Letters from Maine

In her role as the Dowager Countess on Public Broadcasting Service’s Downton Abbey, Maggie Smith has delivered many memorable one-liners, but none as revealing of her character’s social isolation as the clueless query, “What is a weekend?” How could anyone not appreciate the qualitative differences between the first 4 days of the week and the trio of Friday, Saturday, and Sunday?

A recent study by two Stanford University sociologists suggests that one doesn’t even need to have a job to place a higher value on the weekend (“You Don’t Need More Free Time,” by Cristobal Young, New York Times, Jan. 8, 2016). Using data from more than 500,000 respondents to a Gallup Daily Poll, the investigators found that a variety of indicators of well-being were lowest during the beginning of the workweek and then not surprisingly began to climb on Friday, reaching a peak on Saturday and Sunday. However, it turns out that the emotions of the unemployed respondents tracked exactly the same pattern as those of the people who had jobs.

In an effort to explain this unexpected finding, one of the investigators points out that time, particularly free time, is a “network good.” And in sociologist lingo, “Network goods are things that derive their value from being widely shared.” Although someone without a job may have an abundance of free time, the majority of the people with whom he or she could share that time are busy at work.

This study suggests that you may feel that you would be happier if you had more time off from work; part of the problem may be that there is a mismatch between your schedule and the schedules of the people and activities that you value most. You may have done this kind of self-assessment when you were looking for a job, but how successful were you in negotiating your schedule? Have you been able to renegotiate your schedule to match changes in your social situation? Spouse? Children?

How creative have you been in seeking out arrangements with coworkers who don’t share your time-off value profile? Although you might be tempted to say that based on this recent Stanford study, everyone places the same high value on weekend time off, is this really the case? There are a few people out there whose interests, personalities, and social situations make them value time off when you would just as soon work.

For example, I recently encountered a new word as I was scanning the classified advertisements in the back of this month’s Pediatrics. A hospital in California was looking for a “nocturnist.” An Internet search quickly confirmed my suspicion that a nocturnist is a physician, often a hospitalist, who prefers to work the night shift. Now, it may be just for the money, but if I were an avid birdwatcher, I can imagine wanting to maximize my time off when the sun was up.

Of course the trick is finding those coworkers whose lifestyles are as dissimilar from yours as possible ... and who are willing to trade work schedules. While I think that on many campuses, “diversity” has become an overused buzzword, diversity at your workplace might give you the best chance of finding a time-off arrangement that better matches your value profile.

Finally, if you are really unhappy, it may be time to swallow hard and entertain an arrangement in which you worked more and actually had less total free time, but the time you do have off is time you can share with the people you value and the activities you enjoy. It’s all about choosing the right set of compromises and learning to live with them. Good 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.”

In her role as the Dowager Countess on Public Broadcasting Service’s Downton Abbey, Maggie Smith has delivered many memorable one-liners, but none as revealing of her character’s social isolation as the clueless query, “What is a weekend?” How could anyone not appreciate the qualitative differences between the first 4 days of the week and the trio of Friday, Saturday, and Sunday?

A recent study by two Stanford University sociologists suggests that one doesn’t even need to have a job to place a higher value on the weekend (“You Don’t Need More Free Time,” by Cristobal Young, New York Times, Jan. 8, 2016). Using data from more than 500,000 respondents to a Gallup Daily Poll, the investigators found that a variety of indicators of well-being were lowest during the beginning of the workweek and then not surprisingly began to climb on Friday, reaching a peak on Saturday and Sunday. However, it turns out that the emotions of the unemployed respondents tracked exactly the same pattern as those of the people who had jobs.

In an effort to explain this unexpected finding, one of the investigators points out that time, particularly free time, is a “network good.” And in sociologist lingo, “Network goods are things that derive their value from being widely shared.” Although someone without a job may have an abundance of free time, the majority of the people with whom he or she could share that time are busy at work.

This study suggests that you may feel that you would be happier if you had more time off from work; part of the problem may be that there is a mismatch between your schedule and the schedules of the people and activities that you value most. You may have done this kind of self-assessment when you were looking for a job, but how successful were you in negotiating your schedule? Have you been able to renegotiate your schedule to match changes in your social situation? Spouse? Children?

How creative have you been in seeking out arrangements with coworkers who don’t share your time-off value profile? Although you might be tempted to say that based on this recent Stanford study, everyone places the same high value on weekend time off, is this really the case? There are a few people out there whose interests, personalities, and social situations make them value time off when you would just as soon work.

For example, I recently encountered a new word as I was scanning the classified advertisements in the back of this month’s Pediatrics. A hospital in California was looking for a “nocturnist.” An Internet search quickly confirmed my suspicion that a nocturnist is a physician, often a hospitalist, who prefers to work the night shift. Now, it may be just for the money, but if I were an avid birdwatcher, I can imagine wanting to maximize my time off when the sun was up.

Of course the trick is finding those coworkers whose lifestyles are as dissimilar from yours as possible ... and who are willing to trade work schedules. While I think that on many campuses, “diversity” has become an overused buzzword, diversity at your workplace might give you the best chance of finding a time-off arrangement that better matches your value profile.

Finally, if you are really unhappy, it may be time to swallow hard and entertain an arrangement in which you worked more and actually had less total free time, but the time you do have off is time you can share with the people you value and the activities you enjoy. It’s all about choosing the right set of compromises and learning to live with them. Good 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.”

In her role as the Dowager Countess on Public Broadcasting Service’s Downton Abbey, Maggie Smith has delivered many memorable one-liners, but none as revealing of her character’s social isolation as the clueless query, “What is a weekend?” How could anyone not appreciate the qualitative differences between the first 4 days of the week and the trio of Friday, Saturday, and Sunday?

A recent study by two Stanford University sociologists suggests that one doesn’t even need to have a job to place a higher value on the weekend (“You Don’t Need More Free Time,” by Cristobal Young, New York Times, Jan. 8, 2016). Using data from more than 500,000 respondents to a Gallup Daily Poll, the investigators found that a variety of indicators of well-being were lowest during the beginning of the workweek and then not surprisingly began to climb on Friday, reaching a peak on Saturday and Sunday. However, it turns out that the emotions of the unemployed respondents tracked exactly the same pattern as those of the people who had jobs.

In an effort to explain this unexpected finding, one of the investigators points out that time, particularly free time, is a “network good.” And in sociologist lingo, “Network goods are things that derive their value from being widely shared.” Although someone without a job may have an abundance of free time, the majority of the people with whom he or she could share that time are busy at work.

This study suggests that you may feel that you would be happier if you had more time off from work; part of the problem may be that there is a mismatch between your schedule and the schedules of the people and activities that you value most. You may have done this kind of self-assessment when you were looking for a job, but how successful were you in negotiating your schedule? Have you been able to renegotiate your schedule to match changes in your social situation? Spouse? Children?

How creative have you been in seeking out arrangements with coworkers who don’t share your time-off value profile? Although you might be tempted to say that based on this recent Stanford study, everyone places the same high value on weekend time off, is this really the case? There are a few people out there whose interests, personalities, and social situations make them value time off when you would just as soon work.

For example, I recently encountered a new word as I was scanning the classified advertisements in the back of this month’s Pediatrics. A hospital in California was looking for a “nocturnist.” An Internet search quickly confirmed my suspicion that a nocturnist is a physician, often a hospitalist, who prefers to work the night shift. Now, it may be just for the money, but if I were an avid birdwatcher, I can imagine wanting to maximize my time off when the sun was up.

Of course the trick is finding those coworkers whose lifestyles are as dissimilar from yours as possible ... and who are willing to trade work schedules. While I think that on many campuses, “diversity” has become an overused buzzword, diversity at your workplace might give you the best chance of finding a time-off arrangement that better matches your value profile.

Finally, if you are really unhappy, it may be time to swallow hard and entertain an arrangement in which you worked more and actually had less total free time, but the time you do have off is time you can share with the people you value and the activities you enjoy. It’s all about choosing the right set of compromises and learning to live with them. Good 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.”

A few years ago I wrote a column about what promised to be an exciting development in blood testing technology. Using the money her parents had set aside for her education, a young woman dropped out of Stanford University at age 19 and started a company that she claimed would be able to offer hundreds of lab tests on just a few drops of blood. Results would be available in just minutes instead of hours or days. At the time I wrote the column, the company had just landed a contract with a large drug store chain with an arrangement that would eventually allow nearly every resident of the United States to be within a few miles of a site that would offer rapid response blood tests with nothing more than a finger prick.

It seemed a little hard to believe, but the prospect of pediatricians being able to make a diagnosis without running the risk of exsanguinating our smallest patients sounded appealing. On the other hand, I worried that a quick and easy technology might encourage some physicians to use a shotgun approach to diagnosing illness rather than a more rational and cost-effective process based on the traditional skills of history taking and physical examination. Some patients who foolishly wanted to know “everything” about themselves might be tempted to ask their physicians to order the whole smorgasbord of tests. “Hey, it’s only a few drops of blood.”

Turns out there were enough people with more money than reservations and the company quickly attracted hundreds of millions of dollars in venture capital. The company, now calling itself Theranos, has been valued at nine billion dollars. But, recently this startup star has encountered some serious bumps in the road to a full-scale launch (“Hot Startup Theranos Has Struggled With Its Blood-Test Technology” by John Carreyrou, The Wall Street Journal, updated Oct. 16, 2015). The Wall Street Journal reported that despite promises, only a few of the 240 tests offered by the company are currently performed using their proprietary microtechnique. In the days following the Journal article, the Food and Drug Administration warned Theranos that their “nanotainer” is considered a new medical device that must first clear the agency’s time consuming and costly vetting process (“Hot Startup Theranos Dials Back Lab Tests at FDA’s Behest” by John Carreyrou, The Wall Street Journal, updated Oct. 16, 2015).

The venture capitalists who had climbed on the Theranos bandwagon tempted by the just-a-few-drops promise may end up seeing their bank accounts hemorrhage. But I don’t think we should be too critical of their investment decision. It was and may still be good idea that has simply run afoul of the details. However, I recently learned about another new business that I don’t consider to have even started with a good idea, but still has managed to attract enough capital to get itself off the ground (“Should Breast Milk Be Nutritionally Analyzed?” by Laura Johannes, The Wall Street Journal, Dec. 28, 2015).

I’m sure you have seen some new mothers who were concerned that their breast milk was not enough for their babies. But how many of them would pay $150 for a start-up kit and then more than $300 to find out the nutritional content of their breast milk? What if it meant pumping and freezing three samples 2 or 3 days apart and then shipping them in a cooler to a lab? What if you told them that neither you nor anyone else could reliably interpret the results because there aren’t any published guidelines for the optimal composition of human breast milk? Even if your practice is packed to the rafters with anxiety-driven, irrational parents, I don’t think you would find many takers. But that doesn’t seem to have bothered the folks who have invested in Happy Vitals, a company in Washington that is offering a service similar to the one I have just described.

You and I might not have invested in a company whose business plan was to offer such a service. But I fear there may be enough health care “providers” practicing without the benefit of an evidence-based education that what I consider a capital misadventure may actually be able to pay back its investors.

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.”

A few years ago I wrote a column about what promised to be an exciting development in blood testing technology. Using the money her parents had set aside for her education, a young woman dropped out of Stanford University at age 19 and started a company that she claimed would be able to offer hundreds of lab tests on just a few drops of blood. Results would be available in just minutes instead of hours or days. At the time I wrote the column, the company had just landed a contract with a large drug store chain with an arrangement that would eventually allow nearly every resident of the United States to be within a few miles of a site that would offer rapid response blood tests with nothing more than a finger prick.

It seemed a little hard to believe, but the prospect of pediatricians being able to make a diagnosis without running the risk of exsanguinating our smallest patients sounded appealing. On the other hand, I worried that a quick and easy technology might encourage some physicians to use a shotgun approach to diagnosing illness rather than a more rational and cost-effective process based on the traditional skills of history taking and physical examination. Some patients who foolishly wanted to know “everything” about themselves might be tempted to ask their physicians to order the whole smorgasbord of tests. “Hey, it’s only a few drops of blood.”

Turns out there were enough people with more money than reservations and the company quickly attracted hundreds of millions of dollars in venture capital. The company, now calling itself Theranos, has been valued at nine billion dollars. But, recently this startup star has encountered some serious bumps in the road to a full-scale launch (“Hot Startup Theranos Has Struggled With Its Blood-Test Technology” by John Carreyrou, The Wall Street Journal, updated Oct. 16, 2015). The Wall Street Journal reported that despite promises, only a few of the 240 tests offered by the company are currently performed using their proprietary microtechnique. In the days following the Journal article, the Food and Drug Administration warned Theranos that their “nanotainer” is considered a new medical device that must first clear the agency’s time consuming and costly vetting process (“Hot Startup Theranos Dials Back Lab Tests at FDA’s Behest” by John Carreyrou, The Wall Street Journal, updated Oct. 16, 2015).

The venture capitalists who had climbed on the Theranos bandwagon tempted by the just-a-few-drops promise may end up seeing their bank accounts hemorrhage. But I don’t think we should be too critical of their investment decision. It was and may still be good idea that has simply run afoul of the details. However, I recently learned about another new business that I don’t consider to have even started with a good idea, but still has managed to attract enough capital to get itself off the ground (“Should Breast Milk Be Nutritionally Analyzed?” by Laura Johannes, The Wall Street Journal, Dec. 28, 2015).

I’m sure you have seen some new mothers who were concerned that their breast milk was not enough for their babies. But how many of them would pay $150 for a start-up kit and then more than $300 to find out the nutritional content of their breast milk? What if it meant pumping and freezing three samples 2 or 3 days apart and then shipping them in a cooler to a lab? What if you told them that neither you nor anyone else could reliably interpret the results because there aren’t any published guidelines for the optimal composition of human breast milk? Even if your practice is packed to the rafters with anxiety-driven, irrational parents, I don’t think you would find many takers. But that doesn’t seem to have bothered the folks who have invested in Happy Vitals, a company in Washington that is offering a service similar to the one I have just described.

You and I might not have invested in a company whose business plan was to offer such a service. But I fear there may be enough health care “providers” practicing without the benefit of an evidence-based education that what I consider a capital misadventure may actually be able to pay back its investors.

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.”

A few years ago I wrote a column about what promised to be an exciting development in blood testing technology. Using the money her parents had set aside for her education, a young woman dropped out of Stanford University at age 19 and started a company that she claimed would be able to offer hundreds of lab tests on just a few drops of blood. Results would be available in just minutes instead of hours or days. At the time I wrote the column, the company had just landed a contract with a large drug store chain with an arrangement that would eventually allow nearly every resident of the United States to be within a few miles of a site that would offer rapid response blood tests with nothing more than a finger prick.

It seemed a little hard to believe, but the prospect of pediatricians being able to make a diagnosis without running the risk of exsanguinating our smallest patients sounded appealing. On the other hand, I worried that a quick and easy technology might encourage some physicians to use a shotgun approach to diagnosing illness rather than a more rational and cost-effective process based on the traditional skills of history taking and physical examination. Some patients who foolishly wanted to know “everything” about themselves might be tempted to ask their physicians to order the whole smorgasbord of tests. “Hey, it’s only a few drops of blood.”

Turns out there were enough people with more money than reservations and the company quickly attracted hundreds of millions of dollars in venture capital. The company, now calling itself Theranos, has been valued at nine billion dollars. But, recently this startup star has encountered some serious bumps in the road to a full-scale launch (“Hot Startup Theranos Has Struggled With Its Blood-Test Technology” by John Carreyrou, The Wall Street Journal, updated Oct. 16, 2015). The Wall Street Journal reported that despite promises, only a few of the 240 tests offered by the company are currently performed using their proprietary microtechnique. In the days following the Journal article, the Food and Drug Administration warned Theranos that their “nanotainer” is considered a new medical device that must first clear the agency’s time consuming and costly vetting process (“Hot Startup Theranos Dials Back Lab Tests at FDA’s Behest” by John Carreyrou, The Wall Street Journal, updated Oct. 16, 2015).

The venture capitalists who had climbed on the Theranos bandwagon tempted by the just-a-few-drops promise may end up seeing their bank accounts hemorrhage. But I don’t think we should be too critical of their investment decision. It was and may still be good idea that has simply run afoul of the details. However, I recently learned about another new business that I don’t consider to have even started with a good idea, but still has managed to attract enough capital to get itself off the ground (“Should Breast Milk Be Nutritionally Analyzed?” by Laura Johannes, The Wall Street Journal, Dec. 28, 2015).

I’m sure you have seen some new mothers who were concerned that their breast milk was not enough for their babies. But how many of them would pay $150 for a start-up kit and then more than $300 to find out the nutritional content of their breast milk? What if it meant pumping and freezing three samples 2 or 3 days apart and then shipping them in a cooler to a lab? What if you told them that neither you nor anyone else could reliably interpret the results because there aren’t any published guidelines for the optimal composition of human breast milk? Even if your practice is packed to the rafters with anxiety-driven, irrational parents, I don’t think you would find many takers. But that doesn’t seem to have bothered the folks who have invested in Happy Vitals, a company in Washington that is offering a service similar to the one I have just described.

You and I might not have invested in a company whose business plan was to offer such a service. But I fear there may be enough health care “providers” practicing without the benefit of an evidence-based education that what I consider a capital misadventure may actually be able to pay back its investors.

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 dream unfolds late in the semester with just a week to go, usually my final semester. My college career has been exemplary … good grades, honor society member, academic behavior any parent would be proud of. But for some reason I realize that I have failed to attend any of the classes of one of my courses, usually a math course. In fact, I’m not sure I have the text or maybe I never purchased it. More frighteningly, I can’t remember in which classroom it meets or even the hour. No one else seems to have noticed my failure to show up for class. Remember, it’s a math course and BSing doesn’t work in math. There is no way I will be able to resurrect myself from this academic disaster. The dream eventually dissolves without resolution, but it will return in some permutation, fortunately less often as I have gotten older. My wife and many of our friends share similar nightmares.

There are many angles from which one can interpret a dream like this, but one explanation is that I finally have been discovered as an impostor. I had studied hard, gotten good grades but at the core of things I was a goof-off and really wasn’t worthy of the adulation I had received. My good works were merely a shell over a life of not doing all the things that other people thought I had been doing.

It turns out that I had fallen into a surprisingly common psychological trap, probably during medical school. Despite accumulating significant amounts of clinical acumen, and in my later years what some might call wisdom, my dream suggests that I still have been unable to free myself of a nagging self-doubt. In 1978, two American psychologists Pauline Clance and Suzanne Imes labeled this phenomenon “the impostor syndrome” (“Learning to Deal with the Impostor Syndrome” by Carl Richards [The New York Times, Oct. 26, 2015]). They characterized it as a feeling “of phoniness in people who believe that they are not intelligent, capable, or creative despite evidence of high achievement.” The victims “are highly motivated to achieve” but “live in fear of being ‘found out’ or exposed as frauds.”

In college, I was in awe of those classmates who could play bridge for hours day after day, write their papers in the wee morning hours on the day they were due, and still get very acceptable grades. I imagined that if these guys had studied a third as much as I did or had simply begun their term papers on the day before they were due, their academic credentials would have blown mine out of the water.

In medical school I always had a sense that I didn’t belong there. I had never heard of anyone else who had gotten into an elite medical school off the waiting list as I had. There must have been a clerical error, and I had been mistaken for the scion of a wealthy benefactor with a similar sounding name. I had been around some smart people before, but my medical school classmates were in a different league altogether.

It turns out I was not alone bobbing in my sea of self-doubt. I learned from a blog entry on KevinMD.com (“The effect of impostor syndrome on medical students” by Aryeh Goldberg, March 1, 2014) of a lecture by Suzanne Poirier at Northwestern’s Feinberg School of Medicine, during which she reported on her analysis of more than forty book-length medical school memoirs. She discovered that a theme of a sense of not belonging ran through most (if not all) of the sources she reviewed. Other observers have wondered how much the impostor syndrome contributes to burnout, depression, and suicidal ideation in medical students.

I suffered from none of those maladies, but my feeling of unworthiness followed me into practice. Even as I acquired more experience during hundreds of thousands of patient encounters, I continued to worry that the next patient through the door would be the end of a decade’s long string of good fortune and my clinical ineptitude would be unmasked.

One of the most effective strategies for dealing with such feelings is sharing them. Unfortunately, most physicians don’t often find themselves in settings in which they can comfortably share these feelings with their peers. And of course it is probably not the best idea to share your self-doubts when you are trying to reassure a patient who is feeling vulnerable herself. Finding the balance between admitting that we don’t know everything and projecting the image that we know more than enough to help our patients is one of the biggest challenges facing us as we struggle to master the art of clinical medicine.

I will leave the question of whether I was an impostor to those who can be more objective. All I know is that I was damn lucky for 40 years.

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 dream unfolds late in the semester with just a week to go, usually my final semester. My college career has been exemplary … good grades, honor society member, academic behavior any parent would be proud of. But for some reason I realize that I have failed to attend any of the classes of one of my courses, usually a math course. In fact, I’m not sure I have the text or maybe I never purchased it. More frighteningly, I can’t remember in which classroom it meets or even the hour. No one else seems to have noticed my failure to show up for class. Remember, it’s a math course and BSing doesn’t work in math. There is no way I will be able to resurrect myself from this academic disaster. The dream eventually dissolves without resolution, but it will return in some permutation, fortunately less often as I have gotten older. My wife and many of our friends share similar nightmares.

There are many angles from which one can interpret a dream like this, but one explanation is that I finally have been discovered as an impostor. I had studied hard, gotten good grades but at the core of things I was a goof-off and really wasn’t worthy of the adulation I had received. My good works were merely a shell over a life of not doing all the things that other people thought I had been doing.

It turns out that I had fallen into a surprisingly common psychological trap, probably during medical school. Despite accumulating significant amounts of clinical acumen, and in my later years what some might call wisdom, my dream suggests that I still have been unable to free myself of a nagging self-doubt. In 1978, two American psychologists Pauline Clance and Suzanne Imes labeled this phenomenon “the impostor syndrome” (“Learning to Deal with the Impostor Syndrome” by Carl Richards [The New York Times, Oct. 26, 2015]). They characterized it as a feeling “of phoniness in people who believe that they are not intelligent, capable, or creative despite evidence of high achievement.” The victims “are highly motivated to achieve” but “live in fear of being ‘found out’ or exposed as frauds.”

In college, I was in awe of those classmates who could play bridge for hours day after day, write their papers in the wee morning hours on the day they were due, and still get very acceptable grades. I imagined that if these guys had studied a third as much as I did or had simply begun their term papers on the day before they were due, their academic credentials would have blown mine out of the water.

In medical school I always had a sense that I didn’t belong there. I had never heard of anyone else who had gotten into an elite medical school off the waiting list as I had. There must have been a clerical error, and I had been mistaken for the scion of a wealthy benefactor with a similar sounding name. I had been around some smart people before, but my medical school classmates were in a different league altogether.

It turns out I was not alone bobbing in my sea of self-doubt. I learned from a blog entry on KevinMD.com (“The effect of impostor syndrome on medical students” by Aryeh Goldberg, March 1, 2014) of a lecture by Suzanne Poirier at Northwestern’s Feinberg School of Medicine, during which she reported on her analysis of more than forty book-length medical school memoirs. She discovered that a theme of a sense of not belonging ran through most (if not all) of the sources she reviewed. Other observers have wondered how much the impostor syndrome contributes to burnout, depression, and suicidal ideation in medical students.

I suffered from none of those maladies, but my feeling of unworthiness followed me into practice. Even as I acquired more experience during hundreds of thousands of patient encounters, I continued to worry that the next patient through the door would be the end of a decade’s long string of good fortune and my clinical ineptitude would be unmasked.

One of the most effective strategies for dealing with such feelings is sharing them. Unfortunately, most physicians don’t often find themselves in settings in which they can comfortably share these feelings with their peers. And of course it is probably not the best idea to share your self-doubts when you are trying to reassure a patient who is feeling vulnerable herself. Finding the balance between admitting that we don’t know everything and projecting the image that we know more than enough to help our patients is one of the biggest challenges facing us as we struggle to master the art of clinical medicine.

I will leave the question of whether I was an impostor to those who can be more objective. All I know is that I was damn lucky for 40 years.

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 dream unfolds late in the semester with just a week to go, usually my final semester. My college career has been exemplary … good grades, honor society member, academic behavior any parent would be proud of. But for some reason I realize that I have failed to attend any of the classes of one of my courses, usually a math course. In fact, I’m not sure I have the text or maybe I never purchased it. More frighteningly, I can’t remember in which classroom it meets or even the hour. No one else seems to have noticed my failure to show up for class. Remember, it’s a math course and BSing doesn’t work in math. There is no way I will be able to resurrect myself from this academic disaster. The dream eventually dissolves without resolution, but it will return in some permutation, fortunately less often as I have gotten older. My wife and many of our friends share similar nightmares.

There are many angles from which one can interpret a dream like this, but one explanation is that I finally have been discovered as an impostor. I had studied hard, gotten good grades but at the core of things I was a goof-off and really wasn’t worthy of the adulation I had received. My good works were merely a shell over a life of not doing all the things that other people thought I had been doing.

It turns out that I had fallen into a surprisingly common psychological trap, probably during medical school. Despite accumulating significant amounts of clinical acumen, and in my later years what some might call wisdom, my dream suggests that I still have been unable to free myself of a nagging self-doubt. In 1978, two American psychologists Pauline Clance and Suzanne Imes labeled this phenomenon “the impostor syndrome” (“Learning to Deal with the Impostor Syndrome” by Carl Richards [The New York Times, Oct. 26, 2015]). They characterized it as a feeling “of phoniness in people who believe that they are not intelligent, capable, or creative despite evidence of high achievement.” The victims “are highly motivated to achieve” but “live in fear of being ‘found out’ or exposed as frauds.”

In college, I was in awe of those classmates who could play bridge for hours day after day, write their papers in the wee morning hours on the day they were due, and still get very acceptable grades. I imagined that if these guys had studied a third as much as I did or had simply begun their term papers on the day before they were due, their academic credentials would have blown mine out of the water.

In medical school I always had a sense that I didn’t belong there. I had never heard of anyone else who had gotten into an elite medical school off the waiting list as I had. There must have been a clerical error, and I had been mistaken for the scion of a wealthy benefactor with a similar sounding name. I had been around some smart people before, but my medical school classmates were in a different league altogether.

It turns out I was not alone bobbing in my sea of self-doubt. I learned from a blog entry on KevinMD.com (“The effect of impostor syndrome on medical students” by Aryeh Goldberg, March 1, 2014) of a lecture by Suzanne Poirier at Northwestern’s Feinberg School of Medicine, during which she reported on her analysis of more than forty book-length medical school memoirs. She discovered that a theme of a sense of not belonging ran through most (if not all) of the sources she reviewed. Other observers have wondered how much the impostor syndrome contributes to burnout, depression, and suicidal ideation in medical students.

I suffered from none of those maladies, but my feeling of unworthiness followed me into practice. Even as I acquired more experience during hundreds of thousands of patient encounters, I continued to worry that the next patient through the door would be the end of a decade’s long string of good fortune and my clinical ineptitude would be unmasked.

One of the most effective strategies for dealing with such feelings is sharing them. Unfortunately, most physicians don’t often find themselves in settings in which they can comfortably share these feelings with their peers. And of course it is probably not the best idea to share your self-doubts when you are trying to reassure a patient who is feeling vulnerable herself. Finding the balance between admitting that we don’t know everything and projecting the image that we know more than enough to help our patients is one of the biggest challenges facing us as we struggle to master the art of clinical medicine.

I will leave the question of whether I was an impostor to those who can be more objective. All I know is that I was damn lucky for 40 years.

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 haven’t already stopped investing your limited supply of office time in fruitless attempts to convince vaccine-hesitant parents to immunize their children, a small study at the University of North Carolina Women’s Hospital in Chapel Hill might finally convince you it’s time to save your breath for other more achievable goals. In a survey of 171 parents, 72% reported that they already had settled on their vaccine preferences prior to pregnancy.

This was a limited survey and may not reflect the responses of a national sample of parents, but it is concerning in light of several other studies that paint a similar gloomy picture. One such study found that even when vaccine-denying parents were presented with educational materials that they acknowledged seemed valid, they continued to withhold vaccines by falling back on other arguments to support their views (“Effective Messages in Vaccine Promotion: A Randomized Trial” by Nyhan et al. [Pediatrics. 2014 Apr;133(4):e835-42]).

If a larger and more geographically diverse study continues to find that the die is cast well before pediatricians have gotten our chance to discuss vaccines with parents-to-be, we will need to rethink our strategies for dealing with vaccine refusers. For those pediatricians who already ask vaccine decliners to find another practice, this new study suggests that they could save themselves time and trouble by advertising their policy to the obstetricians in their communities. This proactive advertising would require some courage, but in the long run it probably makes economic sense.

However, for most pediatricians it may be better to wait in hopes that future research can determine exactly when and under what circumstances most vaccine decliners arrive at their unfortunate decisions. How often was it a philosophy that they inherited from their parents? How often did it reflect their religious views? How often did it evolve from something they heard in school? Junior high, high school, college? Was it a science class, or history, or philosophy?

Was it the result of some media story? TV? Print? Internet? If they can recall a particular show or website, what was it that made it sound so convincing? If it was an individual, was it a friend, celebrity, or a teacher?

A study this detailed would be time consuming and labor intensive, as it would be best done in face-to-face structured interviews by someone who could project a nonjudgmental aura. It would necessarily be retrospective. But it might yield some surprising and helpful information that could be used to target our attack on the epidemic of vaccine refusal.

We know that outbreaks of certain infectious diseases, smallpox being the prime example, do not respond to media blitzes and immunization campaigns. Epidemics will continue to roll along unchecked until a labor-intensive, boots-on-the-ground, door-to-door case-finding effort is undertaken. Vaccine refusal may be similar to smallpox. It appears to be unresponsive to mass media and educational initiatives. It may continue to plague us until we chase down its roots.

Whatever strategy we try next, it is clear that although most parents report that they consider pediatricians among their most trusted sources of health information for their children, we are failing to reach a segment of our target audience. We are too late, long after the die is cast.

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.”

*This story was updated 1/28/2016.

If you haven’t already stopped investing your limited supply of office time in fruitless attempts to convince vaccine-hesitant parents to immunize their children, a small study at the University of North Carolina Women’s Hospital in Chapel Hill might finally convince you it’s time to save your breath for other more achievable goals. In a survey of 171 parents, 72% reported that they already had settled on their vaccine preferences prior to pregnancy.

This was a limited survey and may not reflect the responses of a national sample of parents, but it is concerning in light of several other studies that paint a similar gloomy picture. One such study found that even when vaccine-denying parents were presented with educational materials that they acknowledged seemed valid, they continued to withhold vaccines by falling back on other arguments to support their views (“Effective Messages in Vaccine Promotion: A Randomized Trial” by Nyhan et al. [Pediatrics. 2014 Apr;133(4):e835-42]).

If a larger and more geographically diverse study continues to find that the die is cast well before pediatricians have gotten our chance to discuss vaccines with parents-to-be, we will need to rethink our strategies for dealing with vaccine refusers. For those pediatricians who already ask vaccine decliners to find another practice, this new study suggests that they could save themselves time and trouble by advertising their policy to the obstetricians in their communities. This proactive advertising would require some courage, but in the long run it probably makes economic sense.

However, for most pediatricians it may be better to wait in hopes that future research can determine exactly when and under what circumstances most vaccine decliners arrive at their unfortunate decisions. How often was it a philosophy that they inherited from their parents? How often did it reflect their religious views? How often did it evolve from something they heard in school? Junior high, high school, college? Was it a science class, or history, or philosophy?

Was it the result of some media story? TV? Print? Internet? If they can recall a particular show or website, what was it that made it sound so convincing? If it was an individual, was it a friend, celebrity, or a teacher?

A study this detailed would be time consuming and labor intensive, as it would be best done in face-to-face structured interviews by someone who could project a nonjudgmental aura. It would necessarily be retrospective. But it might yield some surprising and helpful information that could be used to target our attack on the epidemic of vaccine refusal.

We know that outbreaks of certain infectious diseases, smallpox being the prime example, do not respond to media blitzes and immunization campaigns. Epidemics will continue to roll along unchecked until a labor-intensive, boots-on-the-ground, door-to-door case-finding effort is undertaken. Vaccine refusal may be similar to smallpox. It appears to be unresponsive to mass media and educational initiatives. It may continue to plague us until we chase down its roots.

Whatever strategy we try next, it is clear that although most parents report that they consider pediatricians among their most trusted sources of health information for their children, we are failing to reach a segment of our target audience. We are too late, long after the die is cast.

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.”

*This story was updated 1/28/2016.

If you haven’t already stopped investing your limited supply of office time in fruitless attempts to convince vaccine-hesitant parents to immunize their children, a small study at the University of North Carolina Women’s Hospital in Chapel Hill might finally convince you it’s time to save your breath for other more achievable goals. In a survey of 171 parents, 72% reported that they already had settled on their vaccine preferences prior to pregnancy.

This was a limited survey and may not reflect the responses of a national sample of parents, but it is concerning in light of several other studies that paint a similar gloomy picture. One such study found that even when vaccine-denying parents were presented with educational materials that they acknowledged seemed valid, they continued to withhold vaccines by falling back on other arguments to support their views (“Effective Messages in Vaccine Promotion: A Randomized Trial” by Nyhan et al. [Pediatrics. 2014 Apr;133(4):e835-42]).

If a larger and more geographically diverse study continues to find that the die is cast well before pediatricians have gotten our chance to discuss vaccines with parents-to-be, we will need to rethink our strategies for dealing with vaccine refusers. For those pediatricians who already ask vaccine decliners to find another practice, this new study suggests that they could save themselves time and trouble by advertising their policy to the obstetricians in their communities. This proactive advertising would require some courage, but in the long run it probably makes economic sense.

However, for most pediatricians it may be better to wait in hopes that future research can determine exactly when and under what circumstances most vaccine decliners arrive at their unfortunate decisions. How often was it a philosophy that they inherited from their parents? How often did it reflect their religious views? How often did it evolve from something they heard in school? Junior high, high school, college? Was it a science class, or history, or philosophy?

Was it the result of some media story? TV? Print? Internet? If they can recall a particular show or website, what was it that made it sound so convincing? If it was an individual, was it a friend, celebrity, or a teacher?

A study this detailed would be time consuming and labor intensive, as it would be best done in face-to-face structured interviews by someone who could project a nonjudgmental aura. It would necessarily be retrospective. But it might yield some surprising and helpful information that could be used to target our attack on the epidemic of vaccine refusal.

We know that outbreaks of certain infectious diseases, smallpox being the prime example, do not respond to media blitzes and immunization campaigns. Epidemics will continue to roll along unchecked until a labor-intensive, boots-on-the-ground, door-to-door case-finding effort is undertaken. Vaccine refusal may be similar to smallpox. It appears to be unresponsive to mass media and educational initiatives. It may continue to plague us until we chase down its roots.

Whatever strategy we try next, it is clear that although most parents report that they consider pediatricians among their most trusted sources of health information for their children, we are failing to reach a segment of our target audience. We are too late, long after the die is cast.

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.”

*This story was updated 1/28/2016.

I try to avoid revisiting a subject I have pontificated on in the recent past, but when I encounter a situation in which scientists are behaving unscientifically it is hard to remain silent. In 2002, a Pittsburgh neuropathologist named Bennet Omalu performed an autopsy on Mike Webster, a former National Football League (NFL) lineman who had died in his 50s. Webster had been exhibiting bizarre behaviors and was developing dementia. What Dr. Omalu found in Webster’s brain was a collection of changes that have become known as chronic traumatic encephalopathy (CTE).

In the decade following the publication of Dr. Omalu’s findings in the journal Neurosurgery in 2005, there has been some unsavory back and forths between the NFL’s Mild Traumatic Brain Injury Committee and Dr. Omalu that I learned about in the Wall Street Journal (“The Doctor the NFL Tried to Silence,” by Jeanne Marie Laskas, Nov 24, 2015). The doctor’s side of the story has been published in a book, “Concussion” (New York: Penguin Random House, 2015). “Concussion,” the movie based on the book, was slated for release in December.

The tangle of he said – our experts don’t agree has involved the University of Michigan and Boston University, and the smell of conflict of interest hangs over the NFL’s choice of experts and its decisions to publish or not publish the results of various studies. It now appears that Dr. Omalu’s discovery was the tip of an iceberg of undetermined size. As happens far too often, assumptions and attributions have been made in haste based on scanty evidence from small studies that have surely failed to control for all of the possible contributors.

Considering the results of the autopsies on a few NFL players, it is probably reasonable to suspect that there is something in the culture surrounding professional football that makes some of the players vulnerable to central nervous system damage. And blows to the head are likely to be one of those factors. However, leaping to the conclusion that parents shouldn’t allow their young children to play football is another story. But that is just what Dr. Omalu has done in an op-ed piece that has appeared in the New York Times (“Don’t Let Kids Play Football,” Dec 7, 2015).

Relying heavily on the analogy with cumulative effects of cigarette smoking, Dr. Omalu continues to fan the flame that he ignited with his initial autopsy finding. The timing of the piece is interesting in light of the movie’s release date of Dec. 25. While his discovery of CTE in a professional player is important, Dr. Omalu’s case for prohibiting children from playing football is rife with half-truths and unwarranted conclusions.

For example, he states that in his 30 years as a neuropathologist he has yet to see a “neuron that naturally creates a new neuron to regenerate itself.” True, but he fails to report that there is new evidence that the long-held dictum that neurons can’t heal themselves may be wrong.

Dr. Omalu observes that “if a child who plays football is subjected to advanced radiological and neurocognitive studies during the season and several months after there can be evidence of brain damage at the cellular level even if there were no documented concussions or reported symptoms.” It took some time, but I eventually found the study to which I assume he is referring, by Dr. Christopher T. Whitlow of Wake Forest University, Winston-Salem, N.C., presented at the Radiological Society of North America meeting in December of 2014. Its lead author is careful to state that conclusions should not be drawn from this small preliminary study and observes, “it is unclear whether or not these effects will be associated with any long-term consequences.” However, Dr. Omalu asserts that “If that child continues to play over many seasons, these cellular injuries accumulate to cause irreversible brain damage.” He states this as fact without any supporting evidence.

Fortunately, the American Academy of Pediatrics has presented a more balanced perspective on allowing children to participate in football in light of what we are learning about the health of professional players (“Tackling in Youth Football” [Pediatrics. 2015;136(5)e1419-31]). Dr. William P. Meehan III and Dr. Gregory L. Landry, speaking for the Council on Sports Medicine and Fitness, point out that serious head and neck injury in young football players is very unlikely, and that by teaching proper tackling technique, these injuries can be further decreased.

The real solution to the problem that Dr. Omalu first brought to light in 2002 lies with zero tolerance for the practice of tackling headfirst at all levels of football. Although the NFL has made some feeble attempts to discipline its teams, there is still more that should be done. Every professional and college football game is being video recorded, often from multiple angles. Retrospective analysis of these images should be used to discipline players whose injury-threatening tactics have not been detected by the officials during the game. Multiple game suspensions meted out promptly, and without possibility of appeal, would go a long way to return football to being the safer sport it was when leather helmets discouraged players from using their heads as lethal weapons.

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 try to avoid revisiting a subject I have pontificated on in the recent past, but when I encounter a situation in which scientists are behaving unscientifically it is hard to remain silent. In 2002, a Pittsburgh neuropathologist named Bennet Omalu performed an autopsy on Mike Webster, a former National Football League (NFL) lineman who had died in his 50s. Webster had been exhibiting bizarre behaviors and was developing dementia. What Dr. Omalu found in Webster’s brain was a collection of changes that have become known as chronic traumatic encephalopathy (CTE).

In the decade following the publication of Dr. Omalu’s findings in the journal Neurosurgery in 2005, there has been some unsavory back and forths between the NFL’s Mild Traumatic Brain Injury Committee and Dr. Omalu that I learned about in the Wall Street Journal (“The Doctor the NFL Tried to Silence,” by Jeanne Marie Laskas, Nov 24, 2015). The doctor’s side of the story has been published in a book, “Concussion” (New York: Penguin Random House, 2015). “Concussion,” the movie based on the book, was slated for release in December.

The tangle of he said – our experts don’t agree has involved the University of Michigan and Boston University, and the smell of conflict of interest hangs over the NFL’s choice of experts and its decisions to publish or not publish the results of various studies. It now appears that Dr. Omalu’s discovery was the tip of an iceberg of undetermined size. As happens far too often, assumptions and attributions have been made in haste based on scanty evidence from small studies that have surely failed to control for all of the possible contributors.

Considering the results of the autopsies on a few NFL players, it is probably reasonable to suspect that there is something in the culture surrounding professional football that makes some of the players vulnerable to central nervous system damage. And blows to the head are likely to be one of those factors. However, leaping to the conclusion that parents shouldn’t allow their young children to play football is another story. But that is just what Dr. Omalu has done in an op-ed piece that has appeared in the New York Times (“Don’t Let Kids Play Football,” Dec 7, 2015).

Relying heavily on the analogy with cumulative effects of cigarette smoking, Dr. Omalu continues to fan the flame that he ignited with his initial autopsy finding. The timing of the piece is interesting in light of the movie’s release date of Dec. 25. While his discovery of CTE in a professional player is important, Dr. Omalu’s case for prohibiting children from playing football is rife with half-truths and unwarranted conclusions.

For example, he states that in his 30 years as a neuropathologist he has yet to see a “neuron that naturally creates a new neuron to regenerate itself.” True, but he fails to report that there is new evidence that the long-held dictum that neurons can’t heal themselves may be wrong.

Dr. Omalu observes that “if a child who plays football is subjected to advanced radiological and neurocognitive studies during the season and several months after there can be evidence of brain damage at the cellular level even if there were no documented concussions or reported symptoms.” It took some time, but I eventually found the study to which I assume he is referring, by Dr. Christopher T. Whitlow of Wake Forest University, Winston-Salem, N.C., presented at the Radiological Society of North America meeting in December of 2014. Its lead author is careful to state that conclusions should not be drawn from this small preliminary study and observes, “it is unclear whether or not these effects will be associated with any long-term consequences.” However, Dr. Omalu asserts that “If that child continues to play over many seasons, these cellular injuries accumulate to cause irreversible brain damage.” He states this as fact without any supporting evidence.

Fortunately, the American Academy of Pediatrics has presented a more balanced perspective on allowing children to participate in football in light of what we are learning about the health of professional players (“Tackling in Youth Football” [Pediatrics. 2015;136(5)e1419-31]). Dr. William P. Meehan III and Dr. Gregory L. Landry, speaking for the Council on Sports Medicine and Fitness, point out that serious head and neck injury in young football players is very unlikely, and that by teaching proper tackling technique, these injuries can be further decreased.

The real solution to the problem that Dr. Omalu first brought to light in 2002 lies with zero tolerance for the practice of tackling headfirst at all levels of football. Although the NFL has made some feeble attempts to discipline its teams, there is still more that should be done. Every professional and college football game is being video recorded, often from multiple angles. Retrospective analysis of these images should be used to discipline players whose injury-threatening tactics have not been detected by the officials during the game. Multiple game suspensions meted out promptly, and without possibility of appeal, would go a long way to return football to being the safer sport it was when leather helmets discouraged players from using their heads as lethal weapons.

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 try to avoid revisiting a subject I have pontificated on in the recent past, but when I encounter a situation in which scientists are behaving unscientifically it is hard to remain silent. In 2002, a Pittsburgh neuropathologist named Bennet Omalu performed an autopsy on Mike Webster, a former National Football League (NFL) lineman who had died in his 50s. Webster had been exhibiting bizarre behaviors and was developing dementia. What Dr. Omalu found in Webster’s brain was a collection of changes that have become known as chronic traumatic encephalopathy (CTE).

In the decade following the publication of Dr. Omalu’s findings in the journal Neurosurgery in 2005, there has been some unsavory back and forths between the NFL’s Mild Traumatic Brain Injury Committee and Dr. Omalu that I learned about in the Wall Street Journal (“The Doctor the NFL Tried to Silence,” by Jeanne Marie Laskas, Nov 24, 2015). The doctor’s side of the story has been published in a book, “Concussion” (New York: Penguin Random House, 2015). “Concussion,” the movie based on the book, was slated for release in December.

The tangle of he said – our experts don’t agree has involved the University of Michigan and Boston University, and the smell of conflict of interest hangs over the NFL’s choice of experts and its decisions to publish or not publish the results of various studies. It now appears that Dr. Omalu’s discovery was the tip of an iceberg of undetermined size. As happens far too often, assumptions and attributions have been made in haste based on scanty evidence from small studies that have surely failed to control for all of the possible contributors.

Considering the results of the autopsies on a few NFL players, it is probably reasonable to suspect that there is something in the culture surrounding professional football that makes some of the players vulnerable to central nervous system damage. And blows to the head are likely to be one of those factors. However, leaping to the conclusion that parents shouldn’t allow their young children to play football is another story. But that is just what Dr. Omalu has done in an op-ed piece that has appeared in the New York Times (“Don’t Let Kids Play Football,” Dec 7, 2015).

Relying heavily on the analogy with cumulative effects of cigarette smoking, Dr. Omalu continues to fan the flame that he ignited with his initial autopsy finding. The timing of the piece is interesting in light of the movie’s release date of Dec. 25. While his discovery of CTE in a professional player is important, Dr. Omalu’s case for prohibiting children from playing football is rife with half-truths and unwarranted conclusions.

For example, he states that in his 30 years as a neuropathologist he has yet to see a “neuron that naturally creates a new neuron to regenerate itself.” True, but he fails to report that there is new evidence that the long-held dictum that neurons can’t heal themselves may be wrong.

Dr. Omalu observes that “if a child who plays football is subjected to advanced radiological and neurocognitive studies during the season and several months after there can be evidence of brain damage at the cellular level even if there were no documented concussions or reported symptoms.” It took some time, but I eventually found the study to which I assume he is referring, by Dr. Christopher T. Whitlow of Wake Forest University, Winston-Salem, N.C., presented at the Radiological Society of North America meeting in December of 2014. Its lead author is careful to state that conclusions should not be drawn from this small preliminary study and observes, “it is unclear whether or not these effects will be associated with any long-term consequences.” However, Dr. Omalu asserts that “If that child continues to play over many seasons, these cellular injuries accumulate to cause irreversible brain damage.” He states this as fact without any supporting evidence.

Fortunately, the American Academy of Pediatrics has presented a more balanced perspective on allowing children to participate in football in light of what we are learning about the health of professional players (“Tackling in Youth Football” [Pediatrics. 2015;136(5)e1419-31]). Dr. William P. Meehan III and Dr. Gregory L. Landry, speaking for the Council on Sports Medicine and Fitness, point out that serious head and neck injury in young football players is very unlikely, and that by teaching proper tackling technique, these injuries can be further decreased.

The real solution to the problem that Dr. Omalu first brought to light in 2002 lies with zero tolerance for the practice of tackling headfirst at all levels of football. Although the NFL has made some feeble attempts to discipline its teams, there is still more that should be done. Every professional and college football game is being video recorded, often from multiple angles. Retrospective analysis of these images should be used to discipline players whose injury-threatening tactics have not been detected by the officials during the game. Multiple game suspensions meted out promptly, and without possibility of appeal, would go a long way to return football to being the safer sport it was when leather helmets discouraged players from using their heads as lethal weapons.

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.”

To those of us who live and practice in the northeast, it comes as no surprise that the mortality rate for middle class whites is climbing. Obituaries in our local papers often include men and women in their forties “dying at home,” with no mention of cancer or chronic disease. Rarely, the family can bring itself to announce that their loved one has died of a drug overdose.

Deaths attributable to prescription opioid overdoses quadrupled in the decade from 1999 to 2010, and the trend shows little sign of abating as the number of prescriptions for opioids has risen tenfold over the last 20 years (“How Doctors Helped Drive the Addiction Crisis,” by Dr. Richard Friedman, New York Times, Nov. 7, 2015). Could physician behavior have contributed to outbreak of this deadly plague of addiction? That is like asking if something the zookeeper did or didn’t do could have been responsible for the escape of the man-eating tiger that is devouring the neighborhood children. Regardless of what other factors might be responsible for the epidemic of fatal prescription opioid overdoses, physicians must admit some culpability.

Until recently, I assumed that the problem of prescription opioids finding their way to addicts was unique to physicians treating adults. However, a study reported at the annual meeting of the American Society of Anesthesiologists reveals pediatricians and other clinicians prescribing for children must share in the blame.

Dr. Myron Yaster at Johns Hopkins University Hospital, Baltimore, has found that in a group of nearly 300 pediatric patients (average age, 11 years and average weight of 44 kg), overall the patients used only 42% of the prescribed amount of opioids. Almost half of the patients had a teenage sibling, a group that Dr. Yaster describes as the “target population of drug abuse.”

What’s going on here? Some of the problem dates back to the 1990s when physicians were urged to shift their focus toward the problem of inadequately treated pain. With the help of nurses armed with pain-rating schemes and smiley/grumpy face charts, the mantra became “no pain shall go unmedicated,” when the better response should have been “no pain shall go unmanaged.” But good pain management takes time. It requires that the physician and staff consider each patient as a unique individual. In many cases, reassurance and education can make a non–opioid medication or even no medication a better choice.

However, according to Dr. Yaster, “leftover medicine is the most important element in drug addiction.” Why did physicians prescribe 10 days of medication when his study revealed that most patients took the medication for only 5? It could just be a bad habit. Or it could be ignorance or inexperience. How many physicians ask at follow-up appointments “How long did you take your medication? Tell me the history of your pain.”

Or could it be that physicians are simply trying to prevent those annoying calls from patients who have run out of their medication? Dr. Yaster’s findings suggest that those calls would be few and far between. More careful thought into how much medication we prescribe also would mean that when a patient called for more medication that there was a problem. Either the patient’s recuperation has hit a worrisome bump in the road or possibly her medication is being diverted.

History tells us that physicians, even pediatricians, have been poor stewards of the powerful medications with which we have been entrusted. First, it was antibiotics and now opioids have joined the list.

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].

To those of us who live and practice in the northeast, it comes as no surprise that the mortality rate for middle class whites is climbing. Obituaries in our local papers often include men and women in their forties “dying at home,” with no mention of cancer or chronic disease. Rarely, the family can bring itself to announce that their loved one has died of a drug overdose.

Deaths attributable to prescription opioid overdoses quadrupled in the decade from 1999 to 2010, and the trend shows little sign of abating as the number of prescriptions for opioids has risen tenfold over the last 20 years (“How Doctors Helped Drive the Addiction Crisis,” by Dr. Richard Friedman, New York Times, Nov. 7, 2015). Could physician behavior have contributed to outbreak of this deadly plague of addiction? That is like asking if something the zookeeper did or didn’t do could have been responsible for the escape of the man-eating tiger that is devouring the neighborhood children. Regardless of what other factors might be responsible for the epidemic of fatal prescription opioid overdoses, physicians must admit some culpability.

Until recently, I assumed that the problem of prescription opioids finding their way to addicts was unique to physicians treating adults. However, a study reported at the annual meeting of the American Society of Anesthesiologists reveals pediatricians and other clinicians prescribing for children must share in the blame.

Dr. Myron Yaster at Johns Hopkins University Hospital, Baltimore, has found that in a group of nearly 300 pediatric patients (average age, 11 years and average weight of 44 kg), overall the patients used only 42% of the prescribed amount of opioids. Almost half of the patients had a teenage sibling, a group that Dr. Yaster describes as the “target population of drug abuse.”

What’s going on here? Some of the problem dates back to the 1990s when physicians were urged to shift their focus toward the problem of inadequately treated pain. With the help of nurses armed with pain-rating schemes and smiley/grumpy face charts, the mantra became “no pain shall go unmedicated,” when the better response should have been “no pain shall go unmanaged.” But good pain management takes time. It requires that the physician and staff consider each patient as a unique individual. In many cases, reassurance and education can make a non–opioid medication or even no medication a better choice.

However, according to Dr. Yaster, “leftover medicine is the most important element in drug addiction.” Why did physicians prescribe 10 days of medication when his study revealed that most patients took the medication for only 5? It could just be a bad habit. Or it could be ignorance or inexperience. How many physicians ask at follow-up appointments “How long did you take your medication? Tell me the history of your pain.”

Or could it be that physicians are simply trying to prevent those annoying calls from patients who have run out of their medication? Dr. Yaster’s findings suggest that those calls would be few and far between. More careful thought into how much medication we prescribe also would mean that when a patient called for more medication that there was a problem. Either the patient’s recuperation has hit a worrisome bump in the road or possibly her medication is being diverted.

History tells us that physicians, even pediatricians, have been poor stewards of the powerful medications with which we have been entrusted. First, it was antibiotics and now opioids have joined the list.

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].

To those of us who live and practice in the northeast, it comes as no surprise that the mortality rate for middle class whites is climbing. Obituaries in our local papers often include men and women in their forties “dying at home,” with no mention of cancer or chronic disease. Rarely, the family can bring itself to announce that their loved one has died of a drug overdose.

Deaths attributable to prescription opioid overdoses quadrupled in the decade from 1999 to 2010, and the trend shows little sign of abating as the number of prescriptions for opioids has risen tenfold over the last 20 years (“How Doctors Helped Drive the Addiction Crisis,” by Dr. Richard Friedman, New York Times, Nov. 7, 2015). Could physician behavior have contributed to outbreak of this deadly plague of addiction? That is like asking if something the zookeeper did or didn’t do could have been responsible for the escape of the man-eating tiger that is devouring the neighborhood children. Regardless of what other factors might be responsible for the epidemic of fatal prescription opioid overdoses, physicians must admit some culpability.

Until recently, I assumed that the problem of prescription opioids finding their way to addicts was unique to physicians treating adults. However, a study reported at the annual meeting of the American Society of Anesthesiologists reveals pediatricians and other clinicians prescribing for children must share in the blame.

Dr. Myron Yaster at Johns Hopkins University Hospital, Baltimore, has found that in a group of nearly 300 pediatric patients (average age, 11 years and average weight of 44 kg), overall the patients used only 42% of the prescribed amount of opioids. Almost half of the patients had a teenage sibling, a group that Dr. Yaster describes as the “target population of drug abuse.”

What’s going on here? Some of the problem dates back to the 1990s when physicians were urged to shift their focus toward the problem of inadequately treated pain. With the help of nurses armed with pain-rating schemes and smiley/grumpy face charts, the mantra became “no pain shall go unmedicated,” when the better response should have been “no pain shall go unmanaged.” But good pain management takes time. It requires that the physician and staff consider each patient as a unique individual. In many cases, reassurance and education can make a non–opioid medication or even no medication a better choice.

However, according to Dr. Yaster, “leftover medicine is the most important element in drug addiction.” Why did physicians prescribe 10 days of medication when his study revealed that most patients took the medication for only 5? It could just be a bad habit. Or it could be ignorance or inexperience. How many physicians ask at follow-up appointments “How long did you take your medication? Tell me the history of your pain.”

Or could it be that physicians are simply trying to prevent those annoying calls from patients who have run out of their medication? Dr. Yaster’s findings suggest that those calls would be few and far between. More careful thought into how much medication we prescribe also would mean that when a patient called for more medication that there was a problem. Either the patient’s recuperation has hit a worrisome bump in the road or possibly her medication is being diverted.

History tells us that physicians, even pediatricians, have been poor stewards of the powerful medications with which we have been entrusted. First, it was antibiotics and now opioids have joined the list.

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

It’s 7:30 Monday evening and the good news is that you were able to leave the office a little after 7:00 and are now at home. The bad news is that you are on call tonight and you are scheduled to work a usual 10-hour day tomorrow.

Should you:

A) Tuck the kids in, warm up a bowl of chili, and lie down on the couch in the den and hope to get a few hours of prophylactic sleep?

B) Go to bed at your usual bedtime of 10:30?

C) Stay up until midnight when experience tells you that the likelihood of getting a call drops significantly ... but unfortunately never approaches zero?

D) Say “To hell with it” and stay up all night binge-watching a whole season of “Justified?”

E) Or, stay up all night surfing the Internet looking for job opportunities that don’t include night call?

Of course, there is no correct answer because stuff happens whenever it chooses to and no strategy will ever guarantee you an uninterrupted 8 hours of sleep when you are on call. However, I learned from a recent article in the Wall Street Journal (A Good Night’s Sleep Is Tied to Interruptions, Not Just Hours – Sumathi Reddy – Nov. 30, 2015) that there is some evidence that “C” clearly is the best choice.

A study from John Hopkins University, Baltimore, published in the journal Sleep found that subjects who were awakened multiple times during the night exhibited a greater decline in positive mood than did those subjects who were sleep deprived by being made to stay up past their usual bedtime (2015 Nov 1;38[11]:1735-42).

Another study from the University of Pittsburgh discovered that elderly subjects’ cognitive performance was impaired when their sleep was interrupted but not when they were allowed to sleep uninterrupted for a shorter period of time (J Gerontol B Psychol Sci Soc Sci. 2009 Mar;64B[2]:180-7).

And, investigators at the University of Tel Aviv have found that subjects who endured 8 hours of fragmented sleep demonstrated declines in their positive mood and ability to attend that were similar to subjects who were allowed only 4 hours of uninterrupted sleep (Sleep Med. 2011 Mar;12[3]:257-61).

Where were these sleep researchers 45 years ago, when I was experimenting with my own strategies for navigating a night on call with a minimum of emotional and cognitive damage? It took me several years to discover that it was fruitless to try grabbing an hour or two of prophylactic sleep early in the evening when the risk of being awakened by a call was still relatively high. The rare occasion when I slept without interruption was of little comfort on the other nights when I could feel every wakening erode my feeble attempts at projecting a pleasant bedside (my bed that is) manner.

It took another few years of trial and error to improve my skill at determining the optimal time to turn in on a given night. It was never perfect, but eventually, I developed an instinct – based on the level of disease in the community, the pulse of the office during the day, and the weather – that kept the interruptions to a minimum. Despite what you may have heard, I never found the phase of moon to be terribly helpful in predicting when I could more safely go to bed.

There is no avoiding the unpleasant truth that being on call puts you at risk for sleep deprivation. One way or another, you are going to be sleep deprived when you show up at the office the next day. But, your best chance of continuing to appear to be a sensitive and intelligent physician is staying up late until the likelihood you will be awakened by a call has reached its traditional nadir.

It’s 7:30 Monday evening and the good news is that you were able to leave the office a little after 7:00 and are now at home. The bad news is that you are on call tonight and you are scheduled to work a usual 10-hour day tomorrow.

Should you:

A) Tuck the kids in, warm up a bowl of chili, and lie down on the couch in the den and hope to get a few hours of prophylactic sleep?

B) Go to bed at your usual bedtime of 10:30?

C) Stay up until midnight when experience tells you that the likelihood of getting a call drops significantly ... but unfortunately never approaches zero?

D) Say “To hell with it” and stay up all night binge-watching a whole season of “Justified?”

E) Or, stay up all night surfing the Internet looking for job opportunities that don’t include night call?

Of course, there is no correct answer because stuff happens whenever it chooses to and no strategy will ever guarantee you an uninterrupted 8 hours of sleep when you are on call. However, I learned from a recent article in the Wall Street Journal (A Good Night’s Sleep Is Tied to Interruptions, Not Just Hours – Sumathi Reddy – Nov. 30, 2015) that there is some evidence that “C” clearly is the best choice.

A study from John Hopkins University, Baltimore, published in the journal Sleep found that subjects who were awakened multiple times during the night exhibited a greater decline in positive mood than did those subjects who were sleep deprived by being made to stay up past their usual bedtime (2015 Nov 1;38[11]:1735-42).

Another study from the University of Pittsburgh discovered that elderly subjects’ cognitive performance was impaired when their sleep was interrupted but not when they were allowed to sleep uninterrupted for a shorter period of time (J Gerontol B Psychol Sci Soc Sci. 2009 Mar;64B[2]:180-7).

And, investigators at the University of Tel Aviv have found that subjects who endured 8 hours of fragmented sleep demonstrated declines in their positive mood and ability to attend that were similar to subjects who were allowed only 4 hours of uninterrupted sleep (Sleep Med. 2011 Mar;12[3]:257-61).

Where were these sleep researchers 45 years ago, when I was experimenting with my own strategies for navigating a night on call with a minimum of emotional and cognitive damage? It took me several years to discover that it was fruitless to try grabbing an hour or two of prophylactic sleep early in the evening when the risk of being awakened by a call was still relatively high. The rare occasion when I slept without interruption was of little comfort on the other nights when I could feel every wakening erode my feeble attempts at projecting a pleasant bedside (my bed that is) manner.

It took another few years of trial and error to improve my skill at determining the optimal time to turn in on a given night. It was never perfect, but eventually, I developed an instinct – based on the level of disease in the community, the pulse of the office during the day, and the weather – that kept the interruptions to a minimum. Despite what you may have heard, I never found the phase of moon to be terribly helpful in predicting when I could more safely go to bed.

There is no avoiding the unpleasant truth that being on call puts you at risk for sleep deprivation. One way or another, you are going to be sleep deprived when you show up at the office the next day. But, your best chance of continuing to appear to be a sensitive and intelligent physician is staying up late until the likelihood you will be awakened by a call has reached its traditional nadir.

It’s 7:30 Monday evening and the good news is that you were able to leave the office a little after 7:00 and are now at home. The bad news is that you are on call tonight and you are scheduled to work a usual 10-hour day tomorrow.

Should you:

A) Tuck the kids in, warm up a bowl of chili, and lie down on the couch in the den and hope to get a few hours of prophylactic sleep?

B) Go to bed at your usual bedtime of 10:30?

C) Stay up until midnight when experience tells you that the likelihood of getting a call drops significantly ... but unfortunately never approaches zero?

D) Say “To hell with it” and stay up all night binge-watching a whole season of “Justified?”

E) Or, stay up all night surfing the Internet looking for job opportunities that don’t include night call?

Of course, there is no correct answer because stuff happens whenever it chooses to and no strategy will ever guarantee you an uninterrupted 8 hours of sleep when you are on call. However, I learned from a recent article in the Wall Street Journal (A Good Night’s Sleep Is Tied to Interruptions, Not Just Hours – Sumathi Reddy – Nov. 30, 2015) that there is some evidence that “C” clearly is the best choice.

A study from John Hopkins University, Baltimore, published in the journal Sleep found that subjects who were awakened multiple times during the night exhibited a greater decline in positive mood than did those subjects who were sleep deprived by being made to stay up past their usual bedtime (2015 Nov 1;38[11]:1735-42).

Another study from the University of Pittsburgh discovered that elderly subjects’ cognitive performance was impaired when their sleep was interrupted but not when they were allowed to sleep uninterrupted for a shorter period of time (J Gerontol B Psychol Sci Soc Sci. 2009 Mar;64B[2]:180-7).

And, investigators at the University of Tel Aviv have found that subjects who endured 8 hours of fragmented sleep demonstrated declines in their positive mood and ability to attend that were similar to subjects who were allowed only 4 hours of uninterrupted sleep (Sleep Med. 2011 Mar;12[3]:257-61).

Where were these sleep researchers 45 years ago, when I was experimenting with my own strategies for navigating a night on call with a minimum of emotional and cognitive damage? It took me several years to discover that it was fruitless to try grabbing an hour or two of prophylactic sleep early in the evening when the risk of being awakened by a call was still relatively high. The rare occasion when I slept without interruption was of little comfort on the other nights when I could feel every wakening erode my feeble attempts at projecting a pleasant bedside (my bed that is) manner.

It took another few years of trial and error to improve my skill at determining the optimal time to turn in on a given night. It was never perfect, but eventually, I developed an instinct – based on the level of disease in the community, the pulse of the office during the day, and the weather – that kept the interruptions to a minimum. Despite what you may have heard, I never found the phase of moon to be terribly helpful in predicting when I could more safely go to bed.

There is no avoiding the unpleasant truth that being on call puts you at risk for sleep deprivation. One way or another, you are going to be sleep deprived when you show up at the office the next day. But, your best chance of continuing to appear to be a sensitive and intelligent physician is staying up late until the likelihood you will be awakened by a call has reached its traditional nadir.

If you have ever waited anxiously for the results of a blood test or biopsy, you may be surprised to learn that some psychologists at the University of California, Riverside, believe that there can be a bright side to those dark days you spent worrying (“Two Definitions of Waiting Well.” Emotion 2015 Oct 12 [epub ahead of print]).

Surveying more than 200 recent law school graduates every 2 weeks during their 4-month wait for the results of the California bar exam, the researchers discovered that those who rode it out anxiously and pessimistically handled the bad news of failure “more productively.” And they welcomed the good news “more joyously” than did their peers who had “suffered little during the wait.”

While these psychologists’ findings may be of some help to aspiring lawyers or freshly minted physicians waiting to hear if they have passed their boards, I don’t think we should take them to heart when ordering lab work or imaging studies on our patients. After all, flunking the bar exam may be a life-altering event, but it isn’t a life-ending one such as learning that the biopsy you waited a week for has detected a cancer that has metastasized beyond the reaches of radiation and chemotherapy.

The bottom line is that waiting for potentially bad news is anxiety provoking regardless of whether it is for the results of a qualifying exam or a simple CBC. And, as physicians, it is our responsibility to do whatever we can to minimize that anxiety by following some simple commonsense rules of courtesy and decency.

First, we must understand that even low-risk preop screening lab work that we may view as innocuous may trigger significant anxiety in many patients. For example, a patient who knew someone whose leukemia was discovered as the result of a preop screening CBC may worry that a similar fate will be revealed by his blood test.

Second, we should ask ourselves every time we order some lab work or imaging study if it is really necessary. Are we just trying to cover our behinds and protect ourselves from a malpractice suit? Do we know what we are going to do with an equivocal borderline result? An unnecessary blood test isn’t just a waste of someone’s money and a symptom of sloppy medicine. It can be the cause of an anxiety-provoking wait for the patient.

Finally, if we are going to order a lab test, even if it is just for preop screening, it is our obligation to inform the patient of the result in a timely fashion. In my universe, that means the same day that the physician receives the result. In today’s world with its panoply of communication platforms, informing the patient can be as simple as leaving a message on a system previously approved by the patient. Obviously, bad or complicated news should be delivered directly by the physician with a phone call. Of course, informing the patient of even normal lab work results takes time, but it is the courteous and decent thing to do and signals to the patient that she has a physician who cares. If it seems like too much work, it may be that the physician is ordering too much lab work.

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 have ever waited anxiously for the results of a blood test or biopsy, you may be surprised to learn that some psychologists at the University of California, Riverside, believe that there can be a bright side to those dark days you spent worrying (“Two Definitions of Waiting Well.” Emotion 2015 Oct 12 [epub ahead of print]).

Surveying more than 200 recent law school graduates every 2 weeks during their 4-month wait for the results of the California bar exam, the researchers discovered that those who rode it out anxiously and pessimistically handled the bad news of failure “more productively.” And they welcomed the good news “more joyously” than did their peers who had “suffered little during the wait.”

While these psychologists’ findings may be of some help to aspiring lawyers or freshly minted physicians waiting to hear if they have passed their boards, I don’t think we should take them to heart when ordering lab work or imaging studies on our patients. After all, flunking the bar exam may be a life-altering event, but it isn’t a life-ending one such as learning that the biopsy you waited a week for has detected a cancer that has metastasized beyond the reaches of radiation and chemotherapy.

The bottom line is that waiting for potentially bad news is anxiety provoking regardless of whether it is for the results of a qualifying exam or a simple CBC. And, as physicians, it is our responsibility to do whatever we can to minimize that anxiety by following some simple commonsense rules of courtesy and decency.

First, we must understand that even low-risk preop screening lab work that we may view as innocuous may trigger significant anxiety in many patients. For example, a patient who knew someone whose leukemia was discovered as the result of a preop screening CBC may worry that a similar fate will be revealed by his blood test.

Second, we should ask ourselves every time we order some lab work or imaging study if it is really necessary. Are we just trying to cover our behinds and protect ourselves from a malpractice suit? Do we know what we are going to do with an equivocal borderline result? An unnecessary blood test isn’t just a waste of someone’s money and a symptom of sloppy medicine. It can be the cause of an anxiety-provoking wait for the patient.

Finally, if we are going to order a lab test, even if it is just for preop screening, it is our obligation to inform the patient of the result in a timely fashion. In my universe, that means the same day that the physician receives the result. In today’s world with its panoply of communication platforms, informing the patient can be as simple as leaving a message on a system previously approved by the patient. Obviously, bad or complicated news should be delivered directly by the physician with a phone call. Of course, informing the patient of even normal lab work results takes time, but it is the courteous and decent thing to do and signals to the patient that she has a physician who cares. If it seems like too much work, it may be that the physician is ordering too much lab work.

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 have ever waited anxiously for the results of a blood test or biopsy, you may be surprised to learn that some psychologists at the University of California, Riverside, believe that there can be a bright side to those dark days you spent worrying (“Two Definitions of Waiting Well.” Emotion 2015 Oct 12 [epub ahead of print]).

Surveying more than 200 recent law school graduates every 2 weeks during their 4-month wait for the results of the California bar exam, the researchers discovered that those who rode it out anxiously and pessimistically handled the bad news of failure “more productively.” And they welcomed the good news “more joyously” than did their peers who had “suffered little during the wait.”

While these psychologists’ findings may be of some help to aspiring lawyers or freshly minted physicians waiting to hear if they have passed their boards, I don’t think we should take them to heart when ordering lab work or imaging studies on our patients. After all, flunking the bar exam may be a life-altering event, but it isn’t a life-ending one such as learning that the biopsy you waited a week for has detected a cancer that has metastasized beyond the reaches of radiation and chemotherapy.

The bottom line is that waiting for potentially bad news is anxiety provoking regardless of whether it is for the results of a qualifying exam or a simple CBC. And, as physicians, it is our responsibility to do whatever we can to minimize that anxiety by following some simple commonsense rules of courtesy and decency.

First, we must understand that even low-risk preop screening lab work that we may view as innocuous may trigger significant anxiety in many patients. For example, a patient who knew someone whose leukemia was discovered as the result of a preop screening CBC may worry that a similar fate will be revealed by his blood test.

Second, we should ask ourselves every time we order some lab work or imaging study if it is really necessary. Are we just trying to cover our behinds and protect ourselves from a malpractice suit? Do we know what we are going to do with an equivocal borderline result? An unnecessary blood test isn’t just a waste of someone’s money and a symptom of sloppy medicine. It can be the cause of an anxiety-provoking wait for the patient.

Finally, if we are going to order a lab test, even if it is just for preop screening, it is our obligation to inform the patient of the result in a timely fashion. In my universe, that means the same day that the physician receives the result. In today’s world with its panoply of communication platforms, informing the patient can be as simple as leaving a message on a system previously approved by the patient. Obviously, bad or complicated news should be delivered directly by the physician with a phone call. Of course, informing the patient of even normal lab work results takes time, but it is the courteous and decent thing to do and signals to the patient that she has a physician who cares. If it seems like too much work, it may be that the physician is ordering too much lab work.

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.”

When you finish reading this column … on second thought, stop now and read the Oct. 17, 2015, opinion piece titled “Overselling Breast-Feeding.” You will discover a well-researched and thoughtfully crafted article by Courtney Jung, a political science professor at the University of Toronto, in which she dares to carefully dissect one of our most revered sacred cows. The result is a convincing argument for rethinking how we present and promote breastfeeding. I won’t attempt to reconstruct her rationale. You can read it for yourself. But, I suspect that if you spend any part of your day trying to help new parents navigate the choppy waters of those first 6 months, you will find what she has to say strikes more than a few familiar chords.

Like most of you, what I learned about breastfeeding came as on the job training. Marilyn and I started our family while I was still in medical school, giving me the advantage of having watched the process bump along twice before I found myself on the frontline of private practice. I had been taught in school about all the advantages breast milk, but it didn’t take long in the real world to discover that breastfeeding could have a dark side.

I had to become a chameleon. I needed to be strong advocate for the advantages of breast milk and support new mothers as they tried to match the American Academy of Pediatrics’ guidelines. However, there were situations in which despite everyone’s best efforts, the handwriting on the wall said, “This isn’t working.” Then it was time to change my colors and convincingly convey the new truth that even a baby that isn’t breastfed is going to be fine. That a woman who doesn’t breastfeed can and will be a mother every bit as good as one who doesn’t breastfed her baby for 6 months or a year.

©Jupiterimages/thinkstockphotos.com

The tension between the party line and reality became so great that in frustration I decided to write my third book about breastfeeding. The result was “The Maternity Leave Breastfeeding Plan” (New York: Simon and Schuster, 2002). The watered-down title was chosen by the publisher. The subtitle, “How to Enjoy Nursing for 3 Months and Go Back to Work Guilt-Free,” was a better reflection of my message that there can be some serious challenges to breastfeeding and not to worry if it doesn’t work. Surprisingly, it found itself on a La Leche League list of recommended books – that is until someone in the organization actually read it.

Although I had always harbored doubts that many of the studies purporting to show the advantages of breastfeeding were poorly controlled, in 2002, I couldn’t find any data to support my concerns. But over the last decade those studies have begun to emerge and Professor Jung has found them and included them in her new book, “Lactivism: How Feminists and Fundamentalists, Hippies and Yuppies, and Physicians and Politicians Made Breastfeeding Big Business and Bad Policy” (New York: Basic Books, 2015).

It will be interesting to see how her observations play to the wider audience it deserves. The discussions may be lively and heated, and public opinion may shift a bit. But what won’t change is that those of us who deal with mothers and babies in a very personal way will still have to struggle with promoting a good product that isn’t always easy to obtain.

Breast milk is good … but it isn’t always better or best.

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.”

When you finish reading this column … on second thought, stop now and read the Oct. 17, 2015, opinion piece titled “Overselling Breast-Feeding.” You will discover a well-researched and thoughtfully crafted article by Courtney Jung, a political science professor at the University of Toronto, in which she dares to carefully dissect one of our most revered sacred cows. The result is a convincing argument for rethinking how we present and promote breastfeeding. I won’t attempt to reconstruct her rationale. You can read it for yourself. But, I suspect that if you spend any part of your day trying to help new parents navigate the choppy waters of those first 6 months, you will find what she has to say strikes more than a few familiar chords.

Like most of you, what I learned about breastfeeding came as on the job training. Marilyn and I started our family while I was still in medical school, giving me the advantage of having watched the process bump along twice before I found myself on the frontline of private practice. I had been taught in school about all the advantages breast milk, but it didn’t take long in the real world to discover that breastfeeding could have a dark side.

I had to become a chameleon. I needed to be strong advocate for the advantages of breast milk and support new mothers as they tried to match the American Academy of Pediatrics’ guidelines. However, there were situations in which despite everyone’s best efforts, the handwriting on the wall said, “This isn’t working.” Then it was time to change my colors and convincingly convey the new truth that even a baby that isn’t breastfed is going to be fine. That a woman who doesn’t breastfeed can and will be a mother every bit as good as one who doesn’t breastfed her baby for 6 months or a year.

©Jupiterimages/thinkstockphotos.com

The tension between the party line and reality became so great that in frustration I decided to write my third book about breastfeeding. The result was “The Maternity Leave Breastfeeding Plan” (New York: Simon and Schuster, 2002). The watered-down title was chosen by the publisher. The subtitle, “How to Enjoy Nursing for 3 Months and Go Back to Work Guilt-Free,” was a better reflection of my message that there can be some serious challenges to breastfeeding and not to worry if it doesn’t work. Surprisingly, it found itself on a La Leche League list of recommended books – that is until someone in the organization actually read it.

Although I had always harbored doubts that many of the studies purporting to show the advantages of breastfeeding were poorly controlled, in 2002, I couldn’t find any data to support my concerns. But over the last decade those studies have begun to emerge and Professor Jung has found them and included them in her new book, “Lactivism: How Feminists and Fundamentalists, Hippies and Yuppies, and Physicians and Politicians Made Breastfeeding Big Business and Bad Policy” (New York: Basic Books, 2015).

It will be interesting to see how her observations play to the wider audience it deserves. The discussions may be lively and heated, and public opinion may shift a bit. But what won’t change is that those of us who deal with mothers and babies in a very personal way will still have to struggle with promoting a good product that isn’t always easy to obtain.

Breast milk is good … but it isn’t always better or best.

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.”

When you finish reading this column … on second thought, stop now and read the Oct. 17, 2015, opinion piece titled “Overselling Breast-Feeding.” You will discover a well-researched and thoughtfully crafted article by Courtney Jung, a political science professor at the University of Toronto, in which she dares to carefully dissect one of our most revered sacred cows. The result is a convincing argument for rethinking how we present and promote breastfeeding. I won’t attempt to reconstruct her rationale. You can read it for yourself. But, I suspect that if you spend any part of your day trying to help new parents navigate the choppy waters of those first 6 months, you will find what she has to say strikes more than a few familiar chords.

Like most of you, what I learned about breastfeeding came as on the job training. Marilyn and I started our family while I was still in medical school, giving me the advantage of having watched the process bump along twice before I found myself on the frontline of private practice. I had been taught in school about all the advantages breast milk, but it didn’t take long in the real world to discover that breastfeeding could have a dark side.

I had to become a chameleon. I needed to be strong advocate for the advantages of breast milk and support new mothers as they tried to match the American Academy of Pediatrics’ guidelines. However, there were situations in which despite everyone’s best efforts, the handwriting on the wall said, “This isn’t working.” Then it was time to change my colors and convincingly convey the new truth that even a baby that isn’t breastfed is going to be fine. That a woman who doesn’t breastfeed can and will be a mother every bit as good as one who doesn’t breastfed her baby for 6 months or a year.

©Jupiterimages/thinkstockphotos.com

The tension between the party line and reality became so great that in frustration I decided to write my third book about breastfeeding. The result was “The Maternity Leave Breastfeeding Plan” (New York: Simon and Schuster, 2002). The watered-down title was chosen by the publisher. The subtitle, “How to Enjoy Nursing for 3 Months and Go Back to Work Guilt-Free,” was a better reflection of my message that there can be some serious challenges to breastfeeding and not to worry if it doesn’t work. Surprisingly, it found itself on a La Leche League list of recommended books – that is until someone in the organization actually read it.

Although I had always harbored doubts that many of the studies purporting to show the advantages of breastfeeding were poorly controlled, in 2002, I couldn’t find any data to support my concerns. But over the last decade those studies have begun to emerge and Professor Jung has found them and included them in her new book, “Lactivism: How Feminists and Fundamentalists, Hippies and Yuppies, and Physicians and Politicians Made Breastfeeding Big Business and Bad Policy” (New York: Basic Books, 2015).

It will be interesting to see how her observations play to the wider audience it deserves. The discussions may be lively and heated, and public opinion may shift a bit. But what won’t change is that those of us who deal with mothers and babies in a very personal way will still have to struggle with promoting a good product that isn’t always easy to obtain.

Breast milk is good … but it isn’t always better or best.

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.”

Imagine yourself in a small community hospital standing at the bedside of a tiny preemie waiting for the neonatal transport team to return your call for help.

With one eye shifting between the clock and the oximeter, you have the other one looking out the window hoping that the predicted snow and freezing rain will hold out for another hour. You have done everything you can do, but clearly it’s not going to be enough to rescue this little person who had the misfortune of exiting the birth canal several months too early.

You have been able to insert an umbilical vein catheter and miraculously have threaded an endotracheal tube into a trachea that looked no bigger than a piece of spaghetti, or maybe you have failed and the nurses are taking turns bagging. The transport team returns your call for help and with apologies reports that they are tied up with a similar scenario further south; they predict that it may be an hour and a half before they will be able to get back to their hospital, which is a half hour down the road from you.

They suggest some things that you have already done. Should you wait for more skilled hands and their equipment or transport the patient yourself and get on the road before it becomes a skating rink? There is an antique transport isolette gathering dust in the storage room down the hall, and the local fire department ambulance crew with whom you are on a first-name basis is always ready to help. Is it time to gather the troops and tell them, “Let’s roll!” ?

If you have ever lived through a similar scenario, you may find a recent study interesting (Ann Intern Med. 2015;163[9]:681-90). What these investigators found was that for adults who had suffered major trauma, stroke, respiratory failure, and acute myocardial infarction, those who were transported by crews with basic life support (BLS) skills had significantly better long-term survival and neurologic outcomes than did those victims transported by crews with advanced life support (ALS) skills.

In the flurry of comments that circulated following the release of the study were a few questions about the methodology, but most commentators were searching for an explanation. Was critical time lost by the ALS crews doing stuff when the better course of action would have been to get the ambulance rolling to the hospital and more definitive care? Does the temptation to do things because you can do them sometimes cloud the decision-making process?

Although I have lived the scenario I described, it is less likely to happen now. Backup teams from other institutions may be activated. The teams are so well equipped and trained that the gaps between their capabilities and the neonatal intensive care unit have narrowed, but there is no question that they remain and are significant.

The other thing that hasn’t changed is the weather here in Maine. While we have beautiful summers that prompt us to put “Vacationland” on our license plates, our winters are a challenge. In addition to the patient’s condition and the availability of resources, the decision of whether to invest time in stabilization or get moving toward the referral center also must include the risk to the patient and staff who will be traveling on weather-threatened roads.

On the other hand, we can’t ignore the elephant that occasionally finds its way into the room when decisions are made about how thoroughly a critically ill patient is stabilized and how speedily he is transferred. And, that ponderous pachyderm is the hot potato factor and sometimes answers to its acronym, NIMBY (“not in my back yard”). You know as well as I do that despite the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations, there are cases when a patient is hustled out the door without being appropriately stabilized primarily to avoid having that patient die in the referring hospital. We must continue to ask ourselves if we have done everything that we can do to stabilize the patient before we say, “Let’s roll!”

William G. Wilkoff, M.D., 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.”

Imagine yourself in a small community hospital standing at the bedside of a tiny preemie waiting for the neonatal transport team to return your call for help.

With one eye shifting between the clock and the oximeter, you have the other one looking out the window hoping that the predicted snow and freezing rain will hold out for another hour. You have done everything you can do, but clearly it’s not going to be enough to rescue this little person who had the misfortune of exiting the birth canal several months too early.

You have been able to insert an umbilical vein catheter and miraculously have threaded an endotracheal tube into a trachea that looked no bigger than a piece of spaghetti, or maybe you have failed and the nurses are taking turns bagging. The transport team returns your call for help and with apologies reports that they are tied up with a similar scenario further south; they predict that it may be an hour and a half before they will be able to get back to their hospital, which is a half hour down the road from you.

They suggest some things that you have already done. Should you wait for more skilled hands and their equipment or transport the patient yourself and get on the road before it becomes a skating rink? There is an antique transport isolette gathering dust in the storage room down the hall, and the local fire department ambulance crew with whom you are on a first-name basis is always ready to help. Is it time to gather the troops and tell them, “Let’s roll!” ?

If you have ever lived through a similar scenario, you may find a recent study interesting (Ann Intern Med. 2015;163[9]:681-90). What these investigators found was that for adults who had suffered major trauma, stroke, respiratory failure, and acute myocardial infarction, those who were transported by crews with basic life support (BLS) skills had significantly better long-term survival and neurologic outcomes than did those victims transported by crews with advanced life support (ALS) skills.

In the flurry of comments that circulated following the release of the study were a few questions about the methodology, but most commentators were searching for an explanation. Was critical time lost by the ALS crews doing stuff when the better course of action would have been to get the ambulance rolling to the hospital and more definitive care? Does the temptation to do things because you can do them sometimes cloud the decision-making process?

Although I have lived the scenario I described, it is less likely to happen now. Backup teams from other institutions may be activated. The teams are so well equipped and trained that the gaps between their capabilities and the neonatal intensive care unit have narrowed, but there is no question that they remain and are significant.

The other thing that hasn’t changed is the weather here in Maine. While we have beautiful summers that prompt us to put “Vacationland” on our license plates, our winters are a challenge. In addition to the patient’s condition and the availability of resources, the decision of whether to invest time in stabilization or get moving toward the referral center also must include the risk to the patient and staff who will be traveling on weather-threatened roads.

On the other hand, we can’t ignore the elephant that occasionally finds its way into the room when decisions are made about how thoroughly a critically ill patient is stabilized and how speedily he is transferred. And, that ponderous pachyderm is the hot potato factor and sometimes answers to its acronym, NIMBY (“not in my back yard”). You know as well as I do that despite the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations, there are cases when a patient is hustled out the door without being appropriately stabilized primarily to avoid having that patient die in the referring hospital. We must continue to ask ourselves if we have done everything that we can do to stabilize the patient before we say, “Let’s roll!”

William G. Wilkoff, M.D., 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.”

Imagine yourself in a small community hospital standing at the bedside of a tiny preemie waiting for the neonatal transport team to return your call for help.

With one eye shifting between the clock and the oximeter, you have the other one looking out the window hoping that the predicted snow and freezing rain will hold out for another hour. You have done everything you can do, but clearly it’s not going to be enough to rescue this little person who had the misfortune of exiting the birth canal several months too early.

You have been able to insert an umbilical vein catheter and miraculously have threaded an endotracheal tube into a trachea that looked no bigger than a piece of spaghetti, or maybe you have failed and the nurses are taking turns bagging. The transport team returns your call for help and with apologies reports that they are tied up with a similar scenario further south; they predict that it may be an hour and a half before they will be able to get back to their hospital, which is a half hour down the road from you.

They suggest some things that you have already done. Should you wait for more skilled hands and their equipment or transport the patient yourself and get on the road before it becomes a skating rink? There is an antique transport isolette gathering dust in the storage room down the hall, and the local fire department ambulance crew with whom you are on a first-name basis is always ready to help. Is it time to gather the troops and tell them, “Let’s roll!” ?

If you have ever lived through a similar scenario, you may find a recent study interesting (Ann Intern Med. 2015;163[9]:681-90). What these investigators found was that for adults who had suffered major trauma, stroke, respiratory failure, and acute myocardial infarction, those who were transported by crews with basic life support (BLS) skills had significantly better long-term survival and neurologic outcomes than did those victims transported by crews with advanced life support (ALS) skills.

In the flurry of comments that circulated following the release of the study were a few questions about the methodology, but most commentators were searching for an explanation. Was critical time lost by the ALS crews doing stuff when the better course of action would have been to get the ambulance rolling to the hospital and more definitive care? Does the temptation to do things because you can do them sometimes cloud the decision-making process?

Although I have lived the scenario I described, it is less likely to happen now. Backup teams from other institutions may be activated. The teams are so well equipped and trained that the gaps between their capabilities and the neonatal intensive care unit have narrowed, but there is no question that they remain and are significant.

The other thing that hasn’t changed is the weather here in Maine. While we have beautiful summers that prompt us to put “Vacationland” on our license plates, our winters are a challenge. In addition to the patient’s condition and the availability of resources, the decision of whether to invest time in stabilization or get moving toward the referral center also must include the risk to the patient and staff who will be traveling on weather-threatened roads.

On the other hand, we can’t ignore the elephant that occasionally finds its way into the room when decisions are made about how thoroughly a critically ill patient is stabilized and how speedily he is transferred. And, that ponderous pachyderm is the hot potato factor and sometimes answers to its acronym, NIMBY (“not in my back yard”). You know as well as I do that despite the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations, there are cases when a patient is hustled out the door without being appropriately stabilized primarily to avoid having that patient die in the referring hospital. We must continue to ask ourselves if we have done everything that we can do to stabilize the patient before we say, “Let’s roll!”

William G. Wilkoff, M.D., 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.”