Letters from Maine

I like to project an image of a renegade who at times ventures outside the norms of the profession, but when there are rules, I try to follow them. However, I will confess that for the last 10 or 12 years that I was in practice, I flagrantly disobeyed our hospital’s requirement for attendance at staff meetings. In fact, I didn’t attend a single one for more than a decade.

Thinkstock

I did sign in on the sheet that sat on the table outside of the cafeteria where the meetings were held. But I quickly exited and returned to my office for our scheduled Thursday evening hours. Staying for the meeting didn’t feel like a good investment of my time.

I can’t say that I have never attended what I would consider a good meeting. But the number of meetings that I have I attended that could qualify as time well spent is small ... very small.

Often, the first problem is that the stated or implied goal of the meeting was poorly conceived. That is, if the person who called for the meeting had even considered setting a goal. If the purpose of the meeting was to convey information, there are so many more efficient ways to achieve that goal without pulling people away from their primary missions. In the case of a physician, this would translate to seeing patients.

In this electronic age, emails, videos, social media sites, hard-copy handouts, and memos reach the target audience more efficiently and with more clarity than a sit-down meeting does. If the purpose of the meeting also was to elicit feedback about the new information, that same suite of communication vehicles can be structured to function as effective sounding boards.

If the purpose of the meeting is to foster camaraderie and team spirit, then it clearly should be labeled as a team building exercise. However, the organizers should have done enough research into the proposed activity to be reasonably confident that it will achieve the goal of improved team spirit.

If the goal of the meeting is create something – for example – an office policy about stimulant medication, then that goal must be narrowly focused by an agenda published well ahead of the meeting. In this case, the agenda could include the questions: How often should the patient be seen? If the patient is not going to be seen, what questions should he or she be asked? Who will ask them? And where in the chart should this information be filed?

No meeting should last longer than an hour and a half, but an hour is optimal. If the goal has not been achieved, then a second meeting with a more realistic agenda should be scheduled. Attendees who have been assigned tasks for completion before the next meeting should be contacted several days before the rescheduled meeting. There are few things more frustrating than to sit down at a meeting and discover that homework critical to completing the goals has not been done.

Finally, I must caution to avoid meetings organized or chaired by people who have nothing better to do than go to meetings. Some of those folks may even enjoy the social atmosphere of a meeting, and many are likely being paid to attend. Meanwhile, they are squandering your productive face-to-face patient care time.

Courtesy Dr. William G. Wilkoff

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.”

I like to project an image of a renegade who at times ventures outside the norms of the profession, but when there are rules, I try to follow them. However, I will confess that for the last 10 or 12 years that I was in practice, I flagrantly disobeyed our hospital’s requirement for attendance at staff meetings. In fact, I didn’t attend a single one for more than a decade.

Thinkstock

I did sign in on the sheet that sat on the table outside of the cafeteria where the meetings were held. But I quickly exited and returned to my office for our scheduled Thursday evening hours. Staying for the meeting didn’t feel like a good investment of my time.

I can’t say that I have never attended what I would consider a good meeting. But the number of meetings that I have I attended that could qualify as time well spent is small ... very small.

Often, the first problem is that the stated or implied goal of the meeting was poorly conceived. That is, if the person who called for the meeting had even considered setting a goal. If the purpose of the meeting was to convey information, there are so many more efficient ways to achieve that goal without pulling people away from their primary missions. In the case of a physician, this would translate to seeing patients.

In this electronic age, emails, videos, social media sites, hard-copy handouts, and memos reach the target audience more efficiently and with more clarity than a sit-down meeting does. If the purpose of the meeting also was to elicit feedback about the new information, that same suite of communication vehicles can be structured to function as effective sounding boards.

If the purpose of the meeting is to foster camaraderie and team spirit, then it clearly should be labeled as a team building exercise. However, the organizers should have done enough research into the proposed activity to be reasonably confident that it will achieve the goal of improved team spirit.

If the goal of the meeting is create something – for example – an office policy about stimulant medication, then that goal must be narrowly focused by an agenda published well ahead of the meeting. In this case, the agenda could include the questions: How often should the patient be seen? If the patient is not going to be seen, what questions should he or she be asked? Who will ask them? And where in the chart should this information be filed?

No meeting should last longer than an hour and a half, but an hour is optimal. If the goal has not been achieved, then a second meeting with a more realistic agenda should be scheduled. Attendees who have been assigned tasks for completion before the next meeting should be contacted several days before the rescheduled meeting. There are few things more frustrating than to sit down at a meeting and discover that homework critical to completing the goals has not been done.

Finally, I must caution to avoid meetings organized or chaired by people who have nothing better to do than go to meetings. Some of those folks may even enjoy the social atmosphere of a meeting, and many are likely being paid to attend. Meanwhile, they are squandering your productive face-to-face patient care time.

Courtesy Dr. William G. Wilkoff

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.”

I like to project an image of a renegade who at times ventures outside the norms of the profession, but when there are rules, I try to follow them. However, I will confess that for the last 10 or 12 years that I was in practice, I flagrantly disobeyed our hospital’s requirement for attendance at staff meetings. In fact, I didn’t attend a single one for more than a decade.

Thinkstock

I did sign in on the sheet that sat on the table outside of the cafeteria where the meetings were held. But I quickly exited and returned to my office for our scheduled Thursday evening hours. Staying for the meeting didn’t feel like a good investment of my time.

I can’t say that I have never attended what I would consider a good meeting. But the number of meetings that I have I attended that could qualify as time well spent is small ... very small.

Often, the first problem is that the stated or implied goal of the meeting was poorly conceived. That is, if the person who called for the meeting had even considered setting a goal. If the purpose of the meeting was to convey information, there are so many more efficient ways to achieve that goal without pulling people away from their primary missions. In the case of a physician, this would translate to seeing patients.

In this electronic age, emails, videos, social media sites, hard-copy handouts, and memos reach the target audience more efficiently and with more clarity than a sit-down meeting does. If the purpose of the meeting also was to elicit feedback about the new information, that same suite of communication vehicles can be structured to function as effective sounding boards.

If the purpose of the meeting is to foster camaraderie and team spirit, then it clearly should be labeled as a team building exercise. However, the organizers should have done enough research into the proposed activity to be reasonably confident that it will achieve the goal of improved team spirit.

If the goal of the meeting is create something – for example – an office policy about stimulant medication, then that goal must be narrowly focused by an agenda published well ahead of the meeting. In this case, the agenda could include the questions: How often should the patient be seen? If the patient is not going to be seen, what questions should he or she be asked? Who will ask them? And where in the chart should this information be filed?

No meeting should last longer than an hour and a half, but an hour is optimal. If the goal has not been achieved, then a second meeting with a more realistic agenda should be scheduled. Attendees who have been assigned tasks for completion before the next meeting should be contacted several days before the rescheduled meeting. There are few things more frustrating than to sit down at a meeting and discover that homework critical to completing the goals has not been done.

Finally, I must caution to avoid meetings organized or chaired by people who have nothing better to do than go to meetings. Some of those folks may even enjoy the social atmosphere of a meeting, and many are likely being paid to attend. Meanwhile, they are squandering your productive face-to-face patient care time.

Courtesy Dr. William G. Wilkoff

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.”

 

Haven’t you assumed that a rectal temperature always would be a more accurate measurement than an axillary reading? It seems to me that the closer one could get to the center of the child’s body, the more likely you would get a true reading – and the less likely you would fall victim to operator error. However, a study reported on the Pediatric News website suggests that our intuition is wrong again (“Axillary thermometry is the best choice for newborns,” by M. Alexander Otto, Aug. 24, 2017). In the study of 205 newborns at the University of North Carolina at Chapel Hill Medical Center, multiple temperatures were recorded using three methods over a 15-minute period. Rectal temperatures were accurate but less reliable than axillary readings, while temporal artery measurements tended to “overestimate temperatures by an average of about a quarter of a degree.”

stockce/Thinkstock

At the Pediatric Hospital meeting in Nashville, Tenn., lead investigator Ketan Nadkarni, MD, stated that, based on the data, “we think axillary [thermometry] is what we should continue to use in the newborn nursery.” At first blush, this sounds like a very reasonable and rational recommendation, which I am sure will be greeted warmly by nursery nurses at his hospital and across the nation, if only as a way to save time cleaning bassinet linen. There are few things as good as a rectal thermometer at triggering an enteric explosion of meconium from a newborn who has been saving it up for a couple of trimesters.

However, before we jump on the no-rectal-temps in the nursery bandwagon, let’s look at the rectal probe not just as a way to assess a newborn’s temperature, but as a tool for examining the baby’s rectum. For a variety of reasons, the newborn perineum often seems to escape the careful examination it deserves, particularly if the initial exam is performed with the parents watching.

Of course, parents are interested in their baby’s hair and eye color, and whether it has the requisite number of fingers and toes. They will wait anxiously until you have lifted your stethoscope off the baby’s chest and given them a nod and smile. However, doing a thorough exam of the infant’s genitalia may appear a bit invasive and improper to some parents. Whether it is because we sense some unspoken parental discomfort or because we are trying to save time, the nether regions of little girls are inadequately examined.

My evidence for this unfortunate observation is the number of times I have discovered nearly complete labial fusion in an infant female who had allegedly had a complete well child exam 3 or 4 weeks previously. We can argue how aggressively one should treat the condition, but the scenario suggests to me that some providers are not doing thorough perineal exam on infants.

But back to rectal temperatures. It seems to me that it would be prudent to adopt a guideline that says that a newborn’s first temperature be taken rectally. Not because it is any more accurate than an axillary temperature – which this study suggests that it is not. But because the process of taking the temperature would make it more likely (I hesitate to say guarantee) that someone will be taking a careful look at the newborn’s rectum. That initial rectal temperature is not going to detect every genital anomaly, but it may help find some in a more timely fashion. If nothing else, it will get that meconium moving.
 

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.”

 

Haven’t you assumed that a rectal temperature always would be a more accurate measurement than an axillary reading? It seems to me that the closer one could get to the center of the child’s body, the more likely you would get a true reading – and the less likely you would fall victim to operator error. However, a study reported on the Pediatric News website suggests that our intuition is wrong again (“Axillary thermometry is the best choice for newborns,” by M. Alexander Otto, Aug. 24, 2017). In the study of 205 newborns at the University of North Carolina at Chapel Hill Medical Center, multiple temperatures were recorded using three methods over a 15-minute period. Rectal temperatures were accurate but less reliable than axillary readings, while temporal artery measurements tended to “overestimate temperatures by an average of about a quarter of a degree.”

stockce/Thinkstock

At the Pediatric Hospital meeting in Nashville, Tenn., lead investigator Ketan Nadkarni, MD, stated that, based on the data, “we think axillary [thermometry] is what we should continue to use in the newborn nursery.” At first blush, this sounds like a very reasonable and rational recommendation, which I am sure will be greeted warmly by nursery nurses at his hospital and across the nation, if only as a way to save time cleaning bassinet linen. There are few things as good as a rectal thermometer at triggering an enteric explosion of meconium from a newborn who has been saving it up for a couple of trimesters.

However, before we jump on the no-rectal-temps in the nursery bandwagon, let’s look at the rectal probe not just as a way to assess a newborn’s temperature, but as a tool for examining the baby’s rectum. For a variety of reasons, the newborn perineum often seems to escape the careful examination it deserves, particularly if the initial exam is performed with the parents watching.

Of course, parents are interested in their baby’s hair and eye color, and whether it has the requisite number of fingers and toes. They will wait anxiously until you have lifted your stethoscope off the baby’s chest and given them a nod and smile. However, doing a thorough exam of the infant’s genitalia may appear a bit invasive and improper to some parents. Whether it is because we sense some unspoken parental discomfort or because we are trying to save time, the nether regions of little girls are inadequately examined.

My evidence for this unfortunate observation is the number of times I have discovered nearly complete labial fusion in an infant female who had allegedly had a complete well child exam 3 or 4 weeks previously. We can argue how aggressively one should treat the condition, but the scenario suggests to me that some providers are not doing thorough perineal exam on infants.

But back to rectal temperatures. It seems to me that it would be prudent to adopt a guideline that says that a newborn’s first temperature be taken rectally. Not because it is any more accurate than an axillary temperature – which this study suggests that it is not. But because the process of taking the temperature would make it more likely (I hesitate to say guarantee) that someone will be taking a careful look at the newborn’s rectum. That initial rectal temperature is not going to detect every genital anomaly, but it may help find some in a more timely fashion. If nothing else, it will get that meconium moving.
 

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.”

 

Haven’t you assumed that a rectal temperature always would be a more accurate measurement than an axillary reading? It seems to me that the closer one could get to the center of the child’s body, the more likely you would get a true reading – and the less likely you would fall victim to operator error. However, a study reported on the Pediatric News website suggests that our intuition is wrong again (“Axillary thermometry is the best choice for newborns,” by M. Alexander Otto, Aug. 24, 2017). In the study of 205 newborns at the University of North Carolina at Chapel Hill Medical Center, multiple temperatures were recorded using three methods over a 15-minute period. Rectal temperatures were accurate but less reliable than axillary readings, while temporal artery measurements tended to “overestimate temperatures by an average of about a quarter of a degree.”

stockce/Thinkstock

At the Pediatric Hospital meeting in Nashville, Tenn., lead investigator Ketan Nadkarni, MD, stated that, based on the data, “we think axillary [thermometry] is what we should continue to use in the newborn nursery.” At first blush, this sounds like a very reasonable and rational recommendation, which I am sure will be greeted warmly by nursery nurses at his hospital and across the nation, if only as a way to save time cleaning bassinet linen. There are few things as good as a rectal thermometer at triggering an enteric explosion of meconium from a newborn who has been saving it up for a couple of trimesters.

However, before we jump on the no-rectal-temps in the nursery bandwagon, let’s look at the rectal probe not just as a way to assess a newborn’s temperature, but as a tool for examining the baby’s rectum. For a variety of reasons, the newborn perineum often seems to escape the careful examination it deserves, particularly if the initial exam is performed with the parents watching.

Of course, parents are interested in their baby’s hair and eye color, and whether it has the requisite number of fingers and toes. They will wait anxiously until you have lifted your stethoscope off the baby’s chest and given them a nod and smile. However, doing a thorough exam of the infant’s genitalia may appear a bit invasive and improper to some parents. Whether it is because we sense some unspoken parental discomfort or because we are trying to save time, the nether regions of little girls are inadequately examined.

My evidence for this unfortunate observation is the number of times I have discovered nearly complete labial fusion in an infant female who had allegedly had a complete well child exam 3 or 4 weeks previously. We can argue how aggressively one should treat the condition, but the scenario suggests to me that some providers are not doing thorough perineal exam on infants.

But back to rectal temperatures. It seems to me that it would be prudent to adopt a guideline that says that a newborn’s first temperature be taken rectally. Not because it is any more accurate than an axillary temperature – which this study suggests that it is not. But because the process of taking the temperature would make it more likely (I hesitate to say guarantee) that someone will be taking a careful look at the newborn’s rectum. That initial rectal temperature is not going to detect every genital anomaly, but it may help find some in a more timely fashion. If nothing else, it will get that meconium moving.
 

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.”

 

If you graduated from medical school after 1990, you may be surprised to learn that there was a time when the typical general pediatrician could go through an entire day of seeing patients and not write a single prescription for a stimulant medication. In fact, he or she could go for several months without writing for any controlled substance.

ADHD is a modern phenomenon. There always have been children with “ants in their pants” who couldn’t sit still. And there always were “daydreamers” who didn’t pay attention in school. But in the 1970s, the number of children who might now be labeled as having ADHD was nowhere near the 11% often quoted for the prevalence in the current pediatric population.

Eva-Foreman/Thinkstock

One explanation simply may be that the discrepancy reflects a relabeling phenomenon compounded by a heightened awareness. However, most people – including some of us who have lived and practiced pediatrics over the last 40 years – suspect that there must be some factor or factors driving the emergence of this behavior pattern among an increasing number of children.

Could there be some genetic selection process that is favoring the birth and survival of hyperactive and distractible children? In the last decade or two, biologists have discovered evolutionary changes in some animals occurring at pace far faster than had been previously imagined. However, a Darwinian explanation seems unlikely in the case of the emergence of ADHD.

Could it be a diet laced with high fructose sugars or artificial dyes and food coloring? While there continues to be a significant number of parents whose anecdotal observations point to a relationship between diet and behavior, to date controlled studies have not supported a dietary cause for the ADHD phenomenon.

Within a few years of beginning my dual careers as parent and pediatrician, I began to notice that children who were sleep deprived often were distractible and inattentive. Some also were hyperactive, an observation that initially seemed counterintuitive. Over the ensuing four decades, I have become more convinced that a substantial driver of the emergence of the ADHD phenomenon is the fact that the North American lifestyle places sleep so far down on its priority list that a significant percentage of both the pediatric and adult populations are sleep deprived.

I freely admit that my initial anecdotal observations have evolved to the point of an obsession. Of course, I tend to read the papers, such as those linking obstructive sleep apnea and ADHD, which support my contention that sleep deprivation is a major contributor. I look at the data that show that children are getting less sleep than they did a century ago and suspect that this decline must somehow be reflected in their behavior (“Never enough sleep: A brief history of sleep recommendations for children” by Matricciani et al. Pediatrics. 2012 Mar;129[3]:548-56). And, of course, I wonder whether the success and popularity of stimulant medication to treat ADHD is just chance or whether it simply could be waking up a bunch of children who aren’t getting enough sleep.

At times, it has been a lonely several decades, trying to convince parents and other pediatricians that sleep may be the answer. I can’t point to my own research because I have been too busy doing general pediatrics. I can only point to the observations of others that fit into my construct.

You can imagine the warm glow that swept over me when I came across an article in the Washington Post titled “Could some ADHD be a type of sleep disorder? That would fundamentally change how we treat it” (A.E. Cha, Sep. 20, 2017). The studies referred to in the article are not terribly earth shaking. But it was nice to read some quotes in a national newspaper from scientists who share my suspicions about sleep deprivation as a major contributor to the ADHD phenomenon. I instantly felt less lonely.

Unfortunately, it is still a long way from this token recognition in the Washington Post to convincing parents and pediatricians to do the heavy lifting that will be required to undo decades of our society’s sleep-unfriendly norms. It’s so much easier to pull out a prescription pad and write for a stimulant.

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

Email him at [email protected].
 

 

If you graduated from medical school after 1990, you may be surprised to learn that there was a time when the typical general pediatrician could go through an entire day of seeing patients and not write a single prescription for a stimulant medication. In fact, he or she could go for several months without writing for any controlled substance.

ADHD is a modern phenomenon. There always have been children with “ants in their pants” who couldn’t sit still. And there always were “daydreamers” who didn’t pay attention in school. But in the 1970s, the number of children who might now be labeled as having ADHD was nowhere near the 11% often quoted for the prevalence in the current pediatric population.

Eva-Foreman/Thinkstock

One explanation simply may be that the discrepancy reflects a relabeling phenomenon compounded by a heightened awareness. However, most people – including some of us who have lived and practiced pediatrics over the last 40 years – suspect that there must be some factor or factors driving the emergence of this behavior pattern among an increasing number of children.

Could there be some genetic selection process that is favoring the birth and survival of hyperactive and distractible children? In the last decade or two, biologists have discovered evolutionary changes in some animals occurring at pace far faster than had been previously imagined. However, a Darwinian explanation seems unlikely in the case of the emergence of ADHD.

Could it be a diet laced with high fructose sugars or artificial dyes and food coloring? While there continues to be a significant number of parents whose anecdotal observations point to a relationship between diet and behavior, to date controlled studies have not supported a dietary cause for the ADHD phenomenon.

Within a few years of beginning my dual careers as parent and pediatrician, I began to notice that children who were sleep deprived often were distractible and inattentive. Some also were hyperactive, an observation that initially seemed counterintuitive. Over the ensuing four decades, I have become more convinced that a substantial driver of the emergence of the ADHD phenomenon is the fact that the North American lifestyle places sleep so far down on its priority list that a significant percentage of both the pediatric and adult populations are sleep deprived.

I freely admit that my initial anecdotal observations have evolved to the point of an obsession. Of course, I tend to read the papers, such as those linking obstructive sleep apnea and ADHD, which support my contention that sleep deprivation is a major contributor. I look at the data that show that children are getting less sleep than they did a century ago and suspect that this decline must somehow be reflected in their behavior (“Never enough sleep: A brief history of sleep recommendations for children” by Matricciani et al. Pediatrics. 2012 Mar;129[3]:548-56). And, of course, I wonder whether the success and popularity of stimulant medication to treat ADHD is just chance or whether it simply could be waking up a bunch of children who aren’t getting enough sleep.

At times, it has been a lonely several decades, trying to convince parents and other pediatricians that sleep may be the answer. I can’t point to my own research because I have been too busy doing general pediatrics. I can only point to the observations of others that fit into my construct.

You can imagine the warm glow that swept over me when I came across an article in the Washington Post titled “Could some ADHD be a type of sleep disorder? That would fundamentally change how we treat it” (A.E. Cha, Sep. 20, 2017). The studies referred to in the article are not terribly earth shaking. But it was nice to read some quotes in a national newspaper from scientists who share my suspicions about sleep deprivation as a major contributor to the ADHD phenomenon. I instantly felt less lonely.

Unfortunately, it is still a long way from this token recognition in the Washington Post to convincing parents and pediatricians to do the heavy lifting that will be required to undo decades of our society’s sleep-unfriendly norms. It’s so much easier to pull out a prescription pad and write for a stimulant.

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

Email him at [email protected].
 

 

If you graduated from medical school after 1990, you may be surprised to learn that there was a time when the typical general pediatrician could go through an entire day of seeing patients and not write a single prescription for a stimulant medication. In fact, he or she could go for several months without writing for any controlled substance.

ADHD is a modern phenomenon. There always have been children with “ants in their pants” who couldn’t sit still. And there always were “daydreamers” who didn’t pay attention in school. But in the 1970s, the number of children who might now be labeled as having ADHD was nowhere near the 11% often quoted for the prevalence in the current pediatric population.

Eva-Foreman/Thinkstock

One explanation simply may be that the discrepancy reflects a relabeling phenomenon compounded by a heightened awareness. However, most people – including some of us who have lived and practiced pediatrics over the last 40 years – suspect that there must be some factor or factors driving the emergence of this behavior pattern among an increasing number of children.

Could there be some genetic selection process that is favoring the birth and survival of hyperactive and distractible children? In the last decade or two, biologists have discovered evolutionary changes in some animals occurring at pace far faster than had been previously imagined. However, a Darwinian explanation seems unlikely in the case of the emergence of ADHD.

Could it be a diet laced with high fructose sugars or artificial dyes and food coloring? While there continues to be a significant number of parents whose anecdotal observations point to a relationship between diet and behavior, to date controlled studies have not supported a dietary cause for the ADHD phenomenon.

Within a few years of beginning my dual careers as parent and pediatrician, I began to notice that children who were sleep deprived often were distractible and inattentive. Some also were hyperactive, an observation that initially seemed counterintuitive. Over the ensuing four decades, I have become more convinced that a substantial driver of the emergence of the ADHD phenomenon is the fact that the North American lifestyle places sleep so far down on its priority list that a significant percentage of both the pediatric and adult populations are sleep deprived.

I freely admit that my initial anecdotal observations have evolved to the point of an obsession. Of course, I tend to read the papers, such as those linking obstructive sleep apnea and ADHD, which support my contention that sleep deprivation is a major contributor. I look at the data that show that children are getting less sleep than they did a century ago and suspect that this decline must somehow be reflected in their behavior (“Never enough sleep: A brief history of sleep recommendations for children” by Matricciani et al. Pediatrics. 2012 Mar;129[3]:548-56). And, of course, I wonder whether the success and popularity of stimulant medication to treat ADHD is just chance or whether it simply could be waking up a bunch of children who aren’t getting enough sleep.

At times, it has been a lonely several decades, trying to convince parents and other pediatricians that sleep may be the answer. I can’t point to my own research because I have been too busy doing general pediatrics. I can only point to the observations of others that fit into my construct.

You can imagine the warm glow that swept over me when I came across an article in the Washington Post titled “Could some ADHD be a type of sleep disorder? That would fundamentally change how we treat it” (A.E. Cha, Sep. 20, 2017). The studies referred to in the article are not terribly earth shaking. But it was nice to read some quotes in a national newspaper from scientists who share my suspicions about sleep deprivation as a major contributor to the ADHD phenomenon. I instantly felt less lonely.

Unfortunately, it is still a long way from this token recognition in the Washington Post to convincing parents and pediatricians to do the heavy lifting that will be required to undo decades of our society’s sleep-unfriendly norms. It’s so much easier to pull out a prescription pad and write for a stimulant.

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].
 

 

For the most part pediatricians are insulated from death. Our little patients are surprisingly resilient. Once past that anxiety-provoking transition from placental dependence to air breathing, children will thrive in an environment that includes immunizations, potable water, and adequate nutrition. But pediatric deaths do occur infrequently in North America, and they are particularly unsettling to us because we are so unaccustomed to processing the emotions that swirl around the end of life. When a child’s death is unexpected and unexplained, we are likely to find ourselves tortured by feelings of guilt and inadequacy. Did I miss something at the last health maintenance visit? Should I have taken more seriously that call last week about what sounded like a simple viral prodrome? Should I have asked that mother to make an appointment?

germi_p/Thinkstock

The August 2017 Pediatrics opens with a thought-provoking Pediatrics Perspectives titled, “A new approach to the investigation of sudden unexpected death” (doi: 10.1542/peds.2017-0024). Richard D. Goldstein, MD, and his coauthors describe an exhaustive multidisciplined and multistep approach searching for the rare neuroanatomic, cardiac, and metabolic conditions that might have explained the unexpected death of a child who was under 3 years of age. Using a variety of sophisticated techniques, including DNA analysis and central nervous system imaging, the investigators examined not only the child who died but also his parents and surviving siblings.

Their approach, which has been labeled the Robert’s Program, is particularly appealing because it is careful to address the families’ concerns about their surviving and future children. I found the inclusion of the dead child’s pediatrician and the office of the chief medical examiner in the summation of the investigation especially appealing.

However, I have trouble envisioning how this novel approach, funded by several philanthropic organizations, could be rolled out on a larger scale. Here in Maine and in many other smaller cash-strapped communities, the medical examiner’s office is overburdened with opioid overdoses and traumatic deaths. The police and sheriffs’ departments may lack sufficient training and experience to do careful scene investigations.

In reviewing the summary of the 17 deaths included in the article, I was struck by the inclusion of 3 cases in which the final cause of death was meningitis or encephalitis “without clinical prodrome.”

What exactly does “without clinical prodrome” mean? Does it mean that the parents or a day-care provider missed the subtle signs that the child was ill? Were one or two poor feedings written off as just one of those things? Did the child feel a bit warmer to the touch but not hot enough to warrant hunting for the thermometer? Was the pediatrician involved at any point during the period of time when the disease process must have been evolving? Did he or she miss a subtle change in tone or discount the parents’ observations? These things happen.

While a thorough investigation did eventually unearth the cause of death in these three cases, it is in that devilish prodrome that the seeds of guilt can continue to germinate. Parents and physicians will continue to wonder whether someone else with more sensitive antennae might have picked up those early signs of impending disaster. The answer is that there probably wasn’t anyone with better antennae, but there may have been someone with better luck.
 

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.”

 

For the most part pediatricians are insulated from death. Our little patients are surprisingly resilient. Once past that anxiety-provoking transition from placental dependence to air breathing, children will thrive in an environment that includes immunizations, potable water, and adequate nutrition. But pediatric deaths do occur infrequently in North America, and they are particularly unsettling to us because we are so unaccustomed to processing the emotions that swirl around the end of life. When a child’s death is unexpected and unexplained, we are likely to find ourselves tortured by feelings of guilt and inadequacy. Did I miss something at the last health maintenance visit? Should I have taken more seriously that call last week about what sounded like a simple viral prodrome? Should I have asked that mother to make an appointment?

germi_p/Thinkstock

The August 2017 Pediatrics opens with a thought-provoking Pediatrics Perspectives titled, “A new approach to the investigation of sudden unexpected death” (doi: 10.1542/peds.2017-0024). Richard D. Goldstein, MD, and his coauthors describe an exhaustive multidisciplined and multistep approach searching for the rare neuroanatomic, cardiac, and metabolic conditions that might have explained the unexpected death of a child who was under 3 years of age. Using a variety of sophisticated techniques, including DNA analysis and central nervous system imaging, the investigators examined not only the child who died but also his parents and surviving siblings.

Their approach, which has been labeled the Robert’s Program, is particularly appealing because it is careful to address the families’ concerns about their surviving and future children. I found the inclusion of the dead child’s pediatrician and the office of the chief medical examiner in the summation of the investigation especially appealing.

However, I have trouble envisioning how this novel approach, funded by several philanthropic organizations, could be rolled out on a larger scale. Here in Maine and in many other smaller cash-strapped communities, the medical examiner’s office is overburdened with opioid overdoses and traumatic deaths. The police and sheriffs’ departments may lack sufficient training and experience to do careful scene investigations.

In reviewing the summary of the 17 deaths included in the article, I was struck by the inclusion of 3 cases in which the final cause of death was meningitis or encephalitis “without clinical prodrome.”

What exactly does “without clinical prodrome” mean? Does it mean that the parents or a day-care provider missed the subtle signs that the child was ill? Were one or two poor feedings written off as just one of those things? Did the child feel a bit warmer to the touch but not hot enough to warrant hunting for the thermometer? Was the pediatrician involved at any point during the period of time when the disease process must have been evolving? Did he or she miss a subtle change in tone or discount the parents’ observations? These things happen.

While a thorough investigation did eventually unearth the cause of death in these three cases, it is in that devilish prodrome that the seeds of guilt can continue to germinate. Parents and physicians will continue to wonder whether someone else with more sensitive antennae might have picked up those early signs of impending disaster. The answer is that there probably wasn’t anyone with better antennae, but there may have been someone with better luck.
 

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.”

 

For the most part pediatricians are insulated from death. Our little patients are surprisingly resilient. Once past that anxiety-provoking transition from placental dependence to air breathing, children will thrive in an environment that includes immunizations, potable water, and adequate nutrition. But pediatric deaths do occur infrequently in North America, and they are particularly unsettling to us because we are so unaccustomed to processing the emotions that swirl around the end of life. When a child’s death is unexpected and unexplained, we are likely to find ourselves tortured by feelings of guilt and inadequacy. Did I miss something at the last health maintenance visit? Should I have taken more seriously that call last week about what sounded like a simple viral prodrome? Should I have asked that mother to make an appointment?

germi_p/Thinkstock

The August 2017 Pediatrics opens with a thought-provoking Pediatrics Perspectives titled, “A new approach to the investigation of sudden unexpected death” (doi: 10.1542/peds.2017-0024). Richard D. Goldstein, MD, and his coauthors describe an exhaustive multidisciplined and multistep approach searching for the rare neuroanatomic, cardiac, and metabolic conditions that might have explained the unexpected death of a child who was under 3 years of age. Using a variety of sophisticated techniques, including DNA analysis and central nervous system imaging, the investigators examined not only the child who died but also his parents and surviving siblings.

Their approach, which has been labeled the Robert’s Program, is particularly appealing because it is careful to address the families’ concerns about their surviving and future children. I found the inclusion of the dead child’s pediatrician and the office of the chief medical examiner in the summation of the investigation especially appealing.

However, I have trouble envisioning how this novel approach, funded by several philanthropic organizations, could be rolled out on a larger scale. Here in Maine and in many other smaller cash-strapped communities, the medical examiner’s office is overburdened with opioid overdoses and traumatic deaths. The police and sheriffs’ departments may lack sufficient training and experience to do careful scene investigations.

In reviewing the summary of the 17 deaths included in the article, I was struck by the inclusion of 3 cases in which the final cause of death was meningitis or encephalitis “without clinical prodrome.”

What exactly does “without clinical prodrome” mean? Does it mean that the parents or a day-care provider missed the subtle signs that the child was ill? Were one or two poor feedings written off as just one of those things? Did the child feel a bit warmer to the touch but not hot enough to warrant hunting for the thermometer? Was the pediatrician involved at any point during the period of time when the disease process must have been evolving? Did he or she miss a subtle change in tone or discount the parents’ observations? These things happen.

While a thorough investigation did eventually unearth the cause of death in these three cases, it is in that devilish prodrome that the seeds of guilt can continue to germinate. Parents and physicians will continue to wonder whether someone else with more sensitive antennae might have picked up those early signs of impending disaster. The answer is that there probably wasn’t anyone with better antennae, but there may have been someone with better luck.
 

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.”

 

Do you practice as a team member? How is your team defined? Is it made up solely of physicians? Does it include mid-level providers? Does it extend to mental health and social service providers in your office? Do you consider nonproviders such as receptionists as team members? Do you consider the whole office “your team”? Or, is it a smaller team with just yourself and one or two other physicians along with a mid-level provider or two?

There has been a lot written about primary care teams as a natural consequence of the medical home model. In an article in AAP News, Gonzalo J. Paz-Soldán, MD, a member of the American Academy of Pediatrics Council on Community Pediatrics and regional executive medical director, pediatrics, at Reliant Medical Group, Worcester, Mass., suggests that pediatricians should be taking on leadership roles in directing these teams. He claims that in addition to improving the “quality, value, patient experience,” our leadership also will benefit “provider and staff wellness and engagement.” In other words, taking charge will return the joy of pediatrics, and make us more resilient in the face of burnout.

Copyright thinkstockphotos.com

It’s hard to argue with the notion that having more control improves our chances of satisfaction. Most of us who owned and ran our own small practices will tell you that when we were captains of the ship, those were our most rewarding and productive years.

However, assuming a leadership in a large multilevel team of providers and support staff is another story. As Dr. Paz-Soldán observes, most of us were not trained for leadership roles. I would add that the path to medical school does not select for those skills or interest. In addition to requiring a certain set of skill and aptitudes that we may not have, leadership demands a substantial time commitment.

Leading means attending what are often poorly conceived meetings (the topic for a future Letters from Maine), and receiving and writing emails – none of which involve actually taking care of patients. Like it or not, the ugly truth is that seeing patients is what generates our bottom lines. Time spent going to meetings and communicating with your teams members cannot be considered “billable hours.”

So here is our dilemma: Do we abandon the solo and small group practice model, sell out to large entities, lose control of our professional destiny, and spend our time grousing about it? Or do we attempt to regain some control of where our practices are going by giving up productive time with our patients and going to meetings?

There are a few saintly and gifted physicians who have the skills, energy, and commitment to become leaders and still spend enough time seeing patients to satisfy both their emotional and financial professional needs. However, in my experience, when physicians move into leadership roles, the additional responsibilities cannibalize their commitment to patient care and the skills that made them talented physicians.

Of course, one answer may be that we don’t all need to be leaders in the organizational sense that Dr. Paz-Soldán suggests. Personally, I prefer to lead by example. The problem is that the influence you can have when leading by example is limited to the small circle of people with first-hand knowledge of your activities.

Given my aversion to meetings and my disinterest in organization on a large scale, I think if I were a college student considering a career taking care of children, I would take a hard look at becoming a nurse practitioner or physician’s assistant. I might not make as much money, nor would my parents be able to introduce me as their “son the doctor.” But I would be content spending more time doing what I enjoyed.
 

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

 

Do you practice as a team member? How is your team defined? Is it made up solely of physicians? Does it include mid-level providers? Does it extend to mental health and social service providers in your office? Do you consider nonproviders such as receptionists as team members? Do you consider the whole office “your team”? Or, is it a smaller team with just yourself and one or two other physicians along with a mid-level provider or two?

There has been a lot written about primary care teams as a natural consequence of the medical home model. In an article in AAP News, Gonzalo J. Paz-Soldán, MD, a member of the American Academy of Pediatrics Council on Community Pediatrics and regional executive medical director, pediatrics, at Reliant Medical Group, Worcester, Mass., suggests that pediatricians should be taking on leadership roles in directing these teams. He claims that in addition to improving the “quality, value, patient experience,” our leadership also will benefit “provider and staff wellness and engagement.” In other words, taking charge will return the joy of pediatrics, and make us more resilient in the face of burnout.

Copyright thinkstockphotos.com

It’s hard to argue with the notion that having more control improves our chances of satisfaction. Most of us who owned and ran our own small practices will tell you that when we were captains of the ship, those were our most rewarding and productive years.

However, assuming a leadership in a large multilevel team of providers and support staff is another story. As Dr. Paz-Soldán observes, most of us were not trained for leadership roles. I would add that the path to medical school does not select for those skills or interest. In addition to requiring a certain set of skill and aptitudes that we may not have, leadership demands a substantial time commitment.

Leading means attending what are often poorly conceived meetings (the topic for a future Letters from Maine), and receiving and writing emails – none of which involve actually taking care of patients. Like it or not, the ugly truth is that seeing patients is what generates our bottom lines. Time spent going to meetings and communicating with your teams members cannot be considered “billable hours.”

So here is our dilemma: Do we abandon the solo and small group practice model, sell out to large entities, lose control of our professional destiny, and spend our time grousing about it? Or do we attempt to regain some control of where our practices are going by giving up productive time with our patients and going to meetings?

There are a few saintly and gifted physicians who have the skills, energy, and commitment to become leaders and still spend enough time seeing patients to satisfy both their emotional and financial professional needs. However, in my experience, when physicians move into leadership roles, the additional responsibilities cannibalize their commitment to patient care and the skills that made them talented physicians.

Of course, one answer may be that we don’t all need to be leaders in the organizational sense that Dr. Paz-Soldán suggests. Personally, I prefer to lead by example. The problem is that the influence you can have when leading by example is limited to the small circle of people with first-hand knowledge of your activities.

Given my aversion to meetings and my disinterest in organization on a large scale, I think if I were a college student considering a career taking care of children, I would take a hard look at becoming a nurse practitioner or physician’s assistant. I might not make as much money, nor would my parents be able to introduce me as their “son the doctor.” But I would be content spending more time doing what I enjoyed.
 

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

 

Do you practice as a team member? How is your team defined? Is it made up solely of physicians? Does it include mid-level providers? Does it extend to mental health and social service providers in your office? Do you consider nonproviders such as receptionists as team members? Do you consider the whole office “your team”? Or, is it a smaller team with just yourself and one or two other physicians along with a mid-level provider or two?

There has been a lot written about primary care teams as a natural consequence of the medical home model. In an article in AAP News, Gonzalo J. Paz-Soldán, MD, a member of the American Academy of Pediatrics Council on Community Pediatrics and regional executive medical director, pediatrics, at Reliant Medical Group, Worcester, Mass., suggests that pediatricians should be taking on leadership roles in directing these teams. He claims that in addition to improving the “quality, value, patient experience,” our leadership also will benefit “provider and staff wellness and engagement.” In other words, taking charge will return the joy of pediatrics, and make us more resilient in the face of burnout.

Copyright thinkstockphotos.com

It’s hard to argue with the notion that having more control improves our chances of satisfaction. Most of us who owned and ran our own small practices will tell you that when we were captains of the ship, those were our most rewarding and productive years.

However, assuming a leadership in a large multilevel team of providers and support staff is another story. As Dr. Paz-Soldán observes, most of us were not trained for leadership roles. I would add that the path to medical school does not select for those skills or interest. In addition to requiring a certain set of skill and aptitudes that we may not have, leadership demands a substantial time commitment.

Leading means attending what are often poorly conceived meetings (the topic for a future Letters from Maine), and receiving and writing emails – none of which involve actually taking care of patients. Like it or not, the ugly truth is that seeing patients is what generates our bottom lines. Time spent going to meetings and communicating with your teams members cannot be considered “billable hours.”

So here is our dilemma: Do we abandon the solo and small group practice model, sell out to large entities, lose control of our professional destiny, and spend our time grousing about it? Or do we attempt to regain some control of where our practices are going by giving up productive time with our patients and going to meetings?

There are a few saintly and gifted physicians who have the skills, energy, and commitment to become leaders and still spend enough time seeing patients to satisfy both their emotional and financial professional needs. However, in my experience, when physicians move into leadership roles, the additional responsibilities cannibalize their commitment to patient care and the skills that made them talented physicians.

Of course, one answer may be that we don’t all need to be leaders in the organizational sense that Dr. Paz-Soldán suggests. Personally, I prefer to lead by example. The problem is that the influence you can have when leading by example is limited to the small circle of people with first-hand knowledge of your activities.

Given my aversion to meetings and my disinterest in organization on a large scale, I think if I were a college student considering a career taking care of children, I would take a hard look at becoming a nurse practitioner or physician’s assistant. I might not make as much money, nor would my parents be able to introduce me as their “son the doctor.” But I would be content spending more time doing what I enjoyed.
 

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

What are the age parameters for your practice? I suspect that at one end of the spectrum, you feel that a child is never too young to come to your practice. In fact you may even go out of your way to encourage expectant mothers to make a get-acquainted visit before they deliver because you know that a face-to-face encounter is very likely to make your job easier for the next decade or two.

On the other hand, I suspect that you have set an upper age limit above which you suggest that your patients transition to a physician whose practice is focused on adult care. Is this limit stated as a number – 18? 19? 21? Or are you so uncomfortable with the challenges of adolescent medicine that you urge the teenagers in your practice to find another medical home?

Catherine Yeulet/Thinkstockphotos

You may not have an official upper age limit, but the architecture and decor of your office scream out, “We love little kids! Maybe it’s time for you preteens to move on.” Is your waiting room shared by all ages? Are there zebras on the walls and giraffes on the exam room doors? Is “The Hungry Caterpillar” the most mature reading material in the basket of books and magazines in your waiting room? Do you and your staff dress in scrub suits and jackets plastered with cartoon characters? Is there a monkey hanging from the yoke of your stethoscope?

In my practice, I had a very simple and seldom-enforced upper age limit. A patient who was still a student, not even a full-time student, was welcome to keep coming to see me. This made us very popular with college students who knew that we would be there for them when they came home between semesters with a sore throat or needed a refill for their anxiety medicine. No long waits to see a customer-unfriendly internist. Of course, this meant that it was not unusual for me to see patients who were working on their master’s degree or just a few months short of their doctoral dissertation.

One of our exam rooms had large plywood cutouts of the number 1-10 on the walls, but otherwise I avoided large murals of jungle figures or cartoon characters. A checked shirt and a muted wine-red knit tie were about as wild and crazy as my professional wardrobe ever got. I never really bought into the notion that I could put a nervous young child at ease by dressing like a clown. In my experience, it was the personality and warmth radiating from the caregiver that set the tone of the visit, not what he or she was wearing.

We didn’t have the space or the time to allow adolescents and young adults to have their own waiting room. I am sure that a few moved on to other practices because they felt they were too old to be sharing the waiting room with crying infants and shrieking toddlers. More often, I heard from older patients that they enjoyed the patient mix, and on occasion some of them told me they enjoyed playing with the younger patients.

Recently, the American Academy of Pediatrics published a recommendation discouraging pediatricians from setting upper age limits for their patients (Pediatrics. 2017;140[3]:e20172151). As someone who practiced most of his career with a very lenient age limit policy, I think this is an excellent and long overdue recommendation.

Patients in their older teens and early twenties seldom present with problems that are beyond our professional competency. Furthermore, one cannot underestimate the value that comes from the years of continuity we can fall back on, particularly for those patients with chronic and multiorgan system disease. But most of all, the chance to spend a few quiet minutes having an adult conversation and catching up with someone you have known since infancy can be a pleasant oasis in an otherwise hectic day spent seeing unappreciative, inarticulate infants and whining toddlers.

[polldaddy:{"method":"iframe","type":"survey","src":"//newspolls2017.polldaddy.com/s/never-too-old?iframe=1"}]

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.”

What are the age parameters for your practice? I suspect that at one end of the spectrum, you feel that a child is never too young to come to your practice. In fact you may even go out of your way to encourage expectant mothers to make a get-acquainted visit before they deliver because you know that a face-to-face encounter is very likely to make your job easier for the next decade or two.

On the other hand, I suspect that you have set an upper age limit above which you suggest that your patients transition to a physician whose practice is focused on adult care. Is this limit stated as a number – 18? 19? 21? Or are you so uncomfortable with the challenges of adolescent medicine that you urge the teenagers in your practice to find another medical home?

Catherine Yeulet/Thinkstockphotos

You may not have an official upper age limit, but the architecture and decor of your office scream out, “We love little kids! Maybe it’s time for you preteens to move on.” Is your waiting room shared by all ages? Are there zebras on the walls and giraffes on the exam room doors? Is “The Hungry Caterpillar” the most mature reading material in the basket of books and magazines in your waiting room? Do you and your staff dress in scrub suits and jackets plastered with cartoon characters? Is there a monkey hanging from the yoke of your stethoscope?

In my practice, I had a very simple and seldom-enforced upper age limit. A patient who was still a student, not even a full-time student, was welcome to keep coming to see me. This made us very popular with college students who knew that we would be there for them when they came home between semesters with a sore throat or needed a refill for their anxiety medicine. No long waits to see a customer-unfriendly internist. Of course, this meant that it was not unusual for me to see patients who were working on their master’s degree or just a few months short of their doctoral dissertation.

One of our exam rooms had large plywood cutouts of the number 1-10 on the walls, but otherwise I avoided large murals of jungle figures or cartoon characters. A checked shirt and a muted wine-red knit tie were about as wild and crazy as my professional wardrobe ever got. I never really bought into the notion that I could put a nervous young child at ease by dressing like a clown. In my experience, it was the personality and warmth radiating from the caregiver that set the tone of the visit, not what he or she was wearing.

We didn’t have the space or the time to allow adolescents and young adults to have their own waiting room. I am sure that a few moved on to other practices because they felt they were too old to be sharing the waiting room with crying infants and shrieking toddlers. More often, I heard from older patients that they enjoyed the patient mix, and on occasion some of them told me they enjoyed playing with the younger patients.

Recently, the American Academy of Pediatrics published a recommendation discouraging pediatricians from setting upper age limits for their patients (Pediatrics. 2017;140[3]:e20172151). As someone who practiced most of his career with a very lenient age limit policy, I think this is an excellent and long overdue recommendation.

Patients in their older teens and early twenties seldom present with problems that are beyond our professional competency. Furthermore, one cannot underestimate the value that comes from the years of continuity we can fall back on, particularly for those patients with chronic and multiorgan system disease. But most of all, the chance to spend a few quiet minutes having an adult conversation and catching up with someone you have known since infancy can be a pleasant oasis in an otherwise hectic day spent seeing unappreciative, inarticulate infants and whining toddlers.

[polldaddy:{"method":"iframe","type":"survey","src":"//newspolls2017.polldaddy.com/s/never-too-old?iframe=1"}]

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.”

What are the age parameters for your practice? I suspect that at one end of the spectrum, you feel that a child is never too young to come to your practice. In fact you may even go out of your way to encourage expectant mothers to make a get-acquainted visit before they deliver because you know that a face-to-face encounter is very likely to make your job easier for the next decade or two.

On the other hand, I suspect that you have set an upper age limit above which you suggest that your patients transition to a physician whose practice is focused on adult care. Is this limit stated as a number – 18? 19? 21? Or are you so uncomfortable with the challenges of adolescent medicine that you urge the teenagers in your practice to find another medical home?

Catherine Yeulet/Thinkstockphotos

You may not have an official upper age limit, but the architecture and decor of your office scream out, “We love little kids! Maybe it’s time for you preteens to move on.” Is your waiting room shared by all ages? Are there zebras on the walls and giraffes on the exam room doors? Is “The Hungry Caterpillar” the most mature reading material in the basket of books and magazines in your waiting room? Do you and your staff dress in scrub suits and jackets plastered with cartoon characters? Is there a monkey hanging from the yoke of your stethoscope?

In my practice, I had a very simple and seldom-enforced upper age limit. A patient who was still a student, not even a full-time student, was welcome to keep coming to see me. This made us very popular with college students who knew that we would be there for them when they came home between semesters with a sore throat or needed a refill for their anxiety medicine. No long waits to see a customer-unfriendly internist. Of course, this meant that it was not unusual for me to see patients who were working on their master’s degree or just a few months short of their doctoral dissertation.

One of our exam rooms had large plywood cutouts of the number 1-10 on the walls, but otherwise I avoided large murals of jungle figures or cartoon characters. A checked shirt and a muted wine-red knit tie were about as wild and crazy as my professional wardrobe ever got. I never really bought into the notion that I could put a nervous young child at ease by dressing like a clown. In my experience, it was the personality and warmth radiating from the caregiver that set the tone of the visit, not what he or she was wearing.

We didn’t have the space or the time to allow adolescents and young adults to have their own waiting room. I am sure that a few moved on to other practices because they felt they were too old to be sharing the waiting room with crying infants and shrieking toddlers. More often, I heard from older patients that they enjoyed the patient mix, and on occasion some of them told me they enjoyed playing with the younger patients.

Recently, the American Academy of Pediatrics published a recommendation discouraging pediatricians from setting upper age limits for their patients (Pediatrics. 2017;140[3]:e20172151). As someone who practiced most of his career with a very lenient age limit policy, I think this is an excellent and long overdue recommendation.

Patients in their older teens and early twenties seldom present with problems that are beyond our professional competency. Furthermore, one cannot underestimate the value that comes from the years of continuity we can fall back on, particularly for those patients with chronic and multiorgan system disease. But most of all, the chance to spend a few quiet minutes having an adult conversation and catching up with someone you have known since infancy can be a pleasant oasis in an otherwise hectic day spent seeing unappreciative, inarticulate infants and whining toddlers.

[polldaddy:{"method":"iframe","type":"survey","src":"//newspolls2017.polldaddy.com/s/never-too-old?iframe=1"}]

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.”

You probably aren’t surprised to learn that the jobless rate for young people aged 16-24 years has fallen to the lowest rate recorded since 1969. Those “Hiring” signs you see in every storefront tell the story. Although the jobless rate for young people is still twice that for adults, clearly there are jobs out there.

However, it appears that there are fewer young people looking for those jobs. In fact, the decline in what is referred to as the “labor force participation rate” is down significantly to 60.6% from a high point of 77.5% in 1989 (Summer Youth Unemployment Falls to Lowest Level Since 1969, by Eric Morath. Wall Street Journal. 2017 Aug 17).

Koji_Ishii/Thinkstock

Although I haven’t found any statistics that might explain this lack of interest in joining, even temporarily, the job market, several things come to mind. It may be that the overall improvement in the job market means that families are more secure financially and children feel less pressure to contribute to family coffers. The author of the Wall Street Journal article suggests that some young people see going to school during the summer as a way to shorten their path to graduation, and a full-time job as a better investment than a low-paying summer job. The lure of adventure and the chance to sample other cultures may prompt those who can afford it to travel instead of work.

But it may be that the concept of having a job, particularly a first job, lacks the appeal it did for my generation. While I’m sure my parents would have appreciated any financial contribution I could provide, I felt no direct pressure from them to get a summer job. My mother’s only concern was that without something to do, I would be getting into trouble or hanging around the house and getting in her way. She could easily find me work to do around the house that wasn’t going to be fun or pay me anything.

It was peer pressure that nudged me into working. I had watched my friends and their older siblings reaping the benefits of a summer job – disposable income. Money could buy an old car, pay for insurance and gas, fund dates, and buy 45 rpm records. The money provided some independence. Even the most menial job could allow you to feel a bit more like a grown-up.

In retrospect, my summer job experiences gave me the opportunity to meet people who resided out of my socioeconomic and ethnic comfort zones. I learned the value of good customer service and some of the skills involved in providing it – skills that should be in the toolbox of every practicing physician.

While I don’t think it is our job as pediatricians to instill a work ethic in our patients, it doesn’t hurt to encourage those who seem to be at loose ends to consider getting a job. Unfortunately, many of the businesses hiring young people are offering hours that are certainly not schoolwork- and sleep-friendly. And we must caution our patients to avoid making bad compromises when facing the lure of a steady supply of spending money.

I would hate to see us return to the bad old days when children were enslaved in sweat shops, in dangerous and unhealthy working conditions. However, I fear that in some cases, in our zeal to protect young people from unsafe working conditions, we have made so many rules that we have seriously limited the opportunities for them to get a taste of the hands-on technical skills that our country desperately needs. Just try to get a plumber or electrician when you need one, and you will understand what I mean. A summer spent as an electrician’s gofer just might trigger a floundering 13-year-old to invest more energy in his studies when he sees them as a critical step to a well-paying job he would enjoy.

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.”

You probably aren’t surprised to learn that the jobless rate for young people aged 16-24 years has fallen to the lowest rate recorded since 1969. Those “Hiring” signs you see in every storefront tell the story. Although the jobless rate for young people is still twice that for adults, clearly there are jobs out there.

However, it appears that there are fewer young people looking for those jobs. In fact, the decline in what is referred to as the “labor force participation rate” is down significantly to 60.6% from a high point of 77.5% in 1989 (Summer Youth Unemployment Falls to Lowest Level Since 1969, by Eric Morath. Wall Street Journal. 2017 Aug 17).

Koji_Ishii/Thinkstock

Although I haven’t found any statistics that might explain this lack of interest in joining, even temporarily, the job market, several things come to mind. It may be that the overall improvement in the job market means that families are more secure financially and children feel less pressure to contribute to family coffers. The author of the Wall Street Journal article suggests that some young people see going to school during the summer as a way to shorten their path to graduation, and a full-time job as a better investment than a low-paying summer job. The lure of adventure and the chance to sample other cultures may prompt those who can afford it to travel instead of work.

But it may be that the concept of having a job, particularly a first job, lacks the appeal it did for my generation. While I’m sure my parents would have appreciated any financial contribution I could provide, I felt no direct pressure from them to get a summer job. My mother’s only concern was that without something to do, I would be getting into trouble or hanging around the house and getting in her way. She could easily find me work to do around the house that wasn’t going to be fun or pay me anything.

It was peer pressure that nudged me into working. I had watched my friends and their older siblings reaping the benefits of a summer job – disposable income. Money could buy an old car, pay for insurance and gas, fund dates, and buy 45 rpm records. The money provided some independence. Even the most menial job could allow you to feel a bit more like a grown-up.

In retrospect, my summer job experiences gave me the opportunity to meet people who resided out of my socioeconomic and ethnic comfort zones. I learned the value of good customer service and some of the skills involved in providing it – skills that should be in the toolbox of every practicing physician.

While I don’t think it is our job as pediatricians to instill a work ethic in our patients, it doesn’t hurt to encourage those who seem to be at loose ends to consider getting a job. Unfortunately, many of the businesses hiring young people are offering hours that are certainly not schoolwork- and sleep-friendly. And we must caution our patients to avoid making bad compromises when facing the lure of a steady supply of spending money.

I would hate to see us return to the bad old days when children were enslaved in sweat shops, in dangerous and unhealthy working conditions. However, I fear that in some cases, in our zeal to protect young people from unsafe working conditions, we have made so many rules that we have seriously limited the opportunities for them to get a taste of the hands-on technical skills that our country desperately needs. Just try to get a plumber or electrician when you need one, and you will understand what I mean. A summer spent as an electrician’s gofer just might trigger a floundering 13-year-old to invest more energy in his studies when he sees them as a critical step to a well-paying job he would enjoy.

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.”

You probably aren’t surprised to learn that the jobless rate for young people aged 16-24 years has fallen to the lowest rate recorded since 1969. Those “Hiring” signs you see in every storefront tell the story. Although the jobless rate for young people is still twice that for adults, clearly there are jobs out there.

However, it appears that there are fewer young people looking for those jobs. In fact, the decline in what is referred to as the “labor force participation rate” is down significantly to 60.6% from a high point of 77.5% in 1989 (Summer Youth Unemployment Falls to Lowest Level Since 1969, by Eric Morath. Wall Street Journal. 2017 Aug 17).

Koji_Ishii/Thinkstock

Although I haven’t found any statistics that might explain this lack of interest in joining, even temporarily, the job market, several things come to mind. It may be that the overall improvement in the job market means that families are more secure financially and children feel less pressure to contribute to family coffers. The author of the Wall Street Journal article suggests that some young people see going to school during the summer as a way to shorten their path to graduation, and a full-time job as a better investment than a low-paying summer job. The lure of adventure and the chance to sample other cultures may prompt those who can afford it to travel instead of work.

But it may be that the concept of having a job, particularly a first job, lacks the appeal it did for my generation. While I’m sure my parents would have appreciated any financial contribution I could provide, I felt no direct pressure from them to get a summer job. My mother’s only concern was that without something to do, I would be getting into trouble or hanging around the house and getting in her way. She could easily find me work to do around the house that wasn’t going to be fun or pay me anything.

It was peer pressure that nudged me into working. I had watched my friends and their older siblings reaping the benefits of a summer job – disposable income. Money could buy an old car, pay for insurance and gas, fund dates, and buy 45 rpm records. The money provided some independence. Even the most menial job could allow you to feel a bit more like a grown-up.

In retrospect, my summer job experiences gave me the opportunity to meet people who resided out of my socioeconomic and ethnic comfort zones. I learned the value of good customer service and some of the skills involved in providing it – skills that should be in the toolbox of every practicing physician.

While I don’t think it is our job as pediatricians to instill a work ethic in our patients, it doesn’t hurt to encourage those who seem to be at loose ends to consider getting a job. Unfortunately, many of the businesses hiring young people are offering hours that are certainly not schoolwork- and sleep-friendly. And we must caution our patients to avoid making bad compromises when facing the lure of a steady supply of spending money.

I would hate to see us return to the bad old days when children were enslaved in sweat shops, in dangerous and unhealthy working conditions. However, I fear that in some cases, in our zeal to protect young people from unsafe working conditions, we have made so many rules that we have seriously limited the opportunities for them to get a taste of the hands-on technical skills that our country desperately needs. Just try to get a plumber or electrician when you need one, and you will understand what I mean. A summer spent as an electrician’s gofer just might trigger a floundering 13-year-old to invest more energy in his studies when he sees them as a critical step to a well-paying job he would enjoy.

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 title caught my eye as I skimmed through my daughter’s copy of the New Yorker. “When should a child be taken from his parents?” (Larissa MacFarquar, Aug. 7 & 14, 2017). It is a very complex question, and one for which there has never been an easy answer, certainly not an answer that can be applied universally. However, my reflex response was “sooner rather than later!”

What prompted my hasty from-the-hip answer is 40-plus years of watching the legal system grind along at a pace that too often fails to take into account the emotional needs of a child’s developing personality. While lawyers file for extensions and wait for slots in dockets bloated with less time-sensitive cases, children float in limbo waiting to hear where their home will be and who will constitute their family.

Courtesy Dr. William G. Wilkoff

If a child is lucky, he may pass the time with a single caring family who eventually may adopt him. Or he may be housed with a family member who can offer more stability than his troubled parent(s). More likely he will bounce from foster home to foster home that may be adequate in terms of the basics of food, shelter, and temporary comfort but offer no hope of a lasting relationship.

Even if he is lucky enough to be housed with a single foster home, the odds are that his stays there will be punctuated with returns to his parent as the parent is given one more chance to beat back the demons that have stood in the way of at least an adequate, if not a model, parenthood. The New Yorker article chronicles one such odyssey that spans a mother’s four pregnancies with several fathers.

In the crudest terms, here is the question: “How many strikes does one get before one loses his or her parental rights?” It is a bit easier to make the call when there have been incidents in which a parent’s action or inaction has put the child’s physical health in jeopardy. However, the social workers, physicians, and law enforcement officials who must shoulder the burden of these decisions involving the abusive parent often find themselves in no-win situations. Giving the parent who is suspected of physical abuse having been “just a little heavy handed” one more chance could result in death or life-long impairment.

fiorigianluigi/Thinkstock

The more difficult decisions and one that seems to take much longer come when the parent is struggling with addiction or a mental health illness that has been resistant to therapy. In some cases, the failure is because the parent hasn’t adhered to the therapeutic plan. However, often the relapses are simply part of the expected course of the parent’s illness or addiction. But how many chances should the parent be given? How long do we let a 3-year-old’s or a 13-year-old’s emotions yo-yo up and down before someone says, “Enough is enough – your child is at increasing risk for lifelong mental health problems because of your inconsistent parenting?” In my experience, the decision makers have erred too often in giving the parent one more chance.

I suspect the rationale for giving the parent another chance is based on the belief that the biologic family should always be the preferred option; an assumption that can be called into question. While I don’t think these decisions should be made with the strict application of an algorithm, I believe there is more room for evidence-based decision-making. That evidence may not be currently available, but I think we should be asking questions to get that information. For example, for an individual with a specific substance addiction or mental illness with a certain diagnosis, what are the chances of a remedy that will allow that individual to become a functional parent? And how long will it take?

Information like this may be helpful for those folks with the difficult job of deciding when a parent should lose his parental rights in a time course that takes into account the emotional needs of his children.
 

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 title caught my eye as I skimmed through my daughter’s copy of the New Yorker. “When should a child be taken from his parents?” (Larissa MacFarquar, Aug. 7 & 14, 2017). It is a very complex question, and one for which there has never been an easy answer, certainly not an answer that can be applied universally. However, my reflex response was “sooner rather than later!”

What prompted my hasty from-the-hip answer is 40-plus years of watching the legal system grind along at a pace that too often fails to take into account the emotional needs of a child’s developing personality. While lawyers file for extensions and wait for slots in dockets bloated with less time-sensitive cases, children float in limbo waiting to hear where their home will be and who will constitute their family.

Courtesy Dr. William G. Wilkoff

If a child is lucky, he may pass the time with a single caring family who eventually may adopt him. Or he may be housed with a family member who can offer more stability than his troubled parent(s). More likely he will bounce from foster home to foster home that may be adequate in terms of the basics of food, shelter, and temporary comfort but offer no hope of a lasting relationship.

Even if he is lucky enough to be housed with a single foster home, the odds are that his stays there will be punctuated with returns to his parent as the parent is given one more chance to beat back the demons that have stood in the way of at least an adequate, if not a model, parenthood. The New Yorker article chronicles one such odyssey that spans a mother’s four pregnancies with several fathers.

In the crudest terms, here is the question: “How many strikes does one get before one loses his or her parental rights?” It is a bit easier to make the call when there have been incidents in which a parent’s action or inaction has put the child’s physical health in jeopardy. However, the social workers, physicians, and law enforcement officials who must shoulder the burden of these decisions involving the abusive parent often find themselves in no-win situations. Giving the parent who is suspected of physical abuse having been “just a little heavy handed” one more chance could result in death or life-long impairment.

fiorigianluigi/Thinkstock

The more difficult decisions and one that seems to take much longer come when the parent is struggling with addiction or a mental health illness that has been resistant to therapy. In some cases, the failure is because the parent hasn’t adhered to the therapeutic plan. However, often the relapses are simply part of the expected course of the parent’s illness or addiction. But how many chances should the parent be given? How long do we let a 3-year-old’s or a 13-year-old’s emotions yo-yo up and down before someone says, “Enough is enough – your child is at increasing risk for lifelong mental health problems because of your inconsistent parenting?” In my experience, the decision makers have erred too often in giving the parent one more chance.

I suspect the rationale for giving the parent another chance is based on the belief that the biologic family should always be the preferred option; an assumption that can be called into question. While I don’t think these decisions should be made with the strict application of an algorithm, I believe there is more room for evidence-based decision-making. That evidence may not be currently available, but I think we should be asking questions to get that information. For example, for an individual with a specific substance addiction or mental illness with a certain diagnosis, what are the chances of a remedy that will allow that individual to become a functional parent? And how long will it take?

Information like this may be helpful for those folks with the difficult job of deciding when a parent should lose his parental rights in a time course that takes into account the emotional needs of his children.
 

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 title caught my eye as I skimmed through my daughter’s copy of the New Yorker. “When should a child be taken from his parents?” (Larissa MacFarquar, Aug. 7 & 14, 2017). It is a very complex question, and one for which there has never been an easy answer, certainly not an answer that can be applied universally. However, my reflex response was “sooner rather than later!”

What prompted my hasty from-the-hip answer is 40-plus years of watching the legal system grind along at a pace that too often fails to take into account the emotional needs of a child’s developing personality. While lawyers file for extensions and wait for slots in dockets bloated with less time-sensitive cases, children float in limbo waiting to hear where their home will be and who will constitute their family.

Courtesy Dr. William G. Wilkoff

If a child is lucky, he may pass the time with a single caring family who eventually may adopt him. Or he may be housed with a family member who can offer more stability than his troubled parent(s). More likely he will bounce from foster home to foster home that may be adequate in terms of the basics of food, shelter, and temporary comfort but offer no hope of a lasting relationship.

Even if he is lucky enough to be housed with a single foster home, the odds are that his stays there will be punctuated with returns to his parent as the parent is given one more chance to beat back the demons that have stood in the way of at least an adequate, if not a model, parenthood. The New Yorker article chronicles one such odyssey that spans a mother’s four pregnancies with several fathers.

In the crudest terms, here is the question: “How many strikes does one get before one loses his or her parental rights?” It is a bit easier to make the call when there have been incidents in which a parent’s action or inaction has put the child’s physical health in jeopardy. However, the social workers, physicians, and law enforcement officials who must shoulder the burden of these decisions involving the abusive parent often find themselves in no-win situations. Giving the parent who is suspected of physical abuse having been “just a little heavy handed” one more chance could result in death or life-long impairment.

fiorigianluigi/Thinkstock

The more difficult decisions and one that seems to take much longer come when the parent is struggling with addiction or a mental health illness that has been resistant to therapy. In some cases, the failure is because the parent hasn’t adhered to the therapeutic plan. However, often the relapses are simply part of the expected course of the parent’s illness or addiction. But how many chances should the parent be given? How long do we let a 3-year-old’s or a 13-year-old’s emotions yo-yo up and down before someone says, “Enough is enough – your child is at increasing risk for lifelong mental health problems because of your inconsistent parenting?” In my experience, the decision makers have erred too often in giving the parent one more chance.

I suspect the rationale for giving the parent another chance is based on the belief that the biologic family should always be the preferred option; an assumption that can be called into question. While I don’t think these decisions should be made with the strict application of an algorithm, I believe there is more room for evidence-based decision-making. That evidence may not be currently available, but I think we should be asking questions to get that information. For example, for an individual with a specific substance addiction or mental illness with a certain diagnosis, what are the chances of a remedy that will allow that individual to become a functional parent? And how long will it take?

Information like this may be helpful for those folks with the difficult job of deciding when a parent should lose his parental rights in a time course that takes into account the emotional needs of his children.
 

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

 

Like many adults, I suspect that I may have been living under the cloud of an undiagnosed case of attention-deficit/hyperactivity disorder (ADHD). What else could explain why my mind wanders during the second hole of my wife’s narrative of her morning golf outing with her friends? Why have I never been in a class or lecture in which after 20 minutes I began wishing I were somewhere else? In my student days, I felt compelled to leave my studies and go to the refrigerator every 15 minutes – even though I wasn’t hungry. Sounds like ADHD to me.

But I know what you are thinking. This guy graduated from medical school, and has been married to the same woman for nearly 50 years. He has no criminal record and has held the same job for more than 40 years. I will admit that my life trajectory is atypical for someone even with a mild case of adult ADHD.

Actually, I don’t really believe that I have an undiagnosed case of ADHD. But I do feel that my attention span is at the short end of the normal spectrum. And I think that by good fortune I stumbled on several strategies that helped me thrive in an academic environment despite my relative attention deficit.

Most noteworthy among those strategies was my habit of listening to heavy metal music with a throbbing beat while I was studying. At my recent college reunion, former classmates whom I hadn’t seen in 50 years reminded me of how often I drove them to quieter study oases with the driving rhythms of the Rolling Stones’ misogynistic anthem “Under My Thumb.”My wife still recalls her amazement the first (and last) time she offered to keep me company while I studied for a pathophysiology exam. She found me hunched over my notes spread out on a coffee table, my knees bouncing to the beat of Joe Cocker crowing the Beatles’ classic “She Came in Through the Bathroom Window” (still one of my all-time favorites). Earbuds hadn’t been invented, and I considered earphones the size of chili bowls too dorky.

I always have assumed that my study habits were just a little weird. But recently I discovered an article describing the work of Alexander Pantelyat, MD, assistant professor of neurology and cofounder of the Johns Hopkins Center for Music and Medicine (“Does Listening to Music Improve Your Focus?” by Heidi Mitchell, Wall Street Journal, July 26, 2017). Dr. Pantelyat notes that the early enthusiasm for playing Mozart to newborns has faded with the understanding that any improvement in learning skills was short-lived. However, he sees some evidence that hearing music of a genre you enjoy may help you focus better than listening to music that you don’t like. He says, “If you enjoy heavy metal, you might be more focused when you listen to it.”

monkeybusinessimages/Thinkstock

Dr. Pantelyat goes on to discuss his theory about how music affects various parts of the brain, the names of which I have long forgotten. I prefer to explain my rhythm-fueled study strategy as simply another example of how stimulants, in my case loud music, can keep a sleep-deprived normal individual awake long enough to pay attention to the task at hand.

As Dr. Pantelyat cautions, the response to music is highly individual. I generally have not recommended my peculiar study habits to my patients. However, my experience has left me more open-minded when trying to help young people struggling to find a study strategy that works. You may not share my affinity for the Rolling Stones and Joe Cocker, but you have to admit you would rather have your patients listen to their music than take drugs they may not need.
 

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

 

Like many adults, I suspect that I may have been living under the cloud of an undiagnosed case of attention-deficit/hyperactivity disorder (ADHD). What else could explain why my mind wanders during the second hole of my wife’s narrative of her morning golf outing with her friends? Why have I never been in a class or lecture in which after 20 minutes I began wishing I were somewhere else? In my student days, I felt compelled to leave my studies and go to the refrigerator every 15 minutes – even though I wasn’t hungry. Sounds like ADHD to me.

But I know what you are thinking. This guy graduated from medical school, and has been married to the same woman for nearly 50 years. He has no criminal record and has held the same job for more than 40 years. I will admit that my life trajectory is atypical for someone even with a mild case of adult ADHD.

Actually, I don’t really believe that I have an undiagnosed case of ADHD. But I do feel that my attention span is at the short end of the normal spectrum. And I think that by good fortune I stumbled on several strategies that helped me thrive in an academic environment despite my relative attention deficit.

Most noteworthy among those strategies was my habit of listening to heavy metal music with a throbbing beat while I was studying. At my recent college reunion, former classmates whom I hadn’t seen in 50 years reminded me of how often I drove them to quieter study oases with the driving rhythms of the Rolling Stones’ misogynistic anthem “Under My Thumb.”My wife still recalls her amazement the first (and last) time she offered to keep me company while I studied for a pathophysiology exam. She found me hunched over my notes spread out on a coffee table, my knees bouncing to the beat of Joe Cocker crowing the Beatles’ classic “She Came in Through the Bathroom Window” (still one of my all-time favorites). Earbuds hadn’t been invented, and I considered earphones the size of chili bowls too dorky.

I always have assumed that my study habits were just a little weird. But recently I discovered an article describing the work of Alexander Pantelyat, MD, assistant professor of neurology and cofounder of the Johns Hopkins Center for Music and Medicine (“Does Listening to Music Improve Your Focus?” by Heidi Mitchell, Wall Street Journal, July 26, 2017). Dr. Pantelyat notes that the early enthusiasm for playing Mozart to newborns has faded with the understanding that any improvement in learning skills was short-lived. However, he sees some evidence that hearing music of a genre you enjoy may help you focus better than listening to music that you don’t like. He says, “If you enjoy heavy metal, you might be more focused when you listen to it.”

monkeybusinessimages/Thinkstock

Dr. Pantelyat goes on to discuss his theory about how music affects various parts of the brain, the names of which I have long forgotten. I prefer to explain my rhythm-fueled study strategy as simply another example of how stimulants, in my case loud music, can keep a sleep-deprived normal individual awake long enough to pay attention to the task at hand.

As Dr. Pantelyat cautions, the response to music is highly individual. I generally have not recommended my peculiar study habits to my patients. However, my experience has left me more open-minded when trying to help young people struggling to find a study strategy that works. You may not share my affinity for the Rolling Stones and Joe Cocker, but you have to admit you would rather have your patients listen to their music than take drugs they may not need.
 

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

 

Like many adults, I suspect that I may have been living under the cloud of an undiagnosed case of attention-deficit/hyperactivity disorder (ADHD). What else could explain why my mind wanders during the second hole of my wife’s narrative of her morning golf outing with her friends? Why have I never been in a class or lecture in which after 20 minutes I began wishing I were somewhere else? In my student days, I felt compelled to leave my studies and go to the refrigerator every 15 minutes – even though I wasn’t hungry. Sounds like ADHD to me.

But I know what you are thinking. This guy graduated from medical school, and has been married to the same woman for nearly 50 years. He has no criminal record and has held the same job for more than 40 years. I will admit that my life trajectory is atypical for someone even with a mild case of adult ADHD.

Actually, I don’t really believe that I have an undiagnosed case of ADHD. But I do feel that my attention span is at the short end of the normal spectrum. And I think that by good fortune I stumbled on several strategies that helped me thrive in an academic environment despite my relative attention deficit.

Most noteworthy among those strategies was my habit of listening to heavy metal music with a throbbing beat while I was studying. At my recent college reunion, former classmates whom I hadn’t seen in 50 years reminded me of how often I drove them to quieter study oases with the driving rhythms of the Rolling Stones’ misogynistic anthem “Under My Thumb.”My wife still recalls her amazement the first (and last) time she offered to keep me company while I studied for a pathophysiology exam. She found me hunched over my notes spread out on a coffee table, my knees bouncing to the beat of Joe Cocker crowing the Beatles’ classic “She Came in Through the Bathroom Window” (still one of my all-time favorites). Earbuds hadn’t been invented, and I considered earphones the size of chili bowls too dorky.

I always have assumed that my study habits were just a little weird. But recently I discovered an article describing the work of Alexander Pantelyat, MD, assistant professor of neurology and cofounder of the Johns Hopkins Center for Music and Medicine (“Does Listening to Music Improve Your Focus?” by Heidi Mitchell, Wall Street Journal, July 26, 2017). Dr. Pantelyat notes that the early enthusiasm for playing Mozart to newborns has faded with the understanding that any improvement in learning skills was short-lived. However, he sees some evidence that hearing music of a genre you enjoy may help you focus better than listening to music that you don’t like. He says, “If you enjoy heavy metal, you might be more focused when you listen to it.”

monkeybusinessimages/Thinkstock

Dr. Pantelyat goes on to discuss his theory about how music affects various parts of the brain, the names of which I have long forgotten. I prefer to explain my rhythm-fueled study strategy as simply another example of how stimulants, in my case loud music, can keep a sleep-deprived normal individual awake long enough to pay attention to the task at hand.

As Dr. Pantelyat cautions, the response to music is highly individual. I generally have not recommended my peculiar study habits to my patients. However, my experience has left me more open-minded when trying to help young people struggling to find a study strategy that works. You may not share my affinity for the Rolling Stones and Joe Cocker, but you have to admit you would rather have your patients listen to their music than take drugs they may not need.
 

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

 

As a physician or a patient, you probably have noticed that the quality of health care is better when there is a continuous relationship between the physician and the patient. Discontinuity can make doctor-patient communication less fluid, but familiarity can breed comfort and confidence. Patients often complain when they see a different physician at every visit. And physicians know they are less efficient when they are seeing a patient they have never seen before.

Tomwang112/Thinkstock

It seems to me that the benefits of continuity in medical care are so numerous and intuitive that we don’t need another study in a peer-reviewed journal to confirm the obvious. But I forget that the powers holding the purse strings of health care would like to see some evidence before they fund a delivery system such as the medical home that touts continuity as a cost saving benefit. In light of that reality, I dove into a new study published in the June 2017 Pediatrics (“Continuity of Care in Infancy and Early Childhood Health Outcomes,” doi: 10.1542/peds.2017-0339). The Philadelphia-based researchers looked at a cohort of more than 17,000 infants from birth to age 3 years receiving primary care in a variety of settings.

They discovered that less continuity was associated with more ambulatory sick visits and more ambulatory sensitive hospitalizations, particularly for children with chronic conditions. Interestingly, they could find no association between continuity measured at well visits and patients’ health outcomes.

With only a gut level and personal relationship with the subject, I wondered how the researchers measured something as nebulous as continuity. It turns out there are several ways to measure continuity, of which the investigators focused on two. The Usual Provider of Care is calculated by dividing the number of visits with the most common provider by the total number of primary care visits. The Bice and Boxerman Continuity of Care Index is more difficult to calculate because, rather than using a single provider, it lumps a small core of providers together (such as a team) as the most the common provider.

As a curmudgeonly, old school, egotistical kind of guy, I was surprised and disappointed to learn from this paper’s references of another study that found, in at least one scenario, the individual-based (Usual Provider of Care) and team-based (Bice and Boxerman Continuity of Care Index) methods of defining continuity yielded comparable results (Med Care. 2016 May;54[5]:e30-4). I always have assumed that, regardless of how well it had been crafted, that I could provide better continuity than a team of providers.

I know what you are thinking: This guy hasn’t bought into the maxim that “There is no I in team.” No, no, I do believe in it, but in the context of continuity of care, it seemed to me that sometimes the more links there are in the chain, the more chances there are for miscommunication. And we all know that primary care is 90% communication.

It is interesting that in this study from Philadelphia, despite the small advantage of single provider continuity in their unpublished data, there was basically little difference in the outcomes when continuity was provided by an individual or a small team. So, I guess this is just another example of my decades long self-delusion. However, the real take-home message is that continuity is important, and it is incumbent on all of us to maintain it as best we can – either as individuals or as members of a small team.
 

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

 

As a physician or a patient, you probably have noticed that the quality of health care is better when there is a continuous relationship between the physician and the patient. Discontinuity can make doctor-patient communication less fluid, but familiarity can breed comfort and confidence. Patients often complain when they see a different physician at every visit. And physicians know they are less efficient when they are seeing a patient they have never seen before.

Tomwang112/Thinkstock

It seems to me that the benefits of continuity in medical care are so numerous and intuitive that we don’t need another study in a peer-reviewed journal to confirm the obvious. But I forget that the powers holding the purse strings of health care would like to see some evidence before they fund a delivery system such as the medical home that touts continuity as a cost saving benefit. In light of that reality, I dove into a new study published in the June 2017 Pediatrics (“Continuity of Care in Infancy and Early Childhood Health Outcomes,” doi: 10.1542/peds.2017-0339). The Philadelphia-based researchers looked at a cohort of more than 17,000 infants from birth to age 3 years receiving primary care in a variety of settings.

They discovered that less continuity was associated with more ambulatory sick visits and more ambulatory sensitive hospitalizations, particularly for children with chronic conditions. Interestingly, they could find no association between continuity measured at well visits and patients’ health outcomes.

With only a gut level and personal relationship with the subject, I wondered how the researchers measured something as nebulous as continuity. It turns out there are several ways to measure continuity, of which the investigators focused on two. The Usual Provider of Care is calculated by dividing the number of visits with the most common provider by the total number of primary care visits. The Bice and Boxerman Continuity of Care Index is more difficult to calculate because, rather than using a single provider, it lumps a small core of providers together (such as a team) as the most the common provider.

As a curmudgeonly, old school, egotistical kind of guy, I was surprised and disappointed to learn from this paper’s references of another study that found, in at least one scenario, the individual-based (Usual Provider of Care) and team-based (Bice and Boxerman Continuity of Care Index) methods of defining continuity yielded comparable results (Med Care. 2016 May;54[5]:e30-4). I always have assumed that, regardless of how well it had been crafted, that I could provide better continuity than a team of providers.

I know what you are thinking: This guy hasn’t bought into the maxim that “There is no I in team.” No, no, I do believe in it, but in the context of continuity of care, it seemed to me that sometimes the more links there are in the chain, the more chances there are for miscommunication. And we all know that primary care is 90% communication.

It is interesting that in this study from Philadelphia, despite the small advantage of single provider continuity in their unpublished data, there was basically little difference in the outcomes when continuity was provided by an individual or a small team. So, I guess this is just another example of my decades long self-delusion. However, the real take-home message is that continuity is important, and it is incumbent on all of us to maintain it as best we can – either as individuals or as members of a small team.
 

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

 

As a physician or a patient, you probably have noticed that the quality of health care is better when there is a continuous relationship between the physician and the patient. Discontinuity can make doctor-patient communication less fluid, but familiarity can breed comfort and confidence. Patients often complain when they see a different physician at every visit. And physicians know they are less efficient when they are seeing a patient they have never seen before.

Tomwang112/Thinkstock

It seems to me that the benefits of continuity in medical care are so numerous and intuitive that we don’t need another study in a peer-reviewed journal to confirm the obvious. But I forget that the powers holding the purse strings of health care would like to see some evidence before they fund a delivery system such as the medical home that touts continuity as a cost saving benefit. In light of that reality, I dove into a new study published in the June 2017 Pediatrics (“Continuity of Care in Infancy and Early Childhood Health Outcomes,” doi: 10.1542/peds.2017-0339). The Philadelphia-based researchers looked at a cohort of more than 17,000 infants from birth to age 3 years receiving primary care in a variety of settings.

They discovered that less continuity was associated with more ambulatory sick visits and more ambulatory sensitive hospitalizations, particularly for children with chronic conditions. Interestingly, they could find no association between continuity measured at well visits and patients’ health outcomes.

With only a gut level and personal relationship with the subject, I wondered how the researchers measured something as nebulous as continuity. It turns out there are several ways to measure continuity, of which the investigators focused on two. The Usual Provider of Care is calculated by dividing the number of visits with the most common provider by the total number of primary care visits. The Bice and Boxerman Continuity of Care Index is more difficult to calculate because, rather than using a single provider, it lumps a small core of providers together (such as a team) as the most the common provider.

As a curmudgeonly, old school, egotistical kind of guy, I was surprised and disappointed to learn from this paper’s references of another study that found, in at least one scenario, the individual-based (Usual Provider of Care) and team-based (Bice and Boxerman Continuity of Care Index) methods of defining continuity yielded comparable results (Med Care. 2016 May;54[5]:e30-4). I always have assumed that, regardless of how well it had been crafted, that I could provide better continuity than a team of providers.

I know what you are thinking: This guy hasn’t bought into the maxim that “There is no I in team.” No, no, I do believe in it, but in the context of continuity of care, it seemed to me that sometimes the more links there are in the chain, the more chances there are for miscommunication. And we all know that primary care is 90% communication.

It is interesting that in this study from Philadelphia, despite the small advantage of single provider continuity in their unpublished data, there was basically little difference in the outcomes when continuity was provided by an individual or a small team. So, I guess this is just another example of my decades long self-delusion. However, the real take-home message is that continuity is important, and it is incumbent on all of us to maintain it as best we can – either as individuals or as members of a small team.
 

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].