Letters from Maine

Imagine that you have finished dinner and have just sat down to watch the last half of the nightly news. Your 9-year-old son whom you have watched play soccer since he was 5 years old hands you a crumpled sheet of paper extracted from his backpack and asks, “Dad, can you sign this permission slip so I can play football?” Will you respond, “Sure, when is the first practice?”

Or will this be the jumping-off point for a dissertation on why you think football is a bad idea? Will you tell him that you are concerned that he will sustain a concussion, or two or three? Will you ask him why he would want a play a sport whose top level players are steroid pumped, inarticulate wife beaters? Or, will you tell him that the football culture tolerates the evils of hazing and fosters aggressive behavior?

Before we go any further, I must offer the disclaimer that I played high school football wearing a leather helmet. And that I played college football for 2 years until the handwriting on the locker room wall said, “Your skill level makes it very unlikely that you will ever get off the bench; maybe you should focus on lacrosse.” Which I did.

Although I had a few “stingers,” I never sustained any serious injuries other than a torn hamstring that still plagues me. My two concussions were unrelated to contact sports. As a team doctor for the local high school, I’m sure I sent several concussed players back onto the field. But in retrospect, I and most other physicians back then were working with a definition of concussion that was far too narrow. The most serious injuries I encountered as a game physician occurred during soccer matches.

I read the same headlines you do about what appear to be late effects in professional athletes of repeated blows to the head. I am repulsed by the off-field behavior of both collegiate and professional football players, and I continue to search unsuccessfully for admirable role models in the ranks of high-profile athletes.

Despite all the unseemly publicity, television revenues from professional football continue to surge unabated. However, I hear an undercurrent of discomfort with football from parents and some pediatricians: “Why would I allow my child to play a dangerous sport with despicable role models?” That’s a good question, and is the same one I asked you in the first line of this letter. I wouldn’t be surprised if some time in the not-too-distant future, the level of discomfort reaches a point that groups such as the American Academy of Pediatrics suggest that parents be strongly discouraged from allowing their children to play football.

I hope that this point is never reached because from my personal and professional experience, football can offer enough positives to make its risks acceptable – risks that are on a par with most activities that involve getting off the couch and physically interacting with peers and the environment. Football helped me to learn initiative (some might confuse this with aggression). It allowed me to enjoy the benefits of succeeding and failing as a member of a team. It exposed me to the value of careful preparation and meticulous attention to detail. One could argue that I could have acquired those insights and skills by participating in other activities, athletic or not. But for me it happened to be football. Were there downsides? Yes, because football was the only fall sport at my high school, it had the feel of an exclusive fraternity, a feeling that I have grown to dislike.

Would I sign my son’s permission slip to play football? Yes. Would I worry about him getting hurt? No more than I would when he played soccer and hockey. Because despite his dreams, we live in a town that isn’t football obsessed, and he isn’t going to have a 10-year career in professional sports. The risks of cumulative traumatic brain injury are too small to consider.

The bigger risk is that he might encounter a coach with a win-at-any-cost attitude and the moral character of a doorknob. But that can happen in any sport. Together he and I will continue to search for good role models in other avenues of life.

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 comment, e-mail him at [email protected].

Imagine that you have finished dinner and have just sat down to watch the last half of the nightly news. Your 9-year-old son whom you have watched play soccer since he was 5 years old hands you a crumpled sheet of paper extracted from his backpack and asks, “Dad, can you sign this permission slip so I can play football?” Will you respond, “Sure, when is the first practice?”

Or will this be the jumping-off point for a dissertation on why you think football is a bad idea? Will you tell him that you are concerned that he will sustain a concussion, or two or three? Will you ask him why he would want a play a sport whose top level players are steroid pumped, inarticulate wife beaters? Or, will you tell him that the football culture tolerates the evils of hazing and fosters aggressive behavior?

Before we go any further, I must offer the disclaimer that I played high school football wearing a leather helmet. And that I played college football for 2 years until the handwriting on the locker room wall said, “Your skill level makes it very unlikely that you will ever get off the bench; maybe you should focus on lacrosse.” Which I did.

Although I had a few “stingers,” I never sustained any serious injuries other than a torn hamstring that still plagues me. My two concussions were unrelated to contact sports. As a team doctor for the local high school, I’m sure I sent several concussed players back onto the field. But in retrospect, I and most other physicians back then were working with a definition of concussion that was far too narrow. The most serious injuries I encountered as a game physician occurred during soccer matches.

I read the same headlines you do about what appear to be late effects in professional athletes of repeated blows to the head. I am repulsed by the off-field behavior of both collegiate and professional football players, and I continue to search unsuccessfully for admirable role models in the ranks of high-profile athletes.

Despite all the unseemly publicity, television revenues from professional football continue to surge unabated. However, I hear an undercurrent of discomfort with football from parents and some pediatricians: “Why would I allow my child to play a dangerous sport with despicable role models?” That’s a good question, and is the same one I asked you in the first line of this letter. I wouldn’t be surprised if some time in the not-too-distant future, the level of discomfort reaches a point that groups such as the American Academy of Pediatrics suggest that parents be strongly discouraged from allowing their children to play football.

I hope that this point is never reached because from my personal and professional experience, football can offer enough positives to make its risks acceptable – risks that are on a par with most activities that involve getting off the couch and physically interacting with peers and the environment. Football helped me to learn initiative (some might confuse this with aggression). It allowed me to enjoy the benefits of succeeding and failing as a member of a team. It exposed me to the value of careful preparation and meticulous attention to detail. One could argue that I could have acquired those insights and skills by participating in other activities, athletic or not. But for me it happened to be football. Were there downsides? Yes, because football was the only fall sport at my high school, it had the feel of an exclusive fraternity, a feeling that I have grown to dislike.

Would I sign my son’s permission slip to play football? Yes. Would I worry about him getting hurt? No more than I would when he played soccer and hockey. Because despite his dreams, we live in a town that isn’t football obsessed, and he isn’t going to have a 10-year career in professional sports. The risks of cumulative traumatic brain injury are too small to consider.

The bigger risk is that he might encounter a coach with a win-at-any-cost attitude and the moral character of a doorknob. But that can happen in any sport. Together he and I will continue to search for good role models in other avenues of life.

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 comment, e-mail him at [email protected].

Imagine that you have finished dinner and have just sat down to watch the last half of the nightly news. Your 9-year-old son whom you have watched play soccer since he was 5 years old hands you a crumpled sheet of paper extracted from his backpack and asks, “Dad, can you sign this permission slip so I can play football?” Will you respond, “Sure, when is the first practice?”

Or will this be the jumping-off point for a dissertation on why you think football is a bad idea? Will you tell him that you are concerned that he will sustain a concussion, or two or three? Will you ask him why he would want a play a sport whose top level players are steroid pumped, inarticulate wife beaters? Or, will you tell him that the football culture tolerates the evils of hazing and fosters aggressive behavior?

Before we go any further, I must offer the disclaimer that I played high school football wearing a leather helmet. And that I played college football for 2 years until the handwriting on the locker room wall said, “Your skill level makes it very unlikely that you will ever get off the bench; maybe you should focus on lacrosse.” Which I did.

Although I had a few “stingers,” I never sustained any serious injuries other than a torn hamstring that still plagues me. My two concussions were unrelated to contact sports. As a team doctor for the local high school, I’m sure I sent several concussed players back onto the field. But in retrospect, I and most other physicians back then were working with a definition of concussion that was far too narrow. The most serious injuries I encountered as a game physician occurred during soccer matches.

I read the same headlines you do about what appear to be late effects in professional athletes of repeated blows to the head. I am repulsed by the off-field behavior of both collegiate and professional football players, and I continue to search unsuccessfully for admirable role models in the ranks of high-profile athletes.

Despite all the unseemly publicity, television revenues from professional football continue to surge unabated. However, I hear an undercurrent of discomfort with football from parents and some pediatricians: “Why would I allow my child to play a dangerous sport with despicable role models?” That’s a good question, and is the same one I asked you in the first line of this letter. I wouldn’t be surprised if some time in the not-too-distant future, the level of discomfort reaches a point that groups such as the American Academy of Pediatrics suggest that parents be strongly discouraged from allowing their children to play football.

I hope that this point is never reached because from my personal and professional experience, football can offer enough positives to make its risks acceptable – risks that are on a par with most activities that involve getting off the couch and physically interacting with peers and the environment. Football helped me to learn initiative (some might confuse this with aggression). It allowed me to enjoy the benefits of succeeding and failing as a member of a team. It exposed me to the value of careful preparation and meticulous attention to detail. One could argue that I could have acquired those insights and skills by participating in other activities, athletic or not. But for me it happened to be football. Were there downsides? Yes, because football was the only fall sport at my high school, it had the feel of an exclusive fraternity, a feeling that I have grown to dislike.

Would I sign my son’s permission slip to play football? Yes. Would I worry about him getting hurt? No more than I would when he played soccer and hockey. Because despite his dreams, we live in a town that isn’t football obsessed, and he isn’t going to have a 10-year career in professional sports. The risks of cumulative traumatic brain injury are too small to consider.

The bigger risk is that he might encounter a coach with a win-at-any-cost attitude and the moral character of a doorknob. But that can happen in any sport. Together he and I will continue to search for good role models in other avenues of life.

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 comment, e-mail him at [email protected].

If you manage to struggle your way to the back of the October 2014 Pediatrics, you will find a clinical report authored by members of the American Academy of Pediatrics Section on Integrative Medicine Executive Committee and the AAP Committee on Practice and Ambulatory Medicine (Pediatrics 2014;134:830-35 [doi: 10.1542/peds.2014-2278]). Under the title Physician Health and Wellness, the authors have carved out an approach to physician burnout, not by addressing its treatment but instead addressing it from the perspective of prevention.

Although the authors refer to two systems-based initiatives that have been launched in the last several years, unfortunately they shy away from making any specific recommendations themselves.

Not surprisingly, they observe that a mentally healthy physician is usually a physically healthy physician who eats well, sleeps well, and exercises regularly. He probably has supportive friends and/or family, and knows how to partition his life in a way that allows him time for one or two pursuits that he enjoys outside of his professional activities. Unless, of course, he is one of those lucky few who derives enough enjoyment from his patients. I would add that a mentally healthy, burnout-resistant physician is one whose expectations for his life are well within his abilities and the situation in which he finds himself.

But, why not give us some specifics on how we might guide young physicians onto paths that will maximize their resistance to burnout while it is still a preventable condition? For starters, why not consider a potential medical student’s ability to make healthy lifestyle choices? How many medical school admissions officers ask about the applicant’s exercise and sleep history ... and hobbies? An urban legend has it that the admissions director where I attended medical school occasionally performed his own little stress tests by among other things, asking the interviewee to open a window that had been painted shut. His efforts may have been crude and cruel, but why not give more attention to seeking out medical students who have already demonstrated some ability to find balance in their lives?

Once in medical school, students should have mentors or coaches who are good role models of wellness and who have the commitment to meet with the students on a regular basis. Encourage medical students to keep and share with their mentors diaries that include their exercise, sleep, and dietary schedules as well as observations on their own mental health. It’s gotta be easy on a smart phone. This may sound like smothering with mothering, but the magnitude of the problem of burnout deserves a more hands-on approach.

As students approach the last 2 years of school, they should be coached on what to expect from postgraduate training and the career paths they are considering. They should be encouraged to consider their own strengths and vulnerabilities, and how these will mesh with the realities of life as a practicing physician.

In the generation just ahead of me, some of the elite house officer training programs required that their house officers be single, because the program administrators felt that the life of a house officer was not compatible with married life. I’m not suggesting that we return to those monastic days, but medical students and young physicians need to be coached on how to be more realistic when making career choices and family planning decisions. One survey noted by the authors of this report has shown that not having minor children in the home was associated with less stress.

The authors offer “mindfulness” as an avenue worthy of consideration. It is a concept that I have trouble grasping, other than seeing it as a reminder to folks to stop just going through the motions and make a broad and honest assessment of their current situations. I guess if it helps a young physician to realize that if he moved a half-hour closer to work he would gain an hour a day with his family, “mindfulness” makes sense.

Finally, this AAP clinical report ignores one of the most serious contributors to physician burnout: electronic medical records. Everyone on the front lines knows it and talks about it. But, for the decision makers it continues to be the elephant in the room. It may take someone with a heavy hand and some common sense, but with good leadership a national electronic health record system that works is within reach.

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.” E-mail him at [email protected].

If you manage to struggle your way to the back of the October 2014 Pediatrics, you will find a clinical report authored by members of the American Academy of Pediatrics Section on Integrative Medicine Executive Committee and the AAP Committee on Practice and Ambulatory Medicine (Pediatrics 2014;134:830-35 [doi: 10.1542/peds.2014-2278]). Under the title Physician Health and Wellness, the authors have carved out an approach to physician burnout, not by addressing its treatment but instead addressing it from the perspective of prevention.

Although the authors refer to two systems-based initiatives that have been launched in the last several years, unfortunately they shy away from making any specific recommendations themselves.

Not surprisingly, they observe that a mentally healthy physician is usually a physically healthy physician who eats well, sleeps well, and exercises regularly. He probably has supportive friends and/or family, and knows how to partition his life in a way that allows him time for one or two pursuits that he enjoys outside of his professional activities. Unless, of course, he is one of those lucky few who derives enough enjoyment from his patients. I would add that a mentally healthy, burnout-resistant physician is one whose expectations for his life are well within his abilities and the situation in which he finds himself.

But, why not give us some specifics on how we might guide young physicians onto paths that will maximize their resistance to burnout while it is still a preventable condition? For starters, why not consider a potential medical student’s ability to make healthy lifestyle choices? How many medical school admissions officers ask about the applicant’s exercise and sleep history ... and hobbies? An urban legend has it that the admissions director where I attended medical school occasionally performed his own little stress tests by among other things, asking the interviewee to open a window that had been painted shut. His efforts may have been crude and cruel, but why not give more attention to seeking out medical students who have already demonstrated some ability to find balance in their lives?

Once in medical school, students should have mentors or coaches who are good role models of wellness and who have the commitment to meet with the students on a regular basis. Encourage medical students to keep and share with their mentors diaries that include their exercise, sleep, and dietary schedules as well as observations on their own mental health. It’s gotta be easy on a smart phone. This may sound like smothering with mothering, but the magnitude of the problem of burnout deserves a more hands-on approach.

As students approach the last 2 years of school, they should be coached on what to expect from postgraduate training and the career paths they are considering. They should be encouraged to consider their own strengths and vulnerabilities, and how these will mesh with the realities of life as a practicing physician.

In the generation just ahead of me, some of the elite house officer training programs required that their house officers be single, because the program administrators felt that the life of a house officer was not compatible with married life. I’m not suggesting that we return to those monastic days, but medical students and young physicians need to be coached on how to be more realistic when making career choices and family planning decisions. One survey noted by the authors of this report has shown that not having minor children in the home was associated with less stress.

The authors offer “mindfulness” as an avenue worthy of consideration. It is a concept that I have trouble grasping, other than seeing it as a reminder to folks to stop just going through the motions and make a broad and honest assessment of their current situations. I guess if it helps a young physician to realize that if he moved a half-hour closer to work he would gain an hour a day with his family, “mindfulness” makes sense.

Finally, this AAP clinical report ignores one of the most serious contributors to physician burnout: electronic medical records. Everyone on the front lines knows it and talks about it. But, for the decision makers it continues to be the elephant in the room. It may take someone with a heavy hand and some common sense, but with good leadership a national electronic health record system that works is within reach.

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.” E-mail him at [email protected].

If you manage to struggle your way to the back of the October 2014 Pediatrics, you will find a clinical report authored by members of the American Academy of Pediatrics Section on Integrative Medicine Executive Committee and the AAP Committee on Practice and Ambulatory Medicine (Pediatrics 2014;134:830-35 [doi: 10.1542/peds.2014-2278]). Under the title Physician Health and Wellness, the authors have carved out an approach to physician burnout, not by addressing its treatment but instead addressing it from the perspective of prevention.

Although the authors refer to two systems-based initiatives that have been launched in the last several years, unfortunately they shy away from making any specific recommendations themselves.

Not surprisingly, they observe that a mentally healthy physician is usually a physically healthy physician who eats well, sleeps well, and exercises regularly. He probably has supportive friends and/or family, and knows how to partition his life in a way that allows him time for one or two pursuits that he enjoys outside of his professional activities. Unless, of course, he is one of those lucky few who derives enough enjoyment from his patients. I would add that a mentally healthy, burnout-resistant physician is one whose expectations for his life are well within his abilities and the situation in which he finds himself.

But, why not give us some specifics on how we might guide young physicians onto paths that will maximize their resistance to burnout while it is still a preventable condition? For starters, why not consider a potential medical student’s ability to make healthy lifestyle choices? How many medical school admissions officers ask about the applicant’s exercise and sleep history ... and hobbies? An urban legend has it that the admissions director where I attended medical school occasionally performed his own little stress tests by among other things, asking the interviewee to open a window that had been painted shut. His efforts may have been crude and cruel, but why not give more attention to seeking out medical students who have already demonstrated some ability to find balance in their lives?

Once in medical school, students should have mentors or coaches who are good role models of wellness and who have the commitment to meet with the students on a regular basis. Encourage medical students to keep and share with their mentors diaries that include their exercise, sleep, and dietary schedules as well as observations on their own mental health. It’s gotta be easy on a smart phone. This may sound like smothering with mothering, but the magnitude of the problem of burnout deserves a more hands-on approach.

As students approach the last 2 years of school, they should be coached on what to expect from postgraduate training and the career paths they are considering. They should be encouraged to consider their own strengths and vulnerabilities, and how these will mesh with the realities of life as a practicing physician.

In the generation just ahead of me, some of the elite house officer training programs required that their house officers be single, because the program administrators felt that the life of a house officer was not compatible with married life. I’m not suggesting that we return to those monastic days, but medical students and young physicians need to be coached on how to be more realistic when making career choices and family planning decisions. One survey noted by the authors of this report has shown that not having minor children in the home was associated with less stress.

The authors offer “mindfulness” as an avenue worthy of consideration. It is a concept that I have trouble grasping, other than seeing it as a reminder to folks to stop just going through the motions and make a broad and honest assessment of their current situations. I guess if it helps a young physician to realize that if he moved a half-hour closer to work he would gain an hour a day with his family, “mindfulness” makes sense.

Finally, this AAP clinical report ignores one of the most serious contributors to physician burnout: electronic medical records. Everyone on the front lines knows it and talks about it. But, for the decision makers it continues to be the elephant in the room. It may take someone with a heavy hand and some common sense, but with good leadership a national electronic health record system that works is within reach.

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.” E-mail him at [email protected].

When your pager vibrates at 7 o’clock in the morning, it is unlikely to be alerting you of good news. It may be a parent who assumes that because his child’s medical home has evening office hours that there will be a receptionist sitting there at sunup to help him make an appointment for a nonurgent complaint. Or, it may be a call from a parent who knows that she doesn’t have a medical emergency on her hands, but who would like your advice about whether she should take a day off from work or send her child to day care.

But, an uncomfortable number of daybreak calls come from parents with what eventually turns out to be a desperately ill child. I have witnessed those scenarios often enough that even though I am retired, I break into a cold sweat when the home phone rings anytime between 6 and 7 in the morning.

A study from Wake Forest University, Winston-Salem, N.C., published in the November 2014 issue of Pediatrics, supports my long-standing discomfort with patients who present in the early morning. (McCrory et al. “Off-Hours Admission to Pediatric Intensive Care and Mortality,” Pediatrics 2014;134:e1345-e1353 [doi: 10.1542/peds.2014-1071]). In a retrospective study of nearly a quarter of a million admissions to 99 perinatal ICUs over a 3-year period, the investigators discovered that admission in off-hours and weekends “does not independently increase the odds of mortality.”

However, they found that admission from 6 to 11 in the morning is “associated with an increased risk of death.” This may not have been the result the investigators were expecting, and their analyses don’t suggest a cause. In the discussion portion of the paper, they offer some explanations that are in sync with my observations. First, ICUs are generally fully staffed 24-7-365. While the lights maybe dimmed slightly, there is seldom a diurnal variation in the attentiveness and quality of the caregivers in an ICU. Contrast this to an ordinary medical/surgical floor on which the staffing levels drop precipitously when the sun goes down. The skeletal staff is usually working in the dark, resorting to flashlights and ankle-level lighting to make their observations. And ... things are missed. Things like skin-color changes and the quality of respirations that become obvious when the morning shift arrives and the lights go on. “Holy s**t! This patient needs to be in the PICU!” And, the PICU now receives a patient at 7:30 a.m. who has a greater odds of mortality because the illness has percolated in the dark overnight.

The same phenomenon occurs in the outpatient setting. At night, sleep deprivation may cloud a parent’s observational skills. The lights in the bedroom may have been left off in hopes of keeping the child more comfortable. The parent may have called the doctor and been shunted to a triage nurse who is unfamiliar with the family and whose algorithm fails at a critical branch point. Or, the call may have been fielded by an answering service that is more interested in protecting its client’s sleep than serving the needs of the caller.

Or the parent may have spoken to the doctor early in the evening, but was hesitant to call again and wake her when the child’s condition changed. House officers can fall into the same trap when their misplaced concern about the sleep needs of the physician to whom they report prevents them from making a critical call for help.

Again, the result is that when the sun comes up, a child whose illness might have been more easily managed in the PICU at 2:30 a.m. doesn’t arrive in the unit until those deadly hours between 6 a.m. and 11 a.m. While there may be diurnal variations in the inherent mortality of some pathological conditions, this study from North Carolina suggests that when the lights go out, critical observations go unmade and so do wise decisions.

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.” E-mail him at [email protected].

When your pager vibrates at 7 o’clock in the morning, it is unlikely to be alerting you of good news. It may be a parent who assumes that because his child’s medical home has evening office hours that there will be a receptionist sitting there at sunup to help him make an appointment for a nonurgent complaint. Or, it may be a call from a parent who knows that she doesn’t have a medical emergency on her hands, but who would like your advice about whether she should take a day off from work or send her child to day care.

But, an uncomfortable number of daybreak calls come from parents with what eventually turns out to be a desperately ill child. I have witnessed those scenarios often enough that even though I am retired, I break into a cold sweat when the home phone rings anytime between 6 and 7 in the morning.

A study from Wake Forest University, Winston-Salem, N.C., published in the November 2014 issue of Pediatrics, supports my long-standing discomfort with patients who present in the early morning. (McCrory et al. “Off-Hours Admission to Pediatric Intensive Care and Mortality,” Pediatrics 2014;134:e1345-e1353 [doi: 10.1542/peds.2014-1071]). In a retrospective study of nearly a quarter of a million admissions to 99 perinatal ICUs over a 3-year period, the investigators discovered that admission in off-hours and weekends “does not independently increase the odds of mortality.”

However, they found that admission from 6 to 11 in the morning is “associated with an increased risk of death.” This may not have been the result the investigators were expecting, and their analyses don’t suggest a cause. In the discussion portion of the paper, they offer some explanations that are in sync with my observations. First, ICUs are generally fully staffed 24-7-365. While the lights maybe dimmed slightly, there is seldom a diurnal variation in the attentiveness and quality of the caregivers in an ICU. Contrast this to an ordinary medical/surgical floor on which the staffing levels drop precipitously when the sun goes down. The skeletal staff is usually working in the dark, resorting to flashlights and ankle-level lighting to make their observations. And ... things are missed. Things like skin-color changes and the quality of respirations that become obvious when the morning shift arrives and the lights go on. “Holy s**t! This patient needs to be in the PICU!” And, the PICU now receives a patient at 7:30 a.m. who has a greater odds of mortality because the illness has percolated in the dark overnight.

The same phenomenon occurs in the outpatient setting. At night, sleep deprivation may cloud a parent’s observational skills. The lights in the bedroom may have been left off in hopes of keeping the child more comfortable. The parent may have called the doctor and been shunted to a triage nurse who is unfamiliar with the family and whose algorithm fails at a critical branch point. Or, the call may have been fielded by an answering service that is more interested in protecting its client’s sleep than serving the needs of the caller.

Or the parent may have spoken to the doctor early in the evening, but was hesitant to call again and wake her when the child’s condition changed. House officers can fall into the same trap when their misplaced concern about the sleep needs of the physician to whom they report prevents them from making a critical call for help.

Again, the result is that when the sun comes up, a child whose illness might have been more easily managed in the PICU at 2:30 a.m. doesn’t arrive in the unit until those deadly hours between 6 a.m. and 11 a.m. While there may be diurnal variations in the inherent mortality of some pathological conditions, this study from North Carolina suggests that when the lights go out, critical observations go unmade and so do wise decisions.

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.” E-mail him at [email protected].

When your pager vibrates at 7 o’clock in the morning, it is unlikely to be alerting you of good news. It may be a parent who assumes that because his child’s medical home has evening office hours that there will be a receptionist sitting there at sunup to help him make an appointment for a nonurgent complaint. Or, it may be a call from a parent who knows that she doesn’t have a medical emergency on her hands, but who would like your advice about whether she should take a day off from work or send her child to day care.

But, an uncomfortable number of daybreak calls come from parents with what eventually turns out to be a desperately ill child. I have witnessed those scenarios often enough that even though I am retired, I break into a cold sweat when the home phone rings anytime between 6 and 7 in the morning.

A study from Wake Forest University, Winston-Salem, N.C., published in the November 2014 issue of Pediatrics, supports my long-standing discomfort with patients who present in the early morning. (McCrory et al. “Off-Hours Admission to Pediatric Intensive Care and Mortality,” Pediatrics 2014;134:e1345-e1353 [doi: 10.1542/peds.2014-1071]). In a retrospective study of nearly a quarter of a million admissions to 99 perinatal ICUs over a 3-year period, the investigators discovered that admission in off-hours and weekends “does not independently increase the odds of mortality.”

However, they found that admission from 6 to 11 in the morning is “associated with an increased risk of death.” This may not have been the result the investigators were expecting, and their analyses don’t suggest a cause. In the discussion portion of the paper, they offer some explanations that are in sync with my observations. First, ICUs are generally fully staffed 24-7-365. While the lights maybe dimmed slightly, there is seldom a diurnal variation in the attentiveness and quality of the caregivers in an ICU. Contrast this to an ordinary medical/surgical floor on which the staffing levels drop precipitously when the sun goes down. The skeletal staff is usually working in the dark, resorting to flashlights and ankle-level lighting to make their observations. And ... things are missed. Things like skin-color changes and the quality of respirations that become obvious when the morning shift arrives and the lights go on. “Holy s**t! This patient needs to be in the PICU!” And, the PICU now receives a patient at 7:30 a.m. who has a greater odds of mortality because the illness has percolated in the dark overnight.

The same phenomenon occurs in the outpatient setting. At night, sleep deprivation may cloud a parent’s observational skills. The lights in the bedroom may have been left off in hopes of keeping the child more comfortable. The parent may have called the doctor and been shunted to a triage nurse who is unfamiliar with the family and whose algorithm fails at a critical branch point. Or, the call may have been fielded by an answering service that is more interested in protecting its client’s sleep than serving the needs of the caller.

Or the parent may have spoken to the doctor early in the evening, but was hesitant to call again and wake her when the child’s condition changed. House officers can fall into the same trap when their misplaced concern about the sleep needs of the physician to whom they report prevents them from making a critical call for help.

Again, the result is that when the sun comes up, a child whose illness might have been more easily managed in the PICU at 2:30 a.m. doesn’t arrive in the unit until those deadly hours between 6 a.m. and 11 a.m. While there may be diurnal variations in the inherent mortality of some pathological conditions, this study from North Carolina suggests that when the lights go out, critical observations go unmade and so do wise decisions.

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.” E-mail him at [email protected].

Two years ago, I saw a young man in my office who had decided not to return to college after his freshman year. He had been a very good high school hockey player, and I asked him what he was doing now to stay fit. He replied that he had joined a fitness facility, part of a national franchise system, and “I’m going on the Paleo Diet.” As I was among the clueless at that time, I quizzed him about his diet.

He told me that it was an attempt to duplicate the diet of our ancestors prior to the development of agriculture (thought to be about 10,000 years ago). This meant no processed food, no dairy products, no grains or legumes, no refined sugars. Lean meat, nuts, fruits, and low-starch vegetables were okay.

When I saw him for a follow-up visit 2 months later, I asked how he was doing with what I called his “caveman diet.” He said, “I lasted about 6 weeks, but I’m still working out four times a week.” It turns out that while my patient had drifted away from his paleolithic diet, enough other people have climbed on the bandwagon that there are now a couple of magazines devoted what has broadened beyond diet to what could be called a paleo lifestyle.

Devotees of the live-like-our-ancestors movement hope to avoid the “diseases of civilization by exercising frequently, particularly doing things that mimic our ancestors activities such as running, jumping, climbing, and throwing. A committed paleo person should wear a minimum of clothes and try to go barefoot as often as possible. He should have frequent contact with nature and get plenty of sun exposure for his source of vitamin D. His sleep patterns should be in sync with the sun cycle, and he should avoid stress by simplifying and downsizing his life.

This sounds like a lifestyle most toddlers strive for everyday. They prefer to run around nude and shoeless, climb just for fun, and throw anything within reach. It got me wondering what paleo parenting might be look like. Certainly, it would begin with breastfeeding. But, for how long? I don’t think we know the answer to that. It may not have been as long some breastfeeding advocates believe.

I suspect young children are smart enough to find shade in the middle of day to take a nap if we allow them. My obsession with the hazards of sleep deprivation makes the paleo’s attempt to link sleep to the sun cycle particularly appealing. It would benefit parents as well as the children for them to all go to bed when the sun went down. Paleo parenting would mean no TV. What a concept!

Of course, there are several flies in this ancestral ointment. First, I suspect that our prehistoric ancestors seldom lived into their fourth decade. How many of the “diseases of civilization” are simply the effect of aging on bodies that were not genetically engineered for longevity? How much do we really know about the diet and lifestyle of our paleo ancestors? Carbon isotope studies and microscopic analysis of ancient stool samples are pretty scanty evidence.

And, why choose to set our target to emulate before the development of agriculture? Some grain and a few root vegetables aren’t going to send our children on the road to obesity if they are active and getting adequate amounts of sleep.

There can be many advantages to adopting an “ancestral lifestyle,” but we don’t have to peel the onion all the way back to prehistory to reap the benefits. Heck, I bet if we rolled back to pretelevision, we would be a much healthier society.

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.” E-mail him at [email protected].

Two years ago, I saw a young man in my office who had decided not to return to college after his freshman year. He had been a very good high school hockey player, and I asked him what he was doing now to stay fit. He replied that he had joined a fitness facility, part of a national franchise system, and “I’m going on the Paleo Diet.” As I was among the clueless at that time, I quizzed him about his diet.

He told me that it was an attempt to duplicate the diet of our ancestors prior to the development of agriculture (thought to be about 10,000 years ago). This meant no processed food, no dairy products, no grains or legumes, no refined sugars. Lean meat, nuts, fruits, and low-starch vegetables were okay.

When I saw him for a follow-up visit 2 months later, I asked how he was doing with what I called his “caveman diet.” He said, “I lasted about 6 weeks, but I’m still working out four times a week.” It turns out that while my patient had drifted away from his paleolithic diet, enough other people have climbed on the bandwagon that there are now a couple of magazines devoted what has broadened beyond diet to what could be called a paleo lifestyle.

Devotees of the live-like-our-ancestors movement hope to avoid the “diseases of civilization by exercising frequently, particularly doing things that mimic our ancestors activities such as running, jumping, climbing, and throwing. A committed paleo person should wear a minimum of clothes and try to go barefoot as often as possible. He should have frequent contact with nature and get plenty of sun exposure for his source of vitamin D. His sleep patterns should be in sync with the sun cycle, and he should avoid stress by simplifying and downsizing his life.

This sounds like a lifestyle most toddlers strive for everyday. They prefer to run around nude and shoeless, climb just for fun, and throw anything within reach. It got me wondering what paleo parenting might be look like. Certainly, it would begin with breastfeeding. But, for how long? I don’t think we know the answer to that. It may not have been as long some breastfeeding advocates believe.

I suspect young children are smart enough to find shade in the middle of day to take a nap if we allow them. My obsession with the hazards of sleep deprivation makes the paleo’s attempt to link sleep to the sun cycle particularly appealing. It would benefit parents as well as the children for them to all go to bed when the sun went down. Paleo parenting would mean no TV. What a concept!

Of course, there are several flies in this ancestral ointment. First, I suspect that our prehistoric ancestors seldom lived into their fourth decade. How many of the “diseases of civilization” are simply the effect of aging on bodies that were not genetically engineered for longevity? How much do we really know about the diet and lifestyle of our paleo ancestors? Carbon isotope studies and microscopic analysis of ancient stool samples are pretty scanty evidence.

And, why choose to set our target to emulate before the development of agriculture? Some grain and a few root vegetables aren’t going to send our children on the road to obesity if they are active and getting adequate amounts of sleep.

There can be many advantages to adopting an “ancestral lifestyle,” but we don’t have to peel the onion all the way back to prehistory to reap the benefits. Heck, I bet if we rolled back to pretelevision, we would be a much healthier society.

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.” E-mail him at [email protected].

Two years ago, I saw a young man in my office who had decided not to return to college after his freshman year. He had been a very good high school hockey player, and I asked him what he was doing now to stay fit. He replied that he had joined a fitness facility, part of a national franchise system, and “I’m going on the Paleo Diet.” As I was among the clueless at that time, I quizzed him about his diet.

He told me that it was an attempt to duplicate the diet of our ancestors prior to the development of agriculture (thought to be about 10,000 years ago). This meant no processed food, no dairy products, no grains or legumes, no refined sugars. Lean meat, nuts, fruits, and low-starch vegetables were okay.

When I saw him for a follow-up visit 2 months later, I asked how he was doing with what I called his “caveman diet.” He said, “I lasted about 6 weeks, but I’m still working out four times a week.” It turns out that while my patient had drifted away from his paleolithic diet, enough other people have climbed on the bandwagon that there are now a couple of magazines devoted what has broadened beyond diet to what could be called a paleo lifestyle.

Devotees of the live-like-our-ancestors movement hope to avoid the “diseases of civilization by exercising frequently, particularly doing things that mimic our ancestors activities such as running, jumping, climbing, and throwing. A committed paleo person should wear a minimum of clothes and try to go barefoot as often as possible. He should have frequent contact with nature and get plenty of sun exposure for his source of vitamin D. His sleep patterns should be in sync with the sun cycle, and he should avoid stress by simplifying and downsizing his life.

This sounds like a lifestyle most toddlers strive for everyday. They prefer to run around nude and shoeless, climb just for fun, and throw anything within reach. It got me wondering what paleo parenting might be look like. Certainly, it would begin with breastfeeding. But, for how long? I don’t think we know the answer to that. It may not have been as long some breastfeeding advocates believe.

I suspect young children are smart enough to find shade in the middle of day to take a nap if we allow them. My obsession with the hazards of sleep deprivation makes the paleo’s attempt to link sleep to the sun cycle particularly appealing. It would benefit parents as well as the children for them to all go to bed when the sun went down. Paleo parenting would mean no TV. What a concept!

Of course, there are several flies in this ancestral ointment. First, I suspect that our prehistoric ancestors seldom lived into their fourth decade. How many of the “diseases of civilization” are simply the effect of aging on bodies that were not genetically engineered for longevity? How much do we really know about the diet and lifestyle of our paleo ancestors? Carbon isotope studies and microscopic analysis of ancient stool samples are pretty scanty evidence.

And, why choose to set our target to emulate before the development of agriculture? Some grain and a few root vegetables aren’t going to send our children on the road to obesity if they are active and getting adequate amounts of sleep.

There can be many advantages to adopting an “ancestral lifestyle,” but we don’t have to peel the onion all the way back to prehistory to reap the benefits. Heck, I bet if we rolled back to pretelevision, we would be a much healthier society.

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.” E-mail him at [email protected].

If Maine conjures up images of pine-covered mountains and rocky coastlines, then Fort Kent won’t fit into your construct. Slumbering on the broad flat valley of the Saint John River that forms Maine’s border with Canada, the rolling farmland around this town of 4,000 would remind you more of Iowa. Aroostook County is potato country and is so unique that most Mainers refer to it simply as “The County.”

Fort Kent was originally built as a defense outpost but was seldom used. Today it is an unlikely spot for what could be one of the pivotal battles in a war that could decide our country’s future. But who in 1800 would have guessed that the small town of Gettysburg would have such a crucial role to play in American history.

And, who would imagine that a pixy-faced young woman with strawberry ringlets would be one of the heroes? But, on Halloween Day, 2014, the chief judge of the Maine District Courts ruled that Kaci Hickox was no longer to be quarantined in her home. As a nurse who had recently returned from West Africa where she had been caring for patients with Ebola, she certainly was at a higher risk for contracting the disease. But, there has been no clinical evidence that she had the disease or was contagious.

However, the governor of New Jersey, Chris Christie, ignored the facts and responded to irrational fear and isolated Ms. Hickox when she arrived from Africa in an unheated tent with little regard for her psychological comfort. With the help of her lawyer, she was allowed to travel back to Fort Kent where she had been living with her boyfriend, a nursing student. The governor of Maine, Paul LePage, reacted only slightly less irrationally than his New Jersey counterpart, and Kaci was ordered not leave her home. Negotiations for a more reasonable evidence-based arrangement broke down. And, in a brave and clever show of defiance, Kaci and her boyfriend went for a bike ride, heading away from town on the rural roads around Fort Kent. Were the state troopers following in two squad cars going to don hazmat suits to arrest the couple? Not likely, and the ride ended uneventfully. The next day Judge Charles C. Laverdiere lifted the quarantine and in his decision said that we all owed the nurse “a debt of gratitude” for her decision to treat Ebola patients.

Much of the buzz surrounding this decision has focused on the issue of Ms. Hickox’s personal freedom and even the constitutionality of her quarantine. But, more importantly, her case represents a rare victory in a key battle in a bigger war, the war between science and fear-based irrational thought. It is a war in which we have incurred too many losses. Hundreds of children have died of illnesses from which they could have been protected by immunization because their parents failed to trust the science.

Scientific thought is on the defensive. It is being poorly taught in school, and sadly a few who claim to be scientists have allowed their egos and greed to taint the results of their experiments. In the vacuum created when science has been ignored, fear and emotionally based decisions dominate.

In the case of Ebola, we all have suffered from the absence of a single voice of authority armed with evidence. It could have been the U.S. Surgeon General if the Senate hadn’t declined to confirm President Barack Obama’s appointment because of his position on gun-related issues.

However, even if we had a surgeon general, the most obvious choice for the role of defender and promoter of evidence-based decisions in a case that is so highly charged should have been the president himself. The country deserved a straight talking, look-em-in-the-eye delineation of the facts, a presentation that acknowledged that there are seldom situations in which the risk is zero, but one that reminded us that the only thing we have to fear is fear itself. However, this president’s style seems to be to step back and delegate when we need someone who will step forward and lead. The result of his abdication has been the confusing and conflicting attempts at leadership by three governors who may have been well intended, but lacked the skills and resources to address the scientific evidence.

In a battle with no general and a commander-in-chief who chose to stay in his tent, science has been rescued temporarily by a courageous young nurse and sage judge from Maine where our state motto is “Dirigo” – I lead.

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.” E-mail him at [email protected].

If Maine conjures up images of pine-covered mountains and rocky coastlines, then Fort Kent won’t fit into your construct. Slumbering on the broad flat valley of the Saint John River that forms Maine’s border with Canada, the rolling farmland around this town of 4,000 would remind you more of Iowa. Aroostook County is potato country and is so unique that most Mainers refer to it simply as “The County.”

Fort Kent was originally built as a defense outpost but was seldom used. Today it is an unlikely spot for what could be one of the pivotal battles in a war that could decide our country’s future. But who in 1800 would have guessed that the small town of Gettysburg would have such a crucial role to play in American history.

And, who would imagine that a pixy-faced young woman with strawberry ringlets would be one of the heroes? But, on Halloween Day, 2014, the chief judge of the Maine District Courts ruled that Kaci Hickox was no longer to be quarantined in her home. As a nurse who had recently returned from West Africa where she had been caring for patients with Ebola, she certainly was at a higher risk for contracting the disease. But, there has been no clinical evidence that she had the disease or was contagious.

However, the governor of New Jersey, Chris Christie, ignored the facts and responded to irrational fear and isolated Ms. Hickox when she arrived from Africa in an unheated tent with little regard for her psychological comfort. With the help of her lawyer, she was allowed to travel back to Fort Kent where she had been living with her boyfriend, a nursing student. The governor of Maine, Paul LePage, reacted only slightly less irrationally than his New Jersey counterpart, and Kaci was ordered not leave her home. Negotiations for a more reasonable evidence-based arrangement broke down. And, in a brave and clever show of defiance, Kaci and her boyfriend went for a bike ride, heading away from town on the rural roads around Fort Kent. Were the state troopers following in two squad cars going to don hazmat suits to arrest the couple? Not likely, and the ride ended uneventfully. The next day Judge Charles C. Laverdiere lifted the quarantine and in his decision said that we all owed the nurse “a debt of gratitude” for her decision to treat Ebola patients.

Much of the buzz surrounding this decision has focused on the issue of Ms. Hickox’s personal freedom and even the constitutionality of her quarantine. But, more importantly, her case represents a rare victory in a key battle in a bigger war, the war between science and fear-based irrational thought. It is a war in which we have incurred too many losses. Hundreds of children have died of illnesses from which they could have been protected by immunization because their parents failed to trust the science.

Scientific thought is on the defensive. It is being poorly taught in school, and sadly a few who claim to be scientists have allowed their egos and greed to taint the results of their experiments. In the vacuum created when science has been ignored, fear and emotionally based decisions dominate.

In the case of Ebola, we all have suffered from the absence of a single voice of authority armed with evidence. It could have been the U.S. Surgeon General if the Senate hadn’t declined to confirm President Barack Obama’s appointment because of his position on gun-related issues.

However, even if we had a surgeon general, the most obvious choice for the role of defender and promoter of evidence-based decisions in a case that is so highly charged should have been the president himself. The country deserved a straight talking, look-em-in-the-eye delineation of the facts, a presentation that acknowledged that there are seldom situations in which the risk is zero, but one that reminded us that the only thing we have to fear is fear itself. However, this president’s style seems to be to step back and delegate when we need someone who will step forward and lead. The result of his abdication has been the confusing and conflicting attempts at leadership by three governors who may have been well intended, but lacked the skills and resources to address the scientific evidence.

In a battle with no general and a commander-in-chief who chose to stay in his tent, science has been rescued temporarily by a courageous young nurse and sage judge from Maine where our state motto is “Dirigo” – I lead.

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.” E-mail him at [email protected].

If Maine conjures up images of pine-covered mountains and rocky coastlines, then Fort Kent won’t fit into your construct. Slumbering on the broad flat valley of the Saint John River that forms Maine’s border with Canada, the rolling farmland around this town of 4,000 would remind you more of Iowa. Aroostook County is potato country and is so unique that most Mainers refer to it simply as “The County.”

Fort Kent was originally built as a defense outpost but was seldom used. Today it is an unlikely spot for what could be one of the pivotal battles in a war that could decide our country’s future. But who in 1800 would have guessed that the small town of Gettysburg would have such a crucial role to play in American history.

And, who would imagine that a pixy-faced young woman with strawberry ringlets would be one of the heroes? But, on Halloween Day, 2014, the chief judge of the Maine District Courts ruled that Kaci Hickox was no longer to be quarantined in her home. As a nurse who had recently returned from West Africa where she had been caring for patients with Ebola, she certainly was at a higher risk for contracting the disease. But, there has been no clinical evidence that she had the disease or was contagious.

However, the governor of New Jersey, Chris Christie, ignored the facts and responded to irrational fear and isolated Ms. Hickox when she arrived from Africa in an unheated tent with little regard for her psychological comfort. With the help of her lawyer, she was allowed to travel back to Fort Kent where she had been living with her boyfriend, a nursing student. The governor of Maine, Paul LePage, reacted only slightly less irrationally than his New Jersey counterpart, and Kaci was ordered not leave her home. Negotiations for a more reasonable evidence-based arrangement broke down. And, in a brave and clever show of defiance, Kaci and her boyfriend went for a bike ride, heading away from town on the rural roads around Fort Kent. Were the state troopers following in two squad cars going to don hazmat suits to arrest the couple? Not likely, and the ride ended uneventfully. The next day Judge Charles C. Laverdiere lifted the quarantine and in his decision said that we all owed the nurse “a debt of gratitude” for her decision to treat Ebola patients.

Much of the buzz surrounding this decision has focused on the issue of Ms. Hickox’s personal freedom and even the constitutionality of her quarantine. But, more importantly, her case represents a rare victory in a key battle in a bigger war, the war between science and fear-based irrational thought. It is a war in which we have incurred too many losses. Hundreds of children have died of illnesses from which they could have been protected by immunization because their parents failed to trust the science.

Scientific thought is on the defensive. It is being poorly taught in school, and sadly a few who claim to be scientists have allowed their egos and greed to taint the results of their experiments. In the vacuum created when science has been ignored, fear and emotionally based decisions dominate.

In the case of Ebola, we all have suffered from the absence of a single voice of authority armed with evidence. It could have been the U.S. Surgeon General if the Senate hadn’t declined to confirm President Barack Obama’s appointment because of his position on gun-related issues.

However, even if we had a surgeon general, the most obvious choice for the role of defender and promoter of evidence-based decisions in a case that is so highly charged should have been the president himself. The country deserved a straight talking, look-em-in-the-eye delineation of the facts, a presentation that acknowledged that there are seldom situations in which the risk is zero, but one that reminded us that the only thing we have to fear is fear itself. However, this president’s style seems to be to step back and delegate when we need someone who will step forward and lead. The result of his abdication has been the confusing and conflicting attempts at leadership by three governors who may have been well intended, but lacked the skills and resources to address the scientific evidence.

In a battle with no general and a commander-in-chief who chose to stay in his tent, science has been rescued temporarily by a courageous young nurse and sage judge from Maine where our state motto is “Dirigo” – I lead.

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.” E-mail him at [email protected].

Fear of the unknown is driving many pediatricians to refer out their patients with simple and easily managed orthopedic and dermatologic complaints. From several perspectives, this tendency to dump and run is unfortunate. For the patients and their families, a trip to the specialist may be expensive, certainly time consuming, and often comes after a long anxiety provoking and frustrating delay.

For the physician worried about her bottom line or who is being told by her practice administrator to see more patients, sending away a patient with a skin rash that can be diagnosed in 30 seconds (10 seconds in many cases) and explained in 5 minutes is a poor business decision. The office time required to make the referral could be as much as $20 while the 10-minute visit probably generates twice that in revenue.

But, the real tragedy is that, by referring out patients with simple dermatologic and orthopedic complaints, the physician is depriving herself of a source of intellectually stimulating variety. Parents appreciate the effort when their child’s doctor demonstrates that she is a more complete physician.

At least when it comes to gap in the dermatology training of pediatricians, there is a glimmer of a solution on the horizon. As reported by this news organization (“What should pediatricians know about dermatology?” Sept. 2014, page 1) the Society of Pediatric Dermatologists convened a committee of pediatricians, family practitioners, and pediatric dermatologists to determine what a pediatrician’s training in dermatology should include with the goal of creating an online pediatric dermatologic curricular for primary care providers.

Exactly how this training should be structured is yet to be determined. However, while we are waiting, I’m going to offer a few suggestions on what a pediatricians’ training in dermatology should look like. I would divide the training into three segments. The first would be a couple of hours of a one-on-one or small-group session with a dermatologist (not necessarily a pediatric dermatologist) in which the students were shown and participated in the Sherlock Holmes deductive reasoning approach that a good diagnostician uses as he approaches an unfamiliar skin lesion. Does it seem to be an “inside” or and “outside” job? Is there a sun exposure distribution? Raised or flat? Does it itch? At a minimum, the doctor in training should learn the language used to describe the lesion.

Second, there should be an hour or two of lectures on the diagnosis and management of common dermatologic conditions that require management, with atopic dermatitis and acne leading the short list. This should include a demonstration on how to do skin scraping for fungus, a simple skill that the select committee rejected based on the complaints of its pediatric members.

Finally, there is what one of my instructors called the “Aunt Millie” diagnoses. The scores of common skin findings that one learns by repeated exposure. “If it looks like Aunt Millie, it’s probably Aunt Millie.” This requires abundant exposure to the scores of patients that fill any busy outpatient setting, some of whom who did not even present with a skin complaint. I am sure that technology exists that would allow each student to keep a list of “must-see” findings on his smartphone. This list is updated as he progresses through his training. The program would keep a live data bank of each trainee’s list. When an instructor (not necessarily a dermatologist, could even be a fellow trainee) encounters a common finding, a quick entry in to his or her smartphone could summon for a quick look some or all the trainees whose data bases reflect that they haven’t seen this finding before. Parents and patients are usually impressed when their skin rash gets the special attention of several doctors. If time allows, there may even be a quick 3-minute explanation of the finding. This kind of sharing has been the hallmark of a good training program for years, but now is the time to let our smartphones and computers expand it to fill an embarrassing gap in our education of pediatricians.

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.” E-mail him at [email protected].

Fear of the unknown is driving many pediatricians to refer out their patients with simple and easily managed orthopedic and dermatologic complaints. From several perspectives, this tendency to dump and run is unfortunate. For the patients and their families, a trip to the specialist may be expensive, certainly time consuming, and often comes after a long anxiety provoking and frustrating delay.

For the physician worried about her bottom line or who is being told by her practice administrator to see more patients, sending away a patient with a skin rash that can be diagnosed in 30 seconds (10 seconds in many cases) and explained in 5 minutes is a poor business decision. The office time required to make the referral could be as much as $20 while the 10-minute visit probably generates twice that in revenue.

But, the real tragedy is that, by referring out patients with simple dermatologic and orthopedic complaints, the physician is depriving herself of a source of intellectually stimulating variety. Parents appreciate the effort when their child’s doctor demonstrates that she is a more complete physician.

At least when it comes to gap in the dermatology training of pediatricians, there is a glimmer of a solution on the horizon. As reported by this news organization (“What should pediatricians know about dermatology?” Sept. 2014, page 1) the Society of Pediatric Dermatologists convened a committee of pediatricians, family practitioners, and pediatric dermatologists to determine what a pediatrician’s training in dermatology should include with the goal of creating an online pediatric dermatologic curricular for primary care providers.

Exactly how this training should be structured is yet to be determined. However, while we are waiting, I’m going to offer a few suggestions on what a pediatricians’ training in dermatology should look like. I would divide the training into three segments. The first would be a couple of hours of a one-on-one or small-group session with a dermatologist (not necessarily a pediatric dermatologist) in which the students were shown and participated in the Sherlock Holmes deductive reasoning approach that a good diagnostician uses as he approaches an unfamiliar skin lesion. Does it seem to be an “inside” or and “outside” job? Is there a sun exposure distribution? Raised or flat? Does it itch? At a minimum, the doctor in training should learn the language used to describe the lesion.

Second, there should be an hour or two of lectures on the diagnosis and management of common dermatologic conditions that require management, with atopic dermatitis and acne leading the short list. This should include a demonstration on how to do skin scraping for fungus, a simple skill that the select committee rejected based on the complaints of its pediatric members.

Finally, there is what one of my instructors called the “Aunt Millie” diagnoses. The scores of common skin findings that one learns by repeated exposure. “If it looks like Aunt Millie, it’s probably Aunt Millie.” This requires abundant exposure to the scores of patients that fill any busy outpatient setting, some of whom who did not even present with a skin complaint. I am sure that technology exists that would allow each student to keep a list of “must-see” findings on his smartphone. This list is updated as he progresses through his training. The program would keep a live data bank of each trainee’s list. When an instructor (not necessarily a dermatologist, could even be a fellow trainee) encounters a common finding, a quick entry in to his or her smartphone could summon for a quick look some or all the trainees whose data bases reflect that they haven’t seen this finding before. Parents and patients are usually impressed when their skin rash gets the special attention of several doctors. If time allows, there may even be a quick 3-minute explanation of the finding. This kind of sharing has been the hallmark of a good training program for years, but now is the time to let our smartphones and computers expand it to fill an embarrassing gap in our education of pediatricians.

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.” E-mail him at [email protected].

Fear of the unknown is driving many pediatricians to refer out their patients with simple and easily managed orthopedic and dermatologic complaints. From several perspectives, this tendency to dump and run is unfortunate. For the patients and their families, a trip to the specialist may be expensive, certainly time consuming, and often comes after a long anxiety provoking and frustrating delay.

For the physician worried about her bottom line or who is being told by her practice administrator to see more patients, sending away a patient with a skin rash that can be diagnosed in 30 seconds (10 seconds in many cases) and explained in 5 minutes is a poor business decision. The office time required to make the referral could be as much as $20 while the 10-minute visit probably generates twice that in revenue.

But, the real tragedy is that, by referring out patients with simple dermatologic and orthopedic complaints, the physician is depriving herself of a source of intellectually stimulating variety. Parents appreciate the effort when their child’s doctor demonstrates that she is a more complete physician.

At least when it comes to gap in the dermatology training of pediatricians, there is a glimmer of a solution on the horizon. As reported by this news organization (“What should pediatricians know about dermatology?” Sept. 2014, page 1) the Society of Pediatric Dermatologists convened a committee of pediatricians, family practitioners, and pediatric dermatologists to determine what a pediatrician’s training in dermatology should include with the goal of creating an online pediatric dermatologic curricular for primary care providers.

Exactly how this training should be structured is yet to be determined. However, while we are waiting, I’m going to offer a few suggestions on what a pediatricians’ training in dermatology should look like. I would divide the training into three segments. The first would be a couple of hours of a one-on-one or small-group session with a dermatologist (not necessarily a pediatric dermatologist) in which the students were shown and participated in the Sherlock Holmes deductive reasoning approach that a good diagnostician uses as he approaches an unfamiliar skin lesion. Does it seem to be an “inside” or and “outside” job? Is there a sun exposure distribution? Raised or flat? Does it itch? At a minimum, the doctor in training should learn the language used to describe the lesion.

Second, there should be an hour or two of lectures on the diagnosis and management of common dermatologic conditions that require management, with atopic dermatitis and acne leading the short list. This should include a demonstration on how to do skin scraping for fungus, a simple skill that the select committee rejected based on the complaints of its pediatric members.

Finally, there is what one of my instructors called the “Aunt Millie” diagnoses. The scores of common skin findings that one learns by repeated exposure. “If it looks like Aunt Millie, it’s probably Aunt Millie.” This requires abundant exposure to the scores of patients that fill any busy outpatient setting, some of whom who did not even present with a skin complaint. I am sure that technology exists that would allow each student to keep a list of “must-see” findings on his smartphone. This list is updated as he progresses through his training. The program would keep a live data bank of each trainee’s list. When an instructor (not necessarily a dermatologist, could even be a fellow trainee) encounters a common finding, a quick entry in to his or her smartphone could summon for a quick look some or all the trainees whose data bases reflect that they haven’t seen this finding before. Parents and patients are usually impressed when their skin rash gets the special attention of several doctors. If time allows, there may even be a quick 3-minute explanation of the finding. This kind of sharing has been the hallmark of a good training program for years, but now is the time to let our smartphones and computers expand it to fill an embarrassing gap in our education of pediatricians.

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.” E-mail him at [email protected].

It’s a “Little House on the Prairie” tableau. The whole family is seated around the dinner table enjoying locally grown food that includes an abundance of fruit and vegetables. Animated conversation flows easily around the table, with every family member sharing his or her experiences and opinions. The younger children sit patiently waiting their turn to contribute.

It’s a scenario we all would like to emulate in our own homes because we instinctively assume that a family that dines together produces happy and well-adjusted children. We and many other parents have heard about the studies that suggest children in families that eat together do better in school and are less likely to smoke and drink, become depressed, or develop an eating disorder. And we probably recommend family meals to the families in our practices. The information has become so widely disseminated that family meals have become a gold standard against which parents measure themselves.

But one doesn’t have to scratch the surface too deeply to discover that dining together isn’t all it’s cracked up to be. Other studies that have controlled for a few more variables have shown that family dining is just one of several markers that can identify a well-functioning family. Although a family may eat together only infrequently, if they share other activities together the outcomes for their children are similar to those of families that dine together regularly.

However, the “Little House on the Prairie” image is so indelibly etched into our society’s consciousness that parents (particularly mothers) feel guilty if they can’t have everyone in the family sitting at the dinner table eating a healthy meal, preferably one they have cooked themselves from scratch. A recent ethnographic study by a team of sociologists at North Carolina State University, Raleigh, suggests that attempts by families to have meals together creates enough stress and tension to threaten the alleged benefits the parents had hoped for (“The Joy of Cooking?”, Sarah Bowen, Sinikka Elliot, and Joslyn Brenton, Contexts, Summer 2014, Vol. 13, No. 3, 20-25). The investigators visited 12 working class and poor families and observed their meals. They also interviewed 150 mothers from other families representing a broad range of socioeconomic categories.

The economically challenged mothers felt that cooking healthy meals at home required more time and money than they could afford. Across the board, mothers from all economic strata complained that planning and preparing healthy meals for the family were stressful, particularly when what they had prepared was rejected by some of those at the table. The investigators reported, “We rarely observed a meal in which at least one family member didn’t complain about the food they were served.” It’s not surprising, without immediate positive feedback, that mothers may struggle to see any long-term value.

While eating dinner together may be only one of the markers of a functional family and in spite of this evidence that it can be stressful, it is still an activity worth promoting. However, it must be recast in a more realistic light. Pediatricians can play a role in this transformation from stressful to achievable.

First, we must make it clear that we don’t expect families to eat every evening meal together. Some is better than none. For some families, a big Sunday breakfast may be all that they can work out. Second, we must counter the easy-as-pie attitude pervasive in magazines than anyone should be able to make quick, easy, and healthy meals at home. Again, one bag of chips isn’t going to trash an otherwise reasonably healthy meal. It’s a skill we should have learned as we attempted to ease the minds of the unfortunate women who couldn’t meet the American Academy of Pediatrics’ guidelines of only breast milk for the first 6 months.

Finally, we must help parents learn how to prevent and cope with picky eating. If properly managed, the initial rejection of green beans by a 6-month-old need not be the first step in a downward spiral of “he-won’t-eat-it-so-I-won’t-serve-it.” We must help parents learn to be comfortable with watching their children not eat. And this means helping mothers accept the transition from being a feeder to being merely a presenter of food. It also may mean encouraging parents to adopt a policy that says anyone complaining about what is being served is banished from the room until the meal is over. Initially, this may create a few more stressful meals, but eventually it will result in meals that have become family-building shared experiences.

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

It’s a “Little House on the Prairie” tableau. The whole family is seated around the dinner table enjoying locally grown food that includes an abundance of fruit and vegetables. Animated conversation flows easily around the table, with every family member sharing his or her experiences and opinions. The younger children sit patiently waiting their turn to contribute.

It’s a scenario we all would like to emulate in our own homes because we instinctively assume that a family that dines together produces happy and well-adjusted children. We and many other parents have heard about the studies that suggest children in families that eat together do better in school and are less likely to smoke and drink, become depressed, or develop an eating disorder. And we probably recommend family meals to the families in our practices. The information has become so widely disseminated that family meals have become a gold standard against which parents measure themselves.

But one doesn’t have to scratch the surface too deeply to discover that dining together isn’t all it’s cracked up to be. Other studies that have controlled for a few more variables have shown that family dining is just one of several markers that can identify a well-functioning family. Although a family may eat together only infrequently, if they share other activities together the outcomes for their children are similar to those of families that dine together regularly.

However, the “Little House on the Prairie” image is so indelibly etched into our society’s consciousness that parents (particularly mothers) feel guilty if they can’t have everyone in the family sitting at the dinner table eating a healthy meal, preferably one they have cooked themselves from scratch. A recent ethnographic study by a team of sociologists at North Carolina State University, Raleigh, suggests that attempts by families to have meals together creates enough stress and tension to threaten the alleged benefits the parents had hoped for (“The Joy of Cooking?”, Sarah Bowen, Sinikka Elliot, and Joslyn Brenton, Contexts, Summer 2014, Vol. 13, No. 3, 20-25). The investigators visited 12 working class and poor families and observed their meals. They also interviewed 150 mothers from other families representing a broad range of socioeconomic categories.

The economically challenged mothers felt that cooking healthy meals at home required more time and money than they could afford. Across the board, mothers from all economic strata complained that planning and preparing healthy meals for the family were stressful, particularly when what they had prepared was rejected by some of those at the table. The investigators reported, “We rarely observed a meal in which at least one family member didn’t complain about the food they were served.” It’s not surprising, without immediate positive feedback, that mothers may struggle to see any long-term value.

While eating dinner together may be only one of the markers of a functional family and in spite of this evidence that it can be stressful, it is still an activity worth promoting. However, it must be recast in a more realistic light. Pediatricians can play a role in this transformation from stressful to achievable.

First, we must make it clear that we don’t expect families to eat every evening meal together. Some is better than none. For some families, a big Sunday breakfast may be all that they can work out. Second, we must counter the easy-as-pie attitude pervasive in magazines than anyone should be able to make quick, easy, and healthy meals at home. Again, one bag of chips isn’t going to trash an otherwise reasonably healthy meal. It’s a skill we should have learned as we attempted to ease the minds of the unfortunate women who couldn’t meet the American Academy of Pediatrics’ guidelines of only breast milk for the first 6 months.

Finally, we must help parents learn how to prevent and cope with picky eating. If properly managed, the initial rejection of green beans by a 6-month-old need not be the first step in a downward spiral of “he-won’t-eat-it-so-I-won’t-serve-it.” We must help parents learn to be comfortable with watching their children not eat. And this means helping mothers accept the transition from being a feeder to being merely a presenter of food. It also may mean encouraging parents to adopt a policy that says anyone complaining about what is being served is banished from the room until the meal is over. Initially, this may create a few more stressful meals, but eventually it will result in meals that have become family-building shared experiences.

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

It’s a “Little House on the Prairie” tableau. The whole family is seated around the dinner table enjoying locally grown food that includes an abundance of fruit and vegetables. Animated conversation flows easily around the table, with every family member sharing his or her experiences and opinions. The younger children sit patiently waiting their turn to contribute.

It’s a scenario we all would like to emulate in our own homes because we instinctively assume that a family that dines together produces happy and well-adjusted children. We and many other parents have heard about the studies that suggest children in families that eat together do better in school and are less likely to smoke and drink, become depressed, or develop an eating disorder. And we probably recommend family meals to the families in our practices. The information has become so widely disseminated that family meals have become a gold standard against which parents measure themselves.

But one doesn’t have to scratch the surface too deeply to discover that dining together isn’t all it’s cracked up to be. Other studies that have controlled for a few more variables have shown that family dining is just one of several markers that can identify a well-functioning family. Although a family may eat together only infrequently, if they share other activities together the outcomes for their children are similar to those of families that dine together regularly.

However, the “Little House on the Prairie” image is so indelibly etched into our society’s consciousness that parents (particularly mothers) feel guilty if they can’t have everyone in the family sitting at the dinner table eating a healthy meal, preferably one they have cooked themselves from scratch. A recent ethnographic study by a team of sociologists at North Carolina State University, Raleigh, suggests that attempts by families to have meals together creates enough stress and tension to threaten the alleged benefits the parents had hoped for (“The Joy of Cooking?”, Sarah Bowen, Sinikka Elliot, and Joslyn Brenton, Contexts, Summer 2014, Vol. 13, No. 3, 20-25). The investigators visited 12 working class and poor families and observed their meals. They also interviewed 150 mothers from other families representing a broad range of socioeconomic categories.

The economically challenged mothers felt that cooking healthy meals at home required more time and money than they could afford. Across the board, mothers from all economic strata complained that planning and preparing healthy meals for the family were stressful, particularly when what they had prepared was rejected by some of those at the table. The investigators reported, “We rarely observed a meal in which at least one family member didn’t complain about the food they were served.” It’s not surprising, without immediate positive feedback, that mothers may struggle to see any long-term value.

While eating dinner together may be only one of the markers of a functional family and in spite of this evidence that it can be stressful, it is still an activity worth promoting. However, it must be recast in a more realistic light. Pediatricians can play a role in this transformation from stressful to achievable.

First, we must make it clear that we don’t expect families to eat every evening meal together. Some is better than none. For some families, a big Sunday breakfast may be all that they can work out. Second, we must counter the easy-as-pie attitude pervasive in magazines than anyone should be able to make quick, easy, and healthy meals at home. Again, one bag of chips isn’t going to trash an otherwise reasonably healthy meal. It’s a skill we should have learned as we attempted to ease the minds of the unfortunate women who couldn’t meet the American Academy of Pediatrics’ guidelines of only breast milk for the first 6 months.

Finally, we must help parents learn how to prevent and cope with picky eating. If properly managed, the initial rejection of green beans by a 6-month-old need not be the first step in a downward spiral of “he-won’t-eat-it-so-I-won’t-serve-it.” We must help parents learn to be comfortable with watching their children not eat. And this means helping mothers accept the transition from being a feeder to being merely a presenter of food. It also may mean encouraging parents to adopt a policy that says anyone complaining about what is being served is banished from the room until the meal is over. Initially, this may create a few more stressful meals, but eventually it will result in meals that have become family-building shared experiences.

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

It’s far too early to begin a comprehensive list of the lessons to be learned from the ongoing Ebola situation. Each day brings a new revelation of another misstep or oversight that this frighteningly virulent virus has taken as an opportunity to spread its lethality. However, at the very beginning of the unfortunate debacle in Dallas, the question of who knew what and when became a focus. It is interesting, and not surprising, that the hospital where the index case presented was quick to blame a failure of its electronic health record (EHR) to allow various members of its health team to share information about the patient’s history.

Within days, the hospital retracted this explanation. But, the fact that EHRs were the first scapegoat demonstrates how dissatisfied and distrustful the medical profession is of computerized medical records. Many of us who practice medicine at the first interface with patients feel that we have been sold a bill of goods by the software vendors. Or, at the very least, we see ourselves as lab rats in a nationwide experiment in health information management, a beta-test that is not going well.

One revelation from the Dallas hospital was that the intake nurse took a history to which the doctor had access, but that the doctor took his or her own history during the 10-minute visit. If we ever hear more about the details of this unfortunate clinical encounter, we may discover that it was simply a case of physician seeing the dots but failing to make the correct connections. However, I am going to seize the opportunity to question a situation in health care delivery that troubles me.

If you have ever been a patient anywhere in this country in the last 20 years, you know to expect that you will be asked scores of questions by several people with varying amounts of training and experience. Your interrogation may begin with a clipboard you are handed in the waiting room. It will likely continue with an assistant – someone in a costume that suggests some medical training. Many of the questions will be repeated and repeated and seldom will be used to initiate a dialogue.

If you are lucky, the next person you see will be the “provider,” who may or may not look at the clipboard or computer screen. He or she may ask you some of the same questions again and, if you are very lucky, your answers may result in a conversation during which the provider will learn more about you and what is troubling you. If you are very unlucky, you may be referred to another provider or testing facility where this scenario will be repeated again.

Some of the questions provide necessary demographic information; others are intended to create a distant past history (such as how old you were when your parents misguidedly sent you to have your tonsils and adenoids out) that is unlikely to be of much clinical significance. I accept that this minutiae that has little clinical value is best collected by someone other than the provider. But, I submit that the patient’s chief complaint and the review of systems need only be gathered by one person, the provider. For most simple encounters, certainly those involving pediatric patients and most folks under the age of 50 years, the patient’s description of the present illness should unfold as part of a conversation during which the provider learns more about the patient and why he or she is sitting there in the office.

The notion that having an assistant obtain an extensive review of systems and history of the present illness saves the provider time is flawed. If it does save any time, it is often at the expense of not offering the provider a rich, full-color picture of the patient. Many patients complain that it appears the provider hasn’t read the answers to the questions that they have been asked several times. In cases in which the provider has taken the time to look at the answers, he or she may appear to have “always had his nose in the computer and never looked me in the eye.”

It’s time to reinject a little bit of D.I.Y. (do it yourself) doctoring into our practices. We may never know, but it may be that if one physician in Dallas had been solely responsible for obtaining the patient’s history and review of systems, disaster may have been averted.

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

It’s far too early to begin a comprehensive list of the lessons to be learned from the ongoing Ebola situation. Each day brings a new revelation of another misstep or oversight that this frighteningly virulent virus has taken as an opportunity to spread its lethality. However, at the very beginning of the unfortunate debacle in Dallas, the question of who knew what and when became a focus. It is interesting, and not surprising, that the hospital where the index case presented was quick to blame a failure of its electronic health record (EHR) to allow various members of its health team to share information about the patient’s history.

Within days, the hospital retracted this explanation. But, the fact that EHRs were the first scapegoat demonstrates how dissatisfied and distrustful the medical profession is of computerized medical records. Many of us who practice medicine at the first interface with patients feel that we have been sold a bill of goods by the software vendors. Or, at the very least, we see ourselves as lab rats in a nationwide experiment in health information management, a beta-test that is not going well.

One revelation from the Dallas hospital was that the intake nurse took a history to which the doctor had access, but that the doctor took his or her own history during the 10-minute visit. If we ever hear more about the details of this unfortunate clinical encounter, we may discover that it was simply a case of physician seeing the dots but failing to make the correct connections. However, I am going to seize the opportunity to question a situation in health care delivery that troubles me.

If you have ever been a patient anywhere in this country in the last 20 years, you know to expect that you will be asked scores of questions by several people with varying amounts of training and experience. Your interrogation may begin with a clipboard you are handed in the waiting room. It will likely continue with an assistant – someone in a costume that suggests some medical training. Many of the questions will be repeated and repeated and seldom will be used to initiate a dialogue.

If you are lucky, the next person you see will be the “provider,” who may or may not look at the clipboard or computer screen. He or she may ask you some of the same questions again and, if you are very lucky, your answers may result in a conversation during which the provider will learn more about you and what is troubling you. If you are very unlucky, you may be referred to another provider or testing facility where this scenario will be repeated again.

Some of the questions provide necessary demographic information; others are intended to create a distant past history (such as how old you were when your parents misguidedly sent you to have your tonsils and adenoids out) that is unlikely to be of much clinical significance. I accept that this minutiae that has little clinical value is best collected by someone other than the provider. But, I submit that the patient’s chief complaint and the review of systems need only be gathered by one person, the provider. For most simple encounters, certainly those involving pediatric patients and most folks under the age of 50 years, the patient’s description of the present illness should unfold as part of a conversation during which the provider learns more about the patient and why he or she is sitting there in the office.

The notion that having an assistant obtain an extensive review of systems and history of the present illness saves the provider time is flawed. If it does save any time, it is often at the expense of not offering the provider a rich, full-color picture of the patient. Many patients complain that it appears the provider hasn’t read the answers to the questions that they have been asked several times. In cases in which the provider has taken the time to look at the answers, he or she may appear to have “always had his nose in the computer and never looked me in the eye.”

It’s time to reinject a little bit of D.I.Y. (do it yourself) doctoring into our practices. We may never know, but it may be that if one physician in Dallas had been solely responsible for obtaining the patient’s history and review of systems, disaster may have been averted.

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

It’s far too early to begin a comprehensive list of the lessons to be learned from the ongoing Ebola situation. Each day brings a new revelation of another misstep or oversight that this frighteningly virulent virus has taken as an opportunity to spread its lethality. However, at the very beginning of the unfortunate debacle in Dallas, the question of who knew what and when became a focus. It is interesting, and not surprising, that the hospital where the index case presented was quick to blame a failure of its electronic health record (EHR) to allow various members of its health team to share information about the patient’s history.

Within days, the hospital retracted this explanation. But, the fact that EHRs were the first scapegoat demonstrates how dissatisfied and distrustful the medical profession is of computerized medical records. Many of us who practice medicine at the first interface with patients feel that we have been sold a bill of goods by the software vendors. Or, at the very least, we see ourselves as lab rats in a nationwide experiment in health information management, a beta-test that is not going well.

One revelation from the Dallas hospital was that the intake nurse took a history to which the doctor had access, but that the doctor took his or her own history during the 10-minute visit. If we ever hear more about the details of this unfortunate clinical encounter, we may discover that it was simply a case of physician seeing the dots but failing to make the correct connections. However, I am going to seize the opportunity to question a situation in health care delivery that troubles me.

If you have ever been a patient anywhere in this country in the last 20 years, you know to expect that you will be asked scores of questions by several people with varying amounts of training and experience. Your interrogation may begin with a clipboard you are handed in the waiting room. It will likely continue with an assistant – someone in a costume that suggests some medical training. Many of the questions will be repeated and repeated and seldom will be used to initiate a dialogue.

If you are lucky, the next person you see will be the “provider,” who may or may not look at the clipboard or computer screen. He or she may ask you some of the same questions again and, if you are very lucky, your answers may result in a conversation during which the provider will learn more about you and what is troubling you. If you are very unlucky, you may be referred to another provider or testing facility where this scenario will be repeated again.

Some of the questions provide necessary demographic information; others are intended to create a distant past history (such as how old you were when your parents misguidedly sent you to have your tonsils and adenoids out) that is unlikely to be of much clinical significance. I accept that this minutiae that has little clinical value is best collected by someone other than the provider. But, I submit that the patient’s chief complaint and the review of systems need only be gathered by one person, the provider. For most simple encounters, certainly those involving pediatric patients and most folks under the age of 50 years, the patient’s description of the present illness should unfold as part of a conversation during which the provider learns more about the patient and why he or she is sitting there in the office.

The notion that having an assistant obtain an extensive review of systems and history of the present illness saves the provider time is flawed. If it does save any time, it is often at the expense of not offering the provider a rich, full-color picture of the patient. Many patients complain that it appears the provider hasn’t read the answers to the questions that they have been asked several times. In cases in which the provider has taken the time to look at the answers, he or she may appear to have “always had his nose in the computer and never looked me in the eye.”

It’s time to reinject a little bit of D.I.Y. (do it yourself) doctoring into our practices. We may never know, but it may be that if one physician in Dallas had been solely responsible for obtaining the patient’s history and review of systems, disaster may have been averted.

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

In the wake of the allegations that a star NFL running back abused his 4-year-old son by hitting him with a switch, the debate about spanking and other forms of corporal punishment has reignited. It’s not much of a debate. It’s really just a cacophony of “experts” condemning the act. There are a few dissenting voices who find fault with this particular high-profile event, but still hold the opinion that there are certain situations in which spanking may be an acceptable option. My mother taught me to never say never. But, the occasions in which an open-handed spank on a well-padded bottom are so rare that for all practical purposes, striking a child should not appear on any list of discipline strategies.

However, I’m not sure that spanking should automatically be equated with child abuse. It is seldom effective and should raise a red flag that we are dealing with a parent who needs help in managing his or her child’s behavior, but it’s generally not abuse.

In this recent case, the father has talked about the long lineage of corporal punishment that runs through his family. However, I think that most parents in this country instinctively know that hitting their child is not the best option. They may have learned from experience that it is ineffective and has a very narrow safety margin. But, parents aren’t sure what they should have done.

They may have read magazine articles or heard talking heads on television encouraging parents to engage their misbehaving children in a dialogue to explore their motives. Or, how to condemn the misdeeds without damaging the child’s self-image. To many parents, this kind of advice fells like just so much talk. They have already discovered that one can’t have a meaningful discussion with a child in the throes of a tantrum.

In many cases, the failure of words alone is the natural result of an uncountable number of threats that have never been followed by a consistent consequence. It’s not surprising that parents often fail to follow up on their threats because they lack even the smallest arsenal of safe and effective consequences. They know that corporal punishment is wrong. But, does that mean that discipline must be completely hands off? Is any physical restraint such as a bear hug of a toddler or preschooler in the throes of a tantrum so close to spanking that it could be interpreted as child abuse? Unfortunately, I suspect that there are a few child behavior experts who might say that it is.

What about putting a child in his room for time-out? If he won’t go willingly and has to be carried, is that corporal punishment? If he won’t stay in his room for even 30 seconds unless the door is held shut or latched, is that same as a penal institution’s use of solitary confinement? Although they have a physical component, these restrictions – if done sensibly – are far safer and more effective than hitting a child.

Of course, prevention should be the keystone of any behavior-management strategy. Does the parent understand the spectrum of age-appropriate behavior for his child? Does he accept that his child’s temperament may force him to modify his expectations? Have family dynamics and schedules created situations in which the child feels underappreciated? Is the parent himself in good physical and mental health?

As pediatricians, we must make it clear that we are prepared to help parents to deal with the challenges inherent in setting limits for their children and assist them in creating a strategies of safe consequences to assure that these limits are effective.

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.” E-mail him at [email protected].

In the wake of the allegations that a star NFL running back abused his 4-year-old son by hitting him with a switch, the debate about spanking and other forms of corporal punishment has reignited. It’s not much of a debate. It’s really just a cacophony of “experts” condemning the act. There are a few dissenting voices who find fault with this particular high-profile event, but still hold the opinion that there are certain situations in which spanking may be an acceptable option. My mother taught me to never say never. But, the occasions in which an open-handed spank on a well-padded bottom are so rare that for all practical purposes, striking a child should not appear on any list of discipline strategies.

However, I’m not sure that spanking should automatically be equated with child abuse. It is seldom effective and should raise a red flag that we are dealing with a parent who needs help in managing his or her child’s behavior, but it’s generally not abuse.

In this recent case, the father has talked about the long lineage of corporal punishment that runs through his family. However, I think that most parents in this country instinctively know that hitting their child is not the best option. They may have learned from experience that it is ineffective and has a very narrow safety margin. But, parents aren’t sure what they should have done.

They may have read magazine articles or heard talking heads on television encouraging parents to engage their misbehaving children in a dialogue to explore their motives. Or, how to condemn the misdeeds without damaging the child’s self-image. To many parents, this kind of advice fells like just so much talk. They have already discovered that one can’t have a meaningful discussion with a child in the throes of a tantrum.

In many cases, the failure of words alone is the natural result of an uncountable number of threats that have never been followed by a consistent consequence. It’s not surprising that parents often fail to follow up on their threats because they lack even the smallest arsenal of safe and effective consequences. They know that corporal punishment is wrong. But, does that mean that discipline must be completely hands off? Is any physical restraint such as a bear hug of a toddler or preschooler in the throes of a tantrum so close to spanking that it could be interpreted as child abuse? Unfortunately, I suspect that there are a few child behavior experts who might say that it is.

What about putting a child in his room for time-out? If he won’t go willingly and has to be carried, is that corporal punishment? If he won’t stay in his room for even 30 seconds unless the door is held shut or latched, is that same as a penal institution’s use of solitary confinement? Although they have a physical component, these restrictions – if done sensibly – are far safer and more effective than hitting a child.

Of course, prevention should be the keystone of any behavior-management strategy. Does the parent understand the spectrum of age-appropriate behavior for his child? Does he accept that his child’s temperament may force him to modify his expectations? Have family dynamics and schedules created situations in which the child feels underappreciated? Is the parent himself in good physical and mental health?

As pediatricians, we must make it clear that we are prepared to help parents to deal with the challenges inherent in setting limits for their children and assist them in creating a strategies of safe consequences to assure that these limits are effective.

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.” E-mail him at [email protected].

In the wake of the allegations that a star NFL running back abused his 4-year-old son by hitting him with a switch, the debate about spanking and other forms of corporal punishment has reignited. It’s not much of a debate. It’s really just a cacophony of “experts” condemning the act. There are a few dissenting voices who find fault with this particular high-profile event, but still hold the opinion that there are certain situations in which spanking may be an acceptable option. My mother taught me to never say never. But, the occasions in which an open-handed spank on a well-padded bottom are so rare that for all practical purposes, striking a child should not appear on any list of discipline strategies.

However, I’m not sure that spanking should automatically be equated with child abuse. It is seldom effective and should raise a red flag that we are dealing with a parent who needs help in managing his or her child’s behavior, but it’s generally not abuse.

In this recent case, the father has talked about the long lineage of corporal punishment that runs through his family. However, I think that most parents in this country instinctively know that hitting their child is not the best option. They may have learned from experience that it is ineffective and has a very narrow safety margin. But, parents aren’t sure what they should have done.

They may have read magazine articles or heard talking heads on television encouraging parents to engage their misbehaving children in a dialogue to explore their motives. Or, how to condemn the misdeeds without damaging the child’s self-image. To many parents, this kind of advice fells like just so much talk. They have already discovered that one can’t have a meaningful discussion with a child in the throes of a tantrum.

In many cases, the failure of words alone is the natural result of an uncountable number of threats that have never been followed by a consistent consequence. It’s not surprising that parents often fail to follow up on their threats because they lack even the smallest arsenal of safe and effective consequences. They know that corporal punishment is wrong. But, does that mean that discipline must be completely hands off? Is any physical restraint such as a bear hug of a toddler or preschooler in the throes of a tantrum so close to spanking that it could be interpreted as child abuse? Unfortunately, I suspect that there are a few child behavior experts who might say that it is.

What about putting a child in his room for time-out? If he won’t go willingly and has to be carried, is that corporal punishment? If he won’t stay in his room for even 30 seconds unless the door is held shut or latched, is that same as a penal institution’s use of solitary confinement? Although they have a physical component, these restrictions – if done sensibly – are far safer and more effective than hitting a child.

Of course, prevention should be the keystone of any behavior-management strategy. Does the parent understand the spectrum of age-appropriate behavior for his child? Does he accept that his child’s temperament may force him to modify his expectations? Have family dynamics and schedules created situations in which the child feels underappreciated? Is the parent himself in good physical and mental health?

As pediatricians, we must make it clear that we are prepared to help parents to deal with the challenges inherent in setting limits for their children and assist them in creating a strategies of safe consequences to assure that these limits are effective.

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.” E-mail him at [email protected].

I didn’t have a piggy bank when I was a child. But, I did have a bank. Instead of a porcelain porcine, my coin repository was a fiendishly designed miniature cash register. It would accept pennies, but it only acknowledged the receipt of nickels, dimes, and quarters by revealing the total amount in a window next to the register arm. It was surprisingly complex given that this was many decades prior to the invention of computer chips.

The contents only could be retrieved through a spring-loaded cash drawer that opened when the devilish instrument of torture perceived that it had been fully fed with $10 worth of silver coins. The spring that held the door tight was one tough spring. Trust me, I tried every tool on my dad’s workbench to try to open the door before it was ready. This bank demanded patience, and as a 5-year-old without an allowance, it was painful to wait and then wait and then wait some more until I had accumulated $10.

Once I was in grade school, my classmates and I opened our own accounts with a bank that provided the service to the school. I assume the bank hoped they would harvest a bountiful crop of future customers to whom they could offer mortgages and auto loans. On Wednesdays, we all arrived with our handful of coins, and the teacher recorded the amounts in our little bankbooks. I can’t recall how the interest was calculated, but we all understood that in some mysterious fashion our money was making money.

My diabolical cash register bank and my grade school bank account provided me with an introduction to the concept of saving for the future that has stayed with me to this day. It turns out that those two exercises in financial health may have contributed to my physical health.

In a recent New York Times article ("Your 401(k) Is Healthy. So Maybe You Are, Too." Aug. 16, 2014), I learned about a study published in the journal Psychological Science that found that regular contributors to their 401(k)’s were more likely to take steps to improve their health. Two business school professors at Washington University, St. Louis, studied 200 workers at an industrial laundry business. The subjects were given a baseline health evaluation that included blood tests. When the workers were informed of the results of the evaluation, they also were offered suggestions on how they could address any concerning findings. In follow-up, the regular 401(k) contributors as a group had a 27% improvement in their lab results, while noncontributors continued to suffer health declines (Psychol. Sci. 2014 June 27 [doi: 10.1177/0956797614540467]).

As a pediatrician, wouldn’t you like to know if these healthier investors were born that way? Or, were there factors in their childhood that molded them into adults who will choose to invest in the future, of both their finances and their health? We didn’t talk about money in my family as I was growing up, nor have my wife and I raised the topic with our children. But, we all fund our IRAs and try to lead healthy lifestyles. Were there subliminal messages that my parents conveyed to me and then I passed on to my children?

This country is going through a spell in which saving has slipped out of fashion. This study from St. Louis suggests that it may be linked to our difficulty in getting patients to take better care of themselves. Most of you know that we ask pediatricians to address too many issues at well-child visits. But, maybe we should begin asking every 4-year-old if he or she has a piggy bank. Maybe we even should be giving out piggy banks the way we give out children’s books, and take a moment to discuss the concept of saving. If we can convince this next generation that the future is something worth investing in now, then maybe they will be more receptive to advice about their health when they are adults.

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." E-mail him at [email protected].

I didn’t have a piggy bank when I was a child. But, I did have a bank. Instead of a porcelain porcine, my coin repository was a fiendishly designed miniature cash register. It would accept pennies, but it only acknowledged the receipt of nickels, dimes, and quarters by revealing the total amount in a window next to the register arm. It was surprisingly complex given that this was many decades prior to the invention of computer chips.

The contents only could be retrieved through a spring-loaded cash drawer that opened when the devilish instrument of torture perceived that it had been fully fed with $10 worth of silver coins. The spring that held the door tight was one tough spring. Trust me, I tried every tool on my dad’s workbench to try to open the door before it was ready. This bank demanded patience, and as a 5-year-old without an allowance, it was painful to wait and then wait and then wait some more until I had accumulated $10.

Once I was in grade school, my classmates and I opened our own accounts with a bank that provided the service to the school. I assume the bank hoped they would harvest a bountiful crop of future customers to whom they could offer mortgages and auto loans. On Wednesdays, we all arrived with our handful of coins, and the teacher recorded the amounts in our little bankbooks. I can’t recall how the interest was calculated, but we all understood that in some mysterious fashion our money was making money.

My diabolical cash register bank and my grade school bank account provided me with an introduction to the concept of saving for the future that has stayed with me to this day. It turns out that those two exercises in financial health may have contributed to my physical health.

In a recent New York Times article ("Your 401(k) Is Healthy. So Maybe You Are, Too." Aug. 16, 2014), I learned about a study published in the journal Psychological Science that found that regular contributors to their 401(k)’s were more likely to take steps to improve their health. Two business school professors at Washington University, St. Louis, studied 200 workers at an industrial laundry business. The subjects were given a baseline health evaluation that included blood tests. When the workers were informed of the results of the evaluation, they also were offered suggestions on how they could address any concerning findings. In follow-up, the regular 401(k) contributors as a group had a 27% improvement in their lab results, while noncontributors continued to suffer health declines (Psychol. Sci. 2014 June 27 [doi: 10.1177/0956797614540467]).

As a pediatrician, wouldn’t you like to know if these healthier investors were born that way? Or, were there factors in their childhood that molded them into adults who will choose to invest in the future, of both their finances and their health? We didn’t talk about money in my family as I was growing up, nor have my wife and I raised the topic with our children. But, we all fund our IRAs and try to lead healthy lifestyles. Were there subliminal messages that my parents conveyed to me and then I passed on to my children?

This country is going through a spell in which saving has slipped out of fashion. This study from St. Louis suggests that it may be linked to our difficulty in getting patients to take better care of themselves. Most of you know that we ask pediatricians to address too many issues at well-child visits. But, maybe we should begin asking every 4-year-old if he or she has a piggy bank. Maybe we even should be giving out piggy banks the way we give out children’s books, and take a moment to discuss the concept of saving. If we can convince this next generation that the future is something worth investing in now, then maybe they will be more receptive to advice about their health when they are adults.

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." E-mail him at [email protected].

I didn’t have a piggy bank when I was a child. But, I did have a bank. Instead of a porcelain porcine, my coin repository was a fiendishly designed miniature cash register. It would accept pennies, but it only acknowledged the receipt of nickels, dimes, and quarters by revealing the total amount in a window next to the register arm. It was surprisingly complex given that this was many decades prior to the invention of computer chips.

The contents only could be retrieved through a spring-loaded cash drawer that opened when the devilish instrument of torture perceived that it had been fully fed with $10 worth of silver coins. The spring that held the door tight was one tough spring. Trust me, I tried every tool on my dad’s workbench to try to open the door before it was ready. This bank demanded patience, and as a 5-year-old without an allowance, it was painful to wait and then wait and then wait some more until I had accumulated $10.

Once I was in grade school, my classmates and I opened our own accounts with a bank that provided the service to the school. I assume the bank hoped they would harvest a bountiful crop of future customers to whom they could offer mortgages and auto loans. On Wednesdays, we all arrived with our handful of coins, and the teacher recorded the amounts in our little bankbooks. I can’t recall how the interest was calculated, but we all understood that in some mysterious fashion our money was making money.

My diabolical cash register bank and my grade school bank account provided me with an introduction to the concept of saving for the future that has stayed with me to this day. It turns out that those two exercises in financial health may have contributed to my physical health.

In a recent New York Times article ("Your 401(k) Is Healthy. So Maybe You Are, Too." Aug. 16, 2014), I learned about a study published in the journal Psychological Science that found that regular contributors to their 401(k)’s were more likely to take steps to improve their health. Two business school professors at Washington University, St. Louis, studied 200 workers at an industrial laundry business. The subjects were given a baseline health evaluation that included blood tests. When the workers were informed of the results of the evaluation, they also were offered suggestions on how they could address any concerning findings. In follow-up, the regular 401(k) contributors as a group had a 27% improvement in their lab results, while noncontributors continued to suffer health declines (Psychol. Sci. 2014 June 27 [doi: 10.1177/0956797614540467]).

As a pediatrician, wouldn’t you like to know if these healthier investors were born that way? Or, were there factors in their childhood that molded them into adults who will choose to invest in the future, of both their finances and their health? We didn’t talk about money in my family as I was growing up, nor have my wife and I raised the topic with our children. But, we all fund our IRAs and try to lead healthy lifestyles. Were there subliminal messages that my parents conveyed to me and then I passed on to my children?

This country is going through a spell in which saving has slipped out of fashion. This study from St. Louis suggests that it may be linked to our difficulty in getting patients to take better care of themselves. Most of you know that we ask pediatricians to address too many issues at well-child visits. But, maybe we should begin asking every 4-year-old if he or she has a piggy bank. Maybe we even should be giving out piggy banks the way we give out children’s books, and take a moment to discuss the concept of saving. If we can convince this next generation that the future is something worth investing in now, then maybe they will be more receptive to advice about their health when they are adults.

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." E-mail him at [email protected].