Letters from Maine

[email protected]

My lifestyle and preferences don't include much television viewing anymore. Certainly for the last 8 years I have completely avoided watching any presidential addresses because I found them very uncomfortable and embarrassing. But this week I found myself watching a rebroadcast of President Obama's address to the American Medical Association.

I like him, and like most Americans, I want him to do well. His speech touched all the bases in the health care ball game, and he was refreshingly frank in sharing his opinions. I wasn't embarrassed that I had voted for him, but some of the things he said made me a little uncomfortable.

I have already shared with you my concerns that electronification of health records is going to be a costly nightmare whose payback won't come until long after President Obama has left office—I'm counting on two terms. The basic premise is worthy, but the systems just aren't out there to do the job. When 40% of physicians are functioning as beta testers, it's going to get ugly.

A second, more subtle discomfort crept out of one of the president's statements that at first blush seems to be unarguable. He promises a system that allows you to be physicians “instead of administrators and accountants.” He adds: “You didn't enter this profession to be bean counters and paper pushers. You entered this profession to be healers.”

First, any physician who views himself primarily as a healer is suffering from severe ego inflation. But I'll forgive that as a slip of the tongue. However, some—including many physicians—could interpret Mr. Obama's first statement to mean that physicians will no longer need to concern themselves with the cost of the care we provide.

If you haven't read Atul Gawande's most recent article in the New Yorker (“The Cost Conundrum,” June 1, 2009), after you finish this column set down PEDIATRIC NEWS and immediately access the article on the Internet. Dr. Gawande explores why the cost of medical care in McAllen, Tex., is twice the national average and twice that in El Paso County, a similar geodemographic area. The quality of care in each area is similar.

What he discovers is that in McAllen, the culture of the medical community has shifted toward the entrepreneurial, health-care-for-profit end of the spectrum. Dr. Gawande observes correctly that physicians learn next to nothing about finance in medical school and that many physicians remain “oblivious to the financial implications of their decisions.” But in McAllen, a high percentage of physicians seems to have learned so much about making money in medicine that they have lost the focus on quality.

Good-quality health care doesn't necessarily cost more. In fact, the more I read and observe, the more I find that many expensive tests and interventions are proving to be worthless, and could and should be eliminated.

As appealing as President Obama's promise of financial obliviousness may sound, we don't want to lose sight of the costly ripples and tsunamis of our decisions and interventions. Those of us in solo practice and small groups must understand the concept of overhead to survive. But, even if you are buffered by layers of administration in a large corporation, you have an obligation to know what your patients are paying and why.

As Dr. Gawande observes, “The lesson of high-quality, low-cost care is that someone [I would add all physicians] has to be accountable for the totality of care.”

And that includes its cost.

[email protected]

My lifestyle and preferences don't include much television viewing anymore. Certainly for the last 8 years I have completely avoided watching any presidential addresses because I found them very uncomfortable and embarrassing. But this week I found myself watching a rebroadcast of President Obama's address to the American Medical Association.

I like him, and like most Americans, I want him to do well. His speech touched all the bases in the health care ball game, and he was refreshingly frank in sharing his opinions. I wasn't embarrassed that I had voted for him, but some of the things he said made me a little uncomfortable.

I have already shared with you my concerns that electronification of health records is going to be a costly nightmare whose payback won't come until long after President Obama has left office—I'm counting on two terms. The basic premise is worthy, but the systems just aren't out there to do the job. When 40% of physicians are functioning as beta testers, it's going to get ugly.

A second, more subtle discomfort crept out of one of the president's statements that at first blush seems to be unarguable. He promises a system that allows you to be physicians “instead of administrators and accountants.” He adds: “You didn't enter this profession to be bean counters and paper pushers. You entered this profession to be healers.”

First, any physician who views himself primarily as a healer is suffering from severe ego inflation. But I'll forgive that as a slip of the tongue. However, some—including many physicians—could interpret Mr. Obama's first statement to mean that physicians will no longer need to concern themselves with the cost of the care we provide.

If you haven't read Atul Gawande's most recent article in the New Yorker (“The Cost Conundrum,” June 1, 2009), after you finish this column set down PEDIATRIC NEWS and immediately access the article on the Internet. Dr. Gawande explores why the cost of medical care in McAllen, Tex., is twice the national average and twice that in El Paso County, a similar geodemographic area. The quality of care in each area is similar.

What he discovers is that in McAllen, the culture of the medical community has shifted toward the entrepreneurial, health-care-for-profit end of the spectrum. Dr. Gawande observes correctly that physicians learn next to nothing about finance in medical school and that many physicians remain “oblivious to the financial implications of their decisions.” But in McAllen, a high percentage of physicians seems to have learned so much about making money in medicine that they have lost the focus on quality.

Good-quality health care doesn't necessarily cost more. In fact, the more I read and observe, the more I find that many expensive tests and interventions are proving to be worthless, and could and should be eliminated.

As appealing as President Obama's promise of financial obliviousness may sound, we don't want to lose sight of the costly ripples and tsunamis of our decisions and interventions. Those of us in solo practice and small groups must understand the concept of overhead to survive. But, even if you are buffered by layers of administration in a large corporation, you have an obligation to know what your patients are paying and why.

As Dr. Gawande observes, “The lesson of high-quality, low-cost care is that someone [I would add all physicians] has to be accountable for the totality of care.”

And that includes its cost.

[email protected]

My lifestyle and preferences don't include much television viewing anymore. Certainly for the last 8 years I have completely avoided watching any presidential addresses because I found them very uncomfortable and embarrassing. But this week I found myself watching a rebroadcast of President Obama's address to the American Medical Association.

I like him, and like most Americans, I want him to do well. His speech touched all the bases in the health care ball game, and he was refreshingly frank in sharing his opinions. I wasn't embarrassed that I had voted for him, but some of the things he said made me a little uncomfortable.

I have already shared with you my concerns that electronification of health records is going to be a costly nightmare whose payback won't come until long after President Obama has left office—I'm counting on two terms. The basic premise is worthy, but the systems just aren't out there to do the job. When 40% of physicians are functioning as beta testers, it's going to get ugly.

A second, more subtle discomfort crept out of one of the president's statements that at first blush seems to be unarguable. He promises a system that allows you to be physicians “instead of administrators and accountants.” He adds: “You didn't enter this profession to be bean counters and paper pushers. You entered this profession to be healers.”

First, any physician who views himself primarily as a healer is suffering from severe ego inflation. But I'll forgive that as a slip of the tongue. However, some—including many physicians—could interpret Mr. Obama's first statement to mean that physicians will no longer need to concern themselves with the cost of the care we provide.

If you haven't read Atul Gawande's most recent article in the New Yorker (“The Cost Conundrum,” June 1, 2009), after you finish this column set down PEDIATRIC NEWS and immediately access the article on the Internet. Dr. Gawande explores why the cost of medical care in McAllen, Tex., is twice the national average and twice that in El Paso County, a similar geodemographic area. The quality of care in each area is similar.

What he discovers is that in McAllen, the culture of the medical community has shifted toward the entrepreneurial, health-care-for-profit end of the spectrum. Dr. Gawande observes correctly that physicians learn next to nothing about finance in medical school and that many physicians remain “oblivious to the financial implications of their decisions.” But in McAllen, a high percentage of physicians seems to have learned so much about making money in medicine that they have lost the focus on quality.

Good-quality health care doesn't necessarily cost more. In fact, the more I read and observe, the more I find that many expensive tests and interventions are proving to be worthless, and could and should be eliminated.

As appealing as President Obama's promise of financial obliviousness may sound, we don't want to lose sight of the costly ripples and tsunamis of our decisions and interventions. Those of us in solo practice and small groups must understand the concept of overhead to survive. But, even if you are buffered by layers of administration in a large corporation, you have an obligation to know what your patients are paying and why.

As Dr. Gawande observes, “The lesson of high-quality, low-cost care is that someone [I would add all physicians] has to be accountable for the totality of care.”

And that includes its cost.

[email protected]

Even if you are just a casual fan of professional football, you may have noticed this past season, on the back of every player's helmet, the letters “GU” and the number “63” in a dark circle. This commemorated Gene Upshaw, the long-time president of the National Football League Players Association, who died in August. Upshaw, a former NFL player himself, was a man of imposing stature and appearance. His efforts as an advocate for the players were so effective that it is not surprising that he was remembered with an unprecedented gesture.

During one of the numerous and annoying commercial breaks during the Super Bowl, I was on my way to the refrigerator when I had an epiphany of sorts: “Pediatrics needs a Gene Upshaw.”

Whenever sports fans saw Gene Upshaw on TV or in the newspaper, they knew he was there to represent the interests of professional football players. Whether the issue was salaries, drug testing, or safe playing conditions, he was their advocate and a darn good one. He was not just the voice but the face of professional football players.

Pediatricians' numbers are far greater and our mission is far more worthy, but we don't have a face—at least one that is recognizable on the national stage. From the standpoint of image, we are really a grassroots organization. We are the faces of pediatrics in our own communities. We usually live in the towns that we serve, and when we show up at meetings or on local TV, everyone knows that we are representing the interests of children.

The American Academy of Pediatrics can and will help us become more effective spokespersons by providing training sessions and coaching. From time to time, the AAP taps some of us to appear in the national media, but these are cameo appearances. We may recognize some of our brothers and sisters when we see them on the “Today Show,” but they will fade back into the obscurity of their day jobs and not become household words.

Our governance structure doesn't foster a lasting image. Our academy presidents serve a year of apprenticeship and then a year on the job before they exit the national stage. We do have a Washington office that works extremely hard to keep pediatric issues on the front burners of many legislators and federal administrators, but I suspect that our lobbying could be much more effective if pediatrics had a national face like Gene Upshaw's.

When Jesse Jackson appears at an event, he doesn't even have to say a word. I know he doesn't speak for all African Americans, but when I see his face I ask myself, “How is this situation going to affect people of color?” Wouldn't it be great if we could have a person whose appearance would say, “Think of the children!”

Where can we find someone like that? Does anyone like that even exist? Benjamin Spock certainly became a household word. T. Berry Brazelton's books and personal appearances have made him a trusted voice, but I think even he would admit that his age is a disadvantage. There are other prominent pediatricians, but most have special interests and may not be willing to moderate their positions so that they could speak for almost all of us.

Does our face have to belong to a pediatrician? Bob Keeshan—who was TV's Captain Kangaroo—would have been an excellent candidate, but sadly he is gone. Other celebrities have stepped forward to advocate for specific changes, but they all have their own careers and agendas.

So, I am at a bit of a loss. But we have serious national issues that need our voice and a recognizable face to go with it. Should the president of the AAP serve a longer term? Should we hire a PR firm to do a search for us? Until we find someone, each of us will have to be the Gene Upshaw in our own hometown.

[email protected]

Even if you are just a casual fan of professional football, you may have noticed this past season, on the back of every player's helmet, the letters “GU” and the number “63” in a dark circle. This commemorated Gene Upshaw, the long-time president of the National Football League Players Association, who died in August. Upshaw, a former NFL player himself, was a man of imposing stature and appearance. His efforts as an advocate for the players were so effective that it is not surprising that he was remembered with an unprecedented gesture.

During one of the numerous and annoying commercial breaks during the Super Bowl, I was on my way to the refrigerator when I had an epiphany of sorts: “Pediatrics needs a Gene Upshaw.”

Whenever sports fans saw Gene Upshaw on TV or in the newspaper, they knew he was there to represent the interests of professional football players. Whether the issue was salaries, drug testing, or safe playing conditions, he was their advocate and a darn good one. He was not just the voice but the face of professional football players.

Pediatricians' numbers are far greater and our mission is far more worthy, but we don't have a face—at least one that is recognizable on the national stage. From the standpoint of image, we are really a grassroots organization. We are the faces of pediatrics in our own communities. We usually live in the towns that we serve, and when we show up at meetings or on local TV, everyone knows that we are representing the interests of children.

The American Academy of Pediatrics can and will help us become more effective spokespersons by providing training sessions and coaching. From time to time, the AAP taps some of us to appear in the national media, but these are cameo appearances. We may recognize some of our brothers and sisters when we see them on the “Today Show,” but they will fade back into the obscurity of their day jobs and not become household words.

Our governance structure doesn't foster a lasting image. Our academy presidents serve a year of apprenticeship and then a year on the job before they exit the national stage. We do have a Washington office that works extremely hard to keep pediatric issues on the front burners of many legislators and federal administrators, but I suspect that our lobbying could be much more effective if pediatrics had a national face like Gene Upshaw's.

When Jesse Jackson appears at an event, he doesn't even have to say a word. I know he doesn't speak for all African Americans, but when I see his face I ask myself, “How is this situation going to affect people of color?” Wouldn't it be great if we could have a person whose appearance would say, “Think of the children!”

Where can we find someone like that? Does anyone like that even exist? Benjamin Spock certainly became a household word. T. Berry Brazelton's books and personal appearances have made him a trusted voice, but I think even he would admit that his age is a disadvantage. There are other prominent pediatricians, but most have special interests and may not be willing to moderate their positions so that they could speak for almost all of us.

Does our face have to belong to a pediatrician? Bob Keeshan—who was TV's Captain Kangaroo—would have been an excellent candidate, but sadly he is gone. Other celebrities have stepped forward to advocate for specific changes, but they all have their own careers and agendas.

So, I am at a bit of a loss. But we have serious national issues that need our voice and a recognizable face to go with it. Should the president of the AAP serve a longer term? Should we hire a PR firm to do a search for us? Until we find someone, each of us will have to be the Gene Upshaw in our own hometown.

[email protected]

Even if you are just a casual fan of professional football, you may have noticed this past season, on the back of every player's helmet, the letters “GU” and the number “63” in a dark circle. This commemorated Gene Upshaw, the long-time president of the National Football League Players Association, who died in August. Upshaw, a former NFL player himself, was a man of imposing stature and appearance. His efforts as an advocate for the players were so effective that it is not surprising that he was remembered with an unprecedented gesture.

During one of the numerous and annoying commercial breaks during the Super Bowl, I was on my way to the refrigerator when I had an epiphany of sorts: “Pediatrics needs a Gene Upshaw.”

Whenever sports fans saw Gene Upshaw on TV or in the newspaper, they knew he was there to represent the interests of professional football players. Whether the issue was salaries, drug testing, or safe playing conditions, he was their advocate and a darn good one. He was not just the voice but the face of professional football players.

Pediatricians' numbers are far greater and our mission is far more worthy, but we don't have a face—at least one that is recognizable on the national stage. From the standpoint of image, we are really a grassroots organization. We are the faces of pediatrics in our own communities. We usually live in the towns that we serve, and when we show up at meetings or on local TV, everyone knows that we are representing the interests of children.

The American Academy of Pediatrics can and will help us become more effective spokespersons by providing training sessions and coaching. From time to time, the AAP taps some of us to appear in the national media, but these are cameo appearances. We may recognize some of our brothers and sisters when we see them on the “Today Show,” but they will fade back into the obscurity of their day jobs and not become household words.

Our governance structure doesn't foster a lasting image. Our academy presidents serve a year of apprenticeship and then a year on the job before they exit the national stage. We do have a Washington office that works extremely hard to keep pediatric issues on the front burners of many legislators and federal administrators, but I suspect that our lobbying could be much more effective if pediatrics had a national face like Gene Upshaw's.

When Jesse Jackson appears at an event, he doesn't even have to say a word. I know he doesn't speak for all African Americans, but when I see his face I ask myself, “How is this situation going to affect people of color?” Wouldn't it be great if we could have a person whose appearance would say, “Think of the children!”

Where can we find someone like that? Does anyone like that even exist? Benjamin Spock certainly became a household word. T. Berry Brazelton's books and personal appearances have made him a trusted voice, but I think even he would admit that his age is a disadvantage. There are other prominent pediatricians, but most have special interests and may not be willing to moderate their positions so that they could speak for almost all of us.

Does our face have to belong to a pediatrician? Bob Keeshan—who was TV's Captain Kangaroo—would have been an excellent candidate, but sadly he is gone. Other celebrities have stepped forward to advocate for specific changes, but they all have their own careers and agendas.

So, I am at a bit of a loss. But we have serious national issues that need our voice and a recognizable face to go with it. Should the president of the AAP serve a longer term? Should we hire a PR firm to do a search for us? Until we find someone, each of us will have to be the Gene Upshaw in our own hometown.

[email protected]

The bad news is that the global economy has gone in the toilet. The good news is that most economists agree on something. They suggest that to winch ourselves out of this abyss, we (or our government) must do some serious spending. As a lifelong fiscal conservative, this notion makes me nervous.

However, a New York Times column by recent Nobel Prize recipient Paul Krugman helped me to realize that in a depression economy, we must operate by a different set of rules. Mr. Krugman feels that appropriately targeted spending in huge chunks is the best and only answer. If the economy overheats to the point of inflation, he says that we will have plenty of room to cool things down by increasing interest rates.

So … I'm ready to chime in with my own suggestions about how we should spend all that money we are going to print. It's hard to argue with the value of repairing and improving our roads, bridges, airports, etc. Maybe those of us who prefer to commute by bicycle will get a few more lanes of our own as part of this rehab of our infrastructure.

A comprehensive and totally federally funded immunization program also would be a nice addition. However, I suggest that we invest some of our stimulus package in something less tangible than bridges and vaccines—a plan that will stimulate our children to become more physically active.

The origins of our national epidemic of obesity are many and, in some cases, poorly defined, but it is clear that a sedentary lifestyle is a contributor. Although there are too few valid studies to draw a solid conclusion, intuition tells me that programs including increased physical activity must be beneficial. While I would like to see us take the simple and direct approach and blow up half the televisions in the United States, somehow I don't think Congress will buy it.

Although my friends who are educators have become increasingly frustrated as our public schools have become dumpsters for our society's ills, I am afraid it's time to toss our epidemic of physical inactivity on the pile.

A few primary school educators that I know have cleverly integrated physical activity into their curricula. However, I think the severity of the problem demands the more drastic step of adding an hour to the school day for every kindergarten-through-fifth-grade student in America. Obviously, this is a change with a big price tag. So this is where the stimulus bundle comes in. In the plan, each school that added an hour to the school day would receive a sizeable chunk of change to fund the cost of staff and building maintenance. The only stipulation would be that during that hour the students must be kept physically active.

Each school could use the money as its needs dictate. Upgrade playgrounds, modify classrooms to be activity friendly, pay stipends for teachers who wanted to work more hours—or even better, pay underemployed community members to be supervisors. Each school would be supplied with voluminous educational materials to stimulate creative solutions to fill that hour. For some schools, it may simply mean adding another and longer recess that promotes free play. For others, it could be adding nontraditional school activities such as dance and martial arts.

Presumably, the biggest health payoff for our investment would be a few decades away. For a quicker feedback, one could measure BMIs anonymously and compare them before and after initiating the program. Regardless of how much it bumps up our GDP, one less hour of inactivity will be good for our children.

[email protected]

The bad news is that the global economy has gone in the toilet. The good news is that most economists agree on something. They suggest that to winch ourselves out of this abyss, we (or our government) must do some serious spending. As a lifelong fiscal conservative, this notion makes me nervous.

However, a New York Times column by recent Nobel Prize recipient Paul Krugman helped me to realize that in a depression economy, we must operate by a different set of rules. Mr. Krugman feels that appropriately targeted spending in huge chunks is the best and only answer. If the economy overheats to the point of inflation, he says that we will have plenty of room to cool things down by increasing interest rates.

So … I'm ready to chime in with my own suggestions about how we should spend all that money we are going to print. It's hard to argue with the value of repairing and improving our roads, bridges, airports, etc. Maybe those of us who prefer to commute by bicycle will get a few more lanes of our own as part of this rehab of our infrastructure.

A comprehensive and totally federally funded immunization program also would be a nice addition. However, I suggest that we invest some of our stimulus package in something less tangible than bridges and vaccines—a plan that will stimulate our children to become more physically active.

The origins of our national epidemic of obesity are many and, in some cases, poorly defined, but it is clear that a sedentary lifestyle is a contributor. Although there are too few valid studies to draw a solid conclusion, intuition tells me that programs including increased physical activity must be beneficial. While I would like to see us take the simple and direct approach and blow up half the televisions in the United States, somehow I don't think Congress will buy it.

Although my friends who are educators have become increasingly frustrated as our public schools have become dumpsters for our society's ills, I am afraid it's time to toss our epidemic of physical inactivity on the pile.

A few primary school educators that I know have cleverly integrated physical activity into their curricula. However, I think the severity of the problem demands the more drastic step of adding an hour to the school day for every kindergarten-through-fifth-grade student in America. Obviously, this is a change with a big price tag. So this is where the stimulus bundle comes in. In the plan, each school that added an hour to the school day would receive a sizeable chunk of change to fund the cost of staff and building maintenance. The only stipulation would be that during that hour the students must be kept physically active.

Each school could use the money as its needs dictate. Upgrade playgrounds, modify classrooms to be activity friendly, pay stipends for teachers who wanted to work more hours—or even better, pay underemployed community members to be supervisors. Each school would be supplied with voluminous educational materials to stimulate creative solutions to fill that hour. For some schools, it may simply mean adding another and longer recess that promotes free play. For others, it could be adding nontraditional school activities such as dance and martial arts.

Presumably, the biggest health payoff for our investment would be a few decades away. For a quicker feedback, one could measure BMIs anonymously and compare them before and after initiating the program. Regardless of how much it bumps up our GDP, one less hour of inactivity will be good for our children.

[email protected]

The bad news is that the global economy has gone in the toilet. The good news is that most economists agree on something. They suggest that to winch ourselves out of this abyss, we (or our government) must do some serious spending. As a lifelong fiscal conservative, this notion makes me nervous.

However, a New York Times column by recent Nobel Prize recipient Paul Krugman helped me to realize that in a depression economy, we must operate by a different set of rules. Mr. Krugman feels that appropriately targeted spending in huge chunks is the best and only answer. If the economy overheats to the point of inflation, he says that we will have plenty of room to cool things down by increasing interest rates.

So … I'm ready to chime in with my own suggestions about how we should spend all that money we are going to print. It's hard to argue with the value of repairing and improving our roads, bridges, airports, etc. Maybe those of us who prefer to commute by bicycle will get a few more lanes of our own as part of this rehab of our infrastructure.

A comprehensive and totally federally funded immunization program also would be a nice addition. However, I suggest that we invest some of our stimulus package in something less tangible than bridges and vaccines—a plan that will stimulate our children to become more physically active.

The origins of our national epidemic of obesity are many and, in some cases, poorly defined, but it is clear that a sedentary lifestyle is a contributor. Although there are too few valid studies to draw a solid conclusion, intuition tells me that programs including increased physical activity must be beneficial. While I would like to see us take the simple and direct approach and blow up half the televisions in the United States, somehow I don't think Congress will buy it.

Although my friends who are educators have become increasingly frustrated as our public schools have become dumpsters for our society's ills, I am afraid it's time to toss our epidemic of physical inactivity on the pile.

A few primary school educators that I know have cleverly integrated physical activity into their curricula. However, I think the severity of the problem demands the more drastic step of adding an hour to the school day for every kindergarten-through-fifth-grade student in America. Obviously, this is a change with a big price tag. So this is where the stimulus bundle comes in. In the plan, each school that added an hour to the school day would receive a sizeable chunk of change to fund the cost of staff and building maintenance. The only stipulation would be that during that hour the students must be kept physically active.

Each school could use the money as its needs dictate. Upgrade playgrounds, modify classrooms to be activity friendly, pay stipends for teachers who wanted to work more hours—or even better, pay underemployed community members to be supervisors. Each school would be supplied with voluminous educational materials to stimulate creative solutions to fill that hour. For some schools, it may simply mean adding another and longer recess that promotes free play. For others, it could be adding nontraditional school activities such as dance and martial arts.

Presumably, the biggest health payoff for our investment would be a few decades away. For a quicker feedback, one could measure BMIs anonymously and compare them before and after initiating the program. Regardless of how much it bumps up our GDP, one less hour of inactivity will be good for our children.

[email protected]

If you have given more than a thousand intramuscular injections, you have probably hit bone at least once or twice. This is not the “Eureka!” kind of discovery that one gets from striking oil or seeing that crimson flashback from a successful and intentional arterial puncture. Pricking the periosteum is more of a fingernails-on-the-blackboard moment. Even if somehow you managed to ignore the bone-chilling vibrations that traveled up the syringe, the patient's response told you that going too deep is a bad thing.

In 2007, the Centers for Disease Control and Prevention released a set of guidelines that include a recommendation for longer needles when giving intramuscular injections (Epidemiology and Prevention of Immunization Practices: The Pink Book, 10th ed., Feb. 2007), up to 1 inch for the deltoid and 11/4 inch for the thigh. Their concern was that a failure to penetrate well into the muscle would result in suboptimal vaccine absorption.

At a lunchtime staff meeting that I somehow neglected to attend (it must have been a warm sunny day—or maybe just not raining) we decided that we should comply with the CDC's guidelines and we ordered a couple of boxes of longer needles. Trying to be a good soldier and a team player, I agreed to give these big boys a try. It was an ugly week.

One of my secrets for giving minimally painful injections is to prevent the patient and/or parent from seeing the business end of the syringe. However, even with my best sleight-of-hand techniques, I was having trouble hiding the longer needles. Whenever the patient caught a glimpse of these ice picks, the anxiety level in the room escalated and it was downhill from there.

With longer needles, I was uncomfortably out of control. Wielding an extra few millimeters of steel, I felt like a jousting knight of the Round Table galloping down the runway, my 10-foot lance wobbling in the wind, never quite sure if I was going to hit my intended target. When I did strike pay dirt, watching a 1-inch needle flexing back and forth in the thigh of a squirming toddler was more than I could take. I wasn't going to wait until I had performed an unintended bone marrow biopsy, and we halted the experiment.

It wasn't the first time I had ignored the CDC's recommendation, but I admit that I have harbored a few second thoughts. However, recently I have been rescued from my insecurity by William C. Lippert and Dr. Eric J. Wall, whose article, “Optimal Intramuscular Needle-Penetration Depth,” reassured me that I can stick with my shorter needles (Pediatrics 2008;122:e556–63). Using CT and MRI scans, they have determined that if one followed the CDC guidelines one would overpenetrate the thigh of 11% of the patients using a 1-inch needle and 39% of the patients if a 11/4-incher were used. For the deltoid, the numbers were more troubling. Overpenetration would occur 11% of the time with a 5/8-inch needle, 55% for a 7/8-inch, and a walloping 63% of the time with a 1-inch needle. Ouch!

The authors, neither of whom is a pediatrician, recommend shorter needles for thigh injections and offer weight- and gender-based guidelines to aid in selection of the correct length. In their opinion, the current CDC guidelines for deltoid injections were still appropriate. However, the CDC's Advisory Committee on Immunization Practices has decided to ignore this new creatively obtained evidence. (See story, page 8—Ed.) And so, I will continue to ignore the committees and inject to the beat of my own drummer. I will temper the new evidence with my own experience. In the discussion portion of the paper, Mr. Lippert and Dr. Wall buried a pearl that supports my rogue practice. They said that in light of the great variability in extremity dimensions, “clinical judgment be used and an assortment of different lengths be available.”

Three cheers for a combination of common sense and carefully done science.

[email protected]

If you have given more than a thousand intramuscular injections, you have probably hit bone at least once or twice. This is not the “Eureka!” kind of discovery that one gets from striking oil or seeing that crimson flashback from a successful and intentional arterial puncture. Pricking the periosteum is more of a fingernails-on-the-blackboard moment. Even if somehow you managed to ignore the bone-chilling vibrations that traveled up the syringe, the patient's response told you that going too deep is a bad thing.

In 2007, the Centers for Disease Control and Prevention released a set of guidelines that include a recommendation for longer needles when giving intramuscular injections (Epidemiology and Prevention of Immunization Practices: The Pink Book, 10th ed., Feb. 2007), up to 1 inch for the deltoid and 11/4 inch for the thigh. Their concern was that a failure to penetrate well into the muscle would result in suboptimal vaccine absorption.

At a lunchtime staff meeting that I somehow neglected to attend (it must have been a warm sunny day—or maybe just not raining) we decided that we should comply with the CDC's guidelines and we ordered a couple of boxes of longer needles. Trying to be a good soldier and a team player, I agreed to give these big boys a try. It was an ugly week.

One of my secrets for giving minimally painful injections is to prevent the patient and/or parent from seeing the business end of the syringe. However, even with my best sleight-of-hand techniques, I was having trouble hiding the longer needles. Whenever the patient caught a glimpse of these ice picks, the anxiety level in the room escalated and it was downhill from there.

With longer needles, I was uncomfortably out of control. Wielding an extra few millimeters of steel, I felt like a jousting knight of the Round Table galloping down the runway, my 10-foot lance wobbling in the wind, never quite sure if I was going to hit my intended target. When I did strike pay dirt, watching a 1-inch needle flexing back and forth in the thigh of a squirming toddler was more than I could take. I wasn't going to wait until I had performed an unintended bone marrow biopsy, and we halted the experiment.

It wasn't the first time I had ignored the CDC's recommendation, but I admit that I have harbored a few second thoughts. However, recently I have been rescued from my insecurity by William C. Lippert and Dr. Eric J. Wall, whose article, “Optimal Intramuscular Needle-Penetration Depth,” reassured me that I can stick with my shorter needles (Pediatrics 2008;122:e556–63). Using CT and MRI scans, they have determined that if one followed the CDC guidelines one would overpenetrate the thigh of 11% of the patients using a 1-inch needle and 39% of the patients if a 11/4-incher were used. For the deltoid, the numbers were more troubling. Overpenetration would occur 11% of the time with a 5/8-inch needle, 55% for a 7/8-inch, and a walloping 63% of the time with a 1-inch needle. Ouch!

The authors, neither of whom is a pediatrician, recommend shorter needles for thigh injections and offer weight- and gender-based guidelines to aid in selection of the correct length. In their opinion, the current CDC guidelines for deltoid injections were still appropriate. However, the CDC's Advisory Committee on Immunization Practices has decided to ignore this new creatively obtained evidence. (See story, page 8—Ed.) And so, I will continue to ignore the committees and inject to the beat of my own drummer. I will temper the new evidence with my own experience. In the discussion portion of the paper, Mr. Lippert and Dr. Wall buried a pearl that supports my rogue practice. They said that in light of the great variability in extremity dimensions, “clinical judgment be used and an assortment of different lengths be available.”

Three cheers for a combination of common sense and carefully done science.

[email protected]

If you have given more than a thousand intramuscular injections, you have probably hit bone at least once or twice. This is not the “Eureka!” kind of discovery that one gets from striking oil or seeing that crimson flashback from a successful and intentional arterial puncture. Pricking the periosteum is more of a fingernails-on-the-blackboard moment. Even if somehow you managed to ignore the bone-chilling vibrations that traveled up the syringe, the patient's response told you that going too deep is a bad thing.

In 2007, the Centers for Disease Control and Prevention released a set of guidelines that include a recommendation for longer needles when giving intramuscular injections (Epidemiology and Prevention of Immunization Practices: The Pink Book, 10th ed., Feb. 2007), up to 1 inch for the deltoid and 11/4 inch for the thigh. Their concern was that a failure to penetrate well into the muscle would result in suboptimal vaccine absorption.

At a lunchtime staff meeting that I somehow neglected to attend (it must have been a warm sunny day—or maybe just not raining) we decided that we should comply with the CDC's guidelines and we ordered a couple of boxes of longer needles. Trying to be a good soldier and a team player, I agreed to give these big boys a try. It was an ugly week.

One of my secrets for giving minimally painful injections is to prevent the patient and/or parent from seeing the business end of the syringe. However, even with my best sleight-of-hand techniques, I was having trouble hiding the longer needles. Whenever the patient caught a glimpse of these ice picks, the anxiety level in the room escalated and it was downhill from there.

With longer needles, I was uncomfortably out of control. Wielding an extra few millimeters of steel, I felt like a jousting knight of the Round Table galloping down the runway, my 10-foot lance wobbling in the wind, never quite sure if I was going to hit my intended target. When I did strike pay dirt, watching a 1-inch needle flexing back and forth in the thigh of a squirming toddler was more than I could take. I wasn't going to wait until I had performed an unintended bone marrow biopsy, and we halted the experiment.

It wasn't the first time I had ignored the CDC's recommendation, but I admit that I have harbored a few second thoughts. However, recently I have been rescued from my insecurity by William C. Lippert and Dr. Eric J. Wall, whose article, “Optimal Intramuscular Needle-Penetration Depth,” reassured me that I can stick with my shorter needles (Pediatrics 2008;122:e556–63). Using CT and MRI scans, they have determined that if one followed the CDC guidelines one would overpenetrate the thigh of 11% of the patients using a 1-inch needle and 39% of the patients if a 11/4-incher were used. For the deltoid, the numbers were more troubling. Overpenetration would occur 11% of the time with a 5/8-inch needle, 55% for a 7/8-inch, and a walloping 63% of the time with a 1-inch needle. Ouch!

The authors, neither of whom is a pediatrician, recommend shorter needles for thigh injections and offer weight- and gender-based guidelines to aid in selection of the correct length. In their opinion, the current CDC guidelines for deltoid injections were still appropriate. However, the CDC's Advisory Committee on Immunization Practices has decided to ignore this new creatively obtained evidence. (See story, page 8—Ed.) And so, I will continue to ignore the committees and inject to the beat of my own drummer. I will temper the new evidence with my own experience. In the discussion portion of the paper, Mr. Lippert and Dr. Wall buried a pearl that supports my rogue practice. They said that in light of the great variability in extremity dimensions, “clinical judgment be used and an assortment of different lengths be available.”

Three cheers for a combination of common sense and carefully done science.

[email protected]

I was about to enter an exam room to see my 30th patient of the day. “Dr. Wilkoff, her rapid strep test is negative.” Meredith is our newest PPS (patient placement specialist, a job category I invented several years ago), and she thought she was being helpful. But no one had told her that while one or two of my colleagues have asked their assistants to swab the throats of anyone complaining of sore throat, I prefer to do it myself after I have seen the patient.

There was nothing to be gained by holding my breath and turning purple. The water was over the dam. But now what was I going to do? The whole rhythm of this office visit would be thrown off. Like most people, I thrive on routine. When I am busy, routines and habits (good, bad, or ugly) help maintain my efficiency and sanity.

Of course, I have never sat down and written a script for my typical office visits, but over the years a standard plot pattern has evolved … a plot into which I weave as much drama as the scenario will allow. Each one-act play begins with an introduction during which I make a little small talk about the weather or comment on how well or poorly the Patriots or the Red Sox are doing.

Shifting to a more serious and thoughtful persona, I begin taking a history, scribbling illegibly, and sketching the painful body part. In most situations I am 94% confident that I know the diagnosis and have already begun developing my plan by the time I've heard the story. However, to build and maintain the suspense, I continue to contort my face to reflect curiosity and concern, and then I examine the patient.

In most cases I pause at the end of the exam and announce, “Let me do some more writing, and then we can talk about what might be going on and what we should do about it.” Occasionally, I add the apology that if I don't write things down immediately they will be forgotten. This is true, of course, but the real reason for this 60-second pause for documentation is that it will add even more suspense to the visit.

Hopefully, by the time I am ready to reveal my diagnosis, the patient is squirming with anticipation and will be more likely to accept without question my diagnosis of a simple URI requiring no specific treatment.

It is only in rare cases that my history and physical examination have not solidified the diagnosis. Then and only then is it time for some lab work. This may be an “old school” approach, but I think it is a tradition that serves us all well and not just because it can hype up the drama in a visit and make one feel professorial. Doing the lab work first devalues the two other components of a good clinical evaluation.

One need only look at a typical medical bill to see that the system already places a higher value on diagnostic studies (meaning lab and x-ray) than it does on a good history and physical. If we continue to request lab work and imaging studies before we have examined the patient, we will perpetuate this inequity.

Of course, there is always cost. Not infrequently the patient's chief complaint is so vague or so mangled by the person at the front desk that a routinely ordered preexamination lab or x-ray is unnecessary and makes no sense. I'm sure some of you must deal with orthopedists who demand MRIs before they examine certain patients. We're not talking the chump change of a rapid strep test here.

Finally, knowing the lab work before one examines the patient eliminates the intellectual gamesmanship that keeps me going. Looking at 50 sore throats a week can be a bit mind numbing. Guessing whether the rapid strep test is going to be positive or negative helps keep my head in the game.

[email protected]

I was about to enter an exam room to see my 30th patient of the day. “Dr. Wilkoff, her rapid strep test is negative.” Meredith is our newest PPS (patient placement specialist, a job category I invented several years ago), and she thought she was being helpful. But no one had told her that while one or two of my colleagues have asked their assistants to swab the throats of anyone complaining of sore throat, I prefer to do it myself after I have seen the patient.

There was nothing to be gained by holding my breath and turning purple. The water was over the dam. But now what was I going to do? The whole rhythm of this office visit would be thrown off. Like most people, I thrive on routine. When I am busy, routines and habits (good, bad, or ugly) help maintain my efficiency and sanity.

Of course, I have never sat down and written a script for my typical office visits, but over the years a standard plot pattern has evolved … a plot into which I weave as much drama as the scenario will allow. Each one-act play begins with an introduction during which I make a little small talk about the weather or comment on how well or poorly the Patriots or the Red Sox are doing.

Shifting to a more serious and thoughtful persona, I begin taking a history, scribbling illegibly, and sketching the painful body part. In most situations I am 94% confident that I know the diagnosis and have already begun developing my plan by the time I've heard the story. However, to build and maintain the suspense, I continue to contort my face to reflect curiosity and concern, and then I examine the patient.

In most cases I pause at the end of the exam and announce, “Let me do some more writing, and then we can talk about what might be going on and what we should do about it.” Occasionally, I add the apology that if I don't write things down immediately they will be forgotten. This is true, of course, but the real reason for this 60-second pause for documentation is that it will add even more suspense to the visit.

Hopefully, by the time I am ready to reveal my diagnosis, the patient is squirming with anticipation and will be more likely to accept without question my diagnosis of a simple URI requiring no specific treatment.

It is only in rare cases that my history and physical examination have not solidified the diagnosis. Then and only then is it time for some lab work. This may be an “old school” approach, but I think it is a tradition that serves us all well and not just because it can hype up the drama in a visit and make one feel professorial. Doing the lab work first devalues the two other components of a good clinical evaluation.

One need only look at a typical medical bill to see that the system already places a higher value on diagnostic studies (meaning lab and x-ray) than it does on a good history and physical. If we continue to request lab work and imaging studies before we have examined the patient, we will perpetuate this inequity.

Of course, there is always cost. Not infrequently the patient's chief complaint is so vague or so mangled by the person at the front desk that a routinely ordered preexamination lab or x-ray is unnecessary and makes no sense. I'm sure some of you must deal with orthopedists who demand MRIs before they examine certain patients. We're not talking the chump change of a rapid strep test here.

Finally, knowing the lab work before one examines the patient eliminates the intellectual gamesmanship that keeps me going. Looking at 50 sore throats a week can be a bit mind numbing. Guessing whether the rapid strep test is going to be positive or negative helps keep my head in the game.

[email protected]

I was about to enter an exam room to see my 30th patient of the day. “Dr. Wilkoff, her rapid strep test is negative.” Meredith is our newest PPS (patient placement specialist, a job category I invented several years ago), and she thought she was being helpful. But no one had told her that while one or two of my colleagues have asked their assistants to swab the throats of anyone complaining of sore throat, I prefer to do it myself after I have seen the patient.

There was nothing to be gained by holding my breath and turning purple. The water was over the dam. But now what was I going to do? The whole rhythm of this office visit would be thrown off. Like most people, I thrive on routine. When I am busy, routines and habits (good, bad, or ugly) help maintain my efficiency and sanity.

Of course, I have never sat down and written a script for my typical office visits, but over the years a standard plot pattern has evolved … a plot into which I weave as much drama as the scenario will allow. Each one-act play begins with an introduction during which I make a little small talk about the weather or comment on how well or poorly the Patriots or the Red Sox are doing.

Shifting to a more serious and thoughtful persona, I begin taking a history, scribbling illegibly, and sketching the painful body part. In most situations I am 94% confident that I know the diagnosis and have already begun developing my plan by the time I've heard the story. However, to build and maintain the suspense, I continue to contort my face to reflect curiosity and concern, and then I examine the patient.

In most cases I pause at the end of the exam and announce, “Let me do some more writing, and then we can talk about what might be going on and what we should do about it.” Occasionally, I add the apology that if I don't write things down immediately they will be forgotten. This is true, of course, but the real reason for this 60-second pause for documentation is that it will add even more suspense to the visit.

Hopefully, by the time I am ready to reveal my diagnosis, the patient is squirming with anticipation and will be more likely to accept without question my diagnosis of a simple URI requiring no specific treatment.

It is only in rare cases that my history and physical examination have not solidified the diagnosis. Then and only then is it time for some lab work. This may be an “old school” approach, but I think it is a tradition that serves us all well and not just because it can hype up the drama in a visit and make one feel professorial. Doing the lab work first devalues the two other components of a good clinical evaluation.

One need only look at a typical medical bill to see that the system already places a higher value on diagnostic studies (meaning lab and x-ray) than it does on a good history and physical. If we continue to request lab work and imaging studies before we have examined the patient, we will perpetuate this inequity.

Of course, there is always cost. Not infrequently the patient's chief complaint is so vague or so mangled by the person at the front desk that a routinely ordered preexamination lab or x-ray is unnecessary and makes no sense. I'm sure some of you must deal with orthopedists who demand MRIs before they examine certain patients. We're not talking the chump change of a rapid strep test here.

Finally, knowing the lab work before one examines the patient eliminates the intellectual gamesmanship that keeps me going. Looking at 50 sore throats a week can be a bit mind numbing. Guessing whether the rapid strep test is going to be positive or negative helps keep my head in the game.

[email protected]

A few months ago, I was invited to a retirement party for an old house-officer mate. He wasn't actually retiring, but he was calling it quits from active clinical practice. The food was good and the wine was very good, but the rest of the event left me feeling a bit sour.

The roasts and toasts began with the usual (and well-deserved) compliments by his coworkers. But one of the contributors spoke about how envious she was of my friend because she herself was eagerly anticipating a time when she would no longer have to deal with the stupid and inconsiderate (my words, not hers) patients and parents. She intended her observations to be humorous. However, her scenarios triggered a half-hour-long anecdote-sharing competition during which each physician who stood up tried to one-up his colleagues with a tale of how dumb patients can be. Or, how badly he had been abused by a thoughtless parent who called at an inconvenient time with what he felt was a trivial question.

I must admit that some of the stories made me chuckle until I stepped back and took a longer look at the tableau spread out before me. It bothered me for two reasons. First, we may not like to admit it, but almost every joke is “on” someone. And here I was listening to a bunch of physicians who in the frivolity of the moment were willing to make the patients they served into the butt of their humor.

Physicians must continually struggle with the “we-they” divide. On one hand, it can be important to maintain a reputation and demeanor that give our advice credibility. A patient or a parent facing the unknown of a serious disease is often looking for someone with more “authority” whom can be trusted. On the other hand, we must remember that “the sore throat in Room 7” belongs to another human being who, when all is said and done, is no different from us.

Almost every survey about medical care that I have seen in the last few years contains responses that make it clear that consumers, patients, clients—whoever—want good customer service. Nearly every week I find myself having to remind a receptionist or assistant to reconsider a response to a parent. “What would you have said if your daughter had been the patient?” I think it was Pogo the comic-strip possum who said, “We have met the enemy and he is us.” Customer service boils down to accepting the reality that we are all in this together and so we might as well treat each other as equals.

The second troubling concern that surfaced as I waited for the anecdote swapping to end was that this event had seemed to unroof a festering sore of dissatisfied physicians. Maybe I am reading more into this alcohol-enabled complaint session than I should. But, I have read somewhere that when older physicians are asked if they would encourage young people to enter medicine, many of them reply that they wouldn't.

What is it about being a physician in the new millennium that is making us such an unhappy bunch? Certainly, hassles with third-party payers and the ever-present threat of a malpractice suit can put a few dark clouds in your sky. But listening to these doctors, it sounds as though the day-in and day-out interaction with patients, or certainly with parents, might be a significant source of discontent among some of them.

I've always figured that medicine—and definitely pediatrics—is a people business. And we the people are a quirky sort. We do dumb things with great frequency, and from time to time even the most saintly among us behave inconsiderately. Failure to accept those basic facts of life might be at the root of some of our discontent.

And there might be a good argument for requiring all medical students to have a real job, such as waiting tables, before they start their formal medical education. It might just cut down on the whining.

[email protected]

A few months ago, I was invited to a retirement party for an old house-officer mate. He wasn't actually retiring, but he was calling it quits from active clinical practice. The food was good and the wine was very good, but the rest of the event left me feeling a bit sour.

The roasts and toasts began with the usual (and well-deserved) compliments by his coworkers. But one of the contributors spoke about how envious she was of my friend because she herself was eagerly anticipating a time when she would no longer have to deal with the stupid and inconsiderate (my words, not hers) patients and parents. She intended her observations to be humorous. However, her scenarios triggered a half-hour-long anecdote-sharing competition during which each physician who stood up tried to one-up his colleagues with a tale of how dumb patients can be. Or, how badly he had been abused by a thoughtless parent who called at an inconvenient time with what he felt was a trivial question.

I must admit that some of the stories made me chuckle until I stepped back and took a longer look at the tableau spread out before me. It bothered me for two reasons. First, we may not like to admit it, but almost every joke is “on” someone. And here I was listening to a bunch of physicians who in the frivolity of the moment were willing to make the patients they served into the butt of their humor.

Physicians must continually struggle with the “we-they” divide. On one hand, it can be important to maintain a reputation and demeanor that give our advice credibility. A patient or a parent facing the unknown of a serious disease is often looking for someone with more “authority” whom can be trusted. On the other hand, we must remember that “the sore throat in Room 7” belongs to another human being who, when all is said and done, is no different from us.

Almost every survey about medical care that I have seen in the last few years contains responses that make it clear that consumers, patients, clients—whoever—want good customer service. Nearly every week I find myself having to remind a receptionist or assistant to reconsider a response to a parent. “What would you have said if your daughter had been the patient?” I think it was Pogo the comic-strip possum who said, “We have met the enemy and he is us.” Customer service boils down to accepting the reality that we are all in this together and so we might as well treat each other as equals.

The second troubling concern that surfaced as I waited for the anecdote swapping to end was that this event had seemed to unroof a festering sore of dissatisfied physicians. Maybe I am reading more into this alcohol-enabled complaint session than I should. But, I have read somewhere that when older physicians are asked if they would encourage young people to enter medicine, many of them reply that they wouldn't.

What is it about being a physician in the new millennium that is making us such an unhappy bunch? Certainly, hassles with third-party payers and the ever-present threat of a malpractice suit can put a few dark clouds in your sky. But listening to these doctors, it sounds as though the day-in and day-out interaction with patients, or certainly with parents, might be a significant source of discontent among some of them.

I've always figured that medicine—and definitely pediatrics—is a people business. And we the people are a quirky sort. We do dumb things with great frequency, and from time to time even the most saintly among us behave inconsiderately. Failure to accept those basic facts of life might be at the root of some of our discontent.

And there might be a good argument for requiring all medical students to have a real job, such as waiting tables, before they start their formal medical education. It might just cut down on the whining.

[email protected]

A few months ago, I was invited to a retirement party for an old house-officer mate. He wasn't actually retiring, but he was calling it quits from active clinical practice. The food was good and the wine was very good, but the rest of the event left me feeling a bit sour.

The roasts and toasts began with the usual (and well-deserved) compliments by his coworkers. But one of the contributors spoke about how envious she was of my friend because she herself was eagerly anticipating a time when she would no longer have to deal with the stupid and inconsiderate (my words, not hers) patients and parents. She intended her observations to be humorous. However, her scenarios triggered a half-hour-long anecdote-sharing competition during which each physician who stood up tried to one-up his colleagues with a tale of how dumb patients can be. Or, how badly he had been abused by a thoughtless parent who called at an inconvenient time with what he felt was a trivial question.

I must admit that some of the stories made me chuckle until I stepped back and took a longer look at the tableau spread out before me. It bothered me for two reasons. First, we may not like to admit it, but almost every joke is “on” someone. And here I was listening to a bunch of physicians who in the frivolity of the moment were willing to make the patients they served into the butt of their humor.

Physicians must continually struggle with the “we-they” divide. On one hand, it can be important to maintain a reputation and demeanor that give our advice credibility. A patient or a parent facing the unknown of a serious disease is often looking for someone with more “authority” whom can be trusted. On the other hand, we must remember that “the sore throat in Room 7” belongs to another human being who, when all is said and done, is no different from us.

Almost every survey about medical care that I have seen in the last few years contains responses that make it clear that consumers, patients, clients—whoever—want good customer service. Nearly every week I find myself having to remind a receptionist or assistant to reconsider a response to a parent. “What would you have said if your daughter had been the patient?” I think it was Pogo the comic-strip possum who said, “We have met the enemy and he is us.” Customer service boils down to accepting the reality that we are all in this together and so we might as well treat each other as equals.

The second troubling concern that surfaced as I waited for the anecdote swapping to end was that this event had seemed to unroof a festering sore of dissatisfied physicians. Maybe I am reading more into this alcohol-enabled complaint session than I should. But, I have read somewhere that when older physicians are asked if they would encourage young people to enter medicine, many of them reply that they wouldn't.

What is it about being a physician in the new millennium that is making us such an unhappy bunch? Certainly, hassles with third-party payers and the ever-present threat of a malpractice suit can put a few dark clouds in your sky. But listening to these doctors, it sounds as though the day-in and day-out interaction with patients, or certainly with parents, might be a significant source of discontent among some of them.

I've always figured that medicine—and definitely pediatrics—is a people business. And we the people are a quirky sort. We do dumb things with great frequency, and from time to time even the most saintly among us behave inconsiderately. Failure to accept those basic facts of life might be at the root of some of our discontent.

And there might be a good argument for requiring all medical students to have a real job, such as waiting tables, before they start their formal medical education. It might just cut down on the whining.

[email protected]

Every pediatrician who is sensitive to the needs of his patients believes in the Tooth Fairy. But, do you believe in teething? Sure, we all know that somewhere between birth and their second birthday all children will have teeth erupt through their gums. But do you ever tell parents that their child's symptoms are the result of this eruption?

Many years ago, an old pediatrician told me that the only thing that teething caused was teeth. In the decades since he contributed that pearl to my necklace of inherited wisdom, I have failed to observe anything that makes me doubt his statement. However, I recently discovered that there is actually an ICD 9 code (520.7) called “teething syndrome” and worse yet, one of my colleagues has actually used it.

I vaguely remember reading where some study found a small but statistically significant association between the eruption of teeth and rhinorrhea, loose stools, and a very modest temperature elevation. But, I've never found that observation particularly helpful when I am trying to sort out what ails a fussy infant or toddler.

You have probably heard as many misattributions as I have: “My aunt said his fever of 103 was probably his teeth,” or “I thought his vomiting and blisters on his bottom were because he was teething.” Nearly every day I hear about unerupted or erupting teeth being linked to some constellation of symptoms for which they are blameless. Fortunately, I can't recall a case in which a child has died because life-saving treatment was delayed by a tragic therapeutic detour through a variety of teething remedies. But I fear that it has happened somewhere in this country.

If while relating the history of the current illness, a parent mentions that he has considered teething, I interrupt and correct the misperception. I know that if I don't, silence is often treated as agreement.

All normal 4-month-olds begin to drool in buckets and try to mouth everything then can get their chubby little fingers around. While this oral development stage probably has some remote relationship to eventual tooth eruption, most children don't cut teeth for at least another month or so.

Of course, from time to time some children may have a cranky day or night before a tooth eruption. But in my experience, a hard wood or rubber object for the child to chew on is as effective as any medicinal intervention. The problem comes when we allow this untreatable and benign teething behavior to creep onto our list of working diagnoses.

Even a figment of thought about teething can derail our rational deductive reasoning when we are facing a diagnostic enigma. Potentially serious and treatable conditions may never make it to the radar screen when the little voice in our head says, “It's probably just teething.” As difficult as it may be, the better tack is to come clean and tell the parents, “I'm not absolutely sure what's going on here, but I'm not worried about your child. I will call you tomorrow morning to check on her.”

I tell the parents if they want to think about teething, it should be so low on their list of diagnoses that by the time they have ruled out the other explanations, the problem has resolved. In other words, if teething deserves an ICD 9 code it should carry a footnote warning that it should only be used retrospectively and never as a working diagnosis.

[email protected]

Every pediatrician who is sensitive to the needs of his patients believes in the Tooth Fairy. But, do you believe in teething? Sure, we all know that somewhere between birth and their second birthday all children will have teeth erupt through their gums. But do you ever tell parents that their child's symptoms are the result of this eruption?

Many years ago, an old pediatrician told me that the only thing that teething caused was teeth. In the decades since he contributed that pearl to my necklace of inherited wisdom, I have failed to observe anything that makes me doubt his statement. However, I recently discovered that there is actually an ICD 9 code (520.7) called “teething syndrome” and worse yet, one of my colleagues has actually used it.

I vaguely remember reading where some study found a small but statistically significant association between the eruption of teeth and rhinorrhea, loose stools, and a very modest temperature elevation. But, I've never found that observation particularly helpful when I am trying to sort out what ails a fussy infant or toddler.

You have probably heard as many misattributions as I have: “My aunt said his fever of 103 was probably his teeth,” or “I thought his vomiting and blisters on his bottom were because he was teething.” Nearly every day I hear about unerupted or erupting teeth being linked to some constellation of symptoms for which they are blameless. Fortunately, I can't recall a case in which a child has died because life-saving treatment was delayed by a tragic therapeutic detour through a variety of teething remedies. But I fear that it has happened somewhere in this country.

If while relating the history of the current illness, a parent mentions that he has considered teething, I interrupt and correct the misperception. I know that if I don't, silence is often treated as agreement.

All normal 4-month-olds begin to drool in buckets and try to mouth everything then can get their chubby little fingers around. While this oral development stage probably has some remote relationship to eventual tooth eruption, most children don't cut teeth for at least another month or so.

Of course, from time to time some children may have a cranky day or night before a tooth eruption. But in my experience, a hard wood or rubber object for the child to chew on is as effective as any medicinal intervention. The problem comes when we allow this untreatable and benign teething behavior to creep onto our list of working diagnoses.

Even a figment of thought about teething can derail our rational deductive reasoning when we are facing a diagnostic enigma. Potentially serious and treatable conditions may never make it to the radar screen when the little voice in our head says, “It's probably just teething.” As difficult as it may be, the better tack is to come clean and tell the parents, “I'm not absolutely sure what's going on here, but I'm not worried about your child. I will call you tomorrow morning to check on her.”

I tell the parents if they want to think about teething, it should be so low on their list of diagnoses that by the time they have ruled out the other explanations, the problem has resolved. In other words, if teething deserves an ICD 9 code it should carry a footnote warning that it should only be used retrospectively and never as a working diagnosis.

[email protected]

Every pediatrician who is sensitive to the needs of his patients believes in the Tooth Fairy. But, do you believe in teething? Sure, we all know that somewhere between birth and their second birthday all children will have teeth erupt through their gums. But do you ever tell parents that their child's symptoms are the result of this eruption?

Many years ago, an old pediatrician told me that the only thing that teething caused was teeth. In the decades since he contributed that pearl to my necklace of inherited wisdom, I have failed to observe anything that makes me doubt his statement. However, I recently discovered that there is actually an ICD 9 code (520.7) called “teething syndrome” and worse yet, one of my colleagues has actually used it.

I vaguely remember reading where some study found a small but statistically significant association between the eruption of teeth and rhinorrhea, loose stools, and a very modest temperature elevation. But, I've never found that observation particularly helpful when I am trying to sort out what ails a fussy infant or toddler.

You have probably heard as many misattributions as I have: “My aunt said his fever of 103 was probably his teeth,” or “I thought his vomiting and blisters on his bottom were because he was teething.” Nearly every day I hear about unerupted or erupting teeth being linked to some constellation of symptoms for which they are blameless. Fortunately, I can't recall a case in which a child has died because life-saving treatment was delayed by a tragic therapeutic detour through a variety of teething remedies. But I fear that it has happened somewhere in this country.

If while relating the history of the current illness, a parent mentions that he has considered teething, I interrupt and correct the misperception. I know that if I don't, silence is often treated as agreement.

All normal 4-month-olds begin to drool in buckets and try to mouth everything then can get their chubby little fingers around. While this oral development stage probably has some remote relationship to eventual tooth eruption, most children don't cut teeth for at least another month or so.

Of course, from time to time some children may have a cranky day or night before a tooth eruption. But in my experience, a hard wood or rubber object for the child to chew on is as effective as any medicinal intervention. The problem comes when we allow this untreatable and benign teething behavior to creep onto our list of working diagnoses.

Even a figment of thought about teething can derail our rational deductive reasoning when we are facing a diagnostic enigma. Potentially serious and treatable conditions may never make it to the radar screen when the little voice in our head says, “It's probably just teething.” As difficult as it may be, the better tack is to come clean and tell the parents, “I'm not absolutely sure what's going on here, but I'm not worried about your child. I will call you tomorrow morning to check on her.”

I tell the parents if they want to think about teething, it should be so low on their list of diagnoses that by the time they have ruled out the other explanations, the problem has resolved. In other words, if teething deserves an ICD 9 code it should carry a footnote warning that it should only be used retrospectively and never as a working diagnosis.

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On a low-lying landscape of inert couch potatoes, my longtime patient Jackson, 10 years old, is a refreshing peak of activity. However, sometimes activity leads to injury, and over the weekend he found himself in the emergency department following some head trauma that left him dazed for a minute or 2. He was now fine without any symptoms, but the ED personnel had told him to come to our office in 2 days regardless of how well he was feeling.

I learned from his father that while in the ED, Jackson had undergone a computed axial tomography (CAT, or CT) scan of his head. With mock surprise I asked, “Really? Did they warn you that this procedure involves a pretty hefty radiation dose?” His dad replied, “Actually, the doctor did mention that and said that it might be associated with an increased cancer risk. She was on the fence about ordering the study, but after Jackson vomited she decided to go ahead and have it done.” Heightening my concerns all the more, Dad recalled that Jackson had had another mild concussion 3 years earlier and had also received a CT scan on that ED visit.

Of course, the images then and now were normal. I have never seen a meaningful positive CT scan in a patient who was awake and conversant. It turns out Jackson's emesis was a single event in response to a well-meaning but ill-timed attempt to leave no pain untreated. A big slug of acetaminophen syrup hadn't sat well in his nerved-up stomach.

In a recent paper in the New England Journal of Medicine, the authors pointed out that the dose of radiation from a CT scan is significantly greater than that from a traditional radiograph. For example, an abdominal CT bombards the patient's stomach with 50 times more radiation than does a standard film (N. Engl. J. Med. 2007;357:2277-84).

Equally alarming was their citation of a survey finding that 75% of radiologists and ED physicians significantly underestimated the radiation dose of a CT scan (Radiology 2004;231:393-8). While the risk of cancer from CT scans is as yet unproved, it is troubling that 91% of these ED physicians did not believe that the scans were associated with an increased lifetime risk of cancer. Until we have all of the answers, ordering CT scans is an area in which it seems physicians should be prudent. Whatever happened to primum non nocere?

In a related discussion among pediatric radiologists, it was suggested that there is consensus that “somewhere around 30% of CT scans that we do are unnecessary” (Pediatr. Radiol. 2002;32:298-300). My observations suggest that this number is a serious underestimate, certainly when one is talking head injuries.

We older adults tend to be goofy most of the time. Children, on the other hand, tend to be far more transparent. By the time they present to us in the office or ED, what you see is what you get. It certainly is wise to have them sit around for an hour or 2 to make sure their mental status and physical exam are stable. But, the old nursery rhyme verse “bumped his head, went to bed, and couldn't get up in the morning” is a myth. As is the notion that vomiting is a predictor of intracranial injury (J. Pediatr. 2007;150:274-8).

Unfortunately, even a short observation period in an ED is expensive and can add to the chaos of gridlock. Sadly, for physicians who may not be as confident of their physical exam skills as they could be and who feel the hot breath of opportunistic lawyers on the backs of their necks, ordering a CT scan is the path of least anxiety.

We all must reevaluate use of CT scans and to support and educate those among us who are having the most difficulty being prudent in using these often unnecessary higher-dose imaging techniques.

[email protected]

On a low-lying landscape of inert couch potatoes, my longtime patient Jackson, 10 years old, is a refreshing peak of activity. However, sometimes activity leads to injury, and over the weekend he found himself in the emergency department following some head trauma that left him dazed for a minute or 2. He was now fine without any symptoms, but the ED personnel had told him to come to our office in 2 days regardless of how well he was feeling.

I learned from his father that while in the ED, Jackson had undergone a computed axial tomography (CAT, or CT) scan of his head. With mock surprise I asked, “Really? Did they warn you that this procedure involves a pretty hefty radiation dose?” His dad replied, “Actually, the doctor did mention that and said that it might be associated with an increased cancer risk. She was on the fence about ordering the study, but after Jackson vomited she decided to go ahead and have it done.” Heightening my concerns all the more, Dad recalled that Jackson had had another mild concussion 3 years earlier and had also received a CT scan on that ED visit.

Of course, the images then and now were normal. I have never seen a meaningful positive CT scan in a patient who was awake and conversant. It turns out Jackson's emesis was a single event in response to a well-meaning but ill-timed attempt to leave no pain untreated. A big slug of acetaminophen syrup hadn't sat well in his nerved-up stomach.

In a recent paper in the New England Journal of Medicine, the authors pointed out that the dose of radiation from a CT scan is significantly greater than that from a traditional radiograph. For example, an abdominal CT bombards the patient's stomach with 50 times more radiation than does a standard film (N. Engl. J. Med. 2007;357:2277-84).

Equally alarming was their citation of a survey finding that 75% of radiologists and ED physicians significantly underestimated the radiation dose of a CT scan (Radiology 2004;231:393-8). While the risk of cancer from CT scans is as yet unproved, it is troubling that 91% of these ED physicians did not believe that the scans were associated with an increased lifetime risk of cancer. Until we have all of the answers, ordering CT scans is an area in which it seems physicians should be prudent. Whatever happened to primum non nocere?

In a related discussion among pediatric radiologists, it was suggested that there is consensus that “somewhere around 30% of CT scans that we do are unnecessary” (Pediatr. Radiol. 2002;32:298-300). My observations suggest that this number is a serious underestimate, certainly when one is talking head injuries.

We older adults tend to be goofy most of the time. Children, on the other hand, tend to be far more transparent. By the time they present to us in the office or ED, what you see is what you get. It certainly is wise to have them sit around for an hour or 2 to make sure their mental status and physical exam are stable. But, the old nursery rhyme verse “bumped his head, went to bed, and couldn't get up in the morning” is a myth. As is the notion that vomiting is a predictor of intracranial injury (J. Pediatr. 2007;150:274-8).

Unfortunately, even a short observation period in an ED is expensive and can add to the chaos of gridlock. Sadly, for physicians who may not be as confident of their physical exam skills as they could be and who feel the hot breath of opportunistic lawyers on the backs of their necks, ordering a CT scan is the path of least anxiety.

We all must reevaluate use of CT scans and to support and educate those among us who are having the most difficulty being prudent in using these often unnecessary higher-dose imaging techniques.

[email protected]

On a low-lying landscape of inert couch potatoes, my longtime patient Jackson, 10 years old, is a refreshing peak of activity. However, sometimes activity leads to injury, and over the weekend he found himself in the emergency department following some head trauma that left him dazed for a minute or 2. He was now fine without any symptoms, but the ED personnel had told him to come to our office in 2 days regardless of how well he was feeling.

I learned from his father that while in the ED, Jackson had undergone a computed axial tomography (CAT, or CT) scan of his head. With mock surprise I asked, “Really? Did they warn you that this procedure involves a pretty hefty radiation dose?” His dad replied, “Actually, the doctor did mention that and said that it might be associated with an increased cancer risk. She was on the fence about ordering the study, but after Jackson vomited she decided to go ahead and have it done.” Heightening my concerns all the more, Dad recalled that Jackson had had another mild concussion 3 years earlier and had also received a CT scan on that ED visit.

Of course, the images then and now were normal. I have never seen a meaningful positive CT scan in a patient who was awake and conversant. It turns out Jackson's emesis was a single event in response to a well-meaning but ill-timed attempt to leave no pain untreated. A big slug of acetaminophen syrup hadn't sat well in his nerved-up stomach.

In a recent paper in the New England Journal of Medicine, the authors pointed out that the dose of radiation from a CT scan is significantly greater than that from a traditional radiograph. For example, an abdominal CT bombards the patient's stomach with 50 times more radiation than does a standard film (N. Engl. J. Med. 2007;357:2277-84).

Equally alarming was their citation of a survey finding that 75% of radiologists and ED physicians significantly underestimated the radiation dose of a CT scan (Radiology 2004;231:393-8). While the risk of cancer from CT scans is as yet unproved, it is troubling that 91% of these ED physicians did not believe that the scans were associated with an increased lifetime risk of cancer. Until we have all of the answers, ordering CT scans is an area in which it seems physicians should be prudent. Whatever happened to primum non nocere?

In a related discussion among pediatric radiologists, it was suggested that there is consensus that “somewhere around 30% of CT scans that we do are unnecessary” (Pediatr. Radiol. 2002;32:298-300). My observations suggest that this number is a serious underestimate, certainly when one is talking head injuries.

We older adults tend to be goofy most of the time. Children, on the other hand, tend to be far more transparent. By the time they present to us in the office or ED, what you see is what you get. It certainly is wise to have them sit around for an hour or 2 to make sure their mental status and physical exam are stable. But, the old nursery rhyme verse “bumped his head, went to bed, and couldn't get up in the morning” is a myth. As is the notion that vomiting is a predictor of intracranial injury (J. Pediatr. 2007;150:274-8).

Unfortunately, even a short observation period in an ED is expensive and can add to the chaos of gridlock. Sadly, for physicians who may not be as confident of their physical exam skills as they could be and who feel the hot breath of opportunistic lawyers on the backs of their necks, ordering a CT scan is the path of least anxiety.

We all must reevaluate use of CT scans and to support and educate those among us who are having the most difficulty being prudent in using these often unnecessary higher-dose imaging techniques.

[email protected]

That steady buzzing sound bugging me for the last couple of years has finally gotten so loud that I must write about the two words that are causing all the noise: Medical Home. How could one possibly argue with a concept that has such a nice apple-pie-and-motherhood ring to it?

The term was actually introduced by the American Academy of Pediatrics in 1967 before many of its active members were even born. Originally, “medical home” referred to the notion of archiving a child's medical record in a central location. Most children from traditional families now have what might be called a loosely centralized medical record, including reports from consultants and other providers, housed in the pediatrician's office.

In 2002, buoyed by this very modest success, the AAP expanded the concept to include more attributes of good care such as accessibility, continuity, comprehensiveness, and compassion. They also recommended that a medical home be family centered and culturally effective. With the exception of comprehensiveness, adopting these operational characteristics should be well within the reach of nearly every pediatrician regardless of the size or financial health of his or her practice. For some physicians, meeting this vision of a medical home may require some attitude adjustment about availability, but the upside is that these changes are likely to make their practices more attractive to consumers.

By 2007, the neighborhood around the medical home had become so attractive that the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association joined the AAP in claiming ownership and generated a document titled “Joint Principles of the Patient-Centered Medical Home.” This two-page document significantly expands the concept of a medical home, draping it with wordy garlands such as “physician directed,” “patient-centered,” “whole person orientation,” and “evidence-based.”

The new principles lean heavily on expensive improvements in information technology and quality assessment. Here is where there is more than a little devil lurking in the details, because I'm not confident that an electronic health record system exists that is up to the task as envisioned in these principles at any price.

Small practices like ours also can't generate enough data to allow for valid comparisons and conclusions. When our small group went looking for a system that would permit the data crunching and sharing that is necessary for quality improvement studies, we found that most of the users weren't as happy as we were with our old homegrown system. To make matters worse, sharing data requires that our computer system must be willing to talk with the other systems in our neighborhood. That degree of uniformity doesn't seem to exist yet.

Small practices also have much more difficulty providing the comprehensive services suggested in the advanced guidelines. For example, even if we had the room in our medical home for mental health providers, there aren't any around because they abandoned our neighborhood several years ago.

Although the term “medical home” has a nice “Little House on the Prairie” feel, the concept has morphed into one that favors larger, wealthier, and more highly structured practices. For us small players, return to a more modest definition makes the most sense.

How about, “The medical home, the first place to call for all of your child's health problems”? This may sound a little like the old “gatekeeper” mantra. But, the key difference is that instead of a family being forced to call to obtain access to the system, the availability, quality, and compassion of the medical home should make the decision of where to call an obvious one.

[email protected]

That steady buzzing sound bugging me for the last couple of years has finally gotten so loud that I must write about the two words that are causing all the noise: Medical Home. How could one possibly argue with a concept that has such a nice apple-pie-and-motherhood ring to it?

The term was actually introduced by the American Academy of Pediatrics in 1967 before many of its active members were even born. Originally, “medical home” referred to the notion of archiving a child's medical record in a central location. Most children from traditional families now have what might be called a loosely centralized medical record, including reports from consultants and other providers, housed in the pediatrician's office.

In 2002, buoyed by this very modest success, the AAP expanded the concept to include more attributes of good care such as accessibility, continuity, comprehensiveness, and compassion. They also recommended that a medical home be family centered and culturally effective. With the exception of comprehensiveness, adopting these operational characteristics should be well within the reach of nearly every pediatrician regardless of the size or financial health of his or her practice. For some physicians, meeting this vision of a medical home may require some attitude adjustment about availability, but the upside is that these changes are likely to make their practices more attractive to consumers.

By 2007, the neighborhood around the medical home had become so attractive that the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association joined the AAP in claiming ownership and generated a document titled “Joint Principles of the Patient-Centered Medical Home.” This two-page document significantly expands the concept of a medical home, draping it with wordy garlands such as “physician directed,” “patient-centered,” “whole person orientation,” and “evidence-based.”

The new principles lean heavily on expensive improvements in information technology and quality assessment. Here is where there is more than a little devil lurking in the details, because I'm not confident that an electronic health record system exists that is up to the task as envisioned in these principles at any price.

Small practices like ours also can't generate enough data to allow for valid comparisons and conclusions. When our small group went looking for a system that would permit the data crunching and sharing that is necessary for quality improvement studies, we found that most of the users weren't as happy as we were with our old homegrown system. To make matters worse, sharing data requires that our computer system must be willing to talk with the other systems in our neighborhood. That degree of uniformity doesn't seem to exist yet.

Small practices also have much more difficulty providing the comprehensive services suggested in the advanced guidelines. For example, even if we had the room in our medical home for mental health providers, there aren't any around because they abandoned our neighborhood several years ago.

Although the term “medical home” has a nice “Little House on the Prairie” feel, the concept has morphed into one that favors larger, wealthier, and more highly structured practices. For us small players, return to a more modest definition makes the most sense.

How about, “The medical home, the first place to call for all of your child's health problems”? This may sound a little like the old “gatekeeper” mantra. But, the key difference is that instead of a family being forced to call to obtain access to the system, the availability, quality, and compassion of the medical home should make the decision of where to call an obvious one.

[email protected]

That steady buzzing sound bugging me for the last couple of years has finally gotten so loud that I must write about the two words that are causing all the noise: Medical Home. How could one possibly argue with a concept that has such a nice apple-pie-and-motherhood ring to it?

The term was actually introduced by the American Academy of Pediatrics in 1967 before many of its active members were even born. Originally, “medical home” referred to the notion of archiving a child's medical record in a central location. Most children from traditional families now have what might be called a loosely centralized medical record, including reports from consultants and other providers, housed in the pediatrician's office.

In 2002, buoyed by this very modest success, the AAP expanded the concept to include more attributes of good care such as accessibility, continuity, comprehensiveness, and compassion. They also recommended that a medical home be family centered and culturally effective. With the exception of comprehensiveness, adopting these operational characteristics should be well within the reach of nearly every pediatrician regardless of the size or financial health of his or her practice. For some physicians, meeting this vision of a medical home may require some attitude adjustment about availability, but the upside is that these changes are likely to make their practices more attractive to consumers.

By 2007, the neighborhood around the medical home had become so attractive that the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association joined the AAP in claiming ownership and generated a document titled “Joint Principles of the Patient-Centered Medical Home.” This two-page document significantly expands the concept of a medical home, draping it with wordy garlands such as “physician directed,” “patient-centered,” “whole person orientation,” and “evidence-based.”

The new principles lean heavily on expensive improvements in information technology and quality assessment. Here is where there is more than a little devil lurking in the details, because I'm not confident that an electronic health record system exists that is up to the task as envisioned in these principles at any price.

Small practices like ours also can't generate enough data to allow for valid comparisons and conclusions. When our small group went looking for a system that would permit the data crunching and sharing that is necessary for quality improvement studies, we found that most of the users weren't as happy as we were with our old homegrown system. To make matters worse, sharing data requires that our computer system must be willing to talk with the other systems in our neighborhood. That degree of uniformity doesn't seem to exist yet.

Small practices also have much more difficulty providing the comprehensive services suggested in the advanced guidelines. For example, even if we had the room in our medical home for mental health providers, there aren't any around because they abandoned our neighborhood several years ago.

Although the term “medical home” has a nice “Little House on the Prairie” feel, the concept has morphed into one that favors larger, wealthier, and more highly structured practices. For us small players, return to a more modest definition makes the most sense.

How about, “The medical home, the first place to call for all of your child's health problems”? This may sound a little like the old “gatekeeper” mantra. But, the key difference is that instead of a family being forced to call to obtain access to the system, the availability, quality, and compassion of the medical home should make the decision of where to call an obvious one.

[email protected]

“My goodness, what is that?”

With the golden brown nugget that was the size of a pencil eraser still perched on my stainless magic wand, I waved it triumphantly and replied, “That, Mrs. Alcott, is a cerumen plug, manufactured by your little Jason and now a trophy we can all be proud of.”

“Is that normal?” she replied, still too concerned to bother complimenting me on my skillful extraction. It's happened before. We masters of wax removal have come to expect that our skills are often taken for granted. Fortunately, I have my own sense of satisfaction because for a busy pediatrician there aren't too many bigger highs than removing a big glob of wax in one piece.

Earwax is funny stuff. Most of the time, it's simply providing its owner protection from the elements. Rarely (mostly in teenage boys, it seems), it gets so dense and swollen that it interferes with hearing. More frequently, it serves as an annoying challenge to the assiduous pediatrician who at 4:45 p.m. on a Friday afternoon is trying to determine why an unappreciative 18-month-old has a fever.

When I was in medical school we were offered an hour lecture by someone—a neurologist, I believe—who included among his hobbies the study of earwax and would enlighten us on the topic. Because it was clear that we were never going to be tested on his message, and since it was even clearer that it was a comfortably warm and sunny Thursday afternoon, I opted for some tennis instead.

Had I only known how often my schedule, my emotions, my sense of self-esteem—in effect, my life—would be impacted by cerumen, I think I would have hung around the lecture hall and learned a bit more about my future adversary. But, that's water over the dam.

Once out in practice I learned quickly that if I was going to make good clinical decisions, I needed to see tympanic membranes, and to do this I needed to learn to remove earwax. During my training, no one really showed me how to use an ear curette.

Fortunately, my first partner had a good selection of curettes and I learned which one worked best for me. I learned how deep to go, how to feel with the curette and which way to scrape, how to have a firm hand on the patient and a soft hand on the curette, and certainly how to make sure the child was appropriately restrained. It meant frequent stops to visualize whether I had succeeded, and if not, where I needed to go next.

I learned that if I was unlucky or unskillful and there was some bleeding, that it was best to tell the family that they might see some blood later on, even though it wasn't evident at the moment. Anticipatory guidance saves a mess of evening phone calls.

Even if well done, removing cerumen can be uncomfortable for some patients. Sometimes it can't be avoided. This fact of life and inexperience deters many physicians from doing what is clinically correct and removing enough wax to get a good view of the tympanic membrane.

Every week I see children who were seen in an emergency department or another physician's office, or unfortunately on the floors of tertiary medical centers, whom I know couldn't have had their ears adequately examined. Because when I look in their ears there is a ton of wax, not just a few flakes that may have fallen off the walls of the canal overnight, but a serious amount of impacted wax.

Do I always get enough wax out on the first visit? Of course not, but if the clinical situation demands an adequate exam that day, I don't give up. Luckily there are many situations when I can have the patient return the next day when everyone is more rested.

There is a procedure code for removing cerumen. And if I have done more than scoop out a few flakes, I am not afraid to bill for the work because it appears that I have a skill that is in short supply.

[email protected]

“My goodness, what is that?”

With the golden brown nugget that was the size of a pencil eraser still perched on my stainless magic wand, I waved it triumphantly and replied, “That, Mrs. Alcott, is a cerumen plug, manufactured by your little Jason and now a trophy we can all be proud of.”

“Is that normal?” she replied, still too concerned to bother complimenting me on my skillful extraction. It's happened before. We masters of wax removal have come to expect that our skills are often taken for granted. Fortunately, I have my own sense of satisfaction because for a busy pediatrician there aren't too many bigger highs than removing a big glob of wax in one piece.

Earwax is funny stuff. Most of the time, it's simply providing its owner protection from the elements. Rarely (mostly in teenage boys, it seems), it gets so dense and swollen that it interferes with hearing. More frequently, it serves as an annoying challenge to the assiduous pediatrician who at 4:45 p.m. on a Friday afternoon is trying to determine why an unappreciative 18-month-old has a fever.

When I was in medical school we were offered an hour lecture by someone—a neurologist, I believe—who included among his hobbies the study of earwax and would enlighten us on the topic. Because it was clear that we were never going to be tested on his message, and since it was even clearer that it was a comfortably warm and sunny Thursday afternoon, I opted for some tennis instead.

Had I only known how often my schedule, my emotions, my sense of self-esteem—in effect, my life—would be impacted by cerumen, I think I would have hung around the lecture hall and learned a bit more about my future adversary. But, that's water over the dam.

Once out in practice I learned quickly that if I was going to make good clinical decisions, I needed to see tympanic membranes, and to do this I needed to learn to remove earwax. During my training, no one really showed me how to use an ear curette.

Fortunately, my first partner had a good selection of curettes and I learned which one worked best for me. I learned how deep to go, how to feel with the curette and which way to scrape, how to have a firm hand on the patient and a soft hand on the curette, and certainly how to make sure the child was appropriately restrained. It meant frequent stops to visualize whether I had succeeded, and if not, where I needed to go next.

I learned that if I was unlucky or unskillful and there was some bleeding, that it was best to tell the family that they might see some blood later on, even though it wasn't evident at the moment. Anticipatory guidance saves a mess of evening phone calls.

Even if well done, removing cerumen can be uncomfortable for some patients. Sometimes it can't be avoided. This fact of life and inexperience deters many physicians from doing what is clinically correct and removing enough wax to get a good view of the tympanic membrane.

Every week I see children who were seen in an emergency department or another physician's office, or unfortunately on the floors of tertiary medical centers, whom I know couldn't have had their ears adequately examined. Because when I look in their ears there is a ton of wax, not just a few flakes that may have fallen off the walls of the canal overnight, but a serious amount of impacted wax.

Do I always get enough wax out on the first visit? Of course not, but if the clinical situation demands an adequate exam that day, I don't give up. Luckily there are many situations when I can have the patient return the next day when everyone is more rested.

There is a procedure code for removing cerumen. And if I have done more than scoop out a few flakes, I am not afraid to bill for the work because it appears that I have a skill that is in short supply.

[email protected]

“My goodness, what is that?”

With the golden brown nugget that was the size of a pencil eraser still perched on my stainless magic wand, I waved it triumphantly and replied, “That, Mrs. Alcott, is a cerumen plug, manufactured by your little Jason and now a trophy we can all be proud of.”

“Is that normal?” she replied, still too concerned to bother complimenting me on my skillful extraction. It's happened before. We masters of wax removal have come to expect that our skills are often taken for granted. Fortunately, I have my own sense of satisfaction because for a busy pediatrician there aren't too many bigger highs than removing a big glob of wax in one piece.

Earwax is funny stuff. Most of the time, it's simply providing its owner protection from the elements. Rarely (mostly in teenage boys, it seems), it gets so dense and swollen that it interferes with hearing. More frequently, it serves as an annoying challenge to the assiduous pediatrician who at 4:45 p.m. on a Friday afternoon is trying to determine why an unappreciative 18-month-old has a fever.

When I was in medical school we were offered an hour lecture by someone—a neurologist, I believe—who included among his hobbies the study of earwax and would enlighten us on the topic. Because it was clear that we were never going to be tested on his message, and since it was even clearer that it was a comfortably warm and sunny Thursday afternoon, I opted for some tennis instead.

Had I only known how often my schedule, my emotions, my sense of self-esteem—in effect, my life—would be impacted by cerumen, I think I would have hung around the lecture hall and learned a bit more about my future adversary. But, that's water over the dam.

Once out in practice I learned quickly that if I was going to make good clinical decisions, I needed to see tympanic membranes, and to do this I needed to learn to remove earwax. During my training, no one really showed me how to use an ear curette.

Fortunately, my first partner had a good selection of curettes and I learned which one worked best for me. I learned how deep to go, how to feel with the curette and which way to scrape, how to have a firm hand on the patient and a soft hand on the curette, and certainly how to make sure the child was appropriately restrained. It meant frequent stops to visualize whether I had succeeded, and if not, where I needed to go next.

I learned that if I was unlucky or unskillful and there was some bleeding, that it was best to tell the family that they might see some blood later on, even though it wasn't evident at the moment. Anticipatory guidance saves a mess of evening phone calls.

Even if well done, removing cerumen can be uncomfortable for some patients. Sometimes it can't be avoided. This fact of life and inexperience deters many physicians from doing what is clinically correct and removing enough wax to get a good view of the tympanic membrane.

Every week I see children who were seen in an emergency department or another physician's office, or unfortunately on the floors of tertiary medical centers, whom I know couldn't have had their ears adequately examined. Because when I look in their ears there is a ton of wax, not just a few flakes that may have fallen off the walls of the canal overnight, but a serious amount of impacted wax.

Do I always get enough wax out on the first visit? Of course not, but if the clinical situation demands an adequate exam that day, I don't give up. Luckily there are many situations when I can have the patient return the next day when everyone is more rested.

There is a procedure code for removing cerumen. And if I have done more than scoop out a few flakes, I am not afraid to bill for the work because it appears that I have a skill that is in short supply.