Letters from Maine

In 2002 I wrote a book that the publishers chose to title, "The Maternity Leave Breastfeeding Plan: How to Enjoy Nursing for 3 Months and Go Back to Work Guilt-Free" (Chicago: Touchstone, 2002 ). I have always believed that breast milk is the natural first food for children, and that in most situations, nursing is the best option for mothers. However, after 25 years of trying to help mothers to breastfeed, I had grown increasingly troubled that for too many young mothers, the first years of parenting were shadowed by a cloud of guilt because they had "failed" at breastfeeding.

I felt that someone needed to write a book that presented a realistic view of breastfeeding. For a variety of good and bad reasons, not every woman who gives birth can successfully breastfeed. In my book, I offered as many suggestions as I could think of for making breastfeeding work. I emphasized that prenatal preparation and planning were particularly important for creating workplace, day care, and home environments that are conducive to breastfeeding. I stressed the importance of adopting realistic schedules that would allow enough recovery time from the stresses of parenting and breastfeeding. I suggested a toolbox full of ways in which fathers could improve the chances of breastfeeding success.

Woven through the book was the attitude that breastfeeding isn’t always as easy as some advocates suggest. Despite everyone’s best efforts and planning, stuff happens. I basically said that I think breastfeeding is a good idea, and here are some suggestions that can help you achieve your goal of nursing. But, if it doesn’t work, that’s okay. You are a great mother for having tried, and your child will still love you and grow up healthy.

In the last dozen years, there has been little change in the number of women initiating and successfully breastfeeding their infants.

Data supporting the benefits of breast milk continue to trickle in at a steady rate. However, based on my own anecdotal observations, I still harbor some lingering doubts about how significant these benefits have been for my patients here in North America. A recent study by some investigators at Ohio State University supports my skepticism (Cynthia G. Colen and David Ramey. "Is breast truly best? Estimating the effects of breastfeeding on long term child health and well-being in the United States using sibling comparisons" (Soc. Sci. Med. 2014;109:55-65).

These researchers looked at the National Longitudinal Survey of Youth that contains 25 years of panel data for children aged 4-14 years. If one merely compares breastfed versus nonbreastfed children, those who were breastfed score better on 10 of the 11 outcomes included in the survey. However, when the Ohio State investigators restricted their analyses to siblings, they found that with the exception of one outcome, the differences between breastfed and nonbreastfed children were no longer statistically significant. This observation makes one wonder how many other studies that purport to support the health benefits of breastfeeding have failed to adequately control for socioeconomic and demographic influences.

So where does this leave those of us tasked with helping young women breastfeed? The fact that I first learned about this study in the New York Times suggests that we will be challenged to respond. Obviously, we should still encourage mothers to breastfeed because it appears that the attitudes and environment that prompted a mother to choose to breastfeed at least once may be as important as whether her child actually receives breast milk.

For me, this study won’t change much because I have always avoided giving parents a laundry list of the advantages of breastfeeding.

However, I will keep this study’s findings tucked away to be pulled out when a mother has lost her struggle to breastfeed. Properly used, these results could be a free pass for her to climb off the Breastfeeding Guilt Trip Express.

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 pdnews@ frontlinemedcom.com. 

In 2002 I wrote a book that the publishers chose to title, "The Maternity Leave Breastfeeding Plan: How to Enjoy Nursing for 3 Months and Go Back to Work Guilt-Free" (Chicago: Touchstone, 2002 ). I have always believed that breast milk is the natural first food for children, and that in most situations, nursing is the best option for mothers. However, after 25 years of trying to help mothers to breastfeed, I had grown increasingly troubled that for too many young mothers, the first years of parenting were shadowed by a cloud of guilt because they had "failed" at breastfeeding.

I felt that someone needed to write a book that presented a realistic view of breastfeeding. For a variety of good and bad reasons, not every woman who gives birth can successfully breastfeed. In my book, I offered as many suggestions as I could think of for making breastfeeding work. I emphasized that prenatal preparation and planning were particularly important for creating workplace, day care, and home environments that are conducive to breastfeeding. I stressed the importance of adopting realistic schedules that would allow enough recovery time from the stresses of parenting and breastfeeding. I suggested a toolbox full of ways in which fathers could improve the chances of breastfeeding success.

Woven through the book was the attitude that breastfeeding isn’t always as easy as some advocates suggest. Despite everyone’s best efforts and planning, stuff happens. I basically said that I think breastfeeding is a good idea, and here are some suggestions that can help you achieve your goal of nursing. But, if it doesn’t work, that’s okay. You are a great mother for having tried, and your child will still love you and grow up healthy.

In the last dozen years, there has been little change in the number of women initiating and successfully breastfeeding their infants.

Data supporting the benefits of breast milk continue to trickle in at a steady rate. However, based on my own anecdotal observations, I still harbor some lingering doubts about how significant these benefits have been for my patients here in North America. A recent study by some investigators at Ohio State University supports my skepticism (Cynthia G. Colen and David Ramey. "Is breast truly best? Estimating the effects of breastfeeding on long term child health and well-being in the United States using sibling comparisons" (Soc. Sci. Med. 2014;109:55-65).

These researchers looked at the National Longitudinal Survey of Youth that contains 25 years of panel data for children aged 4-14 years. If one merely compares breastfed versus nonbreastfed children, those who were breastfed score better on 10 of the 11 outcomes included in the survey. However, when the Ohio State investigators restricted their analyses to siblings, they found that with the exception of one outcome, the differences between breastfed and nonbreastfed children were no longer statistically significant. This observation makes one wonder how many other studies that purport to support the health benefits of breastfeeding have failed to adequately control for socioeconomic and demographic influences.

So where does this leave those of us tasked with helping young women breastfeed? The fact that I first learned about this study in the New York Times suggests that we will be challenged to respond. Obviously, we should still encourage mothers to breastfeed because it appears that the attitudes and environment that prompted a mother to choose to breastfeed at least once may be as important as whether her child actually receives breast milk.

For me, this study won’t change much because I have always avoided giving parents a laundry list of the advantages of breastfeeding.

However, I will keep this study’s findings tucked away to be pulled out when a mother has lost her struggle to breastfeed. Properly used, these results could be a free pass for her to climb off the Breastfeeding Guilt Trip Express.

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 pdnews@ frontlinemedcom.com. 

In 2002 I wrote a book that the publishers chose to title, "The Maternity Leave Breastfeeding Plan: How to Enjoy Nursing for 3 Months and Go Back to Work Guilt-Free" (Chicago: Touchstone, 2002 ). I have always believed that breast milk is the natural first food for children, and that in most situations, nursing is the best option for mothers. However, after 25 years of trying to help mothers to breastfeed, I had grown increasingly troubled that for too many young mothers, the first years of parenting were shadowed by a cloud of guilt because they had "failed" at breastfeeding.

I felt that someone needed to write a book that presented a realistic view of breastfeeding. For a variety of good and bad reasons, not every woman who gives birth can successfully breastfeed. In my book, I offered as many suggestions as I could think of for making breastfeeding work. I emphasized that prenatal preparation and planning were particularly important for creating workplace, day care, and home environments that are conducive to breastfeeding. I stressed the importance of adopting realistic schedules that would allow enough recovery time from the stresses of parenting and breastfeeding. I suggested a toolbox full of ways in which fathers could improve the chances of breastfeeding success.

Woven through the book was the attitude that breastfeeding isn’t always as easy as some advocates suggest. Despite everyone’s best efforts and planning, stuff happens. I basically said that I think breastfeeding is a good idea, and here are some suggestions that can help you achieve your goal of nursing. But, if it doesn’t work, that’s okay. You are a great mother for having tried, and your child will still love you and grow up healthy.

In the last dozen years, there has been little change in the number of women initiating and successfully breastfeeding their infants.

Data supporting the benefits of breast milk continue to trickle in at a steady rate. However, based on my own anecdotal observations, I still harbor some lingering doubts about how significant these benefits have been for my patients here in North America. A recent study by some investigators at Ohio State University supports my skepticism (Cynthia G. Colen and David Ramey. "Is breast truly best? Estimating the effects of breastfeeding on long term child health and well-being in the United States using sibling comparisons" (Soc. Sci. Med. 2014;109:55-65).

These researchers looked at the National Longitudinal Survey of Youth that contains 25 years of panel data for children aged 4-14 years. If one merely compares breastfed versus nonbreastfed children, those who were breastfed score better on 10 of the 11 outcomes included in the survey. However, when the Ohio State investigators restricted their analyses to siblings, they found that with the exception of one outcome, the differences between breastfed and nonbreastfed children were no longer statistically significant. This observation makes one wonder how many other studies that purport to support the health benefits of breastfeeding have failed to adequately control for socioeconomic and demographic influences.

So where does this leave those of us tasked with helping young women breastfeed? The fact that I first learned about this study in the New York Times suggests that we will be challenged to respond. Obviously, we should still encourage mothers to breastfeed because it appears that the attitudes and environment that prompted a mother to choose to breastfeed at least once may be as important as whether her child actually receives breast milk.

For me, this study won’t change much because I have always avoided giving parents a laundry list of the advantages of breastfeeding.

However, I will keep this study’s findings tucked away to be pulled out when a mother has lost her struggle to breastfeed. Properly used, these results could be a free pass for her to climb off the Breastfeeding Guilt Trip Express.

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 pdnews@ frontlinemedcom.com. 

Marketing consultants have known it for years. Packaging sells the product. Putting it in the right color box can make the difference between a top seller and a flop. The truth is that most of us select wine by the appearance of the label and books by the design on the jacket.

In medicine, we package signs and symptoms in diagnoses and syndromes, and sometimes add an extra label that says "disease" in bold letters. But, what qualifies a particular constellation of physical findings and patients’ complaints as a "disease"?

This is not a trivial question. For the unfortunate victims, having a "disease" may allow them to tell their friends, "See, I’m not just a whiner. I actually have something. I have a disease." Diseases sometimes have their own specialists. Some have support groups, fund-raising foundations, and spokespersons.

In June 2013, the American Medical Association took the bold step of labeling obesity a "multimetabolic and hormonal disease state." This was the next logical step in an evolution that began with parents being told that their children would outgrow their baby fat if they adjusted their diets. Now we know that the seeds of obesity may be planted well before birth, and have certainly taken firm root before age 3 years to persist as a chronic condition with a myriad of life-altering ramifications. Sounds like a "disease" to me.

In an article in a New York Times Sunday Review, two psychologists from the University of Richmond discuss the dilemmas associated with this repackaging of obesity as a "disease" ("Should Obesity Be a Disease?" Crystal L. Hoyt and Jeni L. Burnette. Feb. 21, 2014). With a colleague from the University of Minnesota, these researchers performed three studies with 700 subjects who were divided into two groups. One group was given an article from a family magazine that included the standard advice on setting weight management goals. The other was provided an article clearly stating that obesity is a disease.

Surveys of the two groups revealed that for the obese individuals, reading the obesity is a disease article improved their "body satisfaction." Not a surprise. Nor is the observation that the same message made attempts at change seem futile. Another of their studies showed that this attitude of futility was correlated with less-healthy, higher-calorie food choices.

So it appears that in labeling obesity as a disease, the AMA has handed us a double-edged sword. We can use the new packaging to help our obese patients feel better about themselves. But, we must be prepared to address a sense of futility that may accompany their acceptance of a disease for which we currently don’t have a cure. Faced with this dilemma, we may need to adopt the style of successful chronic disease specialists. Sharing our frustration, we must remind our obese patients that while we don’t have a cure, we can help them manage their disease in a way that minimizes its ill effects.

While the disease label can cut both ways for our current patients, we should seize the opportunity to use it as a potent weapon in prevention for our patients yet to be born or even conceived. And, now we understand that prevention means taking aggressive steps prenatally and in the first 2 years of life before it’s too late. Armed with the new label, it is time to mount a serious campaign with the slogan, "Baby Fat is a Preventable Disease!"

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].

Marketing consultants have known it for years. Packaging sells the product. Putting it in the right color box can make the difference between a top seller and a flop. The truth is that most of us select wine by the appearance of the label and books by the design on the jacket.

In medicine, we package signs and symptoms in diagnoses and syndromes, and sometimes add an extra label that says "disease" in bold letters. But, what qualifies a particular constellation of physical findings and patients’ complaints as a "disease"?

This is not a trivial question. For the unfortunate victims, having a "disease" may allow them to tell their friends, "See, I’m not just a whiner. I actually have something. I have a disease." Diseases sometimes have their own specialists. Some have support groups, fund-raising foundations, and spokespersons.

In June 2013, the American Medical Association took the bold step of labeling obesity a "multimetabolic and hormonal disease state." This was the next logical step in an evolution that began with parents being told that their children would outgrow their baby fat if they adjusted their diets. Now we know that the seeds of obesity may be planted well before birth, and have certainly taken firm root before age 3 years to persist as a chronic condition with a myriad of life-altering ramifications. Sounds like a "disease" to me.

In an article in a New York Times Sunday Review, two psychologists from the University of Richmond discuss the dilemmas associated with this repackaging of obesity as a "disease" ("Should Obesity Be a Disease?" Crystal L. Hoyt and Jeni L. Burnette. Feb. 21, 2014). With a colleague from the University of Minnesota, these researchers performed three studies with 700 subjects who were divided into two groups. One group was given an article from a family magazine that included the standard advice on setting weight management goals. The other was provided an article clearly stating that obesity is a disease.

Surveys of the two groups revealed that for the obese individuals, reading the obesity is a disease article improved their "body satisfaction." Not a surprise. Nor is the observation that the same message made attempts at change seem futile. Another of their studies showed that this attitude of futility was correlated with less-healthy, higher-calorie food choices.

So it appears that in labeling obesity as a disease, the AMA has handed us a double-edged sword. We can use the new packaging to help our obese patients feel better about themselves. But, we must be prepared to address a sense of futility that may accompany their acceptance of a disease for which we currently don’t have a cure. Faced with this dilemma, we may need to adopt the style of successful chronic disease specialists. Sharing our frustration, we must remind our obese patients that while we don’t have a cure, we can help them manage their disease in a way that minimizes its ill effects.

While the disease label can cut both ways for our current patients, we should seize the opportunity to use it as a potent weapon in prevention for our patients yet to be born or even conceived. And, now we understand that prevention means taking aggressive steps prenatally and in the first 2 years of life before it’s too late. Armed with the new label, it is time to mount a serious campaign with the slogan, "Baby Fat is a Preventable Disease!"

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].

Marketing consultants have known it for years. Packaging sells the product. Putting it in the right color box can make the difference between a top seller and a flop. The truth is that most of us select wine by the appearance of the label and books by the design on the jacket.

In medicine, we package signs and symptoms in diagnoses and syndromes, and sometimes add an extra label that says "disease" in bold letters. But, what qualifies a particular constellation of physical findings and patients’ complaints as a "disease"?

This is not a trivial question. For the unfortunate victims, having a "disease" may allow them to tell their friends, "See, I’m not just a whiner. I actually have something. I have a disease." Diseases sometimes have their own specialists. Some have support groups, fund-raising foundations, and spokespersons.

In June 2013, the American Medical Association took the bold step of labeling obesity a "multimetabolic and hormonal disease state." This was the next logical step in an evolution that began with parents being told that their children would outgrow their baby fat if they adjusted their diets. Now we know that the seeds of obesity may be planted well before birth, and have certainly taken firm root before age 3 years to persist as a chronic condition with a myriad of life-altering ramifications. Sounds like a "disease" to me.

In an article in a New York Times Sunday Review, two psychologists from the University of Richmond discuss the dilemmas associated with this repackaging of obesity as a "disease" ("Should Obesity Be a Disease?" Crystal L. Hoyt and Jeni L. Burnette. Feb. 21, 2014). With a colleague from the University of Minnesota, these researchers performed three studies with 700 subjects who were divided into two groups. One group was given an article from a family magazine that included the standard advice on setting weight management goals. The other was provided an article clearly stating that obesity is a disease.

Surveys of the two groups revealed that for the obese individuals, reading the obesity is a disease article improved their "body satisfaction." Not a surprise. Nor is the observation that the same message made attempts at change seem futile. Another of their studies showed that this attitude of futility was correlated with less-healthy, higher-calorie food choices.

So it appears that in labeling obesity as a disease, the AMA has handed us a double-edged sword. We can use the new packaging to help our obese patients feel better about themselves. But, we must be prepared to address a sense of futility that may accompany their acceptance of a disease for which we currently don’t have a cure. Faced with this dilemma, we may need to adopt the style of successful chronic disease specialists. Sharing our frustration, we must remind our obese patients that while we don’t have a cure, we can help them manage their disease in a way that minimizes its ill effects.

While the disease label can cut both ways for our current patients, we should seize the opportunity to use it as a potent weapon in prevention for our patients yet to be born or even conceived. And, now we understand that prevention means taking aggressive steps prenatally and in the first 2 years of life before it’s too late. Armed with the new label, it is time to mount a serious campaign with the slogan, "Baby Fat is a Preventable Disease!"

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].

Ouppfostrade ... Is it a) The sound of a pendulum that has swung too far to the left? Or is it b) a Swedish word that means "badly raised children"?

As I learned in a Wall Street Journal article, the correct answer is b ("Badly Raised Kids? Sweden Has a Word for That," Jens Hansegard, Feb. 11, 2014).

In the opinion of Dr. David Eberhard, a Swedish psychiatrist, decades of child-centric policies have "gone too far" and the result is a nation of poorly raised children who may be more vulnerable to anxiety and depression as they grow older.

Dr. Eberhard, who is also the father of six, freely admits that his conclusions are based on "common sense" and observations that are not the result of scientific studies. However, his opinions have touched a sympathetic nerve with more than a few of his fellow countrymen. Although most newspaper editorials have been critical of his ideas, blogs are divided 50/50. Apparently, there are plenty of Swedes who feel that new millennium parents are spineless wimps being pushed around by their children. Dr. Eberhard’s critics counter that Sweden’s reputation for innovation in a broad variety of fields and its enviable happiness rating are in part the result of its policies empowering children.

Does any of this parenting brouhaha strike a familiar chord? Or, is the issue of poorly disciplined children a uniquely Swedish phenomenon? The United States has certainly not enacted as many robust child-centric policies as Sweden and her Scandinavian sisters have. But, while critics have little cause to blame the government, one certainly feels a rumbling of discontent in some circles that America has an overabundance of poorly disciplined children. It is tempting to assume that most of the grumbling is coming from grandparents and their peers in the form of "when-I-was-your-age" rhetoric. But I think there are enough young parents who feel that they have lost (if they ever had) control of the situation that it is an issue worth considering by pediatricians.

As in Sweden, the situation is probably the result of generational drift in which today’s children are being parented by parents whose parents and even grandparents were uncomfortable saying "no." Without solid role models and without a cultural tradition to follow, many modern parents are adrift. Blown in one direction by "experts" with overly child-centric advice and pushed in another by a vocal minority who advocate an authoritarian style, parents can be paralyzed by the fear of doing it all wrong. So they don’t do anything about creating structure and discipline.

Most parents know that spanking is wrong, but they aren’t sure what strategy they should use when their child misbehaves. They may have tried time-out, but for a variety of reasons it didn’t work. Some parents may have trouble overcoming a nagging feeling of guilt that they have to leave their children in day care. Once home, it is hard for a working parent, in fact any parent, to be a friend to the child, and still be the person who makes the rules and metes out the consequences. And, of course, there are a few parents who even question whether there should be any rules for children.

Fortunately, the examples of extreme child-centricity are rare. Most of the time, parents are eager to hear parenting advice from their pediatricians. However, it is up to the pediatrician to make it clear that she or he is interested in the everyday behavior issues, such as saying "no." Pediatricians must be prepared to offer advice that is based on their knowledge of normal child development and not tilted toward either extreme. But, this kind of counseling takes time. To help parents develop a system of limits and consequences that is appropriate for their child’s temperament and developmental age can’t be done in a 10-minute visit. But, first, pediatricians must make it clear that we aren’t just the ear infection folks. We have the skills and experience to deal with ouppfostrade before it becomes epidemic here in America.

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].

Ouppfostrade ... Is it a) The sound of a pendulum that has swung too far to the left? Or is it b) a Swedish word that means "badly raised children"?

As I learned in a Wall Street Journal article, the correct answer is b ("Badly Raised Kids? Sweden Has a Word for That," Jens Hansegard, Feb. 11, 2014).

In the opinion of Dr. David Eberhard, a Swedish psychiatrist, decades of child-centric policies have "gone too far" and the result is a nation of poorly raised children who may be more vulnerable to anxiety and depression as they grow older.

Dr. Eberhard, who is also the father of six, freely admits that his conclusions are based on "common sense" and observations that are not the result of scientific studies. However, his opinions have touched a sympathetic nerve with more than a few of his fellow countrymen. Although most newspaper editorials have been critical of his ideas, blogs are divided 50/50. Apparently, there are plenty of Swedes who feel that new millennium parents are spineless wimps being pushed around by their children. Dr. Eberhard’s critics counter that Sweden’s reputation for innovation in a broad variety of fields and its enviable happiness rating are in part the result of its policies empowering children.

Does any of this parenting brouhaha strike a familiar chord? Or, is the issue of poorly disciplined children a uniquely Swedish phenomenon? The United States has certainly not enacted as many robust child-centric policies as Sweden and her Scandinavian sisters have. But, while critics have little cause to blame the government, one certainly feels a rumbling of discontent in some circles that America has an overabundance of poorly disciplined children. It is tempting to assume that most of the grumbling is coming from grandparents and their peers in the form of "when-I-was-your-age" rhetoric. But I think there are enough young parents who feel that they have lost (if they ever had) control of the situation that it is an issue worth considering by pediatricians.

As in Sweden, the situation is probably the result of generational drift in which today’s children are being parented by parents whose parents and even grandparents were uncomfortable saying "no." Without solid role models and without a cultural tradition to follow, many modern parents are adrift. Blown in one direction by "experts" with overly child-centric advice and pushed in another by a vocal minority who advocate an authoritarian style, parents can be paralyzed by the fear of doing it all wrong. So they don’t do anything about creating structure and discipline.

Most parents know that spanking is wrong, but they aren’t sure what strategy they should use when their child misbehaves. They may have tried time-out, but for a variety of reasons it didn’t work. Some parents may have trouble overcoming a nagging feeling of guilt that they have to leave their children in day care. Once home, it is hard for a working parent, in fact any parent, to be a friend to the child, and still be the person who makes the rules and metes out the consequences. And, of course, there are a few parents who even question whether there should be any rules for children.

Fortunately, the examples of extreme child-centricity are rare. Most of the time, parents are eager to hear parenting advice from their pediatricians. However, it is up to the pediatrician to make it clear that she or he is interested in the everyday behavior issues, such as saying "no." Pediatricians must be prepared to offer advice that is based on their knowledge of normal child development and not tilted toward either extreme. But, this kind of counseling takes time. To help parents develop a system of limits and consequences that is appropriate for their child’s temperament and developmental age can’t be done in a 10-minute visit. But, first, pediatricians must make it clear that we aren’t just the ear infection folks. We have the skills and experience to deal with ouppfostrade before it becomes epidemic here in America.

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].

Ouppfostrade ... Is it a) The sound of a pendulum that has swung too far to the left? Or is it b) a Swedish word that means "badly raised children"?

As I learned in a Wall Street Journal article, the correct answer is b ("Badly Raised Kids? Sweden Has a Word for That," Jens Hansegard, Feb. 11, 2014).

In the opinion of Dr. David Eberhard, a Swedish psychiatrist, decades of child-centric policies have "gone too far" and the result is a nation of poorly raised children who may be more vulnerable to anxiety and depression as they grow older.

Dr. Eberhard, who is also the father of six, freely admits that his conclusions are based on "common sense" and observations that are not the result of scientific studies. However, his opinions have touched a sympathetic nerve with more than a few of his fellow countrymen. Although most newspaper editorials have been critical of his ideas, blogs are divided 50/50. Apparently, there are plenty of Swedes who feel that new millennium parents are spineless wimps being pushed around by their children. Dr. Eberhard’s critics counter that Sweden’s reputation for innovation in a broad variety of fields and its enviable happiness rating are in part the result of its policies empowering children.

Does any of this parenting brouhaha strike a familiar chord? Or, is the issue of poorly disciplined children a uniquely Swedish phenomenon? The United States has certainly not enacted as many robust child-centric policies as Sweden and her Scandinavian sisters have. But, while critics have little cause to blame the government, one certainly feels a rumbling of discontent in some circles that America has an overabundance of poorly disciplined children. It is tempting to assume that most of the grumbling is coming from grandparents and their peers in the form of "when-I-was-your-age" rhetoric. But I think there are enough young parents who feel that they have lost (if they ever had) control of the situation that it is an issue worth considering by pediatricians.

As in Sweden, the situation is probably the result of generational drift in which today’s children are being parented by parents whose parents and even grandparents were uncomfortable saying "no." Without solid role models and without a cultural tradition to follow, many modern parents are adrift. Blown in one direction by "experts" with overly child-centric advice and pushed in another by a vocal minority who advocate an authoritarian style, parents can be paralyzed by the fear of doing it all wrong. So they don’t do anything about creating structure and discipline.

Most parents know that spanking is wrong, but they aren’t sure what strategy they should use when their child misbehaves. They may have tried time-out, but for a variety of reasons it didn’t work. Some parents may have trouble overcoming a nagging feeling of guilt that they have to leave their children in day care. Once home, it is hard for a working parent, in fact any parent, to be a friend to the child, and still be the person who makes the rules and metes out the consequences. And, of course, there are a few parents who even question whether there should be any rules for children.

Fortunately, the examples of extreme child-centricity are rare. Most of the time, parents are eager to hear parenting advice from their pediatricians. However, it is up to the pediatrician to make it clear that she or he is interested in the everyday behavior issues, such as saying "no." Pediatricians must be prepared to offer advice that is based on their knowledge of normal child development and not tilted toward either extreme. But, this kind of counseling takes time. To help parents develop a system of limits and consequences that is appropriate for their child’s temperament and developmental age can’t be done in a 10-minute visit. But, first, pediatricians must make it clear that we aren’t just the ear infection folks. We have the skills and experience to deal with ouppfostrade before it becomes epidemic here in America.

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

I’m willing to give the Affordable Care Act several more months before I finally decide that it is as poorly conceived and executed as it appears to be at the moment. However, when it comes to the efforts by the federal government to speed the adoption of electronic health records, I’m sure that the result has been several giant steps backward for both the quality of medical care and the level of satisfaction for the physicians in this country.

Doctors who have begun to use electronic health records (EHRs) are finding that they are spending more hours of their day in front of a computer screen doing clerical work. If they can’t afford to see fewer patients, the result is an extra hour or two at the end of the day catching up with the paperless work. This means that hours of family and rejuvenation time that were already in short supply are lost. A recent survey by Mark William Friedberg of the Rand Corp. and his associates listed the burden caused by electronic health records as the leading contributor to physician dissatisfaction. Neither physicians nor their patients are happy with the loss of eye to eye contact that also accompanies the adoption of EHRs.

I suspect that most physicians continue to hold out hope that computerized medical records will prove to benefit patient care in the long run. But, their patience has worn so thin it is easy to see the frustration on their faces and hear it in their voices. Those of us who have already endured more than once the steep learning curve that comes with a new computer system have found that at the top of the curve is a plateau – a plateau that leaves us no more productive than we were when we started the painful and expensive climb, despite promises from the vendors and administrators who bought their sales pitches.

But, there may be a solution to at least some of the downside to electronic health records, namely, scribes. A scribe is an assistant who accompanies the physician as he sees patients and records the pertinent information generated from the visit in real time. The result is a completed medical record and a bill for services without the physician having to lift a pen, move a cursor, or take her eyes off the patient. It is estimated that there are nearly 10,000 scribes working in this country, and there are companies who promise to provide a turnkey operation that includes hiring, training, and updating skills. The charge for the service runs about $20-$25 per hour, with the scribe receiving $8-$16 per hour.

Scribes have been most popular in hospitals and emergency departments where the expense may be less of a hurdle than elsewhere, but they work in outpatient settings as well. The issue of confidentiality has been raised, but it doesn’t seem to have been a problem. Patients are accustomed to having a nurse or chaperone, and for many years haven’t expressed much concern about having their medical records read or listened to by transcriptionists.

If I were still in practice, I think I could easily rationalize the cost of a scribe if he or she allowed me to get home an hour or two earlier. I suspect my children would even have been willing to chip in some of their allowance to fund the service if it allowed their father to show up for dinner and in a sunnier frame of mind.

Two little wrinkles come to mind, but I think they could be easily ironed out. My exam rooms have never been terribly spacious, and now that two parents and a grandparent often accompany the patient, I wonder where we would put another warm body. And, with the increasing volume of mental health–related visits that pediatricians are seeing, I can imagine a few situations in which the presence of a scribe might be a deterrent to effective communication. However, I am sure that it would be easy to arrange a system in which the physician wore a microphone that would connect to the scribe in another room. A prominently displayed sign reminding the patient that a scribe was listening and recording would blend in with the other informational signs that paper the walls of most examining rooms and are being ignored.

So what do you think? Would a scribe system work for you? Would it be worth the expense? Can you imagine some downsides that I haven’t considered?

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 pdnews@ frontlinemedcom.com. Scan this QR code or go to pediatricnews.com to read similar columns.

I’m willing to give the Affordable Care Act several more months before I finally decide that it is as poorly conceived and executed as it appears to be at the moment. However, when it comes to the efforts by the federal government to speed the adoption of electronic health records, I’m sure that the result has been several giant steps backward for both the quality of medical care and the level of satisfaction for the physicians in this country.

Doctors who have begun to use electronic health records (EHRs) are finding that they are spending more hours of their day in front of a computer screen doing clerical work. If they can’t afford to see fewer patients, the result is an extra hour or two at the end of the day catching up with the paperless work. This means that hours of family and rejuvenation time that were already in short supply are lost. A recent survey by Mark William Friedberg of the Rand Corp. and his associates listed the burden caused by electronic health records as the leading contributor to physician dissatisfaction. Neither physicians nor their patients are happy with the loss of eye to eye contact that also accompanies the adoption of EHRs.

I suspect that most physicians continue to hold out hope that computerized medical records will prove to benefit patient care in the long run. But, their patience has worn so thin it is easy to see the frustration on their faces and hear it in their voices. Those of us who have already endured more than once the steep learning curve that comes with a new computer system have found that at the top of the curve is a plateau – a plateau that leaves us no more productive than we were when we started the painful and expensive climb, despite promises from the vendors and administrators who bought their sales pitches.

But, there may be a solution to at least some of the downside to electronic health records, namely, scribes. A scribe is an assistant who accompanies the physician as he sees patients and records the pertinent information generated from the visit in real time. The result is a completed medical record and a bill for services without the physician having to lift a pen, move a cursor, or take her eyes off the patient. It is estimated that there are nearly 10,000 scribes working in this country, and there are companies who promise to provide a turnkey operation that includes hiring, training, and updating skills. The charge for the service runs about $20-$25 per hour, with the scribe receiving $8-$16 per hour.

Scribes have been most popular in hospitals and emergency departments where the expense may be less of a hurdle than elsewhere, but they work in outpatient settings as well. The issue of confidentiality has been raised, but it doesn’t seem to have been a problem. Patients are accustomed to having a nurse or chaperone, and for many years haven’t expressed much concern about having their medical records read or listened to by transcriptionists.

If I were still in practice, I think I could easily rationalize the cost of a scribe if he or she allowed me to get home an hour or two earlier. I suspect my children would even have been willing to chip in some of their allowance to fund the service if it allowed their father to show up for dinner and in a sunnier frame of mind.

Two little wrinkles come to mind, but I think they could be easily ironed out. My exam rooms have never been terribly spacious, and now that two parents and a grandparent often accompany the patient, I wonder where we would put another warm body. And, with the increasing volume of mental health–related visits that pediatricians are seeing, I can imagine a few situations in which the presence of a scribe might be a deterrent to effective communication. However, I am sure that it would be easy to arrange a system in which the physician wore a microphone that would connect to the scribe in another room. A prominently displayed sign reminding the patient that a scribe was listening and recording would blend in with the other informational signs that paper the walls of most examining rooms and are being ignored.

So what do you think? Would a scribe system work for you? Would it be worth the expense? Can you imagine some downsides that I haven’t considered?

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 pdnews@ frontlinemedcom.com. Scan this QR code or go to pediatricnews.com to read similar columns.

I’m willing to give the Affordable Care Act several more months before I finally decide that it is as poorly conceived and executed as it appears to be at the moment. However, when it comes to the efforts by the federal government to speed the adoption of electronic health records, I’m sure that the result has been several giant steps backward for both the quality of medical care and the level of satisfaction for the physicians in this country.

Doctors who have begun to use electronic health records (EHRs) are finding that they are spending more hours of their day in front of a computer screen doing clerical work. If they can’t afford to see fewer patients, the result is an extra hour or two at the end of the day catching up with the paperless work. This means that hours of family and rejuvenation time that were already in short supply are lost. A recent survey by Mark William Friedberg of the Rand Corp. and his associates listed the burden caused by electronic health records as the leading contributor to physician dissatisfaction. Neither physicians nor their patients are happy with the loss of eye to eye contact that also accompanies the adoption of EHRs.

I suspect that most physicians continue to hold out hope that computerized medical records will prove to benefit patient care in the long run. But, their patience has worn so thin it is easy to see the frustration on their faces and hear it in their voices. Those of us who have already endured more than once the steep learning curve that comes with a new computer system have found that at the top of the curve is a plateau – a plateau that leaves us no more productive than we were when we started the painful and expensive climb, despite promises from the vendors and administrators who bought their sales pitches.

But, there may be a solution to at least some of the downside to electronic health records, namely, scribes. A scribe is an assistant who accompanies the physician as he sees patients and records the pertinent information generated from the visit in real time. The result is a completed medical record and a bill for services without the physician having to lift a pen, move a cursor, or take her eyes off the patient. It is estimated that there are nearly 10,000 scribes working in this country, and there are companies who promise to provide a turnkey operation that includes hiring, training, and updating skills. The charge for the service runs about $20-$25 per hour, with the scribe receiving $8-$16 per hour.

Scribes have been most popular in hospitals and emergency departments where the expense may be less of a hurdle than elsewhere, but they work in outpatient settings as well. The issue of confidentiality has been raised, but it doesn’t seem to have been a problem. Patients are accustomed to having a nurse or chaperone, and for many years haven’t expressed much concern about having their medical records read or listened to by transcriptionists.

If I were still in practice, I think I could easily rationalize the cost of a scribe if he or she allowed me to get home an hour or two earlier. I suspect my children would even have been willing to chip in some of their allowance to fund the service if it allowed their father to show up for dinner and in a sunnier frame of mind.

Two little wrinkles come to mind, but I think they could be easily ironed out. My exam rooms have never been terribly spacious, and now that two parents and a grandparent often accompany the patient, I wonder where we would put another warm body. And, with the increasing volume of mental health–related visits that pediatricians are seeing, I can imagine a few situations in which the presence of a scribe might be a deterrent to effective communication. However, I am sure that it would be easy to arrange a system in which the physician wore a microphone that would connect to the scribe in another room. A prominently displayed sign reminding the patient that a scribe was listening and recording would blend in with the other informational signs that paper the walls of most examining rooms and are being ignored.

So what do you think? Would a scribe system work for you? Would it be worth the expense? Can you imagine some downsides that I haven’t considered?

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 pdnews@ frontlinemedcom.com. Scan this QR code or go to pediatricnews.com to read similar columns.

Would you tell your children to eliminate the practice of medicine from their list of potential career paths? It’s not a question I ever needed to consider. Although my three children are bright and have a good work ethic, none of them considered becoming a doctor. At least if they did, I wasn’t consulted. Two of them have always been squeamish about body fluids, and that was probably a deal breaker for them. It certainly wasn’t because I complained about my job. I don’t recall ever grumbling about being a pediatrician. Although my considerably less-than-perfect attendance at dinner and their sporting events may have prompted them to seek a more family-friendly profession.

In a recent column, Dr. Allan M. Block wrote a piece titled "Why I’m happy my kids don’t want to be doctors"(January 2014, p. 16). In his sad-but-true commentary, he imagines how uncomfortable it must be to leave medical school with nearly a quarter of a million dollars in debt, a burden that must affect how young doctors choose what and how they practice. While none of us planned to practice rogue medicine, Dr. Block also bemoans the fact that "people who know nothing about medicine try to tell us what we can or can’t do."

Is his commentary merely a burnout candidate’s last rant before the flames reach his vital organs? Or, is he speaking for the many physicians who have worked long enough to realize that the practice of medicine has moved perilously close to the point where the cost/benefit ratio has tipped to the "it-isn’t-worth-it" side?

While none of my children sought my opinion on medicine as a career path, scores of my patients have shared their dreams of becoming physicians. Whenever this has happened, I egotistically hope that in some way I may have served as a positive role model they wish to emulate. But, I have learned that there are usually more potent motivators lurking in the background. While still puffed up with undeserved pride, I also assume that they are asking for my opinion on their plans . . . which of course they are not.

I ignore the obvious and offer, "Well, it may not be as much fun as it was 20 years ago, but being a pediatrician is still a lot of fun." Of course, this begs the question, If I were in their shoes today, would I apply to medical school?

Hesitant to throw too much cold water on their enthusiasm, I am sure to reassure them that I think they would make wonderful doctors. But, I add that becoming a physician is a long and expensive process. I hope that they are still listening when I add, "You know that nurse practitioners and physician assistants get to do almost all of the cool things I enjoy the most about being a pediatrician, . . . and the training is certainly shorter and less costly."

Of course, choosing either of these nonphysician career paths will rob their parents of the opportunity to introduce them at cocktail parties as "Our daughter, the doctor." But, the trade-off is that they will be more likely to be content with their jobs.

While my observations may be good advice for some of my patients, it leaves unanswered what to do about the malaise that hangs over Dr. Block and many of our colleagues. Educational debt has robbed some young doctors of their entrepreneurial spirit. Pressures from the government and third-party payers have nibbled away at our autonomy. And, the threat of malpractice action has smothered many of us in a blanket of fear.

Even in the face of all this gloom, if one of my grandchildren told me that they really wanted to be a pediatrician and expressed no interest in the nurse practitioner option, I would be candid in describing the erosion that has occurred over the course of my career. But, I would challenge them to tell me another job that could offer them even half of the opportunities to feel needed and appreciated that I have enjoyed. Hopefully, at least some of the frustrating downsides of medicine today will be reversed by the time they enter practice.

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].

Would you tell your children to eliminate the practice of medicine from their list of potential career paths? It’s not a question I ever needed to consider. Although my three children are bright and have a good work ethic, none of them considered becoming a doctor. At least if they did, I wasn’t consulted. Two of them have always been squeamish about body fluids, and that was probably a deal breaker for them. It certainly wasn’t because I complained about my job. I don’t recall ever grumbling about being a pediatrician. Although my considerably less-than-perfect attendance at dinner and their sporting events may have prompted them to seek a more family-friendly profession.

In a recent column, Dr. Allan M. Block wrote a piece titled "Why I’m happy my kids don’t want to be doctors"(January 2014, p. 16). In his sad-but-true commentary, he imagines how uncomfortable it must be to leave medical school with nearly a quarter of a million dollars in debt, a burden that must affect how young doctors choose what and how they practice. While none of us planned to practice rogue medicine, Dr. Block also bemoans the fact that "people who know nothing about medicine try to tell us what we can or can’t do."

Is his commentary merely a burnout candidate’s last rant before the flames reach his vital organs? Or, is he speaking for the many physicians who have worked long enough to realize that the practice of medicine has moved perilously close to the point where the cost/benefit ratio has tipped to the "it-isn’t-worth-it" side?

While none of my children sought my opinion on medicine as a career path, scores of my patients have shared their dreams of becoming physicians. Whenever this has happened, I egotistically hope that in some way I may have served as a positive role model they wish to emulate. But, I have learned that there are usually more potent motivators lurking in the background. While still puffed up with undeserved pride, I also assume that they are asking for my opinion on their plans . . . which of course they are not.

I ignore the obvious and offer, "Well, it may not be as much fun as it was 20 years ago, but being a pediatrician is still a lot of fun." Of course, this begs the question, If I were in their shoes today, would I apply to medical school?

Hesitant to throw too much cold water on their enthusiasm, I am sure to reassure them that I think they would make wonderful doctors. But, I add that becoming a physician is a long and expensive process. I hope that they are still listening when I add, "You know that nurse practitioners and physician assistants get to do almost all of the cool things I enjoy the most about being a pediatrician, . . . and the training is certainly shorter and less costly."

Of course, choosing either of these nonphysician career paths will rob their parents of the opportunity to introduce them at cocktail parties as "Our daughter, the doctor." But, the trade-off is that they will be more likely to be content with their jobs.

While my observations may be good advice for some of my patients, it leaves unanswered what to do about the malaise that hangs over Dr. Block and many of our colleagues. Educational debt has robbed some young doctors of their entrepreneurial spirit. Pressures from the government and third-party payers have nibbled away at our autonomy. And, the threat of malpractice action has smothered many of us in a blanket of fear.

Even in the face of all this gloom, if one of my grandchildren told me that they really wanted to be a pediatrician and expressed no interest in the nurse practitioner option, I would be candid in describing the erosion that has occurred over the course of my career. But, I would challenge them to tell me another job that could offer them even half of the opportunities to feel needed and appreciated that I have enjoyed. Hopefully, at least some of the frustrating downsides of medicine today will be reversed by the time they enter practice.

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].

Would you tell your children to eliminate the practice of medicine from their list of potential career paths? It’s not a question I ever needed to consider. Although my three children are bright and have a good work ethic, none of them considered becoming a doctor. At least if they did, I wasn’t consulted. Two of them have always been squeamish about body fluids, and that was probably a deal breaker for them. It certainly wasn’t because I complained about my job. I don’t recall ever grumbling about being a pediatrician. Although my considerably less-than-perfect attendance at dinner and their sporting events may have prompted them to seek a more family-friendly profession.

In a recent column, Dr. Allan M. Block wrote a piece titled "Why I’m happy my kids don’t want to be doctors"(January 2014, p. 16). In his sad-but-true commentary, he imagines how uncomfortable it must be to leave medical school with nearly a quarter of a million dollars in debt, a burden that must affect how young doctors choose what and how they practice. While none of us planned to practice rogue medicine, Dr. Block also bemoans the fact that "people who know nothing about medicine try to tell us what we can or can’t do."

Is his commentary merely a burnout candidate’s last rant before the flames reach his vital organs? Or, is he speaking for the many physicians who have worked long enough to realize that the practice of medicine has moved perilously close to the point where the cost/benefit ratio has tipped to the "it-isn’t-worth-it" side?

While none of my children sought my opinion on medicine as a career path, scores of my patients have shared their dreams of becoming physicians. Whenever this has happened, I egotistically hope that in some way I may have served as a positive role model they wish to emulate. But, I have learned that there are usually more potent motivators lurking in the background. While still puffed up with undeserved pride, I also assume that they are asking for my opinion on their plans . . . which of course they are not.

I ignore the obvious and offer, "Well, it may not be as much fun as it was 20 years ago, but being a pediatrician is still a lot of fun." Of course, this begs the question, If I were in their shoes today, would I apply to medical school?

Hesitant to throw too much cold water on their enthusiasm, I am sure to reassure them that I think they would make wonderful doctors. But, I add that becoming a physician is a long and expensive process. I hope that they are still listening when I add, "You know that nurse practitioners and physician assistants get to do almost all of the cool things I enjoy the most about being a pediatrician, . . . and the training is certainly shorter and less costly."

Of course, choosing either of these nonphysician career paths will rob their parents of the opportunity to introduce them at cocktail parties as "Our daughter, the doctor." But, the trade-off is that they will be more likely to be content with their jobs.

While my observations may be good advice for some of my patients, it leaves unanswered what to do about the malaise that hangs over Dr. Block and many of our colleagues. Educational debt has robbed some young doctors of their entrepreneurial spirit. Pressures from the government and third-party payers have nibbled away at our autonomy. And, the threat of malpractice action has smothered many of us in a blanket of fear.

Even in the face of all this gloom, if one of my grandchildren told me that they really wanted to be a pediatrician and expressed no interest in the nurse practitioner option, I would be candid in describing the erosion that has occurred over the course of my career. But, I would challenge them to tell me another job that could offer them even half of the opportunities to feel needed and appreciated that I have enjoyed. Hopefully, at least some of the frustrating downsides of medicine today will be reversed by the time they enter practice.

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

I recently received an e-mail from a pediatrician who described the awkward situation in her community in which many of the other pediatricians don’t include a genital exam as part of their complete physicals.

While patients who have grown up in her practice expect a complete exam, new patients or the patients of other physicians for whom she is covering are surprised. And, it is usually not a pleasant surprise. I assume she doesn’t force the issue, but I am sure that the differing expectations cast an uncomfortable cloud over the clinical encounter.

This is an unpleasant experience that I have shared with her on more than several occasions. Again, the usual scenario is a new patient who has come from "away"(as we say here in Maine). They may already be skeptical about whether any of us here in the North Country ever finished high school and harbor the unspoken concern that "Vacation Land" is a place that attracts sexual deviants.

As much as we would like to present ourselves as scientists, physicians are no less immune to ambivalence and discomfort with issues of a sexual nature. None of us likes to have our genitals examined regardless of the sex of the examiner, and, most of us have a lingering discomfort being the examiner. I suspect that in large part this discomfort is the result of our concerns about what the examinee and his or her parents are thinking.

This doctor’s e-mail raises at least two issues. First, it is another example of the value of continuity. The young patient who has had his or her genitals examined by the same physician at multiple visits over the course of years is less likely to feel uncomfortable about the process, and this comfort level may delay the inevitable onset of the modesty years.

The bigger issue is really a collection of questions. Should pediatricians include a genital exam when they do complete physicals? The obvious and politically correct answer is "yes." But, my correspondent’s experience and my own say that it isn’t happening. As an example, I have often seen 9-month-old girls with nearly complete labial fusion who have been examined multiple times by other physicians. We can argue about whether there is anything we should do about labial fusion, but the bottom line is that no one was looking for it. Do you share our observations about this inconsistency?

What does constitute a genital exam in a 7-year-old? And, what is its value? I don’t have the answers, but I will share my thoughts. I suspect that a hands-off visual inspection is enough most of the time. Is there pubic hair? Do you see two testicles? Does the penis appear normal in size? This kind of an examination takes seconds and doesn’t require a total strip down. But, it would appear that even this briefest of looks isn’t getting done as often as it should.

So, the biggest question is what should be done about this kind of doctor-to-doctor inconsistency? Is it worth doing anything about? It is certainly creating some discomfort for physicians who have to explain and defend their practices to patients they have never met before. Is it an issue for the American Academy of Pediatrics to tackle? Should it be a topic for state chapters or local pediatric societies to address? Or, should it just be kept as a topic for physician-to-physician discussions in group practices?

I will be interested to hear what you all think about venturing into the nether regions.

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 pdnews@ frontlinemedcom.com.

I recently received an e-mail from a pediatrician who described the awkward situation in her community in which many of the other pediatricians don’t include a genital exam as part of their complete physicals.

While patients who have grown up in her practice expect a complete exam, new patients or the patients of other physicians for whom she is covering are surprised. And, it is usually not a pleasant surprise. I assume she doesn’t force the issue, but I am sure that the differing expectations cast an uncomfortable cloud over the clinical encounter.

This is an unpleasant experience that I have shared with her on more than several occasions. Again, the usual scenario is a new patient who has come from "away"(as we say here in Maine). They may already be skeptical about whether any of us here in the North Country ever finished high school and harbor the unspoken concern that "Vacation Land" is a place that attracts sexual deviants.

As much as we would like to present ourselves as scientists, physicians are no less immune to ambivalence and discomfort with issues of a sexual nature. None of us likes to have our genitals examined regardless of the sex of the examiner, and, most of us have a lingering discomfort being the examiner. I suspect that in large part this discomfort is the result of our concerns about what the examinee and his or her parents are thinking.

This doctor’s e-mail raises at least two issues. First, it is another example of the value of continuity. The young patient who has had his or her genitals examined by the same physician at multiple visits over the course of years is less likely to feel uncomfortable about the process, and this comfort level may delay the inevitable onset of the modesty years.

The bigger issue is really a collection of questions. Should pediatricians include a genital exam when they do complete physicals? The obvious and politically correct answer is "yes." But, my correspondent’s experience and my own say that it isn’t happening. As an example, I have often seen 9-month-old girls with nearly complete labial fusion who have been examined multiple times by other physicians. We can argue about whether there is anything we should do about labial fusion, but the bottom line is that no one was looking for it. Do you share our observations about this inconsistency?

What does constitute a genital exam in a 7-year-old? And, what is its value? I don’t have the answers, but I will share my thoughts. I suspect that a hands-off visual inspection is enough most of the time. Is there pubic hair? Do you see two testicles? Does the penis appear normal in size? This kind of an examination takes seconds and doesn’t require a total strip down. But, it would appear that even this briefest of looks isn’t getting done as often as it should.

So, the biggest question is what should be done about this kind of doctor-to-doctor inconsistency? Is it worth doing anything about? It is certainly creating some discomfort for physicians who have to explain and defend their practices to patients they have never met before. Is it an issue for the American Academy of Pediatrics to tackle? Should it be a topic for state chapters or local pediatric societies to address? Or, should it just be kept as a topic for physician-to-physician discussions in group practices?

I will be interested to hear what you all think about venturing into the nether regions.

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 pdnews@ frontlinemedcom.com.

I recently received an e-mail from a pediatrician who described the awkward situation in her community in which many of the other pediatricians don’t include a genital exam as part of their complete physicals.

While patients who have grown up in her practice expect a complete exam, new patients or the patients of other physicians for whom she is covering are surprised. And, it is usually not a pleasant surprise. I assume she doesn’t force the issue, but I am sure that the differing expectations cast an uncomfortable cloud over the clinical encounter.

This is an unpleasant experience that I have shared with her on more than several occasions. Again, the usual scenario is a new patient who has come from "away"(as we say here in Maine). They may already be skeptical about whether any of us here in the North Country ever finished high school and harbor the unspoken concern that "Vacation Land" is a place that attracts sexual deviants.

As much as we would like to present ourselves as scientists, physicians are no less immune to ambivalence and discomfort with issues of a sexual nature. None of us likes to have our genitals examined regardless of the sex of the examiner, and, most of us have a lingering discomfort being the examiner. I suspect that in large part this discomfort is the result of our concerns about what the examinee and his or her parents are thinking.

This doctor’s e-mail raises at least two issues. First, it is another example of the value of continuity. The young patient who has had his or her genitals examined by the same physician at multiple visits over the course of years is less likely to feel uncomfortable about the process, and this comfort level may delay the inevitable onset of the modesty years.

The bigger issue is really a collection of questions. Should pediatricians include a genital exam when they do complete physicals? The obvious and politically correct answer is "yes." But, my correspondent’s experience and my own say that it isn’t happening. As an example, I have often seen 9-month-old girls with nearly complete labial fusion who have been examined multiple times by other physicians. We can argue about whether there is anything we should do about labial fusion, but the bottom line is that no one was looking for it. Do you share our observations about this inconsistency?

What does constitute a genital exam in a 7-year-old? And, what is its value? I don’t have the answers, but I will share my thoughts. I suspect that a hands-off visual inspection is enough most of the time. Is there pubic hair? Do you see two testicles? Does the penis appear normal in size? This kind of an examination takes seconds and doesn’t require a total strip down. But, it would appear that even this briefest of looks isn’t getting done as often as it should.

So, the biggest question is what should be done about this kind of doctor-to-doctor inconsistency? Is it worth doing anything about? It is certainly creating some discomfort for physicians who have to explain and defend their practices to patients they have never met before. Is it an issue for the American Academy of Pediatrics to tackle? Should it be a topic for state chapters or local pediatric societies to address? Or, should it just be kept as a topic for physician-to-physician discussions in group practices?

I will be interested to hear what you all think about venturing into the nether regions.

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 pdnews@ frontlinemedcom.com.

If you are at your desk or have your laptop or tablet handy, take a look at the screen. No, no, not the glowing pixels. Turn the device off and look at the glass surface. Unless you are someone who carries a bottle of glass cleaner in a holster on your belt, you will see a speckled pattern. Depending on how vigilant you are, what you are looking at is a day, or a week, or in my case, several months’ accumulation of sneezes. I recently learned that each of these droplets of dried snot is called a biofilm. I acquired this addition to my vocabulary by chasing down an article I found in one of our local newspapers. ("Researchers report strep bacteria can last up to several months on objects," Portland (Maine) Press Herald, Dec. 29, 2013).

I found the original article in Infection and Immunology ("Biofilm formation enhances fomite survival of S. pneumoniae and S. pyogenes" 2013 Dec. 26 [doi: 10.1128/IAI.01310-13]), and discovered that it was previously thought that once a fomite dried, the bacteria it contained died in a matter of a few days. However, this assumption was based on microbiologic studies using a plankton-containing broth. Using a different technique, the researchers from Buffalo demonstrated that bacteria can survive in biofilm for months and are virulent enough to infect mice.

This is new information about bacterial survival, but does it warrant inclusion in a lay publication intent on alarming its readers? Even if the bacteria from one sneeze survive only for a couple of days as was once thought, the sneezer is going to continue to replenish his environment with fomites for a week or three. And, by the time he is no longer spewing a spray of fomites, a new cohort of children he has exposed will have taken over his role. So, does it really matter whether bacteria survive for 2 days or 2 months?

There is plenty of evidence that bacteria are crafty survivors that can mutate so quickly that they can fill environmental niches in the blink of an eye. For example, some viruses survive longer on hard smooth surfaces than on soft rough ones. Who would have guessed that? Recently, veterinarians have discovered that some individual bovines are "super shedders" of pathogenic Escherichia coli. This may be the result of a coinfection with parasites. It’s not unreasonable to postulate that certain children are also "super shedders," the modern day equivalents of Typhoid Mary. Should we enter the murky twilight zone of ethics and begin looking for the respiratory syncytial virus (RSV) Jasons in our day cares?

Does all this recent news about germ survival and dispersal mean that we are losing the war? Should we rethink the utility of day cares? Or, should we be steam cleaning them every evening on a daily basis?

On the contrary, this news on bacterial survival is good news. When one considers how many virulent bacteria surround our children, it is encouraging how few of them become seriously ill. Looking back on 40 years of practice, it seems to me that with few exceptions, it wasn’t supervirulent germs that were keeping me busy. It was the variability in host vulnerability that made things interesting. The reason that only a few children in a class became sick with strep was less a result of fomite concentration than the poorly understood child to child differences in immune response. It remains our obligation to be frugal with our use of antibiotics so that when those few unlucky or vulnerable children become ill, we will have an effective arsenal.

Look back at your computer screen. The authors of a recent letter to the editor in the American Journal of Infection Control report that a damp microfiber cloth was effective in removing methicillin-resistant Staphylococcus aureus (MRSA) type A bacteria from iPad screens (Am. J. Infect. Control 2013;41:1136-7). That’s what my grandmother would have suggested.

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

If you are at your desk or have your laptop or tablet handy, take a look at the screen. No, no, not the glowing pixels. Turn the device off and look at the glass surface. Unless you are someone who carries a bottle of glass cleaner in a holster on your belt, you will see a speckled pattern. Depending on how vigilant you are, what you are looking at is a day, or a week, or in my case, several months’ accumulation of sneezes. I recently learned that each of these droplets of dried snot is called a biofilm. I acquired this addition to my vocabulary by chasing down an article I found in one of our local newspapers. ("Researchers report strep bacteria can last up to several months on objects," Portland (Maine) Press Herald, Dec. 29, 2013).

I found the original article in Infection and Immunology ("Biofilm formation enhances fomite survival of S. pneumoniae and S. pyogenes" 2013 Dec. 26 [doi: 10.1128/IAI.01310-13]), and discovered that it was previously thought that once a fomite dried, the bacteria it contained died in a matter of a few days. However, this assumption was based on microbiologic studies using a plankton-containing broth. Using a different technique, the researchers from Buffalo demonstrated that bacteria can survive in biofilm for months and are virulent enough to infect mice.

This is new information about bacterial survival, but does it warrant inclusion in a lay publication intent on alarming its readers? Even if the bacteria from one sneeze survive only for a couple of days as was once thought, the sneezer is going to continue to replenish his environment with fomites for a week or three. And, by the time he is no longer spewing a spray of fomites, a new cohort of children he has exposed will have taken over his role. So, does it really matter whether bacteria survive for 2 days or 2 months?

There is plenty of evidence that bacteria are crafty survivors that can mutate so quickly that they can fill environmental niches in the blink of an eye. For example, some viruses survive longer on hard smooth surfaces than on soft rough ones. Who would have guessed that? Recently, veterinarians have discovered that some individual bovines are "super shedders" of pathogenic Escherichia coli. This may be the result of a coinfection with parasites. It’s not unreasonable to postulate that certain children are also "super shedders," the modern day equivalents of Typhoid Mary. Should we enter the murky twilight zone of ethics and begin looking for the respiratory syncytial virus (RSV) Jasons in our day cares?

Does all this recent news about germ survival and dispersal mean that we are losing the war? Should we rethink the utility of day cares? Or, should we be steam cleaning them every evening on a daily basis?

On the contrary, this news on bacterial survival is good news. When one considers how many virulent bacteria surround our children, it is encouraging how few of them become seriously ill. Looking back on 40 years of practice, it seems to me that with few exceptions, it wasn’t supervirulent germs that were keeping me busy. It was the variability in host vulnerability that made things interesting. The reason that only a few children in a class became sick with strep was less a result of fomite concentration than the poorly understood child to child differences in immune response. It remains our obligation to be frugal with our use of antibiotics so that when those few unlucky or vulnerable children become ill, we will have an effective arsenal.

Look back at your computer screen. The authors of a recent letter to the editor in the American Journal of Infection Control report that a damp microfiber cloth was effective in removing methicillin-resistant Staphylococcus aureus (MRSA) type A bacteria from iPad screens (Am. J. Infect. Control 2013;41:1136-7). That’s what my grandmother would have suggested.

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

If you are at your desk or have your laptop or tablet handy, take a look at the screen. No, no, not the glowing pixels. Turn the device off and look at the glass surface. Unless you are someone who carries a bottle of glass cleaner in a holster on your belt, you will see a speckled pattern. Depending on how vigilant you are, what you are looking at is a day, or a week, or in my case, several months’ accumulation of sneezes. I recently learned that each of these droplets of dried snot is called a biofilm. I acquired this addition to my vocabulary by chasing down an article I found in one of our local newspapers. ("Researchers report strep bacteria can last up to several months on objects," Portland (Maine) Press Herald, Dec. 29, 2013).

I found the original article in Infection and Immunology ("Biofilm formation enhances fomite survival of S. pneumoniae and S. pyogenes" 2013 Dec. 26 [doi: 10.1128/IAI.01310-13]), and discovered that it was previously thought that once a fomite dried, the bacteria it contained died in a matter of a few days. However, this assumption was based on microbiologic studies using a plankton-containing broth. Using a different technique, the researchers from Buffalo demonstrated that bacteria can survive in biofilm for months and are virulent enough to infect mice.

This is new information about bacterial survival, but does it warrant inclusion in a lay publication intent on alarming its readers? Even if the bacteria from one sneeze survive only for a couple of days as was once thought, the sneezer is going to continue to replenish his environment with fomites for a week or three. And, by the time he is no longer spewing a spray of fomites, a new cohort of children he has exposed will have taken over his role. So, does it really matter whether bacteria survive for 2 days or 2 months?

There is plenty of evidence that bacteria are crafty survivors that can mutate so quickly that they can fill environmental niches in the blink of an eye. For example, some viruses survive longer on hard smooth surfaces than on soft rough ones. Who would have guessed that? Recently, veterinarians have discovered that some individual bovines are "super shedders" of pathogenic Escherichia coli. This may be the result of a coinfection with parasites. It’s not unreasonable to postulate that certain children are also "super shedders," the modern day equivalents of Typhoid Mary. Should we enter the murky twilight zone of ethics and begin looking for the respiratory syncytial virus (RSV) Jasons in our day cares?

Does all this recent news about germ survival and dispersal mean that we are losing the war? Should we rethink the utility of day cares? Or, should we be steam cleaning them every evening on a daily basis?

On the contrary, this news on bacterial survival is good news. When one considers how many virulent bacteria surround our children, it is encouraging how few of them become seriously ill. Looking back on 40 years of practice, it seems to me that with few exceptions, it wasn’t supervirulent germs that were keeping me busy. It was the variability in host vulnerability that made things interesting. The reason that only a few children in a class became sick with strep was less a result of fomite concentration than the poorly understood child to child differences in immune response. It remains our obligation to be frugal with our use of antibiotics so that when those few unlucky or vulnerable children become ill, we will have an effective arsenal.

Look back at your computer screen. The authors of a recent letter to the editor in the American Journal of Infection Control report that a damp microfiber cloth was effective in removing methicillin-resistant Staphylococcus aureus (MRSA) type A bacteria from iPad screens (Am. J. Infect. Control 2013;41:1136-7). That’s what my grandmother would have suggested.

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].

Every so often I have been offered an opportunity to donate a week or 2 of my pediatric skills in an underdeveloped country, mostly in Central and South America, but occasionally in Africa. The offers sound exciting, but the din from a chaotic waiting room and exam rooms overflowing with sick children made it difficult to imagine extracting myself long enough to take advantage of those opportunities to practice abroad. With weekends off in short supply, I would always fall back on the flimsy excuse that charity begins at home. I am embarrassed to admit that in those preretirement days, time was money. The lost income during my time away and the cost of the airfare left me feeling a bit uneasy. But now, I have been made redundant, and time and money have been disconnected. Time is just time, and I have enough to share.

So, when I received an e-mail a few days ago, offering me the chance to work with children in Central America, I had time to consider it seriously. I would be expected to pay about $700 in room and board and, of course, purchase my own plane ticket. I would be working with a group of other North American physicians and a few translators to supplement a full-time physician.

It sounded appealing. By March, I would have had enough cross-country skiing and snow shoveling and would be ready to enjoy some warm weather. And, of course, the chance to work with children again would make it a real feel-good experience.

I began to envision what my days in the tropics would be like. Shorts and a loose-fitting flowered shirt, I could wear those new sandals I bought at that end-of-summer sale last year. But, what exactly would I be doing? I doubt there would be many, "Does my child have attention-deficit/hyperactivity disorder?" discussions. Was I going to see any children with functional abdominal pain? I’m good at that, particularly if it is triggered by school anxiety. Although I’m pretty skillful with an otoscope and a stethoscope, the skills that have become the sharpest over the last 4 decades are those of taking a targeted history and then sorting out the red herrings. Most of the time, I have arrived at the diagnosis before I even put the stethoscope in my ears.

As I considered what I have become, I realized that my skills are primarily language based, and I don’t speak Spanish. Of course, there would be translators, but in the short space of a week, would the translator and I understand each other well to make sure that my questions and the patients’ answers were properly nuanced. Like all experienced physicians, I also read body language, but I have noticed that different cultures speak body language with accents that I sometimes don’t understand. I’m comfortable diagnosing the common dermatologic problems in North America, but I fear that just as I wouldn’t recognize the tropical birds, I would need a serious field guide to the rashes of Central America.

Having listened to other physicians who have been on similar missions, I am sure that I would enjoy myself. I would see new flora and fauna, eat some different foods, and meet some wonderful people. I have no doubt that everyone would make me feel appreciated.

But, then my thoughts drifted back to money, the damn money. I now have enough time and money so that I can easily afford the adventure. But, if my primary goal was to improve the health of disadvantaged children, would my thousand dollars do more good if I wrote a check for a refrigerator to store vaccines or a pump and filter to make safe water more available? How valuable a gift is a week of my language-challenged skills going to be?

I have time to decide, and I will talk to some physicians who have made the trip before. If I decide to go, I’ll send you all a note from the tropics to let you know how it went.

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 pdnews@ frontlinemedcom.com.

Every so often I have been offered an opportunity to donate a week or 2 of my pediatric skills in an underdeveloped country, mostly in Central and South America, but occasionally in Africa. The offers sound exciting, but the din from a chaotic waiting room and exam rooms overflowing with sick children made it difficult to imagine extracting myself long enough to take advantage of those opportunities to practice abroad. With weekends off in short supply, I would always fall back on the flimsy excuse that charity begins at home. I am embarrassed to admit that in those preretirement days, time was money. The lost income during my time away and the cost of the airfare left me feeling a bit uneasy. But now, I have been made redundant, and time and money have been disconnected. Time is just time, and I have enough to share.

So, when I received an e-mail a few days ago, offering me the chance to work with children in Central America, I had time to consider it seriously. I would be expected to pay about $700 in room and board and, of course, purchase my own plane ticket. I would be working with a group of other North American physicians and a few translators to supplement a full-time physician.

It sounded appealing. By March, I would have had enough cross-country skiing and snow shoveling and would be ready to enjoy some warm weather. And, of course, the chance to work with children again would make it a real feel-good experience.

I began to envision what my days in the tropics would be like. Shorts and a loose-fitting flowered shirt, I could wear those new sandals I bought at that end-of-summer sale last year. But, what exactly would I be doing? I doubt there would be many, "Does my child have attention-deficit/hyperactivity disorder?" discussions. Was I going to see any children with functional abdominal pain? I’m good at that, particularly if it is triggered by school anxiety. Although I’m pretty skillful with an otoscope and a stethoscope, the skills that have become the sharpest over the last 4 decades are those of taking a targeted history and then sorting out the red herrings. Most of the time, I have arrived at the diagnosis before I even put the stethoscope in my ears.

As I considered what I have become, I realized that my skills are primarily language based, and I don’t speak Spanish. Of course, there would be translators, but in the short space of a week, would the translator and I understand each other well to make sure that my questions and the patients’ answers were properly nuanced. Like all experienced physicians, I also read body language, but I have noticed that different cultures speak body language with accents that I sometimes don’t understand. I’m comfortable diagnosing the common dermatologic problems in North America, but I fear that just as I wouldn’t recognize the tropical birds, I would need a serious field guide to the rashes of Central America.

Having listened to other physicians who have been on similar missions, I am sure that I would enjoy myself. I would see new flora and fauna, eat some different foods, and meet some wonderful people. I have no doubt that everyone would make me feel appreciated.

But, then my thoughts drifted back to money, the damn money. I now have enough time and money so that I can easily afford the adventure. But, if my primary goal was to improve the health of disadvantaged children, would my thousand dollars do more good if I wrote a check for a refrigerator to store vaccines or a pump and filter to make safe water more available? How valuable a gift is a week of my language-challenged skills going to be?

I have time to decide, and I will talk to some physicians who have made the trip before. If I decide to go, I’ll send you all a note from the tropics to let you know how it went.

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 pdnews@ frontlinemedcom.com.

Every so often I have been offered an opportunity to donate a week or 2 of my pediatric skills in an underdeveloped country, mostly in Central and South America, but occasionally in Africa. The offers sound exciting, but the din from a chaotic waiting room and exam rooms overflowing with sick children made it difficult to imagine extracting myself long enough to take advantage of those opportunities to practice abroad. With weekends off in short supply, I would always fall back on the flimsy excuse that charity begins at home. I am embarrassed to admit that in those preretirement days, time was money. The lost income during my time away and the cost of the airfare left me feeling a bit uneasy. But now, I have been made redundant, and time and money have been disconnected. Time is just time, and I have enough to share.

So, when I received an e-mail a few days ago, offering me the chance to work with children in Central America, I had time to consider it seriously. I would be expected to pay about $700 in room and board and, of course, purchase my own plane ticket. I would be working with a group of other North American physicians and a few translators to supplement a full-time physician.

It sounded appealing. By March, I would have had enough cross-country skiing and snow shoveling and would be ready to enjoy some warm weather. And, of course, the chance to work with children again would make it a real feel-good experience.

I began to envision what my days in the tropics would be like. Shorts and a loose-fitting flowered shirt, I could wear those new sandals I bought at that end-of-summer sale last year. But, what exactly would I be doing? I doubt there would be many, "Does my child have attention-deficit/hyperactivity disorder?" discussions. Was I going to see any children with functional abdominal pain? I’m good at that, particularly if it is triggered by school anxiety. Although I’m pretty skillful with an otoscope and a stethoscope, the skills that have become the sharpest over the last 4 decades are those of taking a targeted history and then sorting out the red herrings. Most of the time, I have arrived at the diagnosis before I even put the stethoscope in my ears.

As I considered what I have become, I realized that my skills are primarily language based, and I don’t speak Spanish. Of course, there would be translators, but in the short space of a week, would the translator and I understand each other well to make sure that my questions and the patients’ answers were properly nuanced. Like all experienced physicians, I also read body language, but I have noticed that different cultures speak body language with accents that I sometimes don’t understand. I’m comfortable diagnosing the common dermatologic problems in North America, but I fear that just as I wouldn’t recognize the tropical birds, I would need a serious field guide to the rashes of Central America.

Having listened to other physicians who have been on similar missions, I am sure that I would enjoy myself. I would see new flora and fauna, eat some different foods, and meet some wonderful people. I have no doubt that everyone would make me feel appreciated.

But, then my thoughts drifted back to money, the damn money. I now have enough time and money so that I can easily afford the adventure. But, if my primary goal was to improve the health of disadvantaged children, would my thousand dollars do more good if I wrote a check for a refrigerator to store vaccines or a pump and filter to make safe water more available? How valuable a gift is a week of my language-challenged skills going to be?

I have time to decide, and I will talk to some physicians who have made the trip before. If I decide to go, I’ll send you all a note from the tropics to let you know how it went.

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 pdnews@ frontlinemedcom.com.

In the flurry of responses I received in response to my column, "Heresy," about annual checkups on older children (November 2013, p. 14) was an e-mail from a pediatrician who observed that while she doesn’t advocate annual checkups on older children, she tries to see her patients for as many of their visits as she can. I suspect that whether we are believers in annual checkups or not, we all share her goal.

And why is that? It’s because we feel that if a family has chosen us to be their pediatrician, availability is something we owe them as part of that unwritten contract. But it’s also because we realize a doctor-patient relationship is not created in a day and certainly not in a half-hour well-child visit. It is an evolving process that is the summation of multiple, sometimes very brief, encounters: a sore throat here, a sprained ankle there, maybe even a chance encounter in the express checkout line at the grocery store. Over time, repeated visits foster a familiarity that allows the physician to make more accurate diagnoses and suggest the most effective therapies.

Hopefully, familiarity also breeds confidence and comfort in the patient and family. One occasionally hears the complaint that "in a small town everyone knows your business," but most people prefer the comfort that comes from repeated encounters with the same cashier, hairdresser, and crossing guard, whether these frequent meetings occur here on the rural coast of Maine or in a four-square block neighborhood in a large city.

But let’s be honest, how good are we at providing that kind of continuity in our offices? During the 10 years I was in solo practice, it was easy. My patients could count on seeing me 94% of the time. However, for a variety of good and bad reasons, solo practice is no longer sustainable. It certainly wasn’t for me. Group practice is the reality, and groups are growing larger.

The shared coverage group model by definition means that sometimes our patients will not be seeing their chosen physician as often as they would in the solo practice model. But I worry that many practices aren’t doing enough to preserve continuity. How often do you hear people complain, "I never get to see my own doctor" or "Every time I go in, I see someone different?"

How continuity-friendly is your group and your appointment schedule? Do you leave enough same-day slots to maximize the chances that your patients will get to see you when they call with problems? Is the mix of sick and well visits seasonally adjusted to match the ebb and flow of illness in the community? Are the receptionists and nurses committed to having patients see their own physicians?

Another trend that has challenged the limits of continuity is the shift toward more physicians working less than full time. Driven by the struggle to balance our personal and professional lives, many of us put in fewer hours in the office, making it more likely that our patients will be seeing another provider. I suspect that some part-time work schedules are more continuity friendly than others. For example, do we know whether a pediatrician who works four 5-hour days is more available to his or her patients than one who works three 7-hour days? If we believe that continuity is important (and the patients certainly do) then that is the kind of question we should be asking ourselves.

With the more widespread adoption of electronic medical records, there may come the day when we will be able to promise our patients, "We are all on the same page." However, I suspect the patients will continue to complain: "Great, but I would feel much better if I could see the same face more often when I come into the office."

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say ‘No’ to Your Toddler." E-mail him at [email protected].

In the flurry of responses I received in response to my column, "Heresy," about annual checkups on older children (November 2013, p. 14) was an e-mail from a pediatrician who observed that while she doesn’t advocate annual checkups on older children, she tries to see her patients for as many of their visits as she can. I suspect that whether we are believers in annual checkups or not, we all share her goal.

And why is that? It’s because we feel that if a family has chosen us to be their pediatrician, availability is something we owe them as part of that unwritten contract. But it’s also because we realize a doctor-patient relationship is not created in a day and certainly not in a half-hour well-child visit. It is an evolving process that is the summation of multiple, sometimes very brief, encounters: a sore throat here, a sprained ankle there, maybe even a chance encounter in the express checkout line at the grocery store. Over time, repeated visits foster a familiarity that allows the physician to make more accurate diagnoses and suggest the most effective therapies.

Hopefully, familiarity also breeds confidence and comfort in the patient and family. One occasionally hears the complaint that "in a small town everyone knows your business," but most people prefer the comfort that comes from repeated encounters with the same cashier, hairdresser, and crossing guard, whether these frequent meetings occur here on the rural coast of Maine or in a four-square block neighborhood in a large city.

But let’s be honest, how good are we at providing that kind of continuity in our offices? During the 10 years I was in solo practice, it was easy. My patients could count on seeing me 94% of the time. However, for a variety of good and bad reasons, solo practice is no longer sustainable. It certainly wasn’t for me. Group practice is the reality, and groups are growing larger.

The shared coverage group model by definition means that sometimes our patients will not be seeing their chosen physician as often as they would in the solo practice model. But I worry that many practices aren’t doing enough to preserve continuity. How often do you hear people complain, "I never get to see my own doctor" or "Every time I go in, I see someone different?"

How continuity-friendly is your group and your appointment schedule? Do you leave enough same-day slots to maximize the chances that your patients will get to see you when they call with problems? Is the mix of sick and well visits seasonally adjusted to match the ebb and flow of illness in the community? Are the receptionists and nurses committed to having patients see their own physicians?

Another trend that has challenged the limits of continuity is the shift toward more physicians working less than full time. Driven by the struggle to balance our personal and professional lives, many of us put in fewer hours in the office, making it more likely that our patients will be seeing another provider. I suspect that some part-time work schedules are more continuity friendly than others. For example, do we know whether a pediatrician who works four 5-hour days is more available to his or her patients than one who works three 7-hour days? If we believe that continuity is important (and the patients certainly do) then that is the kind of question we should be asking ourselves.

With the more widespread adoption of electronic medical records, there may come the day when we will be able to promise our patients, "We are all on the same page." However, I suspect the patients will continue to complain: "Great, but I would feel much better if I could see the same face more often when I come into the office."

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say ‘No’ to Your Toddler." E-mail him at [email protected].

In the flurry of responses I received in response to my column, "Heresy," about annual checkups on older children (November 2013, p. 14) was an e-mail from a pediatrician who observed that while she doesn’t advocate annual checkups on older children, she tries to see her patients for as many of their visits as she can. I suspect that whether we are believers in annual checkups or not, we all share her goal.

And why is that? It’s because we feel that if a family has chosen us to be their pediatrician, availability is something we owe them as part of that unwritten contract. But it’s also because we realize a doctor-patient relationship is not created in a day and certainly not in a half-hour well-child visit. It is an evolving process that is the summation of multiple, sometimes very brief, encounters: a sore throat here, a sprained ankle there, maybe even a chance encounter in the express checkout line at the grocery store. Over time, repeated visits foster a familiarity that allows the physician to make more accurate diagnoses and suggest the most effective therapies.

Hopefully, familiarity also breeds confidence and comfort in the patient and family. One occasionally hears the complaint that "in a small town everyone knows your business," but most people prefer the comfort that comes from repeated encounters with the same cashier, hairdresser, and crossing guard, whether these frequent meetings occur here on the rural coast of Maine or in a four-square block neighborhood in a large city.

But let’s be honest, how good are we at providing that kind of continuity in our offices? During the 10 years I was in solo practice, it was easy. My patients could count on seeing me 94% of the time. However, for a variety of good and bad reasons, solo practice is no longer sustainable. It certainly wasn’t for me. Group practice is the reality, and groups are growing larger.

The shared coverage group model by definition means that sometimes our patients will not be seeing their chosen physician as often as they would in the solo practice model. But I worry that many practices aren’t doing enough to preserve continuity. How often do you hear people complain, "I never get to see my own doctor" or "Every time I go in, I see someone different?"

How continuity-friendly is your group and your appointment schedule? Do you leave enough same-day slots to maximize the chances that your patients will get to see you when they call with problems? Is the mix of sick and well visits seasonally adjusted to match the ebb and flow of illness in the community? Are the receptionists and nurses committed to having patients see their own physicians?

Another trend that has challenged the limits of continuity is the shift toward more physicians working less than full time. Driven by the struggle to balance our personal and professional lives, many of us put in fewer hours in the office, making it more likely that our patients will be seeing another provider. I suspect that some part-time work schedules are more continuity friendly than others. For example, do we know whether a pediatrician who works four 5-hour days is more available to his or her patients than one who works three 7-hour days? If we believe that continuity is important (and the patients certainly do) then that is the kind of question we should be asking ourselves.

With the more widespread adoption of electronic medical records, there may come the day when we will be able to promise our patients, "We are all on the same page." However, I suspect the patients will continue to complain: "Great, but I would feel much better if I could see the same face more often when I come into the office."

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].

Another heretic

I could not agree more with Dr. William G. Wilkoff’s Letters From Maine column entitled "Heresy" (November 2013, p. 14) that suggests that pediatricians should drop doing well-child exams on healthy school-age children! Having been at this for about 30 years, I can well remember not seeing older kids for 3 or 4 years at a stretch. There were a number of reasons for this: 1) They were perfectly healthy; 2) The parents had to pay for the visit (i.e., there was some disincentive to unnecessary utilization of medical services); 3) Schools did not require a form for every sneeze, fever, or sports activity; 4) The insurance companies were not telling us how to practice medicine.

What I don’t remember is any major medical problems that I discovered on these episodic well visits.

Currently, our office is engaged in a major campaign to bring in every adolescent who is "behind" in his or her yearly physical, because we are not meeting the insurance companies’ "quality metrics" and are thus missing uncaptured revenue. It seems as if every time I have a break in my 10-minute per sick patient schedule, I am asked if I can "squeeze in" another physical.

Worse yet, we have just added 1-month and 2-1/2 year physicals (after deciding many years back that they really were unnecessary), again for the same reasons!

Alas, I must ask you not to use my name, as my employer does not like squeaky wheels, but I do feel much better after whining to someone other than my wife. (Just don’t ask me how I feel about the indignities I just endured taking my recertification exam at a secured and proctored testing center.)

Anyway, thanks for articulating so many issues that are relevant to we "real" pediatricians.

Anonymous

I disagree

With all due respect for Dr. Wilkoff’s emeritus status, I politely disagree that pediatricians should not do routine physical exams on healthy older children. Gestalt: An integrated entity where the sum is greater than the added individual parts. That is what regular annual physical exams for older children represent to me. After 29-plus years of pediatric practice, it is hard for me to believe that school-based health care alone can uniformly provide equivalent evaluations on older children and teens. Yes, they can do hypertension and body mass index screenings. Yes, school nurses are an integral part of pediatric care, identifying children who need further evaluations and treatments, but they have distinctive educational and experience-based limitations. We diminish our profession when we degrade the importance of the annual pediatric exam.

So you may ask me, what more can the pediatrician provide? How about:

• Providing age-based anticipatory guidance.

• Providing the most up-to-date immunization information and discussions in our immunization-adverse society.

• Clarifying for families the frequent misinformation presented by television, the Internet, and social media.

• Assessing teen, social, and behavioral issues for children and families. (Example: More than 50% of initial attention-deficit/hyperactivity disorder inquiries in my practice come at a routine well-child visit.)

• Assessing risk factors and counseling for cardiovascular and other adult diseases.

• Assessing psychological issues for at-risk children.

• Providing continuity of care and identifying family issues.

• Assisting families by accessing comprehensive community resources when needed.

• Providing transition counseling for older teens as they enter college or the workforce.

Of course, all of this cannot be done at one well visit, but over the course of multiple annual exams, pediatricians can provide superior continuity of care. Perhaps I am a glutton for punishment. While some may groan as the summer approaches, I look forward to physical exams and touching base with my older patients. Fully 40%-50% of older children or teens with no identifiable issues at initial intake for a physical exam will have additional diagnoses at checkout. This occurs based only on simple questions and conversations during the exam. This is the gestalt of good pediatric care. So no, Dr. Wilkoff, your suggestion is not heresy, it is just not smart!

Ivri K. Messinger, D.O.

San Marcos, Tex.

Count me in

Count me a fellow heretic! I completely agree that my healthy school-age patients would thrive just as well without their annual well-child visits with me! Of course, we all enjoy maintaining the relationship with our families, and the visits are well reimbursed, but is there really any medical benefit?

I think not.

Vaccines and appropriate screening could be performed by registered nurses, freeing up slots for the pediatricians to see kids currently running to the urgent care centers.

My partners may consider excommunicating me, but I agree with you!

Preston Herrington, M.D.

Farmington, N.M.

Annual checkup is essential

I am a pediatrician in Brookline, Mass., and have been in practice for 18 years. I am a huge fan of your column. While I completely agree that at first glance, the annual pediatric checkup doesn’t seem to add much to our patients’ health, I believe it is essential. It is part of the process of building a relationship so that when those angst-filled teen years come along, the patients feel as if you have known them forever. And perhaps they will tell you their concerns before they admit them to any other adult. Or that’s the hope, anyway.

I think if kids viewed their doctor only as "the strep throat person," it would diminish the role we play in their lives, and quite frankly, vice versa.

Susan Laster, M.D.

Brookline, Mass.

Fostering better relations

Let me start by saying I am a fan of your column, and have been for years. I am a (slightly) younger than you (based on your updated photo) general pediatrician, and I generally agree with your homespun, sensible advice regarding patients, practice, and pediatrics. I have to disagree with your column on reassessing the value of well visits for older well children.

I certainly don’t find a lot of earth-shattering exam findings at these visits (although there are some rare surprises that need to be dealt with). I think the benefit of these appointments is found in the myriad of questions and concerns a parent has about raising their child in this modern era. I think that gentle reassurance from me that a mother is handling behavioral/school/social media situations properly, or (hopefully) gentle prodding from me if mom is off base, is valuable, even to the parents of the healthiest child. I always have tried to maintain all well-child visits with my own patients – I practice in a midsize (nine-provider) group.

I think that over time, the better a family gets to know me as I help them with little problems, the more likely they are to follow my advice when bigger problems crop up. Time constraints will always be with us, but I don’t think giving up on the "well visits" is the right way to grease the wheel.

Tim Welby, M.D.

Dickson City, Pa.

Pediatrician as preventative

I usually agree with your Letters from Maine column, but I don’t agree with your latest one entitled "Heresy." I certainly agree with you that TV, the Internet, and social media sites are powerful communicators to children, and that is exactly why I strongly disagree with your position.

The pediatrician can and must be a source of correct advice and information, and is in the best position to counteract a lot of false information the child may be receiving. As pediatricians, we are in the prevention business, and the annual checkup is when we can best do our work, and is probably the only time.

Certainly the preteen and teen years must be carefully monitored. Doing away with the yearly visits would only lead to disaster.

Alvin N. Eden, M.D.

Forest Hills, N.Y.

Mostly agree

I truly appreciate your broaching this topic of "heresy," particularly in your neck of the woods where the stakes have been quite high.

That being said, I do agree with you for the most part. I have been doing my pediatric thing in Michigan for 38 years, and have probably come up with as many startling findings on a well-child exam after age 5 years as you have. It is also true (like it or not) that our newly acquired "business model" mentality drains significant time and energy out of all of us, and our lives can be much better spent not doing well exams in the well population.

However, I still worry about kids in their latency period, because I believe that still waters run deep. I hate it when someone shows up at age 15 with a significant drug problem who has not seen us for 5 years.

I strongly believe these kids should not be shelved. Their psychosocial development is important and can be addressed, as it is in just about every other country, by physician extenders. As issues of "turf" are well ingrained in us, who controls this (health department, practice) could be a topic for another Letter from Maine.

Arthur N. Feinberg, M.D.

Department of Pediatrics

Western Michigan University School of Medicine

Kalamazoo

Most schools not adequate

Dr. Wilkoff suggests in his column "Heresy" that we outsource well-check measurements and immunizations to schools. Implicit here is an assumption that all school-age children attend a well-funded public school system with adequate resources to take on this project. While Maine school nurses may be well versed in best practices regarding blood pressure cuff size and immunization protocols, our Tennessee school nurses (in my county, 1 registered nurse for 11 county schools) do not have the resources to, say, make sure their school’s vaccine refrigerators have VFC-compliant thermometry.

The nature of any well-designed screening program, by definition, is that the number of normals will substantially exceed the number of abnormals. Checkups are screening visits. "Targeted screening" implies that there is a simple, validated prescreen upon which to apply the second-tier targeted screen. Dr. Wilkoff suggests we use a nonexistent prescreen when he writes, "For the school-age child who is growing well and doesn’t have any chronic conditions or genetic predispositions, do annual physical exams make sense?" How, exactly, will I know which children are growing well and don’t have chronic conditions or genetic predispositions unless I’m doing checkups on them?

Suzanne Berman, M.D.

Crossville, Tenn.

Another heretic

I could not agree more with Dr. William G. Wilkoff’s Letters From Maine column entitled "Heresy" (November 2013, p. 14) that suggests that pediatricians should drop doing well-child exams on healthy school-age children! Having been at this for about 30 years, I can well remember not seeing older kids for 3 or 4 years at a stretch. There were a number of reasons for this: 1) They were perfectly healthy; 2) The parents had to pay for the visit (i.e., there was some disincentive to unnecessary utilization of medical services); 3) Schools did not require a form for every sneeze, fever, or sports activity; 4) The insurance companies were not telling us how to practice medicine.

What I don’t remember is any major medical problems that I discovered on these episodic well visits.

Currently, our office is engaged in a major campaign to bring in every adolescent who is "behind" in his or her yearly physical, because we are not meeting the insurance companies’ "quality metrics" and are thus missing uncaptured revenue. It seems as if every time I have a break in my 10-minute per sick patient schedule, I am asked if I can "squeeze in" another physical.

Worse yet, we have just added 1-month and 2-1/2 year physicals (after deciding many years back that they really were unnecessary), again for the same reasons!

Alas, I must ask you not to use my name, as my employer does not like squeaky wheels, but I do feel much better after whining to someone other than my wife. (Just don’t ask me how I feel about the indignities I just endured taking my recertification exam at a secured and proctored testing center.)

Anyway, thanks for articulating so many issues that are relevant to we "real" pediatricians.

Anonymous

I disagree

With all due respect for Dr. Wilkoff’s emeritus status, I politely disagree that pediatricians should not do routine physical exams on healthy older children. Gestalt: An integrated entity where the sum is greater than the added individual parts. That is what regular annual physical exams for older children represent to me. After 29-plus years of pediatric practice, it is hard for me to believe that school-based health care alone can uniformly provide equivalent evaluations on older children and teens. Yes, they can do hypertension and body mass index screenings. Yes, school nurses are an integral part of pediatric care, identifying children who need further evaluations and treatments, but they have distinctive educational and experience-based limitations. We diminish our profession when we degrade the importance of the annual pediatric exam.

So you may ask me, what more can the pediatrician provide? How about:

• Providing age-based anticipatory guidance.

• Providing the most up-to-date immunization information and discussions in our immunization-adverse society.

• Clarifying for families the frequent misinformation presented by television, the Internet, and social media.

• Assessing teen, social, and behavioral issues for children and families. (Example: More than 50% of initial attention-deficit/hyperactivity disorder inquiries in my practice come at a routine well-child visit.)

• Assessing risk factors and counseling for cardiovascular and other adult diseases.

• Assessing psychological issues for at-risk children.

• Providing continuity of care and identifying family issues.

• Assisting families by accessing comprehensive community resources when needed.

• Providing transition counseling for older teens as they enter college or the workforce.

Of course, all of this cannot be done at one well visit, but over the course of multiple annual exams, pediatricians can provide superior continuity of care. Perhaps I am a glutton for punishment. While some may groan as the summer approaches, I look forward to physical exams and touching base with my older patients. Fully 40%-50% of older children or teens with no identifiable issues at initial intake for a physical exam will have additional diagnoses at checkout. This occurs based only on simple questions and conversations during the exam. This is the gestalt of good pediatric care. So no, Dr. Wilkoff, your suggestion is not heresy, it is just not smart!

Ivri K. Messinger, D.O.

San Marcos, Tex.

Count me in

Count me a fellow heretic! I completely agree that my healthy school-age patients would thrive just as well without their annual well-child visits with me! Of course, we all enjoy maintaining the relationship with our families, and the visits are well reimbursed, but is there really any medical benefit?

I think not.

Vaccines and appropriate screening could be performed by registered nurses, freeing up slots for the pediatricians to see kids currently running to the urgent care centers.

My partners may consider excommunicating me, but I agree with you!

Preston Herrington, M.D.

Farmington, N.M.

Annual checkup is essential

I am a pediatrician in Brookline, Mass., and have been in practice for 18 years. I am a huge fan of your column. While I completely agree that at first glance, the annual pediatric checkup doesn’t seem to add much to our patients’ health, I believe it is essential. It is part of the process of building a relationship so that when those angst-filled teen years come along, the patients feel as if you have known them forever. And perhaps they will tell you their concerns before they admit them to any other adult. Or that’s the hope, anyway.

I think if kids viewed their doctor only as "the strep throat person," it would diminish the role we play in their lives, and quite frankly, vice versa.

Susan Laster, M.D.

Brookline, Mass.

Fostering better relations

Let me start by saying I am a fan of your column, and have been for years. I am a (slightly) younger than you (based on your updated photo) general pediatrician, and I generally agree with your homespun, sensible advice regarding patients, practice, and pediatrics. I have to disagree with your column on reassessing the value of well visits for older well children.

I certainly don’t find a lot of earth-shattering exam findings at these visits (although there are some rare surprises that need to be dealt with). I think the benefit of these appointments is found in the myriad of questions and concerns a parent has about raising their child in this modern era. I think that gentle reassurance from me that a mother is handling behavioral/school/social media situations properly, or (hopefully) gentle prodding from me if mom is off base, is valuable, even to the parents of the healthiest child. I always have tried to maintain all well-child visits with my own patients – I practice in a midsize (nine-provider) group.

I think that over time, the better a family gets to know me as I help them with little problems, the more likely they are to follow my advice when bigger problems crop up. Time constraints will always be with us, but I don’t think giving up on the "well visits" is the right way to grease the wheel.

Tim Welby, M.D.

Dickson City, Pa.

Pediatrician as preventative

I usually agree with your Letters from Maine column, but I don’t agree with your latest one entitled "Heresy." I certainly agree with you that TV, the Internet, and social media sites are powerful communicators to children, and that is exactly why I strongly disagree with your position.

The pediatrician can and must be a source of correct advice and information, and is in the best position to counteract a lot of false information the child may be receiving. As pediatricians, we are in the prevention business, and the annual checkup is when we can best do our work, and is probably the only time.

Certainly the preteen and teen years must be carefully monitored. Doing away with the yearly visits would only lead to disaster.

Alvin N. Eden, M.D.

Forest Hills, N.Y.

Mostly agree

I truly appreciate your broaching this topic of "heresy," particularly in your neck of the woods where the stakes have been quite high.

That being said, I do agree with you for the most part. I have been doing my pediatric thing in Michigan for 38 years, and have probably come up with as many startling findings on a well-child exam after age 5 years as you have. It is also true (like it or not) that our newly acquired "business model" mentality drains significant time and energy out of all of us, and our lives can be much better spent not doing well exams in the well population.

However, I still worry about kids in their latency period, because I believe that still waters run deep. I hate it when someone shows up at age 15 with a significant drug problem who has not seen us for 5 years.

I strongly believe these kids should not be shelved. Their psychosocial development is important and can be addressed, as it is in just about every other country, by physician extenders. As issues of "turf" are well ingrained in us, who controls this (health department, practice) could be a topic for another Letter from Maine.

Arthur N. Feinberg, M.D.

Department of Pediatrics

Western Michigan University School of Medicine

Kalamazoo

Most schools not adequate

Dr. Wilkoff suggests in his column "Heresy" that we outsource well-check measurements and immunizations to schools. Implicit here is an assumption that all school-age children attend a well-funded public school system with adequate resources to take on this project. While Maine school nurses may be well versed in best practices regarding blood pressure cuff size and immunization protocols, our Tennessee school nurses (in my county, 1 registered nurse for 11 county schools) do not have the resources to, say, make sure their school’s vaccine refrigerators have VFC-compliant thermometry.

The nature of any well-designed screening program, by definition, is that the number of normals will substantially exceed the number of abnormals. Checkups are screening visits. "Targeted screening" implies that there is a simple, validated prescreen upon which to apply the second-tier targeted screen. Dr. Wilkoff suggests we use a nonexistent prescreen when he writes, "For the school-age child who is growing well and doesn’t have any chronic conditions or genetic predispositions, do annual physical exams make sense?" How, exactly, will I know which children are growing well and don’t have chronic conditions or genetic predispositions unless I’m doing checkups on them?

Suzanne Berman, M.D.

Crossville, Tenn.

Another heretic

I could not agree more with Dr. William G. Wilkoff’s Letters From Maine column entitled "Heresy" (November 2013, p. 14) that suggests that pediatricians should drop doing well-child exams on healthy school-age children! Having been at this for about 30 years, I can well remember not seeing older kids for 3 or 4 years at a stretch. There were a number of reasons for this: 1) They were perfectly healthy; 2) The parents had to pay for the visit (i.e., there was some disincentive to unnecessary utilization of medical services); 3) Schools did not require a form for every sneeze, fever, or sports activity; 4) The insurance companies were not telling us how to practice medicine.

What I don’t remember is any major medical problems that I discovered on these episodic well visits.

Currently, our office is engaged in a major campaign to bring in every adolescent who is "behind" in his or her yearly physical, because we are not meeting the insurance companies’ "quality metrics" and are thus missing uncaptured revenue. It seems as if every time I have a break in my 10-minute per sick patient schedule, I am asked if I can "squeeze in" another physical.

Worse yet, we have just added 1-month and 2-1/2 year physicals (after deciding many years back that they really were unnecessary), again for the same reasons!

Alas, I must ask you not to use my name, as my employer does not like squeaky wheels, but I do feel much better after whining to someone other than my wife. (Just don’t ask me how I feel about the indignities I just endured taking my recertification exam at a secured and proctored testing center.)

Anyway, thanks for articulating so many issues that are relevant to we "real" pediatricians.

Anonymous

I disagree

With all due respect for Dr. Wilkoff’s emeritus status, I politely disagree that pediatricians should not do routine physical exams on healthy older children. Gestalt: An integrated entity where the sum is greater than the added individual parts. That is what regular annual physical exams for older children represent to me. After 29-plus years of pediatric practice, it is hard for me to believe that school-based health care alone can uniformly provide equivalent evaluations on older children and teens. Yes, they can do hypertension and body mass index screenings. Yes, school nurses are an integral part of pediatric care, identifying children who need further evaluations and treatments, but they have distinctive educational and experience-based limitations. We diminish our profession when we degrade the importance of the annual pediatric exam.

So you may ask me, what more can the pediatrician provide? How about:

• Providing age-based anticipatory guidance.

• Providing the most up-to-date immunization information and discussions in our immunization-adverse society.

• Clarifying for families the frequent misinformation presented by television, the Internet, and social media.

• Assessing teen, social, and behavioral issues for children and families. (Example: More than 50% of initial attention-deficit/hyperactivity disorder inquiries in my practice come at a routine well-child visit.)

• Assessing risk factors and counseling for cardiovascular and other adult diseases.

• Assessing psychological issues for at-risk children.

• Providing continuity of care and identifying family issues.

• Assisting families by accessing comprehensive community resources when needed.

• Providing transition counseling for older teens as they enter college or the workforce.

Of course, all of this cannot be done at one well visit, but over the course of multiple annual exams, pediatricians can provide superior continuity of care. Perhaps I am a glutton for punishment. While some may groan as the summer approaches, I look forward to physical exams and touching base with my older patients. Fully 40%-50% of older children or teens with no identifiable issues at initial intake for a physical exam will have additional diagnoses at checkout. This occurs based only on simple questions and conversations during the exam. This is the gestalt of good pediatric care. So no, Dr. Wilkoff, your suggestion is not heresy, it is just not smart!

Ivri K. Messinger, D.O.

San Marcos, Tex.

Count me in

Count me a fellow heretic! I completely agree that my healthy school-age patients would thrive just as well without their annual well-child visits with me! Of course, we all enjoy maintaining the relationship with our families, and the visits are well reimbursed, but is there really any medical benefit?

I think not.

Vaccines and appropriate screening could be performed by registered nurses, freeing up slots for the pediatricians to see kids currently running to the urgent care centers.

My partners may consider excommunicating me, but I agree with you!

Preston Herrington, M.D.

Farmington, N.M.

Annual checkup is essential

I am a pediatrician in Brookline, Mass., and have been in practice for 18 years. I am a huge fan of your column. While I completely agree that at first glance, the annual pediatric checkup doesn’t seem to add much to our patients’ health, I believe it is essential. It is part of the process of building a relationship so that when those angst-filled teen years come along, the patients feel as if you have known them forever. And perhaps they will tell you their concerns before they admit them to any other adult. Or that’s the hope, anyway.

I think if kids viewed their doctor only as "the strep throat person," it would diminish the role we play in their lives, and quite frankly, vice versa.

Susan Laster, M.D.

Brookline, Mass.

Fostering better relations

Let me start by saying I am a fan of your column, and have been for years. I am a (slightly) younger than you (based on your updated photo) general pediatrician, and I generally agree with your homespun, sensible advice regarding patients, practice, and pediatrics. I have to disagree with your column on reassessing the value of well visits for older well children.

I certainly don’t find a lot of earth-shattering exam findings at these visits (although there are some rare surprises that need to be dealt with). I think the benefit of these appointments is found in the myriad of questions and concerns a parent has about raising their child in this modern era. I think that gentle reassurance from me that a mother is handling behavioral/school/social media situations properly, or (hopefully) gentle prodding from me if mom is off base, is valuable, even to the parents of the healthiest child. I always have tried to maintain all well-child visits with my own patients – I practice in a midsize (nine-provider) group.

I think that over time, the better a family gets to know me as I help them with little problems, the more likely they are to follow my advice when bigger problems crop up. Time constraints will always be with us, but I don’t think giving up on the "well visits" is the right way to grease the wheel.

Tim Welby, M.D.

Dickson City, Pa.

Pediatrician as preventative

I usually agree with your Letters from Maine column, but I don’t agree with your latest one entitled "Heresy." I certainly agree with you that TV, the Internet, and social media sites are powerful communicators to children, and that is exactly why I strongly disagree with your position.

The pediatrician can and must be a source of correct advice and information, and is in the best position to counteract a lot of false information the child may be receiving. As pediatricians, we are in the prevention business, and the annual checkup is when we can best do our work, and is probably the only time.

Certainly the preteen and teen years must be carefully monitored. Doing away with the yearly visits would only lead to disaster.

Alvin N. Eden, M.D.

Forest Hills, N.Y.

Mostly agree

I truly appreciate your broaching this topic of "heresy," particularly in your neck of the woods where the stakes have been quite high.

That being said, I do agree with you for the most part. I have been doing my pediatric thing in Michigan for 38 years, and have probably come up with as many startling findings on a well-child exam after age 5 years as you have. It is also true (like it or not) that our newly acquired "business model" mentality drains significant time and energy out of all of us, and our lives can be much better spent not doing well exams in the well population.

However, I still worry about kids in their latency period, because I believe that still waters run deep. I hate it when someone shows up at age 15 with a significant drug problem who has not seen us for 5 years.

I strongly believe these kids should not be shelved. Their psychosocial development is important and can be addressed, as it is in just about every other country, by physician extenders. As issues of "turf" are well ingrained in us, who controls this (health department, practice) could be a topic for another Letter from Maine.

Arthur N. Feinberg, M.D.

Department of Pediatrics

Western Michigan University School of Medicine

Kalamazoo

Most schools not adequate

Dr. Wilkoff suggests in his column "Heresy" that we outsource well-check measurements and immunizations to schools. Implicit here is an assumption that all school-age children attend a well-funded public school system with adequate resources to take on this project. While Maine school nurses may be well versed in best practices regarding blood pressure cuff size and immunization protocols, our Tennessee school nurses (in my county, 1 registered nurse for 11 county schools) do not have the resources to, say, make sure their school’s vaccine refrigerators have VFC-compliant thermometry.

The nature of any well-designed screening program, by definition, is that the number of normals will substantially exceed the number of abnormals. Checkups are screening visits. "Targeted screening" implies that there is a simple, validated prescreen upon which to apply the second-tier targeted screen. Dr. Wilkoff suggests we use a nonexistent prescreen when he writes, "For the school-age child who is growing well and doesn’t have any chronic conditions or genetic predispositions, do annual physical exams make sense?" How, exactly, will I know which children are growing well and don’t have chronic conditions or genetic predispositions unless I’m doing checkups on them?

Suzanne Berman, M.D.

Crossville, Tenn.