Letters from Maine

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.

For the last decade or two, a higher percentage of my patients were adequately immunized than were my younger partners’ patients. The gap wasn’t always dramatic, but it was consistent. We all thought this phenomenon was primarily based on a physician selection bias. My age and gender seemed to attract families who tended to be more traditional in their parenting style and predisposed to accepting the party line on immunizations. The families who were more liberal and skeptical about immunization sought out my younger female partners.

Although our suspicions of causation were for the most part correct, an article in the December 2013 issue of Pediatrics (132:1037-46) suggests that how I presented the immunization opportunities may have contributed to my relative success. These investigators observed more than 100 vaccine discussions by 16 providers in nine practices. They categorized the providers’ formats as being presumptive ("Well, we have to do some shots") or participatory ("What do you want to do about shots?").

The researchers found that parents had a "significantly higher odds of resisting vaccine recommendations if the provider used a participatory rather than a presumptive format." We shouldn’t be surprised at this observation. If you present an issue as a "can do" instead of a "will do" situation, hesitant parents are more likely to say, "Won’t do."

However, I am surprised how many providers presented the issue of immunization in what might be called a shared-decision format. But I guess it is just another example of how the role of physicians has changed in the past few generations. For the first half of the last century, most physicians could be characterized as paternalistic. They were accustomed to telling patients what to do. The patient brought the doctor a complaint. The doctor would provide a diagnosis and dictate what the patient should do to get better. End of discussion.

I’m not exactly sure of all the forces that have created the shift, but it became clear that although medical knowledge was expanding exponentially, doctors still didn’t have all the answers. And, in many situations, the outcome was better when the patient participated in the decisions about his or her care.

In pediatrics, the use of a shared-decision, participatory format for managing otitis media has been successful in reducing the amount of antibiotics prescribed. However, this new study makes it clear that welcoming the patient or parents into the decision-making process may not always be the best strategy. My direct, no-nonsense let’s-get-it-done style helped me to achieve a better immunization record than the softer tell-me-what-you-think approach of my partners.

The problem is that one style doesn’t fit every clinical situation. To be a successful physician, one must be able to adjust one’s style to match the diagnosis, personality, and emotional needs of the patient and the myriad of societal and economic features that make up the landscape of the real world. I admit that I haven’t always achieved the perfect match. Although my basic inclination is to use a presumptive approach, I found over the years that I tended to lean more toward a participatory format. It just seemed to work better. But, when it came to immunizations, I wanted to give families the best chance of avoiding a bad decision.

Although most of us would feel uncomfortable with having our clinical encounters videotaped, the results of this study suggest that we should be examining more closely what we say to patients and how we say it. Our success as physicians depends on it.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He continues to monitor and comment on anything pediatric. E-mail him at [email protected].

For the last decade or two, a higher percentage of my patients were adequately immunized than were my younger partners’ patients. The gap wasn’t always dramatic, but it was consistent. We all thought this phenomenon was primarily based on a physician selection bias. My age and gender seemed to attract families who tended to be more traditional in their parenting style and predisposed to accepting the party line on immunizations. The families who were more liberal and skeptical about immunization sought out my younger female partners.

Although our suspicions of causation were for the most part correct, an article in the December 2013 issue of Pediatrics (132:1037-46) suggests that how I presented the immunization opportunities may have contributed to my relative success. These investigators observed more than 100 vaccine discussions by 16 providers in nine practices. They categorized the providers’ formats as being presumptive ("Well, we have to do some shots") or participatory ("What do you want to do about shots?").

The researchers found that parents had a "significantly higher odds of resisting vaccine recommendations if the provider used a participatory rather than a presumptive format." We shouldn’t be surprised at this observation. If you present an issue as a "can do" instead of a "will do" situation, hesitant parents are more likely to say, "Won’t do."

However, I am surprised how many providers presented the issue of immunization in what might be called a shared-decision format. But I guess it is just another example of how the role of physicians has changed in the past few generations. For the first half of the last century, most physicians could be characterized as paternalistic. They were accustomed to telling patients what to do. The patient brought the doctor a complaint. The doctor would provide a diagnosis and dictate what the patient should do to get better. End of discussion.

I’m not exactly sure of all the forces that have created the shift, but it became clear that although medical knowledge was expanding exponentially, doctors still didn’t have all the answers. And, in many situations, the outcome was better when the patient participated in the decisions about his or her care.

In pediatrics, the use of a shared-decision, participatory format for managing otitis media has been successful in reducing the amount of antibiotics prescribed. However, this new study makes it clear that welcoming the patient or parents into the decision-making process may not always be the best strategy. My direct, no-nonsense let’s-get-it-done style helped me to achieve a better immunization record than the softer tell-me-what-you-think approach of my partners.

The problem is that one style doesn’t fit every clinical situation. To be a successful physician, one must be able to adjust one’s style to match the diagnosis, personality, and emotional needs of the patient and the myriad of societal and economic features that make up the landscape of the real world. I admit that I haven’t always achieved the perfect match. Although my basic inclination is to use a presumptive approach, I found over the years that I tended to lean more toward a participatory format. It just seemed to work better. But, when it came to immunizations, I wanted to give families the best chance of avoiding a bad decision.

Although most of us would feel uncomfortable with having our clinical encounters videotaped, the results of this study suggest that we should be examining more closely what we say to patients and how we say it. Our success as physicians depends on it.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He continues to monitor and comment on anything pediatric. E-mail him at [email protected].

For the last decade or two, a higher percentage of my patients were adequately immunized than were my younger partners’ patients. The gap wasn’t always dramatic, but it was consistent. We all thought this phenomenon was primarily based on a physician selection bias. My age and gender seemed to attract families who tended to be more traditional in their parenting style and predisposed to accepting the party line on immunizations. The families who were more liberal and skeptical about immunization sought out my younger female partners.

Although our suspicions of causation were for the most part correct, an article in the December 2013 issue of Pediatrics (132:1037-46) suggests that how I presented the immunization opportunities may have contributed to my relative success. These investigators observed more than 100 vaccine discussions by 16 providers in nine practices. They categorized the providers’ formats as being presumptive ("Well, we have to do some shots") or participatory ("What do you want to do about shots?").

The researchers found that parents had a "significantly higher odds of resisting vaccine recommendations if the provider used a participatory rather than a presumptive format." We shouldn’t be surprised at this observation. If you present an issue as a "can do" instead of a "will do" situation, hesitant parents are more likely to say, "Won’t do."

However, I am surprised how many providers presented the issue of immunization in what might be called a shared-decision format. But I guess it is just another example of how the role of physicians has changed in the past few generations. For the first half of the last century, most physicians could be characterized as paternalistic. They were accustomed to telling patients what to do. The patient brought the doctor a complaint. The doctor would provide a diagnosis and dictate what the patient should do to get better. End of discussion.

I’m not exactly sure of all the forces that have created the shift, but it became clear that although medical knowledge was expanding exponentially, doctors still didn’t have all the answers. And, in many situations, the outcome was better when the patient participated in the decisions about his or her care.

In pediatrics, the use of a shared-decision, participatory format for managing otitis media has been successful in reducing the amount of antibiotics prescribed. However, this new study makes it clear that welcoming the patient or parents into the decision-making process may not always be the best strategy. My direct, no-nonsense let’s-get-it-done style helped me to achieve a better immunization record than the softer tell-me-what-you-think approach of my partners.

The problem is that one style doesn’t fit every clinical situation. To be a successful physician, one must be able to adjust one’s style to match the diagnosis, personality, and emotional needs of the patient and the myriad of societal and economic features that make up the landscape of the real world. I admit that I haven’t always achieved the perfect match. Although my basic inclination is to use a presumptive approach, I found over the years that I tended to lean more toward a participatory format. It just seemed to work better. But, when it came to immunizations, I wanted to give families the best chance of avoiding a bad decision.

Although most of us would feel uncomfortable with having our clinical encounters videotaped, the results of this study suggest that we should be examining more closely what we say to patients and how we say it. Our success as physicians depends on it.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He continues to monitor and comment on anything pediatric. E-mail him at [email protected].

There were days when I really didn’t like doing annual checkups, in fact, sometimes I hated it. I always enjoyed talking with the kids who wanted to engage, but I would wonder if the whole preventive care thing was just a bunch of bunk. There, I said it.

Stand back because at any moment lightning may strike me for coming out as a heretic. We pediatricians are supposed to be the preventive care standard-bearers. We are the immunizers. We are the growth-chart plotters. We are the ones toiling at ground zero, hoping to steer our little patients toward the paths of a healthy adulthood.

But, are annual checkups on well children really making a difference? The Society of General Internal Medicine has recently released a list of Five Things Physicians and Patients Should Question (Choose Wisely, an initiative of the ABIM Foundation). No. 2 on the list is "Don’t perform routine general health checks on asymptomatic adults." The authors observe that "annual visit have not shown to be effective in reducing morbidity, mortality, or hospitalization." Could the same claim be made for annual checkups on asymptomatic older children? Has anyone had the courage to ask the question?

Take a deep breath. Please don’t call the American Academy of Pediatrics and demand that they revoke my emeritus membership. Let me do some quick backpedaling. Yes, there were days when doing checkups on apparently healthy tight-lipped 10-year-olds who would rather be elsewhere made me feel worthless. But, children aren’t adults. Preverbal children can’t really be said to have "no complaints." Up to the point that a child has successfully negotiated kindergarten and first grade, they are dependent on us to find out if there is anything wrong with them. Annual or more often checkups makes sense.

But, 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? Let’s be honest. How many novel physical findings did you make last year in the course of doing hundreds of well-child exams on children without complaints. Of course, you found some concerning growth curves and a few elevated blood pressures. But wouldn’t a complete set of vital signs done at school been just as effective a screening device?

You might ask, "What about immunizations?" Couldn’t the school be a more efficient place to administer them? You might also question whether curtailing annual checkups might remove the office as a critical venue for health education. I think we have to be realistic here and admit that television, the Internet, and social medial sites are probably more powerful communicators.

Wouldn’t being more selective about doing annual exams narrow an important income stream for physicians? Just listen to the receptionists and nurse triage specialists in the average office struggle to deflect calls from concerned parents who would like to have their children seen promptly. Pediatricians could easily fill the appointment slots vacated by older children having needless checkups with the sick and the worried well who need and/or want to be seen. Two of the most frequent complaints we hear about physicians is that it’s "impossible" to get in for an appointment, and we don’t spend enough time with the patients.

As the ill conceived and poorly administered push to adopt electronic health records gobbles up more and more of the time physicians can spend with patients, we are going to have to be smarter and thoughtful about who we see. When there is a shortage of lubricant, the squeaky wheel should get the grease. The other three wheels are rolling along just fine.

If any of you have harbored the same heretical thoughts, please share them, anonymously if you choose.

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].

There were days when I really didn’t like doing annual checkups, in fact, sometimes I hated it. I always enjoyed talking with the kids who wanted to engage, but I would wonder if the whole preventive care thing was just a bunch of bunk. There, I said it.

Stand back because at any moment lightning may strike me for coming out as a heretic. We pediatricians are supposed to be the preventive care standard-bearers. We are the immunizers. We are the growth-chart plotters. We are the ones toiling at ground zero, hoping to steer our little patients toward the paths of a healthy adulthood.

But, are annual checkups on well children really making a difference? The Society of General Internal Medicine has recently released a list of Five Things Physicians and Patients Should Question (Choose Wisely, an initiative of the ABIM Foundation). No. 2 on the list is "Don’t perform routine general health checks on asymptomatic adults." The authors observe that "annual visit have not shown to be effective in reducing morbidity, mortality, or hospitalization." Could the same claim be made for annual checkups on asymptomatic older children? Has anyone had the courage to ask the question?

Take a deep breath. Please don’t call the American Academy of Pediatrics and demand that they revoke my emeritus membership. Let me do some quick backpedaling. Yes, there were days when doing checkups on apparently healthy tight-lipped 10-year-olds who would rather be elsewhere made me feel worthless. But, children aren’t adults. Preverbal children can’t really be said to have "no complaints." Up to the point that a child has successfully negotiated kindergarten and first grade, they are dependent on us to find out if there is anything wrong with them. Annual or more often checkups makes sense.

But, 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? Let’s be honest. How many novel physical findings did you make last year in the course of doing hundreds of well-child exams on children without complaints. Of course, you found some concerning growth curves and a few elevated blood pressures. But wouldn’t a complete set of vital signs done at school been just as effective a screening device?

You might ask, "What about immunizations?" Couldn’t the school be a more efficient place to administer them? You might also question whether curtailing annual checkups might remove the office as a critical venue for health education. I think we have to be realistic here and admit that television, the Internet, and social medial sites are probably more powerful communicators.

Wouldn’t being more selective about doing annual exams narrow an important income stream for physicians? Just listen to the receptionists and nurse triage specialists in the average office struggle to deflect calls from concerned parents who would like to have their children seen promptly. Pediatricians could easily fill the appointment slots vacated by older children having needless checkups with the sick and the worried well who need and/or want to be seen. Two of the most frequent complaints we hear about physicians is that it’s "impossible" to get in for an appointment, and we don’t spend enough time with the patients.

As the ill conceived and poorly administered push to adopt electronic health records gobbles up more and more of the time physicians can spend with patients, we are going to have to be smarter and thoughtful about who we see. When there is a shortage of lubricant, the squeaky wheel should get the grease. The other three wheels are rolling along just fine.

If any of you have harbored the same heretical thoughts, please share them, anonymously if you choose.

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].

There were days when I really didn’t like doing annual checkups, in fact, sometimes I hated it. I always enjoyed talking with the kids who wanted to engage, but I would wonder if the whole preventive care thing was just a bunch of bunk. There, I said it.

Stand back because at any moment lightning may strike me for coming out as a heretic. We pediatricians are supposed to be the preventive care standard-bearers. We are the immunizers. We are the growth-chart plotters. We are the ones toiling at ground zero, hoping to steer our little patients toward the paths of a healthy adulthood.

But, are annual checkups on well children really making a difference? The Society of General Internal Medicine has recently released a list of Five Things Physicians and Patients Should Question (Choose Wisely, an initiative of the ABIM Foundation). No. 2 on the list is "Don’t perform routine general health checks on asymptomatic adults." The authors observe that "annual visit have not shown to be effective in reducing morbidity, mortality, or hospitalization." Could the same claim be made for annual checkups on asymptomatic older children? Has anyone had the courage to ask the question?

Take a deep breath. Please don’t call the American Academy of Pediatrics and demand that they revoke my emeritus membership. Let me do some quick backpedaling. Yes, there were days when doing checkups on apparently healthy tight-lipped 10-year-olds who would rather be elsewhere made me feel worthless. But, children aren’t adults. Preverbal children can’t really be said to have "no complaints." Up to the point that a child has successfully negotiated kindergarten and first grade, they are dependent on us to find out if there is anything wrong with them. Annual or more often checkups makes sense.

But, 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? Let’s be honest. How many novel physical findings did you make last year in the course of doing hundreds of well-child exams on children without complaints. Of course, you found some concerning growth curves and a few elevated blood pressures. But wouldn’t a complete set of vital signs done at school been just as effective a screening device?

You might ask, "What about immunizations?" Couldn’t the school be a more efficient place to administer them? You might also question whether curtailing annual checkups might remove the office as a critical venue for health education. I think we have to be realistic here and admit that television, the Internet, and social medial sites are probably more powerful communicators.

Wouldn’t being more selective about doing annual exams narrow an important income stream for physicians? Just listen to the receptionists and nurse triage specialists in the average office struggle to deflect calls from concerned parents who would like to have their children seen promptly. Pediatricians could easily fill the appointment slots vacated by older children having needless checkups with the sick and the worried well who need and/or want to be seen. Two of the most frequent complaints we hear about physicians is that it’s "impossible" to get in for an appointment, and we don’t spend enough time with the patients.

As the ill conceived and poorly administered push to adopt electronic health records gobbles up more and more of the time physicians can spend with patients, we are going to have to be smarter and thoughtful about who we see. When there is a shortage of lubricant, the squeaky wheel should get the grease. The other three wheels are rolling along just fine.

If any of you have harbored the same heretical thoughts, please share them, anonymously if you choose.

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].

Some of the darkest hours during my house officer training (and there were more than a few) came when it was my job to extract a blood sample from a young child or infant, or even worse, a preemie. Those were the days before multiport indwelling catheters had been invented. Finding an unused vein could take an hour. Eventually, one might resort to a femoral stick or the infamous internal jugular approach.

Even in hospitals devoted to the care of children, laboratories often asked for samples that if successfully obtained would result in an iatrogenic anemia or exsanguination. For house officers, the three most dreaded letters were Q-N-S on a lab slip.

Some tests had been successfully miniaturized, but even getting a free-flowing finger or heel stick in a sick infant isn’t easy. Heavy-handed attempts at getting blood out of one of these little turnips often resulted in a useless hemolyzed sample.

It’s not surprising that pediatricians in my demographic are often loath to order lab tests. Posttraumatic stress can be a potent behavior modifier. But, I’m sure that despite advances in lab diagnostics and phlebotomy techniques, those of you who were trained in the last 20 years have also had your share of frustrating experiences getting blood from your smallest patients.

However, it appears that the next generation of house officers isn’t going to have any phlebotomy war stories to share. The woman who promises to put an end to this bloodletting torture that my patients and I endured is a 29-year-old who dropped out of Stanford at 19, cashed in her parents’ education trust, and started her own bioscience company, now known as Theranos.

After 10 years of research and development Elizabeth Holmes says she now has a system that can provide accurate results for more than a thousand tests on a blood sample the size of a raindrop. And, the results will be ready "in as little as 2 hours" ("Elizabeth Holmes: The Breakthrough of Instant Diagnosis," by Joseph Rago, Wall Street Journal, Sept. 8, 2013). And, she claims the results will be more accurate than current lab techniques, in part because of reduced bench and handling time. And, and ... there’s more. The tests will be half the cost and could save Medicare and Medicaid $150 billion over a 10-year period.

Ms. Holmes has already entered into an arrangement with Walgreens to develop in-store sample collection centers. Her long-term goal is to provide her service "within 5 miles of virtually every American home."

Hmmm. Maybe it’s time for us to pause and take a breath. Listen. Is that creaking sound I hear the rusty hinges of Pandora’s box opening? It’s hard to argue with cutting health care costs, improving accuracy, and shortening the anxiety-provoking wait that many patients endure waiting for their lab results to reach them. But, this "breakthrough" sounds like it has the potential for creating a tsunami of TMI (too much information).

Physicians already order too many lab tests, in many cases a defensive strategy. Often physicians don’t know what to do with borderline results. The temptation is to retest, and soon the doctor finds herself in unfamiliar waters chasing an elusive school of red herring. The Theranos technology promises to make ordering blood tests cheaper and easier, and, predictably, physicians will respond by ordering more of them.

We know that pathologists and the folks who run for-profit laboratories are going to balk at this new system. But, the rest of us will need to figure out how we can deal with the glut of data and help our patients benefit from what promises to be a significant upside of this breakthrough technology.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He continues to monitor and comment on anything pediatric. E-mail him at [email protected].

Some of the darkest hours during my house officer training (and there were more than a few) came when it was my job to extract a blood sample from a young child or infant, or even worse, a preemie. Those were the days before multiport indwelling catheters had been invented. Finding an unused vein could take an hour. Eventually, one might resort to a femoral stick or the infamous internal jugular approach.

Even in hospitals devoted to the care of children, laboratories often asked for samples that if successfully obtained would result in an iatrogenic anemia or exsanguination. For house officers, the three most dreaded letters were Q-N-S on a lab slip.

Some tests had been successfully miniaturized, but even getting a free-flowing finger or heel stick in a sick infant isn’t easy. Heavy-handed attempts at getting blood out of one of these little turnips often resulted in a useless hemolyzed sample.

It’s not surprising that pediatricians in my demographic are often loath to order lab tests. Posttraumatic stress can be a potent behavior modifier. But, I’m sure that despite advances in lab diagnostics and phlebotomy techniques, those of you who were trained in the last 20 years have also had your share of frustrating experiences getting blood from your smallest patients.

However, it appears that the next generation of house officers isn’t going to have any phlebotomy war stories to share. The woman who promises to put an end to this bloodletting torture that my patients and I endured is a 29-year-old who dropped out of Stanford at 19, cashed in her parents’ education trust, and started her own bioscience company, now known as Theranos.

After 10 years of research and development Elizabeth Holmes says she now has a system that can provide accurate results for more than a thousand tests on a blood sample the size of a raindrop. And, the results will be ready "in as little as 2 hours" ("Elizabeth Holmes: The Breakthrough of Instant Diagnosis," by Joseph Rago, Wall Street Journal, Sept. 8, 2013). And, she claims the results will be more accurate than current lab techniques, in part because of reduced bench and handling time. And, and ... there’s more. The tests will be half the cost and could save Medicare and Medicaid $150 billion over a 10-year period.

Ms. Holmes has already entered into an arrangement with Walgreens to develop in-store sample collection centers. Her long-term goal is to provide her service "within 5 miles of virtually every American home."

Hmmm. Maybe it’s time for us to pause and take a breath. Listen. Is that creaking sound I hear the rusty hinges of Pandora’s box opening? It’s hard to argue with cutting health care costs, improving accuracy, and shortening the anxiety-provoking wait that many patients endure waiting for their lab results to reach them. But, this "breakthrough" sounds like it has the potential for creating a tsunami of TMI (too much information).

Physicians already order too many lab tests, in many cases a defensive strategy. Often physicians don’t know what to do with borderline results. The temptation is to retest, and soon the doctor finds herself in unfamiliar waters chasing an elusive school of red herring. The Theranos technology promises to make ordering blood tests cheaper and easier, and, predictably, physicians will respond by ordering more of them.

We know that pathologists and the folks who run for-profit laboratories are going to balk at this new system. But, the rest of us will need to figure out how we can deal with the glut of data and help our patients benefit from what promises to be a significant upside of this breakthrough technology.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He continues to monitor and comment on anything pediatric. E-mail him at [email protected].

Some of the darkest hours during my house officer training (and there were more than a few) came when it was my job to extract a blood sample from a young child or infant, or even worse, a preemie. Those were the days before multiport indwelling catheters had been invented. Finding an unused vein could take an hour. Eventually, one might resort to a femoral stick or the infamous internal jugular approach.

Even in hospitals devoted to the care of children, laboratories often asked for samples that if successfully obtained would result in an iatrogenic anemia or exsanguination. For house officers, the three most dreaded letters were Q-N-S on a lab slip.

Some tests had been successfully miniaturized, but even getting a free-flowing finger or heel stick in a sick infant isn’t easy. Heavy-handed attempts at getting blood out of one of these little turnips often resulted in a useless hemolyzed sample.

It’s not surprising that pediatricians in my demographic are often loath to order lab tests. Posttraumatic stress can be a potent behavior modifier. But, I’m sure that despite advances in lab diagnostics and phlebotomy techniques, those of you who were trained in the last 20 years have also had your share of frustrating experiences getting blood from your smallest patients.

However, it appears that the next generation of house officers isn’t going to have any phlebotomy war stories to share. The woman who promises to put an end to this bloodletting torture that my patients and I endured is a 29-year-old who dropped out of Stanford at 19, cashed in her parents’ education trust, and started her own bioscience company, now known as Theranos.

After 10 years of research and development Elizabeth Holmes says she now has a system that can provide accurate results for more than a thousand tests on a blood sample the size of a raindrop. And, the results will be ready "in as little as 2 hours" ("Elizabeth Holmes: The Breakthrough of Instant Diagnosis," by Joseph Rago, Wall Street Journal, Sept. 8, 2013). And, she claims the results will be more accurate than current lab techniques, in part because of reduced bench and handling time. And, and ... there’s more. The tests will be half the cost and could save Medicare and Medicaid $150 billion over a 10-year period.

Ms. Holmes has already entered into an arrangement with Walgreens to develop in-store sample collection centers. Her long-term goal is to provide her service "within 5 miles of virtually every American home."

Hmmm. Maybe it’s time for us to pause and take a breath. Listen. Is that creaking sound I hear the rusty hinges of Pandora’s box opening? It’s hard to argue with cutting health care costs, improving accuracy, and shortening the anxiety-provoking wait that many patients endure waiting for their lab results to reach them. But, this "breakthrough" sounds like it has the potential for creating a tsunami of TMI (too much information).

Physicians already order too many lab tests, in many cases a defensive strategy. Often physicians don’t know what to do with borderline results. The temptation is to retest, and soon the doctor finds herself in unfamiliar waters chasing an elusive school of red herring. The Theranos technology promises to make ordering blood tests cheaper and easier, and, predictably, physicians will respond by ordering more of them.

We know that pathologists and the folks who run for-profit laboratories are going to balk at this new system. But, the rest of us will need to figure out how we can deal with the glut of data and help our patients benefit from what promises to be a significant upside of this breakthrough technology.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He continues to monitor and comment on anything pediatric. E-mail him at [email protected].

On Aug. 27, Dr. John Kennell died at the age of 91. I learned from his obituary in the New York Times that he was the guy who put maternal-infant bonding on the map. It was his observations as a neonatologist, when neonatology was in its infancy, that ended the common and unnatural practice of separating mother and infants for hours and in some sad cases even days, so that each could recover from the ordeal of an uncomplicated hospital childbirth.

In a book coauthored with Dr. Marshall Klaus in 1976 titled "Maternal-Infant Bonding," Dr. Kennell claimed that there was a critical period in the first few hours after delivery during which mothers were biochemically primed to form bonds with their infants. And, that these bonds were crucial for normal development. Over the next few decades, he nuanced his position. In fact, his most recent efforts were in support of doula care, which if poorly done could conceivably interfere with the bonding he had pioneered.

But, the damage was already done. At least two generations of parents still live in dread fear that they didn’t spend enough of the right kind of time with their newborns. For example, 2 years ago, I received a call from a friend whose daughter had recently delivered her second child by C-section. The baby was fine, but the mother nearly died of intrapartum group A beta-hemolytic sepsis. The ordeal included DIC [disseminated intravascular coagulation],multiorgan failure, and the partial amputation of a couple of digits.

Not surprisingly, this young woman was in no condition to interact with anyone for more than 2 weeks. The new grandmother’s call was prompted by the observation that now in the third week postpartum when her daughter was awake she seemed to have little interest in holding or nurturing the baby. And, she was more than willing to have nurses and family members do the hugging and cuddling.

I asked, "Is this about that bonding thing? If your daughter really wanted to have this baby, we could send her to Cleveland for 3 months and the two of them would still form a normal mother-daughter relationship." I could have added, "Let’s remember, we aren’t geese who will imprint on the first adult figure they see after hatching. Even if it is a 6-foot-tall researcher with a beard." This summer I got to meet this young woman and her daughter and could tell that the two made a beautifully adjusted dyad.

It is unfortunate that Dr. Kennell’s early work that was so critical to creating a more humane birthing experience had a dark side that sent a ripple of needless anxiety that still shakes parents 3 decades later. Tragically, there are cases of seriously disordered maternal-infant bonding so severe that they result in infanticide. But, in my experience these incidents are the result of a long or deep mental illness and are not caused by a few hours or days of separation immediately after birth.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected].

Updated: 10/8/2013

On Aug. 27, Dr. John Kennell died at the age of 91. I learned from his obituary in the New York Times that he was the guy who put maternal-infant bonding on the map. It was his observations as a neonatologist, when neonatology was in its infancy, that ended the common and unnatural practice of separating mother and infants for hours and in some sad cases even days, so that each could recover from the ordeal of an uncomplicated hospital childbirth.

In a book coauthored with Dr. Marshall Klaus in 1976 titled "Maternal-Infant Bonding," Dr. Kennell claimed that there was a critical period in the first few hours after delivery during which mothers were biochemically primed to form bonds with their infants. And, that these bonds were crucial for normal development. Over the next few decades, he nuanced his position. In fact, his most recent efforts were in support of doula care, which if poorly done could conceivably interfere with the bonding he had pioneered.

But, the damage was already done. At least two generations of parents still live in dread fear that they didn’t spend enough of the right kind of time with their newborns. For example, 2 years ago, I received a call from a friend whose daughter had recently delivered her second child by C-section. The baby was fine, but the mother nearly died of intrapartum group A beta-hemolytic sepsis. The ordeal included DIC [disseminated intravascular coagulation],multiorgan failure, and the partial amputation of a couple of digits.

Not surprisingly, this young woman was in no condition to interact with anyone for more than 2 weeks. The new grandmother’s call was prompted by the observation that now in the third week postpartum when her daughter was awake she seemed to have little interest in holding or nurturing the baby. And, she was more than willing to have nurses and family members do the hugging and cuddling.

I asked, "Is this about that bonding thing? If your daughter really wanted to have this baby, we could send her to Cleveland for 3 months and the two of them would still form a normal mother-daughter relationship." I could have added, "Let’s remember, we aren’t geese who will imprint on the first adult figure they see after hatching. Even if it is a 6-foot-tall researcher with a beard." This summer I got to meet this young woman and her daughter and could tell that the two made a beautifully adjusted dyad.

It is unfortunate that Dr. Kennell’s early work that was so critical to creating a more humane birthing experience had a dark side that sent a ripple of needless anxiety that still shakes parents 3 decades later. Tragically, there are cases of seriously disordered maternal-infant bonding so severe that they result in infanticide. But, in my experience these incidents are the result of a long or deep mental illness and are not caused by a few hours or days of separation immediately after birth.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected].

Updated: 10/8/2013

On Aug. 27, Dr. John Kennell died at the age of 91. I learned from his obituary in the New York Times that he was the guy who put maternal-infant bonding on the map. It was his observations as a neonatologist, when neonatology was in its infancy, that ended the common and unnatural practice of separating mother and infants for hours and in some sad cases even days, so that each could recover from the ordeal of an uncomplicated hospital childbirth.

In a book coauthored with Dr. Marshall Klaus in 1976 titled "Maternal-Infant Bonding," Dr. Kennell claimed that there was a critical period in the first few hours after delivery during which mothers were biochemically primed to form bonds with their infants. And, that these bonds were crucial for normal development. Over the next few decades, he nuanced his position. In fact, his most recent efforts were in support of doula care, which if poorly done could conceivably interfere with the bonding he had pioneered.

But, the damage was already done. At least two generations of parents still live in dread fear that they didn’t spend enough of the right kind of time with their newborns. For example, 2 years ago, I received a call from a friend whose daughter had recently delivered her second child by C-section. The baby was fine, but the mother nearly died of intrapartum group A beta-hemolytic sepsis. The ordeal included DIC [disseminated intravascular coagulation],multiorgan failure, and the partial amputation of a couple of digits.

Not surprisingly, this young woman was in no condition to interact with anyone for more than 2 weeks. The new grandmother’s call was prompted by the observation that now in the third week postpartum when her daughter was awake she seemed to have little interest in holding or nurturing the baby. And, she was more than willing to have nurses and family members do the hugging and cuddling.

I asked, "Is this about that bonding thing? If your daughter really wanted to have this baby, we could send her to Cleveland for 3 months and the two of them would still form a normal mother-daughter relationship." I could have added, "Let’s remember, we aren’t geese who will imprint on the first adult figure they see after hatching. Even if it is a 6-foot-tall researcher with a beard." This summer I got to meet this young woman and her daughter and could tell that the two made a beautifully adjusted dyad.

It is unfortunate that Dr. Kennell’s early work that was so critical to creating a more humane birthing experience had a dark side that sent a ripple of needless anxiety that still shakes parents 3 decades later. Tragically, there are cases of seriously disordered maternal-infant bonding so severe that they result in infanticide. But, in my experience these incidents are the result of a long or deep mental illness and are not caused by a few hours or days of separation immediately after birth.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected].

Updated: 10/8/2013

Most days, I feel that the Affordable Care Act’s negatives outweigh its positives, but I’m not quite ready to throw out the baby with the bathwater. For example, I recently discovered that the ACA requires that all insurance companies pay for breast pumps and lactation counseling. Great idea! But, then I learned that the law neither specifies the type of breast pump nor defines who qualifies as a trained provider of lactation counseling services (Breast-Feeding Services Lag Behind the Law, Catherine Saint Louis, New York Times, Sept. 30, 2013). It turns out that with rare exceptions, finding a lactation consultant who is approved by the insurance company and then securing payment are fraught with delays that are measured in days or weeks. Of course, these delays and snafus come during a critical window for breastfeeding success.

A recent study by Wagner et al. (Breastfeeding Concerns at 3 and 7 Days Postpartum and Feeding Status at 2 Months; Pediatrics 2013;132:e865-e75) reports the obvious. Maternal concerns about their infant’s feeding difficulties, breastfeeding pain, and milk quantity were associated with early cessation of breastfeeding, with peaks at 3 and 7 days postpartum. The fact is that even mothers who had a solid intent to nurse their babies for at least 2 months worry. They become upset if they perceive that their babies are struggling to feed, or if they suspect that the babies aren’t getting enough to eat. And, they are just as vulnerable to pain as everyone else.

These concerns and worries occur in a compressed time frame of very few days and are magnified by the sleep deprivation that accompanies most deliveries. The correct advice provided by compassionate lactation consultants (and here I include pediatricians) can be critical to breastfeeding success. But, it must be provided on a time scale that matches the tempo of the lactation process. Here I am talking about hours, not days.

Interestingly and sadly, the hospital where Ms. Wagner and her colleagues collected their data doesn’t seem to understand that time-sensitive urgency. The investigators report that lactation consultants are "generally available on the maternity unit 6 days per week." Heaven help the poor mother and infant who are struggling with a poor latch on that 7th day. And, what does "generally available" mean? Folks, a new mother’s breastfeeding concerns require intensive care. The nurses and doctors in an ICU just aren’t "generally available."

The researchers also postulate that the increase in adverse outcomes later in the first week postpartum may be because "there is often a gap between hospital and community lactation services." Really? There’s the problem in a nutshell. If we want more babies to be breastfed, we have to treat the support services as critical and time sensitive. We have done a pretty good job of convincing mothers that breastfeeding is the best way to feed their newborns. Now we have to acknowledge their concerns and support them with quality advice 24/7.

Medical homes must function like homes. Your parents may have turned the lights out at 10:00 p.m., but they didn’t leave you alone and go to a motel for the night. To achieve the kind of seamless support net that new mothers need and deserve, pediatricians need to learn more about giving lactation advice themselves. They need to join with lactation consultants with whom they feel comfortable to provide 24/7 phone support and face-to-face visits on a 365/365 schedule.

The ACA appears to be offering us the opportunity to take breastfeeding support seriously. Obviously, it has some rough edges at this point. But, let’s take advantage of this chance by seeing that the support for our patients is provided in a time frame that matches the biology of breastfeeding.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected].

Updated: 10/8/2013

Most days, I feel that the Affordable Care Act’s negatives outweigh its positives, but I’m not quite ready to throw out the baby with the bathwater. For example, I recently discovered that the ACA requires that all insurance companies pay for breast pumps and lactation counseling. Great idea! But, then I learned that the law neither specifies the type of breast pump nor defines who qualifies as a trained provider of lactation counseling services (Breast-Feeding Services Lag Behind the Law, Catherine Saint Louis, New York Times, Sept. 30, 2013). It turns out that with rare exceptions, finding a lactation consultant who is approved by the insurance company and then securing payment are fraught with delays that are measured in days or weeks. Of course, these delays and snafus come during a critical window for breastfeeding success.

A recent study by Wagner et al. (Breastfeeding Concerns at 3 and 7 Days Postpartum and Feeding Status at 2 Months; Pediatrics 2013;132:e865-e75) reports the obvious. Maternal concerns about their infant’s feeding difficulties, breastfeeding pain, and milk quantity were associated with early cessation of breastfeeding, with peaks at 3 and 7 days postpartum. The fact is that even mothers who had a solid intent to nurse their babies for at least 2 months worry. They become upset if they perceive that their babies are struggling to feed, or if they suspect that the babies aren’t getting enough to eat. And, they are just as vulnerable to pain as everyone else.

These concerns and worries occur in a compressed time frame of very few days and are magnified by the sleep deprivation that accompanies most deliveries. The correct advice provided by compassionate lactation consultants (and here I include pediatricians) can be critical to breastfeeding success. But, it must be provided on a time scale that matches the tempo of the lactation process. Here I am talking about hours, not days.

Interestingly and sadly, the hospital where Ms. Wagner and her colleagues collected their data doesn’t seem to understand that time-sensitive urgency. The investigators report that lactation consultants are "generally available on the maternity unit 6 days per week." Heaven help the poor mother and infant who are struggling with a poor latch on that 7th day. And, what does "generally available" mean? Folks, a new mother’s breastfeeding concerns require intensive care. The nurses and doctors in an ICU just aren’t "generally available."

The researchers also postulate that the increase in adverse outcomes later in the first week postpartum may be because "there is often a gap between hospital and community lactation services." Really? There’s the problem in a nutshell. If we want more babies to be breastfed, we have to treat the support services as critical and time sensitive. We have done a pretty good job of convincing mothers that breastfeeding is the best way to feed their newborns. Now we have to acknowledge their concerns and support them with quality advice 24/7.

Medical homes must function like homes. Your parents may have turned the lights out at 10:00 p.m., but they didn’t leave you alone and go to a motel for the night. To achieve the kind of seamless support net that new mothers need and deserve, pediatricians need to learn more about giving lactation advice themselves. They need to join with lactation consultants with whom they feel comfortable to provide 24/7 phone support and face-to-face visits on a 365/365 schedule.

The ACA appears to be offering us the opportunity to take breastfeeding support seriously. Obviously, it has some rough edges at this point. But, let’s take advantage of this chance by seeing that the support for our patients is provided in a time frame that matches the biology of breastfeeding.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected].

Updated: 10/8/2013

Most days, I feel that the Affordable Care Act’s negatives outweigh its positives, but I’m not quite ready to throw out the baby with the bathwater. For example, I recently discovered that the ACA requires that all insurance companies pay for breast pumps and lactation counseling. Great idea! But, then I learned that the law neither specifies the type of breast pump nor defines who qualifies as a trained provider of lactation counseling services (Breast-Feeding Services Lag Behind the Law, Catherine Saint Louis, New York Times, Sept. 30, 2013). It turns out that with rare exceptions, finding a lactation consultant who is approved by the insurance company and then securing payment are fraught with delays that are measured in days or weeks. Of course, these delays and snafus come during a critical window for breastfeeding success.

A recent study by Wagner et al. (Breastfeeding Concerns at 3 and 7 Days Postpartum and Feeding Status at 2 Months; Pediatrics 2013;132:e865-e75) reports the obvious. Maternal concerns about their infant’s feeding difficulties, breastfeeding pain, and milk quantity were associated with early cessation of breastfeeding, with peaks at 3 and 7 days postpartum. The fact is that even mothers who had a solid intent to nurse their babies for at least 2 months worry. They become upset if they perceive that their babies are struggling to feed, or if they suspect that the babies aren’t getting enough to eat. And, they are just as vulnerable to pain as everyone else.

These concerns and worries occur in a compressed time frame of very few days and are magnified by the sleep deprivation that accompanies most deliveries. The correct advice provided by compassionate lactation consultants (and here I include pediatricians) can be critical to breastfeeding success. But, it must be provided on a time scale that matches the tempo of the lactation process. Here I am talking about hours, not days.

Interestingly and sadly, the hospital where Ms. Wagner and her colleagues collected their data doesn’t seem to understand that time-sensitive urgency. The investigators report that lactation consultants are "generally available on the maternity unit 6 days per week." Heaven help the poor mother and infant who are struggling with a poor latch on that 7th day. And, what does "generally available" mean? Folks, a new mother’s breastfeeding concerns require intensive care. The nurses and doctors in an ICU just aren’t "generally available."

The researchers also postulate that the increase in adverse outcomes later in the first week postpartum may be because "there is often a gap between hospital and community lactation services." Really? There’s the problem in a nutshell. If we want more babies to be breastfed, we have to treat the support services as critical and time sensitive. We have done a pretty good job of convincing mothers that breastfeeding is the best way to feed their newborns. Now we have to acknowledge their concerns and support them with quality advice 24/7.

Medical homes must function like homes. Your parents may have turned the lights out at 10:00 p.m., but they didn’t leave you alone and go to a motel for the night. To achieve the kind of seamless support net that new mothers need and deserve, pediatricians need to learn more about giving lactation advice themselves. They need to join with lactation consultants with whom they feel comfortable to provide 24/7 phone support and face-to-face visits on a 365/365 schedule.

The ACA appears to be offering us the opportunity to take breastfeeding support seriously. Obviously, it has some rough edges at this point. But, let’s take advantage of this chance by seeing that the support for our patients is provided in a time frame that matches the biology of breastfeeding.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected].

Updated: 10/8/2013

Recently my primary computer began to act sick off and on. I took it to the folks behind the tech support bar at the corporate store who were eager to help. They ran a bunch of diagnostic tests that were inconclusive. They couldn’t be sure whether it was a hard drive or a software issue, so they reloaded a clean copy of the software and wished me luck. They warned me that the hardware was too old for them to work should the problem recur.

Well, it did. So on a rainy weekend afternoon, I found myself visiting the independent computer mechanic who had been recommended. After a half an hour of running some more tests and a bit of head scratching, he stood up, leaned over the computer, and put his ear against the back of the panel for about a minute and a half. "I could do a bunch more tests tomorrow, but when the hard drive in these babies begins to fail, they make a different sound," he said. He told me I needed a new hard drive. I got one, and was soon back in business.

Two articles reinforce what I relearned during my visit with the computer doctor: A well-trained ear is a valuable tool, and more testing often doesn’t result in a more accurate diagnosis. Nor does it correlate with better quality care.

Dr. Todd A. Florin and his fellow investigators found that emergency departments that used more tests to diagnose and manage community-acquired pneumonia had higher hospitalization rates and were no more likely to experience revisitations than were lower utilizing EDs (Pediatrics 2013;132:237-44).

In the other study, Dr. Jane F. Knapp and her associates observed that pediatric-focused EDs used significantly fewer chest x-rays to diagnose asthma than did general EDs (Pediatrics 2013;132:245-52).

Neither of these groups examined the factors that might have influenced the differences in utilization that they observed. It is unlikely that standard lab and x-ray resources are any less available at the kind of institutions they were studying. Could it be that physicians practicing in pediatric-focused EDs somehow feel more insulated from the threat of a malpractice suit? Are they "better" trained? And if so, what was it about that training that allowed these physicians to rely more on their history taking and physical exams to arrive at a diagnosis? Or is there some test-ordering virus that has infected the culture of certain hospitals while sparing others?

Of course, one of the explanations may be that physicians who limit their practices to children are more likely to acquire a comfort level with diagnosing community-acquired pneumonia, because it represents a higher percentage of the volume of illness that they see. If a physician is well mentored, familiarity can breed competency.

I suspect that if the investigators in these studies had examined the relationship between physician age and resource utilization, they would have found that older physicians ordered fewer lab tests and x-rays. Forty or 50 years ago, physicians were more likely to practice in settings geographically separated from hospitals, and as such were less likely to have ready access to lab and x-ray equipment. Out of necessity, they had to become comfortable using their eyes and ears to make a diagnosis. As physicians huddled together in groups and/or became extensions of hospitals, diagnostic equipment became more available. And when it gets built, it will get used, particularly if it can provide some income.

Community-acquired pneumonia is usually not a difficult diagnosis to make. If I hear crackles in a febrile child, do I need to know his exact temperature or his white count? If the x-ray is normal, will I withhold antibiotics? Not if I know that x-ray images can lag behind reality.

However, if there has been a recent choking episode or the child looks sick enough to hospitalize, I would like more information before I treat. Or if a phone call from my office staff the next day isn’t reassuring, it may be time for some tests. But one phone call is cheaper than a complete blood count and emits far less radiation than a chest x-ray.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected].

Updated: 10/8/2013

Recently my primary computer began to act sick off and on. I took it to the folks behind the tech support bar at the corporate store who were eager to help. They ran a bunch of diagnostic tests that were inconclusive. They couldn’t be sure whether it was a hard drive or a software issue, so they reloaded a clean copy of the software and wished me luck. They warned me that the hardware was too old for them to work should the problem recur.

Well, it did. So on a rainy weekend afternoon, I found myself visiting the independent computer mechanic who had been recommended. After a half an hour of running some more tests and a bit of head scratching, he stood up, leaned over the computer, and put his ear against the back of the panel for about a minute and a half. "I could do a bunch more tests tomorrow, but when the hard drive in these babies begins to fail, they make a different sound," he said. He told me I needed a new hard drive. I got one, and was soon back in business.

Two articles reinforce what I relearned during my visit with the computer doctor: A well-trained ear is a valuable tool, and more testing often doesn’t result in a more accurate diagnosis. Nor does it correlate with better quality care.

Dr. Todd A. Florin and his fellow investigators found that emergency departments that used more tests to diagnose and manage community-acquired pneumonia had higher hospitalization rates and were no more likely to experience revisitations than were lower utilizing EDs (Pediatrics 2013;132:237-44).

In the other study, Dr. Jane F. Knapp and her associates observed that pediatric-focused EDs used significantly fewer chest x-rays to diagnose asthma than did general EDs (Pediatrics 2013;132:245-52).

Neither of these groups examined the factors that might have influenced the differences in utilization that they observed. It is unlikely that standard lab and x-ray resources are any less available at the kind of institutions they were studying. Could it be that physicians practicing in pediatric-focused EDs somehow feel more insulated from the threat of a malpractice suit? Are they "better" trained? And if so, what was it about that training that allowed these physicians to rely more on their history taking and physical exams to arrive at a diagnosis? Or is there some test-ordering virus that has infected the culture of certain hospitals while sparing others?

Of course, one of the explanations may be that physicians who limit their practices to children are more likely to acquire a comfort level with diagnosing community-acquired pneumonia, because it represents a higher percentage of the volume of illness that they see. If a physician is well mentored, familiarity can breed competency.

I suspect that if the investigators in these studies had examined the relationship between physician age and resource utilization, they would have found that older physicians ordered fewer lab tests and x-rays. Forty or 50 years ago, physicians were more likely to practice in settings geographically separated from hospitals, and as such were less likely to have ready access to lab and x-ray equipment. Out of necessity, they had to become comfortable using their eyes and ears to make a diagnosis. As physicians huddled together in groups and/or became extensions of hospitals, diagnostic equipment became more available. And when it gets built, it will get used, particularly if it can provide some income.

Community-acquired pneumonia is usually not a difficult diagnosis to make. If I hear crackles in a febrile child, do I need to know his exact temperature or his white count? If the x-ray is normal, will I withhold antibiotics? Not if I know that x-ray images can lag behind reality.

However, if there has been a recent choking episode or the child looks sick enough to hospitalize, I would like more information before I treat. Or if a phone call from my office staff the next day isn’t reassuring, it may be time for some tests. But one phone call is cheaper than a complete blood count and emits far less radiation than a chest x-ray.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected].

Updated: 10/8/2013

Recently my primary computer began to act sick off and on. I took it to the folks behind the tech support bar at the corporate store who were eager to help. They ran a bunch of diagnostic tests that were inconclusive. They couldn’t be sure whether it was a hard drive or a software issue, so they reloaded a clean copy of the software and wished me luck. They warned me that the hardware was too old for them to work should the problem recur.

Well, it did. So on a rainy weekend afternoon, I found myself visiting the independent computer mechanic who had been recommended. After a half an hour of running some more tests and a bit of head scratching, he stood up, leaned over the computer, and put his ear against the back of the panel for about a minute and a half. "I could do a bunch more tests tomorrow, but when the hard drive in these babies begins to fail, they make a different sound," he said. He told me I needed a new hard drive. I got one, and was soon back in business.

Two articles reinforce what I relearned during my visit with the computer doctor: A well-trained ear is a valuable tool, and more testing often doesn’t result in a more accurate diagnosis. Nor does it correlate with better quality care.

Dr. Todd A. Florin and his fellow investigators found that emergency departments that used more tests to diagnose and manage community-acquired pneumonia had higher hospitalization rates and were no more likely to experience revisitations than were lower utilizing EDs (Pediatrics 2013;132:237-44).

In the other study, Dr. Jane F. Knapp and her associates observed that pediatric-focused EDs used significantly fewer chest x-rays to diagnose asthma than did general EDs (Pediatrics 2013;132:245-52).

Neither of these groups examined the factors that might have influenced the differences in utilization that they observed. It is unlikely that standard lab and x-ray resources are any less available at the kind of institutions they were studying. Could it be that physicians practicing in pediatric-focused EDs somehow feel more insulated from the threat of a malpractice suit? Are they "better" trained? And if so, what was it about that training that allowed these physicians to rely more on their history taking and physical exams to arrive at a diagnosis? Or is there some test-ordering virus that has infected the culture of certain hospitals while sparing others?

Of course, one of the explanations may be that physicians who limit their practices to children are more likely to acquire a comfort level with diagnosing community-acquired pneumonia, because it represents a higher percentage of the volume of illness that they see. If a physician is well mentored, familiarity can breed competency.

I suspect that if the investigators in these studies had examined the relationship between physician age and resource utilization, they would have found that older physicians ordered fewer lab tests and x-rays. Forty or 50 years ago, physicians were more likely to practice in settings geographically separated from hospitals, and as such were less likely to have ready access to lab and x-ray equipment. Out of necessity, they had to become comfortable using their eyes and ears to make a diagnosis. As physicians huddled together in groups and/or became extensions of hospitals, diagnostic equipment became more available. And when it gets built, it will get used, particularly if it can provide some income.

Community-acquired pneumonia is usually not a difficult diagnosis to make. If I hear crackles in a febrile child, do I need to know his exact temperature or his white count? If the x-ray is normal, will I withhold antibiotics? Not if I know that x-ray images can lag behind reality.

However, if there has been a recent choking episode or the child looks sick enough to hospitalize, I would like more information before I treat. Or if a phone call from my office staff the next day isn’t reassuring, it may be time for some tests. But one phone call is cheaper than a complete blood count and emits far less radiation than a chest x-ray.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected].

Updated: 10/8/2013

Two of my physician friends recently had knee surgery. Both have had good outcomes, but during their hospital stays they struggled to defend themselves against the troops of the no-pain-goes-untreated army. They have been paying attention, and realize that every medication and intervention carries a downside. So when they were badgered into taking something for pain in the immediate postop period, their inclination was to decline.

Weakened by preop fatigue, each eventually relented and "took the damn pills." The result was for each of them the worst experience of their surgical adventure. One vomited and wisely declined anything more than acetaminophen. The other became so loopy and disoriented that his hospital stay was extended by a day as the physicians and nurses struggled to make sure he hadn’t suffered a stroke.

If you had asked each of my friends whether they were having pain, they would have answered, "Sure." But, if you had asked them to rate their pain on a scale of 1-10, they would have screwed up their faces and asked, "What are you talking about?" If you rephrased the question and asked, "How does this compare to the worst pain you have ever had?" they would reply, "I’m sorry, are we talking apples or oranges?"

Pain is one of those things that doesn’t fit into any definable category. Because of their commitment to helping patients be as comfortable as they can, nurses are eager to use the tools at their disposal. They have been taught that in most cases, early mobility results in a better outcome, and that pain can discourage patients from wanting to move or even participate in their own recovery.

In the last several decades, there has been a well-intentioned but misguided movement toward asking patients to quantify their pain. I wonder whether there is much good evidence to support this effort. But it sounds oh so terribly scientific to put a number on something. Suffering is such a personal experience that pain can’t really be distilled down to a number or a smiley face emoticon. Although it requires more time and skill, a better approach for caregivers is to engage the patient in a dialogue about his or her discomfort. I suspect that most of the best nurses do just that.

Some well-crafted questions delivered with an empathetic tone will detect confounding issues, such as anxiety. From my observations and personal experience, anxiety is a powerful multiplier of pain. The more the patient understands about what is causing his pain and the more realistic his expectations are about how long it will last, the more tolerable the pain can be. But finding out what is making the patient anxious, and explaining the management options, including likely side effects, take time. My physician friends who initially declined pain medications (and certainly will again) did so because they have seen scores of their own patients suffer similar side effects. I’m sure that they share my suspicion that reports of side effects seriously underestimate reality.

When it comes to very young children and unconscious adults, we are limited in our ability to have a dialogue about discomfort. In those cases, we are obligated to treat and accept the risk of side effects. We must make inferences from vital signs and other biophysical measurements that the patient is uncomfortable. However, for the patient who can communicate, I think we should put more stock in what the patient tells us about what is bothering him, and why, than in the tracings on a monitor or some sketchy number.

While dictionaries usually make little distinction between "pain" and "suffering," it may be time for those of us who treat patients to consider assigning each word its own working definition. Pain could be reserved for the neurophysiologists and described in terms of spike potentials and neurotransmitter levels. Suffering, on the other hand, would be a much broader term that is unique to each patient’s experience and takes into account factors such as anxiety and depression. We may find with this redefinition that we are using less medication and that patients are more comfortable.

Dr. Wilkoff practiced general pediatrics in Brunswick, Maine, for nearly forty years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected]. 

 Updated 9/4/13, 10/8/2013

Two of my physician friends recently had knee surgery. Both have had good outcomes, but during their hospital stays they struggled to defend themselves against the troops of the no-pain-goes-untreated army. They have been paying attention, and realize that every medication and intervention carries a downside. So when they were badgered into taking something for pain in the immediate postop period, their inclination was to decline.

Weakened by preop fatigue, each eventually relented and "took the damn pills." The result was for each of them the worst experience of their surgical adventure. One vomited and wisely declined anything more than acetaminophen. The other became so loopy and disoriented that his hospital stay was extended by a day as the physicians and nurses struggled to make sure he hadn’t suffered a stroke.

If you had asked each of my friends whether they were having pain, they would have answered, "Sure." But, if you had asked them to rate their pain on a scale of 1-10, they would have screwed up their faces and asked, "What are you talking about?" If you rephrased the question and asked, "How does this compare to the worst pain you have ever had?" they would reply, "I’m sorry, are we talking apples or oranges?"

Pain is one of those things that doesn’t fit into any definable category. Because of their commitment to helping patients be as comfortable as they can, nurses are eager to use the tools at their disposal. They have been taught that in most cases, early mobility results in a better outcome, and that pain can discourage patients from wanting to move or even participate in their own recovery.

In the last several decades, there has been a well-intentioned but misguided movement toward asking patients to quantify their pain. I wonder whether there is much good evidence to support this effort. But it sounds oh so terribly scientific to put a number on something. Suffering is such a personal experience that pain can’t really be distilled down to a number or a smiley face emoticon. Although it requires more time and skill, a better approach for caregivers is to engage the patient in a dialogue about his or her discomfort. I suspect that most of the best nurses do just that.

Some well-crafted questions delivered with an empathetic tone will detect confounding issues, such as anxiety. From my observations and personal experience, anxiety is a powerful multiplier of pain. The more the patient understands about what is causing his pain and the more realistic his expectations are about how long it will last, the more tolerable the pain can be. But finding out what is making the patient anxious, and explaining the management options, including likely side effects, take time. My physician friends who initially declined pain medications (and certainly will again) did so because they have seen scores of their own patients suffer similar side effects. I’m sure that they share my suspicion that reports of side effects seriously underestimate reality.

When it comes to very young children and unconscious adults, we are limited in our ability to have a dialogue about discomfort. In those cases, we are obligated to treat and accept the risk of side effects. We must make inferences from vital signs and other biophysical measurements that the patient is uncomfortable. However, for the patient who can communicate, I think we should put more stock in what the patient tells us about what is bothering him, and why, than in the tracings on a monitor or some sketchy number.

While dictionaries usually make little distinction between "pain" and "suffering," it may be time for those of us who treat patients to consider assigning each word its own working definition. Pain could be reserved for the neurophysiologists and described in terms of spike potentials and neurotransmitter levels. Suffering, on the other hand, would be a much broader term that is unique to each patient’s experience and takes into account factors such as anxiety and depression. We may find with this redefinition that we are using less medication and that patients are more comfortable.

Dr. Wilkoff practiced general pediatrics in Brunswick, Maine, for nearly forty years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected]. 

 Updated 9/4/13, 10/8/2013

Two of my physician friends recently had knee surgery. Both have had good outcomes, but during their hospital stays they struggled to defend themselves against the troops of the no-pain-goes-untreated army. They have been paying attention, and realize that every medication and intervention carries a downside. So when they were badgered into taking something for pain in the immediate postop period, their inclination was to decline.

Weakened by preop fatigue, each eventually relented and "took the damn pills." The result was for each of them the worst experience of their surgical adventure. One vomited and wisely declined anything more than acetaminophen. The other became so loopy and disoriented that his hospital stay was extended by a day as the physicians and nurses struggled to make sure he hadn’t suffered a stroke.

If you had asked each of my friends whether they were having pain, they would have answered, "Sure." But, if you had asked them to rate their pain on a scale of 1-10, they would have screwed up their faces and asked, "What are you talking about?" If you rephrased the question and asked, "How does this compare to the worst pain you have ever had?" they would reply, "I’m sorry, are we talking apples or oranges?"

Pain is one of those things that doesn’t fit into any definable category. Because of their commitment to helping patients be as comfortable as they can, nurses are eager to use the tools at their disposal. They have been taught that in most cases, early mobility results in a better outcome, and that pain can discourage patients from wanting to move or even participate in their own recovery.

In the last several decades, there has been a well-intentioned but misguided movement toward asking patients to quantify their pain. I wonder whether there is much good evidence to support this effort. But it sounds oh so terribly scientific to put a number on something. Suffering is such a personal experience that pain can’t really be distilled down to a number or a smiley face emoticon. Although it requires more time and skill, a better approach for caregivers is to engage the patient in a dialogue about his or her discomfort. I suspect that most of the best nurses do just that.

Some well-crafted questions delivered with an empathetic tone will detect confounding issues, such as anxiety. From my observations and personal experience, anxiety is a powerful multiplier of pain. The more the patient understands about what is causing his pain and the more realistic his expectations are about how long it will last, the more tolerable the pain can be. But finding out what is making the patient anxious, and explaining the management options, including likely side effects, take time. My physician friends who initially declined pain medications (and certainly will again) did so because they have seen scores of their own patients suffer similar side effects. I’m sure that they share my suspicion that reports of side effects seriously underestimate reality.

When it comes to very young children and unconscious adults, we are limited in our ability to have a dialogue about discomfort. In those cases, we are obligated to treat and accept the risk of side effects. We must make inferences from vital signs and other biophysical measurements that the patient is uncomfortable. However, for the patient who can communicate, I think we should put more stock in what the patient tells us about what is bothering him, and why, than in the tracings on a monitor or some sketchy number.

While dictionaries usually make little distinction between "pain" and "suffering," it may be time for those of us who treat patients to consider assigning each word its own working definition. Pain could be reserved for the neurophysiologists and described in terms of spike potentials and neurotransmitter levels. Suffering, on the other hand, would be a much broader term that is unique to each patient’s experience and takes into account factors such as anxiety and depression. We may find with this redefinition that we are using less medication and that patients are more comfortable.

Dr. Wilkoff practiced general pediatrics in Brunswick, Maine, for nearly forty years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected]. 

 Updated 9/4/13, 10/8/2013

I grew up in a small town about 30 miles north of New York City. Back then, it was a quiet, semirural community proud of its excellent school system. It was a wonderful place for raising children and still affordable for families with modest means.

Like half of the other men in town, my father commuted into the city for his job. As a result, he spent more than 2 hours of his day travelling. My memories of how he looked and what he said when he arrived home in the evening convinced me that I would never allow commuting to gobble up a large chunk of my life. As commutes go, I guess his was relatively benign. Most nights he had a seat on the train and could read the newspaper and do the crossword.

My sister and I will be forever grateful for those sacrifices he made by commuting so that we could grow up in a safe and supportive community. But as I considered my options for work, I ruled out the subspecialties of pediatric dermatology and radiology, which suited my visual skills, because they would have required me to live in a city of several hundred thousand people. My preference for small town life and an aversion to commuting meant that happiness would be more likely if I worked and resided in the same town.

Until one of our hospitals moved 4 miles to the other side of town a few years ago, my commute consisted of a 5-minute bike ride or a 12-minute walk. When our children were young, it meant that, even though I might not be able to make it home for dinner or tuck-in time, we could have lunch and play ball in the yard before their afternoon naps.

As I have watched other parents struggle to fabricate quality time with their children, I wish that more of them could have made the decision my wife and I made when we chose to live and work in the same community. I know that this will never be a viable option for many families, particularly for those saintly folks who have chosen to provide health care to underserved inner city populations. However, I fear that too many families underestimate the toll that commuting can take on the fabric of their lives.

A parent exhausted by a long drive in rush-hour traffic is generally not the best parent he or she could be. Young children have trouble understanding why they need to wait for the weekend to spend time with their parents. Workdays inflated by lengthy commutes may nudge parents into making the unwise decision of delaying their children’s bedtimes to an unhealthy hour so that they can be part of the process.

I suspect that most of you have long ago made the big decisions about location and have either endured the consequences or made creative adjustments that have allowed you to comfortably bridge the gap between where you work and where you live. But for those of you who are on the threshold of your professional career or who are facing burnout fueled by too-few-hours-in-a-day, do the math. Imagine what you could do with the time you will be or have been investing in your commute. Are there things you could be doing to make the community where you work a place where you would also like to live? If you eliminate your commute you may have the time to do all sorts of wonderful things.

Dr. Wilkoff practiced general pediatrics in Brunswick, Maine, for nearly forty years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected]. 

Updated 9/4/13, 10/8/13

I grew up in a small town about 30 miles north of New York City. Back then, it was a quiet, semirural community proud of its excellent school system. It was a wonderful place for raising children and still affordable for families with modest means.

Like half of the other men in town, my father commuted into the city for his job. As a result, he spent more than 2 hours of his day travelling. My memories of how he looked and what he said when he arrived home in the evening convinced me that I would never allow commuting to gobble up a large chunk of my life. As commutes go, I guess his was relatively benign. Most nights he had a seat on the train and could read the newspaper and do the crossword.

My sister and I will be forever grateful for those sacrifices he made by commuting so that we could grow up in a safe and supportive community. But as I considered my options for work, I ruled out the subspecialties of pediatric dermatology and radiology, which suited my visual skills, because they would have required me to live in a city of several hundred thousand people. My preference for small town life and an aversion to commuting meant that happiness would be more likely if I worked and resided in the same town.

Until one of our hospitals moved 4 miles to the other side of town a few years ago, my commute consisted of a 5-minute bike ride or a 12-minute walk. When our children were young, it meant that, even though I might not be able to make it home for dinner or tuck-in time, we could have lunch and play ball in the yard before their afternoon naps.

As I have watched other parents struggle to fabricate quality time with their children, I wish that more of them could have made the decision my wife and I made when we chose to live and work in the same community. I know that this will never be a viable option for many families, particularly for those saintly folks who have chosen to provide health care to underserved inner city populations. However, I fear that too many families underestimate the toll that commuting can take on the fabric of their lives.

A parent exhausted by a long drive in rush-hour traffic is generally not the best parent he or she could be. Young children have trouble understanding why they need to wait for the weekend to spend time with their parents. Workdays inflated by lengthy commutes may nudge parents into making the unwise decision of delaying their children’s bedtimes to an unhealthy hour so that they can be part of the process.

I suspect that most of you have long ago made the big decisions about location and have either endured the consequences or made creative adjustments that have allowed you to comfortably bridge the gap between where you work and where you live. But for those of you who are on the threshold of your professional career or who are facing burnout fueled by too-few-hours-in-a-day, do the math. Imagine what you could do with the time you will be or have been investing in your commute. Are there things you could be doing to make the community where you work a place where you would also like to live? If you eliminate your commute you may have the time to do all sorts of wonderful things.

Dr. Wilkoff practiced general pediatrics in Brunswick, Maine, for nearly forty years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected]. 

Updated 9/4/13, 10/8/13

I grew up in a small town about 30 miles north of New York City. Back then, it was a quiet, semirural community proud of its excellent school system. It was a wonderful place for raising children and still affordable for families with modest means.

Like half of the other men in town, my father commuted into the city for his job. As a result, he spent more than 2 hours of his day travelling. My memories of how he looked and what he said when he arrived home in the evening convinced me that I would never allow commuting to gobble up a large chunk of my life. As commutes go, I guess his was relatively benign. Most nights he had a seat on the train and could read the newspaper and do the crossword.

My sister and I will be forever grateful for those sacrifices he made by commuting so that we could grow up in a safe and supportive community. But as I considered my options for work, I ruled out the subspecialties of pediatric dermatology and radiology, which suited my visual skills, because they would have required me to live in a city of several hundred thousand people. My preference for small town life and an aversion to commuting meant that happiness would be more likely if I worked and resided in the same town.

Until one of our hospitals moved 4 miles to the other side of town a few years ago, my commute consisted of a 5-minute bike ride or a 12-minute walk. When our children were young, it meant that, even though I might not be able to make it home for dinner or tuck-in time, we could have lunch and play ball in the yard before their afternoon naps.

As I have watched other parents struggle to fabricate quality time with their children, I wish that more of them could have made the decision my wife and I made when we chose to live and work in the same community. I know that this will never be a viable option for many families, particularly for those saintly folks who have chosen to provide health care to underserved inner city populations. However, I fear that too many families underestimate the toll that commuting can take on the fabric of their lives.

A parent exhausted by a long drive in rush-hour traffic is generally not the best parent he or she could be. Young children have trouble understanding why they need to wait for the weekend to spend time with their parents. Workdays inflated by lengthy commutes may nudge parents into making the unwise decision of delaying their children’s bedtimes to an unhealthy hour so that they can be part of the process.

I suspect that most of you have long ago made the big decisions about location and have either endured the consequences or made creative adjustments that have allowed you to comfortably bridge the gap between where you work and where you live. But for those of you who are on the threshold of your professional career or who are facing burnout fueled by too-few-hours-in-a-day, do the math. Imagine what you could do with the time you will be or have been investing in your commute. Are there things you could be doing to make the community where you work a place where you would also like to live? If you eliminate your commute you may have the time to do all sorts of wonderful things.

Dr. Wilkoff practiced general pediatrics in Brunswick, Maine, for nearly forty years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected]. 

Updated 9/4/13, 10/8/13

If a physician focuses on his patients and their responses to illness rather than the illness itself, he is less likely find the practice of general pediatrics boring. However, there are days when a steady diet of runny noses, ear infections, depressed teenagers, and rule-out-attention-deficit/hyperactivity disorder can numb the senses of even the most patient-centered pediatrician.

Half a century ago, pediatricians saw a wider variety of illnesses and injuries in their offices than they do now. For various reasons, the scope of practice for most pediatricians has narrowed. Residency programs churned out subspecialists, who then moved into communities that had previously been "underserved." Alert parents interested in the "best" care options could now bypass the general pediatrician and self-refer for problems that he had been successfully managing himself.

Newly trained pediatricians accustomed to having easy access to subspecialists during their residency may become more likely to reach for the phone and a quick-and-easy referral instead of tackling a problem that their older colleagues would have managed on their own. While necessity was once the mother of invention, an abundance of subspecialists eager to market their skills has fathered a generation of physicians hesitant to venture beyond a narrow comfort zone. Of course, the perceived threat of malpractice suits has amplified this shift toward specialty dependence.

Twenty-five years ago, hospitals and pharmacy chains began to realize that opening urgent care centers and walk-in clinics could be profitable or at least function as attractive portals to their other income streams. Some physicians welcomed these new kids on the block. But even pediatricians who encouraged families with minor emergencies to come to their offices, and who offered extended office hours, faced stiff competition from hospital walk-in clinics with hefty advertising budgets.

The end result of these forces of competition and short-sighted self-pruning is that many families no longer think of their pediatrician’s office as the place to go for minor injuries. With less exposure, a physician and his staff can become increasingly uncomfortable with these simple problems.

A report in the Journal of Pediatric Orthopedics (2012;32:732-6) documents how far this trend to avoidance has gone. Of more than 500 new referrals to a hospital-based orthopedic clinic, the investigators determined that nearly half of the patients had a problem that a health care provider with "basic musculoskeletal education and experience can manage." The list of conditions included undisplaced finger fractures, displaced single bone upper extremity fractures, femoral anteversion, and radial buckle fractures.

I was lucky enough to have been trained by physicians who assumed that I wouldn’t have ready access to orthopedists. This left me with some very basic skills that have allowed me to enjoy a more balanced diet of presenting complaints in the office. Primary care orthopedics is not rocket science or neurosurgery. Children’s bones heal quickly. Splinting and casting is hands-on fun with rewarding results. And parents appreciate the convenience of one-stop shopping.

If you want to build a medical home that provides you with a more stimulating variety of chief complaints and offers families an attractive place to get good care, it’s time to bone up on your basic musculoskeletal education.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

If a physician focuses on his patients and their responses to illness rather than the illness itself, he is less likely find the practice of general pediatrics boring. However, there are days when a steady diet of runny noses, ear infections, depressed teenagers, and rule-out-attention-deficit/hyperactivity disorder can numb the senses of even the most patient-centered pediatrician.

Half a century ago, pediatricians saw a wider variety of illnesses and injuries in their offices than they do now. For various reasons, the scope of practice for most pediatricians has narrowed. Residency programs churned out subspecialists, who then moved into communities that had previously been "underserved." Alert parents interested in the "best" care options could now bypass the general pediatrician and self-refer for problems that he had been successfully managing himself.

Newly trained pediatricians accustomed to having easy access to subspecialists during their residency may become more likely to reach for the phone and a quick-and-easy referral instead of tackling a problem that their older colleagues would have managed on their own. While necessity was once the mother of invention, an abundance of subspecialists eager to market their skills has fathered a generation of physicians hesitant to venture beyond a narrow comfort zone. Of course, the perceived threat of malpractice suits has amplified this shift toward specialty dependence.

Twenty-five years ago, hospitals and pharmacy chains began to realize that opening urgent care centers and walk-in clinics could be profitable or at least function as attractive portals to their other income streams. Some physicians welcomed these new kids on the block. But even pediatricians who encouraged families with minor emergencies to come to their offices, and who offered extended office hours, faced stiff competition from hospital walk-in clinics with hefty advertising budgets.

The end result of these forces of competition and short-sighted self-pruning is that many families no longer think of their pediatrician’s office as the place to go for minor injuries. With less exposure, a physician and his staff can become increasingly uncomfortable with these simple problems.

A report in the Journal of Pediatric Orthopedics (2012;32:732-6) documents how far this trend to avoidance has gone. Of more than 500 new referrals to a hospital-based orthopedic clinic, the investigators determined that nearly half of the patients had a problem that a health care provider with "basic musculoskeletal education and experience can manage." The list of conditions included undisplaced finger fractures, displaced single bone upper extremity fractures, femoral anteversion, and radial buckle fractures.

I was lucky enough to have been trained by physicians who assumed that I wouldn’t have ready access to orthopedists. This left me with some very basic skills that have allowed me to enjoy a more balanced diet of presenting complaints in the office. Primary care orthopedics is not rocket science or neurosurgery. Children’s bones heal quickly. Splinting and casting is hands-on fun with rewarding results. And parents appreciate the convenience of one-stop shopping.

If you want to build a medical home that provides you with a more stimulating variety of chief complaints and offers families an attractive place to get good care, it’s time to bone up on your basic musculoskeletal education.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

If a physician focuses on his patients and their responses to illness rather than the illness itself, he is less likely find the practice of general pediatrics boring. However, there are days when a steady diet of runny noses, ear infections, depressed teenagers, and rule-out-attention-deficit/hyperactivity disorder can numb the senses of even the most patient-centered pediatrician.

Half a century ago, pediatricians saw a wider variety of illnesses and injuries in their offices than they do now. For various reasons, the scope of practice for most pediatricians has narrowed. Residency programs churned out subspecialists, who then moved into communities that had previously been "underserved." Alert parents interested in the "best" care options could now bypass the general pediatrician and self-refer for problems that he had been successfully managing himself.

Newly trained pediatricians accustomed to having easy access to subspecialists during their residency may become more likely to reach for the phone and a quick-and-easy referral instead of tackling a problem that their older colleagues would have managed on their own. While necessity was once the mother of invention, an abundance of subspecialists eager to market their skills has fathered a generation of physicians hesitant to venture beyond a narrow comfort zone. Of course, the perceived threat of malpractice suits has amplified this shift toward specialty dependence.

Twenty-five years ago, hospitals and pharmacy chains began to realize that opening urgent care centers and walk-in clinics could be profitable or at least function as attractive portals to their other income streams. Some physicians welcomed these new kids on the block. But even pediatricians who encouraged families with minor emergencies to come to their offices, and who offered extended office hours, faced stiff competition from hospital walk-in clinics with hefty advertising budgets.

The end result of these forces of competition and short-sighted self-pruning is that many families no longer think of their pediatrician’s office as the place to go for minor injuries. With less exposure, a physician and his staff can become increasingly uncomfortable with these simple problems.

A report in the Journal of Pediatric Orthopedics (2012;32:732-6) documents how far this trend to avoidance has gone. Of more than 500 new referrals to a hospital-based orthopedic clinic, the investigators determined that nearly half of the patients had a problem that a health care provider with "basic musculoskeletal education and experience can manage." The list of conditions included undisplaced finger fractures, displaced single bone upper extremity fractures, femoral anteversion, and radial buckle fractures.

I was lucky enough to have been trained by physicians who assumed that I wouldn’t have ready access to orthopedists. This left me with some very basic skills that have allowed me to enjoy a more balanced diet of presenting complaints in the office. Primary care orthopedics is not rocket science or neurosurgery. Children’s bones heal quickly. Splinting and casting is hands-on fun with rewarding results. And parents appreciate the convenience of one-stop shopping.

If you want to build a medical home that provides you with a more stimulating variety of chief complaints and offers families an attractive place to get good care, it’s time to bone up on your basic musculoskeletal education.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].