Letters from Maine

Like most of you, my wife and I have come to rely on the Internet as our primary link to the outside world. One evening, my wife complained that she couldn’t download one of the few television shows she watches on her laptop. I tried a few of the tricks I know, but failed and told her that it was probably Hulu’s problem and not ours. However, over the next week, slow download speeds continued to be a problem. But it was an intermittent condition and seemed to begin as the sun went down and didn’t occur during the daytime.

I called our Internet provider’s tech support line and described the issues we were having. This Maine-based company has been our only provider since its inception more than a decade ago. They have always been easy to reach and responsive. My call was handled in the same concerned and polite manner as usual. The representative listened to my story, made some suggestions of things I should try at home (which I had already done), and tweaked a few adjustments on his end.

From what he could see everything looked fine, and at that time it seemed to be. He ended the call asking me if there was anything else he could help me with and reminded me that their call line was open 24/7.

However, the problem continued to occur and I continued to call and continued to receive polite and apparently knowledgeable advice. Each of the six different technicians had a slightly different take on my story and made new suggestions, and I continued to do as they suggested. Finally, they sent a repair guy out to the house who installed a new wall jack and a filter that would cover the whole system. Things were running fine when he arrived and fine when he left, but by evening we were running too slow to do anything except receive very delayed emails.

The next morning, although our download speeds were back up, my patience had worn thin, and the very polite technician suggested that I wait until 8:30 when the level II people arrived. When I talked to "Bob," he listened to my story patiently, paused a second or two and asked, "Do you have a street light in front of your house?" I replied that we did, and it had been out for a couple of weeks. He said he had seen it happen a couple of dozen times, and was pretty sure it was the problem. Interference from a faulty starter was slowing our speeds during the dark hours. He was correct.

There are at least three lessons to be learned from this adventure that are applicable to the practice of medicine.

First, good customer service can help a physician maintain a relationship with his or her patient when things aren’t going well. I could have easily canceled my contract with this company and signed on with another, but because everyone had sounded so polite and interested in our problem, I continued to give them yet another chance.

Second and most importantly, while customer service is nice, there is no substitute for the correct diagnosis. Had my problem been medical, I would likely have been subjected to numerous needless studies and radiation exposures. The lost time and expense would have been significant, but even more troubling is that I could have died for the lack of the right answer.

Finally, and here is where the company failed, clearly they had at least one technician who had enough experience to arrive at the correct diagnosis. However, they had not created a system or fostered the environment in which this wisdom could easily be transmitted to the inexperienced. It seems to me that organized medicine also needs a better system to capture the wisdom of our level II fogies before they move on.

This column, "Letters From Maine," appears regularly in Pediatric News. Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

Like most of you, my wife and I have come to rely on the Internet as our primary link to the outside world. One evening, my wife complained that she couldn’t download one of the few television shows she watches on her laptop. I tried a few of the tricks I know, but failed and told her that it was probably Hulu’s problem and not ours. However, over the next week, slow download speeds continued to be a problem. But it was an intermittent condition and seemed to begin as the sun went down and didn’t occur during the daytime.

I called our Internet provider’s tech support line and described the issues we were having. This Maine-based company has been our only provider since its inception more than a decade ago. They have always been easy to reach and responsive. My call was handled in the same concerned and polite manner as usual. The representative listened to my story, made some suggestions of things I should try at home (which I had already done), and tweaked a few adjustments on his end.

From what he could see everything looked fine, and at that time it seemed to be. He ended the call asking me if there was anything else he could help me with and reminded me that their call line was open 24/7.

However, the problem continued to occur and I continued to call and continued to receive polite and apparently knowledgeable advice. Each of the six different technicians had a slightly different take on my story and made new suggestions, and I continued to do as they suggested. Finally, they sent a repair guy out to the house who installed a new wall jack and a filter that would cover the whole system. Things were running fine when he arrived and fine when he left, but by evening we were running too slow to do anything except receive very delayed emails.

The next morning, although our download speeds were back up, my patience had worn thin, and the very polite technician suggested that I wait until 8:30 when the level II people arrived. When I talked to "Bob," he listened to my story patiently, paused a second or two and asked, "Do you have a street light in front of your house?" I replied that we did, and it had been out for a couple of weeks. He said he had seen it happen a couple of dozen times, and was pretty sure it was the problem. Interference from a faulty starter was slowing our speeds during the dark hours. He was correct.

There are at least three lessons to be learned from this adventure that are applicable to the practice of medicine.

First, good customer service can help a physician maintain a relationship with his or her patient when things aren’t going well. I could have easily canceled my contract with this company and signed on with another, but because everyone had sounded so polite and interested in our problem, I continued to give them yet another chance.

Second and most importantly, while customer service is nice, there is no substitute for the correct diagnosis. Had my problem been medical, I would likely have been subjected to numerous needless studies and radiation exposures. The lost time and expense would have been significant, but even more troubling is that I could have died for the lack of the right answer.

Finally, and here is where the company failed, clearly they had at least one technician who had enough experience to arrive at the correct diagnosis. However, they had not created a system or fostered the environment in which this wisdom could easily be transmitted to the inexperienced. It seems to me that organized medicine also needs a better system to capture the wisdom of our level II fogies before they move on.

This column, "Letters From Maine," appears regularly in Pediatric News. Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

Like most of you, my wife and I have come to rely on the Internet as our primary link to the outside world. One evening, my wife complained that she couldn’t download one of the few television shows she watches on her laptop. I tried a few of the tricks I know, but failed and told her that it was probably Hulu’s problem and not ours. However, over the next week, slow download speeds continued to be a problem. But it was an intermittent condition and seemed to begin as the sun went down and didn’t occur during the daytime.

I called our Internet provider’s tech support line and described the issues we were having. This Maine-based company has been our only provider since its inception more than a decade ago. They have always been easy to reach and responsive. My call was handled in the same concerned and polite manner as usual. The representative listened to my story, made some suggestions of things I should try at home (which I had already done), and tweaked a few adjustments on his end.

From what he could see everything looked fine, and at that time it seemed to be. He ended the call asking me if there was anything else he could help me with and reminded me that their call line was open 24/7.

However, the problem continued to occur and I continued to call and continued to receive polite and apparently knowledgeable advice. Each of the six different technicians had a slightly different take on my story and made new suggestions, and I continued to do as they suggested. Finally, they sent a repair guy out to the house who installed a new wall jack and a filter that would cover the whole system. Things were running fine when he arrived and fine when he left, but by evening we were running too slow to do anything except receive very delayed emails.

The next morning, although our download speeds were back up, my patience had worn thin, and the very polite technician suggested that I wait until 8:30 when the level II people arrived. When I talked to "Bob," he listened to my story patiently, paused a second or two and asked, "Do you have a street light in front of your house?" I replied that we did, and it had been out for a couple of weeks. He said he had seen it happen a couple of dozen times, and was pretty sure it was the problem. Interference from a faulty starter was slowing our speeds during the dark hours. He was correct.

There are at least three lessons to be learned from this adventure that are applicable to the practice of medicine.

First, good customer service can help a physician maintain a relationship with his or her patient when things aren’t going well. I could have easily canceled my contract with this company and signed on with another, but because everyone had sounded so polite and interested in our problem, I continued to give them yet another chance.

Second and most importantly, while customer service is nice, there is no substitute for the correct diagnosis. Had my problem been medical, I would likely have been subjected to numerous needless studies and radiation exposures. The lost time and expense would have been significant, but even more troubling is that I could have died for the lack of the right answer.

Finally, and here is where the company failed, clearly they had at least one technician who had enough experience to arrive at the correct diagnosis. However, they had not created a system or fostered the environment in which this wisdom could easily be transmitted to the inexperienced. It seems to me that organized medicine also needs a better system to capture the wisdom of our level II fogies before they move on.

This column, "Letters From Maine," appears regularly in Pediatric News. Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

Like most of you, my wife and I have come to rely on the Internet as our primary link to the outside world. One evening, my wife complained that she couldn’t download one of the few television shows she watches on her laptop. I tried a few of the tricks I know, but failed and told her that it was probably Hulu’s problem and not ours. However, over the next week, slow download speeds continued to be a problem. But it was an intermittent condition and seemed to begin as the sun went down and didn’t occur during the daytime.

I called our Internet provider’s tech support line and described the issues we were having. This Maine-based company has been our only provider since its inception more than a decade ago. They have always been easy to reach and responsive. My call was handled in the same concerned and polite manner as usual. The representative listened to my story, made some suggestions of things I should try at home (which I had already done), and tweaked a few adjustments on his end.

From what he could see everything looked fine, and at that time it seemed to be. He ended the call asking me if there was anything else he could help me with and reminded me that their call line was open 24/7.

However, the problem continued to occur and I continued to call and continued to receive polite and apparently knowledgeable advice. Each of the six different technicians had a slightly different take on my story and made new suggestions, and I continued to do as they suggested. Finally, they sent a repair guy out to the house who installed a new wall jack and a filter that would cover the whole system. Things were running fine when he arrived and fine when he left, but by evening we were running too slow to do anything except receive very delayed emails.

The next morning, although our download speeds were back up, my patience had worn thin, and the very polite technician suggested that I wait until 8:30 when the level II people arrived. When I talked to "Bob," he listened to my story patiently, paused a second or two and asked, "Do you have a street light in front of your house?" I replied that we did, and it had been out for a couple of weeks. He said he had seen it happen a couple of dozen times, and was pretty sure it was the problem. Interference from a faulty starter was slowing our speeds during the dark hours. He was correct.

There are at least three lessons to be learned from this adventure that are applicable to the practice of medicine.

First, good customer service can help a physician maintain a relationship with his or her patient when things aren’t going well. I could have easily canceled my contract with this company and signed on with another, but because everyone had sounded so polite and interested in our problem, I continued to give them yet another chance.

Second and most importantly, while customer service is nice, there is no substitute for the correct diagnosis. Had my problem been medical, I would likely have been subjected to numerous needless studies and radiation exposures. The lost time and expense would have been significant, but even more troubling is that I could have died for the lack of the right answer.

Finally, and here is where the company failed, clearly they had at least one technician who had enough experience to arrive at the correct diagnosis. However, they had not created a system or fostered the environment in which this wisdom could easily be transmitted to the inexperienced. It seems to me that organized medicine also needs a better system to capture the wisdom of our level II fogies before they move on.

This column, "Letters From Maine," appears regularly in Pediatric News. Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

Like most of you, my wife and I have come to rely on the Internet as our primary link to the outside world. One evening, my wife complained that she couldn’t download one of the few television shows she watches on her laptop. I tried a few of the tricks I know, but failed and told her that it was probably Hulu’s problem and not ours. However, over the next week, slow download speeds continued to be a problem. But it was an intermittent condition and seemed to begin as the sun went down and didn’t occur during the daytime.

I called our Internet provider’s tech support line and described the issues we were having. This Maine-based company has been our only provider since its inception more than a decade ago. They have always been easy to reach and responsive. My call was handled in the same concerned and polite manner as usual. The representative listened to my story, made some suggestions of things I should try at home (which I had already done), and tweaked a few adjustments on his end.

From what he could see everything looked fine, and at that time it seemed to be. He ended the call asking me if there was anything else he could help me with and reminded me that their call line was open 24/7.

However, the problem continued to occur and I continued to call and continued to receive polite and apparently knowledgeable advice. Each of the six different technicians had a slightly different take on my story and made new suggestions, and I continued to do as they suggested. Finally, they sent a repair guy out to the house who installed a new wall jack and a filter that would cover the whole system. Things were running fine when he arrived and fine when he left, but by evening we were running too slow to do anything except receive very delayed emails.

The next morning, although our download speeds were back up, my patience had worn thin, and the very polite technician suggested that I wait until 8:30 when the level II people arrived. When I talked to "Bob," he listened to my story patiently, paused a second or two and asked, "Do you have a street light in front of your house?" I replied that we did, and it had been out for a couple of weeks. He said he had seen it happen a couple of dozen times, and was pretty sure it was the problem. Interference from a faulty starter was slowing our speeds during the dark hours. He was correct.

There are at least three lessons to be learned from this adventure that are applicable to the practice of medicine.

First, good customer service can help a physician maintain a relationship with his or her patient when things aren’t going well. I could have easily canceled my contract with this company and signed on with another, but because everyone had sounded so polite and interested in our problem, I continued to give them yet another chance.

Second and most importantly, while customer service is nice, there is no substitute for the correct diagnosis. Had my problem been medical, I would likely have been subjected to numerous needless studies and radiation exposures. The lost time and expense would have been significant, but even more troubling is that I could have died for the lack of the right answer.

Finally, and here is where the company failed, clearly they had at least one technician who had enough experience to arrive at the correct diagnosis. However, they had not created a system or fostered the environment in which this wisdom could easily be transmitted to the inexperienced. It seems to me that organized medicine also needs a better system to capture the wisdom of our level II fogies before they move on.

This column, "Letters From Maine," appears regularly in Pediatric News. Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

Like most of you, my wife and I have come to rely on the Internet as our primary link to the outside world. One evening, my wife complained that she couldn’t download one of the few television shows she watches on her laptop. I tried a few of the tricks I know, but failed and told her that it was probably Hulu’s problem and not ours. However, over the next week, slow download speeds continued to be a problem. But it was an intermittent condition and seemed to begin as the sun went down and didn’t occur during the daytime.

I called our Internet provider’s tech support line and described the issues we were having. This Maine-based company has been our only provider since its inception more than a decade ago. They have always been easy to reach and responsive. My call was handled in the same concerned and polite manner as usual. The representative listened to my story, made some suggestions of things I should try at home (which I had already done), and tweaked a few adjustments on his end.

From what he could see everything looked fine, and at that time it seemed to be. He ended the call asking me if there was anything else he could help me with and reminded me that their call line was open 24/7.

However, the problem continued to occur and I continued to call and continued to receive polite and apparently knowledgeable advice. Each of the six different technicians had a slightly different take on my story and made new suggestions, and I continued to do as they suggested. Finally, they sent a repair guy out to the house who installed a new wall jack and a filter that would cover the whole system. Things were running fine when he arrived and fine when he left, but by evening we were running too slow to do anything except receive very delayed emails.

The next morning, although our download speeds were back up, my patience had worn thin, and the very polite technician suggested that I wait until 8:30 when the level II people arrived. When I talked to "Bob," he listened to my story patiently, paused a second or two and asked, "Do you have a street light in front of your house?" I replied that we did, and it had been out for a couple of weeks. He said he had seen it happen a couple of dozen times, and was pretty sure it was the problem. Interference from a faulty starter was slowing our speeds during the dark hours. He was correct.

There are at least three lessons to be learned from this adventure that are applicable to the practice of medicine.

First, good customer service can help a physician maintain a relationship with his or her patient when things aren’t going well. I could have easily canceled my contract with this company and signed on with another, but because everyone had sounded so polite and interested in our problem, I continued to give them yet another chance.

Second and most importantly, while customer service is nice, there is no substitute for the correct diagnosis. Had my problem been medical, I would likely have been subjected to numerous needless studies and radiation exposures. The lost time and expense would have been significant, but even more troubling is that I could have died for the lack of the right answer.

Finally, and here is where the company failed, clearly they had at least one technician who had enough experience to arrive at the correct diagnosis. However, they had not created a system or fostered the environment in which this wisdom could easily be transmitted to the inexperienced. It seems to me that organized medicine also needs a better system to capture the wisdom of our level II fogies before they move on.

This column, "Letters From Maine," appears regularly in Pediatric News. Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

Like most of you, my wife and I have come to rely on the Internet as our primary link to the outside world. One evening, my wife complained that she couldn’t download one of the few television shows she watches on her laptop. I tried a few of the tricks I know, but failed and told her that it was probably Hulu’s problem and not ours. However, over the next week, slow download speeds continued to be a problem. But it was an intermittent condition and seemed to begin as the sun went down and didn’t occur during the daytime.

I called our Internet provider’s tech support line and described the issues we were having. This Maine-based company has been our only provider since its inception more than a decade ago. They have always been easy to reach and responsive. My call was handled in the same concerned and polite manner as usual. The representative listened to my story, made some suggestions of things I should try at home (which I had already done), and tweaked a few adjustments on his end.

From what he could see everything looked fine, and at that time it seemed to be. He ended the call asking me if there was anything else he could help me with and reminded me that their call line was open 24/7.

However, the problem continued to occur and I continued to call and continued to receive polite and apparently knowledgeable advice. Each of the six different technicians had a slightly different take on my story and made new suggestions, and I continued to do as they suggested. Finally, they sent a repair guy out to the house who installed a new wall jack and a filter that would cover the whole system. Things were running fine when he arrived and fine when he left, but by evening we were running too slow to do anything except receive very delayed emails.

The next morning, although our download speeds were back up, my patience had worn thin, and the very polite technician suggested that I wait until 8:30 when the level II people arrived. When I talked to "Bob," he listened to my story patiently, paused a second or two and asked, "Do you have a street light in front of your house?" I replied that we did, and it had been out for a couple of weeks. He said he had seen it happen a couple of dozen times, and was pretty sure it was the problem. Interference from a faulty starter was slowing our speeds during the dark hours. He was correct.

There are at least three lessons to be learned from this adventure that are applicable to the practice of medicine.

First, good customer service can help a physician maintain a relationship with his or her patient when things aren’t going well. I could have easily canceled my contract with this company and signed on with another, but because everyone had sounded so polite and interested in our problem, I continued to give them yet another chance.

Second and most importantly, while customer service is nice, there is no substitute for the correct diagnosis. Had my problem been medical, I would likely have been subjected to numerous needless studies and radiation exposures. The lost time and expense would have been significant, but even more troubling is that I could have died for the lack of the right answer.

Finally, and here is where the company failed, clearly they had at least one technician who had enough experience to arrive at the correct diagnosis. However, they had not created a system or fostered the environment in which this wisdom could easily be transmitted to the inexperienced. It seems to me that organized medicine also needs a better system to capture the wisdom of our level II fogies before they move on.

This column, "Letters From Maine," appears regularly in Pediatric News. Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

Like most of you, my wife and I have come to rely on the Internet as our primary link to the outside world. One evening, my wife complained that she couldn’t download one of the few television shows she watches on her laptop. I tried a few of the tricks I know, but failed and told her that it was probably Hulu’s problem and not ours. However, over the next week, slow download speeds continued to be a problem. But it was an intermittent condition and seemed to begin as the sun went down and didn’t occur during the daytime.

I called our Internet provider’s tech support line and described the issues we were having. This Maine-based company has been our only provider since its inception more than a decade ago. They have always been easy to reach and responsive. My call was handled in the same concerned and polite manner as usual. The representative listened to my story, made some suggestions of things I should try at home (which I had already done), and tweaked a few adjustments on his end.

From what he could see everything looked fine, and at that time it seemed to be. He ended the call asking me if there was anything else he could help me with and reminded me that their call line was open 24/7.

However, the problem continued to occur and I continued to call and continued to receive polite and apparently knowledgeable advice. Each of the six different technicians had a slightly different take on my story and made new suggestions, and I continued to do as they suggested. Finally, they sent a repair guy out to the house who installed a new wall jack and a filter that would cover the whole system. Things were running fine when he arrived and fine when he left, but by evening we were running too slow to do anything except receive very delayed emails.

The next morning, although our download speeds were back up, my patience had worn thin, and the very polite technician suggested that I wait until 8:30 when the level II people arrived. When I talked to "Bob," he listened to my story patiently, paused a second or two and asked, "Do you have a street light in front of your house?" I replied that we did, and it had been out for a couple of weeks. He said he had seen it happen a couple of dozen times, and was pretty sure it was the problem. Interference from a faulty starter was slowing our speeds during the dark hours. He was correct.

There are at least three lessons to be learned from this adventure that are applicable to the practice of medicine.

First, good customer service can help a physician maintain a relationship with his or her patient when things aren’t going well. I could have easily canceled my contract with this company and signed on with another, but because everyone had sounded so polite and interested in our problem, I continued to give them yet another chance.

Second and most importantly, while customer service is nice, there is no substitute for the correct diagnosis. Had my problem been medical, I would likely have been subjected to numerous needless studies and radiation exposures. The lost time and expense would have been significant, but even more troubling is that I could have died for the lack of the right answer.

Finally, and here is where the company failed, clearly they had at least one technician who had enough experience to arrive at the correct diagnosis. However, they had not created a system or fostered the environment in which this wisdom could easily be transmitted to the inexperienced. It seems to me that organized medicine also needs a better system to capture the wisdom of our level II fogies before they move on.

This column, "Letters From Maine," appears regularly in Pediatric News. Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

Like most of you, my wife and I have come to rely on the Internet as our primary link to the outside world. One evening, my wife complained that she couldn’t download one of the few television shows she watches on her laptop. I tried a few of the tricks I know, but failed and told her that it was probably Hulu’s problem and not ours. However, over the next week, slow download speeds continued to be a problem. But it was an intermittent condition and seemed to begin as the sun went down and didn’t occur during the daytime.

I called our Internet provider’s tech support line and described the issues we were having. This Maine-based company has been our only provider since its inception more than a decade ago. They have always been easy to reach and responsive. My call was handled in the same concerned and polite manner as usual. The representative listened to my story, made some suggestions of things I should try at home (which I had already done), and tweaked a few adjustments on his end.

From what he could see everything looked fine, and at that time it seemed to be. He ended the call asking me if there was anything else he could help me with and reminded me that their call line was open 24/7.

However, the problem continued to occur and I continued to call and continued to receive polite and apparently knowledgeable advice. Each of the six different technicians had a slightly different take on my story and made new suggestions, and I continued to do as they suggested. Finally, they sent a repair guy out to the house who installed a new wall jack and a filter that would cover the whole system. Things were running fine when he arrived and fine when he left, but by evening we were running too slow to do anything except receive very delayed emails.

The next morning, although our download speeds were back up, my patience had worn thin, and the very polite technician suggested that I wait until 8:30 when the level II people arrived. When I talked to "Bob," he listened to my story patiently, paused a second or two and asked, "Do you have a street light in front of your house?" I replied that we did, and it had been out for a couple of weeks. He said he had seen it happen a couple of dozen times, and was pretty sure it was the problem. Interference from a faulty starter was slowing our speeds during the dark hours. He was correct.

There are at least three lessons to be learned from this adventure that are applicable to the practice of medicine.

First, good customer service can help a physician maintain a relationship with his or her patient when things aren’t going well. I could have easily canceled my contract with this company and signed on with another, but because everyone had sounded so polite and interested in our problem, I continued to give them yet another chance.

Second and most importantly, while customer service is nice, there is no substitute for the correct diagnosis. Had my problem been medical, I would likely have been subjected to numerous needless studies and radiation exposures. The lost time and expense would have been significant, but even more troubling is that I could have died for the lack of the right answer.

Finally, and here is where the company failed, clearly they had at least one technician who had enough experience to arrive at the correct diagnosis. However, they had not created a system or fostered the environment in which this wisdom could easily be transmitted to the inexperienced. It seems to me that organized medicine also needs a better system to capture the wisdom of our level II fogies before they move on.

This column, "Letters From Maine," appears regularly in Pediatric News. Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected].

Every parent and every patient mature enough to verbalize issues of cause and effect harbors an explanation for his or her symptoms. This may be one of the traits that defines us as humans and probably was a necessary ingredient for the birth of religion. Often, the patient’s explanation is naïve and unsophisticated. One might call it a proto-diagnosis.

However, as science and information technology have blossomed, an increasing number of parents and patients concoct elaborate and sophisticated explanations for what is ailing them before they arrive at our offices. Often the culprit is "something I ate." Sometimes it is an "allergy." The wise physician will always listen attentively because many parents’ and patients’ suspicions are surprisingly accurate. However, sadly the majority of parents and patients get the diagnosis wrong. This is fortunate for physicians because otherwise many of us would be made redundant.

Redirecting a parent’s off-target diagnosis is one of the primary tasks for primary care physicians. It’s when we get to show off our diagnostic artistry, and it’s fun. But it isn’t fun when a parent has talked to one too many well-meaning amateur diagnosticians or clicked on one too many websites. Their once naïve proto-diagnosis can become ossified into, "I know Jason has X diagnosis and needs Y and Z medications."

Cracking this concretized misdiagnosis can be a frustrating challenge for even the most patient and experienced physician. This is particularly true if the complaint is a symptom of a naturally occurring benign phenomenon requiring nothing more than watchful waiting.

Dismantling a solidly constructed but incorrect parent-crafted diagnosis can take time. Often unnecessary laboratory work and imaging studies may be required to get parents to a place in which they can accept an alternative explanation with an open mind. Sometimes the result is a confrontational encounter that ends with the parent seeking a second opinion that more closely matches their own.

On the other side of the spectrum is the patient or parent who begins the visit with, "I am sure there is nothing wrong with my son, but I just want you to reassure me." This refreshing degree of candor can be a much-needed oasis in the otherwise hectic day of a primary care physician. And it can reflect a hard-earned level of confidence in the physician’s diagnostic ability and style.

But there can be a catch. Because even the parent who claims that all he or she wants is reassurance also harbors a proto-diagnosis or fear that they may not be able to verbalize without some coaxing. The physician can’t adequately reassure unless he understands what the parent or patient is worried about. I have met a few parents who have been very helpful by telling me at our very first meeting, "I want you to know, Dr. Wilkoff, that my cousin died of leukemia, and I may ask you to order a blood test at visits where you may not think it’s necessary."

Unfortunately, finding the chinks in a parent’s armor of denial is not always easy. I find that as the decades have rolled on I ask more often, "What do you think is wrong with your child?" Or, "What are you worried he might have?" At least it gives me a vague idea of the target where I should be aiming my reassurance. If I’m lucky, the distance between their concerns and theories and my perception of reality is manageable.

The scenario becomes most difficult when the fears or proto-diagnoses belong to someone who hasn’t come to the visit. I don’t want to send the messenger home empty handed. Arming them with an ample supply of convincing arguments and explanations that can survive a 20-minute drive home, or even worse, the 6 hours until the other parent gets home for dinner, is a challenge. Unfortunately, despite my best efforts, the message may still come across as, "The doctor said there was nothing wrong."

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected]. This column, "Letters From Maine," appears regularly in Pediatric News, a publication of Elsevier.

Every parent and every patient mature enough to verbalize issues of cause and effect harbors an explanation for his or her symptoms. This may be one of the traits that defines us as humans and probably was a necessary ingredient for the birth of religion. Often, the patient’s explanation is naïve and unsophisticated. One might call it a proto-diagnosis.

However, as science and information technology have blossomed, an increasing number of parents and patients concoct elaborate and sophisticated explanations for what is ailing them before they arrive at our offices. Often the culprit is "something I ate." Sometimes it is an "allergy." The wise physician will always listen attentively because many parents’ and patients’ suspicions are surprisingly accurate. However, sadly the majority of parents and patients get the diagnosis wrong. This is fortunate for physicians because otherwise many of us would be made redundant.

Redirecting a parent’s off-target diagnosis is one of the primary tasks for primary care physicians. It’s when we get to show off our diagnostic artistry, and it’s fun. But it isn’t fun when a parent has talked to one too many well-meaning amateur diagnosticians or clicked on one too many websites. Their once naïve proto-diagnosis can become ossified into, "I know Jason has X diagnosis and needs Y and Z medications."

Cracking this concretized misdiagnosis can be a frustrating challenge for even the most patient and experienced physician. This is particularly true if the complaint is a symptom of a naturally occurring benign phenomenon requiring nothing more than watchful waiting.

Dismantling a solidly constructed but incorrect parent-crafted diagnosis can take time. Often unnecessary laboratory work and imaging studies may be required to get parents to a place in which they can accept an alternative explanation with an open mind. Sometimes the result is a confrontational encounter that ends with the parent seeking a second opinion that more closely matches their own.

On the other side of the spectrum is the patient or parent who begins the visit with, "I am sure there is nothing wrong with my son, but I just want you to reassure me." This refreshing degree of candor can be a much-needed oasis in the otherwise hectic day of a primary care physician. And it can reflect a hard-earned level of confidence in the physician’s diagnostic ability and style.

But there can be a catch. Because even the parent who claims that all he or she wants is reassurance also harbors a proto-diagnosis or fear that they may not be able to verbalize without some coaxing. The physician can’t adequately reassure unless he understands what the parent or patient is worried about. I have met a few parents who have been very helpful by telling me at our very first meeting, "I want you to know, Dr. Wilkoff, that my cousin died of leukemia, and I may ask you to order a blood test at visits where you may not think it’s necessary."

Unfortunately, finding the chinks in a parent’s armor of denial is not always easy. I find that as the decades have rolled on I ask more often, "What do you think is wrong with your child?" Or, "What are you worried he might have?" At least it gives me a vague idea of the target where I should be aiming my reassurance. If I’m lucky, the distance between their concerns and theories and my perception of reality is manageable.

The scenario becomes most difficult when the fears or proto-diagnoses belong to someone who hasn’t come to the visit. I don’t want to send the messenger home empty handed. Arming them with an ample supply of convincing arguments and explanations that can survive a 20-minute drive home, or even worse, the 6 hours until the other parent gets home for dinner, is a challenge. Unfortunately, despite my best efforts, the message may still come across as, "The doctor said there was nothing wrong."

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected]. This column, "Letters From Maine," appears regularly in Pediatric News, a publication of Elsevier.

Every parent and every patient mature enough to verbalize issues of cause and effect harbors an explanation for his or her symptoms. This may be one of the traits that defines us as humans and probably was a necessary ingredient for the birth of religion. Often, the patient’s explanation is naïve and unsophisticated. One might call it a proto-diagnosis.

However, as science and information technology have blossomed, an increasing number of parents and patients concoct elaborate and sophisticated explanations for what is ailing them before they arrive at our offices. Often the culprit is "something I ate." Sometimes it is an "allergy." The wise physician will always listen attentively because many parents’ and patients’ suspicions are surprisingly accurate. However, sadly the majority of parents and patients get the diagnosis wrong. This is fortunate for physicians because otherwise many of us would be made redundant.

Redirecting a parent’s off-target diagnosis is one of the primary tasks for primary care physicians. It’s when we get to show off our diagnostic artistry, and it’s fun. But it isn’t fun when a parent has talked to one too many well-meaning amateur diagnosticians or clicked on one too many websites. Their once naïve proto-diagnosis can become ossified into, "I know Jason has X diagnosis and needs Y and Z medications."

Cracking this concretized misdiagnosis can be a frustrating challenge for even the most patient and experienced physician. This is particularly true if the complaint is a symptom of a naturally occurring benign phenomenon requiring nothing more than watchful waiting.

Dismantling a solidly constructed but incorrect parent-crafted diagnosis can take time. Often unnecessary laboratory work and imaging studies may be required to get parents to a place in which they can accept an alternative explanation with an open mind. Sometimes the result is a confrontational encounter that ends with the parent seeking a second opinion that more closely matches their own.

On the other side of the spectrum is the patient or parent who begins the visit with, "I am sure there is nothing wrong with my son, but I just want you to reassure me." This refreshing degree of candor can be a much-needed oasis in the otherwise hectic day of a primary care physician. And it can reflect a hard-earned level of confidence in the physician’s diagnostic ability and style.

But there can be a catch. Because even the parent who claims that all he or she wants is reassurance also harbors a proto-diagnosis or fear that they may not be able to verbalize without some coaxing. The physician can’t adequately reassure unless he understands what the parent or patient is worried about. I have met a few parents who have been very helpful by telling me at our very first meeting, "I want you to know, Dr. Wilkoff, that my cousin died of leukemia, and I may ask you to order a blood test at visits where you may not think it’s necessary."

Unfortunately, finding the chinks in a parent’s armor of denial is not always easy. I find that as the decades have rolled on I ask more often, "What do you think is wrong with your child?" Or, "What are you worried he might have?" At least it gives me a vague idea of the target where I should be aiming my reassurance. If I’m lucky, the distance between their concerns and theories and my perception of reality is manageable.

The scenario becomes most difficult when the fears or proto-diagnoses belong to someone who hasn’t come to the visit. I don’t want to send the messenger home empty handed. Arming them with an ample supply of convincing arguments and explanations that can survive a 20-minute drive home, or even worse, the 6 hours until the other parent gets home for dinner, is a challenge. Unfortunately, despite my best efforts, the message may still come across as, "The doctor said there was nothing wrong."

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected]. This column, "Letters From Maine," appears regularly in Pediatric News, a publication of Elsevier.

It was Natalie Saunders’ (not her real name) first visit to our practice. As usual I asked her why she had chosen our office. She replied that the practice she had been going to "wouldn’t see my son. I called several times, and I was always transferred to a nurse who would ask me a whole bunch of questions, some of which made me wonder if she had been listening to my answers. She would tell me that everything sounded okay, but to call if his symptoms persisted. When I would call back it was the same runaround."

I asked her if she had ever told the nurse that she wanted her son to see the doctor. She wasn’t sure that she had. And, knowing just a little about the pediatricians in that practice several towns away, I’m sure that had she been more assertive they would have seen her son promptly.

Unfortunately, I have heard similar stories from other parents, friends, and family members scattered across the country. And, even more unfortunately, I have had a few parents tell me that it has happened in our office

After listening to the history of her son’s complaint and examining him, it was clear that his symptoms hadn’t required an office visit. However, it also was apparent that the face-to-face encounter had allowed her to close that chapter and move on.

Many doctor’s offices are struggling to meet the demands of the population they serve. Sometimes it is the result of a shortage of providers. Sometimes it is because a practice has become too popular for its own good. Occasionally, "too-busy-to-see-you" situations are temporary, such as during an influenza or respiratory syncytial virus (RSV) outbreak. However, there are times when deflecting patients is a reflection of disorganization and lack of communication within an office. As in Natalie Saunders’ case, I’ll bet if someone had told the doctor the story, he or she would have said, "Sure, I don’t think we need to see him, but have him come on in."

But, the person on the front line, be it a nurse or a receptionist, may have incorrectly perceived that the doctors were too busy to squeeze in a patient whose symptoms didn’t require a face-to-face encounter. Sometimes this is a genuine desire to protect a dangerously stressed physician. Occasionally, triage personnel have developed a pride in their ability to deflect calls and view every scheduled office visit as a failure. Armed with a lengthy algorithm, a nurse or receptionist can wear down even the most persistent parent.

One of the worst culprits is an unrealistically crafted appointment book or computer screen. If applied correctly, the concept of "open-access booking" might have solved Natalie’s problem. It may be that every triage algorithm should begin, "I sense you are concerned. Do you want to come in and see the doctor?" The time saved answering repeat calls and employing tedious deflecting strategies usually compensates for that invested in seeing the patient.

I fear that some physicians have avoided open-access booking because they have developed a habit of scheduling follow-up visits in situations where a phone call would have been at least as effective. Parents appreciate phone calls even if it is from an assistant, but they don’t appreciate taking time off from work and sitting in a waiting room for an appointment that they realize has little or no value.

Second, a schedule that is too heavily weighted toward health maintenance visits doesn’t leave enough room for same-day calls. Does an 8-year-old with a spotless health record really need annual checkups? If the physician has time. Maybe. But, if the trade-off is a front office deflecting calls from the worried well, not to mention the seriously ill who might slip through the cracks in a triage algorithm, it’s a bad deal. The notion that a pediatrician can’t or doesn’t do some targeted anticipatory guidance and health promotion at an acute sick visit is bogus.

Twenty years ago when we had only 3 pediatricians for the same population base that is now served by 12, the office staff was too busy to deflect calls for an appointment. If you called, you got seen.

Dr. William G. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him. 

It was Natalie Saunders’ (not her real name) first visit to our practice. As usual I asked her why she had chosen our office. She replied that the practice she had been going to "wouldn’t see my son. I called several times, and I was always transferred to a nurse who would ask me a whole bunch of questions, some of which made me wonder if she had been listening to my answers. She would tell me that everything sounded okay, but to call if his symptoms persisted. When I would call back it was the same runaround."

I asked her if she had ever told the nurse that she wanted her son to see the doctor. She wasn’t sure that she had. And, knowing just a little about the pediatricians in that practice several towns away, I’m sure that had she been more assertive they would have seen her son promptly.

Unfortunately, I have heard similar stories from other parents, friends, and family members scattered across the country. And, even more unfortunately, I have had a few parents tell me that it has happened in our office

After listening to the history of her son’s complaint and examining him, it was clear that his symptoms hadn’t required an office visit. However, it also was apparent that the face-to-face encounter had allowed her to close that chapter and move on.

Many doctor’s offices are struggling to meet the demands of the population they serve. Sometimes it is the result of a shortage of providers. Sometimes it is because a practice has become too popular for its own good. Occasionally, "too-busy-to-see-you" situations are temporary, such as during an influenza or respiratory syncytial virus (RSV) outbreak. However, there are times when deflecting patients is a reflection of disorganization and lack of communication within an office. As in Natalie Saunders’ case, I’ll bet if someone had told the doctor the story, he or she would have said, "Sure, I don’t think we need to see him, but have him come on in."

But, the person on the front line, be it a nurse or a receptionist, may have incorrectly perceived that the doctors were too busy to squeeze in a patient whose symptoms didn’t require a face-to-face encounter. Sometimes this is a genuine desire to protect a dangerously stressed physician. Occasionally, triage personnel have developed a pride in their ability to deflect calls and view every scheduled office visit as a failure. Armed with a lengthy algorithm, a nurse or receptionist can wear down even the most persistent parent.

One of the worst culprits is an unrealistically crafted appointment book or computer screen. If applied correctly, the concept of "open-access booking" might have solved Natalie’s problem. It may be that every triage algorithm should begin, "I sense you are concerned. Do you want to come in and see the doctor?" The time saved answering repeat calls and employing tedious deflecting strategies usually compensates for that invested in seeing the patient.

I fear that some physicians have avoided open-access booking because they have developed a habit of scheduling follow-up visits in situations where a phone call would have been at least as effective. Parents appreciate phone calls even if it is from an assistant, but they don’t appreciate taking time off from work and sitting in a waiting room for an appointment that they realize has little or no value.

Second, a schedule that is too heavily weighted toward health maintenance visits doesn’t leave enough room for same-day calls. Does an 8-year-old with a spotless health record really need annual checkups? If the physician has time. Maybe. But, if the trade-off is a front office deflecting calls from the worried well, not to mention the seriously ill who might slip through the cracks in a triage algorithm, it’s a bad deal. The notion that a pediatrician can’t or doesn’t do some targeted anticipatory guidance and health promotion at an acute sick visit is bogus.

Twenty years ago when we had only 3 pediatricians for the same population base that is now served by 12, the office staff was too busy to deflect calls for an appointment. If you called, you got seen.

Dr. William G. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him. 

It was Natalie Saunders’ (not her real name) first visit to our practice. As usual I asked her why she had chosen our office. She replied that the practice she had been going to "wouldn’t see my son. I called several times, and I was always transferred to a nurse who would ask me a whole bunch of questions, some of which made me wonder if she had been listening to my answers. She would tell me that everything sounded okay, but to call if his symptoms persisted. When I would call back it was the same runaround."

I asked her if she had ever told the nurse that she wanted her son to see the doctor. She wasn’t sure that she had. And, knowing just a little about the pediatricians in that practice several towns away, I’m sure that had she been more assertive they would have seen her son promptly.

Unfortunately, I have heard similar stories from other parents, friends, and family members scattered across the country. And, even more unfortunately, I have had a few parents tell me that it has happened in our office

After listening to the history of her son’s complaint and examining him, it was clear that his symptoms hadn’t required an office visit. However, it also was apparent that the face-to-face encounter had allowed her to close that chapter and move on.

Many doctor’s offices are struggling to meet the demands of the population they serve. Sometimes it is the result of a shortage of providers. Sometimes it is because a practice has become too popular for its own good. Occasionally, "too-busy-to-see-you" situations are temporary, such as during an influenza or respiratory syncytial virus (RSV) outbreak. However, there are times when deflecting patients is a reflection of disorganization and lack of communication within an office. As in Natalie Saunders’ case, I’ll bet if someone had told the doctor the story, he or she would have said, "Sure, I don’t think we need to see him, but have him come on in."

But, the person on the front line, be it a nurse or a receptionist, may have incorrectly perceived that the doctors were too busy to squeeze in a patient whose symptoms didn’t require a face-to-face encounter. Sometimes this is a genuine desire to protect a dangerously stressed physician. Occasionally, triage personnel have developed a pride in their ability to deflect calls and view every scheduled office visit as a failure. Armed with a lengthy algorithm, a nurse or receptionist can wear down even the most persistent parent.

One of the worst culprits is an unrealistically crafted appointment book or computer screen. If applied correctly, the concept of "open-access booking" might have solved Natalie’s problem. It may be that every triage algorithm should begin, "I sense you are concerned. Do you want to come in and see the doctor?" The time saved answering repeat calls and employing tedious deflecting strategies usually compensates for that invested in seeing the patient.

I fear that some physicians have avoided open-access booking because they have developed a habit of scheduling follow-up visits in situations where a phone call would have been at least as effective. Parents appreciate phone calls even if it is from an assistant, but they don’t appreciate taking time off from work and sitting in a waiting room for an appointment that they realize has little or no value.

Second, a schedule that is too heavily weighted toward health maintenance visits doesn’t leave enough room for same-day calls. Does an 8-year-old with a spotless health record really need annual checkups? If the physician has time. Maybe. But, if the trade-off is a front office deflecting calls from the worried well, not to mention the seriously ill who might slip through the cracks in a triage algorithm, it’s a bad deal. The notion that a pediatrician can’t or doesn’t do some targeted anticipatory guidance and health promotion at an acute sick visit is bogus.

Twenty years ago when we had only 3 pediatricians for the same population base that is now served by 12, the office staff was too busy to deflect calls for an appointment. If you called, you got seen.

Dr. William G. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him. 

When a 65-year-old pediatrician retires, it may be a sad moment for him and the community he has served, but it usually isn’t an event that makes the New York Times. However, Don Berwick is not your usual pediatrician. For the last 17 months, he has been head administrator of the Centers for Medicare and Medicaid Services. He entered the job under a dark political cloud, and what followed has been a frustrating year and a half. Formal confirmation by the Senate is unlikely to occur, and his temporary status will expire at the end of 2011.

I met Don when we were fellow house officers. From that point, our paths couldn’t have been more divergent. I chose to practice small-town primary care, and he focused on health care delivery on a much larger scale. However, after 40 years of very different careers, we seem to have retained surprisingly similar perspectives on health care delivery.

On his last day on the job, he observed that 20%-30% of spending on health care is "waste." He included on his list of waste categories burdensome rules, the administrative complexity of the system, and the failure to coordinate care. While he feels that computerizing medical records will ameliorate these issues, I am not quite so sure now is the best time. More than a decade of daily use has convinced me that electronic medical records (EMRs) aren’t ready for prime time.

While I tend to favor free market solutions, when it comes to EMRs the immediate need is for standardization and concentration on hard data (lab work, immunization records, vital signs). These are areas in which the government should take a lead role, and then let free enterprise fine-tune the system.

I also believe that creating large health care delivery networks is not going to create the efficiencies I think he believes can be achieved. However, where Don Berwick and I see eye to eye is the issue that has been at the heart of his frustration. He has observed, "Much is done that does not help patients at all, and many physicians know it" (Health Officer Takes Parting Shot at Waste, by Robert Pear, N.Y. Times, Dec. 3, 2011). Please count me in as one of the "many." How about you?

Do you see the same 20%-30% of lab work, imaging studies, medications, and consultations that we are ordering as unnecessary? I haven’t figured out what more I can do to encourage us to trim these excesses. When I used to go to meetings I would speak out from time to time, and I continue to grumble to my colleagues in the hall. After awhile, one begins to feel like a curmudgeonly old-schooler. I am lucky enough to have this column as a soapbox to climb on when the frustration gets too great. But from your responses, I feel that often I am preaching to the choir.

The problem seems to have become woven into the system. The recent responses to the new recommendations about more-rational screening for prostate cancer are just one example. To some extent, the undercurrent of antiscience is to blame. But when people who call themselves "scientists" misbehave badly, we can’t be too surprised.

Speaking out about waste can leave one vulnerable to being labeled as an advocate of rationing, a tag that has dogged Dr. Berwick during his short public service career. But, as he wrote in 2009, "The decision is not whether we will ration care – the decision is whether we will ration with our eyes open."

Although Dr. Berwick was often frustrated by the system he hoped to change (more quickly than it was ready for), I suspect he is the same quick learner that he was as an intern. I am sure we will hear from him again, seasoned by the hard knocks of public service. Will we be ready to join him in speaking out against waste? I am interested to hear what waste you see around you, and what you think we can do about it.

When a 65-year-old pediatrician retires, it may be a sad moment for him and the community he has served, but it usually isn’t an event that makes the New York Times. However, Don Berwick is not your usual pediatrician. For the last 17 months, he has been head administrator of the Centers for Medicare and Medicaid Services. He entered the job under a dark political cloud, and what followed has been a frustrating year and a half. Formal confirmation by the Senate is unlikely to occur, and his temporary status will expire at the end of 2011.

I met Don when we were fellow house officers. From that point, our paths couldn’t have been more divergent. I chose to practice small-town primary care, and he focused on health care delivery on a much larger scale. However, after 40 years of very different careers, we seem to have retained surprisingly similar perspectives on health care delivery.

On his last day on the job, he observed that 20%-30% of spending on health care is "waste." He included on his list of waste categories burdensome rules, the administrative complexity of the system, and the failure to coordinate care. While he feels that computerizing medical records will ameliorate these issues, I am not quite so sure now is the best time. More than a decade of daily use has convinced me that electronic medical records (EMRs) aren’t ready for prime time.

While I tend to favor free market solutions, when it comes to EMRs the immediate need is for standardization and concentration on hard data (lab work, immunization records, vital signs). These are areas in which the government should take a lead role, and then let free enterprise fine-tune the system.

I also believe that creating large health care delivery networks is not going to create the efficiencies I think he believes can be achieved. However, where Don Berwick and I see eye to eye is the issue that has been at the heart of his frustration. He has observed, "Much is done that does not help patients at all, and many physicians know it" (Health Officer Takes Parting Shot at Waste, by Robert Pear, N.Y. Times, Dec. 3, 2011). Please count me in as one of the "many." How about you?

Do you see the same 20%-30% of lab work, imaging studies, medications, and consultations that we are ordering as unnecessary? I haven’t figured out what more I can do to encourage us to trim these excesses. When I used to go to meetings I would speak out from time to time, and I continue to grumble to my colleagues in the hall. After awhile, one begins to feel like a curmudgeonly old-schooler. I am lucky enough to have this column as a soapbox to climb on when the frustration gets too great. But from your responses, I feel that often I am preaching to the choir.

The problem seems to have become woven into the system. The recent responses to the new recommendations about more-rational screening for prostate cancer are just one example. To some extent, the undercurrent of antiscience is to blame. But when people who call themselves "scientists" misbehave badly, we can’t be too surprised.

Speaking out about waste can leave one vulnerable to being labeled as an advocate of rationing, a tag that has dogged Dr. Berwick during his short public service career. But, as he wrote in 2009, "The decision is not whether we will ration care – the decision is whether we will ration with our eyes open."

Although Dr. Berwick was often frustrated by the system he hoped to change (more quickly than it was ready for), I suspect he is the same quick learner that he was as an intern. I am sure we will hear from him again, seasoned by the hard knocks of public service. Will we be ready to join him in speaking out against waste? I am interested to hear what waste you see around you, and what you think we can do about it.

When a 65-year-old pediatrician retires, it may be a sad moment for him and the community he has served, but it usually isn’t an event that makes the New York Times. However, Don Berwick is not your usual pediatrician. For the last 17 months, he has been head administrator of the Centers for Medicare and Medicaid Services. He entered the job under a dark political cloud, and what followed has been a frustrating year and a half. Formal confirmation by the Senate is unlikely to occur, and his temporary status will expire at the end of 2011.

I met Don when we were fellow house officers. From that point, our paths couldn’t have been more divergent. I chose to practice small-town primary care, and he focused on health care delivery on a much larger scale. However, after 40 years of very different careers, we seem to have retained surprisingly similar perspectives on health care delivery.

On his last day on the job, he observed that 20%-30% of spending on health care is "waste." He included on his list of waste categories burdensome rules, the administrative complexity of the system, and the failure to coordinate care. While he feels that computerizing medical records will ameliorate these issues, I am not quite so sure now is the best time. More than a decade of daily use has convinced me that electronic medical records (EMRs) aren’t ready for prime time.

While I tend to favor free market solutions, when it comes to EMRs the immediate need is for standardization and concentration on hard data (lab work, immunization records, vital signs). These are areas in which the government should take a lead role, and then let free enterprise fine-tune the system.

I also believe that creating large health care delivery networks is not going to create the efficiencies I think he believes can be achieved. However, where Don Berwick and I see eye to eye is the issue that has been at the heart of his frustration. He has observed, "Much is done that does not help patients at all, and many physicians know it" (Health Officer Takes Parting Shot at Waste, by Robert Pear, N.Y. Times, Dec. 3, 2011). Please count me in as one of the "many." How about you?

Do you see the same 20%-30% of lab work, imaging studies, medications, and consultations that we are ordering as unnecessary? I haven’t figured out what more I can do to encourage us to trim these excesses. When I used to go to meetings I would speak out from time to time, and I continue to grumble to my colleagues in the hall. After awhile, one begins to feel like a curmudgeonly old-schooler. I am lucky enough to have this column as a soapbox to climb on when the frustration gets too great. But from your responses, I feel that often I am preaching to the choir.

The problem seems to have become woven into the system. The recent responses to the new recommendations about more-rational screening for prostate cancer are just one example. To some extent, the undercurrent of antiscience is to blame. But when people who call themselves "scientists" misbehave badly, we can’t be too surprised.

Speaking out about waste can leave one vulnerable to being labeled as an advocate of rationing, a tag that has dogged Dr. Berwick during his short public service career. But, as he wrote in 2009, "The decision is not whether we will ration care – the decision is whether we will ration with our eyes open."

Although Dr. Berwick was often frustrated by the system he hoped to change (more quickly than it was ready for), I suspect he is the same quick learner that he was as an intern. I am sure we will hear from him again, seasoned by the hard knocks of public service. Will we be ready to join him in speaking out against waste? I am interested to hear what waste you see around you, and what you think we can do about it.

I suspect that some of you saw the changes in the ICD-9-CM codes that were published in the September 2011 issue of the AAP News. But I’ll bet that very few of you took the time to read them. Certainly, had I not had several hours to kill in an airport waiting for a connection delay, I wouldn’t have even paused on the page.

When it comes to coding, I’m a less-is-better kind of guy. I keep about a dozen near the front of my memory banks. There is URI, UTI. There’s one for otitis and one for pneumonitis. I make frequent use of the NOS (Not Otherwise Specified) option. 729.5 is a favorite for any extremity pain or injury.

When your patient is bitten by a bird, you can specify from as many as nine species of duck, macaw, parrot, goose, or chicken.

While I see a wide variety of patients, the range of illnesses and injuries is actually quite narrow. Looking at my ICD-9-CM coding profile, even if I quadrupled it by being more specific, some people might consider my professional life boring. For me, the fun comes not from seeing 20 different diseases in a day but from watching how dozens of unique children manifest a few common conditions.

I realize that there are some physicians who see more complex conditions than I do. And as I reviewed the new ICD-9-CM codes, I could understand why it might be helpful to them to have specific codes for three different kinds of shock or for four different thalassemias. For the most part, the more than 100 new additions listed in the AAP News seem reasonable.

However, when I returned from my trip and began working through a backlog of newspapers, I discovered a story by Anna Wilde Mathews in the Wall Street Journal (Sept. 13, 2011, "Walked Into a Lamppost? Hurt While Crocheting? Help Is on the Way") that took me to the coding wonderland that is just over the horizon. ICD-10 is coming on Oct. 1, 2013, and with it, your coding choices will expand from a more than generous 18,000 to a mind-blowing 140,000. If you are into serious hair splitting, you will have found nirvana.

When your patient is bitten by a bird, you can specify from as many as nine species of duck, macaw, parrot, goose, or chicken, for example. You will be able to specify whether your 7-year-old patient is bitten by or struck by a turtle. If your 17-year-old patient is burned when his water skis catch fire, V91.07XA is for you. Unfortunately, I’m not making this up. In 2 years, coding will move from its current status as a serious inconvenience to a boondoggle of unworkable lunacy.

Who’s driving this bus to the funny farm? It’s certainly not you or I. It’s a collection of government agencies that are data hungry. Pat Brooks, senior technical adviser for the Centers for Medicare and Medicaid Services says, "It’s for accuracy of data and quality of care." Really?

I guess I haven’t been paying enough attention to the critical issues that differentiate the care of macaw bites from turkey peckings. I hope the new system ferrets out those unscrupulous doctors who have been billing for snapping turtle bites when their patients have been merely bruised by tossed box turtles.

It’s all about data collection ... and the money. It takes time and that means money to collect data. If they are expecting me to move beyond my simple NOS style of coding, they had better pay me for my time.

I have a better idea: PDC, Patient Directed Coding. When the patients (or parents) arrive in the office, they will be given the coding book and be asked to select the code(s) that describe their problem. The physician is paid based on those previsit codes. Codes for vague complaints are of higher value because they take more time and effort to get to the bottom of things. And, of course, the more codes the patient selects the more the doctor is paid.

PDC would relieve us of the time-consuming burden of ICD coding and reward those of us who accept more time-consuming and effort-intensive patients. What do you think? Isn’t worth a try?

I suspect that some of you saw the changes in the ICD-9-CM codes that were published in the September 2011 issue of the AAP News. But I’ll bet that very few of you took the time to read them. Certainly, had I not had several hours to kill in an airport waiting for a connection delay, I wouldn’t have even paused on the page.

When it comes to coding, I’m a less-is-better kind of guy. I keep about a dozen near the front of my memory banks. There is URI, UTI. There’s one for otitis and one for pneumonitis. I make frequent use of the NOS (Not Otherwise Specified) option. 729.5 is a favorite for any extremity pain or injury.

When your patient is bitten by a bird, you can specify from as many as nine species of duck, macaw, parrot, goose, or chicken.

While I see a wide variety of patients, the range of illnesses and injuries is actually quite narrow. Looking at my ICD-9-CM coding profile, even if I quadrupled it by being more specific, some people might consider my professional life boring. For me, the fun comes not from seeing 20 different diseases in a day but from watching how dozens of unique children manifest a few common conditions.

I realize that there are some physicians who see more complex conditions than I do. And as I reviewed the new ICD-9-CM codes, I could understand why it might be helpful to them to have specific codes for three different kinds of shock or for four different thalassemias. For the most part, the more than 100 new additions listed in the AAP News seem reasonable.

However, when I returned from my trip and began working through a backlog of newspapers, I discovered a story by Anna Wilde Mathews in the Wall Street Journal (Sept. 13, 2011, "Walked Into a Lamppost? Hurt While Crocheting? Help Is on the Way") that took me to the coding wonderland that is just over the horizon. ICD-10 is coming on Oct. 1, 2013, and with it, your coding choices will expand from a more than generous 18,000 to a mind-blowing 140,000. If you are into serious hair splitting, you will have found nirvana.

When your patient is bitten by a bird, you can specify from as many as nine species of duck, macaw, parrot, goose, or chicken, for example. You will be able to specify whether your 7-year-old patient is bitten by or struck by a turtle. If your 17-year-old patient is burned when his water skis catch fire, V91.07XA is for you. Unfortunately, I’m not making this up. In 2 years, coding will move from its current status as a serious inconvenience to a boondoggle of unworkable lunacy.

Who’s driving this bus to the funny farm? It’s certainly not you or I. It’s a collection of government agencies that are data hungry. Pat Brooks, senior technical adviser for the Centers for Medicare and Medicaid Services says, "It’s for accuracy of data and quality of care." Really?

I guess I haven’t been paying enough attention to the critical issues that differentiate the care of macaw bites from turkey peckings. I hope the new system ferrets out those unscrupulous doctors who have been billing for snapping turtle bites when their patients have been merely bruised by tossed box turtles.

It’s all about data collection ... and the money. It takes time and that means money to collect data. If they are expecting me to move beyond my simple NOS style of coding, they had better pay me for my time.

I have a better idea: PDC, Patient Directed Coding. When the patients (or parents) arrive in the office, they will be given the coding book and be asked to select the code(s) that describe their problem. The physician is paid based on those previsit codes. Codes for vague complaints are of higher value because they take more time and effort to get to the bottom of things. And, of course, the more codes the patient selects the more the doctor is paid.

PDC would relieve us of the time-consuming burden of ICD coding and reward those of us who accept more time-consuming and effort-intensive patients. What do you think? Isn’t worth a try?

I suspect that some of you saw the changes in the ICD-9-CM codes that were published in the September 2011 issue of the AAP News. But I’ll bet that very few of you took the time to read them. Certainly, had I not had several hours to kill in an airport waiting for a connection delay, I wouldn’t have even paused on the page.

When it comes to coding, I’m a less-is-better kind of guy. I keep about a dozen near the front of my memory banks. There is URI, UTI. There’s one for otitis and one for pneumonitis. I make frequent use of the NOS (Not Otherwise Specified) option. 729.5 is a favorite for any extremity pain or injury.

When your patient is bitten by a bird, you can specify from as many as nine species of duck, macaw, parrot, goose, or chicken.

While I see a wide variety of patients, the range of illnesses and injuries is actually quite narrow. Looking at my ICD-9-CM coding profile, even if I quadrupled it by being more specific, some people might consider my professional life boring. For me, the fun comes not from seeing 20 different diseases in a day but from watching how dozens of unique children manifest a few common conditions.

I realize that there are some physicians who see more complex conditions than I do. And as I reviewed the new ICD-9-CM codes, I could understand why it might be helpful to them to have specific codes for three different kinds of shock or for four different thalassemias. For the most part, the more than 100 new additions listed in the AAP News seem reasonable.

However, when I returned from my trip and began working through a backlog of newspapers, I discovered a story by Anna Wilde Mathews in the Wall Street Journal (Sept. 13, 2011, "Walked Into a Lamppost? Hurt While Crocheting? Help Is on the Way") that took me to the coding wonderland that is just over the horizon. ICD-10 is coming on Oct. 1, 2013, and with it, your coding choices will expand from a more than generous 18,000 to a mind-blowing 140,000. If you are into serious hair splitting, you will have found nirvana.

When your patient is bitten by a bird, you can specify from as many as nine species of duck, macaw, parrot, goose, or chicken, for example. You will be able to specify whether your 7-year-old patient is bitten by or struck by a turtle. If your 17-year-old patient is burned when his water skis catch fire, V91.07XA is for you. Unfortunately, I’m not making this up. In 2 years, coding will move from its current status as a serious inconvenience to a boondoggle of unworkable lunacy.

Who’s driving this bus to the funny farm? It’s certainly not you or I. It’s a collection of government agencies that are data hungry. Pat Brooks, senior technical adviser for the Centers for Medicare and Medicaid Services says, "It’s for accuracy of data and quality of care." Really?

I guess I haven’t been paying enough attention to the critical issues that differentiate the care of macaw bites from turkey peckings. I hope the new system ferrets out those unscrupulous doctors who have been billing for snapping turtle bites when their patients have been merely bruised by tossed box turtles.

It’s all about data collection ... and the money. It takes time and that means money to collect data. If they are expecting me to move beyond my simple NOS style of coding, they had better pay me for my time.

I have a better idea: PDC, Patient Directed Coding. When the patients (or parents) arrive in the office, they will be given the coding book and be asked to select the code(s) that describe their problem. The physician is paid based on those previsit codes. Codes for vague complaints are of higher value because they take more time and effort to get to the bottom of things. And, of course, the more codes the patient selects the more the doctor is paid.

PDC would relieve us of the time-consuming burden of ICD coding and reward those of us who accept more time-consuming and effort-intensive patients. What do you think? Isn’t worth a try?

Old wives’ tales and suburban legends don’t die easily, but the American Academy of Pediatrics has decided to tackle one of our most deeply embedded ... fever phobia.

It’s easy to understand how fever acquired its fearsome reputation. In the days before antibiotics – and even in the 1970s before the Haemophilus influenzae vaccine – there was a good chance that a child with a fever might be developing meningitis or pneumonia.

The Fever was indistinguishable from the illness. Instead of being seen as a nonspecific symptom, it became part of the problem. When medications were discovered that seemed to lower the fever, it became something to treat. This further distracted the focus of both parents and physicians.

As fatal febrile illnesses became less prevalent in developed countries, the phobia persisted because the frightening, but usually benign, phenomenon of febrile seizures persisted. It is hard to reassure anyone who has witnessed a febrile seizure for the first time that fever is nothing to worry about. Another reality, unique to the United States, is the threat of a malpractice suit. Even though almost every febrile illness will end happily, some physicians can’t see past the fear of litigation and act irrationally when the patient has a fever.

The academy’s recommendations in its clinical report, "Fever and Antipyretic Use" (Pediatrics 2011;127:580-7) certainly state the case for shifting our focus from fruitless attempts at battling temperature to helping sick children be more comfortable. But they stop short of suggesting that we add our actions (or in this case inactions) to our words.

Do your assistants take temperatures on every sick patient? Why? If we want to help parents refocus their attention away from fever, then we need to demonstrate that our focus has shifted.

For 25 years, I rarely used a thermometer in the office. Babies in the first 3 months of life deserved special attention if the history suggested any hint of illness. A child with a swollen joint and a vague or nonexistent history of trauma had his temperature taken. But otherwise, I assumed that if a parent said his child had had a fever, it was so. Whether I could document it in the office was irrelevant. There were occasional situations in which my diagnostic algorithm reached a branch point and I needed to know whether a fever was present. But for the most part, my thermometer (maybe I had two) sat in the drawer.

When I joined a larger group, I lost a bit of control over the setup procedure, and recording a temperature on every non-well patient became the standard. I’m not sure whether this was out of fear of malpractice suits or whether it was believed that a more complete set of vital signs made it easier to argue for a certain level of coding.

Regardless, I don’t like it because it makes it appear that I believe fever is something to worry about. But I try to be a team player. The good news is that with the new gadgetry, taking a temperature (forget about accuracy) requires very little of my assistant’s time. And if a parent asks about the temperature, it gives me the opportunity to launch into a mini-lecture about fever that I have honed over the last 35 years.

If my tutorial is successful, my hope is that the parents will have the fortitude and good sense to stop taking temperatures at inappropriate times. I wonder if we can all have the same courage and let our inactions speak with our words.

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

Old wives’ tales and suburban legends don’t die easily, but the American Academy of Pediatrics has decided to tackle one of our most deeply embedded ... fever phobia.

It’s easy to understand how fever acquired its fearsome reputation. In the days before antibiotics – and even in the 1970s before the Haemophilus influenzae vaccine – there was a good chance that a child with a fever might be developing meningitis or pneumonia.

The Fever was indistinguishable from the illness. Instead of being seen as a nonspecific symptom, it became part of the problem. When medications were discovered that seemed to lower the fever, it became something to treat. This further distracted the focus of both parents and physicians.

As fatal febrile illnesses became less prevalent in developed countries, the phobia persisted because the frightening, but usually benign, phenomenon of febrile seizures persisted. It is hard to reassure anyone who has witnessed a febrile seizure for the first time that fever is nothing to worry about. Another reality, unique to the United States, is the threat of a malpractice suit. Even though almost every febrile illness will end happily, some physicians can’t see past the fear of litigation and act irrationally when the patient has a fever.

The academy’s recommendations in its clinical report, "Fever and Antipyretic Use" (Pediatrics 2011;127:580-7) certainly state the case for shifting our focus from fruitless attempts at battling temperature to helping sick children be more comfortable. But they stop short of suggesting that we add our actions (or in this case inactions) to our words.

Do your assistants take temperatures on every sick patient? Why? If we want to help parents refocus their attention away from fever, then we need to demonstrate that our focus has shifted.

For 25 years, I rarely used a thermometer in the office. Babies in the first 3 months of life deserved special attention if the history suggested any hint of illness. A child with a swollen joint and a vague or nonexistent history of trauma had his temperature taken. But otherwise, I assumed that if a parent said his child had had a fever, it was so. Whether I could document it in the office was irrelevant. There were occasional situations in which my diagnostic algorithm reached a branch point and I needed to know whether a fever was present. But for the most part, my thermometer (maybe I had two) sat in the drawer.

When I joined a larger group, I lost a bit of control over the setup procedure, and recording a temperature on every non-well patient became the standard. I’m not sure whether this was out of fear of malpractice suits or whether it was believed that a more complete set of vital signs made it easier to argue for a certain level of coding.

Regardless, I don’t like it because it makes it appear that I believe fever is something to worry about. But I try to be a team player. The good news is that with the new gadgetry, taking a temperature (forget about accuracy) requires very little of my assistant’s time. And if a parent asks about the temperature, it gives me the opportunity to launch into a mini-lecture about fever that I have honed over the last 35 years.

If my tutorial is successful, my hope is that the parents will have the fortitude and good sense to stop taking temperatures at inappropriate times. I wonder if we can all have the same courage and let our inactions speak with our words.

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

Old wives’ tales and suburban legends don’t die easily, but the American Academy of Pediatrics has decided to tackle one of our most deeply embedded ... fever phobia.

It’s easy to understand how fever acquired its fearsome reputation. In the days before antibiotics – and even in the 1970s before the Haemophilus influenzae vaccine – there was a good chance that a child with a fever might be developing meningitis or pneumonia.

The Fever was indistinguishable from the illness. Instead of being seen as a nonspecific symptom, it became part of the problem. When medications were discovered that seemed to lower the fever, it became something to treat. This further distracted the focus of both parents and physicians.

As fatal febrile illnesses became less prevalent in developed countries, the phobia persisted because the frightening, but usually benign, phenomenon of febrile seizures persisted. It is hard to reassure anyone who has witnessed a febrile seizure for the first time that fever is nothing to worry about. Another reality, unique to the United States, is the threat of a malpractice suit. Even though almost every febrile illness will end happily, some physicians can’t see past the fear of litigation and act irrationally when the patient has a fever.

The academy’s recommendations in its clinical report, "Fever and Antipyretic Use" (Pediatrics 2011;127:580-7) certainly state the case for shifting our focus from fruitless attempts at battling temperature to helping sick children be more comfortable. But they stop short of suggesting that we add our actions (or in this case inactions) to our words.

Do your assistants take temperatures on every sick patient? Why? If we want to help parents refocus their attention away from fever, then we need to demonstrate that our focus has shifted.

For 25 years, I rarely used a thermometer in the office. Babies in the first 3 months of life deserved special attention if the history suggested any hint of illness. A child with a swollen joint and a vague or nonexistent history of trauma had his temperature taken. But otherwise, I assumed that if a parent said his child had had a fever, it was so. Whether I could document it in the office was irrelevant. There were occasional situations in which my diagnostic algorithm reached a branch point and I needed to know whether a fever was present. But for the most part, my thermometer (maybe I had two) sat in the drawer.

When I joined a larger group, I lost a bit of control over the setup procedure, and recording a temperature on every non-well patient became the standard. I’m not sure whether this was out of fear of malpractice suits or whether it was believed that a more complete set of vital signs made it easier to argue for a certain level of coding.

Regardless, I don’t like it because it makes it appear that I believe fever is something to worry about. But I try to be a team player. The good news is that with the new gadgetry, taking a temperature (forget about accuracy) requires very little of my assistant’s time. And if a parent asks about the temperature, it gives me the opportunity to launch into a mini-lecture about fever that I have honed over the last 35 years.

If my tutorial is successful, my hope is that the parents will have the fortitude and good sense to stop taking temperatures at inappropriate times. I wonder if we can all have the same courage and let our inactions speak with our words.

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

One of my daughters recently gave birth to a healthy little girl after a relatively short labor induced because of a few decelerations noted on a nonstress test. (Haven’t we already figured out that fetal heart monitors cause more angst than they are worth?) Anyway ... apparently as labor was nearing completion, a few more deep decelerations raised the tension in the delivery to the point that there was a stat call for a pediatrician to come and stand by.

That’s all my daughter recalls until a couple of minutes of suction-aided yanking resulted in a pink and crying baby she was able to cuddle and feed. I asked, "Did you see or talk to the pediatrician in the delivery room?" "No." She didn’t recall seeing him until later in the day. "I was too busy enjoying being a new mother again."

I said to myself, "Now, that was an experienced and sensitive pediatrician." When it was clear he wasn’t needed, he took a quick look at the baby and vanished into the haze of postpartum amnesia.

"I wish I could say that as the decades ticked away I became immune to anxiety that accompanies a birth, but I haven't."

I can’t even guess how many times I have been called to the delivery room stat only to watch the delivery of a vigorous and healthy baby. Fortunately, my standing around time is usually measured in minutes. But, there have been times when it took the obstetrician more than an hour to realize that a C-section was inevitable. Once I had checked to see that the laryngoscope light was working and the selection of endotracheal tubes was complete, there wasn’t much to do but stand there and listen to two or three people who aren’t in pain encouraging one poor woman who is. Of course, from time to time, I will discover that the warmer hasn’t been turned on, but for the most part, well-trained nurses armed with complete checklists have seen that everything we’ll need is within reach.

I wish I could say that as the decades ticked away I became immune to anxiety that accompanies a birth, but I haven’t. However, I did gradually develop the skill of at least appearing unconcerned as tension filled the delivery room. I have seen enough obstetric disasters to know that stuff happens.

But when it doesn’t happen, the pediatrician must seamlessly change roles from potentially being the star of the show to becoming just another member of the audience watching a truly miraculous transition. One moment we are the must-be-there person. Then in less time than it takes to say "Apgar of 8," we have instantly become Dr. Who?

How we handle this sudden demotion says something about how we see our role in the bigger health care picture. Once that healthy baby sees the bright lights of the extra-uterine world, it needs to see and be close to its mother. But something (mostly risk management concerns, I suspect) urges us to do a thorough exam. Heck, we’ve been standing around for a half an hour. Don’t we get to do something?

This is a time for compromise. In my view, and it sounds like the one shared by my daughter’s pediatrician, the need for family building easily trumps our need to feel important or at least be thorough. A quick pass of the stethoscope over the chest and a two-finger trip around the abdomen can easily be done while the nurse is doing a quick wipe off. Let’s be honest, when it comes to newborns (and maybe all children) 90% of our exam is done with our naked eyes. There will be a better time later in the day to abduct hips and demonstrate a symmetric Moro reflex. It may not be a better time for us, but it will be a better time for a new mother more or less recovered from the emotional explosion of childbirth.

As I slip out of the delivery room I might mumble, "Good-looking baby." But, at that point, my words would be superfluous. There would be plenty of others to tell these new parents how beautiful their baby is. They don’t need to hear the terrible truth from Dr. Who. All newborns are ugly while they are still wet behind the ears. Even my grandchildren.

One of my daughters recently gave birth to a healthy little girl after a relatively short labor induced because of a few decelerations noted on a nonstress test. (Haven’t we already figured out that fetal heart monitors cause more angst than they are worth?) Anyway ... apparently as labor was nearing completion, a few more deep decelerations raised the tension in the delivery to the point that there was a stat call for a pediatrician to come and stand by.

That’s all my daughter recalls until a couple of minutes of suction-aided yanking resulted in a pink and crying baby she was able to cuddle and feed. I asked, "Did you see or talk to the pediatrician in the delivery room?" "No." She didn’t recall seeing him until later in the day. "I was too busy enjoying being a new mother again."

I said to myself, "Now, that was an experienced and sensitive pediatrician." When it was clear he wasn’t needed, he took a quick look at the baby and vanished into the haze of postpartum amnesia.

"I wish I could say that as the decades ticked away I became immune to anxiety that accompanies a birth, but I haven't."

I can’t even guess how many times I have been called to the delivery room stat only to watch the delivery of a vigorous and healthy baby. Fortunately, my standing around time is usually measured in minutes. But, there have been times when it took the obstetrician more than an hour to realize that a C-section was inevitable. Once I had checked to see that the laryngoscope light was working and the selection of endotracheal tubes was complete, there wasn’t much to do but stand there and listen to two or three people who aren’t in pain encouraging one poor woman who is. Of course, from time to time, I will discover that the warmer hasn’t been turned on, but for the most part, well-trained nurses armed with complete checklists have seen that everything we’ll need is within reach.

I wish I could say that as the decades ticked away I became immune to anxiety that accompanies a birth, but I haven’t. However, I did gradually develop the skill of at least appearing unconcerned as tension filled the delivery room. I have seen enough obstetric disasters to know that stuff happens.

But when it doesn’t happen, the pediatrician must seamlessly change roles from potentially being the star of the show to becoming just another member of the audience watching a truly miraculous transition. One moment we are the must-be-there person. Then in less time than it takes to say "Apgar of 8," we have instantly become Dr. Who?

How we handle this sudden demotion says something about how we see our role in the bigger health care picture. Once that healthy baby sees the bright lights of the extra-uterine world, it needs to see and be close to its mother. But something (mostly risk management concerns, I suspect) urges us to do a thorough exam. Heck, we’ve been standing around for a half an hour. Don’t we get to do something?

This is a time for compromise. In my view, and it sounds like the one shared by my daughter’s pediatrician, the need for family building easily trumps our need to feel important or at least be thorough. A quick pass of the stethoscope over the chest and a two-finger trip around the abdomen can easily be done while the nurse is doing a quick wipe off. Let’s be honest, when it comes to newborns (and maybe all children) 90% of our exam is done with our naked eyes. There will be a better time later in the day to abduct hips and demonstrate a symmetric Moro reflex. It may not be a better time for us, but it will be a better time for a new mother more or less recovered from the emotional explosion of childbirth.

As I slip out of the delivery room I might mumble, "Good-looking baby." But, at that point, my words would be superfluous. There would be plenty of others to tell these new parents how beautiful their baby is. They don’t need to hear the terrible truth from Dr. Who. All newborns are ugly while they are still wet behind the ears. Even my grandchildren.

One of my daughters recently gave birth to a healthy little girl after a relatively short labor induced because of a few decelerations noted on a nonstress test. (Haven’t we already figured out that fetal heart monitors cause more angst than they are worth?) Anyway ... apparently as labor was nearing completion, a few more deep decelerations raised the tension in the delivery to the point that there was a stat call for a pediatrician to come and stand by.

That’s all my daughter recalls until a couple of minutes of suction-aided yanking resulted in a pink and crying baby she was able to cuddle and feed. I asked, "Did you see or talk to the pediatrician in the delivery room?" "No." She didn’t recall seeing him until later in the day. "I was too busy enjoying being a new mother again."

I said to myself, "Now, that was an experienced and sensitive pediatrician." When it was clear he wasn’t needed, he took a quick look at the baby and vanished into the haze of postpartum amnesia.

"I wish I could say that as the decades ticked away I became immune to anxiety that accompanies a birth, but I haven't."

I can’t even guess how many times I have been called to the delivery room stat only to watch the delivery of a vigorous and healthy baby. Fortunately, my standing around time is usually measured in minutes. But, there have been times when it took the obstetrician more than an hour to realize that a C-section was inevitable. Once I had checked to see that the laryngoscope light was working and the selection of endotracheal tubes was complete, there wasn’t much to do but stand there and listen to two or three people who aren’t in pain encouraging one poor woman who is. Of course, from time to time, I will discover that the warmer hasn’t been turned on, but for the most part, well-trained nurses armed with complete checklists have seen that everything we’ll need is within reach.

I wish I could say that as the decades ticked away I became immune to anxiety that accompanies a birth, but I haven’t. However, I did gradually develop the skill of at least appearing unconcerned as tension filled the delivery room. I have seen enough obstetric disasters to know that stuff happens.

But when it doesn’t happen, the pediatrician must seamlessly change roles from potentially being the star of the show to becoming just another member of the audience watching a truly miraculous transition. One moment we are the must-be-there person. Then in less time than it takes to say "Apgar of 8," we have instantly become Dr. Who?

How we handle this sudden demotion says something about how we see our role in the bigger health care picture. Once that healthy baby sees the bright lights of the extra-uterine world, it needs to see and be close to its mother. But something (mostly risk management concerns, I suspect) urges us to do a thorough exam. Heck, we’ve been standing around for a half an hour. Don’t we get to do something?

This is a time for compromise. In my view, and it sounds like the one shared by my daughter’s pediatrician, the need for family building easily trumps our need to feel important or at least be thorough. A quick pass of the stethoscope over the chest and a two-finger trip around the abdomen can easily be done while the nurse is doing a quick wipe off. Let’s be honest, when it comes to newborns (and maybe all children) 90% of our exam is done with our naked eyes. There will be a better time later in the day to abduct hips and demonstrate a symmetric Moro reflex. It may not be a better time for us, but it will be a better time for a new mother more or less recovered from the emotional explosion of childbirth.

As I slip out of the delivery room I might mumble, "Good-looking baby." But, at that point, my words would be superfluous. There would be plenty of others to tell these new parents how beautiful their baby is. They don’t need to hear the terrible truth from Dr. Who. All newborns are ugly while they are still wet behind the ears. Even my grandchildren.

A restaurant owner in Pennsylvania recently stopped allowing children younger than 6 years to dine at his establishment. As you might imagine, this change in policy touched off a flurry of comments. What might surprise you (but shouldn't) is that he reports that his e-mails, which number more than 2,000, are running 11-1 in favor of his restrictive policy. In a local television station survey of more than 10,000 respondents, 64% supported his decision. And he seems to be busier than before he stopped seating young children.

Is this scenario simply a reflection of one of our shifting demographics, as millions of baby boomers age into grumpy old men and women who don't want their dinners disturbed? Or is it a statement by a larger silent majority who believe that American parents have dropped the ball when it comes to discipline?

As with most societal hot buttons, the answer lies somewhere in the middle. Demographics certainly play a role, but it's not just the growing population of older folks, some of whom can be irritated by even the normal buzz that radiates from well-behaved children. The other growing segment of the population is that of families in which both parents work out of the home. When our children were young, we didn't take them to restaurants. We couldn't afford it. A stop at a hotdog cart or an ice cream stand was about it for extramural dining experiences.

Modern two-income families have fewer meals at home and, in some cases, have more disposable income to spend at restaurants. Dining has become another opportunity for young families to snatch some precious time together, and this often means dining at an hour when my children would have been in bed. The result can be an uncomfortable clash of cultures at a restaurant.

Compounding the collision of dining expectations has been the unfortunate emergence of the notion that meals must include some stimulating amusement. When I was young, we were entertained by each other's reports of how our days had gone. But today, the television has won a place at the dinner table in many homes. More and more restaurants (and not just fast-food places) have recreation areas and video-game consoles to fill those awkward moments of silence that can occur between bites.

However, I suspect that the response that surfaced at that small Pennsylvania restaurant also reflects a broader discontent by those who see the unruly behavior of young children in restaurants as just the tip of the iceberg of parents who have not mastered the skill of saying no to their children.

It's clear from my experiences in the office that most parents realize they need help with discipline, and they are eager to learn. The fact that of the four books I've written, the one that has been translated into two foreign languages (Polish and Italian) is titled “How to Say No to Your Toddler” suggests that this appetite for help is not limited to North American parents.

While the American Academy of Pediatrics should probably avoid setting age guidelines for dining establishments, the issue of unruly young children in restaurants is one that often bounces into our court as primary care pediatricians. Helping parents to set age-appropriate limits and develop humane and effective consequences is primarily about safety, but it is also the cornerstone in the development of civility. A healthy society is one in which all age groups can coexist, but sometimes that just can't happen in a nice restaurant at 7:30 in the evening.

I am interested in what you all think about this issue. If you respond, please include your age.

A restaurant owner in Pennsylvania recently stopped allowing children younger than 6 years to dine at his establishment. As you might imagine, this change in policy touched off a flurry of comments. What might surprise you (but shouldn't) is that he reports that his e-mails, which number more than 2,000, are running 11-1 in favor of his restrictive policy. In a local television station survey of more than 10,000 respondents, 64% supported his decision. And he seems to be busier than before he stopped seating young children.

Is this scenario simply a reflection of one of our shifting demographics, as millions of baby boomers age into grumpy old men and women who don't want their dinners disturbed? Or is it a statement by a larger silent majority who believe that American parents have dropped the ball when it comes to discipline?

As with most societal hot buttons, the answer lies somewhere in the middle. Demographics certainly play a role, but it's not just the growing population of older folks, some of whom can be irritated by even the normal buzz that radiates from well-behaved children. The other growing segment of the population is that of families in which both parents work out of the home. When our children were young, we didn't take them to restaurants. We couldn't afford it. A stop at a hotdog cart or an ice cream stand was about it for extramural dining experiences.

Modern two-income families have fewer meals at home and, in some cases, have more disposable income to spend at restaurants. Dining has become another opportunity for young families to snatch some precious time together, and this often means dining at an hour when my children would have been in bed. The result can be an uncomfortable clash of cultures at a restaurant.

Compounding the collision of dining expectations has been the unfortunate emergence of the notion that meals must include some stimulating amusement. When I was young, we were entertained by each other's reports of how our days had gone. But today, the television has won a place at the dinner table in many homes. More and more restaurants (and not just fast-food places) have recreation areas and video-game consoles to fill those awkward moments of silence that can occur between bites.

However, I suspect that the response that surfaced at that small Pennsylvania restaurant also reflects a broader discontent by those who see the unruly behavior of young children in restaurants as just the tip of the iceberg of parents who have not mastered the skill of saying no to their children.

It's clear from my experiences in the office that most parents realize they need help with discipline, and they are eager to learn. The fact that of the four books I've written, the one that has been translated into two foreign languages (Polish and Italian) is titled “How to Say No to Your Toddler” suggests that this appetite for help is not limited to North American parents.

While the American Academy of Pediatrics should probably avoid setting age guidelines for dining establishments, the issue of unruly young children in restaurants is one that often bounces into our court as primary care pediatricians. Helping parents to set age-appropriate limits and develop humane and effective consequences is primarily about safety, but it is also the cornerstone in the development of civility. A healthy society is one in which all age groups can coexist, but sometimes that just can't happen in a nice restaurant at 7:30 in the evening.

I am interested in what you all think about this issue. If you respond, please include your age.

A restaurant owner in Pennsylvania recently stopped allowing children younger than 6 years to dine at his establishment. As you might imagine, this change in policy touched off a flurry of comments. What might surprise you (but shouldn't) is that he reports that his e-mails, which number more than 2,000, are running 11-1 in favor of his restrictive policy. In a local television station survey of more than 10,000 respondents, 64% supported his decision. And he seems to be busier than before he stopped seating young children.

Is this scenario simply a reflection of one of our shifting demographics, as millions of baby boomers age into grumpy old men and women who don't want their dinners disturbed? Or is it a statement by a larger silent majority who believe that American parents have dropped the ball when it comes to discipline?

As with most societal hot buttons, the answer lies somewhere in the middle. Demographics certainly play a role, but it's not just the growing population of older folks, some of whom can be irritated by even the normal buzz that radiates from well-behaved children. The other growing segment of the population is that of families in which both parents work out of the home. When our children were young, we didn't take them to restaurants. We couldn't afford it. A stop at a hotdog cart or an ice cream stand was about it for extramural dining experiences.

Modern two-income families have fewer meals at home and, in some cases, have more disposable income to spend at restaurants. Dining has become another opportunity for young families to snatch some precious time together, and this often means dining at an hour when my children would have been in bed. The result can be an uncomfortable clash of cultures at a restaurant.

Compounding the collision of dining expectations has been the unfortunate emergence of the notion that meals must include some stimulating amusement. When I was young, we were entertained by each other's reports of how our days had gone. But today, the television has won a place at the dinner table in many homes. More and more restaurants (and not just fast-food places) have recreation areas and video-game consoles to fill those awkward moments of silence that can occur between bites.

However, I suspect that the response that surfaced at that small Pennsylvania restaurant also reflects a broader discontent by those who see the unruly behavior of young children in restaurants as just the tip of the iceberg of parents who have not mastered the skill of saying no to their children.

It's clear from my experiences in the office that most parents realize they need help with discipline, and they are eager to learn. The fact that of the four books I've written, the one that has been translated into two foreign languages (Polish and Italian) is titled “How to Say No to Your Toddler” suggests that this appetite for help is not limited to North American parents.

While the American Academy of Pediatrics should probably avoid setting age guidelines for dining establishments, the issue of unruly young children in restaurants is one that often bounces into our court as primary care pediatricians. Helping parents to set age-appropriate limits and develop humane and effective consequences is primarily about safety, but it is also the cornerstone in the development of civility. A healthy society is one in which all age groups can coexist, but sometimes that just can't happen in a nice restaurant at 7:30 in the evening.

I am interested in what you all think about this issue. If you respond, please include your age.