Letters from Maine

Let me begin by saying that I agree with those who feel our decision-making habits could use some spiffing up. We should not be choosing medications based on what our local pharmaceutical representatives tell us over a sumptuous meal at a nice little French restaurant. Nor should we be ordering lab tests out of fear that we will be sued for missing a rare and extremely unlikely disease. Nor should we continue to recommend a certain therapy because that's the way we've been doing it since we finished our residencies.

I agree that medical decisions (and probably all of our decisions) should reflect the best evidence available. However, I am having trouble wrapping my mind and my heart around many of the strategies that I encounter in articles about how I might practice evidence-based medicine. For the most part, they seem unrealistic and impractical.

Let's start with the initial premise that there is enough good evidence out there to support my decisions. New studies are being performed at such a rate that what seems to be correct information today may well be hogwash tomorrow. Yes, there are statistical manipulations that can help sort out the wheat from the chaff, none with a clear advantage. But I don't think that someone can reasonably expect most primary care pediatricians to carry these kinds of analytical skills in our decision-making “tool boxes.”

It's not that we are stupid. It's just that we don't have the time to stop the merry-go-round long enough to do the footwork to perform these analyses. A computer can help, but I'm sure you have discovered that once you open up the Internet, time flies. An extra click here or there and before you know it a half an hour has zipped by.

So how can we make more rational decisions? First, many of the good evidence-based studies I have read (and trust) often suggest that what we've been doing out of habit and tradition isn't achieving our goals. The authors usually suggest further studies, but for the moment doing nothing sounds like the better course of action for those of us in the trenches. Therefore, I recommend we begin teaching medical students how to do nothing.

This isn't as crazy as it sounds. The therapeutic nihilists who trained me are long gone, so this will mean a new core curriculum that teaches young doctors how to just stand there instead of doing something for which there is no good evidence. One must learn the best body language to adopt while standing inert, and some comforting and reassuring words to say that can help parents understand and accept our inaction. Nihilism also can save money and lives by minimizing expensive tests and risky interventions.

A second and related strategy involves learning how to stop the clock. A recent article posed a scenario in which a primary care physician is consulted by an ENT specialist about the safety of doing elective surgery on a child with both a personal and family history that suggests a bleeding disorder (Pediatr. Rev. 2009;30:317–22).

The recommended approach included searching for several articles and then applying a formula to determine probability and likelihood ratios. The issue of time was never raised in the article, but in my experience, the real scenario would have to include the fact that the call from the ENT came at 4:30 in the afternoon and surgery was scheduled for 7:30 the next morning. Why? Because that's the way it always is.

Good decisions can take time and searching for evidence can take even more time. A shortage of time can contribute to bad decisions. Sometimes we need to be bolder about asking for more time to make our decisions. If I were faced with this scenario I would have picked up the phone and asked Ann, my saintly hematologist friend down in Portland, what she would do.

Let me begin by saying that I agree with those who feel our decision-making habits could use some spiffing up. We should not be choosing medications based on what our local pharmaceutical representatives tell us over a sumptuous meal at a nice little French restaurant. Nor should we be ordering lab tests out of fear that we will be sued for missing a rare and extremely unlikely disease. Nor should we continue to recommend a certain therapy because that's the way we've been doing it since we finished our residencies.

I agree that medical decisions (and probably all of our decisions) should reflect the best evidence available. However, I am having trouble wrapping my mind and my heart around many of the strategies that I encounter in articles about how I might practice evidence-based medicine. For the most part, they seem unrealistic and impractical.

Let's start with the initial premise that there is enough good evidence out there to support my decisions. New studies are being performed at such a rate that what seems to be correct information today may well be hogwash tomorrow. Yes, there are statistical manipulations that can help sort out the wheat from the chaff, none with a clear advantage. But I don't think that someone can reasonably expect most primary care pediatricians to carry these kinds of analytical skills in our decision-making “tool boxes.”

It's not that we are stupid. It's just that we don't have the time to stop the merry-go-round long enough to do the footwork to perform these analyses. A computer can help, but I'm sure you have discovered that once you open up the Internet, time flies. An extra click here or there and before you know it a half an hour has zipped by.

So how can we make more rational decisions? First, many of the good evidence-based studies I have read (and trust) often suggest that what we've been doing out of habit and tradition isn't achieving our goals. The authors usually suggest further studies, but for the moment doing nothing sounds like the better course of action for those of us in the trenches. Therefore, I recommend we begin teaching medical students how to do nothing.

This isn't as crazy as it sounds. The therapeutic nihilists who trained me are long gone, so this will mean a new core curriculum that teaches young doctors how to just stand there instead of doing something for which there is no good evidence. One must learn the best body language to adopt while standing inert, and some comforting and reassuring words to say that can help parents understand and accept our inaction. Nihilism also can save money and lives by minimizing expensive tests and risky interventions.

A second and related strategy involves learning how to stop the clock. A recent article posed a scenario in which a primary care physician is consulted by an ENT specialist about the safety of doing elective surgery on a child with both a personal and family history that suggests a bleeding disorder (Pediatr. Rev. 2009;30:317–22).

The recommended approach included searching for several articles and then applying a formula to determine probability and likelihood ratios. The issue of time was never raised in the article, but in my experience, the real scenario would have to include the fact that the call from the ENT came at 4:30 in the afternoon and surgery was scheduled for 7:30 the next morning. Why? Because that's the way it always is.

Good decisions can take time and searching for evidence can take even more time. A shortage of time can contribute to bad decisions. Sometimes we need to be bolder about asking for more time to make our decisions. If I were faced with this scenario I would have picked up the phone and asked Ann, my saintly hematologist friend down in Portland, what she would do.

Let me begin by saying that I agree with those who feel our decision-making habits could use some spiffing up. We should not be choosing medications based on what our local pharmaceutical representatives tell us over a sumptuous meal at a nice little French restaurant. Nor should we be ordering lab tests out of fear that we will be sued for missing a rare and extremely unlikely disease. Nor should we continue to recommend a certain therapy because that's the way we've been doing it since we finished our residencies.

I agree that medical decisions (and probably all of our decisions) should reflect the best evidence available. However, I am having trouble wrapping my mind and my heart around many of the strategies that I encounter in articles about how I might practice evidence-based medicine. For the most part, they seem unrealistic and impractical.

Let's start with the initial premise that there is enough good evidence out there to support my decisions. New studies are being performed at such a rate that what seems to be correct information today may well be hogwash tomorrow. Yes, there are statistical manipulations that can help sort out the wheat from the chaff, none with a clear advantage. But I don't think that someone can reasonably expect most primary care pediatricians to carry these kinds of analytical skills in our decision-making “tool boxes.”

It's not that we are stupid. It's just that we don't have the time to stop the merry-go-round long enough to do the footwork to perform these analyses. A computer can help, but I'm sure you have discovered that once you open up the Internet, time flies. An extra click here or there and before you know it a half an hour has zipped by.

So how can we make more rational decisions? First, many of the good evidence-based studies I have read (and trust) often suggest that what we've been doing out of habit and tradition isn't achieving our goals. The authors usually suggest further studies, but for the moment doing nothing sounds like the better course of action for those of us in the trenches. Therefore, I recommend we begin teaching medical students how to do nothing.

This isn't as crazy as it sounds. The therapeutic nihilists who trained me are long gone, so this will mean a new core curriculum that teaches young doctors how to just stand there instead of doing something for which there is no good evidence. One must learn the best body language to adopt while standing inert, and some comforting and reassuring words to say that can help parents understand and accept our inaction. Nihilism also can save money and lives by minimizing expensive tests and risky interventions.

A second and related strategy involves learning how to stop the clock. A recent article posed a scenario in which a primary care physician is consulted by an ENT specialist about the safety of doing elective surgery on a child with both a personal and family history that suggests a bleeding disorder (Pediatr. Rev. 2009;30:317–22).

The recommended approach included searching for several articles and then applying a formula to determine probability and likelihood ratios. The issue of time was never raised in the article, but in my experience, the real scenario would have to include the fact that the call from the ENT came at 4:30 in the afternoon and surgery was scheduled for 7:30 the next morning. Why? Because that's the way it always is.

Good decisions can take time and searching for evidence can take even more time. A shortage of time can contribute to bad decisions. Sometimes we need to be bolder about asking for more time to make our decisions. If I were faced with this scenario I would have picked up the phone and asked Ann, my saintly hematologist friend down in Portland, what she would do.

[email protected]

Hx: runny nose × 3 d—fever 101 ax yest afternoon—very fussy last night'some cough—no Breakfast—no V or D

PE: Well—N.A.D. sl fussy—orients to Mom—Chest clear—Rt TM honey colored opaque bulging—Lt creamy fluid level 2/3 immobile

Dx: B.O.M.

Plan: Amox 250 tid × 10 d/Ret 3 wks

Does this look familiar? It's a typical note that has been scanned into a patient's electronic medical record. It was originally handwritten and includes a small schematic diagram of a tympanic membrane. But it could have been typed or dictated with a system such as Dragonspeak.

Does it seem skimpy? How does it compare to your own office records or those you receive from an emergency room? Is the format familiar?

You may wonder why I don't use the SOAP format (subjective, objective, assessment, plan). I was already a few steps into my training when SOAP was introduced and promoted. One of those old dog/new tricks deals. But a more philosophic answer is that I have some real reservations about the objectivity of most physical exams, my own included.

Look at our poor track record in observing and recording the appearance of tympanic membranes or heart murmurs or lung sounds. How many of us are disciplined enough to describe a skin eruption beyond reporting it as “maculopapular”? If we were to change the “O” in SOAP to “observation” instead of “objective,” I could buy it. Otherwise a physical exam is in the eye of the beholder. The only objective portions are the vital signs and the lab work. And I have my doubts about the accuracy of weights and BPs coming out of many offices and emergency rooms. My notes are divided into history, physical exam, diagnosis (or assessment), and plan. If the child has multiple problems, I number them and match them with similarly numbered plans.

If you can accept my old-school format, can you accept my note's skimpiness? You may ask, “Where are the pertinent negatives?” Good question. But here's a better question: What is the value of listing pertinent negatives?

When we were medical students, a list of pertinent negatives proved that we had taken a thorough history and done a complete exam. My colleagues who cover for me know how thoroughly I interview and examine patients. I owe them a thumbnail sketch of how sick the child looked and a description of the positives in case it's helpful for comparison at a subsequent visit. I include “chest clear” out of habit, but otherwise I try to spare my busy brother and sister pediatricians the tedium of a laundry list of negatives.

Two groups retain a perverse curiosity about what I haven't seen or heard: the lawyers and the third-party bean counters. They remain zealous believers in the myth that, “if you didn't document it, it did not happen.” Obviously this is rubbish, but they wield power (mostly financial), and unfortunately that power has influenced, and I fear will continue to influence, the format and style of electronic medical records. Templates, drop-down lists, and preprogrammed phrases will become the norm. The busy physician will click or tap with a stylus to create a voluminous list of negatives, pertinent and otherwise, that only a medical school instructor would care about.

Navigating these electronic shortcuts is not as easy as it sounds. The extensive lists they generate mean more wasted time for a covering physician. The finished note's spell-checked and laser-printed clarity doesn't guarantee that the right questions have been asked or that the exam was expertly done.

[email protected]

Hx: runny nose × 3 d—fever 101 ax yest afternoon—very fussy last night'some cough—no Breakfast—no V or D

PE: Well—N.A.D. sl fussy—orients to Mom—Chest clear—Rt TM honey colored opaque bulging—Lt creamy fluid level 2/3 immobile

Dx: B.O.M.

Plan: Amox 250 tid × 10 d/Ret 3 wks

Does this look familiar? It's a typical note that has been scanned into a patient's electronic medical record. It was originally handwritten and includes a small schematic diagram of a tympanic membrane. But it could have been typed or dictated with a system such as Dragonspeak.

Does it seem skimpy? How does it compare to your own office records or those you receive from an emergency room? Is the format familiar?

You may wonder why I don't use the SOAP format (subjective, objective, assessment, plan). I was already a few steps into my training when SOAP was introduced and promoted. One of those old dog/new tricks deals. But a more philosophic answer is that I have some real reservations about the objectivity of most physical exams, my own included.

Look at our poor track record in observing and recording the appearance of tympanic membranes or heart murmurs or lung sounds. How many of us are disciplined enough to describe a skin eruption beyond reporting it as “maculopapular”? If we were to change the “O” in SOAP to “observation” instead of “objective,” I could buy it. Otherwise a physical exam is in the eye of the beholder. The only objective portions are the vital signs and the lab work. And I have my doubts about the accuracy of weights and BPs coming out of many offices and emergency rooms. My notes are divided into history, physical exam, diagnosis (or assessment), and plan. If the child has multiple problems, I number them and match them with similarly numbered plans.

If you can accept my old-school format, can you accept my note's skimpiness? You may ask, “Where are the pertinent negatives?” Good question. But here's a better question: What is the value of listing pertinent negatives?

When we were medical students, a list of pertinent negatives proved that we had taken a thorough history and done a complete exam. My colleagues who cover for me know how thoroughly I interview and examine patients. I owe them a thumbnail sketch of how sick the child looked and a description of the positives in case it's helpful for comparison at a subsequent visit. I include “chest clear” out of habit, but otherwise I try to spare my busy brother and sister pediatricians the tedium of a laundry list of negatives.

Two groups retain a perverse curiosity about what I haven't seen or heard: the lawyers and the third-party bean counters. They remain zealous believers in the myth that, “if you didn't document it, it did not happen.” Obviously this is rubbish, but they wield power (mostly financial), and unfortunately that power has influenced, and I fear will continue to influence, the format and style of electronic medical records. Templates, drop-down lists, and preprogrammed phrases will become the norm. The busy physician will click or tap with a stylus to create a voluminous list of negatives, pertinent and otherwise, that only a medical school instructor would care about.

Navigating these electronic shortcuts is not as easy as it sounds. The extensive lists they generate mean more wasted time for a covering physician. The finished note's spell-checked and laser-printed clarity doesn't guarantee that the right questions have been asked or that the exam was expertly done.

[email protected]

Hx: runny nose × 3 d—fever 101 ax yest afternoon—very fussy last night'some cough—no Breakfast—no V or D

PE: Well—N.A.D. sl fussy—orients to Mom—Chest clear—Rt TM honey colored opaque bulging—Lt creamy fluid level 2/3 immobile

Dx: B.O.M.

Plan: Amox 250 tid × 10 d/Ret 3 wks

Does this look familiar? It's a typical note that has been scanned into a patient's electronic medical record. It was originally handwritten and includes a small schematic diagram of a tympanic membrane. But it could have been typed or dictated with a system such as Dragonspeak.

Does it seem skimpy? How does it compare to your own office records or those you receive from an emergency room? Is the format familiar?

You may wonder why I don't use the SOAP format (subjective, objective, assessment, plan). I was already a few steps into my training when SOAP was introduced and promoted. One of those old dog/new tricks deals. But a more philosophic answer is that I have some real reservations about the objectivity of most physical exams, my own included.

Look at our poor track record in observing and recording the appearance of tympanic membranes or heart murmurs or lung sounds. How many of us are disciplined enough to describe a skin eruption beyond reporting it as “maculopapular”? If we were to change the “O” in SOAP to “observation” instead of “objective,” I could buy it. Otherwise a physical exam is in the eye of the beholder. The only objective portions are the vital signs and the lab work. And I have my doubts about the accuracy of weights and BPs coming out of many offices and emergency rooms. My notes are divided into history, physical exam, diagnosis (or assessment), and plan. If the child has multiple problems, I number them and match them with similarly numbered plans.

If you can accept my old-school format, can you accept my note's skimpiness? You may ask, “Where are the pertinent negatives?” Good question. But here's a better question: What is the value of listing pertinent negatives?

When we were medical students, a list of pertinent negatives proved that we had taken a thorough history and done a complete exam. My colleagues who cover for me know how thoroughly I interview and examine patients. I owe them a thumbnail sketch of how sick the child looked and a description of the positives in case it's helpful for comparison at a subsequent visit. I include “chest clear” out of habit, but otherwise I try to spare my busy brother and sister pediatricians the tedium of a laundry list of negatives.

Two groups retain a perverse curiosity about what I haven't seen or heard: the lawyers and the third-party bean counters. They remain zealous believers in the myth that, “if you didn't document it, it did not happen.” Obviously this is rubbish, but they wield power (mostly financial), and unfortunately that power has influenced, and I fear will continue to influence, the format and style of electronic medical records. Templates, drop-down lists, and preprogrammed phrases will become the norm. The busy physician will click or tap with a stylus to create a voluminous list of negatives, pertinent and otherwise, that only a medical school instructor would care about.

Navigating these electronic shortcuts is not as easy as it sounds. The extensive lists they generate mean more wasted time for a covering physician. The finished note's spell-checked and laser-printed clarity doesn't guarantee that the right questions have been asked or that the exam was expertly done.

[email protected]

I've been a bit grumpy the last couple of weeks. We had to put down our 10-year-old electronic medical record system, and I am still working through the grieving process.

She was getting long in the tooth. Homemade by one of our doctors, she had served us well. Everybody loved her from Day 1. But keeping her healthy had become expensive and frustrating. She didn't interface with our off-the-shelf billing and prescribing platforms. She had to go.

What we pediatricians had liked about her was that she allowed us to handwrite our notes and scan them in quickly. Our new system is point and click or type in free text boxes. Dictation just doesn't fit our practice styles. For me, typing isn't much of an issue. In one of her wiser moments, my mom decided that I wasn't going to waste the entire summer of my 11th year at the town swimming pool. She taped over the keys of one of my Dad's old typewriters; gave me a water-stained copy of a learn-to-type book and set me to transcribing Reader's Digest articles. The result is that I am a fast but inaccurate typist whose brain is littered with deep pockets of useless knowledge and anecdotes.

I am trying to learn to keep my eyes off the keyboard and the screen. It's a struggle but I know I can make the adjustment. The reason for my persistent grumpiness is that while the keyboard can replace my handwriting (and probably should have years ago) it can't replace the scores of drawings that decorate my charts.

I have always been a drawer. Ask me for directions and I'll draw you a map. Ask me any question and the odds are 2:1 that I will pull out my pen and illustrate my answer on an old envelope or a paper napkin. It must be genetic. My mom was trained to be an art teacher. My dad always designed and made our Christmas cards. My sister is a whiz with fine-tipped colored markers. My college major was art history. I'm just a visual guy.

It's always been easier for me to draw the distribution of a rash than to describe it. “It hurts here” is more efficiently sketched than written about. The size, shape, and location of laceration are unmistakable when I can draw the wound. A quick outline of the tympanic membrane allows me to remember how much and where the fluid was collecting.

While I am a prolific medical illustrator, the quality of my work is spotty. I have certain favorites and strengths. I am particularly proud of my renderings of legs, fingers, trunks, and genitalia. My sketches of faces and noses are good, my tongues and tonsils are fair. Profiles, ankles, and teeth are pretty shaky but always unmistakable. Even my worst work offers our medical record staff multiple opportunities for a good laugh at the end of a long day.

I have never warmed up to the concept of adding my own lines and dots to the preprinted anatomically correct drawings available on off-the-shelf forms. Somehow it makes me feel that I am prostituting my artistic talents.

There is technology out there that might allow me to draw on the computer, but I've been told it won't be finding its way to our little corner of Maine for quite awhile. So I will be struggling to describe what I have been drawing for years. My vocabulary of anatomical names, which has atrophied from disuse, will have to be rebuilt. For decades I have relied on my sketches and shoddy penmanship to disguise my spelling deficiencies.

But in my darkest hours of grumpiness I am reassured that I will still need my pen and paper to illustrate my mini lectures for patients and parents. They need to “see” what a middle ear looks like and how an inguinal hernia forms. Or why a swollen prepatellar bursa is not as serious as an intra-articular effusion.

Every picture is worth a thousand words … at least.

[email protected]

I've been a bit grumpy the last couple of weeks. We had to put down our 10-year-old electronic medical record system, and I am still working through the grieving process.

She was getting long in the tooth. Homemade by one of our doctors, she had served us well. Everybody loved her from Day 1. But keeping her healthy had become expensive and frustrating. She didn't interface with our off-the-shelf billing and prescribing platforms. She had to go.

What we pediatricians had liked about her was that she allowed us to handwrite our notes and scan them in quickly. Our new system is point and click or type in free text boxes. Dictation just doesn't fit our practice styles. For me, typing isn't much of an issue. In one of her wiser moments, my mom decided that I wasn't going to waste the entire summer of my 11th year at the town swimming pool. She taped over the keys of one of my Dad's old typewriters; gave me a water-stained copy of a learn-to-type book and set me to transcribing Reader's Digest articles. The result is that I am a fast but inaccurate typist whose brain is littered with deep pockets of useless knowledge and anecdotes.

I am trying to learn to keep my eyes off the keyboard and the screen. It's a struggle but I know I can make the adjustment. The reason for my persistent grumpiness is that while the keyboard can replace my handwriting (and probably should have years ago) it can't replace the scores of drawings that decorate my charts.

I have always been a drawer. Ask me for directions and I'll draw you a map. Ask me any question and the odds are 2:1 that I will pull out my pen and illustrate my answer on an old envelope or a paper napkin. It must be genetic. My mom was trained to be an art teacher. My dad always designed and made our Christmas cards. My sister is a whiz with fine-tipped colored markers. My college major was art history. I'm just a visual guy.

It's always been easier for me to draw the distribution of a rash than to describe it. “It hurts here” is more efficiently sketched than written about. The size, shape, and location of laceration are unmistakable when I can draw the wound. A quick outline of the tympanic membrane allows me to remember how much and where the fluid was collecting.

While I am a prolific medical illustrator, the quality of my work is spotty. I have certain favorites and strengths. I am particularly proud of my renderings of legs, fingers, trunks, and genitalia. My sketches of faces and noses are good, my tongues and tonsils are fair. Profiles, ankles, and teeth are pretty shaky but always unmistakable. Even my worst work offers our medical record staff multiple opportunities for a good laugh at the end of a long day.

I have never warmed up to the concept of adding my own lines and dots to the preprinted anatomically correct drawings available on off-the-shelf forms. Somehow it makes me feel that I am prostituting my artistic talents.

There is technology out there that might allow me to draw on the computer, but I've been told it won't be finding its way to our little corner of Maine for quite awhile. So I will be struggling to describe what I have been drawing for years. My vocabulary of anatomical names, which has atrophied from disuse, will have to be rebuilt. For decades I have relied on my sketches and shoddy penmanship to disguise my spelling deficiencies.

But in my darkest hours of grumpiness I am reassured that I will still need my pen and paper to illustrate my mini lectures for patients and parents. They need to “see” what a middle ear looks like and how an inguinal hernia forms. Or why a swollen prepatellar bursa is not as serious as an intra-articular effusion.

Every picture is worth a thousand words … at least.

[email protected]

I've been a bit grumpy the last couple of weeks. We had to put down our 10-year-old electronic medical record system, and I am still working through the grieving process.

She was getting long in the tooth. Homemade by one of our doctors, she had served us well. Everybody loved her from Day 1. But keeping her healthy had become expensive and frustrating. She didn't interface with our off-the-shelf billing and prescribing platforms. She had to go.

What we pediatricians had liked about her was that she allowed us to handwrite our notes and scan them in quickly. Our new system is point and click or type in free text boxes. Dictation just doesn't fit our practice styles. For me, typing isn't much of an issue. In one of her wiser moments, my mom decided that I wasn't going to waste the entire summer of my 11th year at the town swimming pool. She taped over the keys of one of my Dad's old typewriters; gave me a water-stained copy of a learn-to-type book and set me to transcribing Reader's Digest articles. The result is that I am a fast but inaccurate typist whose brain is littered with deep pockets of useless knowledge and anecdotes.

I am trying to learn to keep my eyes off the keyboard and the screen. It's a struggle but I know I can make the adjustment. The reason for my persistent grumpiness is that while the keyboard can replace my handwriting (and probably should have years ago) it can't replace the scores of drawings that decorate my charts.

I have always been a drawer. Ask me for directions and I'll draw you a map. Ask me any question and the odds are 2:1 that I will pull out my pen and illustrate my answer on an old envelope or a paper napkin. It must be genetic. My mom was trained to be an art teacher. My dad always designed and made our Christmas cards. My sister is a whiz with fine-tipped colored markers. My college major was art history. I'm just a visual guy.

It's always been easier for me to draw the distribution of a rash than to describe it. “It hurts here” is more efficiently sketched than written about. The size, shape, and location of laceration are unmistakable when I can draw the wound. A quick outline of the tympanic membrane allows me to remember how much and where the fluid was collecting.

While I am a prolific medical illustrator, the quality of my work is spotty. I have certain favorites and strengths. I am particularly proud of my renderings of legs, fingers, trunks, and genitalia. My sketches of faces and noses are good, my tongues and tonsils are fair. Profiles, ankles, and teeth are pretty shaky but always unmistakable. Even my worst work offers our medical record staff multiple opportunities for a good laugh at the end of a long day.

I have never warmed up to the concept of adding my own lines and dots to the preprinted anatomically correct drawings available on off-the-shelf forms. Somehow it makes me feel that I am prostituting my artistic talents.

There is technology out there that might allow me to draw on the computer, but I've been told it won't be finding its way to our little corner of Maine for quite awhile. So I will be struggling to describe what I have been drawing for years. My vocabulary of anatomical names, which has atrophied from disuse, will have to be rebuilt. For decades I have relied on my sketches and shoddy penmanship to disguise my spelling deficiencies.

But in my darkest hours of grumpiness I am reassured that I will still need my pen and paper to illustrate my mini lectures for patients and parents. They need to “see” what a middle ear looks like and how an inguinal hernia forms. Or why a swollen prepatellar bursa is not as serious as an intra-articular effusion.

Every picture is worth a thousand words … at least.

[email protected]

“Oops” is probably my most frequently used subject when creating e-mails. The recipient is immediately alerted that in the text they are going to find an extensive mea culpa. Often I am apologizing for forgetting to attend a meeting. Although “forgetting” may not be the most accurate word when it comes to group exercises destined to go nowhere slowly.

Warriors have their own versions of “oops.” Both conjure up horrible and tragic images of death and destruction. One is “friendly fire.” The other is “collateral damage,” a term that refers to devastation outside the expected target area.

A few months ago I opened the Sunday morning paper and encountered an explosive event on page 4. You have probably read or heard other versions of the story of a 56-year-old pediatrician from Lewes, Del., who is in jail awaiting prosecution for a 471-count indictment for sexually molesting some of his patients over at least 11 years in practice.

The details of the case that have come to light so far are complex and terribly disturbing. The ground zero for this horrible explosion is predictably the children who were molested, particularly those who have some memory of the events. Sharing the epicenter are their parents whose anger is directed outward to the alleged perpetrator. And inward at themselves for not acting on the occasional uneasy feeling that the physician whom they had trusted with their children seemed a little too weird.

We can only hope that with time both parents and children will find a physician with whom they can feel comfortable. For some I am sure it will take many years to repair the damage. But, because we live in an age of instant and global communication, this horrible bomb of mistrust is radiating and will continue to radiate damage far beyond the borders of that tiny town on the Delaware Coast.

Parents from Portland, Maine, to San Diego will be looking at their pediatricians with a new and suspicious eye. “Does he seem overly interested in my daughter's private parts?” “Does she spend too much time trying to find my 8-month-old son's testicle?” “Doesn't that beard make him seem just a little too weird?” Those of us who wear oversized polka dot bow ties or occasionally don red clown noses to put our patients at ease may be in for special scrutiny.

Although some of us may feel we need to traditionalize our attire, sartorial alterations are relatively easy to make. Behavioral adjustments will present more of a problem. Doctoring can and at times must be hands on. In some circumstances private places must be carefully inspected. Complicating matters is the fact that even on our most hectic days we don't just tolerate our patients. We like them.

There are times when this genuine affection emerges in a big hug for the 4-year-old who has weathered his preschool shots with only a glint of a tear in his eyes. Or a pat on the head for a 3-year-old who has finally mastered the skill of holding still for an ear exam. Two-month-old infants can be too cute not to cradle in one's arms.

But because of the alleged and horribly inappropriate behavior of one of our number, some things will have to change. We will always have to explain what and why we are doing the sensitive portions of our exams. We can no longer assume that because we are pediatricians, our behavior will be interpreted as appropriate.

But what won't and mustn't change is our affection for our patients. However, we may have to begin asking permission for some things that once came so naturally. Unfortunately, the spontaneous hug may have become a casualty of collateral damage.

[email protected]

“Oops” is probably my most frequently used subject when creating e-mails. The recipient is immediately alerted that in the text they are going to find an extensive mea culpa. Often I am apologizing for forgetting to attend a meeting. Although “forgetting” may not be the most accurate word when it comes to group exercises destined to go nowhere slowly.

Warriors have their own versions of “oops.” Both conjure up horrible and tragic images of death and destruction. One is “friendly fire.” The other is “collateral damage,” a term that refers to devastation outside the expected target area.

A few months ago I opened the Sunday morning paper and encountered an explosive event on page 4. You have probably read or heard other versions of the story of a 56-year-old pediatrician from Lewes, Del., who is in jail awaiting prosecution for a 471-count indictment for sexually molesting some of his patients over at least 11 years in practice.

The details of the case that have come to light so far are complex and terribly disturbing. The ground zero for this horrible explosion is predictably the children who were molested, particularly those who have some memory of the events. Sharing the epicenter are their parents whose anger is directed outward to the alleged perpetrator. And inward at themselves for not acting on the occasional uneasy feeling that the physician whom they had trusted with their children seemed a little too weird.

We can only hope that with time both parents and children will find a physician with whom they can feel comfortable. For some I am sure it will take many years to repair the damage. But, because we live in an age of instant and global communication, this horrible bomb of mistrust is radiating and will continue to radiate damage far beyond the borders of that tiny town on the Delaware Coast.

Parents from Portland, Maine, to San Diego will be looking at their pediatricians with a new and suspicious eye. “Does he seem overly interested in my daughter's private parts?” “Does she spend too much time trying to find my 8-month-old son's testicle?” “Doesn't that beard make him seem just a little too weird?” Those of us who wear oversized polka dot bow ties or occasionally don red clown noses to put our patients at ease may be in for special scrutiny.

Although some of us may feel we need to traditionalize our attire, sartorial alterations are relatively easy to make. Behavioral adjustments will present more of a problem. Doctoring can and at times must be hands on. In some circumstances private places must be carefully inspected. Complicating matters is the fact that even on our most hectic days we don't just tolerate our patients. We like them.

There are times when this genuine affection emerges in a big hug for the 4-year-old who has weathered his preschool shots with only a glint of a tear in his eyes. Or a pat on the head for a 3-year-old who has finally mastered the skill of holding still for an ear exam. Two-month-old infants can be too cute not to cradle in one's arms.

But because of the alleged and horribly inappropriate behavior of one of our number, some things will have to change. We will always have to explain what and why we are doing the sensitive portions of our exams. We can no longer assume that because we are pediatricians, our behavior will be interpreted as appropriate.

But what won't and mustn't change is our affection for our patients. However, we may have to begin asking permission for some things that once came so naturally. Unfortunately, the spontaneous hug may have become a casualty of collateral damage.

[email protected]

“Oops” is probably my most frequently used subject when creating e-mails. The recipient is immediately alerted that in the text they are going to find an extensive mea culpa. Often I am apologizing for forgetting to attend a meeting. Although “forgetting” may not be the most accurate word when it comes to group exercises destined to go nowhere slowly.

Warriors have their own versions of “oops.” Both conjure up horrible and tragic images of death and destruction. One is “friendly fire.” The other is “collateral damage,” a term that refers to devastation outside the expected target area.

A few months ago I opened the Sunday morning paper and encountered an explosive event on page 4. You have probably read or heard other versions of the story of a 56-year-old pediatrician from Lewes, Del., who is in jail awaiting prosecution for a 471-count indictment for sexually molesting some of his patients over at least 11 years in practice.

The details of the case that have come to light so far are complex and terribly disturbing. The ground zero for this horrible explosion is predictably the children who were molested, particularly those who have some memory of the events. Sharing the epicenter are their parents whose anger is directed outward to the alleged perpetrator. And inward at themselves for not acting on the occasional uneasy feeling that the physician whom they had trusted with their children seemed a little too weird.

We can only hope that with time both parents and children will find a physician with whom they can feel comfortable. For some I am sure it will take many years to repair the damage. But, because we live in an age of instant and global communication, this horrible bomb of mistrust is radiating and will continue to radiate damage far beyond the borders of that tiny town on the Delaware Coast.

Parents from Portland, Maine, to San Diego will be looking at their pediatricians with a new and suspicious eye. “Does he seem overly interested in my daughter's private parts?” “Does she spend too much time trying to find my 8-month-old son's testicle?” “Doesn't that beard make him seem just a little too weird?” Those of us who wear oversized polka dot bow ties or occasionally don red clown noses to put our patients at ease may be in for special scrutiny.

Although some of us may feel we need to traditionalize our attire, sartorial alterations are relatively easy to make. Behavioral adjustments will present more of a problem. Doctoring can and at times must be hands on. In some circumstances private places must be carefully inspected. Complicating matters is the fact that even on our most hectic days we don't just tolerate our patients. We like them.

There are times when this genuine affection emerges in a big hug for the 4-year-old who has weathered his preschool shots with only a glint of a tear in his eyes. Or a pat on the head for a 3-year-old who has finally mastered the skill of holding still for an ear exam. Two-month-old infants can be too cute not to cradle in one's arms.

But because of the alleged and horribly inappropriate behavior of one of our number, some things will have to change. We will always have to explain what and why we are doing the sensitive portions of our exams. We can no longer assume that because we are pediatricians, our behavior will be interpreted as appropriate.

But what won't and mustn't change is our affection for our patients. However, we may have to begin asking permission for some things that once came so naturally. Unfortunately, the spontaneous hug may have become a casualty of collateral damage.

[email protected]

Do you use templates? If you haven't stepped over the threshold into the costly world of electronic health records, you may not understand the question.

In the old days, a template was a pattern or gauge for accurately creating a product. A stencil is a template. In addition to ensuring accuracy, a template allows its user to replicate the original product more efficiently.

Even if you haven't begun using electronic templates but practice in a group, you probably have adopted standard forms for a variety of patient interactions—for example, ones for sick visits, which may be disease specific, or for well visits, which may be age specific. Obviously, standardization can make it easier for practicing physicians and their staffs to find information through documentation guided by templates. These forms can be bought off the shelf or developed internally by members of the group after what can be contentious negotiations between providers. Those of us who practiced by ourselves quickly became wedded to the formats we developed ourselves. When one joins a group, it can be difficult to leave our old favorite forms. And, when new editions are proposed, tugs-of-war can erupt over where to position, and how big to make, the boxes.

Some physicians prefer detailed and exhaustive checklists; others like myself prefer broad categories with plenty of elbow room to scribble and create anatomically incorrect drawings. We don't like being fenced in by a myriad of little boxes. Instead we crave the wide-open spaces to create and express our individuality.

Should a template dictate practice? Is it the purpose of the form to remind, coach, or arm twist the practitioner into asking certain questions or performing certain tests? There is certainly mounting evidence that checklists for procedures can improve outcomes. But when we are talking about an office visit encounter, one could ask, “Is the form the boss of me? Or is it merely a tool to guide my documentation so that my coworkers can find and understand what I have done?”

When templates become electronic, they can become tools for replicating documents of dubious quality. For example, when one clicks on a box that says “normal pharynx,” the computer may spit out a stored bit of dialogue that includes “uvula midline, tonsils not enlarged.” In reality the child may have a bifid uvula and his tonsils may have been surgically removed. Although these inaccuracies may be trivial, one can easily imagine others that are not so innocuous.

How many of us really carefully read the final documents generated by our clicks or wand taps? How many of us remember what the computer is going to say when we click “normal”? This kind of error by click is most obvious in emergency department records, which read like textbooks. Having spent more time in emergency departments than I care to remember, I know that the computer-generated record often bears little resemblance to what was actually examined.

Few of us intend to deceive when we document our findings, but a computerized template can make it easy to do so inadvertently.

Even more troubling is the phenomenon in which templates become too narrow and disease specific. All children with earaches are not made equal.

The diagnosis may not be otitis media but school avoidance or anxiety. If the office staff has already loaded in a template specific for otitis, the practitioner may be influenced away from other diagnoses.

A template that functions too much like a cookie cutter can discourage a broader assessment of the patient as a unique individual.

[email protected]

Do you use templates? If you haven't stepped over the threshold into the costly world of electronic health records, you may not understand the question.

In the old days, a template was a pattern or gauge for accurately creating a product. A stencil is a template. In addition to ensuring accuracy, a template allows its user to replicate the original product more efficiently.

Even if you haven't begun using electronic templates but practice in a group, you probably have adopted standard forms for a variety of patient interactions—for example, ones for sick visits, which may be disease specific, or for well visits, which may be age specific. Obviously, standardization can make it easier for practicing physicians and their staffs to find information through documentation guided by templates. These forms can be bought off the shelf or developed internally by members of the group after what can be contentious negotiations between providers. Those of us who practiced by ourselves quickly became wedded to the formats we developed ourselves. When one joins a group, it can be difficult to leave our old favorite forms. And, when new editions are proposed, tugs-of-war can erupt over where to position, and how big to make, the boxes.

Some physicians prefer detailed and exhaustive checklists; others like myself prefer broad categories with plenty of elbow room to scribble and create anatomically incorrect drawings. We don't like being fenced in by a myriad of little boxes. Instead we crave the wide-open spaces to create and express our individuality.

Should a template dictate practice? Is it the purpose of the form to remind, coach, or arm twist the practitioner into asking certain questions or performing certain tests? There is certainly mounting evidence that checklists for procedures can improve outcomes. But when we are talking about an office visit encounter, one could ask, “Is the form the boss of me? Or is it merely a tool to guide my documentation so that my coworkers can find and understand what I have done?”

When templates become electronic, they can become tools for replicating documents of dubious quality. For example, when one clicks on a box that says “normal pharynx,” the computer may spit out a stored bit of dialogue that includes “uvula midline, tonsils not enlarged.” In reality the child may have a bifid uvula and his tonsils may have been surgically removed. Although these inaccuracies may be trivial, one can easily imagine others that are not so innocuous.

How many of us really carefully read the final documents generated by our clicks or wand taps? How many of us remember what the computer is going to say when we click “normal”? This kind of error by click is most obvious in emergency department records, which read like textbooks. Having spent more time in emergency departments than I care to remember, I know that the computer-generated record often bears little resemblance to what was actually examined.

Few of us intend to deceive when we document our findings, but a computerized template can make it easy to do so inadvertently.

Even more troubling is the phenomenon in which templates become too narrow and disease specific. All children with earaches are not made equal.

The diagnosis may not be otitis media but school avoidance or anxiety. If the office staff has already loaded in a template specific for otitis, the practitioner may be influenced away from other diagnoses.

A template that functions too much like a cookie cutter can discourage a broader assessment of the patient as a unique individual.

[email protected]

Do you use templates? If you haven't stepped over the threshold into the costly world of electronic health records, you may not understand the question.

In the old days, a template was a pattern or gauge for accurately creating a product. A stencil is a template. In addition to ensuring accuracy, a template allows its user to replicate the original product more efficiently.

Even if you haven't begun using electronic templates but practice in a group, you probably have adopted standard forms for a variety of patient interactions—for example, ones for sick visits, which may be disease specific, or for well visits, which may be age specific. Obviously, standardization can make it easier for practicing physicians and their staffs to find information through documentation guided by templates. These forms can be bought off the shelf or developed internally by members of the group after what can be contentious negotiations between providers. Those of us who practiced by ourselves quickly became wedded to the formats we developed ourselves. When one joins a group, it can be difficult to leave our old favorite forms. And, when new editions are proposed, tugs-of-war can erupt over where to position, and how big to make, the boxes.

Some physicians prefer detailed and exhaustive checklists; others like myself prefer broad categories with plenty of elbow room to scribble and create anatomically incorrect drawings. We don't like being fenced in by a myriad of little boxes. Instead we crave the wide-open spaces to create and express our individuality.

Should a template dictate practice? Is it the purpose of the form to remind, coach, or arm twist the practitioner into asking certain questions or performing certain tests? There is certainly mounting evidence that checklists for procedures can improve outcomes. But when we are talking about an office visit encounter, one could ask, “Is the form the boss of me? Or is it merely a tool to guide my documentation so that my coworkers can find and understand what I have done?”

When templates become electronic, they can become tools for replicating documents of dubious quality. For example, when one clicks on a box that says “normal pharynx,” the computer may spit out a stored bit of dialogue that includes “uvula midline, tonsils not enlarged.” In reality the child may have a bifid uvula and his tonsils may have been surgically removed. Although these inaccuracies may be trivial, one can easily imagine others that are not so innocuous.

How many of us really carefully read the final documents generated by our clicks or wand taps? How many of us remember what the computer is going to say when we click “normal”? This kind of error by click is most obvious in emergency department records, which read like textbooks. Having spent more time in emergency departments than I care to remember, I know that the computer-generated record often bears little resemblance to what was actually examined.

Few of us intend to deceive when we document our findings, but a computerized template can make it easy to do so inadvertently.

Even more troubling is the phenomenon in which templates become too narrow and disease specific. All children with earaches are not made equal.

The diagnosis may not be otitis media but school avoidance or anxiety. If the office staff has already loaded in a template specific for otitis, the practitioner may be influenced away from other diagnoses.

A template that functions too much like a cookie cutter can discourage a broader assessment of the patient as a unique individual.

[email protected]

“That's so borrrring!” How many times have you heard those words roll off the tongue of a teenager or preteen? For a decade or two, “boring” has been the description du jour for any activity that a young person doesn't want to or can't perform. Adolescents seem to be particularly vulnerable to this misuse of language. In part, it is the result of their position on the learning curve. But, just as often, teenagers are mirrors for adult behavior they see around them.

For example, I can recall seeing a 14-year-old boy whose office encounter sheet listed his chief complaint as “anxiety.” His mother began the visit by telling me that her son was doing poorly in school because school made him “anxious” and that he was having trouble paying attention.

I struggled for 20 minutes trying to discover what was creating this young man's anxiety. He denied fears about bullying, or using the toilet, or getting ill. He interacted easily with his peers and some teachers.

The only clue he gave me was that he became more anxious as the school day wore on and culminated in the last class of the day in which he was doing relatively well academically. Finally, I asked him the question I should have started with, “So, tell me what it feels like when you're anxious?” “Well,” he replied, “as it gets closer to the end of the day, I am just very anxious to get out of that place. It's so bad by the last period that I have trouble paying attention.”

So without pulling out my prescription pad, I was able to cure him of his anxiety disorder by pointing out that “anxious” can have a variety of meanings. I can't recall whether we eventually unearthed any learning disabilities. But I'm pretty sure we decided that he was simply suffering from garden-variety boredom, aggravated by the school system's recent conversion to 80-minute classes—a format that would have challenged my adolescent mind and still often tests my adult attention span.

As in this young man's case, boredom can be difficult to diagnose. Many parents attribute their child's misbehavior in school and poor academic performance to their belief that the school is failing to present material that is sufficiently challenging. Often the bigger problem is not boredom, but that the child's social skills aren't up to the challenge of a classroom setting.

But maybe we should not always consider boredom a challenge to be mastered. To my surprise, boredom has recently become the target of psychological and neuropsychological research. In a New York Times book review by Jennifer Schuessler entitled, “Our Boredom, Ourselves” (Jan. 24, 2010), the reviewer refers to a study in which healthy subjects were placed in a functional MRI scanner with nothing to do except lie there. The researchers discovered that the portion of the subject's brain that is believed to participate in thinking about what other people are feeling, thinking, and hypothesizing was firing actively. Their brains were consuming only slightly less energy than when they had been asked to perform basic tasks.

Parents who are allowing their children's brains to be continually bombarded by video displays are depriving them of something we all should value more—a little more time alone with our thoughts.

On the other hand, in a study of civil servants in England who reported being very bored at work, they were 2½ times more likely to die of cardiac causes, suggesting the old adage holds: You can have too much of a good thing.

[email protected]

“That's so borrrring!” How many times have you heard those words roll off the tongue of a teenager or preteen? For a decade or two, “boring” has been the description du jour for any activity that a young person doesn't want to or can't perform. Adolescents seem to be particularly vulnerable to this misuse of language. In part, it is the result of their position on the learning curve. But, just as often, teenagers are mirrors for adult behavior they see around them.

For example, I can recall seeing a 14-year-old boy whose office encounter sheet listed his chief complaint as “anxiety.” His mother began the visit by telling me that her son was doing poorly in school because school made him “anxious” and that he was having trouble paying attention.

I struggled for 20 minutes trying to discover what was creating this young man's anxiety. He denied fears about bullying, or using the toilet, or getting ill. He interacted easily with his peers and some teachers.

The only clue he gave me was that he became more anxious as the school day wore on and culminated in the last class of the day in which he was doing relatively well academically. Finally, I asked him the question I should have started with, “So, tell me what it feels like when you're anxious?” “Well,” he replied, “as it gets closer to the end of the day, I am just very anxious to get out of that place. It's so bad by the last period that I have trouble paying attention.”

So without pulling out my prescription pad, I was able to cure him of his anxiety disorder by pointing out that “anxious” can have a variety of meanings. I can't recall whether we eventually unearthed any learning disabilities. But I'm pretty sure we decided that he was simply suffering from garden-variety boredom, aggravated by the school system's recent conversion to 80-minute classes—a format that would have challenged my adolescent mind and still often tests my adult attention span.

As in this young man's case, boredom can be difficult to diagnose. Many parents attribute their child's misbehavior in school and poor academic performance to their belief that the school is failing to present material that is sufficiently challenging. Often the bigger problem is not boredom, but that the child's social skills aren't up to the challenge of a classroom setting.

But maybe we should not always consider boredom a challenge to be mastered. To my surprise, boredom has recently become the target of psychological and neuropsychological research. In a New York Times book review by Jennifer Schuessler entitled, “Our Boredom, Ourselves” (Jan. 24, 2010), the reviewer refers to a study in which healthy subjects were placed in a functional MRI scanner with nothing to do except lie there. The researchers discovered that the portion of the subject's brain that is believed to participate in thinking about what other people are feeling, thinking, and hypothesizing was firing actively. Their brains were consuming only slightly less energy than when they had been asked to perform basic tasks.

Parents who are allowing their children's brains to be continually bombarded by video displays are depriving them of something we all should value more—a little more time alone with our thoughts.

On the other hand, in a study of civil servants in England who reported being very bored at work, they were 2½ times more likely to die of cardiac causes, suggesting the old adage holds: You can have too much of a good thing.

[email protected]

“That's so borrrring!” How many times have you heard those words roll off the tongue of a teenager or preteen? For a decade or two, “boring” has been the description du jour for any activity that a young person doesn't want to or can't perform. Adolescents seem to be particularly vulnerable to this misuse of language. In part, it is the result of their position on the learning curve. But, just as often, teenagers are mirrors for adult behavior they see around them.

For example, I can recall seeing a 14-year-old boy whose office encounter sheet listed his chief complaint as “anxiety.” His mother began the visit by telling me that her son was doing poorly in school because school made him “anxious” and that he was having trouble paying attention.

I struggled for 20 minutes trying to discover what was creating this young man's anxiety. He denied fears about bullying, or using the toilet, or getting ill. He interacted easily with his peers and some teachers.

The only clue he gave me was that he became more anxious as the school day wore on and culminated in the last class of the day in which he was doing relatively well academically. Finally, I asked him the question I should have started with, “So, tell me what it feels like when you're anxious?” “Well,” he replied, “as it gets closer to the end of the day, I am just very anxious to get out of that place. It's so bad by the last period that I have trouble paying attention.”

So without pulling out my prescription pad, I was able to cure him of his anxiety disorder by pointing out that “anxious” can have a variety of meanings. I can't recall whether we eventually unearthed any learning disabilities. But I'm pretty sure we decided that he was simply suffering from garden-variety boredom, aggravated by the school system's recent conversion to 80-minute classes—a format that would have challenged my adolescent mind and still often tests my adult attention span.

As in this young man's case, boredom can be difficult to diagnose. Many parents attribute their child's misbehavior in school and poor academic performance to their belief that the school is failing to present material that is sufficiently challenging. Often the bigger problem is not boredom, but that the child's social skills aren't up to the challenge of a classroom setting.

But maybe we should not always consider boredom a challenge to be mastered. To my surprise, boredom has recently become the target of psychological and neuropsychological research. In a New York Times book review by Jennifer Schuessler entitled, “Our Boredom, Ourselves” (Jan. 24, 2010), the reviewer refers to a study in which healthy subjects were placed in a functional MRI scanner with nothing to do except lie there. The researchers discovered that the portion of the subject's brain that is believed to participate in thinking about what other people are feeling, thinking, and hypothesizing was firing actively. Their brains were consuming only slightly less energy than when they had been asked to perform basic tasks.

Parents who are allowing their children's brains to be continually bombarded by video displays are depriving them of something we all should value more—a little more time alone with our thoughts.

On the other hand, in a study of civil servants in England who reported being very bored at work, they were 2½ times more likely to die of cardiac causes, suggesting the old adage holds: You can have too much of a good thing.

[email protected]

If there is one quality that predominates among new parents, it is self-doubt. Fortunes have been made, (although not by me) in the publishing industry by tapping into the large and predictable market of confidence-deficient neo-parents. I suspect that to some extent it's always been this way. While familiarity may breed contempt, unfamiliarity has always bred trepidation.

The drive to make babies is a powerful force we are comfortable with because Mother Nature does the driving. But we often feel she has abandoned us the moment she hands us that wet, wailing, and totally dependent newborn.

While I am sure that back in the 1700's new parents worried, I suspect they suffered far less from self-doubt than new millennium parents. Several generations ago, new parents were surrounded by their families and grandparents who had been there, done that a dozen times. They grew up in large families and were familiar with what babies and children do.

Contrast this to the parents we see today. They are often geographically divorced from their own families. They come from small families, and may not have participated in raising their siblings, if they had them. They have delayed having children, and it may have been decades since they had any close contact with babies. Their only experience that is anywhere close to parenting has been raising a Labrador retriever. Although they may have been initially deluded that there will be some carryover, it takes only a few minutes to realize that parenting is a whole new ball game.

New parents are older and, to some extent, wiser. They have seen more and read more and know that the world presents much more to worry about than they imagined as teenagers. Of course, the media compounds this with horror stories about how even the most everyday events can go awry. We physicians unwittingly compound the situation with well-meaning suggestions about things like how long to breastfeed.

The bottom line is that new parents seriously need reassurance. Too few of them articulate this by asking, “Am I doing this right?” And too few of us answer the unasked question by unambiguously stating,” You're doing a great job!”

In a recent issue of AAP News (October 2009), Dr. Martin Stein and Dr. J. Lane Tanner reported on some findings from their study of 20 parent focus groups and 31 pediatric clinician focus groups. Among other things, they asked how an ideal pediatric practice would look. They observed, “Parents spoke to an issue that many doctors may be less aware of—how much they value the reassurance that the pediatrician or PNP can give, not only that their child is healthy, but also that they are doing a good job as parents.”

Sometimes we feel that saying, “That's a good weight gain” or complimenting parents on their child's cuteness is sufficient. But I've found that it's not. Parents hear those platitudes from their family and even strangers in the grocery store checkout line all the time. There is nothing more powerful than a respected child health provider saying, “I just want to tell you that you're doing a nice job!”

It's even more important when things aren't going well. Be reassuring during those first few weight checks in the office for the mother who's struggling with a marginal milk supply or who has terribly sore nipples. One doesn't have to be specific. “I know you're worried about how the breastfeeding is going, but you are doing a very good job of parenting.”

There are so few overconfident new parents that it is easy to recommend a shot of confidence at every well-child visit. I promise it won't hurt.

[email protected]

If there is one quality that predominates among new parents, it is self-doubt. Fortunes have been made, (although not by me) in the publishing industry by tapping into the large and predictable market of confidence-deficient neo-parents. I suspect that to some extent it's always been this way. While familiarity may breed contempt, unfamiliarity has always bred trepidation.

The drive to make babies is a powerful force we are comfortable with because Mother Nature does the driving. But we often feel she has abandoned us the moment she hands us that wet, wailing, and totally dependent newborn.

While I am sure that back in the 1700's new parents worried, I suspect they suffered far less from self-doubt than new millennium parents. Several generations ago, new parents were surrounded by their families and grandparents who had been there, done that a dozen times. They grew up in large families and were familiar with what babies and children do.

Contrast this to the parents we see today. They are often geographically divorced from their own families. They come from small families, and may not have participated in raising their siblings, if they had them. They have delayed having children, and it may have been decades since they had any close contact with babies. Their only experience that is anywhere close to parenting has been raising a Labrador retriever. Although they may have been initially deluded that there will be some carryover, it takes only a few minutes to realize that parenting is a whole new ball game.

New parents are older and, to some extent, wiser. They have seen more and read more and know that the world presents much more to worry about than they imagined as teenagers. Of course, the media compounds this with horror stories about how even the most everyday events can go awry. We physicians unwittingly compound the situation with well-meaning suggestions about things like how long to breastfeed.

The bottom line is that new parents seriously need reassurance. Too few of them articulate this by asking, “Am I doing this right?” And too few of us answer the unasked question by unambiguously stating,” You're doing a great job!”

In a recent issue of AAP News (October 2009), Dr. Martin Stein and Dr. J. Lane Tanner reported on some findings from their study of 20 parent focus groups and 31 pediatric clinician focus groups. Among other things, they asked how an ideal pediatric practice would look. They observed, “Parents spoke to an issue that many doctors may be less aware of—how much they value the reassurance that the pediatrician or PNP can give, not only that their child is healthy, but also that they are doing a good job as parents.”

Sometimes we feel that saying, “That's a good weight gain” or complimenting parents on their child's cuteness is sufficient. But I've found that it's not. Parents hear those platitudes from their family and even strangers in the grocery store checkout line all the time. There is nothing more powerful than a respected child health provider saying, “I just want to tell you that you're doing a nice job!”

It's even more important when things aren't going well. Be reassuring during those first few weight checks in the office for the mother who's struggling with a marginal milk supply or who has terribly sore nipples. One doesn't have to be specific. “I know you're worried about how the breastfeeding is going, but you are doing a very good job of parenting.”

There are so few overconfident new parents that it is easy to recommend a shot of confidence at every well-child visit. I promise it won't hurt.

[email protected]

If there is one quality that predominates among new parents, it is self-doubt. Fortunes have been made, (although not by me) in the publishing industry by tapping into the large and predictable market of confidence-deficient neo-parents. I suspect that to some extent it's always been this way. While familiarity may breed contempt, unfamiliarity has always bred trepidation.

The drive to make babies is a powerful force we are comfortable with because Mother Nature does the driving. But we often feel she has abandoned us the moment she hands us that wet, wailing, and totally dependent newborn.

While I am sure that back in the 1700's new parents worried, I suspect they suffered far less from self-doubt than new millennium parents. Several generations ago, new parents were surrounded by their families and grandparents who had been there, done that a dozen times. They grew up in large families and were familiar with what babies and children do.

Contrast this to the parents we see today. They are often geographically divorced from their own families. They come from small families, and may not have participated in raising their siblings, if they had them. They have delayed having children, and it may have been decades since they had any close contact with babies. Their only experience that is anywhere close to parenting has been raising a Labrador retriever. Although they may have been initially deluded that there will be some carryover, it takes only a few minutes to realize that parenting is a whole new ball game.

New parents are older and, to some extent, wiser. They have seen more and read more and know that the world presents much more to worry about than they imagined as teenagers. Of course, the media compounds this with horror stories about how even the most everyday events can go awry. We physicians unwittingly compound the situation with well-meaning suggestions about things like how long to breastfeed.

The bottom line is that new parents seriously need reassurance. Too few of them articulate this by asking, “Am I doing this right?” And too few of us answer the unasked question by unambiguously stating,” You're doing a great job!”

In a recent issue of AAP News (October 2009), Dr. Martin Stein and Dr. J. Lane Tanner reported on some findings from their study of 20 parent focus groups and 31 pediatric clinician focus groups. Among other things, they asked how an ideal pediatric practice would look. They observed, “Parents spoke to an issue that many doctors may be less aware of—how much they value the reassurance that the pediatrician or PNP can give, not only that their child is healthy, but also that they are doing a good job as parents.”

Sometimes we feel that saying, “That's a good weight gain” or complimenting parents on their child's cuteness is sufficient. But I've found that it's not. Parents hear those platitudes from their family and even strangers in the grocery store checkout line all the time. There is nothing more powerful than a respected child health provider saying, “I just want to tell you that you're doing a nice job!”

It's even more important when things aren't going well. Be reassuring during those first few weight checks in the office for the mother who's struggling with a marginal milk supply or who has terribly sore nipples. One doesn't have to be specific. “I know you're worried about how the breastfeeding is going, but you are doing a very good job of parenting.”

There are so few overconfident new parents that it is easy to recommend a shot of confidence at every well-child visit. I promise it won't hurt.

[email protected]

I snaked my way between the crowded tables of Friday evening revelers, late again. Despite continuous tweaking and re-tweaking of our schedules, we still manage to run late at least 25% of the time. If your goal is to never be too busy, you'll never be busy enough to pay the bills.

“Hey, Willis, how many lives did you save today?” The familiar voice told me I was nearing our table of regulars. I mulled over the perfunctory greeting I had received.

How many lives had I saved today? None! In fact I couldn't remember the last time I had actually saved a life. Sure, every time I give an immunization I am protecting the herd. And two or three times every year I have to jump start a newborn who had had a particularly harrowing obstetrical adventure.

But I don't consider that saving lives, certainly not like in the gold old days when Haemophilus influenzae stalked the infants and toddlers and new diabetics stayed in town instead of being shipped to the big city before the urine dipstick had dried. So who or what am I saving?

I thought back over the high points of the day I had just completed. Late in the morning I had seen a 6-year-old who had fallen on the playground and gotten a big goose egg on his forehead. Luckily his mother arrived at the school just before the ambulance did, and she had the good sense to call our office. The 15-minute visit did not include a head CT. In addition to saving him the radiation dose, I saved someone a $2,000 emergency room bill.

Just after lunch I saw a child whose left arm was hanging limply at his side. Within 2 minutes he was using it to reach eagerly for a sticker held over his head. I know that half of my partners would have ordered an x-ray before attempting a reduction, and I am sure that, had he been seen in an emergency room, he would have had the x-ray and maybe an orthopedic consult. Savings for this child were somewhere between $150 and $1,000.

At 3:15 p.m., I saw a new mother with a 2-week-old who was finally doing well at the breast and gaining weight. It had been a struggle over several visits that nearly exhausted my bag of tricks. Now the mom was confident and ready to nurse for at least 6 months. Savings to that family would be at least $600 in formula costs alone.

The last patient of the afternoon was an 18-month-old I had never seen before. His record documented several ear infections. He had a new cold and had been a bit fussy. His parents were convinced that he had another ear infection or that the last one was still bothering him. They had already been on the Internet and found an ear, nose, and throat specialist in Boston and were planning on having him insert pressure equalization tubes. The child's tympanic membranes were transparent and moved briskly on insufflation, a procedure the parents had never seen before.

Although it was late on a Friday afternoon, I decided to share with the family what I knew about the natural history of otitis media and the role of surgical management in its management. It's too early to tell, but I think I may have saved them a trip to Boston. Cost of travel, parking, and lost time at work could easily have run to $250.

So as my pint of ale arrived I did a little quick math. I had saved these four families at least $3,000. So, I guess when it comes to saving these days, at least for the primary care physician it's all about the money. For a pediatrician, though, the bulk of the rewards comes from intangibles like watching parents relax and seeing children grow into happy, productive adults.

[email protected]

I snaked my way between the crowded tables of Friday evening revelers, late again. Despite continuous tweaking and re-tweaking of our schedules, we still manage to run late at least 25% of the time. If your goal is to never be too busy, you'll never be busy enough to pay the bills.

“Hey, Willis, how many lives did you save today?” The familiar voice told me I was nearing our table of regulars. I mulled over the perfunctory greeting I had received.

How many lives had I saved today? None! In fact I couldn't remember the last time I had actually saved a life. Sure, every time I give an immunization I am protecting the herd. And two or three times every year I have to jump start a newborn who had had a particularly harrowing obstetrical adventure.

But I don't consider that saving lives, certainly not like in the gold old days when Haemophilus influenzae stalked the infants and toddlers and new diabetics stayed in town instead of being shipped to the big city before the urine dipstick had dried. So who or what am I saving?

I thought back over the high points of the day I had just completed. Late in the morning I had seen a 6-year-old who had fallen on the playground and gotten a big goose egg on his forehead. Luckily his mother arrived at the school just before the ambulance did, and she had the good sense to call our office. The 15-minute visit did not include a head CT. In addition to saving him the radiation dose, I saved someone a $2,000 emergency room bill.

Just after lunch I saw a child whose left arm was hanging limply at his side. Within 2 minutes he was using it to reach eagerly for a sticker held over his head. I know that half of my partners would have ordered an x-ray before attempting a reduction, and I am sure that, had he been seen in an emergency room, he would have had the x-ray and maybe an orthopedic consult. Savings for this child were somewhere between $150 and $1,000.

At 3:15 p.m., I saw a new mother with a 2-week-old who was finally doing well at the breast and gaining weight. It had been a struggle over several visits that nearly exhausted my bag of tricks. Now the mom was confident and ready to nurse for at least 6 months. Savings to that family would be at least $600 in formula costs alone.

The last patient of the afternoon was an 18-month-old I had never seen before. His record documented several ear infections. He had a new cold and had been a bit fussy. His parents were convinced that he had another ear infection or that the last one was still bothering him. They had already been on the Internet and found an ear, nose, and throat specialist in Boston and were planning on having him insert pressure equalization tubes. The child's tympanic membranes were transparent and moved briskly on insufflation, a procedure the parents had never seen before.

Although it was late on a Friday afternoon, I decided to share with the family what I knew about the natural history of otitis media and the role of surgical management in its management. It's too early to tell, but I think I may have saved them a trip to Boston. Cost of travel, parking, and lost time at work could easily have run to $250.

So as my pint of ale arrived I did a little quick math. I had saved these four families at least $3,000. So, I guess when it comes to saving these days, at least for the primary care physician it's all about the money. For a pediatrician, though, the bulk of the rewards comes from intangibles like watching parents relax and seeing children grow into happy, productive adults.

[email protected]

I snaked my way between the crowded tables of Friday evening revelers, late again. Despite continuous tweaking and re-tweaking of our schedules, we still manage to run late at least 25% of the time. If your goal is to never be too busy, you'll never be busy enough to pay the bills.

“Hey, Willis, how many lives did you save today?” The familiar voice told me I was nearing our table of regulars. I mulled over the perfunctory greeting I had received.

How many lives had I saved today? None! In fact I couldn't remember the last time I had actually saved a life. Sure, every time I give an immunization I am protecting the herd. And two or three times every year I have to jump start a newborn who had had a particularly harrowing obstetrical adventure.

But I don't consider that saving lives, certainly not like in the gold old days when Haemophilus influenzae stalked the infants and toddlers and new diabetics stayed in town instead of being shipped to the big city before the urine dipstick had dried. So who or what am I saving?

I thought back over the high points of the day I had just completed. Late in the morning I had seen a 6-year-old who had fallen on the playground and gotten a big goose egg on his forehead. Luckily his mother arrived at the school just before the ambulance did, and she had the good sense to call our office. The 15-minute visit did not include a head CT. In addition to saving him the radiation dose, I saved someone a $2,000 emergency room bill.

Just after lunch I saw a child whose left arm was hanging limply at his side. Within 2 minutes he was using it to reach eagerly for a sticker held over his head. I know that half of my partners would have ordered an x-ray before attempting a reduction, and I am sure that, had he been seen in an emergency room, he would have had the x-ray and maybe an orthopedic consult. Savings for this child were somewhere between $150 and $1,000.

At 3:15 p.m., I saw a new mother with a 2-week-old who was finally doing well at the breast and gaining weight. It had been a struggle over several visits that nearly exhausted my bag of tricks. Now the mom was confident and ready to nurse for at least 6 months. Savings to that family would be at least $600 in formula costs alone.

The last patient of the afternoon was an 18-month-old I had never seen before. His record documented several ear infections. He had a new cold and had been a bit fussy. His parents were convinced that he had another ear infection or that the last one was still bothering him. They had already been on the Internet and found an ear, nose, and throat specialist in Boston and were planning on having him insert pressure equalization tubes. The child's tympanic membranes were transparent and moved briskly on insufflation, a procedure the parents had never seen before.

Although it was late on a Friday afternoon, I decided to share with the family what I knew about the natural history of otitis media and the role of surgical management in its management. It's too early to tell, but I think I may have saved them a trip to Boston. Cost of travel, parking, and lost time at work could easily have run to $250.

So as my pint of ale arrived I did a little quick math. I had saved these four families at least $3,000. So, I guess when it comes to saving these days, at least for the primary care physician it's all about the money. For a pediatrician, though, the bulk of the rewards comes from intangibles like watching parents relax and seeing children grow into happy, productive adults.

[email protected]

It was getting to be a long day. Starting at 5:30 a.m. with an hour-long row on the glassy waters of Harpswell Sound meant that I would have to sacrifice my lunchtime bike ride. Without this energy booster, I was beginning to drag by 6 p.m. when the evening shift of receptionists arrived.

On paper, or more accurately on the computer screen, the patient mix for the evening didn't look too challenging. The prescheduled checkups were low-maintenance old friends. So far the acute visits were listed as “rashes.” Usually, I know what they are with one glance, but if not they will present a stimulating challenge to my powers of deductive reasoning.

But, as the evening progressed, more blue folders kept appearing in the chart rack. I was keeping ahead of the tide, but just barely. By 7:50 p.m. I was done, but it had been a frustrating couple of hours. To try and figure out why I hadn't been having as much fun as usual I did a little math.

Among the other assorted patients, I had seen four patients all over the age of 2 who had been sick for a total of 12 hours. That's not average; that's T-O-T-A-L. One patient had been ill for 4 hours, two for 3 hours each, and one for just short of 2 hours. They all had fevers of 101 or higher, but the grand total of their symptoms not including fever was three: vomiting, headache, and possible sore throat in one patient each (an 8-year-old had eventually answered yes to sore throat in an extensive parental survey); the fourth patient had only fever.

Like most pediatricians, I have seen a few deathly ill children with septicemia who by parental history have been ill for only a couple of hours. But, it's a rare occurrence. Now, I fancy myself a fairly capable diagnostician, but, give me a break. I need more than a few hours of accumulated symptoms to even take a stab at a diagnosis.

Premature visits are a fact of life for the new millennium pediatrician, and this evening's cluster got me thinking about why they are so prevalent. Certainly, a prime factor is our open access appointment policy. If you're open and coach receptionists to be receptive, the patients will come. But, why would the parent of a 4-year-old who doesn't have a chronic disease think about calling for 2 hours of fever and “looks a bit off?”

In some cases, the child has been in day care or with the “other” parent. A combination of guilt and uncertainty will often prompt a call. In other cases it is the result of educational failure. Grandma didn't do her job, and we pediatricians didn't provide sufficient anticipatory guidance. The media are more than happy to fill this void with dramatic stories about the rare and disastrous complication of common illness.

Some parents are compelled to call by their own anxiety that goes deeper than the normal parental anxiety we all have. But, whatever the cause of these premature visits, I am left gazing into my cloudy crystal ball. I must choose my words carefully. I don't want to be accused of being the doctor who “said there was nothing wrong.” I don't want to sound condescending, but I would like to prevent another premature visit.

I will suggest an algorithm that I hope guarantees that the child will be brought back when the symptoms warrant reevaluation. But, I don't want to paint so many scenarios I create more anxiety than already exists. In the end, I fall back on the pediatrician's old friend, and I promise to call the next morning to check in.

As frustrating as these premature visits are, of course, I wouldn't trade one of these parents who call too early for one who calls too late. It's those parents who keep me awake at night.

[email protected]

It was getting to be a long day. Starting at 5:30 a.m. with an hour-long row on the glassy waters of Harpswell Sound meant that I would have to sacrifice my lunchtime bike ride. Without this energy booster, I was beginning to drag by 6 p.m. when the evening shift of receptionists arrived.

On paper, or more accurately on the computer screen, the patient mix for the evening didn't look too challenging. The prescheduled checkups were low-maintenance old friends. So far the acute visits were listed as “rashes.” Usually, I know what they are with one glance, but if not they will present a stimulating challenge to my powers of deductive reasoning.

But, as the evening progressed, more blue folders kept appearing in the chart rack. I was keeping ahead of the tide, but just barely. By 7:50 p.m. I was done, but it had been a frustrating couple of hours. To try and figure out why I hadn't been having as much fun as usual I did a little math.

Among the other assorted patients, I had seen four patients all over the age of 2 who had been sick for a total of 12 hours. That's not average; that's T-O-T-A-L. One patient had been ill for 4 hours, two for 3 hours each, and one for just short of 2 hours. They all had fevers of 101 or higher, but the grand total of their symptoms not including fever was three: vomiting, headache, and possible sore throat in one patient each (an 8-year-old had eventually answered yes to sore throat in an extensive parental survey); the fourth patient had only fever.

Like most pediatricians, I have seen a few deathly ill children with septicemia who by parental history have been ill for only a couple of hours. But, it's a rare occurrence. Now, I fancy myself a fairly capable diagnostician, but, give me a break. I need more than a few hours of accumulated symptoms to even take a stab at a diagnosis.

Premature visits are a fact of life for the new millennium pediatrician, and this evening's cluster got me thinking about why they are so prevalent. Certainly, a prime factor is our open access appointment policy. If you're open and coach receptionists to be receptive, the patients will come. But, why would the parent of a 4-year-old who doesn't have a chronic disease think about calling for 2 hours of fever and “looks a bit off?”

In some cases, the child has been in day care or with the “other” parent. A combination of guilt and uncertainty will often prompt a call. In other cases it is the result of educational failure. Grandma didn't do her job, and we pediatricians didn't provide sufficient anticipatory guidance. The media are more than happy to fill this void with dramatic stories about the rare and disastrous complication of common illness.

Some parents are compelled to call by their own anxiety that goes deeper than the normal parental anxiety we all have. But, whatever the cause of these premature visits, I am left gazing into my cloudy crystal ball. I must choose my words carefully. I don't want to be accused of being the doctor who “said there was nothing wrong.” I don't want to sound condescending, but I would like to prevent another premature visit.

I will suggest an algorithm that I hope guarantees that the child will be brought back when the symptoms warrant reevaluation. But, I don't want to paint so many scenarios I create more anxiety than already exists. In the end, I fall back on the pediatrician's old friend, and I promise to call the next morning to check in.

As frustrating as these premature visits are, of course, I wouldn't trade one of these parents who call too early for one who calls too late. It's those parents who keep me awake at night.

[email protected]

It was getting to be a long day. Starting at 5:30 a.m. with an hour-long row on the glassy waters of Harpswell Sound meant that I would have to sacrifice my lunchtime bike ride. Without this energy booster, I was beginning to drag by 6 p.m. when the evening shift of receptionists arrived.

On paper, or more accurately on the computer screen, the patient mix for the evening didn't look too challenging. The prescheduled checkups were low-maintenance old friends. So far the acute visits were listed as “rashes.” Usually, I know what they are with one glance, but if not they will present a stimulating challenge to my powers of deductive reasoning.

But, as the evening progressed, more blue folders kept appearing in the chart rack. I was keeping ahead of the tide, but just barely. By 7:50 p.m. I was done, but it had been a frustrating couple of hours. To try and figure out why I hadn't been having as much fun as usual I did a little math.

Among the other assorted patients, I had seen four patients all over the age of 2 who had been sick for a total of 12 hours. That's not average; that's T-O-T-A-L. One patient had been ill for 4 hours, two for 3 hours each, and one for just short of 2 hours. They all had fevers of 101 or higher, but the grand total of their symptoms not including fever was three: vomiting, headache, and possible sore throat in one patient each (an 8-year-old had eventually answered yes to sore throat in an extensive parental survey); the fourth patient had only fever.

Like most pediatricians, I have seen a few deathly ill children with septicemia who by parental history have been ill for only a couple of hours. But, it's a rare occurrence. Now, I fancy myself a fairly capable diagnostician, but, give me a break. I need more than a few hours of accumulated symptoms to even take a stab at a diagnosis.

Premature visits are a fact of life for the new millennium pediatrician, and this evening's cluster got me thinking about why they are so prevalent. Certainly, a prime factor is our open access appointment policy. If you're open and coach receptionists to be receptive, the patients will come. But, why would the parent of a 4-year-old who doesn't have a chronic disease think about calling for 2 hours of fever and “looks a bit off?”

In some cases, the child has been in day care or with the “other” parent. A combination of guilt and uncertainty will often prompt a call. In other cases it is the result of educational failure. Grandma didn't do her job, and we pediatricians didn't provide sufficient anticipatory guidance. The media are more than happy to fill this void with dramatic stories about the rare and disastrous complication of common illness.

Some parents are compelled to call by their own anxiety that goes deeper than the normal parental anxiety we all have. But, whatever the cause of these premature visits, I am left gazing into my cloudy crystal ball. I must choose my words carefully. I don't want to be accused of being the doctor who “said there was nothing wrong.” I don't want to sound condescending, but I would like to prevent another premature visit.

I will suggest an algorithm that I hope guarantees that the child will be brought back when the symptoms warrant reevaluation. But, I don't want to paint so many scenarios I create more anxiety than already exists. In the end, I fall back on the pediatrician's old friend, and I promise to call the next morning to check in.

As frustrating as these premature visits are, of course, I wouldn't trade one of these parents who call too early for one who calls too late. It's those parents who keep me awake at night.

[email protected]

One of my plans for this year is to read more widely and think more deeply. As part of that plan I read a column by New York Times columnist David Brooks. In it he refers to “On Thinking Institutionally (On Politics)” (Boulder, Colo.: Paradigm, 2008)—a book by political scientist Hugh Heclo.

According to Mr. Heclo, we are all shaped by the institutions through which we navigate our lives. In this broad sense institutions include our family, the schools we attend, and eventually our profession.

The extent to which we internalize the rules and traditions of those institutions defines us as either an institutionalist or an individualist.

Those of us who revere the ones who preceded us and accumulated the rules that support the institution are thinking institutionally. According to Mr. Heclo, institutionalists “see themselves as debtors who owe something, not creditors to whom something is owed.”

You don't have to look very far to see that currently our society is tilting toward individualism. Chest-thumping end zone performances by egocentric professional football players and former senators who don't think paying taxes is important are all part of a phenomenon that has spilled over from the Me generation.

But, there remain a few high-profile figures who still revere the institutions in which they have thrived.

Mr. Brooks and Mr. Heclo quote Ryne Sandberg on the occasion of his induction into the Baseball Hall of Fame: “I didn't play the game right because I saw a reward at the end of the tunnel. I played it right because that's what you're supposed to do, play it right and with respect.…

“If this validates anything, it's that guys who taught me the game … did what they were supposed to do.”

Now it's time to start thinking more deeply. Do you see yourself more as an individualist or an institutionalist? What about your fellow physicians? Do they treat the practice of medicine with reverence? You may want to ask yourself, “What are the institutional values that define medicine?” Is it the Hippocratic oath? And, who were your physician models?

Ironically, it was probably the 10 years I was in solo practice that injected me with a reverence for the institution of pediatrics. Parents had other choices. They could have trusted the health, and on rare occasions, the lives of their children to someone else. But because I had adopted a set of skills and attitudes from the instructors in my training programs and through the mentorship of my former partner, and because I conformed to what parents viewed as the principles of the institution of pediatrics, they chose me.

Among my role models were two older surgeons. These gentlemen dressed in a manner that respected the sensibilities of their patients.

They introduced themselves with a handshake. They were instantly available when they were on call and never sounded as though my call for help was an imposition. There was never a hint that profit was a motive in their decisions to operate. They were classy and professional physicians who revered their profession.

Fortunately, there is room for creative thinking and action in most institutions. Great institutions like pediatrics not only tolerate but encourage their members to think outside the institutional box. And, luckily we have chosen a profession that still deserves our reverence. I hope you agree that we owe pediatrics far more than it owes us.

[email protected]

One of my plans for this year is to read more widely and think more deeply. As part of that plan I read a column by New York Times columnist David Brooks. In it he refers to “On Thinking Institutionally (On Politics)” (Boulder, Colo.: Paradigm, 2008)—a book by political scientist Hugh Heclo.

According to Mr. Heclo, we are all shaped by the institutions through which we navigate our lives. In this broad sense institutions include our family, the schools we attend, and eventually our profession.

The extent to which we internalize the rules and traditions of those institutions defines us as either an institutionalist or an individualist.

Those of us who revere the ones who preceded us and accumulated the rules that support the institution are thinking institutionally. According to Mr. Heclo, institutionalists “see themselves as debtors who owe something, not creditors to whom something is owed.”

You don't have to look very far to see that currently our society is tilting toward individualism. Chest-thumping end zone performances by egocentric professional football players and former senators who don't think paying taxes is important are all part of a phenomenon that has spilled over from the Me generation.

But, there remain a few high-profile figures who still revere the institutions in which they have thrived.

Mr. Brooks and Mr. Heclo quote Ryne Sandberg on the occasion of his induction into the Baseball Hall of Fame: “I didn't play the game right because I saw a reward at the end of the tunnel. I played it right because that's what you're supposed to do, play it right and with respect.…

“If this validates anything, it's that guys who taught me the game … did what they were supposed to do.”

Now it's time to start thinking more deeply. Do you see yourself more as an individualist or an institutionalist? What about your fellow physicians? Do they treat the practice of medicine with reverence? You may want to ask yourself, “What are the institutional values that define medicine?” Is it the Hippocratic oath? And, who were your physician models?

Ironically, it was probably the 10 years I was in solo practice that injected me with a reverence for the institution of pediatrics. Parents had other choices. They could have trusted the health, and on rare occasions, the lives of their children to someone else. But because I had adopted a set of skills and attitudes from the instructors in my training programs and through the mentorship of my former partner, and because I conformed to what parents viewed as the principles of the institution of pediatrics, they chose me.

Among my role models were two older surgeons. These gentlemen dressed in a manner that respected the sensibilities of their patients.

They introduced themselves with a handshake. They were instantly available when they were on call and never sounded as though my call for help was an imposition. There was never a hint that profit was a motive in their decisions to operate. They were classy and professional physicians who revered their profession.

Fortunately, there is room for creative thinking and action in most institutions. Great institutions like pediatrics not only tolerate but encourage their members to think outside the institutional box. And, luckily we have chosen a profession that still deserves our reverence. I hope you agree that we owe pediatrics far more than it owes us.

[email protected]

One of my plans for this year is to read more widely and think more deeply. As part of that plan I read a column by New York Times columnist David Brooks. In it he refers to “On Thinking Institutionally (On Politics)” (Boulder, Colo.: Paradigm, 2008)—a book by political scientist Hugh Heclo.

According to Mr. Heclo, we are all shaped by the institutions through which we navigate our lives. In this broad sense institutions include our family, the schools we attend, and eventually our profession.

The extent to which we internalize the rules and traditions of those institutions defines us as either an institutionalist or an individualist.

Those of us who revere the ones who preceded us and accumulated the rules that support the institution are thinking institutionally. According to Mr. Heclo, institutionalists “see themselves as debtors who owe something, not creditors to whom something is owed.”

You don't have to look very far to see that currently our society is tilting toward individualism. Chest-thumping end zone performances by egocentric professional football players and former senators who don't think paying taxes is important are all part of a phenomenon that has spilled over from the Me generation.

But, there remain a few high-profile figures who still revere the institutions in which they have thrived.

Mr. Brooks and Mr. Heclo quote Ryne Sandberg on the occasion of his induction into the Baseball Hall of Fame: “I didn't play the game right because I saw a reward at the end of the tunnel. I played it right because that's what you're supposed to do, play it right and with respect.…

“If this validates anything, it's that guys who taught me the game … did what they were supposed to do.”

Now it's time to start thinking more deeply. Do you see yourself more as an individualist or an institutionalist? What about your fellow physicians? Do they treat the practice of medicine with reverence? You may want to ask yourself, “What are the institutional values that define medicine?” Is it the Hippocratic oath? And, who were your physician models?

Ironically, it was probably the 10 years I was in solo practice that injected me with a reverence for the institution of pediatrics. Parents had other choices. They could have trusted the health, and on rare occasions, the lives of their children to someone else. But because I had adopted a set of skills and attitudes from the instructors in my training programs and through the mentorship of my former partner, and because I conformed to what parents viewed as the principles of the institution of pediatrics, they chose me.

Among my role models were two older surgeons. These gentlemen dressed in a manner that respected the sensibilities of their patients.

They introduced themselves with a handshake. They were instantly available when they were on call and never sounded as though my call for help was an imposition. There was never a hint that profit was a motive in their decisions to operate. They were classy and professional physicians who revered their profession.

Fortunately, there is room for creative thinking and action in most institutions. Great institutions like pediatrics not only tolerate but encourage their members to think outside the institutional box. And, luckily we have chosen a profession that still deserves our reverence. I hope you agree that we owe pediatrics far more than it owes us.