was your click to order the study just a reflex subliminally related to the fear of a lawsuit? Was it important enough to deserve a firsthand look?

At the very least, being able to say, “I’ve looked at your x-rays myself, and they look fine” may be more comforting to your patient than a third-hand relay of a “negative reading” performed by someone whom they have likely never met.

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.”

 

About 800 million radiology exams were performed in this country in the past year, and they generated approximately 60 billion images, according to an article published in 2017 in the Wall Street Journal (“No need for radiologists to be negative on AI,” by Greg Ip, Nov. 24, 2017). How many of those millions of radiology studies did you order? And how many of the scores of images you requested did you see with your own two eyes? In fact, how many of the radiologists’ reports that were sent to you did you read in their entirety? How often did you just skip over the radiologist’s CYA disclaimers and simply read the final summary, “exam negative”?

XiXinXing/Thinkstock

Can you sense that I’m warming up for a when-I-was-your-age lecture? Good! You won’t be disappointed when I tell you that, when I was a house officer, we were expected to shuffle off to the darkened bowels of the hospital (the radiology department had no need for windows) and take a look at any x-ray we had ordered on our patients. During the day, this exercise was intended to be an educational field trip. But, at night, when the radiologists were sleeping comfortably at home in the suburbs, this trip to the basement was a fact-finding mission in which we were asked to rely on our memory bank of images we had seen during our brief training. Of course, we could call in the radiologist if we felt the patient’s situation was so critical that we needed an official interpretation of the study we had ordered. But often, house officer machismo kept us from reaching for the phone. To some extent, this rule of if-you-order-it-you-look-at-it functioned as a healthy deterrent against frivolous ordering of marginally valuable studies.

I enjoy the challenge of interpreting x-ray images. In fact, I toyed with becoming a pediatric radiologist, but that career path would have meant settling in or near a large city, a compromise my wife and I were unwilling to make. I hoped to continue my habit of looking at all my patients’ x-rays, but because my practice was not in or near the hospital, I reluctantly had to bend my rules and admit I didn’t see every image I had ordered. But, I did read every report in its entirety. In one case, an offhand comment buried in the middle of the radiologist’s report referring to the “residual barium from a previous study” caught my eye, because I knew the patient hadn’t had a previous contrast study. Unfortunately, the neuroblastoma that the radiologist had missed initially, and I had seen the next day, never responded to treatment.

Toward the end of my career, digital imagery allowed me to view my patients’ x-rays without having to leave my desk, which got me closer to my goal of seeing all my patients’ studies. However, the advent of computerized axial tomography and magnetic resonance imaging meant that an increasing number of studies pushed my anatomic knowledge beyond its limits.

I suspect that many of you benefited from the if-you-order-it-look-at-it mantra during your training. How many of you have continued to follow the dictum? With the advent of digitized imagery, there is really little excuse for not taking a minute or 2 to pull up your patients’ images on your desktop. One could argue that looking inside your patient is part of a complete exam. Forcing yourself to take that extra step and look at the study may nudge you into thinking twice about whether you really needed the information the imaging study might add to the diagnostic process. Was your click to order the study just a reflex subliminally related to the fear of a lawsuit? Was it important enough to deserve a firsthand look?

At the very least, being able to say, “I’ve looked at your x-rays myself, and they look fine” may be more comforting to your patient than a third-hand relay of a “negative reading” performed by someone whom they have likely never met.

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.”

 

Most accomplished public speakers will tell you that critical to their success is the ability to understand and adapt to their audiences. It turns out that even chimpanzees accept and use this cornerstone of effective communication.

In a study published in Science Advances (2017 Nov 15;3[11]:e1701742), three scientists working in Uganda reported that chimpanzees who encounter a potential threat in the form of a realistic snake model will vocalize significantly fewer alert hoots if they hear other alert calls coming from the jungle in the vicinity. In other words, the chimp is saying to himself, “Why should I bother wasting my time and lung power hooting to warn my troop mates? Those guys already know about the snake.”

gpointstudio/Thinkstock

At the risk of doing some preaching to the choir myself, I am going to remind you that, as primary care pediatricians, we must continue to work on our communication skills by adjusting our message to fit our audiences. With only 15 minutes of face-to-face contact with a patient and his or her parents for a health maintenance visit, it is impossible to touch on all the anticipatory guidance topics that we are expected to address. Each threat to the health of children has its own advocacy group. Whether the issue is gun safety, sleep position, vaccines, breastfeeding, or postpartum depression detection, to name just a few, there is someone out there who would like us to keep their favorite cause near the top of our list.

To select which anticipatory guidance topics to include and still be effective communicators, we have to know the families we are trying to help. Gaining this more nuanced picture of a family takes time and is fostered by continuity. Seeing a different provider at each visit doesn’t work very well here. What are this unique family’s concerns, regardless of what some committee thinks we should be asking?

How much can we rely on the media and groups such as the American Academy of Pediatrics and the Centers for Disease Control and Prevention to get out the messages that we have decided to skip over to address this family’s special concerns? Is the message about the benefits of breastfeeding so widely known that we will be wasting our limited office time repeating it? Is the same true for gun safety and seat belts? This is where research can help us decide where to target messages on a national level. But large population studies don’t always apply to our communities and the families we serve.

Where does our role as primary care physicians fit into the bigger picture of health education? The warning messages issued on a national level may have little relevance for our individual patients’ concerns. Is it our role to echo the message, or are we the ones who must do the fine-tuning?

And then there are the recent depressing and counterintuitive findings that for hot-button topics like immunization, education has little if any value. Those families with firmly held beliefs might acknowledge the rationale of our reasoning, but then quickly slide to another argument to tighten their grips on their original position.

Finally, we must be careful to avoid being labeled as the folks whose message is all about what parents should be afraid of. There are plenty of snakes out there in the jungle, but the chimpanzees have realized that when enough of the population is aware of the threat, then it is time to adjust their message. Certainly enough health problems exist on a national level to warrant continued messaging from the large groups in organized medicine. However, it is up to us out in the jungle to learn enough about our patients to know when we should echo those alerts and when it’s time to save our breath. We can’t hoot about every snake in the grass.

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.”

 

Most accomplished public speakers will tell you that critical to their success is the ability to understand and adapt to their audiences. It turns out that even chimpanzees accept and use this cornerstone of effective communication.

In a study published in Science Advances (2017 Nov 15;3[11]:e1701742), three scientists working in Uganda reported that chimpanzees who encounter a potential threat in the form of a realistic snake model will vocalize significantly fewer alert hoots if they hear other alert calls coming from the jungle in the vicinity. In other words, the chimp is saying to himself, “Why should I bother wasting my time and lung power hooting to warn my troop mates? Those guys already know about the snake.”

gpointstudio/Thinkstock

At the risk of doing some preaching to the choir myself, I am going to remind you that, as primary care pediatricians, we must continue to work on our communication skills by adjusting our message to fit our audiences. With only 15 minutes of face-to-face contact with a patient and his or her parents for a health maintenance visit, it is impossible to touch on all the anticipatory guidance topics that we are expected to address. Each threat to the health of children has its own advocacy group. Whether the issue is gun safety, sleep position, vaccines, breastfeeding, or postpartum depression detection, to name just a few, there is someone out there who would like us to keep their favorite cause near the top of our list.

To select which anticipatory guidance topics to include and still be effective communicators, we have to know the families we are trying to help. Gaining this more nuanced picture of a family takes time and is fostered by continuity. Seeing a different provider at each visit doesn’t work very well here. What are this unique family’s concerns, regardless of what some committee thinks we should be asking?

How much can we rely on the media and groups such as the American Academy of Pediatrics and the Centers for Disease Control and Prevention to get out the messages that we have decided to skip over to address this family’s special concerns? Is the message about the benefits of breastfeeding so widely known that we will be wasting our limited office time repeating it? Is the same true for gun safety and seat belts? This is where research can help us decide where to target messages on a national level. But large population studies don’t always apply to our communities and the families we serve.

Where does our role as primary care physicians fit into the bigger picture of health education? The warning messages issued on a national level may have little relevance for our individual patients’ concerns. Is it our role to echo the message, or are we the ones who must do the fine-tuning?

And then there are the recent depressing and counterintuitive findings that for hot-button topics like immunization, education has little if any value. Those families with firmly held beliefs might acknowledge the rationale of our reasoning, but then quickly slide to another argument to tighten their grips on their original position.

Finally, we must be careful to avoid being labeled as the folks whose message is all about what parents should be afraid of. There are plenty of snakes out there in the jungle, but the chimpanzees have realized that when enough of the population is aware of the threat, then it is time to adjust their message. Certainly enough health problems exist on a national level to warrant continued messaging from the large groups in organized medicine. However, it is up to us out in the jungle to learn enough about our patients to know when we should echo those alerts and when it’s time to save our breath. We can’t hoot about every snake in the grass.

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.”

 

Most accomplished public speakers will tell you that critical to their success is the ability to understand and adapt to their audiences. It turns out that even chimpanzees accept and use this cornerstone of effective communication.

In a study published in Science Advances (2017 Nov 15;3[11]:e1701742), three scientists working in Uganda reported that chimpanzees who encounter a potential threat in the form of a realistic snake model will vocalize significantly fewer alert hoots if they hear other alert calls coming from the jungle in the vicinity. In other words, the chimp is saying to himself, “Why should I bother wasting my time and lung power hooting to warn my troop mates? Those guys already know about the snake.”

gpointstudio/Thinkstock

At the risk of doing some preaching to the choir myself, I am going to remind you that, as primary care pediatricians, we must continue to work on our communication skills by adjusting our message to fit our audiences. With only 15 minutes of face-to-face contact with a patient and his or her parents for a health maintenance visit, it is impossible to touch on all the anticipatory guidance topics that we are expected to address. Each threat to the health of children has its own advocacy group. Whether the issue is gun safety, sleep position, vaccines, breastfeeding, or postpartum depression detection, to name just a few, there is someone out there who would like us to keep their favorite cause near the top of our list.

To select which anticipatory guidance topics to include and still be effective communicators, we have to know the families we are trying to help. Gaining this more nuanced picture of a family takes time and is fostered by continuity. Seeing a different provider at each visit doesn’t work very well here. What are this unique family’s concerns, regardless of what some committee thinks we should be asking?

How much can we rely on the media and groups such as the American Academy of Pediatrics and the Centers for Disease Control and Prevention to get out the messages that we have decided to skip over to address this family’s special concerns? Is the message about the benefits of breastfeeding so widely known that we will be wasting our limited office time repeating it? Is the same true for gun safety and seat belts? This is where research can help us decide where to target messages on a national level. But large population studies don’t always apply to our communities and the families we serve.

Where does our role as primary care physicians fit into the bigger picture of health education? The warning messages issued on a national level may have little relevance for our individual patients’ concerns. Is it our role to echo the message, or are we the ones who must do the fine-tuning?

And then there are the recent depressing and counterintuitive findings that for hot-button topics like immunization, education has little if any value. Those families with firmly held beliefs might acknowledge the rationale of our reasoning, but then quickly slide to another argument to tighten their grips on their original position.

Finally, we must be careful to avoid being labeled as the folks whose message is all about what parents should be afraid of. There are plenty of snakes out there in the jungle, but the chimpanzees have realized that when enough of the population is aware of the threat, then it is time to adjust their message. Certainly enough health problems exist on a national level to warrant continued messaging from the large groups in organized medicine. However, it is up to us out in the jungle to learn enough about our patients to know when we should echo those alerts and when it’s time to save our breath. We can’t hoot about every snake in the grass.

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.”

 

The provider has received “advanced-level education in pharmacology, pathophysiology, and physical assessment, diagnosis, and management” and provides patient care in a medical home “in a holistic fashion including physical care, therapeutic treatments, education, and coordination of services.”

This quote comes from a recent story in Pediatric News about collaborative practice. Was the author offering a job description of a) a chiropractor, b) a nurse practitioner, c) a pediatric oncologist, or d) a primary care physician?

I think the description could easily be applied to a nurse practitioner or a physician. However, the author Cathy Haut, DNP, CPNP-PC, a nurse practitioner herself, was describing the qualifications of a nurse practitioner in primary care practice (“Nurse practitioner/pediatrician collaboration: Try a pediatric health care/medical home model,” Pediatric News, November 2017). A major theme in Dr. Haut’s column is that the skills and training of a nurse practitioner can be complementary to those of a physician. She provides several examples of how such a complementary relationship can result in a collaboration that advances patient care, particularly in a medical home setting.

Based on my personal experience working with nurse practitioners, both in hospital and office settings, I wholeheartedly concur with Dr. Haut’s list of their qualifications and capabilities. My problem is that she doesn’t list, nor can I comfortably imagine, the additional skills that a physician should have in his or her toolbox to complete the complementary relationships in a primary care practice that Dr. Haut envisions.

From my perspective, nurse practitioners and primary care physicians share the same job description, the one I listed in the first paragraph of this column. They both provide face-to-face, usually hands-on, medical care. At that critical interface between patient and provider, how do their roles differ? What other skills does a physician need to complement those of a competent and already experienced nurse practitioner?

Does being a physician guarantee that he or she has more experience than a nurse practitioner? You know as well as I do that you finished your training pretty wet behind the ears, and the first 5 years or more of your practice career were when you really began to feel like a competent provider. If my child has an earache, I would probably be more comfortable, or at least as comfortable, with her seeing a nurse practitioner with 5 years of experience in a busy practice than a newly minted, board-eligible pediatrician.

Is the breadth of a physician’s training in medical school an asset? Does the 2-month rotation he or she did on the adult neurology service taking care of stroke victims give the physician an advantage when it comes to taking care of pediatric patients with asthma?

Actually, I can imagine a suite of skills that a physician might bring to a collaborative practice that a nurse practitioner may not have, or more likely may have chosen not to pursue. Those skills have little to do with direct patient care, but can be critical for survival in today’s medical care environment. Here I am thinking of things such as negotiating with third-party payers, and leading and/or administering the complexities of a medium-sized or larger medical group. Does having a degree from a medical school automatically mean that the graduate is a skilled leader or administrator?

I can envision that over time a physician and a nurse practitioner might create an arrangement in which one of them focuses on the patients with asthma and attention-deficit/hyperactivity disorder, and the other develops an expertise in breastfeeding management and picky eating. That kind of relationship fits my definition of complementary. However, a relationship in which the doctor is the boss and the nurse practitioner is not doesn’t feel complementary or collaborative to me.
 

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.”

 

The provider has received “advanced-level education in pharmacology, pathophysiology, and physical assessment, diagnosis, and management” and provides patient care in a medical home “in a holistic fashion including physical care, therapeutic treatments, education, and coordination of services.”

This quote comes from a recent story in Pediatric News about collaborative practice. Was the author offering a job description of a) a chiropractor, b) a nurse practitioner, c) a pediatric oncologist, or d) a primary care physician?

I think the description could easily be applied to a nurse practitioner or a physician. However, the author Cathy Haut, DNP, CPNP-PC, a nurse practitioner herself, was describing the qualifications of a nurse practitioner in primary care practice (“Nurse practitioner/pediatrician collaboration: Try a pediatric health care/medical home model,” Pediatric News, November 2017). A major theme in Dr. Haut’s column is that the skills and training of a nurse practitioner can be complementary to those of a physician. She provides several examples of how such a complementary relationship can result in a collaboration that advances patient care, particularly in a medical home setting.

Based on my personal experience working with nurse practitioners, both in hospital and office settings, I wholeheartedly concur with Dr. Haut’s list of their qualifications and capabilities. My problem is that she doesn’t list, nor can I comfortably imagine, the additional skills that a physician should have in his or her toolbox to complete the complementary relationships in a primary care practice that Dr. Haut envisions.

From my perspective, nurse practitioners and primary care physicians share the same job description, the one I listed in the first paragraph of this column. They both provide face-to-face, usually hands-on, medical care. At that critical interface between patient and provider, how do their roles differ? What other skills does a physician need to complement those of a competent and already experienced nurse practitioner?

Does being a physician guarantee that he or she has more experience than a nurse practitioner? You know as well as I do that you finished your training pretty wet behind the ears, and the first 5 years or more of your practice career were when you really began to feel like a competent provider. If my child has an earache, I would probably be more comfortable, or at least as comfortable, with her seeing a nurse practitioner with 5 years of experience in a busy practice than a newly minted, board-eligible pediatrician.

Is the breadth of a physician’s training in medical school an asset? Does the 2-month rotation he or she did on the adult neurology service taking care of stroke victims give the physician an advantage when it comes to taking care of pediatric patients with asthma?

Actually, I can imagine a suite of skills that a physician might bring to a collaborative practice that a nurse practitioner may not have, or more likely may have chosen not to pursue. Those skills have little to do with direct patient care, but can be critical for survival in today’s medical care environment. Here I am thinking of things such as negotiating with third-party payers, and leading and/or administering the complexities of a medium-sized or larger medical group. Does having a degree from a medical school automatically mean that the graduate is a skilled leader or administrator?

I can envision that over time a physician and a nurse practitioner might create an arrangement in which one of them focuses on the patients with asthma and attention-deficit/hyperactivity disorder, and the other develops an expertise in breastfeeding management and picky eating. That kind of relationship fits my definition of complementary. However, a relationship in which the doctor is the boss and the nurse practitioner is not doesn’t feel complementary or collaborative to me.
 

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.”

 

The provider has received “advanced-level education in pharmacology, pathophysiology, and physical assessment, diagnosis, and management” and provides patient care in a medical home “in a holistic fashion including physical care, therapeutic treatments, education, and coordination of services.”

This quote comes from a recent story in Pediatric News about collaborative practice. Was the author offering a job description of a) a chiropractor, b) a nurse practitioner, c) a pediatric oncologist, or d) a primary care physician?

I think the description could easily be applied to a nurse practitioner or a physician. However, the author Cathy Haut, DNP, CPNP-PC, a nurse practitioner herself, was describing the qualifications of a nurse practitioner in primary care practice (“Nurse practitioner/pediatrician collaboration: Try a pediatric health care/medical home model,” Pediatric News, November 2017). A major theme in Dr. Haut’s column is that the skills and training of a nurse practitioner can be complementary to those of a physician. She provides several examples of how such a complementary relationship can result in a collaboration that advances patient care, particularly in a medical home setting.

Based on my personal experience working with nurse practitioners, both in hospital and office settings, I wholeheartedly concur with Dr. Haut’s list of their qualifications and capabilities. My problem is that she doesn’t list, nor can I comfortably imagine, the additional skills that a physician should have in his or her toolbox to complete the complementary relationships in a primary care practice that Dr. Haut envisions.

From my perspective, nurse practitioners and primary care physicians share the same job description, the one I listed in the first paragraph of this column. They both provide face-to-face, usually hands-on, medical care. At that critical interface between patient and provider, how do their roles differ? What other skills does a physician need to complement those of a competent and already experienced nurse practitioner?

Does being a physician guarantee that he or she has more experience than a nurse practitioner? You know as well as I do that you finished your training pretty wet behind the ears, and the first 5 years or more of your practice career were when you really began to feel like a competent provider. If my child has an earache, I would probably be more comfortable, or at least as comfortable, with her seeing a nurse practitioner with 5 years of experience in a busy practice than a newly minted, board-eligible pediatrician.

Is the breadth of a physician’s training in medical school an asset? Does the 2-month rotation he or she did on the adult neurology service taking care of stroke victims give the physician an advantage when it comes to taking care of pediatric patients with asthma?

Actually, I can imagine a suite of skills that a physician might bring to a collaborative practice that a nurse practitioner may not have, or more likely may have chosen not to pursue. Those skills have little to do with direct patient care, but can be critical for survival in today’s medical care environment. Here I am thinking of things such as negotiating with third-party payers, and leading and/or administering the complexities of a medium-sized or larger medical group. Does having a degree from a medical school automatically mean that the graduate is a skilled leader or administrator?

I can envision that over time a physician and a nurse practitioner might create an arrangement in which one of them focuses on the patients with asthma and attention-deficit/hyperactivity disorder, and the other develops an expertise in breastfeeding management and picky eating. That kind of relationship fits my definition of complementary. However, a relationship in which the doctor is the boss and the nurse practitioner is not doesn’t feel complementary or collaborative to me.
 

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.”

 

How do you feel about apple pie? Is it a concept that evokes a positive feeling for you? Even if you prefer pumpkin or blueberry? Although your attitude toward apple pie may be relevant as we approach the holidays, is it a topic worthy of discussion in a publication devoted to pediatrics?

Certainly not, but what about motherhood? How do you feel about motherhood? As someone who is devoting his or her professional energies to the health of children, you must have formed some opinions about motherhood. Although your patients are children, it is their parents – and more often their mothers – with whom you communicate, particularly in the first several years of life. The interaction between a child and his or her mother can provide the child critical emotional support.

BananaStock/Thinkstock

My guess is that, like the majority of people, you will answer that the concept of motherhood is one about which you have positive thoughts, regardless of how you feel about apple pie. But let’s sharpen the focus of my question and ask if you believe that, for biological and physiological reasons, mothers are necessary for babies. And, here, I am asking you to look beyond the obvious events of pregnancy and childbirth. Do you believe that a mother is uniquely equipped to provide some things for her child that can be critically important for that child’s emotional development, particularly in the first 3 years of the child’s life?

You may never have been asked that question in exactly that way before, but I suspect you have thought about it both professionally and personally. You may have considered the answer as you were deciding if, when, and how you were going to return to work after maternity leave. Or you may have been forced to consider the question in formulating an opinion in a case of contested child custody.

An opinion piece in the Wall Street Journal (“The Politicization of Motherhood,” by James Taranto, Oct. 27, 2017) suggests that how you answer my question about the biological necessity of motherhood will determine your position on one of our nation’s political divides. The article focuses on Erica Komisar, who has written a book in which she lays out evidence from the fields of neuroscience, psychology, and epigenetics supporting her view that a mother is biologically equipped to provide for the emotional development of her child (“Being There: Why Prioritizing Motherhood in the First Three Years Matters,” New York: TarcherPerigee, 2017).

As you might suspect, her book has been embraced by the more conservative among us who feel that a mother’s place is in the home. On the other hand, she has been shunned by more liberal folks who believe that much of what one might consider traditional motherhood can be subcontracted out to fathers and day care providers. However, Ms. Komisar’s liberal roots become apparent when she suggests that the federal government should mandate employers to provide generous maternity benefits including flexible and extended maternity leaves.

I haven’t read Ms. Komisar’s book, nor am I aware of the studies she cites, but reading the article prompted me to think a bit more deeply regarding how I feel about motherhood. I guess I always have felt that there is something special that a mother can provide her children, particularly during the first 3 years of life. I don’t know whether there is a neurobiological basis for this special something, but if it is missing, the child’s emotional development can suffer. Are there situations where another person(s) can provide a substitute for this special maternal sauce? Of course, but it doesn’t always work as well as the real thing. And not every mother has an adequate amount of that certain maternal something.

As pediatricians, we are faced with two challenges. The first is to help families cope with situations in which that special maternal ingredient is absent or in short supply. Our second challenge is to help mothers who believe there is something special they can offer their children but feel guilty because, for whatever reason, they can’t be there to provide it.

I am interested to hear how you feel about motherhood ... and apple pie.
 

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 apple pie? Is it a concept that evokes a positive feeling for you? Even if you prefer pumpkin or blueberry? Although your attitude toward apple pie may be relevant as we approach the holidays, is it a topic worthy of discussion in a publication devoted to pediatrics?

Certainly not, but what about motherhood? How do you feel about motherhood? As someone who is devoting his or her professional energies to the health of children, you must have formed some opinions about motherhood. Although your patients are children, it is their parents – and more often their mothers – with whom you communicate, particularly in the first several years of life. The interaction between a child and his or her mother can provide the child critical emotional support.

BananaStock/Thinkstock

My guess is that, like the majority of people, you will answer that the concept of motherhood is one about which you have positive thoughts, regardless of how you feel about apple pie. But let’s sharpen the focus of my question and ask if you believe that, for biological and physiological reasons, mothers are necessary for babies. And, here, I am asking you to look beyond the obvious events of pregnancy and childbirth. Do you believe that a mother is uniquely equipped to provide some things for her child that can be critically important for that child’s emotional development, particularly in the first 3 years of the child’s life?

You may never have been asked that question in exactly that way before, but I suspect you have thought about it both professionally and personally. You may have considered the answer as you were deciding if, when, and how you were going to return to work after maternity leave. Or you may have been forced to consider the question in formulating an opinion in a case of contested child custody.

An opinion piece in the Wall Street Journal (“The Politicization of Motherhood,” by James Taranto, Oct. 27, 2017) suggests that how you answer my question about the biological necessity of motherhood will determine your position on one of our nation’s political divides. The article focuses on Erica Komisar, who has written a book in which she lays out evidence from the fields of neuroscience, psychology, and epigenetics supporting her view that a mother is biologically equipped to provide for the emotional development of her child (“Being There: Why Prioritizing Motherhood in the First Three Years Matters,” New York: TarcherPerigee, 2017).

As you might suspect, her book has been embraced by the more conservative among us who feel that a mother’s place is in the home. On the other hand, she has been shunned by more liberal folks who believe that much of what one might consider traditional motherhood can be subcontracted out to fathers and day care providers. However, Ms. Komisar’s liberal roots become apparent when she suggests that the federal government should mandate employers to provide generous maternity benefits including flexible and extended maternity leaves.

I haven’t read Ms. Komisar’s book, nor am I aware of the studies she cites, but reading the article prompted me to think a bit more deeply regarding how I feel about motherhood. I guess I always have felt that there is something special that a mother can provide her children, particularly during the first 3 years of life. I don’t know whether there is a neurobiological basis for this special something, but if it is missing, the child’s emotional development can suffer. Are there situations where another person(s) can provide a substitute for this special maternal sauce? Of course, but it doesn’t always work as well as the real thing. And not every mother has an adequate amount of that certain maternal something.

As pediatricians, we are faced with two challenges. The first is to help families cope with situations in which that special maternal ingredient is absent or in short supply. Our second challenge is to help mothers who believe there is something special they can offer their children but feel guilty because, for whatever reason, they can’t be there to provide it.

I am interested to hear how you feel about motherhood ... and apple pie.
 

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 apple pie? Is it a concept that evokes a positive feeling for you? Even if you prefer pumpkin or blueberry? Although your attitude toward apple pie may be relevant as we approach the holidays, is it a topic worthy of discussion in a publication devoted to pediatrics?

Certainly not, but what about motherhood? How do you feel about motherhood? As someone who is devoting his or her professional energies to the health of children, you must have formed some opinions about motherhood. Although your patients are children, it is their parents – and more often their mothers – with whom you communicate, particularly in the first several years of life. The interaction between a child and his or her mother can provide the child critical emotional support.

BananaStock/Thinkstock

My guess is that, like the majority of people, you will answer that the concept of motherhood is one about which you have positive thoughts, regardless of how you feel about apple pie. But let’s sharpen the focus of my question and ask if you believe that, for biological and physiological reasons, mothers are necessary for babies. And, here, I am asking you to look beyond the obvious events of pregnancy and childbirth. Do you believe that a mother is uniquely equipped to provide some things for her child that can be critically important for that child’s emotional development, particularly in the first 3 years of the child’s life?

You may never have been asked that question in exactly that way before, but I suspect you have thought about it both professionally and personally. You may have considered the answer as you were deciding if, when, and how you were going to return to work after maternity leave. Or you may have been forced to consider the question in formulating an opinion in a case of contested child custody.

An opinion piece in the Wall Street Journal (“The Politicization of Motherhood,” by James Taranto, Oct. 27, 2017) suggests that how you answer my question about the biological necessity of motherhood will determine your position on one of our nation’s political divides. The article focuses on Erica Komisar, who has written a book in which she lays out evidence from the fields of neuroscience, psychology, and epigenetics supporting her view that a mother is biologically equipped to provide for the emotional development of her child (“Being There: Why Prioritizing Motherhood in the First Three Years Matters,” New York: TarcherPerigee, 2017).

As you might suspect, her book has been embraced by the more conservative among us who feel that a mother’s place is in the home. On the other hand, she has been shunned by more liberal folks who believe that much of what one might consider traditional motherhood can be subcontracted out to fathers and day care providers. However, Ms. Komisar’s liberal roots become apparent when she suggests that the federal government should mandate employers to provide generous maternity benefits including flexible and extended maternity leaves.

I haven’t read Ms. Komisar’s book, nor am I aware of the studies she cites, but reading the article prompted me to think a bit more deeply regarding how I feel about motherhood. I guess I always have felt that there is something special that a mother can provide her children, particularly during the first 3 years of life. I don’t know whether there is a neurobiological basis for this special something, but if it is missing, the child’s emotional development can suffer. Are there situations where another person(s) can provide a substitute for this special maternal sauce? Of course, but it doesn’t always work as well as the real thing. And not every mother has an adequate amount of that certain maternal something.

As pediatricians, we are faced with two challenges. The first is to help families cope with situations in which that special maternal ingredient is absent or in short supply. Our second challenge is to help mothers who believe there is something special they can offer their children but feel guilty because, for whatever reason, they can’t be there to provide it.

I am interested to hear how you feel about motherhood ... and apple pie.
 

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 widespread use of fetal ultrasound has dramatically decreased the number of delivery room surprises. In this country, most infants with a cardiac anomaly detected in utero probably are delivered at tertiary medical centers, leapfrogging over the maternity units at their local community hospitals. But infants with critical cardiac conditions continue to arrive unheralded at every hospital, both large and small. And many of these babies are asymptomatic without tachypnea or cyanosis. A study reported in the October 2017 Pediatrics by Hu et al. suggests a strategy for detecting these little masters of disguise before their lesions get them into serious trouble (doi: 10.1542/peds.2017-1154).

Pulse oximetry has been widely debated as a method for detecting congenital heart disease, because of course it misses the cases that are acyanotic. In a series of more than 150,000 asymptomatic neonates, these investigators combined cardiac auscultation with pulse oximetry and achieved a sensitivity of 96% in detecting critical congenital heart disease and 92% for major congenital heart disease. Their false-positive rate for both categories was just a bit over 1%.

Courtesy Dr. William G. Wilkoff

The abstract left me with several questions, because I wondered if there was something about the auscultation procedure they were using. The paper doesn’t describe the exact technique used or the timing, but it does say that the clinicians who did the auscultating were “highly trained” and closely supervised. And the procedure was performed in a “quiet environment.”

This may be another case in which the training of the examiner and the environment are critical to a positive result. As I think back to the conditions in which I examined newborns, I wonder how careful I was that my auscultating was being done in a quiet environment. If I was in the nursery, there may have been other babies crying, a radio playing, or nurses conversing with one another. I may have been deluding myself that, over the years in practice, I had developed the ability to cancel out those auditory distractions. It was probably dumb luck that I didn’t miss any critical murmurs.

And then there is the timing. The investigators don’t describe how soon after birth the auscultation was performed. Is there an optimum time in relation to the neonate’s transition from his/her fetal circulation? How long did the examiners listen? Were they in a rush to get back to their offices and busy waiting room or were they hospitalists?

I found this to be an interesting study, and if repeated by other investigators, it provides an example of how technology advancement doesn’t always render our old examining skills obsolete. In fact, it may demand we sharpen 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].

 

The widespread use of fetal ultrasound has dramatically decreased the number of delivery room surprises. In this country, most infants with a cardiac anomaly detected in utero probably are delivered at tertiary medical centers, leapfrogging over the maternity units at their local community hospitals. But infants with critical cardiac conditions continue to arrive unheralded at every hospital, both large and small. And many of these babies are asymptomatic without tachypnea or cyanosis. A study reported in the October 2017 Pediatrics by Hu et al. suggests a strategy for detecting these little masters of disguise before their lesions get them into serious trouble (doi: 10.1542/peds.2017-1154).

Pulse oximetry has been widely debated as a method for detecting congenital heart disease, because of course it misses the cases that are acyanotic. In a series of more than 150,000 asymptomatic neonates, these investigators combined cardiac auscultation with pulse oximetry and achieved a sensitivity of 96% in detecting critical congenital heart disease and 92% for major congenital heart disease. Their false-positive rate for both categories was just a bit over 1%.

Courtesy Dr. William G. Wilkoff

The abstract left me with several questions, because I wondered if there was something about the auscultation procedure they were using. The paper doesn’t describe the exact technique used or the timing, but it does say that the clinicians who did the auscultating were “highly trained” and closely supervised. And the procedure was performed in a “quiet environment.”

This may be another case in which the training of the examiner and the environment are critical to a positive result. As I think back to the conditions in which I examined newborns, I wonder how careful I was that my auscultating was being done in a quiet environment. If I was in the nursery, there may have been other babies crying, a radio playing, or nurses conversing with one another. I may have been deluding myself that, over the years in practice, I had developed the ability to cancel out those auditory distractions. It was probably dumb luck that I didn’t miss any critical murmurs.

And then there is the timing. The investigators don’t describe how soon after birth the auscultation was performed. Is there an optimum time in relation to the neonate’s transition from his/her fetal circulation? How long did the examiners listen? Were they in a rush to get back to their offices and busy waiting room or were they hospitalists?

I found this to be an interesting study, and if repeated by other investigators, it provides an example of how technology advancement doesn’t always render our old examining skills obsolete. In fact, it may demand we sharpen 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].

 

The widespread use of fetal ultrasound has dramatically decreased the number of delivery room surprises. In this country, most infants with a cardiac anomaly detected in utero probably are delivered at tertiary medical centers, leapfrogging over the maternity units at their local community hospitals. But infants with critical cardiac conditions continue to arrive unheralded at every hospital, both large and small. And many of these babies are asymptomatic without tachypnea or cyanosis. A study reported in the October 2017 Pediatrics by Hu et al. suggests a strategy for detecting these little masters of disguise before their lesions get them into serious trouble (doi: 10.1542/peds.2017-1154).

Pulse oximetry has been widely debated as a method for detecting congenital heart disease, because of course it misses the cases that are acyanotic. In a series of more than 150,000 asymptomatic neonates, these investigators combined cardiac auscultation with pulse oximetry and achieved a sensitivity of 96% in detecting critical congenital heart disease and 92% for major congenital heart disease. Their false-positive rate for both categories was just a bit over 1%.

Courtesy Dr. William G. Wilkoff

The abstract left me with several questions, because I wondered if there was something about the auscultation procedure they were using. The paper doesn’t describe the exact technique used or the timing, but it does say that the clinicians who did the auscultating were “highly trained” and closely supervised. And the procedure was performed in a “quiet environment.”

This may be another case in which the training of the examiner and the environment are critical to a positive result. As I think back to the conditions in which I examined newborns, I wonder how careful I was that my auscultating was being done in a quiet environment. If I was in the nursery, there may have been other babies crying, a radio playing, or nurses conversing with one another. I may have been deluding myself that, over the years in practice, I had developed the ability to cancel out those auditory distractions. It was probably dumb luck that I didn’t miss any critical murmurs.

And then there is the timing. The investigators don’t describe how soon after birth the auscultation was performed. Is there an optimum time in relation to the neonate’s transition from his/her fetal circulation? How long did the examiners listen? Were they in a rush to get back to their offices and busy waiting room or were they hospitalists?

I found this to be an interesting study, and if repeated by other investigators, it provides an example of how technology advancement doesn’t always render our old examining skills obsolete. In fact, it may demand we sharpen 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].

 

The headline in the Oct. 13, 2017, Portland (Maine) Press Herald hinted that I was about to read a sad story: “New Hampshire doctor, 85, may lose practice because she doesn’t use computer.” Anna Konopka, MD, who has a 300-patient practice in New London, doesn’t use a computer in her office, and as a consequence can’t participate in her state’s mandated prescription drug monitoring program. She has appealed to the governor, but if her appeal is denied she will be forced to close her office.

The closure will present a hardship for the residents of this small New Hampshire town, who will have to replace their obviously committed physician who has served them for more than 30 years. And I am sure that Dr. Konopka would have preferred to end her professional career on her own terms. It isn’t going to be easy to give up that positive feedback from her patients that every primary care physician enjoys even on her worst day.

copyright monkeybusinessimages/Thinkstock

However, this news story is about a tragedy that extends far beyond this little college town nestled among the hills and lakes of New Hampshire. Why do you think Dr. Konopka chose not to use a computer in her office? The short 100-word news story doesn’t provide an answer. But I suspect that Dr. Konopka is not a Luddite. It is very likely that she has a computer at home. She may email her grandchildren and do some shopping on Amazon. Being 85 years old does not exclude a person from enjoying the conveniences of cyberspace.

I wouldn’t be surprised to learn that Dr. Konopka has listened to other physicians in her community complain about the cost and time-gobbling inefficiencies of their EHRs. She may have been put off by her own experiences as a patient whose physician spends too much time looking at his computer screen and fails to engage with her. Or she may have simply done the math and come up with the obvious answer that a computer system would be a bad investment for her small practice.

I suspect that there are days that you wish you had followed this wise older physician’s lead and never plugged into that “good-for-nothing piece of junk” sitting on the desk in your exam room. The sadness in this story is that the computer and the Internet are (or at least could be) good for some things, including the statewide prescription drug monitoring program that Dr. Konopka can’t participate in. Immunization data banks, prescribing programs that minimize physician error, and systems for storing and plotting your patient’s lab work and metrics are just a few of the things that a good computer system is good for. And, of course, there is the real-time access to the vast store of medical and research knowledge that has made textbooks obsolete.

But somewhere along the way the computer has been hijacked by those who see it primarily as a billing instrument and a tool for risk management. This unfortunate detour has forced physicians into the mind-numbing and time-consuming role of data entry clerks. Fueled by the myth that clicking a box on a computer screen guarantees that a history was taken or that a body part was actually examined has resulted in the generation of crisply formatted reports of dubious value.

I’m not sure where we can go from here without throwing out the baby with the bathwater and starting from scratch. We have computer scientists and physicians who I am sure could create a patient- and physician-friendly system that could cover the whole country. The trick will be keeping the politicians out of the room.
 

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 headline in the Oct. 13, 2017, Portland (Maine) Press Herald hinted that I was about to read a sad story: “New Hampshire doctor, 85, may lose practice because she doesn’t use computer.” Anna Konopka, MD, who has a 300-patient practice in New London, doesn’t use a computer in her office, and as a consequence can’t participate in her state’s mandated prescription drug monitoring program. She has appealed to the governor, but if her appeal is denied she will be forced to close her office.

The closure will present a hardship for the residents of this small New Hampshire town, who will have to replace their obviously committed physician who has served them for more than 30 years. And I am sure that Dr. Konopka would have preferred to end her professional career on her own terms. It isn’t going to be easy to give up that positive feedback from her patients that every primary care physician enjoys even on her worst day.

copyright monkeybusinessimages/Thinkstock

However, this news story is about a tragedy that extends far beyond this little college town nestled among the hills and lakes of New Hampshire. Why do you think Dr. Konopka chose not to use a computer in her office? The short 100-word news story doesn’t provide an answer. But I suspect that Dr. Konopka is not a Luddite. It is very likely that she has a computer at home. She may email her grandchildren and do some shopping on Amazon. Being 85 years old does not exclude a person from enjoying the conveniences of cyberspace.

I wouldn’t be surprised to learn that Dr. Konopka has listened to other physicians in her community complain about the cost and time-gobbling inefficiencies of their EHRs. She may have been put off by her own experiences as a patient whose physician spends too much time looking at his computer screen and fails to engage with her. Or she may have simply done the math and come up with the obvious answer that a computer system would be a bad investment for her small practice.

I suspect that there are days that you wish you had followed this wise older physician’s lead and never plugged into that “good-for-nothing piece of junk” sitting on the desk in your exam room. The sadness in this story is that the computer and the Internet are (or at least could be) good for some things, including the statewide prescription drug monitoring program that Dr. Konopka can’t participate in. Immunization data banks, prescribing programs that minimize physician error, and systems for storing and plotting your patient’s lab work and metrics are just a few of the things that a good computer system is good for. And, of course, there is the real-time access to the vast store of medical and research knowledge that has made textbooks obsolete.

But somewhere along the way the computer has been hijacked by those who see it primarily as a billing instrument and a tool for risk management. This unfortunate detour has forced physicians into the mind-numbing and time-consuming role of data entry clerks. Fueled by the myth that clicking a box on a computer screen guarantees that a history was taken or that a body part was actually examined has resulted in the generation of crisply formatted reports of dubious value.

I’m not sure where we can go from here without throwing out the baby with the bathwater and starting from scratch. We have computer scientists and physicians who I am sure could create a patient- and physician-friendly system that could cover the whole country. The trick will be keeping the politicians out of the room.
 

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 headline in the Oct. 13, 2017, Portland (Maine) Press Herald hinted that I was about to read a sad story: “New Hampshire doctor, 85, may lose practice because she doesn’t use computer.” Anna Konopka, MD, who has a 300-patient practice in New London, doesn’t use a computer in her office, and as a consequence can’t participate in her state’s mandated prescription drug monitoring program. She has appealed to the governor, but if her appeal is denied she will be forced to close her office.

The closure will present a hardship for the residents of this small New Hampshire town, who will have to replace their obviously committed physician who has served them for more than 30 years. And I am sure that Dr. Konopka would have preferred to end her professional career on her own terms. It isn’t going to be easy to give up that positive feedback from her patients that every primary care physician enjoys even on her worst day.

copyright monkeybusinessimages/Thinkstock

However, this news story is about a tragedy that extends far beyond this little college town nestled among the hills and lakes of New Hampshire. Why do you think Dr. Konopka chose not to use a computer in her office? The short 100-word news story doesn’t provide an answer. But I suspect that Dr. Konopka is not a Luddite. It is very likely that she has a computer at home. She may email her grandchildren and do some shopping on Amazon. Being 85 years old does not exclude a person from enjoying the conveniences of cyberspace.

I wouldn’t be surprised to learn that Dr. Konopka has listened to other physicians in her community complain about the cost and time-gobbling inefficiencies of their EHRs. She may have been put off by her own experiences as a patient whose physician spends too much time looking at his computer screen and fails to engage with her. Or she may have simply done the math and come up with the obvious answer that a computer system would be a bad investment for her small practice.

I suspect that there are days that you wish you had followed this wise older physician’s lead and never plugged into that “good-for-nothing piece of junk” sitting on the desk in your exam room. The sadness in this story is that the computer and the Internet are (or at least could be) good for some things, including the statewide prescription drug monitoring program that Dr. Konopka can’t participate in. Immunization data banks, prescribing programs that minimize physician error, and systems for storing and plotting your patient’s lab work and metrics are just a few of the things that a good computer system is good for. And, of course, there is the real-time access to the vast store of medical and research knowledge that has made textbooks obsolete.

But somewhere along the way the computer has been hijacked by those who see it primarily as a billing instrument and a tool for risk management. This unfortunate detour has forced physicians into the mind-numbing and time-consuming role of data entry clerks. Fueled by the myth that clicking a box on a computer screen guarantees that a history was taken or that a body part was actually examined has resulted in the generation of crisply formatted reports of dubious value.

I’m not sure where we can go from here without throwing out the baby with the bathwater and starting from scratch. We have computer scientists and physicians who I am sure could create a patient- and physician-friendly system that could cover the whole country. The trick will be keeping the politicians out of the room.
 

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].

 

Five years ago, while I still was actively practicing primary care pediatrics, I did a rough calculation that the EHR the practice had purchased was adding an hour to my workday. We were not computer neophytes. This was our third EHR system in 10 years. Not a single minute of that extra time included face-to-face interaction with my patients. In the ensuing years, I have been listening to former colleagues and reading emails from readers of this column. It is clear that my unfortunate experience with our new EHR in 2012 was just a hint at how bad things would get for primary care physicians indentured to EHRs. The short learning curve that was promised has not flattened out, and my rough calculation of an hour at the computer was clearly an underestimate. Most physicians I hear from feel they are spending significantly more than an hour scrolling and clicking.

Although I frequently have used this column to grumble about EHRs, I have been hesitant to launch into a vein-popping tirade because my evidence has been primarily anecdotal. However, a few weeks ago a friend shared a link to a study that provided some startling figures that went beyond my expectation (“Tethered to the EHR: Primary care physician workload assessment using EHR event log data and time motion observations,” Ann Fam Med. 2017;15[5]:419-26).

CreativaImages/Thinkstock

In following 142 family medicine physicians over a 3-year period, the investigators found that clinicians spend 5.9 hours of an 11.4-hour workday in the EHR. Of this time, 4.5 hours were spent during clinic hours and 1.4 hours after hours. In the investigators’ words: “Primary care physicians in our study worked an average of 11.4 hours per weekday, both during and after clinic hours, with nearly 6 hours spent interacting with the computer.”

Let that sentence sink in for a moment. How do those numbers compare with your own practice experience? Has anyone in your clinic or hospital taken the time to collect the data? I suspect that your time expenditure on the EHR is similar. Are you or anyone else in your group doing anything more than grumbling to one another about this situation?

Isn’t it time for us to do more than just grouse about this electronic elephant in the room? How many successful businesses would tolerate a situation in which the employees responsible for producing the company’s signature product are allowed to spend half of their time idle? From a purely business perspective, the current EHR/provider interface makes no sense.

Although the cost of physician productivity misdirected to EHRs is probably less than the billions of dollars lost to overpriced medication in this country, this is a topic that deserves a spotlight in ongoing discussions of the Affordable Care Act. At a time when the adequacy of our physician workforce is being questioned, we must take seriously the anecdotal evidence that frustration with EHRs is driving older and experienced physicians into early retirement.

And there is the hot topic of physician burnout and quality of life issues. If I were a physician spending half my time on the computer, of which more than an hour and a half was after clinic hours, I think I would start doing something about that before I enrolled in a mindfulness program. I am sure that the American Academy of Pediatrics has more than one committee working on the problem, but the physician time lost to EHRs deserves a higher priority. In the long run, computers have great potential for improving the delivery of health care. However, we are all suffering through a failed beta test that has gone on far too long.

Our patients can be our best allies because most of them don’t like us looking at our computer screens when we should be looking them in the eye … and listening. Like it or not, we now have a president who is a disruptor of the status quo. Maybe it’s time for us to follow his example and begin making some real noise about the personal and financial cost of EHRs. Talk to your legislators, practice administrators, the American Academy of Pediatrics, anyone … even if they don’t seem to be listening.
 

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].

 

Five years ago, while I still was actively practicing primary care pediatrics, I did a rough calculation that the EHR the practice had purchased was adding an hour to my workday. We were not computer neophytes. This was our third EHR system in 10 years. Not a single minute of that extra time included face-to-face interaction with my patients. In the ensuing years, I have been listening to former colleagues and reading emails from readers of this column. It is clear that my unfortunate experience with our new EHR in 2012 was just a hint at how bad things would get for primary care physicians indentured to EHRs. The short learning curve that was promised has not flattened out, and my rough calculation of an hour at the computer was clearly an underestimate. Most physicians I hear from feel they are spending significantly more than an hour scrolling and clicking.

Although I frequently have used this column to grumble about EHRs, I have been hesitant to launch into a vein-popping tirade because my evidence has been primarily anecdotal. However, a few weeks ago a friend shared a link to a study that provided some startling figures that went beyond my expectation (“Tethered to the EHR: Primary care physician workload assessment using EHR event log data and time motion observations,” Ann Fam Med. 2017;15[5]:419-26).

CreativaImages/Thinkstock

In following 142 family medicine physicians over a 3-year period, the investigators found that clinicians spend 5.9 hours of an 11.4-hour workday in the EHR. Of this time, 4.5 hours were spent during clinic hours and 1.4 hours after hours. In the investigators’ words: “Primary care physicians in our study worked an average of 11.4 hours per weekday, both during and after clinic hours, with nearly 6 hours spent interacting with the computer.”

Let that sentence sink in for a moment. How do those numbers compare with your own practice experience? Has anyone in your clinic or hospital taken the time to collect the data? I suspect that your time expenditure on the EHR is similar. Are you or anyone else in your group doing anything more than grumbling to one another about this situation?

Isn’t it time for us to do more than just grouse about this electronic elephant in the room? How many successful businesses would tolerate a situation in which the employees responsible for producing the company’s signature product are allowed to spend half of their time idle? From a purely business perspective, the current EHR/provider interface makes no sense.

Although the cost of physician productivity misdirected to EHRs is probably less than the billions of dollars lost to overpriced medication in this country, this is a topic that deserves a spotlight in ongoing discussions of the Affordable Care Act. At a time when the adequacy of our physician workforce is being questioned, we must take seriously the anecdotal evidence that frustration with EHRs is driving older and experienced physicians into early retirement.

And there is the hot topic of physician burnout and quality of life issues. If I were a physician spending half my time on the computer, of which more than an hour and a half was after clinic hours, I think I would start doing something about that before I enrolled in a mindfulness program. I am sure that the American Academy of Pediatrics has more than one committee working on the problem, but the physician time lost to EHRs deserves a higher priority. In the long run, computers have great potential for improving the delivery of health care. However, we are all suffering through a failed beta test that has gone on far too long.

Our patients can be our best allies because most of them don’t like us looking at our computer screens when we should be looking them in the eye … and listening. Like it or not, we now have a president who is a disruptor of the status quo. Maybe it’s time for us to follow his example and begin making some real noise about the personal and financial cost of EHRs. Talk to your legislators, practice administrators, the American Academy of Pediatrics, anyone … even if they don’t seem to be listening.
 

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].

 

Five years ago, while I still was actively practicing primary care pediatrics, I did a rough calculation that the EHR the practice had purchased was adding an hour to my workday. We were not computer neophytes. This was our third EHR system in 10 years. Not a single minute of that extra time included face-to-face interaction with my patients. In the ensuing years, I have been listening to former colleagues and reading emails from readers of this column. It is clear that my unfortunate experience with our new EHR in 2012 was just a hint at how bad things would get for primary care physicians indentured to EHRs. The short learning curve that was promised has not flattened out, and my rough calculation of an hour at the computer was clearly an underestimate. Most physicians I hear from feel they are spending significantly more than an hour scrolling and clicking.

Although I frequently have used this column to grumble about EHRs, I have been hesitant to launch into a vein-popping tirade because my evidence has been primarily anecdotal. However, a few weeks ago a friend shared a link to a study that provided some startling figures that went beyond my expectation (“Tethered to the EHR: Primary care physician workload assessment using EHR event log data and time motion observations,” Ann Fam Med. 2017;15[5]:419-26).

CreativaImages/Thinkstock

In following 142 family medicine physicians over a 3-year period, the investigators found that clinicians spend 5.9 hours of an 11.4-hour workday in the EHR. Of this time, 4.5 hours were spent during clinic hours and 1.4 hours after hours. In the investigators’ words: “Primary care physicians in our study worked an average of 11.4 hours per weekday, both during and after clinic hours, with nearly 6 hours spent interacting with the computer.”

Let that sentence sink in for a moment. How do those numbers compare with your own practice experience? Has anyone in your clinic or hospital taken the time to collect the data? I suspect that your time expenditure on the EHR is similar. Are you or anyone else in your group doing anything more than grumbling to one another about this situation?

Isn’t it time for us to do more than just grouse about this electronic elephant in the room? How many successful businesses would tolerate a situation in which the employees responsible for producing the company’s signature product are allowed to spend half of their time idle? From a purely business perspective, the current EHR/provider interface makes no sense.

Although the cost of physician productivity misdirected to EHRs is probably less than the billions of dollars lost to overpriced medication in this country, this is a topic that deserves a spotlight in ongoing discussions of the Affordable Care Act. At a time when the adequacy of our physician workforce is being questioned, we must take seriously the anecdotal evidence that frustration with EHRs is driving older and experienced physicians into early retirement.

And there is the hot topic of physician burnout and quality of life issues. If I were a physician spending half my time on the computer, of which more than an hour and a half was after clinic hours, I think I would start doing something about that before I enrolled in a mindfulness program. I am sure that the American Academy of Pediatrics has more than one committee working on the problem, but the physician time lost to EHRs deserves a higher priority. In the long run, computers have great potential for improving the delivery of health care. However, we are all suffering through a failed beta test that has gone on far too long.

Our patients can be our best allies because most of them don’t like us looking at our computer screens when we should be looking them in the eye … and listening. Like it or not, we now have a president who is a disruptor of the status quo. Maybe it’s time for us to follow his example and begin making some real noise about the personal and financial cost of EHRs. Talk to your legislators, practice administrators, the American Academy of Pediatrics, anyone … even if they don’t seem to be listening.
 

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].

 

I suspect that there is at least one person in your office or on your team whose name is followed by the initials “RN.” How do you refer to that individual? Do you introduce her as “My nurse Louise”? Or do you say “I would like you to meet Lance, who is one of our nurses”? How often do you say “Rachel will be your nurse today”?

Is there really much difference between “my,” “our,” and “your” in this context? I suspect that most of us unconsciously avoid “my.” But, back in the era when solo practitioner owner/operators walked the earth, “my nurse” was a more frequent descriptor. The system was male dominated and hierarchical. And, of course, the doctor was paying the nurse’s salary.

MichaelJung/Thinkstock

On the other hand, I wouldn’t be surprised that you refer to the RN on your care team as “our nurse,” even though you don’t sign his or her paycheck. And I suspect that most nurses would probably not be offended by “our” and view it as an acknowledgment of his or her status as a team member.

However, a recent Ethics Rounds in the September 2017 Pediatrics titled “Physician-Nurse Interactions in Critical Care” has gotten me thinking more about what may seem to be semantic hairsplitting between “our nurse” and “your nurse” (doi: 10.1542/peds.2017-0352). The scenario revolves around a young neonatal ICU nurse in her first clinical position who is criticized by her supervisor for advocating for a young mother by questioning the doctor. A good part of the discussion focuses on the ethical dilemma faced by someone whose training has emphasized her obligation to advocate for her patients suddenly finding herself in a situation in which she sees the doctor’s care plan as flawed or at best inadequate. In this particular case, a more experienced nurse would probably already have acquired strategies and a vocabulary that could minimize or avert the conflict. However, the question still remains: to whom does the nurse in your office or on your team owe her/his primary allegiance?

I hope that you have fostered a professional atmosphere that leaves room in which – as well as a process by which – a nurse can question your management of a patient without fear of retribution. Although it is never easy to have your actions questioned, it is certainly easier when the process takes place in a retrospective review rather than when the issue presents itself in the glare of real time and the nurse feels he must speak up now to advocate for the patient adequately.

Another less discussed situation occurs when the nurse feels an obligation to protect the physical and mental health of a physician with whom she is working. It may be that the physician has made it very clear that he “must finish” his day by a certain hour so that he can attend his daughter’s soccer playoff game. Or it may be that the nurse perceives that the doctor is teetering on the edge of burnout and worries that adding one more patient to his schedule may precipitate a crisis or at least speed up the process.

When the call comes in from a panicked parent at 4 p.m., pleading to have her sick child seen, how does the nurse balance his commitment to the health of the patients against his concern for the doctor’s well being. Occasionally, I hear a nurse erring on the side of being zealous guardians of the doctor’s free time. However, I sense that, day in and day out, it is the nurse’s obligation to the patient that prevails most of the time. I hope I am correct.

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].

 

I suspect that there is at least one person in your office or on your team whose name is followed by the initials “RN.” How do you refer to that individual? Do you introduce her as “My nurse Louise”? Or do you say “I would like you to meet Lance, who is one of our nurses”? How often do you say “Rachel will be your nurse today”?

Is there really much difference between “my,” “our,” and “your” in this context? I suspect that most of us unconsciously avoid “my.” But, back in the era when solo practitioner owner/operators walked the earth, “my nurse” was a more frequent descriptor. The system was male dominated and hierarchical. And, of course, the doctor was paying the nurse’s salary.

MichaelJung/Thinkstock

On the other hand, I wouldn’t be surprised that you refer to the RN on your care team as “our nurse,” even though you don’t sign his or her paycheck. And I suspect that most nurses would probably not be offended by “our” and view it as an acknowledgment of his or her status as a team member.

However, a recent Ethics Rounds in the September 2017 Pediatrics titled “Physician-Nurse Interactions in Critical Care” has gotten me thinking more about what may seem to be semantic hairsplitting between “our nurse” and “your nurse” (doi: 10.1542/peds.2017-0352). The scenario revolves around a young neonatal ICU nurse in her first clinical position who is criticized by her supervisor for advocating for a young mother by questioning the doctor. A good part of the discussion focuses on the ethical dilemma faced by someone whose training has emphasized her obligation to advocate for her patients suddenly finding herself in a situation in which she sees the doctor’s care plan as flawed or at best inadequate. In this particular case, a more experienced nurse would probably already have acquired strategies and a vocabulary that could minimize or avert the conflict. However, the question still remains: to whom does the nurse in your office or on your team owe her/his primary allegiance?

I hope that you have fostered a professional atmosphere that leaves room in which – as well as a process by which – a nurse can question your management of a patient without fear of retribution. Although it is never easy to have your actions questioned, it is certainly easier when the process takes place in a retrospective review rather than when the issue presents itself in the glare of real time and the nurse feels he must speak up now to advocate for the patient adequately.

Another less discussed situation occurs when the nurse feels an obligation to protect the physical and mental health of a physician with whom she is working. It may be that the physician has made it very clear that he “must finish” his day by a certain hour so that he can attend his daughter’s soccer playoff game. Or it may be that the nurse perceives that the doctor is teetering on the edge of burnout and worries that adding one more patient to his schedule may precipitate a crisis or at least speed up the process.

When the call comes in from a panicked parent at 4 p.m., pleading to have her sick child seen, how does the nurse balance his commitment to the health of the patients against his concern for the doctor’s well being. Occasionally, I hear a nurse erring on the side of being zealous guardians of the doctor’s free time. However, I sense that, day in and day out, it is the nurse’s obligation to the patient that prevails most of the time. I hope I am correct.

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].

 

I suspect that there is at least one person in your office or on your team whose name is followed by the initials “RN.” How do you refer to that individual? Do you introduce her as “My nurse Louise”? Or do you say “I would like you to meet Lance, who is one of our nurses”? How often do you say “Rachel will be your nurse today”?

Is there really much difference between “my,” “our,” and “your” in this context? I suspect that most of us unconsciously avoid “my.” But, back in the era when solo practitioner owner/operators walked the earth, “my nurse” was a more frequent descriptor. The system was male dominated and hierarchical. And, of course, the doctor was paying the nurse’s salary.

MichaelJung/Thinkstock

On the other hand, I wouldn’t be surprised that you refer to the RN on your care team as “our nurse,” even though you don’t sign his or her paycheck. And I suspect that most nurses would probably not be offended by “our” and view it as an acknowledgment of his or her status as a team member.

However, a recent Ethics Rounds in the September 2017 Pediatrics titled “Physician-Nurse Interactions in Critical Care” has gotten me thinking more about what may seem to be semantic hairsplitting between “our nurse” and “your nurse” (doi: 10.1542/peds.2017-0352). The scenario revolves around a young neonatal ICU nurse in her first clinical position who is criticized by her supervisor for advocating for a young mother by questioning the doctor. A good part of the discussion focuses on the ethical dilemma faced by someone whose training has emphasized her obligation to advocate for her patients suddenly finding herself in a situation in which she sees the doctor’s care plan as flawed or at best inadequate. In this particular case, a more experienced nurse would probably already have acquired strategies and a vocabulary that could minimize or avert the conflict. However, the question still remains: to whom does the nurse in your office or on your team owe her/his primary allegiance?

I hope that you have fostered a professional atmosphere that leaves room in which – as well as a process by which – a nurse can question your management of a patient without fear of retribution. Although it is never easy to have your actions questioned, it is certainly easier when the process takes place in a retrospective review rather than when the issue presents itself in the glare of real time and the nurse feels he must speak up now to advocate for the patient adequately.

Another less discussed situation occurs when the nurse feels an obligation to protect the physical and mental health of a physician with whom she is working. It may be that the physician has made it very clear that he “must finish” his day by a certain hour so that he can attend his daughter’s soccer playoff game. Or it may be that the nurse perceives that the doctor is teetering on the edge of burnout and worries that adding one more patient to his schedule may precipitate a crisis or at least speed up the process.

When the call comes in from a panicked parent at 4 p.m., pleading to have her sick child seen, how does the nurse balance his commitment to the health of the patients against his concern for the doctor’s well being. Occasionally, I hear a nurse erring on the side of being zealous guardians of the doctor’s free time. However, I sense that, day in and day out, it is the nurse’s obligation to the patient that prevails most of the time. I hope I am correct.

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].