Letters from Maine

Last week I was on the last leg of my usual three-peninsula bicycle ride. Every now and then, I turned my gaze away from the spectacular ocean scenery and looked down at the road ahead. On one of those glances, I saw a small orange, noodlelike object that seemed to move. I braked and pedaled back, and I was surprised to find it was a salamander. I had not seen an orange salamander in nearly 60 years.

There are several reasons for that 6-decade gap. First, as I approached adolescence, I spent increasingly less time poking around in the woods and along the stream beds around my home, natural habitats for salamanders. However, after I finished my training and was a few years into practice, I returned to a woodsier lifestyle, and I spent hours on my hands and knees gardening in what should have been amphibian- and reptilian-friendly environs. I occasionally saw a toad, but never a salamander. While I had been metamorphing into an adult physician, the amphibians had been suffering a serious global decline, the causes of which are still largely unknown and hotly debated.

As I continued on my ride home, my mind drifted back to my childhood and my life with reptiles and amphibians. I spent hours on solitary forays along the streams and ponds in our neighborhood, collecting specimens. Most of my buddies were doing the same. There were tadpoles in Mason jars, toads in an old cracked aquarium I got from the neighbors, and turtles in cardboard boxes and discarded dishpans. Snakes were more of a challenge to catch and house, but every now and then I got lucky. None of the inhabitants of my menagerie ever made it into our house. My mother had a few, but sensible, rules.

These animals weren’t pets. Dog and cats were pets. Amphibians and reptiles were curiosities to be observed and studied, not stroked or petted. Those that survived their brief captivities were returned to the wild.

One could buy small turtles at the pet store. At the circus, there were racks of small perforated cellophane bags for sale, in which small lizards and chameleon were encased. Even as I child I knew those poor little captives were never going to survive for long after their car ride home. No, my friends and I were into wild specimens, caught for scientific study. Although there has been a surge of health warnings about the health risks from handling reptiles and amphibians, none of us ever got salmonella poisoning. Granted, our sample size was small, but our exposure was extensive.

When I arrived home from my ride, I decided to review the Centers for Disease Control and Prevention warnings, and to look a little bit more deeply into the real risks that we had survived from our amphibian and reptilian encounters. The CDC website list of cautions and recommendations are for the most part reasonable ... and not much different from my mother’s house rules and requirements for basic hygiene.

However, I was troubled by one warning that "children younger than 5 years old ... should not handle or touch reptiles, or anything in the area where they live and roam." If my parents had followed this recommendation, they would have set me down me in front of the television and never let me play outside. No more stream side exploring, no more turning over rocks and old logs, no more building fairy houses in the mossy woods.

No distinction is made in the CDC warnings between wild and captive animals. In the little research I could find on the subject, it turns out that wild reptiles are less likely to carry and shed salmonella. A study of red-sliders, a common pet store turtle with a long rap sheet of salmonella outbreaks, could find no salmonella in the wild specimens tested. Another study found that the tadpoles they cultured had no salmonella. One author postulated that the stress of captivity renders reptiles and amphibians more vulnerable to infection, as it has been found to do in other animals.

So it turns out that, as usual, my mother was correct. Go out and explore. Don’t buy at the pet store. Don’t bring ’em into the house. Sadly, even if we are successful in getting kids off the couch and into the woods, they will be less likely to find reptiles and amphibians when they go exploring. But, I am a hopeful guy. Maybe the little orange salamander I saw is the vanguard of an amphibian return.

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].

Last week I was on the last leg of my usual three-peninsula bicycle ride. Every now and then, I turned my gaze away from the spectacular ocean scenery and looked down at the road ahead. On one of those glances, I saw a small orange, noodlelike object that seemed to move. I braked and pedaled back, and I was surprised to find it was a salamander. I had not seen an orange salamander in nearly 60 years.

There are several reasons for that 6-decade gap. First, as I approached adolescence, I spent increasingly less time poking around in the woods and along the stream beds around my home, natural habitats for salamanders. However, after I finished my training and was a few years into practice, I returned to a woodsier lifestyle, and I spent hours on my hands and knees gardening in what should have been amphibian- and reptilian-friendly environs. I occasionally saw a toad, but never a salamander. While I had been metamorphing into an adult physician, the amphibians had been suffering a serious global decline, the causes of which are still largely unknown and hotly debated.

As I continued on my ride home, my mind drifted back to my childhood and my life with reptiles and amphibians. I spent hours on solitary forays along the streams and ponds in our neighborhood, collecting specimens. Most of my buddies were doing the same. There were tadpoles in Mason jars, toads in an old cracked aquarium I got from the neighbors, and turtles in cardboard boxes and discarded dishpans. Snakes were more of a challenge to catch and house, but every now and then I got lucky. None of the inhabitants of my menagerie ever made it into our house. My mother had a few, but sensible, rules.

These animals weren’t pets. Dog and cats were pets. Amphibians and reptiles were curiosities to be observed and studied, not stroked or petted. Those that survived their brief captivities were returned to the wild.

One could buy small turtles at the pet store. At the circus, there were racks of small perforated cellophane bags for sale, in which small lizards and chameleon were encased. Even as I child I knew those poor little captives were never going to survive for long after their car ride home. No, my friends and I were into wild specimens, caught for scientific study. Although there has been a surge of health warnings about the health risks from handling reptiles and amphibians, none of us ever got salmonella poisoning. Granted, our sample size was small, but our exposure was extensive.

When I arrived home from my ride, I decided to review the Centers for Disease Control and Prevention warnings, and to look a little bit more deeply into the real risks that we had survived from our amphibian and reptilian encounters. The CDC website list of cautions and recommendations are for the most part reasonable ... and not much different from my mother’s house rules and requirements for basic hygiene.

However, I was troubled by one warning that "children younger than 5 years old ... should not handle or touch reptiles, or anything in the area where they live and roam." If my parents had followed this recommendation, they would have set me down me in front of the television and never let me play outside. No more stream side exploring, no more turning over rocks and old logs, no more building fairy houses in the mossy woods.

No distinction is made in the CDC warnings between wild and captive animals. In the little research I could find on the subject, it turns out that wild reptiles are less likely to carry and shed salmonella. A study of red-sliders, a common pet store turtle with a long rap sheet of salmonella outbreaks, could find no salmonella in the wild specimens tested. Another study found that the tadpoles they cultured had no salmonella. One author postulated that the stress of captivity renders reptiles and amphibians more vulnerable to infection, as it has been found to do in other animals.

So it turns out that, as usual, my mother was correct. Go out and explore. Don’t buy at the pet store. Don’t bring ’em into the house. Sadly, even if we are successful in getting kids off the couch and into the woods, they will be less likely to find reptiles and amphibians when they go exploring. But, I am a hopeful guy. Maybe the little orange salamander I saw is the vanguard of an amphibian return.

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].

Last week I was on the last leg of my usual three-peninsula bicycle ride. Every now and then, I turned my gaze away from the spectacular ocean scenery and looked down at the road ahead. On one of those glances, I saw a small orange, noodlelike object that seemed to move. I braked and pedaled back, and I was surprised to find it was a salamander. I had not seen an orange salamander in nearly 60 years.

There are several reasons for that 6-decade gap. First, as I approached adolescence, I spent increasingly less time poking around in the woods and along the stream beds around my home, natural habitats for salamanders. However, after I finished my training and was a few years into practice, I returned to a woodsier lifestyle, and I spent hours on my hands and knees gardening in what should have been amphibian- and reptilian-friendly environs. I occasionally saw a toad, but never a salamander. While I had been metamorphing into an adult physician, the amphibians had been suffering a serious global decline, the causes of which are still largely unknown and hotly debated.

As I continued on my ride home, my mind drifted back to my childhood and my life with reptiles and amphibians. I spent hours on solitary forays along the streams and ponds in our neighborhood, collecting specimens. Most of my buddies were doing the same. There were tadpoles in Mason jars, toads in an old cracked aquarium I got from the neighbors, and turtles in cardboard boxes and discarded dishpans. Snakes were more of a challenge to catch and house, but every now and then I got lucky. None of the inhabitants of my menagerie ever made it into our house. My mother had a few, but sensible, rules.

These animals weren’t pets. Dog and cats were pets. Amphibians and reptiles were curiosities to be observed and studied, not stroked or petted. Those that survived their brief captivities were returned to the wild.

One could buy small turtles at the pet store. At the circus, there were racks of small perforated cellophane bags for sale, in which small lizards and chameleon were encased. Even as I child I knew those poor little captives were never going to survive for long after their car ride home. No, my friends and I were into wild specimens, caught for scientific study. Although there has been a surge of health warnings about the health risks from handling reptiles and amphibians, none of us ever got salmonella poisoning. Granted, our sample size was small, but our exposure was extensive.

When I arrived home from my ride, I decided to review the Centers for Disease Control and Prevention warnings, and to look a little bit more deeply into the real risks that we had survived from our amphibian and reptilian encounters. The CDC website list of cautions and recommendations are for the most part reasonable ... and not much different from my mother’s house rules and requirements for basic hygiene.

However, I was troubled by one warning that "children younger than 5 years old ... should not handle or touch reptiles, or anything in the area where they live and roam." If my parents had followed this recommendation, they would have set me down me in front of the television and never let me play outside. No more stream side exploring, no more turning over rocks and old logs, no more building fairy houses in the mossy woods.

No distinction is made in the CDC warnings between wild and captive animals. In the little research I could find on the subject, it turns out that wild reptiles are less likely to carry and shed salmonella. A study of red-sliders, a common pet store turtle with a long rap sheet of salmonella outbreaks, could find no salmonella in the wild specimens tested. Another study found that the tadpoles they cultured had no salmonella. One author postulated that the stress of captivity renders reptiles and amphibians more vulnerable to infection, as it has been found to do in other animals.

So it turns out that, as usual, my mother was correct. Go out and explore. Don’t buy at the pet store. Don’t bring ’em into the house. Sadly, even if we are successful in getting kids off the couch and into the woods, they will be less likely to find reptiles and amphibians when they go exploring. But, I am a hopeful guy. Maybe the little orange salamander I saw is the vanguard of an amphibian return.

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].

Being on call means different things to different people, but it is safe to say that on call is a state that most physicians would avoid if they could. On call obligations are almost always included in advertisements in search of primary care physicians because both recent graduates of training programs and older physicians with their eyes on a retirement horizon put less-taxing call rotations high on their priority lists.

What makes on call so onerous? There is the obvious fact of life that the on call person is working at times when everyone else would rather not work ... nights, weekends, holidays, etc. Being on call can mess with your mind. It smacks of martyrdom for those of us who weren’t cut out to be saints. In places like Maine where warm sunny days are a rarity, being on call can tempt even the most altruistic among us to silently harbor hopes for rain so that we won’t be missing out on as much fun.

Being on call means that you will be fielding questions and interacting with patients and families who haven’t chosen you to be their primary care physician and with whom you are unfamiliar. This mutual unfamiliarity can breed discontent. It certainly doesn’t foster confidence. As on call physicians, you may be forced to invest extra time and effort to establish a therapeutic relationship with patients to whom you are a stranger. The failure to accept this challenge makes you more vulnerable to lawsuit should there be an unexpected outcome.

The physician who has made an effort to educate his patients and families is usually rewarded with fewer calls from them after hours. But, he will be frustrated by calls from patients of physicians who haven’t been as diligent at providing anticipatory guidance.

And, of course, there is always the problem of "But, Doctor Otherguy always just calls in a prescription for eye drops." There isn’t a perfect solution to this problem because physicians don’t all pop out of the same mold. However, discussions at group or hospital meetings, even if just informal chats in front of a chafing dish of overcooked vegetables, can help create some semblance of uniformity and minimize on call friction.

In some ways, a busy on call day that involves scores of calls and patient encounters can be more tolerable than a quiet day sitting at home waiting for the occasional call or beep. When it’s busy, the time passes more quickly, and encounters may generate some income (but never enough to justify the inconvenience and discomfort of being on call). However, when it’s quiet, you can slip into denial that you are on call. You may be tempted to make plans and begin activities that if interrupted could tip you into a cauldron of anger and self-pity.

There is an art to crafting an on call lifestyle that is compatible with a quiet on call. Choosing activities that one enjoys, but can be easily interrupted is a skill that comes after years of painful trial and error. When I was carving birds, I could drop my knives and head out to the office or hospital without a whimper. However, if I was in the middle of painting a project, the process of cleaning up and preserving the mixed color was too frustrating. So I only painted when I was off call.

Choosing which social invitations to accept also can be a challenge. Backyard cookouts are usually easier to exit by disappearing into the foliage. However, a small dinner party is a bad choice when one is on call. Several years ago, I discussed the issue of drinking on call in this column, and clearly, this is a personal decision that we all must make after a period of honest introspection.

Finally, communicating to one’s family the reality of on call and the inevitability of interruptions is of critical importance. Spouses and children can learn that "it-is-what-it-is" as long as we don’t allow ourselves to dip into denial and communicate our frustrations to them. They can learn to build their own lives while we are in that onerous other world of being on call.

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].

Being on call means different things to different people, but it is safe to say that on call is a state that most physicians would avoid if they could. On call obligations are almost always included in advertisements in search of primary care physicians because both recent graduates of training programs and older physicians with their eyes on a retirement horizon put less-taxing call rotations high on their priority lists.

What makes on call so onerous? There is the obvious fact of life that the on call person is working at times when everyone else would rather not work ... nights, weekends, holidays, etc. Being on call can mess with your mind. It smacks of martyrdom for those of us who weren’t cut out to be saints. In places like Maine where warm sunny days are a rarity, being on call can tempt even the most altruistic among us to silently harbor hopes for rain so that we won’t be missing out on as much fun.

Being on call means that you will be fielding questions and interacting with patients and families who haven’t chosen you to be their primary care physician and with whom you are unfamiliar. This mutual unfamiliarity can breed discontent. It certainly doesn’t foster confidence. As on call physicians, you may be forced to invest extra time and effort to establish a therapeutic relationship with patients to whom you are a stranger. The failure to accept this challenge makes you more vulnerable to lawsuit should there be an unexpected outcome.

The physician who has made an effort to educate his patients and families is usually rewarded with fewer calls from them after hours. But, he will be frustrated by calls from patients of physicians who haven’t been as diligent at providing anticipatory guidance.

And, of course, there is always the problem of "But, Doctor Otherguy always just calls in a prescription for eye drops." There isn’t a perfect solution to this problem because physicians don’t all pop out of the same mold. However, discussions at group or hospital meetings, even if just informal chats in front of a chafing dish of overcooked vegetables, can help create some semblance of uniformity and minimize on call friction.

In some ways, a busy on call day that involves scores of calls and patient encounters can be more tolerable than a quiet day sitting at home waiting for the occasional call or beep. When it’s busy, the time passes more quickly, and encounters may generate some income (but never enough to justify the inconvenience and discomfort of being on call). However, when it’s quiet, you can slip into denial that you are on call. You may be tempted to make plans and begin activities that if interrupted could tip you into a cauldron of anger and self-pity.

There is an art to crafting an on call lifestyle that is compatible with a quiet on call. Choosing activities that one enjoys, but can be easily interrupted is a skill that comes after years of painful trial and error. When I was carving birds, I could drop my knives and head out to the office or hospital without a whimper. However, if I was in the middle of painting a project, the process of cleaning up and preserving the mixed color was too frustrating. So I only painted when I was off call.

Choosing which social invitations to accept also can be a challenge. Backyard cookouts are usually easier to exit by disappearing into the foliage. However, a small dinner party is a bad choice when one is on call. Several years ago, I discussed the issue of drinking on call in this column, and clearly, this is a personal decision that we all must make after a period of honest introspection.

Finally, communicating to one’s family the reality of on call and the inevitability of interruptions is of critical importance. Spouses and children can learn that "it-is-what-it-is" as long as we don’t allow ourselves to dip into denial and communicate our frustrations to them. They can learn to build their own lives while we are in that onerous other world of being on call.

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].

Being on call means different things to different people, but it is safe to say that on call is a state that most physicians would avoid if they could. On call obligations are almost always included in advertisements in search of primary care physicians because both recent graduates of training programs and older physicians with their eyes on a retirement horizon put less-taxing call rotations high on their priority lists.

What makes on call so onerous? There is the obvious fact of life that the on call person is working at times when everyone else would rather not work ... nights, weekends, holidays, etc. Being on call can mess with your mind. It smacks of martyrdom for those of us who weren’t cut out to be saints. In places like Maine where warm sunny days are a rarity, being on call can tempt even the most altruistic among us to silently harbor hopes for rain so that we won’t be missing out on as much fun.

Being on call means that you will be fielding questions and interacting with patients and families who haven’t chosen you to be their primary care physician and with whom you are unfamiliar. This mutual unfamiliarity can breed discontent. It certainly doesn’t foster confidence. As on call physicians, you may be forced to invest extra time and effort to establish a therapeutic relationship with patients to whom you are a stranger. The failure to accept this challenge makes you more vulnerable to lawsuit should there be an unexpected outcome.

The physician who has made an effort to educate his patients and families is usually rewarded with fewer calls from them after hours. But, he will be frustrated by calls from patients of physicians who haven’t been as diligent at providing anticipatory guidance.

And, of course, there is always the problem of "But, Doctor Otherguy always just calls in a prescription for eye drops." There isn’t a perfect solution to this problem because physicians don’t all pop out of the same mold. However, discussions at group or hospital meetings, even if just informal chats in front of a chafing dish of overcooked vegetables, can help create some semblance of uniformity and minimize on call friction.

In some ways, a busy on call day that involves scores of calls and patient encounters can be more tolerable than a quiet day sitting at home waiting for the occasional call or beep. When it’s busy, the time passes more quickly, and encounters may generate some income (but never enough to justify the inconvenience and discomfort of being on call). However, when it’s quiet, you can slip into denial that you are on call. You may be tempted to make plans and begin activities that if interrupted could tip you into a cauldron of anger and self-pity.

There is an art to crafting an on call lifestyle that is compatible with a quiet on call. Choosing activities that one enjoys, but can be easily interrupted is a skill that comes after years of painful trial and error. When I was carving birds, I could drop my knives and head out to the office or hospital without a whimper. However, if I was in the middle of painting a project, the process of cleaning up and preserving the mixed color was too frustrating. So I only painted when I was off call.

Choosing which social invitations to accept also can be a challenge. Backyard cookouts are usually easier to exit by disappearing into the foliage. However, a small dinner party is a bad choice when one is on call. Several years ago, I discussed the issue of drinking on call in this column, and clearly, this is a personal decision that we all must make after a period of honest introspection.

Finally, communicating to one’s family the reality of on call and the inevitability of interruptions is of critical importance. Spouses and children can learn that "it-is-what-it-is" as long as we don’t allow ourselves to dip into denial and communicate our frustrations to them. They can learn to build their own lives while we are in that onerous other world of being on call.

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].

Doctors once received a free pass when it came to penmanship. We wrote our prescriptions in Latin. So, it was okay that everything else we scribbled looked like Greek. Referrals and consultations occurred in hospital corridors or doctors’ lounges. Documentation was spotty if it happened at all. Our handwriting was a joke. As long as we could sort of decipher our own scribbling, that was okay. But, the laughing stopped when third-party payers began to ask for proof that they were getting their money’s worth for our services – a proof that they could read.

Dictation with transcription was the obvious solution. It was efficient and produced a legible result. Whatever was lost in transcription resulted in humorous and usually harmless errors. As a card-carrying cheapskate, I typed my own letters. My typos added a kind of homey touch to my communications, and they were certainly more readable than my scrawl.

Dictated and transcribed reports seemed to be a relatively accurate reflection of what had occurred at an office visit, and it kept the payers happy for a while. Most physicians continued to handwrite their office notes. But, it was clear that handwriting was coming off the walls. Insurance companies, the government, quality control folks, and risk assessment managers all wanted more documentation. Computerization seemed to offer a reasonable compromise. The payers got the data, and physicians could take advantage of the efficiencies that electronic records promised.

The software vendors’ sales pitch went like this, "Doc, aren’t most of your visits pretty much the same? History, physical, lab, diagnosis, plan? And, you do pretty much the same exam on everyone? And most of the stuff is normal, right? We’ll show you how to make some templates that will save you a ton of time without all that repetition – done in just a couple of mouse clicks."

So, the templates were made, sometimes with the physician’s help, but often without. And accuracy was sacrificed in the name of legibility and efficiency. The problem is that patients with the same diagnosis aren’t all the same. Their examinations are as different as snowflakes.

What makes a normal ENT exam normal? Is the absence of tonsils worth noting? A bifid uvula? It depends. What does the template include in its definition of normal? More importantly, does the physician remember or did he ever know what his computer considers normal? With a single mouse click, he can create a crisp, laser-printable document that because of its legibility and level of detail appears to be the gospel truth.

But of course, sometimes and certainly too often, it’s not the truth. I recently received an e-mail from a pediatrician who said that he files the EHR records from specialists, emergency departments, and urgent care centers in the "fiction section." He cited an example of a report from a neurologist about a 10-month-old that included a "normal sense of smell" and a warning against driving while taking the medicine prescribed. I can’t top that; maybe you can. But I certainly have received numerous reports that clearly bore little relationship to what had transpired in the clinic or specialist’s office – complete neurologic exams that would have taken 30 minutes to perform, normal tympanic membranes in children with PE (pressure equalization) tubes or cavernous perforations.

Although I frequently complain about the sad state of the physical examination, a bigger problem may be the reliance on the EHR to document the result of the exam. I fear there is little incentive to correct the problem because of the malpractice lawyers’ mantra, "if you didn’t document it, it wasn’t done." Unfortunately, that has come to mean that if it’s legible and detailed, it must be the truth. I would enjoy hearing from you some examples in which you know this clearly wasn’t the case.

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].

Doctors once received a free pass when it came to penmanship. We wrote our prescriptions in Latin. So, it was okay that everything else we scribbled looked like Greek. Referrals and consultations occurred in hospital corridors or doctors’ lounges. Documentation was spotty if it happened at all. Our handwriting was a joke. As long as we could sort of decipher our own scribbling, that was okay. But, the laughing stopped when third-party payers began to ask for proof that they were getting their money’s worth for our services – a proof that they could read.

Dictation with transcription was the obvious solution. It was efficient and produced a legible result. Whatever was lost in transcription resulted in humorous and usually harmless errors. As a card-carrying cheapskate, I typed my own letters. My typos added a kind of homey touch to my communications, and they were certainly more readable than my scrawl.

Dictated and transcribed reports seemed to be a relatively accurate reflection of what had occurred at an office visit, and it kept the payers happy for a while. Most physicians continued to handwrite their office notes. But, it was clear that handwriting was coming off the walls. Insurance companies, the government, quality control folks, and risk assessment managers all wanted more documentation. Computerization seemed to offer a reasonable compromise. The payers got the data, and physicians could take advantage of the efficiencies that electronic records promised.

The software vendors’ sales pitch went like this, "Doc, aren’t most of your visits pretty much the same? History, physical, lab, diagnosis, plan? And, you do pretty much the same exam on everyone? And most of the stuff is normal, right? We’ll show you how to make some templates that will save you a ton of time without all that repetition – done in just a couple of mouse clicks."

So, the templates were made, sometimes with the physician’s help, but often without. And accuracy was sacrificed in the name of legibility and efficiency. The problem is that patients with the same diagnosis aren’t all the same. Their examinations are as different as snowflakes.

What makes a normal ENT exam normal? Is the absence of tonsils worth noting? A bifid uvula? It depends. What does the template include in its definition of normal? More importantly, does the physician remember or did he ever know what his computer considers normal? With a single mouse click, he can create a crisp, laser-printable document that because of its legibility and level of detail appears to be the gospel truth.

But of course, sometimes and certainly too often, it’s not the truth. I recently received an e-mail from a pediatrician who said that he files the EHR records from specialists, emergency departments, and urgent care centers in the "fiction section." He cited an example of a report from a neurologist about a 10-month-old that included a "normal sense of smell" and a warning against driving while taking the medicine prescribed. I can’t top that; maybe you can. But I certainly have received numerous reports that clearly bore little relationship to what had transpired in the clinic or specialist’s office – complete neurologic exams that would have taken 30 minutes to perform, normal tympanic membranes in children with PE (pressure equalization) tubes or cavernous perforations.

Although I frequently complain about the sad state of the physical examination, a bigger problem may be the reliance on the EHR to document the result of the exam. I fear there is little incentive to correct the problem because of the malpractice lawyers’ mantra, "if you didn’t document it, it wasn’t done." Unfortunately, that has come to mean that if it’s legible and detailed, it must be the truth. I would enjoy hearing from you some examples in which you know this clearly wasn’t the case.

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].

Doctors once received a free pass when it came to penmanship. We wrote our prescriptions in Latin. So, it was okay that everything else we scribbled looked like Greek. Referrals and consultations occurred in hospital corridors or doctors’ lounges. Documentation was spotty if it happened at all. Our handwriting was a joke. As long as we could sort of decipher our own scribbling, that was okay. But, the laughing stopped when third-party payers began to ask for proof that they were getting their money’s worth for our services – a proof that they could read.

Dictation with transcription was the obvious solution. It was efficient and produced a legible result. Whatever was lost in transcription resulted in humorous and usually harmless errors. As a card-carrying cheapskate, I typed my own letters. My typos added a kind of homey touch to my communications, and they were certainly more readable than my scrawl.

Dictated and transcribed reports seemed to be a relatively accurate reflection of what had occurred at an office visit, and it kept the payers happy for a while. Most physicians continued to handwrite their office notes. But, it was clear that handwriting was coming off the walls. Insurance companies, the government, quality control folks, and risk assessment managers all wanted more documentation. Computerization seemed to offer a reasonable compromise. The payers got the data, and physicians could take advantage of the efficiencies that electronic records promised.

The software vendors’ sales pitch went like this, "Doc, aren’t most of your visits pretty much the same? History, physical, lab, diagnosis, plan? And, you do pretty much the same exam on everyone? And most of the stuff is normal, right? We’ll show you how to make some templates that will save you a ton of time without all that repetition – done in just a couple of mouse clicks."

So, the templates were made, sometimes with the physician’s help, but often without. And accuracy was sacrificed in the name of legibility and efficiency. The problem is that patients with the same diagnosis aren’t all the same. Their examinations are as different as snowflakes.

What makes a normal ENT exam normal? Is the absence of tonsils worth noting? A bifid uvula? It depends. What does the template include in its definition of normal? More importantly, does the physician remember or did he ever know what his computer considers normal? With a single mouse click, he can create a crisp, laser-printable document that because of its legibility and level of detail appears to be the gospel truth.

But of course, sometimes and certainly too often, it’s not the truth. I recently received an e-mail from a pediatrician who said that he files the EHR records from specialists, emergency departments, and urgent care centers in the "fiction section." He cited an example of a report from a neurologist about a 10-month-old that included a "normal sense of smell" and a warning against driving while taking the medicine prescribed. I can’t top that; maybe you can. But I certainly have received numerous reports that clearly bore little relationship to what had transpired in the clinic or specialist’s office – complete neurologic exams that would have taken 30 minutes to perform, normal tympanic membranes in children with PE (pressure equalization) tubes or cavernous perforations.

Although I frequently complain about the sad state of the physical examination, a bigger problem may be the reliance on the EHR to document the result of the exam. I fear there is little incentive to correct the problem because of the malpractice lawyers’ mantra, "if you didn’t document it, it wasn’t done." Unfortunately, that has come to mean that if it’s legible and detailed, it must be the truth. I would enjoy hearing from you some examples in which you know this clearly wasn’t the case.

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].

During a recent interview on public radio, the CEO of one of Maine’s small hospitals (we have only one hospital that might qualify as not small) observed that the implementation of the Affordable Care Act had already resulted in a decrease in the length of hospital stay and shifted some of the health care utilization away from his hospital. These changes have been reflected in decreased revenue for his institution. This in turn was making it difficult for it to subsidize the outpatient practices it had purchased. He added that over the last several years, outpatient medicine was not sustainable without subsidies.

We hear a lot these days about sustainability, but I had never considered outpatient pediatrics in terms of sustainability. But as I thought more about it, I realized that on several levels that primary care pediatrics had frequently had to adjust when its resources had been unable to keep up with demand.

Fifty years ago, outpatient pediatrics was comfortably sustainable, at least from the profit and loss perspective. Most practices were solo, owner-operated enterprises. Real estate was cheap, and many physicians practiced out of their homes. Overhead costs were low. There were no expensive immunizations to stockpile and then, as now, most pediatricians didn’t require much in the way of high tech equipment to make diagnoses. And certainly there were no costly computer systems to purchase and invest valuable time in learning to operate.

If there was something unsustainable about solo practice, it was the issue of coverage. A surprising number of physicians were able to find a balance between being available to their patients and having enough time and energy for personal restoration and a family. However, over time, an increasing number of physicians found solo practice unsustainable. They simply ran out of emotional capital. The solution was to join together in groups. This provided an answer to the on-call issue and offered the promise of an improved financial balance sheet. Business consultants preached the economy of scale. A group could buy things like toilet paper at a discount, and group members could share support staff, saving on payroll.

But it turns out that seeing patients in an outpatient setting doesn’t follow the rules of economy of scale that apply to a factory cranking out widgets. Physicians practice with different levels of efficiency. They are often independent-minded individuals for whom sharing overhead is a difficult concept to grasp. Sometimes, the result is an unsustainable dynamic in which the overhead of the less-efficient members dictates the overhead for the group. As groups grow bigger, even the physicians who understood how to run an office efficiently surrender control to business managers who may not understand medicine. The overhead continues to rise.

The result can be a tense and unsustainable atmosphere with the business manager saying, "You need to bring in more money by doing more studies and/or seeing more patients." The physicians respond, "But doing more procedures doesn’t translate into good medicine. And neither does seeing too many patients."

Even groups that had been able to craft a sustainable model began to face threat from third-party payers whose preferred provider lists that could change year to year might exclude them. This threat of instability created an unsustainable situation in which a practice could no longer count on having a panel of patients large enough to be profitable. The result was often selling out to an even larger entity.

On top of these scenarios consider the rising cost of college and medical school, and the reality that even the best electronic medical record systems adds at least 5 minutes to the physician’s time investment in each office visit. It is surprising that young people still choose primary care.

Is there hope for this bleak picture of unsustainability? I’m not sure, but there is clearly enough fat and waste in our health care system that a redistribution of resources toward primary care could make it sustainable and improve the quality.

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].

During a recent interview on public radio, the CEO of one of Maine’s small hospitals (we have only one hospital that might qualify as not small) observed that the implementation of the Affordable Care Act had already resulted in a decrease in the length of hospital stay and shifted some of the health care utilization away from his hospital. These changes have been reflected in decreased revenue for his institution. This in turn was making it difficult for it to subsidize the outpatient practices it had purchased. He added that over the last several years, outpatient medicine was not sustainable without subsidies.

We hear a lot these days about sustainability, but I had never considered outpatient pediatrics in terms of sustainability. But as I thought more about it, I realized that on several levels that primary care pediatrics had frequently had to adjust when its resources had been unable to keep up with demand.

Fifty years ago, outpatient pediatrics was comfortably sustainable, at least from the profit and loss perspective. Most practices were solo, owner-operated enterprises. Real estate was cheap, and many physicians practiced out of their homes. Overhead costs were low. There were no expensive immunizations to stockpile and then, as now, most pediatricians didn’t require much in the way of high tech equipment to make diagnoses. And certainly there were no costly computer systems to purchase and invest valuable time in learning to operate.

If there was something unsustainable about solo practice, it was the issue of coverage. A surprising number of physicians were able to find a balance between being available to their patients and having enough time and energy for personal restoration and a family. However, over time, an increasing number of physicians found solo practice unsustainable. They simply ran out of emotional capital. The solution was to join together in groups. This provided an answer to the on-call issue and offered the promise of an improved financial balance sheet. Business consultants preached the economy of scale. A group could buy things like toilet paper at a discount, and group members could share support staff, saving on payroll.

But it turns out that seeing patients in an outpatient setting doesn’t follow the rules of economy of scale that apply to a factory cranking out widgets. Physicians practice with different levels of efficiency. They are often independent-minded individuals for whom sharing overhead is a difficult concept to grasp. Sometimes, the result is an unsustainable dynamic in which the overhead of the less-efficient members dictates the overhead for the group. As groups grow bigger, even the physicians who understood how to run an office efficiently surrender control to business managers who may not understand medicine. The overhead continues to rise.

The result can be a tense and unsustainable atmosphere with the business manager saying, "You need to bring in more money by doing more studies and/or seeing more patients." The physicians respond, "But doing more procedures doesn’t translate into good medicine. And neither does seeing too many patients."

Even groups that had been able to craft a sustainable model began to face threat from third-party payers whose preferred provider lists that could change year to year might exclude them. This threat of instability created an unsustainable situation in which a practice could no longer count on having a panel of patients large enough to be profitable. The result was often selling out to an even larger entity.

On top of these scenarios consider the rising cost of college and medical school, and the reality that even the best electronic medical record systems adds at least 5 minutes to the physician’s time investment in each office visit. It is surprising that young people still choose primary care.

Is there hope for this bleak picture of unsustainability? I’m not sure, but there is clearly enough fat and waste in our health care system that a redistribution of resources toward primary care could make it sustainable and improve the quality.

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].

During a recent interview on public radio, the CEO of one of Maine’s small hospitals (we have only one hospital that might qualify as not small) observed that the implementation of the Affordable Care Act had already resulted in a decrease in the length of hospital stay and shifted some of the health care utilization away from his hospital. These changes have been reflected in decreased revenue for his institution. This in turn was making it difficult for it to subsidize the outpatient practices it had purchased. He added that over the last several years, outpatient medicine was not sustainable without subsidies.

We hear a lot these days about sustainability, but I had never considered outpatient pediatrics in terms of sustainability. But as I thought more about it, I realized that on several levels that primary care pediatrics had frequently had to adjust when its resources had been unable to keep up with demand.

Fifty years ago, outpatient pediatrics was comfortably sustainable, at least from the profit and loss perspective. Most practices were solo, owner-operated enterprises. Real estate was cheap, and many physicians practiced out of their homes. Overhead costs were low. There were no expensive immunizations to stockpile and then, as now, most pediatricians didn’t require much in the way of high tech equipment to make diagnoses. And certainly there were no costly computer systems to purchase and invest valuable time in learning to operate.

If there was something unsustainable about solo practice, it was the issue of coverage. A surprising number of physicians were able to find a balance between being available to their patients and having enough time and energy for personal restoration and a family. However, over time, an increasing number of physicians found solo practice unsustainable. They simply ran out of emotional capital. The solution was to join together in groups. This provided an answer to the on-call issue and offered the promise of an improved financial balance sheet. Business consultants preached the economy of scale. A group could buy things like toilet paper at a discount, and group members could share support staff, saving on payroll.

But it turns out that seeing patients in an outpatient setting doesn’t follow the rules of economy of scale that apply to a factory cranking out widgets. Physicians practice with different levels of efficiency. They are often independent-minded individuals for whom sharing overhead is a difficult concept to grasp. Sometimes, the result is an unsustainable dynamic in which the overhead of the less-efficient members dictates the overhead for the group. As groups grow bigger, even the physicians who understood how to run an office efficiently surrender control to business managers who may not understand medicine. The overhead continues to rise.

The result can be a tense and unsustainable atmosphere with the business manager saying, "You need to bring in more money by doing more studies and/or seeing more patients." The physicians respond, "But doing more procedures doesn’t translate into good medicine. And neither does seeing too many patients."

Even groups that had been able to craft a sustainable model began to face threat from third-party payers whose preferred provider lists that could change year to year might exclude them. This threat of instability created an unsustainable situation in which a practice could no longer count on having a panel of patients large enough to be profitable. The result was often selling out to an even larger entity.

On top of these scenarios consider the rising cost of college and medical school, and the reality that even the best electronic medical record systems adds at least 5 minutes to the physician’s time investment in each office visit. It is surprising that young people still choose primary care.

Is there hope for this bleak picture of unsustainability? I’m not sure, but there is clearly enough fat and waste in our health care system that a redistribution of resources toward primary care could make it sustainable and improve the quality.

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].

Pediatricians tend to be rather easygoing or at least to survive they must learn to appear calm. It is our job to keep our heads when all about us are losing theirs. However, there are certain words that can rattle even the most apparently unflappable pediatrician. For example, when a parent or nurse says a child is "grunting," I begin to get twitchy. I drop everything I’m doing, and that child receives all of my professional attention.

"Lethargic" used to be one of those pulse-quickening words for me, but over the years, it began to lose some of its coronary-tightening qualities. I had always considered "lethargic" to be a rather ominous descriptor. But, people seem to apply the term to children who were merely sleepy, listless, or just plain unmotivated. It took me a decade or two of rushing to bedsides or opening the office in the middle of the night to see a "lethargic" child who turned out, in my vocabulary, to be just a bit "droopy" or unusually quiet but not seriously ill.

I found that to minimize the number of false alarms, I just needed to ask more questions to flesh out the child’s appearance and determine what had prompted the caller to use the "L" word. "Lethargy" seemed to mean too many different things to too many people to be of much use as a descriptor. Nonetheless, I still feel twinges of fear when I hear the word. When I encounter it in a nurse’s progress note, I always feel the need to counter it in my own note by providing a more specific description of the child’s condition.

A recent study in Pediatric Emergency Care (Webb, T. et al. 2014;30: 151-6) mirrors my experience with "lethargy." In a retrospective chart review of 272 patients aged 0-6 months, the investigators found that only 12.5% of the children who were described as having poor feeding or lethargy had a condition that required intervention. Infants who were feverish, hypothermic, or less than 35 weeks’ gestation were excluded from the study. However, infants that were described as appearing "ill" were much more likely to require intervention.

So what does a pediatrician mean when she or he describes a child as "ill looking" or "sick looking?" That is the $64,000 question (actually $560,000 in today’s dollars). We could generate a list that include abnormal vital signs, a spectrum of colors from pale to blue, and some neurologic observations, but a child looking sick or ill (and here I mean sick at level of needing immediate attention and probably intervention) is a gestalt.

Knowing when a child is seriously ill is a skill that is difficult to teach and can only come with seeing scores, and scores, and scores of children with a variety of conditions. The physician in training may not necessarily be directly involved with the care of those children, but she or he should have been close enough long enough to feel, see, smell, and hear what is going on. House officers and students should be encouraged to seek out as many of these chances to see sick and well children as they can to sharpen this skill. A mentor may help by pointing out a certain finding or collection of findings that are useful in forming the impression that this is a seriously ill child. But, it is a mistake to focus on one or two observations and not to emphasize the total picture. The ability to correctly determine that a child is desperately ill requires that the physician be able to see the trees, but not ignore the forest.

While most parents have that special sense when things are terribly wrong, we have all witnessed tragic situations when a focus on the thermometer has blurred the bigger picture that the child is desperately ill. Unfortunately, I have seen cases when a physician or nurse has been similarly deceived by a normal vital sign or laboratory result and failed to step back, look at the child, and say to themselves, "But, this child looks sick."

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].

Pediatricians tend to be rather easygoing or at least to survive they must learn to appear calm. It is our job to keep our heads when all about us are losing theirs. However, there are certain words that can rattle even the most apparently unflappable pediatrician. For example, when a parent or nurse says a child is "grunting," I begin to get twitchy. I drop everything I’m doing, and that child receives all of my professional attention.

"Lethargic" used to be one of those pulse-quickening words for me, but over the years, it began to lose some of its coronary-tightening qualities. I had always considered "lethargic" to be a rather ominous descriptor. But, people seem to apply the term to children who were merely sleepy, listless, or just plain unmotivated. It took me a decade or two of rushing to bedsides or opening the office in the middle of the night to see a "lethargic" child who turned out, in my vocabulary, to be just a bit "droopy" or unusually quiet but not seriously ill.

I found that to minimize the number of false alarms, I just needed to ask more questions to flesh out the child’s appearance and determine what had prompted the caller to use the "L" word. "Lethargy" seemed to mean too many different things to too many people to be of much use as a descriptor. Nonetheless, I still feel twinges of fear when I hear the word. When I encounter it in a nurse’s progress note, I always feel the need to counter it in my own note by providing a more specific description of the child’s condition.

A recent study in Pediatric Emergency Care (Webb, T. et al. 2014;30: 151-6) mirrors my experience with "lethargy." In a retrospective chart review of 272 patients aged 0-6 months, the investigators found that only 12.5% of the children who were described as having poor feeding or lethargy had a condition that required intervention. Infants who were feverish, hypothermic, or less than 35 weeks’ gestation were excluded from the study. However, infants that were described as appearing "ill" were much more likely to require intervention.

So what does a pediatrician mean when she or he describes a child as "ill looking" or "sick looking?" That is the $64,000 question (actually $560,000 in today’s dollars). We could generate a list that include abnormal vital signs, a spectrum of colors from pale to blue, and some neurologic observations, but a child looking sick or ill (and here I mean sick at level of needing immediate attention and probably intervention) is a gestalt.

Knowing when a child is seriously ill is a skill that is difficult to teach and can only come with seeing scores, and scores, and scores of children with a variety of conditions. The physician in training may not necessarily be directly involved with the care of those children, but she or he should have been close enough long enough to feel, see, smell, and hear what is going on. House officers and students should be encouraged to seek out as many of these chances to see sick and well children as they can to sharpen this skill. A mentor may help by pointing out a certain finding or collection of findings that are useful in forming the impression that this is a seriously ill child. But, it is a mistake to focus on one or two observations and not to emphasize the total picture. The ability to correctly determine that a child is desperately ill requires that the physician be able to see the trees, but not ignore the forest.

While most parents have that special sense when things are terribly wrong, we have all witnessed tragic situations when a focus on the thermometer has blurred the bigger picture that the child is desperately ill. Unfortunately, I have seen cases when a physician or nurse has been similarly deceived by a normal vital sign or laboratory result and failed to step back, look at the child, and say to themselves, "But, this child looks sick."

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].

Pediatricians tend to be rather easygoing or at least to survive they must learn to appear calm. It is our job to keep our heads when all about us are losing theirs. However, there are certain words that can rattle even the most apparently unflappable pediatrician. For example, when a parent or nurse says a child is "grunting," I begin to get twitchy. I drop everything I’m doing, and that child receives all of my professional attention.

"Lethargic" used to be one of those pulse-quickening words for me, but over the years, it began to lose some of its coronary-tightening qualities. I had always considered "lethargic" to be a rather ominous descriptor. But, people seem to apply the term to children who were merely sleepy, listless, or just plain unmotivated. It took me a decade or two of rushing to bedsides or opening the office in the middle of the night to see a "lethargic" child who turned out, in my vocabulary, to be just a bit "droopy" or unusually quiet but not seriously ill.

I found that to minimize the number of false alarms, I just needed to ask more questions to flesh out the child’s appearance and determine what had prompted the caller to use the "L" word. "Lethargy" seemed to mean too many different things to too many people to be of much use as a descriptor. Nonetheless, I still feel twinges of fear when I hear the word. When I encounter it in a nurse’s progress note, I always feel the need to counter it in my own note by providing a more specific description of the child’s condition.

A recent study in Pediatric Emergency Care (Webb, T. et al. 2014;30: 151-6) mirrors my experience with "lethargy." In a retrospective chart review of 272 patients aged 0-6 months, the investigators found that only 12.5% of the children who were described as having poor feeding or lethargy had a condition that required intervention. Infants who were feverish, hypothermic, or less than 35 weeks’ gestation were excluded from the study. However, infants that were described as appearing "ill" were much more likely to require intervention.

So what does a pediatrician mean when she or he describes a child as "ill looking" or "sick looking?" That is the $64,000 question (actually $560,000 in today’s dollars). We could generate a list that include abnormal vital signs, a spectrum of colors from pale to blue, and some neurologic observations, but a child looking sick or ill (and here I mean sick at level of needing immediate attention and probably intervention) is a gestalt.

Knowing when a child is seriously ill is a skill that is difficult to teach and can only come with seeing scores, and scores, and scores of children with a variety of conditions. The physician in training may not necessarily be directly involved with the care of those children, but she or he should have been close enough long enough to feel, see, smell, and hear what is going on. House officers and students should be encouraged to seek out as many of these chances to see sick and well children as they can to sharpen this skill. A mentor may help by pointing out a certain finding or collection of findings that are useful in forming the impression that this is a seriously ill child. But, it is a mistake to focus on one or two observations and not to emphasize the total picture. The ability to correctly determine that a child is desperately ill requires that the physician be able to see the trees, but not ignore the forest.

While most parents have that special sense when things are terribly wrong, we have all witnessed tragic situations when a focus on the thermometer has blurred the bigger picture that the child is desperately ill. Unfortunately, I have seen cases when a physician or nurse has been similarly deceived by a normal vital sign or laboratory result and failed to step back, look at the child, and say to themselves, "But, this child looks sick."

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 weeks ago, I received a few video clips of my granddaughter’s 5th birthday party. Although my daughter had loosely scripted a fairy-themed event, she was wise enough to have stepped back and let the children freewheel. What I watched was a half a dozen 4- and 5-year-old girls wearing their self-decorated fairy wings running and running and running in a tree-shaded park jumping (or in their minds flying) on and off a small stage yelling "Calling all fairies, calling all fairies." Forty minutes of nonstop running and jumping, a cupcake and small scoop of ice cream, and that was it ... the perfect party.

No one was coaching these little cherubs to run. No one had set up traffic cones or a finish line. No ribbons or plastic medals were awarded in recognition of their participation. They were running for the sheer pleasure of activity, driven by what is probably an inborn urge to move. Every toddler I have known functions like a tightly wound windup toy ready to hit the ground running when placed down on the straight flat surface of a shopping mall or airport concourse.

It appears that this drive to run is not unique to young Homo sapiens. Two Dutch scientists set up a small running wheel in a wooded setting and then using motion sensors and remote video recorders watched what happened (Proc. R. Soc. B 2014 [doi:10.1098/rspb.2014.0210]). It turns out that wild mice enjoy running, spending from 1 to 18 minutes freewheeling. Frogs also occasionally jumped on and off the wheel, but running was obviously not their thing.

While the drive to run seems to be bred into us, unfortunately it is an urge that is easily extinguished. One needs only to watch a physical education class of sixth graders being asked to do a 1-mile run/walk to become painfully aware that too many children can no longer run, let alone do it for the pure enjoyment. How did such a strong drive disappear?

I wonder what would have happened if the Dutch investigators had put a smart phone with a colorful app running next to the wheel. How many of the mice have chosen to sit down and watch the screen instead of climbing on for a run? If a small electric train running in a circle had been placed next in the environment, would some of the mice have preferred to hop on for a ride? Or suppose they had played a recording of an older mouse squeaking a warning call that was the rodent equivalent of "Don’t climb on that; you could hurt yourself"?

I certainly believe (and there is animal evidence to support) that certain individuals inherit a preference for a sedentary lifestyle. However, I am equally sure that we have created a society that provides an abundance of powerfully attractive sedentary options to remaining active. In my mind, first and foremost among these attractions is color television (I don’t recall black and white TV being all that exciting). The magnetic attraction of colorful and active video images is difficult for anyone to resist. As pediatricians, we must continue to preach the word about the health hazards associated with screen time. And, I would add again my plea for us to spend less energy on worrying about what’s on the screen and instead emphasize the need to keep the exposure time down.

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 weeks ago, I received a few video clips of my granddaughter’s 5th birthday party. Although my daughter had loosely scripted a fairy-themed event, she was wise enough to have stepped back and let the children freewheel. What I watched was a half a dozen 4- and 5-year-old girls wearing their self-decorated fairy wings running and running and running in a tree-shaded park jumping (or in their minds flying) on and off a small stage yelling "Calling all fairies, calling all fairies." Forty minutes of nonstop running and jumping, a cupcake and small scoop of ice cream, and that was it ... the perfect party.

No one was coaching these little cherubs to run. No one had set up traffic cones or a finish line. No ribbons or plastic medals were awarded in recognition of their participation. They were running for the sheer pleasure of activity, driven by what is probably an inborn urge to move. Every toddler I have known functions like a tightly wound windup toy ready to hit the ground running when placed down on the straight flat surface of a shopping mall or airport concourse.

It appears that this drive to run is not unique to young Homo sapiens. Two Dutch scientists set up a small running wheel in a wooded setting and then using motion sensors and remote video recorders watched what happened (Proc. R. Soc. B 2014 [doi:10.1098/rspb.2014.0210]). It turns out that wild mice enjoy running, spending from 1 to 18 minutes freewheeling. Frogs also occasionally jumped on and off the wheel, but running was obviously not their thing.

While the drive to run seems to be bred into us, unfortunately it is an urge that is easily extinguished. One needs only to watch a physical education class of sixth graders being asked to do a 1-mile run/walk to become painfully aware that too many children can no longer run, let alone do it for the pure enjoyment. How did such a strong drive disappear?

I wonder what would have happened if the Dutch investigators had put a smart phone with a colorful app running next to the wheel. How many of the mice have chosen to sit down and watch the screen instead of climbing on for a run? If a small electric train running in a circle had been placed next in the environment, would some of the mice have preferred to hop on for a ride? Or suppose they had played a recording of an older mouse squeaking a warning call that was the rodent equivalent of "Don’t climb on that; you could hurt yourself"?

I certainly believe (and there is animal evidence to support) that certain individuals inherit a preference for a sedentary lifestyle. However, I am equally sure that we have created a society that provides an abundance of powerfully attractive sedentary options to remaining active. In my mind, first and foremost among these attractions is color television (I don’t recall black and white TV being all that exciting). The magnetic attraction of colorful and active video images is difficult for anyone to resist. As pediatricians, we must continue to preach the word about the health hazards associated with screen time. And, I would add again my plea for us to spend less energy on worrying about what’s on the screen and instead emphasize the need to keep the exposure time down.

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 weeks ago, I received a few video clips of my granddaughter’s 5th birthday party. Although my daughter had loosely scripted a fairy-themed event, she was wise enough to have stepped back and let the children freewheel. What I watched was a half a dozen 4- and 5-year-old girls wearing their self-decorated fairy wings running and running and running in a tree-shaded park jumping (or in their minds flying) on and off a small stage yelling "Calling all fairies, calling all fairies." Forty minutes of nonstop running and jumping, a cupcake and small scoop of ice cream, and that was it ... the perfect party.

No one was coaching these little cherubs to run. No one had set up traffic cones or a finish line. No ribbons or plastic medals were awarded in recognition of their participation. They were running for the sheer pleasure of activity, driven by what is probably an inborn urge to move. Every toddler I have known functions like a tightly wound windup toy ready to hit the ground running when placed down on the straight flat surface of a shopping mall or airport concourse.

It appears that this drive to run is not unique to young Homo sapiens. Two Dutch scientists set up a small running wheel in a wooded setting and then using motion sensors and remote video recorders watched what happened (Proc. R. Soc. B 2014 [doi:10.1098/rspb.2014.0210]). It turns out that wild mice enjoy running, spending from 1 to 18 minutes freewheeling. Frogs also occasionally jumped on and off the wheel, but running was obviously not their thing.

While the drive to run seems to be bred into us, unfortunately it is an urge that is easily extinguished. One needs only to watch a physical education class of sixth graders being asked to do a 1-mile run/walk to become painfully aware that too many children can no longer run, let alone do it for the pure enjoyment. How did such a strong drive disappear?

I wonder what would have happened if the Dutch investigators had put a smart phone with a colorful app running next to the wheel. How many of the mice have chosen to sit down and watch the screen instead of climbing on for a run? If a small electric train running in a circle had been placed next in the environment, would some of the mice have preferred to hop on for a ride? Or suppose they had played a recording of an older mouse squeaking a warning call that was the rodent equivalent of "Don’t climb on that; you could hurt yourself"?

I certainly believe (and there is animal evidence to support) that certain individuals inherit a preference for a sedentary lifestyle. However, I am equally sure that we have created a society that provides an abundance of powerfully attractive sedentary options to remaining active. In my mind, first and foremost among these attractions is color television (I don’t recall black and white TV being all that exciting). The magnetic attraction of colorful and active video images is difficult for anyone to resist. As pediatricians, we must continue to preach the word about the health hazards associated with screen time. And, I would add again my plea for us to spend less energy on worrying about what’s on the screen and instead emphasize the need to keep the exposure time down.

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].

Thirty-five years ago my wife was the volunteer coordinator at the grade school down the street. She seldom had to do much coordinating because there weren’t many volunteers. My daughter-in-law currently holds the same position in the same school. And although she would always like to have additional volunteers, she manages many more than my wife ever did.

When I was a child, if I saw a parent in the school it was a bad sign. Either someone had gotten sick or some poor soul had done something that had put him on the path to expulsion. School was a treasured parent-free zone, my own little social laboratory where I could experiment with the person I was going to be when I grew up.

But now parental involvement is viewed as one of the keystones of child rearing. Parents feel they need to be active participants in their child’s schooling, and this has increased parental involvement in the classroom. This would seem to be a good thing, propelled partly by a genuine desire to help schools where resources are being stretched thin by budgetary constraints. But occasionally, volunteering is a misguided attempt to deal with unresolved, sometimes bidirectional, separation anxiety.

And I fear that sometimes volunteering is a cover story for spying. Most children are stingy with stories about their school days. "What happened in school today?" The typical response is "nothing special." Unless of course, "Rachel vomited on her desk during math this morning."

I have always suspected that parental involvement is a double-edged sword. And some recent work by two sociology professors – Keith Robinson of the University of Texas in Austin and Angel L. Harris of Duke University in Durham, N.C. – suggests that the blade more often cuts in an unintended direction ("Parental Involvement Is Overrated" – New York Times Sunday Review, April 13, 2014). Their longitudinal study involved a survey of American families in the 1980’s to the 2000’s that looked at demographics, ethnicity, socioeconomic status, and levels of parental engagement (not just classroom volunteering) in relation to academic outcomes.

What they discovered was that in two groups divided by ethnicity and race but with similar levels of parental involvement, the children whose families valued education less highly did less well academically. The investigators also discovered that most forms of parental involvement "yielded no benefit to children’s test scores or grades regardless of racial or ethnic background or socioeconomic standing." In fact, when involvement did make a difference, it was more often negative.

Although most of us believe that regular reading to elementary school children has a positive effect, these authors found that while white and Hispanic children benefited, blacks did not. Obviously, parental involvement is a complex factor in children’s lives, and we must be careful about making assumptions before we make blanket recommendations. For example "consistent help with homework never improved test scores or grades," and in fact, regular help usually resulted in poorer performance.

However, parents can have a positive effect when they make it clear from the beginning that they value education and expect the child will go to college. Requesting a particular teacher helps as does discussing the child’s school activities at home. However, parents must expect that most of these discussions will be short.

I suspect that the professors would agree with my suggestion to parents that if they would like to help in the schools, they should volunteer in a classroom other than their own child’s, or even better, run the copier machine in the office or sweep out the equipment room in the gym.

Most of us cringe when we hear about extreme cases of helicopter parenting when parents rent apartments near campuses to be close to their college age children. But, few of us would have predicted the findings of this study that suggest parental involvement in younger children’s school lives is not only ineffective but often detrimental. As pediatricians, we can help parents do the counterintuitive thing and as these authors suggest, "set the stage and then get off."

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].

Thirty-five years ago my wife was the volunteer coordinator at the grade school down the street. She seldom had to do much coordinating because there weren’t many volunteers. My daughter-in-law currently holds the same position in the same school. And although she would always like to have additional volunteers, she manages many more than my wife ever did.

When I was a child, if I saw a parent in the school it was a bad sign. Either someone had gotten sick or some poor soul had done something that had put him on the path to expulsion. School was a treasured parent-free zone, my own little social laboratory where I could experiment with the person I was going to be when I grew up.

But now parental involvement is viewed as one of the keystones of child rearing. Parents feel they need to be active participants in their child’s schooling, and this has increased parental involvement in the classroom. This would seem to be a good thing, propelled partly by a genuine desire to help schools where resources are being stretched thin by budgetary constraints. But occasionally, volunteering is a misguided attempt to deal with unresolved, sometimes bidirectional, separation anxiety.

And I fear that sometimes volunteering is a cover story for spying. Most children are stingy with stories about their school days. "What happened in school today?" The typical response is "nothing special." Unless of course, "Rachel vomited on her desk during math this morning."

I have always suspected that parental involvement is a double-edged sword. And some recent work by two sociology professors – Keith Robinson of the University of Texas in Austin and Angel L. Harris of Duke University in Durham, N.C. – suggests that the blade more often cuts in an unintended direction ("Parental Involvement Is Overrated" – New York Times Sunday Review, April 13, 2014). Their longitudinal study involved a survey of American families in the 1980’s to the 2000’s that looked at demographics, ethnicity, socioeconomic status, and levels of parental engagement (not just classroom volunteering) in relation to academic outcomes.

What they discovered was that in two groups divided by ethnicity and race but with similar levels of parental involvement, the children whose families valued education less highly did less well academically. The investigators also discovered that most forms of parental involvement "yielded no benefit to children’s test scores or grades regardless of racial or ethnic background or socioeconomic standing." In fact, when involvement did make a difference, it was more often negative.

Although most of us believe that regular reading to elementary school children has a positive effect, these authors found that while white and Hispanic children benefited, blacks did not. Obviously, parental involvement is a complex factor in children’s lives, and we must be careful about making assumptions before we make blanket recommendations. For example "consistent help with homework never improved test scores or grades," and in fact, regular help usually resulted in poorer performance.

However, parents can have a positive effect when they make it clear from the beginning that they value education and expect the child will go to college. Requesting a particular teacher helps as does discussing the child’s school activities at home. However, parents must expect that most of these discussions will be short.

I suspect that the professors would agree with my suggestion to parents that if they would like to help in the schools, they should volunteer in a classroom other than their own child’s, or even better, run the copier machine in the office or sweep out the equipment room in the gym.

Most of us cringe when we hear about extreme cases of helicopter parenting when parents rent apartments near campuses to be close to their college age children. But, few of us would have predicted the findings of this study that suggest parental involvement in younger children’s school lives is not only ineffective but often detrimental. As pediatricians, we can help parents do the counterintuitive thing and as these authors suggest, "set the stage and then get off."

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].

Thirty-five years ago my wife was the volunteer coordinator at the grade school down the street. She seldom had to do much coordinating because there weren’t many volunteers. My daughter-in-law currently holds the same position in the same school. And although she would always like to have additional volunteers, she manages many more than my wife ever did.

When I was a child, if I saw a parent in the school it was a bad sign. Either someone had gotten sick or some poor soul had done something that had put him on the path to expulsion. School was a treasured parent-free zone, my own little social laboratory where I could experiment with the person I was going to be when I grew up.

But now parental involvement is viewed as one of the keystones of child rearing. Parents feel they need to be active participants in their child’s schooling, and this has increased parental involvement in the classroom. This would seem to be a good thing, propelled partly by a genuine desire to help schools where resources are being stretched thin by budgetary constraints. But occasionally, volunteering is a misguided attempt to deal with unresolved, sometimes bidirectional, separation anxiety.

And I fear that sometimes volunteering is a cover story for spying. Most children are stingy with stories about their school days. "What happened in school today?" The typical response is "nothing special." Unless of course, "Rachel vomited on her desk during math this morning."

I have always suspected that parental involvement is a double-edged sword. And some recent work by two sociology professors – Keith Robinson of the University of Texas in Austin and Angel L. Harris of Duke University in Durham, N.C. – suggests that the blade more often cuts in an unintended direction ("Parental Involvement Is Overrated" – New York Times Sunday Review, April 13, 2014). Their longitudinal study involved a survey of American families in the 1980’s to the 2000’s that looked at demographics, ethnicity, socioeconomic status, and levels of parental engagement (not just classroom volunteering) in relation to academic outcomes.

What they discovered was that in two groups divided by ethnicity and race but with similar levels of parental involvement, the children whose families valued education less highly did less well academically. The investigators also discovered that most forms of parental involvement "yielded no benefit to children’s test scores or grades regardless of racial or ethnic background or socioeconomic standing." In fact, when involvement did make a difference, it was more often negative.

Although most of us believe that regular reading to elementary school children has a positive effect, these authors found that while white and Hispanic children benefited, blacks did not. Obviously, parental involvement is a complex factor in children’s lives, and we must be careful about making assumptions before we make blanket recommendations. For example "consistent help with homework never improved test scores or grades," and in fact, regular help usually resulted in poorer performance.

However, parents can have a positive effect when they make it clear from the beginning that they value education and expect the child will go to college. Requesting a particular teacher helps as does discussing the child’s school activities at home. However, parents must expect that most of these discussions will be short.

I suspect that the professors would agree with my suggestion to parents that if they would like to help in the schools, they should volunteer in a classroom other than their own child’s, or even better, run the copier machine in the office or sweep out the equipment room in the gym.

Most of us cringe when we hear about extreme cases of helicopter parenting when parents rent apartments near campuses to be close to their college age children. But, few of us would have predicted the findings of this study that suggest parental involvement in younger children’s school lives is not only ineffective but often detrimental. As pediatricians, we can help parents do the counterintuitive thing and as these authors suggest, "set the stage and then get off."

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].

Let’s be honest. Although pediatricians invest most of their days, some of their nights, and untold cockles of heartfelt concern trying to keep their patients well, there is very little evidence that what we do actually makes a difference. The one shining exception comes when we administer immunizations. This humbling fact makes the problem of vaccine refusal so frustrating and depressing.

I have always considered the increasing number of parents who refuse or who are hesitant about immunization just another example of decay in our nation’s educational system. How could anyone who was even half awake in American History class not be aware of the toll that infectious diseases took on the children born before 1900? Diseases that are now preventable. Do introductory science courses even touch on the basic mechanisms that underlie immunizations? High school students may not be expected to know that John Enders was the lead investigator in the development of the measles vaccine, but someone should have told them the story of Jonas Salk and polio.

Like many of you, I assumed that if I could just do a better job of filling in the gaps in our educational system that vaccine-hesitant parents would see the light. If I could share with parents even a small fraction of what I know about the efficacy of vaccines they couldn’t possibly refuse to immunize their children. However, after 40 years of failed attempts and frustration, I have begun to doubt my communication skills.

Some work by Brendan Nyhan, Ph.D., a government professor at Dartmouth College, and his colleagues suggests that my attempts at education were destined to fail. ("Effective Messages in Vaccine Promotion: A Randomized Trial," [Pediatrics 2014;133:1-8]). Aware that people frequently resist information that contradicts their views, these investigators began a small study. Nearly 1,800 parents were randomized to receive one of four messages supporting the value of MMR vaccine from textual excerpts to pictures of children with the diseases prevented by the vaccine.

What they discovered was that parents who had "mixed or negative feelings" about the vaccine were actually less likely to say that they would choose to vaccinate a future child after they had been presented with literature refuting the MMR-autism link. While these families were less likely to accept the vaccine-autism link, the informational materials had prompted them to consider other reasons that supported their negative views about vaccines.

Although other studies have found that parents still consider their children’s doctor to be the most trusted source of vaccine information, it appears that education as we understand it may not be our best tool. In fact, it may even be counterproductive. Attempts to engender fear may seem logical to us, but in reality they may be backfiring.

Dr. Nyhan and his colleagues didn’t bore down to discover what factors made a particular view so resistant to education. But, in my experience inheritance doesn’t seem to play a role. I hear from many fearful and frustrated grandparents who can’t understand why their grandchildren aren’t being immunized.

There is the hermit mentality that says by keeping apart from "all those other people" in society and by living a better life, we can protect ourselves from their diseases and don’t need immunizations. And, of course, there is the notion that even though we understand the rationale for immunization, God will protect us.

This important study suggests that we must be very thoughtful about our attempts at education in all public health issues. Our intuition has failed us here. As unfair as it may be to the child victims of this parental foolishness, we may need to fall back on strict exclusion and quarantine to protect the rest us until we learn how to convince families that they are making a serious mistake.

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].

Let’s be honest. Although pediatricians invest most of their days, some of their nights, and untold cockles of heartfelt concern trying to keep their patients well, there is very little evidence that what we do actually makes a difference. The one shining exception comes when we administer immunizations. This humbling fact makes the problem of vaccine refusal so frustrating and depressing.

I have always considered the increasing number of parents who refuse or who are hesitant about immunization just another example of decay in our nation’s educational system. How could anyone who was even half awake in American History class not be aware of the toll that infectious diseases took on the children born before 1900? Diseases that are now preventable. Do introductory science courses even touch on the basic mechanisms that underlie immunizations? High school students may not be expected to know that John Enders was the lead investigator in the development of the measles vaccine, but someone should have told them the story of Jonas Salk and polio.

Like many of you, I assumed that if I could just do a better job of filling in the gaps in our educational system that vaccine-hesitant parents would see the light. If I could share with parents even a small fraction of what I know about the efficacy of vaccines they couldn’t possibly refuse to immunize their children. However, after 40 years of failed attempts and frustration, I have begun to doubt my communication skills.

Some work by Brendan Nyhan, Ph.D., a government professor at Dartmouth College, and his colleagues suggests that my attempts at education were destined to fail. ("Effective Messages in Vaccine Promotion: A Randomized Trial," [Pediatrics 2014;133:1-8]). Aware that people frequently resist information that contradicts their views, these investigators began a small study. Nearly 1,800 parents were randomized to receive one of four messages supporting the value of MMR vaccine from textual excerpts to pictures of children with the diseases prevented by the vaccine.

What they discovered was that parents who had "mixed or negative feelings" about the vaccine were actually less likely to say that they would choose to vaccinate a future child after they had been presented with literature refuting the MMR-autism link. While these families were less likely to accept the vaccine-autism link, the informational materials had prompted them to consider other reasons that supported their negative views about vaccines.

Although other studies have found that parents still consider their children’s doctor to be the most trusted source of vaccine information, it appears that education as we understand it may not be our best tool. In fact, it may even be counterproductive. Attempts to engender fear may seem logical to us, but in reality they may be backfiring.

Dr. Nyhan and his colleagues didn’t bore down to discover what factors made a particular view so resistant to education. But, in my experience inheritance doesn’t seem to play a role. I hear from many fearful and frustrated grandparents who can’t understand why their grandchildren aren’t being immunized.

There is the hermit mentality that says by keeping apart from "all those other people" in society and by living a better life, we can protect ourselves from their diseases and don’t need immunizations. And, of course, there is the notion that even though we understand the rationale for immunization, God will protect us.

This important study suggests that we must be very thoughtful about our attempts at education in all public health issues. Our intuition has failed us here. As unfair as it may be to the child victims of this parental foolishness, we may need to fall back on strict exclusion and quarantine to protect the rest us until we learn how to convince families that they are making a serious mistake.

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].

Let’s be honest. Although pediatricians invest most of their days, some of their nights, and untold cockles of heartfelt concern trying to keep their patients well, there is very little evidence that what we do actually makes a difference. The one shining exception comes when we administer immunizations. This humbling fact makes the problem of vaccine refusal so frustrating and depressing.

I have always considered the increasing number of parents who refuse or who are hesitant about immunization just another example of decay in our nation’s educational system. How could anyone who was even half awake in American History class not be aware of the toll that infectious diseases took on the children born before 1900? Diseases that are now preventable. Do introductory science courses even touch on the basic mechanisms that underlie immunizations? High school students may not be expected to know that John Enders was the lead investigator in the development of the measles vaccine, but someone should have told them the story of Jonas Salk and polio.

Like many of you, I assumed that if I could just do a better job of filling in the gaps in our educational system that vaccine-hesitant parents would see the light. If I could share with parents even a small fraction of what I know about the efficacy of vaccines they couldn’t possibly refuse to immunize their children. However, after 40 years of failed attempts and frustration, I have begun to doubt my communication skills.

Some work by Brendan Nyhan, Ph.D., a government professor at Dartmouth College, and his colleagues suggests that my attempts at education were destined to fail. ("Effective Messages in Vaccine Promotion: A Randomized Trial," [Pediatrics 2014;133:1-8]). Aware that people frequently resist information that contradicts their views, these investigators began a small study. Nearly 1,800 parents were randomized to receive one of four messages supporting the value of MMR vaccine from textual excerpts to pictures of children with the diseases prevented by the vaccine.

What they discovered was that parents who had "mixed or negative feelings" about the vaccine were actually less likely to say that they would choose to vaccinate a future child after they had been presented with literature refuting the MMR-autism link. While these families were less likely to accept the vaccine-autism link, the informational materials had prompted them to consider other reasons that supported their negative views about vaccines.

Although other studies have found that parents still consider their children’s doctor to be the most trusted source of vaccine information, it appears that education as we understand it may not be our best tool. In fact, it may even be counterproductive. Attempts to engender fear may seem logical to us, but in reality they may be backfiring.

Dr. Nyhan and his colleagues didn’t bore down to discover what factors made a particular view so resistant to education. But, in my experience inheritance doesn’t seem to play a role. I hear from many fearful and frustrated grandparents who can’t understand why their grandchildren aren’t being immunized.

There is the hermit mentality that says by keeping apart from "all those other people" in society and by living a better life, we can protect ourselves from their diseases and don’t need immunizations. And, of course, there is the notion that even though we understand the rationale for immunization, God will protect us.

This important study suggests that we must be very thoughtful about our attempts at education in all public health issues. Our intuition has failed us here. As unfair as it may be to the child victims of this parental foolishness, we may need to fall back on strict exclusion and quarantine to protect the rest us until we learn how to convince families that they are making a serious mistake.

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].

Actually the complete phrase is "vox clamantis in deserto," and it is the motto of my alma mater. We were told as freshmen that it translated as "a voice crying in the wilderness" – which prior to the Internet, cheap long distance rates, and Interstate 89 seemed to be an apt description of my situation. The words resurfaced in my consciousness a few months ago when I met one of the regular readers of this column. A man of my vintage, he observed that over the 40-plus years he had been in practice, parents had grown increasingly less interested in his views on health and child rearing. He asked if I had experienced the same phenomenon.

In other words, he wondered if we both had become just voices crying in the wilderness. As we discussed his observation in more depth, it became clear that he wasn’t talking about the age-old phenomenon in which young people begin to tune out their elders who have persisted in palavering the same old "when-I-was-your-age" bologna. No, his question was more general. Is anyone listening to what pediatricians of any age are saying? Are our opinions less valued than they were 40 years ago? If our audience is less attentive, then why?

I agree that it does feel like, over the last 40 years, parents are less influenced by our opinions and are using increasing amounts of salt when they do listen. One only needs to consider the issue of vaccine refusal to appreciate that our advice often goes unheeded with potentially dangerous consequences.

Is the muting of our voices simply an example of dilution? Fifty years ago, pediatricians didn’t have much competition for the ears of new parents. There were Ben Spock and the always to be reckoned with army of grandmothers. Yes, there were magazines for parents, but they paled in comparison to the profusion of websites, blogs, and chat rooms that offer advice of varying quality just a mouse click away. Now we share the stage with anyone who cares to venture an opinion on health or parenting. No wonder we have trouble having our voices heard over the cacophony.

But, the din from the media is only part of the problem. I’m not sure exactly why, but over the last several decades, science has lost its mojo. Some of it has to do with the ease with which junk science can find an audience. Some of it is fallout from an educational system that is trying to regain its legs. While a good physician is more of an artist than a scientist, we were all trained as scientists. And, the public sees us as scientists, and as such, we are vulnerable to being painted with the same broad brush strokes of the antiscience folks.

To some degree we have been guilty of diluting our own messages. The trend toward health maintenance visits that are scripted by committee has done little to encourage parents to ask the questions about which they are most concerned. If we return to a model in which the patient or the parent is in the driver’s seat, we may start hearing more questions and discover our answers are given more consideration.

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].

Actually the complete phrase is "vox clamantis in deserto," and it is the motto of my alma mater. We were told as freshmen that it translated as "a voice crying in the wilderness" – which prior to the Internet, cheap long distance rates, and Interstate 89 seemed to be an apt description of my situation. The words resurfaced in my consciousness a few months ago when I met one of the regular readers of this column. A man of my vintage, he observed that over the 40-plus years he had been in practice, parents had grown increasingly less interested in his views on health and child rearing. He asked if I had experienced the same phenomenon.

In other words, he wondered if we both had become just voices crying in the wilderness. As we discussed his observation in more depth, it became clear that he wasn’t talking about the age-old phenomenon in which young people begin to tune out their elders who have persisted in palavering the same old "when-I-was-your-age" bologna. No, his question was more general. Is anyone listening to what pediatricians of any age are saying? Are our opinions less valued than they were 40 years ago? If our audience is less attentive, then why?

I agree that it does feel like, over the last 40 years, parents are less influenced by our opinions and are using increasing amounts of salt when they do listen. One only needs to consider the issue of vaccine refusal to appreciate that our advice often goes unheeded with potentially dangerous consequences.

Is the muting of our voices simply an example of dilution? Fifty years ago, pediatricians didn’t have much competition for the ears of new parents. There were Ben Spock and the always to be reckoned with army of grandmothers. Yes, there were magazines for parents, but they paled in comparison to the profusion of websites, blogs, and chat rooms that offer advice of varying quality just a mouse click away. Now we share the stage with anyone who cares to venture an opinion on health or parenting. No wonder we have trouble having our voices heard over the cacophony.

But, the din from the media is only part of the problem. I’m not sure exactly why, but over the last several decades, science has lost its mojo. Some of it has to do with the ease with which junk science can find an audience. Some of it is fallout from an educational system that is trying to regain its legs. While a good physician is more of an artist than a scientist, we were all trained as scientists. And, the public sees us as scientists, and as such, we are vulnerable to being painted with the same broad brush strokes of the antiscience folks.

To some degree we have been guilty of diluting our own messages. The trend toward health maintenance visits that are scripted by committee has done little to encourage parents to ask the questions about which they are most concerned. If we return to a model in which the patient or the parent is in the driver’s seat, we may start hearing more questions and discover our answers are given more consideration.

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].

Actually the complete phrase is "vox clamantis in deserto," and it is the motto of my alma mater. We were told as freshmen that it translated as "a voice crying in the wilderness" – which prior to the Internet, cheap long distance rates, and Interstate 89 seemed to be an apt description of my situation. The words resurfaced in my consciousness a few months ago when I met one of the regular readers of this column. A man of my vintage, he observed that over the 40-plus years he had been in practice, parents had grown increasingly less interested in his views on health and child rearing. He asked if I had experienced the same phenomenon.

In other words, he wondered if we both had become just voices crying in the wilderness. As we discussed his observation in more depth, it became clear that he wasn’t talking about the age-old phenomenon in which young people begin to tune out their elders who have persisted in palavering the same old "when-I-was-your-age" bologna. No, his question was more general. Is anyone listening to what pediatricians of any age are saying? Are our opinions less valued than they were 40 years ago? If our audience is less attentive, then why?

I agree that it does feel like, over the last 40 years, parents are less influenced by our opinions and are using increasing amounts of salt when they do listen. One only needs to consider the issue of vaccine refusal to appreciate that our advice often goes unheeded with potentially dangerous consequences.

Is the muting of our voices simply an example of dilution? Fifty years ago, pediatricians didn’t have much competition for the ears of new parents. There were Ben Spock and the always to be reckoned with army of grandmothers. Yes, there were magazines for parents, but they paled in comparison to the profusion of websites, blogs, and chat rooms that offer advice of varying quality just a mouse click away. Now we share the stage with anyone who cares to venture an opinion on health or parenting. No wonder we have trouble having our voices heard over the cacophony.

But, the din from the media is only part of the problem. I’m not sure exactly why, but over the last several decades, science has lost its mojo. Some of it has to do with the ease with which junk science can find an audience. Some of it is fallout from an educational system that is trying to regain its legs. While a good physician is more of an artist than a scientist, we were all trained as scientists. And, the public sees us as scientists, and as such, we are vulnerable to being painted with the same broad brush strokes of the antiscience folks.

To some degree we have been guilty of diluting our own messages. The trend toward health maintenance visits that are scripted by committee has done little to encourage parents to ask the questions about which they are most concerned. If we return to a model in which the patient or the parent is in the driver’s seat, we may start hearing more questions and discover our answers are given more consideration.

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 was nearly 20 years ago that I first learned about the efforts to delay school start time in hopes that it might help sleep deprived teenagers become better students. From its epicenter in greater Minneapolis, this low amplitude groundswell has rattled a few school districts to change their schedules. But, it hasn’t really caught on. When it was considered here in Brunswick about 15 years ago, parents and school board members were sympathetic to the plight of teenagers suffering from morning drowsiness. But, the cascade of schedule disruptions that would be triggered by tinkering with high school start times was too daunting, and the issue faded on everyone’s radar screens.

However, according to an article in the New York Times ("To Keep Teenagers Alert, Schools Let Them Sleep In," Jan Hoffman, March 13, 2014), the movement has rumbled to life in a variety of school districts across the country. Some of the resurgence in interest may be the result of recent data collected by researchers at the University of Minnesota. They found that teenagers who took advantage of the delayed starts by getting more sleep performed better academically and were involved in fewer motor vehicle crashes.

There is now a growing body of evidence linking sleep deprivation to a variety of ills including depression, hyperactivity, inattention, and migraine headaches, just to name a few. Research at Brown University by Mary Carskadon, Ph.D., suggests that the adolescent brain is chemically and structurally vulnerable to changes in sleep onset and duration. In her studies on humans and a variety of small mammals Dr. Carskadon has demonstrated that while the adolescent brain is more capable at staying awake later in the day, it still requires the same amount of sleep as it did during prepuberty. In other words, if we allow teenagers to push back their bedtimes by 2 hours but continue to demand that they be in school at 7:30 in the morning, we will continue to see the behavioral and physiologic damage related to sleep deprivation. This is clearly a case of watching a generation of candles burning at both ends. The efforts to delay school start times address only the smoldering at one end of the candle.

While Dr. Carskadon’s research suggests that it is physiologically easier for teenagers to stay up later, it doesn’t mean that we need fan the flame by making it any easier. The result of one study has shown that teenagers got more sleep if their parents had set a bedtime ... even if it wasn’t enforced. They got even more if it was enforced.

In the recent University of Minnesota studies, 88% of the students had cell phones in their bedrooms. Other studies have shown that having a television or other electronic distraction in the bedroom delays sleep onset and shortens sleep duration. Clearly, there is abundance of room for change in the sleep onset side of equation if we want our teenagers to be less sleep deprived. But, parents need to initiate the change.

Unfortunately, some of this research has spawned a myth that teenagers are biologically predestined to stay up late and sleep late, and, there’s nothing we can do about it. The armed services have disproved this myth many times over. I’m not suggesting we turn our schools into boot camps. But, any community that is considering a delayed high school start time should make it part of broad and frank discussion about sleep hygiene. Merely allowing teenagers to sleep an extra hour doesn’t even address half of the problem of sleep deprivation.

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."

It was nearly 20 years ago that I first learned about the efforts to delay school start time in hopes that it might help sleep deprived teenagers become better students. From its epicenter in greater Minneapolis, this low amplitude groundswell has rattled a few school districts to change their schedules. But, it hasn’t really caught on. When it was considered here in Brunswick about 15 years ago, parents and school board members were sympathetic to the plight of teenagers suffering from morning drowsiness. But, the cascade of schedule disruptions that would be triggered by tinkering with high school start times was too daunting, and the issue faded on everyone’s radar screens.

However, according to an article in the New York Times ("To Keep Teenagers Alert, Schools Let Them Sleep In," Jan Hoffman, March 13, 2014), the movement has rumbled to life in a variety of school districts across the country. Some of the resurgence in interest may be the result of recent data collected by researchers at the University of Minnesota. They found that teenagers who took advantage of the delayed starts by getting more sleep performed better academically and were involved in fewer motor vehicle crashes.

There is now a growing body of evidence linking sleep deprivation to a variety of ills including depression, hyperactivity, inattention, and migraine headaches, just to name a few. Research at Brown University by Mary Carskadon, Ph.D., suggests that the adolescent brain is chemically and structurally vulnerable to changes in sleep onset and duration. In her studies on humans and a variety of small mammals Dr. Carskadon has demonstrated that while the adolescent brain is more capable at staying awake later in the day, it still requires the same amount of sleep as it did during prepuberty. In other words, if we allow teenagers to push back their bedtimes by 2 hours but continue to demand that they be in school at 7:30 in the morning, we will continue to see the behavioral and physiologic damage related to sleep deprivation. This is clearly a case of watching a generation of candles burning at both ends. The efforts to delay school start times address only the smoldering at one end of the candle.

While Dr. Carskadon’s research suggests that it is physiologically easier for teenagers to stay up later, it doesn’t mean that we need fan the flame by making it any easier. The result of one study has shown that teenagers got more sleep if their parents had set a bedtime ... even if it wasn’t enforced. They got even more if it was enforced.

In the recent University of Minnesota studies, 88% of the students had cell phones in their bedrooms. Other studies have shown that having a television or other electronic distraction in the bedroom delays sleep onset and shortens sleep duration. Clearly, there is abundance of room for change in the sleep onset side of equation if we want our teenagers to be less sleep deprived. But, parents need to initiate the change.

Unfortunately, some of this research has spawned a myth that teenagers are biologically predestined to stay up late and sleep late, and, there’s nothing we can do about it. The armed services have disproved this myth many times over. I’m not suggesting we turn our schools into boot camps. But, any community that is considering a delayed high school start time should make it part of broad and frank discussion about sleep hygiene. Merely allowing teenagers to sleep an extra hour doesn’t even address half of the problem of sleep deprivation.

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."

It was nearly 20 years ago that I first learned about the efforts to delay school start time in hopes that it might help sleep deprived teenagers become better students. From its epicenter in greater Minneapolis, this low amplitude groundswell has rattled a few school districts to change their schedules. But, it hasn’t really caught on. When it was considered here in Brunswick about 15 years ago, parents and school board members were sympathetic to the plight of teenagers suffering from morning drowsiness. But, the cascade of schedule disruptions that would be triggered by tinkering with high school start times was too daunting, and the issue faded on everyone’s radar screens.

However, according to an article in the New York Times ("To Keep Teenagers Alert, Schools Let Them Sleep In," Jan Hoffman, March 13, 2014), the movement has rumbled to life in a variety of school districts across the country. Some of the resurgence in interest may be the result of recent data collected by researchers at the University of Minnesota. They found that teenagers who took advantage of the delayed starts by getting more sleep performed better academically and were involved in fewer motor vehicle crashes.

There is now a growing body of evidence linking sleep deprivation to a variety of ills including depression, hyperactivity, inattention, and migraine headaches, just to name a few. Research at Brown University by Mary Carskadon, Ph.D., suggests that the adolescent brain is chemically and structurally vulnerable to changes in sleep onset and duration. In her studies on humans and a variety of small mammals Dr. Carskadon has demonstrated that while the adolescent brain is more capable at staying awake later in the day, it still requires the same amount of sleep as it did during prepuberty. In other words, if we allow teenagers to push back their bedtimes by 2 hours but continue to demand that they be in school at 7:30 in the morning, we will continue to see the behavioral and physiologic damage related to sleep deprivation. This is clearly a case of watching a generation of candles burning at both ends. The efforts to delay school start times address only the smoldering at one end of the candle.

While Dr. Carskadon’s research suggests that it is physiologically easier for teenagers to stay up later, it doesn’t mean that we need fan the flame by making it any easier. The result of one study has shown that teenagers got more sleep if their parents had set a bedtime ... even if it wasn’t enforced. They got even more if it was enforced.

In the recent University of Minnesota studies, 88% of the students had cell phones in their bedrooms. Other studies have shown that having a television or other electronic distraction in the bedroom delays sleep onset and shortens sleep duration. Clearly, there is abundance of room for change in the sleep onset side of equation if we want our teenagers to be less sleep deprived. But, parents need to initiate the change.

Unfortunately, some of this research has spawned a myth that teenagers are biologically predestined to stay up late and sleep late, and, there’s nothing we can do about it. The armed services have disproved this myth many times over. I’m not suggesting we turn our schools into boot camps. But, any community that is considering a delayed high school start time should make it part of broad and frank discussion about sleep hygiene. Merely allowing teenagers to sleep an extra hour doesn’t even address half of the problem of sleep deprivation.

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."