Letters from Maine

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Unless you've handed over the care of all of your sick patients to the hospitalists, you will have noticed cookbook medicine creeping into the care of your hospitalized patients. It comes clothed in several transparent disguises: “CareMaps,” “standardized orders,” and “algorithms” are the euphemisms for “recipe,” the term with which we here in Brunswick are most familiar.

Now, when I admit a patient to the hospital with the diagnosis of bronchiolitis or a baby has the misfortune of being born a bit on the heavy side, a printer somewhere at the nurses' station spits out a set of legible and detailed orders that will determine that child's care for his or her hospital stay. So long as I manage to get a history and physical into the chart and sign the orders, no one will bother me.

I'm not sure exactly where the trend began or who was responsible for getting this ball of red tape rolling. Most of the push for standardized orders seems to be coming from the nursing service. However, I wonder if the risk-management folks also might have a hand in the process. I vaguely remember sitting through several tedious meetings where the standard orders were discussed, but like most documents created by committee, these orders ended up being inclusive rather than thoughtful. Few of the items would successfully pass an evidence-based test of validity.

While I have never claimed that inpatient pediatrics is fun, standardized orders make the process less intellectually stimulating and more impersonal. Whenever I sign on the bottom line, I feel as though I am admitting that I haven't been paying attention during my CME exercises and that I'm too old to be trusted making clinical decisions about sick patients. It's safe to say that since their introduction I have never been a big fan of standardized orders.

However, one of my partners recently gave me an article from the Dec. 10, 2007, issue of the New Yorker magazine by Dr. Atul Gawande, a surgeon/author. (If you haven't read any of his writings, I urge you to start with his first book, “Complications.”) The article is titled “The Checklist” and describes how by developing a simple checklist for central line placement, Dr. Peter Pronovost, a Johns Hopkins University critical specialist, was able to prevent eight deaths from line infections and save $2 million in a single hospital in a single year.

The article goes on to describe how Dr. Pronovost has developed other evidence-based checklists, including one for the care of ventilated patients. The cost savings and life-sparing statistics are truly remarkable and have been effective in many other hospitals. Even the country of Spain has bought into the program and plans to implement it nationwide.

The ingredients in Dr. Pronovost's recipes are rather mundane and include such simple tasks as making sure the head of the bed is raised to 30 degrees for ventilator patients, that all ventilated patients receive antacids, and that any patient having a line placed has sterile drapes. Critical care units have such complex patients that rigorous attention to even the most basic factors is necessary to achieve a significantly improved outcome. As I read the article, I was reminded of the story of how a girl in Wisconsin was rescued from rabies by a combination of heavy sedation and scrupulous attention to life support.

I'm not sure how Dr. Pronovost's checklists for critical care units translate to my unsatisfying experience with the standard orders. I guess that for me, the big take-home message would be that checklists or recipes must be clearly evidence based, not just cobbled together by those of us at the grassroots. The results aren't going to be dramatic because I'm not dealing with critically ill patients, but after reading Dr. Gawande's article, I'm ready to try a few new recipes from a well-documented cookbook.

[email protected]

Unless you've handed over the care of all of your sick patients to the hospitalists, you will have noticed cookbook medicine creeping into the care of your hospitalized patients. It comes clothed in several transparent disguises: “CareMaps,” “standardized orders,” and “algorithms” are the euphemisms for “recipe,” the term with which we here in Brunswick are most familiar.

Now, when I admit a patient to the hospital with the diagnosis of bronchiolitis or a baby has the misfortune of being born a bit on the heavy side, a printer somewhere at the nurses' station spits out a set of legible and detailed orders that will determine that child's care for his or her hospital stay. So long as I manage to get a history and physical into the chart and sign the orders, no one will bother me.

I'm not sure exactly where the trend began or who was responsible for getting this ball of red tape rolling. Most of the push for standardized orders seems to be coming from the nursing service. However, I wonder if the risk-management folks also might have a hand in the process. I vaguely remember sitting through several tedious meetings where the standard orders were discussed, but like most documents created by committee, these orders ended up being inclusive rather than thoughtful. Few of the items would successfully pass an evidence-based test of validity.

While I have never claimed that inpatient pediatrics is fun, standardized orders make the process less intellectually stimulating and more impersonal. Whenever I sign on the bottom line, I feel as though I am admitting that I haven't been paying attention during my CME exercises and that I'm too old to be trusted making clinical decisions about sick patients. It's safe to say that since their introduction I have never been a big fan of standardized orders.

However, one of my partners recently gave me an article from the Dec. 10, 2007, issue of the New Yorker magazine by Dr. Atul Gawande, a surgeon/author. (If you haven't read any of his writings, I urge you to start with his first book, “Complications.”) The article is titled “The Checklist” and describes how by developing a simple checklist for central line placement, Dr. Peter Pronovost, a Johns Hopkins University critical specialist, was able to prevent eight deaths from line infections and save $2 million in a single hospital in a single year.

The article goes on to describe how Dr. Pronovost has developed other evidence-based checklists, including one for the care of ventilated patients. The cost savings and life-sparing statistics are truly remarkable and have been effective in many other hospitals. Even the country of Spain has bought into the program and plans to implement it nationwide.

The ingredients in Dr. Pronovost's recipes are rather mundane and include such simple tasks as making sure the head of the bed is raised to 30 degrees for ventilator patients, that all ventilated patients receive antacids, and that any patient having a line placed has sterile drapes. Critical care units have such complex patients that rigorous attention to even the most basic factors is necessary to achieve a significantly improved outcome. As I read the article, I was reminded of the story of how a girl in Wisconsin was rescued from rabies by a combination of heavy sedation and scrupulous attention to life support.

I'm not sure how Dr. Pronovost's checklists for critical care units translate to my unsatisfying experience with the standard orders. I guess that for me, the big take-home message would be that checklists or recipes must be clearly evidence based, not just cobbled together by those of us at the grassroots. The results aren't going to be dramatic because I'm not dealing with critically ill patients, but after reading Dr. Gawande's article, I'm ready to try a few new recipes from a well-documented cookbook.

[email protected]

Unless you've handed over the care of all of your sick patients to the hospitalists, you will have noticed cookbook medicine creeping into the care of your hospitalized patients. It comes clothed in several transparent disguises: “CareMaps,” “standardized orders,” and “algorithms” are the euphemisms for “recipe,” the term with which we here in Brunswick are most familiar.

Now, when I admit a patient to the hospital with the diagnosis of bronchiolitis or a baby has the misfortune of being born a bit on the heavy side, a printer somewhere at the nurses' station spits out a set of legible and detailed orders that will determine that child's care for his or her hospital stay. So long as I manage to get a history and physical into the chart and sign the orders, no one will bother me.

I'm not sure exactly where the trend began or who was responsible for getting this ball of red tape rolling. Most of the push for standardized orders seems to be coming from the nursing service. However, I wonder if the risk-management folks also might have a hand in the process. I vaguely remember sitting through several tedious meetings where the standard orders were discussed, but like most documents created by committee, these orders ended up being inclusive rather than thoughtful. Few of the items would successfully pass an evidence-based test of validity.

While I have never claimed that inpatient pediatrics is fun, standardized orders make the process less intellectually stimulating and more impersonal. Whenever I sign on the bottom line, I feel as though I am admitting that I haven't been paying attention during my CME exercises and that I'm too old to be trusted making clinical decisions about sick patients. It's safe to say that since their introduction I have never been a big fan of standardized orders.

However, one of my partners recently gave me an article from the Dec. 10, 2007, issue of the New Yorker magazine by Dr. Atul Gawande, a surgeon/author. (If you haven't read any of his writings, I urge you to start with his first book, “Complications.”) The article is titled “The Checklist” and describes how by developing a simple checklist for central line placement, Dr. Peter Pronovost, a Johns Hopkins University critical specialist, was able to prevent eight deaths from line infections and save $2 million in a single hospital in a single year.

The article goes on to describe how Dr. Pronovost has developed other evidence-based checklists, including one for the care of ventilated patients. The cost savings and life-sparing statistics are truly remarkable and have been effective in many other hospitals. Even the country of Spain has bought into the program and plans to implement it nationwide.

The ingredients in Dr. Pronovost's recipes are rather mundane and include such simple tasks as making sure the head of the bed is raised to 30 degrees for ventilator patients, that all ventilated patients receive antacids, and that any patient having a line placed has sterile drapes. Critical care units have such complex patients that rigorous attention to even the most basic factors is necessary to achieve a significantly improved outcome. As I read the article, I was reminded of the story of how a girl in Wisconsin was rescued from rabies by a combination of heavy sedation and scrupulous attention to life support.

I'm not sure how Dr. Pronovost's checklists for critical care units translate to my unsatisfying experience with the standard orders. I guess that for me, the big take-home message would be that checklists or recipes must be clearly evidence based, not just cobbled together by those of us at the grassroots. The results aren't going to be dramatic because I'm not dealing with critically ill patients, but after reading Dr. Gawande's article, I'm ready to try a few new recipes from a well-documented cookbook.

[email protected]

Since I had seen her last year, my 5-year-old patient Tiana had gained so much weight that I almost didn't recognize her. I knew that when I looked at her growth curve it would now include a steep upslope. The change had not caught her mother, Maria, by surprise. Tiana's weight was the first topic of her answer to my usual, “How are things goin'?”

Over the years we had had many discussions about how she might remedy the girls' sleep problems. Now we had a new issue to discuss: impending obesity.

My simplistic understanding of obesity has always been that if someone takes in more packets of energy than are burned, those packets will accumulate in the body as fat.

One must also account for genetic variation because it is clear that some of us are better at storing fat than others are.

Likewise, two automobiles of the same size may have dramatically different fuel efficiency ratings just because that's the way they were designed and built.

It seems, to those of who were blessed with lean parents, to be such a blatantly simple concept that we are easily frustrated by other families who “just don't get it.”

Which side of my simplistic equation had changed for Tiana?

Suspecting that it was an intake problem, I began to quiz Maria about the family's diet. It continues to be predominantly vegetables and grains, no soda, rare desserts. She admitted that there has been a slight increase in chips and snack food since she and her husband had taken over a mom-and-pop convenience store. But, the amounts didn't sound excessive.

I then began to explore the energy utilization side of the balance sheet.

“How much TV are the girls watching?” Here the answer was significantly different from the year before. The television was now on all the time.

“Why?” It turns out that since taking over the new business, Maria had been so busy keeping the books that she admitted using television as a babysitter. In the past, she would often take them outside and spend a good part of the day playing. But now the girls are full-time couch potatoes.

I told Maria what she had suspected herself: that the inactivity was the major contributor to Tiana's weight gain.

Digging deeper, I asked if there was a way that she could do the bookkeeping in the evening after the girls were asleep. The problem with that solution is that the younger child still sleeps poorly and Maria feels she must lie down with her whenever she wakes. She feels that she can't let her cry because it will interrupt her already sleep-deprived and overworked husband. With evenings consumed by sleep refusal, Maria must steal daytime from the girls to do the books. So we were back to talking about sleep, the same issue that Maria and I had batted around for the last 4 years.

Although growth curves as dramatic as Tiana's are unusual, when they do occur they reopen my eyes to the complexity of the obesity problem.

Sometimes the steep rise in body mass index is the result of a cookie-baking grandmother assuming the full-time day-care responsibilities. In other cases, opportunities for activity are lost and dietary supervision gets lost in the family shuffle.

In any case, obesity is one of those rare situations where my simplistic survival tool fails me.

[email protected]

Since I had seen her last year, my 5-year-old patient Tiana had gained so much weight that I almost didn't recognize her. I knew that when I looked at her growth curve it would now include a steep upslope. The change had not caught her mother, Maria, by surprise. Tiana's weight was the first topic of her answer to my usual, “How are things goin'?”

Over the years we had had many discussions about how she might remedy the girls' sleep problems. Now we had a new issue to discuss: impending obesity.

My simplistic understanding of obesity has always been that if someone takes in more packets of energy than are burned, those packets will accumulate in the body as fat.

One must also account for genetic variation because it is clear that some of us are better at storing fat than others are.

Likewise, two automobiles of the same size may have dramatically different fuel efficiency ratings just because that's the way they were designed and built.

It seems, to those of who were blessed with lean parents, to be such a blatantly simple concept that we are easily frustrated by other families who “just don't get it.”

Which side of my simplistic equation had changed for Tiana?

Suspecting that it was an intake problem, I began to quiz Maria about the family's diet. It continues to be predominantly vegetables and grains, no soda, rare desserts. She admitted that there has been a slight increase in chips and snack food since she and her husband had taken over a mom-and-pop convenience store. But, the amounts didn't sound excessive.

I then began to explore the energy utilization side of the balance sheet.

“How much TV are the girls watching?” Here the answer was significantly different from the year before. The television was now on all the time.

“Why?” It turns out that since taking over the new business, Maria had been so busy keeping the books that she admitted using television as a babysitter. In the past, she would often take them outside and spend a good part of the day playing. But now the girls are full-time couch potatoes.

I told Maria what she had suspected herself: that the inactivity was the major contributor to Tiana's weight gain.

Digging deeper, I asked if there was a way that she could do the bookkeeping in the evening after the girls were asleep. The problem with that solution is that the younger child still sleeps poorly and Maria feels she must lie down with her whenever she wakes. She feels that she can't let her cry because it will interrupt her already sleep-deprived and overworked husband. With evenings consumed by sleep refusal, Maria must steal daytime from the girls to do the books. So we were back to talking about sleep, the same issue that Maria and I had batted around for the last 4 years.

Although growth curves as dramatic as Tiana's are unusual, when they do occur they reopen my eyes to the complexity of the obesity problem.

Sometimes the steep rise in body mass index is the result of a cookie-baking grandmother assuming the full-time day-care responsibilities. In other cases, opportunities for activity are lost and dietary supervision gets lost in the family shuffle.

In any case, obesity is one of those rare situations where my simplistic survival tool fails me.

[email protected]

Since I had seen her last year, my 5-year-old patient Tiana had gained so much weight that I almost didn't recognize her. I knew that when I looked at her growth curve it would now include a steep upslope. The change had not caught her mother, Maria, by surprise. Tiana's weight was the first topic of her answer to my usual, “How are things goin'?”

Over the years we had had many discussions about how she might remedy the girls' sleep problems. Now we had a new issue to discuss: impending obesity.

My simplistic understanding of obesity has always been that if someone takes in more packets of energy than are burned, those packets will accumulate in the body as fat.

One must also account for genetic variation because it is clear that some of us are better at storing fat than others are.

Likewise, two automobiles of the same size may have dramatically different fuel efficiency ratings just because that's the way they were designed and built.

It seems, to those of who were blessed with lean parents, to be such a blatantly simple concept that we are easily frustrated by other families who “just don't get it.”

Which side of my simplistic equation had changed for Tiana?

Suspecting that it was an intake problem, I began to quiz Maria about the family's diet. It continues to be predominantly vegetables and grains, no soda, rare desserts. She admitted that there has been a slight increase in chips and snack food since she and her husband had taken over a mom-and-pop convenience store. But, the amounts didn't sound excessive.

I then began to explore the energy utilization side of the balance sheet.

“How much TV are the girls watching?” Here the answer was significantly different from the year before. The television was now on all the time.

“Why?” It turns out that since taking over the new business, Maria had been so busy keeping the books that she admitted using television as a babysitter. In the past, she would often take them outside and spend a good part of the day playing. But now the girls are full-time couch potatoes.

I told Maria what she had suspected herself: that the inactivity was the major contributor to Tiana's weight gain.

Digging deeper, I asked if there was a way that she could do the bookkeeping in the evening after the girls were asleep. The problem with that solution is that the younger child still sleeps poorly and Maria feels she must lie down with her whenever she wakes. She feels that she can't let her cry because it will interrupt her already sleep-deprived and overworked husband. With evenings consumed by sleep refusal, Maria must steal daytime from the girls to do the books. So we were back to talking about sleep, the same issue that Maria and I had batted around for the last 4 years.

Although growth curves as dramatic as Tiana's are unusual, when they do occur they reopen my eyes to the complexity of the obesity problem.

Sometimes the steep rise in body mass index is the result of a cookie-baking grandmother assuming the full-time day-care responsibilities. In other cases, opportunities for activity are lost and dietary supervision gets lost in the family shuffle.

In any case, obesity is one of those rare situations where my simplistic survival tool fails me.

[email protected]

No one who knows me well would ever describe me as a political animal. As a registered Independent, I switch allegiances based on my gut response to a candidate's stated position, his voting record … and, of course, his or her hairstyle and sartorial choices. When forced to choose based solely on the issues, I tend to side with those who claim that less government is better.

However, from time to time, this attitude of “just leave us alone and we'll sort it out ourselves” just doesn't work. A frightening example in which market forces and communal altruism have failed us is the current shambles we have made of our national vaccine program.

I had already begun to write this letter when Dr. Michael Pichichero's I.D. Consult column appeared in the February issue of PEDIATRIC NEWS (“Feds Should Help Bring Vaccines to U.S. Market”). He knows far more than I do about the details of how the system works and fails. And, he offers some rational solutions to at least some of the problems. But I can't resist the temptation to add my less knowledgeable and more emotional 2 cents' worth to his observations.

First, let me restate his frustration and concern about the current state of our vaccine supplies. While I admit that when it comes to remembering PIN numbers and passwords, age has taken its toll on my memory, I think I still qualify for a “pretty sharp” rating in most categories. But I have thrown in the towel when it comes to keeping up to date with the latest recommended vaccine schedule and its many addenda.

I now rely totally on our nurses to compare the patient's immunization records with the newest guidelines and our fluctuating vaccine supply and then come up with the best fit. The process is so time consuming for our clinical staff that I routinely room more than 50% of my patients. The patients and their parents may at times be flattered when the doctor summons them from the waiting room himself. And it does add a bit more of a homey quality to our medical home. But clearly it is not the most efficient way of providing medical care.

Vaccine costs and the inscrutable, unscrupulous, and variable reimbursement practices of the third-party payers has left us gun-shy when it comes to adding new vaccines to our offerings. We stay clear of the cutting edge of vaccine technology to avoid being shredded to ribbons and left holding a very expensive bag of immunizations. As someone who remembers when Haemophilus influenzae meningitis sat at the top of the rule-out diagnoses for a young child with fever, the Hib vaccine shortage makes me very nervous.

It is clear to even the less-government-is-better folks like myself that the federal government must step into the arena and ensure that vaccines are not only safe, but available. It must also create and maintain sufficient financial incentives to keep the private sector enthusiastic about vaccine research and development.

Regardless of whom we elect this November, the year 2009 should provide an excellent opportunity for change. Dr. Pichichero's recommendations take advantage of the current system, but I think we need to think bigger. Let's raise vaccine supply and safety issues to the cabinet level.

It's time for a Vaccine Czar, a Godfather (or Godmother) of Immunization. Someone who has the president's ear every day. Someone armed with a sharp knife that cuts red tape like warm butter. Someone who carries a big stick to whack the kneecaps of the insurance companies. And someone with an ample supply of carrots to keep the pharmaceutical companies drooling for the profits of newly developed vaccines.

I fell under the spell of Obama Charisma many months ago, but I think any of the top candidates can be convinced that vaccine supply is a critical issue. We just need to start yelling louder and they'll hear us.

[email protected]

No one who knows me well would ever describe me as a political animal. As a registered Independent, I switch allegiances based on my gut response to a candidate's stated position, his voting record … and, of course, his or her hairstyle and sartorial choices. When forced to choose based solely on the issues, I tend to side with those who claim that less government is better.

However, from time to time, this attitude of “just leave us alone and we'll sort it out ourselves” just doesn't work. A frightening example in which market forces and communal altruism have failed us is the current shambles we have made of our national vaccine program.

I had already begun to write this letter when Dr. Michael Pichichero's I.D. Consult column appeared in the February issue of PEDIATRIC NEWS (“Feds Should Help Bring Vaccines to U.S. Market”). He knows far more than I do about the details of how the system works and fails. And, he offers some rational solutions to at least some of the problems. But I can't resist the temptation to add my less knowledgeable and more emotional 2 cents' worth to his observations.

First, let me restate his frustration and concern about the current state of our vaccine supplies. While I admit that when it comes to remembering PIN numbers and passwords, age has taken its toll on my memory, I think I still qualify for a “pretty sharp” rating in most categories. But I have thrown in the towel when it comes to keeping up to date with the latest recommended vaccine schedule and its many addenda.

I now rely totally on our nurses to compare the patient's immunization records with the newest guidelines and our fluctuating vaccine supply and then come up with the best fit. The process is so time consuming for our clinical staff that I routinely room more than 50% of my patients. The patients and their parents may at times be flattered when the doctor summons them from the waiting room himself. And it does add a bit more of a homey quality to our medical home. But clearly it is not the most efficient way of providing medical care.

Vaccine costs and the inscrutable, unscrupulous, and variable reimbursement practices of the third-party payers has left us gun-shy when it comes to adding new vaccines to our offerings. We stay clear of the cutting edge of vaccine technology to avoid being shredded to ribbons and left holding a very expensive bag of immunizations. As someone who remembers when Haemophilus influenzae meningitis sat at the top of the rule-out diagnoses for a young child with fever, the Hib vaccine shortage makes me very nervous.

It is clear to even the less-government-is-better folks like myself that the federal government must step into the arena and ensure that vaccines are not only safe, but available. It must also create and maintain sufficient financial incentives to keep the private sector enthusiastic about vaccine research and development.

Regardless of whom we elect this November, the year 2009 should provide an excellent opportunity for change. Dr. Pichichero's recommendations take advantage of the current system, but I think we need to think bigger. Let's raise vaccine supply and safety issues to the cabinet level.

It's time for a Vaccine Czar, a Godfather (or Godmother) of Immunization. Someone who has the president's ear every day. Someone armed with a sharp knife that cuts red tape like warm butter. Someone who carries a big stick to whack the kneecaps of the insurance companies. And someone with an ample supply of carrots to keep the pharmaceutical companies drooling for the profits of newly developed vaccines.

I fell under the spell of Obama Charisma many months ago, but I think any of the top candidates can be convinced that vaccine supply is a critical issue. We just need to start yelling louder and they'll hear us.

[email protected]

No one who knows me well would ever describe me as a political animal. As a registered Independent, I switch allegiances based on my gut response to a candidate's stated position, his voting record … and, of course, his or her hairstyle and sartorial choices. When forced to choose based solely on the issues, I tend to side with those who claim that less government is better.

However, from time to time, this attitude of “just leave us alone and we'll sort it out ourselves” just doesn't work. A frightening example in which market forces and communal altruism have failed us is the current shambles we have made of our national vaccine program.

I had already begun to write this letter when Dr. Michael Pichichero's I.D. Consult column appeared in the February issue of PEDIATRIC NEWS (“Feds Should Help Bring Vaccines to U.S. Market”). He knows far more than I do about the details of how the system works and fails. And, he offers some rational solutions to at least some of the problems. But I can't resist the temptation to add my less knowledgeable and more emotional 2 cents' worth to his observations.

First, let me restate his frustration and concern about the current state of our vaccine supplies. While I admit that when it comes to remembering PIN numbers and passwords, age has taken its toll on my memory, I think I still qualify for a “pretty sharp” rating in most categories. But I have thrown in the towel when it comes to keeping up to date with the latest recommended vaccine schedule and its many addenda.

I now rely totally on our nurses to compare the patient's immunization records with the newest guidelines and our fluctuating vaccine supply and then come up with the best fit. The process is so time consuming for our clinical staff that I routinely room more than 50% of my patients. The patients and their parents may at times be flattered when the doctor summons them from the waiting room himself. And it does add a bit more of a homey quality to our medical home. But clearly it is not the most efficient way of providing medical care.

Vaccine costs and the inscrutable, unscrupulous, and variable reimbursement practices of the third-party payers has left us gun-shy when it comes to adding new vaccines to our offerings. We stay clear of the cutting edge of vaccine technology to avoid being shredded to ribbons and left holding a very expensive bag of immunizations. As someone who remembers when Haemophilus influenzae meningitis sat at the top of the rule-out diagnoses for a young child with fever, the Hib vaccine shortage makes me very nervous.

It is clear to even the less-government-is-better folks like myself that the federal government must step into the arena and ensure that vaccines are not only safe, but available. It must also create and maintain sufficient financial incentives to keep the private sector enthusiastic about vaccine research and development.

Regardless of whom we elect this November, the year 2009 should provide an excellent opportunity for change. Dr. Pichichero's recommendations take advantage of the current system, but I think we need to think bigger. Let's raise vaccine supply and safety issues to the cabinet level.

It's time for a Vaccine Czar, a Godfather (or Godmother) of Immunization. Someone who has the president's ear every day. Someone armed with a sharp knife that cuts red tape like warm butter. Someone who carries a big stick to whack the kneecaps of the insurance companies. And someone with an ample supply of carrots to keep the pharmaceutical companies drooling for the profits of newly developed vaccines.

I fell under the spell of Obama Charisma many months ago, but I think any of the top candidates can be convinced that vaccine supply is a critical issue. We just need to start yelling louder and they'll hear us.

[email protected]

Feet up on my desk, with my phone headset glued to my better ear, I was just extricating myself from the last call of the morning's half-hour call time. Sensing a presence behind me, I turned to find Allison, our newest receptionist, patiently waiting with a sheaf of unsigned health forms in her hand.

“I was eavesdropping on your last two calls,” she said. “It sounds like you're not very worried about all this stuff I read about lead-containing toys from China.”

“I guess I'm not disguising my impatience with the silliness of the whole thing,” I replied. “Let me tell you a little story that might help explain my lack of enthusiasm for the current lead flap.”

The story went something like this: When I was a preschooler, I and many of my peers played with toy soldiers made out of lead. But I was really into these little hand-painted warriors. I suspect that I had an army of at least 200 soldiers representing several different nations. I would line them up in a variety of battle formations and have them flank and outflank each other for hours. My father built me several elaborate storage trays as my collection grew. With heavy use, many of their hand-painted uniforms chipped off, exposing their lead bodies.

By the time I was 11, my interest had shifted to sports and building boat and airplane models. For one project, I needed some ballast, and I knew that lead had the weight-to-volume ratio that I wanted. So, I built myself some little ½-by-½-by-2-inch molds out of scrap wood I found in the basement. I asked my mother if I could borrow one of her old saucepans and I proceeded to melt down a third of my lead soldier collection on the kitchen stove. I carefully poured the molten lead into my molds and my little homemade ingots came out exactly as I had planned. And I continued to use them for a variety of projects over the next several years. My father was very upset because I had destroyed what he correctly suspected would have become a valuable collection in 20 years. Neither of my parents expressed any concern about my health.

While I never got straight A's in school, I still managed to graduate from college and an accredited medical school. In recent years, I have wondered how well I might have done had I not dabbled in metallurgy as a youngster, but I don't think I can blame lead for any of my numerous shortcomings.

So you can see that the tiny amounts of lead that have been getting so much attention don't get me very excited. However, when asked, I do suggest that parents toss out or return any toys that appear on the lead-tainted recall list. Not so much because I'm concerned about the lead, but because many of the toys are media driven and encourage more TV viewing.

Sadly, some of the parents who have become concerned about these toys also have been withholding valuable and potentially lifesaving vaccines based on irrational and unsubstantiated concerns about the safety of another heavy metal, mercury. But, don't get me wrong. Lead can be and still is a serious problem for some young children.

Fortunately, the young families who are buying and rehabbing old farmhouses here in Maine are generally well-educated and very aware of the risks of lead paint chips, dust, and plumbing. However, we still encounter problems with unscrupulous landlords who rent lead-contaminated apartments to economically disadvantaged families. We try to stay ahead of the problem with our screening tests, but we aren't perfect. Even when we identify a child at risk, the family often moves on, the apartment remains a problem, and another unsuspecting family moves in and the cycle goes on.

I could sense Allison was beginning to lose interest in my harangue. But, she politely thanked me for the anecdote and reminded me to “remember to please sign these forms.”

[email protected]

Feet up on my desk, with my phone headset glued to my better ear, I was just extricating myself from the last call of the morning's half-hour call time. Sensing a presence behind me, I turned to find Allison, our newest receptionist, patiently waiting with a sheaf of unsigned health forms in her hand.

“I was eavesdropping on your last two calls,” she said. “It sounds like you're not very worried about all this stuff I read about lead-containing toys from China.”

“I guess I'm not disguising my impatience with the silliness of the whole thing,” I replied. “Let me tell you a little story that might help explain my lack of enthusiasm for the current lead flap.”

The story went something like this: When I was a preschooler, I and many of my peers played with toy soldiers made out of lead. But I was really into these little hand-painted warriors. I suspect that I had an army of at least 200 soldiers representing several different nations. I would line them up in a variety of battle formations and have them flank and outflank each other for hours. My father built me several elaborate storage trays as my collection grew. With heavy use, many of their hand-painted uniforms chipped off, exposing their lead bodies.

By the time I was 11, my interest had shifted to sports and building boat and airplane models. For one project, I needed some ballast, and I knew that lead had the weight-to-volume ratio that I wanted. So, I built myself some little ½-by-½-by-2-inch molds out of scrap wood I found in the basement. I asked my mother if I could borrow one of her old saucepans and I proceeded to melt down a third of my lead soldier collection on the kitchen stove. I carefully poured the molten lead into my molds and my little homemade ingots came out exactly as I had planned. And I continued to use them for a variety of projects over the next several years. My father was very upset because I had destroyed what he correctly suspected would have become a valuable collection in 20 years. Neither of my parents expressed any concern about my health.

While I never got straight A's in school, I still managed to graduate from college and an accredited medical school. In recent years, I have wondered how well I might have done had I not dabbled in metallurgy as a youngster, but I don't think I can blame lead for any of my numerous shortcomings.

So you can see that the tiny amounts of lead that have been getting so much attention don't get me very excited. However, when asked, I do suggest that parents toss out or return any toys that appear on the lead-tainted recall list. Not so much because I'm concerned about the lead, but because many of the toys are media driven and encourage more TV viewing.

Sadly, some of the parents who have become concerned about these toys also have been withholding valuable and potentially lifesaving vaccines based on irrational and unsubstantiated concerns about the safety of another heavy metal, mercury. But, don't get me wrong. Lead can be and still is a serious problem for some young children.

Fortunately, the young families who are buying and rehabbing old farmhouses here in Maine are generally well-educated and very aware of the risks of lead paint chips, dust, and plumbing. However, we still encounter problems with unscrupulous landlords who rent lead-contaminated apartments to economically disadvantaged families. We try to stay ahead of the problem with our screening tests, but we aren't perfect. Even when we identify a child at risk, the family often moves on, the apartment remains a problem, and another unsuspecting family moves in and the cycle goes on.

I could sense Allison was beginning to lose interest in my harangue. But, she politely thanked me for the anecdote and reminded me to “remember to please sign these forms.”

[email protected]

Feet up on my desk, with my phone headset glued to my better ear, I was just extricating myself from the last call of the morning's half-hour call time. Sensing a presence behind me, I turned to find Allison, our newest receptionist, patiently waiting with a sheaf of unsigned health forms in her hand.

“I was eavesdropping on your last two calls,” she said. “It sounds like you're not very worried about all this stuff I read about lead-containing toys from China.”

“I guess I'm not disguising my impatience with the silliness of the whole thing,” I replied. “Let me tell you a little story that might help explain my lack of enthusiasm for the current lead flap.”

The story went something like this: When I was a preschooler, I and many of my peers played with toy soldiers made out of lead. But I was really into these little hand-painted warriors. I suspect that I had an army of at least 200 soldiers representing several different nations. I would line them up in a variety of battle formations and have them flank and outflank each other for hours. My father built me several elaborate storage trays as my collection grew. With heavy use, many of their hand-painted uniforms chipped off, exposing their lead bodies.

By the time I was 11, my interest had shifted to sports and building boat and airplane models. For one project, I needed some ballast, and I knew that lead had the weight-to-volume ratio that I wanted. So, I built myself some little ½-by-½-by-2-inch molds out of scrap wood I found in the basement. I asked my mother if I could borrow one of her old saucepans and I proceeded to melt down a third of my lead soldier collection on the kitchen stove. I carefully poured the molten lead into my molds and my little homemade ingots came out exactly as I had planned. And I continued to use them for a variety of projects over the next several years. My father was very upset because I had destroyed what he correctly suspected would have become a valuable collection in 20 years. Neither of my parents expressed any concern about my health.

While I never got straight A's in school, I still managed to graduate from college and an accredited medical school. In recent years, I have wondered how well I might have done had I not dabbled in metallurgy as a youngster, but I don't think I can blame lead for any of my numerous shortcomings.

So you can see that the tiny amounts of lead that have been getting so much attention don't get me very excited. However, when asked, I do suggest that parents toss out or return any toys that appear on the lead-tainted recall list. Not so much because I'm concerned about the lead, but because many of the toys are media driven and encourage more TV viewing.

Sadly, some of the parents who have become concerned about these toys also have been withholding valuable and potentially lifesaving vaccines based on irrational and unsubstantiated concerns about the safety of another heavy metal, mercury. But, don't get me wrong. Lead can be and still is a serious problem for some young children.

Fortunately, the young families who are buying and rehabbing old farmhouses here in Maine are generally well-educated and very aware of the risks of lead paint chips, dust, and plumbing. However, we still encounter problems with unscrupulous landlords who rent lead-contaminated apartments to economically disadvantaged families. We try to stay ahead of the problem with our screening tests, but we aren't perfect. Even when we identify a child at risk, the family often moves on, the apartment remains a problem, and another unsuspecting family moves in and the cycle goes on.

I could sense Allison was beginning to lose interest in my harangue. But, she politely thanked me for the anecdote and reminded me to “remember to please sign these forms.”

[email protected]

I glanced at the chief complaint scribbled on the top of the billing sheet before I entered the exam room. I usually ignore these little “heads-ups” from the receptionists because they often bear little if any resemblance to the parent's real concern or the patient's problem.

In this case, I was hoping the “?development” was one of those red herrings.

The patient I was about to see was a 16-month-old whom I had examined at least nine times since his birth, and I couldn't recall receiving bad vibes on any of those previous health maintenance visits.

So, I took a deep breath and gave my nose the habitual rub before entering a patient encounter, and opened the door carefully because one can never tell where a toddler might be motoring. Fortunately, the history spilled out quickly.

It turns out that a friend of a sister-in-law of the child's day-care provider is a recently trained occupational therapist. She had paid a social call at the day-care center one day the previous week and after a 20-minute informal observation, had shared her concerns about this young man's development.

Apparently, she was troubled by how he rose from sitting to standing and by the fact that he was totally uninterested in television. The day-care provider felt obligated to share these unsolicited observations with the parents and voila, we have an office visit.

I re-asked a handful of questions from the previous two well-child visits as I watched this little rascal cavort around the room. I then took him for a run down the hall and examined him.

Luckily, the parents were already skeptical about the off-the-cuff appraisal they had received secondhand. They readily accepted my qualified reassurances, including, “I don't know whether he is going to graduate first in his class, but I don't have any worries about your son's development.”

The scenario could have been much different. At any one moment, there are three or four infants and toddlers with soft signs of developmental delay circulating in my subconscious. I haven't shared my concerns with their parents because I know that within 12 months, the tincture of time will have coaxed 90% of these little outliers back under the safe umbrella of the bell-shaped curve.

Of course, once or twice a year it will become obvious that things haven't moved along as well as I had hoped, and I must begin the careful process of sharing my concerns with the parents.

I'm sure that people who equate early intervention with motherhood and apple pie will feel that by keeping my worries to myself for a few months, I have done irreparable harm to these patients and their families.

Trust me, I would much prefer to cleanse my mind of all those private worries I harbor about my patients. But, it is just part of being a physician. One can minimize some of these worries by ordering unnecessary but reassuring lab work and CT scans. But when the worry is about something as nebulous as a subtle developmental delay, the lab and the imaging department can't bail me out. Only time will tell, and I choose to keep my tongue clenched firmly between my teeth while I wait.

To do otherwise can open a can of worms that has parental angst written all over it. When I finally say, “Mrs. James, I'm just a teeny bit concerned because your baby is just a little bit floppy,” I had better be ready for several long discussions about what this can mean and have a plan of how we are going to move forward with evaluations and therapy.

If I'm lucky, the parents will say, “We're glad you mentioned that because we were just beginning to wonder about his development ourselves.”

Timing is everything.

[email protected]

I glanced at the chief complaint scribbled on the top of the billing sheet before I entered the exam room. I usually ignore these little “heads-ups” from the receptionists because they often bear little if any resemblance to the parent's real concern or the patient's problem.

In this case, I was hoping the “?development” was one of those red herrings.

The patient I was about to see was a 16-month-old whom I had examined at least nine times since his birth, and I couldn't recall receiving bad vibes on any of those previous health maintenance visits.

So, I took a deep breath and gave my nose the habitual rub before entering a patient encounter, and opened the door carefully because one can never tell where a toddler might be motoring. Fortunately, the history spilled out quickly.

It turns out that a friend of a sister-in-law of the child's day-care provider is a recently trained occupational therapist. She had paid a social call at the day-care center one day the previous week and after a 20-minute informal observation, had shared her concerns about this young man's development.

Apparently, she was troubled by how he rose from sitting to standing and by the fact that he was totally uninterested in television. The day-care provider felt obligated to share these unsolicited observations with the parents and voila, we have an office visit.

I re-asked a handful of questions from the previous two well-child visits as I watched this little rascal cavort around the room. I then took him for a run down the hall and examined him.

Luckily, the parents were already skeptical about the off-the-cuff appraisal they had received secondhand. They readily accepted my qualified reassurances, including, “I don't know whether he is going to graduate first in his class, but I don't have any worries about your son's development.”

The scenario could have been much different. At any one moment, there are three or four infants and toddlers with soft signs of developmental delay circulating in my subconscious. I haven't shared my concerns with their parents because I know that within 12 months, the tincture of time will have coaxed 90% of these little outliers back under the safe umbrella of the bell-shaped curve.

Of course, once or twice a year it will become obvious that things haven't moved along as well as I had hoped, and I must begin the careful process of sharing my concerns with the parents.

I'm sure that people who equate early intervention with motherhood and apple pie will feel that by keeping my worries to myself for a few months, I have done irreparable harm to these patients and their families.

Trust me, I would much prefer to cleanse my mind of all those private worries I harbor about my patients. But, it is just part of being a physician. One can minimize some of these worries by ordering unnecessary but reassuring lab work and CT scans. But when the worry is about something as nebulous as a subtle developmental delay, the lab and the imaging department can't bail me out. Only time will tell, and I choose to keep my tongue clenched firmly between my teeth while I wait.

To do otherwise can open a can of worms that has parental angst written all over it. When I finally say, “Mrs. James, I'm just a teeny bit concerned because your baby is just a little bit floppy,” I had better be ready for several long discussions about what this can mean and have a plan of how we are going to move forward with evaluations and therapy.

If I'm lucky, the parents will say, “We're glad you mentioned that because we were just beginning to wonder about his development ourselves.”

Timing is everything.

[email protected]

I glanced at the chief complaint scribbled on the top of the billing sheet before I entered the exam room. I usually ignore these little “heads-ups” from the receptionists because they often bear little if any resemblance to the parent's real concern or the patient's problem.

In this case, I was hoping the “?development” was one of those red herrings.

The patient I was about to see was a 16-month-old whom I had examined at least nine times since his birth, and I couldn't recall receiving bad vibes on any of those previous health maintenance visits.

So, I took a deep breath and gave my nose the habitual rub before entering a patient encounter, and opened the door carefully because one can never tell where a toddler might be motoring. Fortunately, the history spilled out quickly.

It turns out that a friend of a sister-in-law of the child's day-care provider is a recently trained occupational therapist. She had paid a social call at the day-care center one day the previous week and after a 20-minute informal observation, had shared her concerns about this young man's development.

Apparently, she was troubled by how he rose from sitting to standing and by the fact that he was totally uninterested in television. The day-care provider felt obligated to share these unsolicited observations with the parents and voila, we have an office visit.

I re-asked a handful of questions from the previous two well-child visits as I watched this little rascal cavort around the room. I then took him for a run down the hall and examined him.

Luckily, the parents were already skeptical about the off-the-cuff appraisal they had received secondhand. They readily accepted my qualified reassurances, including, “I don't know whether he is going to graduate first in his class, but I don't have any worries about your son's development.”

The scenario could have been much different. At any one moment, there are three or four infants and toddlers with soft signs of developmental delay circulating in my subconscious. I haven't shared my concerns with their parents because I know that within 12 months, the tincture of time will have coaxed 90% of these little outliers back under the safe umbrella of the bell-shaped curve.

Of course, once or twice a year it will become obvious that things haven't moved along as well as I had hoped, and I must begin the careful process of sharing my concerns with the parents.

I'm sure that people who equate early intervention with motherhood and apple pie will feel that by keeping my worries to myself for a few months, I have done irreparable harm to these patients and their families.

Trust me, I would much prefer to cleanse my mind of all those private worries I harbor about my patients. But, it is just part of being a physician. One can minimize some of these worries by ordering unnecessary but reassuring lab work and CT scans. But when the worry is about something as nebulous as a subtle developmental delay, the lab and the imaging department can't bail me out. Only time will tell, and I choose to keep my tongue clenched firmly between my teeth while I wait.

To do otherwise can open a can of worms that has parental angst written all over it. When I finally say, “Mrs. James, I'm just a teeny bit concerned because your baby is just a little bit floppy,” I had better be ready for several long discussions about what this can mean and have a plan of how we are going to move forward with evaluations and therapy.

If I'm lucky, the parents will say, “We're glad you mentioned that because we were just beginning to wonder about his development ourselves.”

Timing is everything.

[email protected]

I had just finished a full morning of seeing patients with a third-year medical student who was beginning his second clinical rotation. His half day with me was billed as an “Introduction to Outpatient Community Pediatrics.” And, I thought I had given him a pretty good run for his 3-hour investment.

We sat down in my cluttered but homey office for a brief recap of the morning's experience. Unless it is a question about a physical finding that will vanish when the patient leaves, I usually ask students to hold most of their questions until the end of the half-day session, when we can have a more leisurely opportunity to explore the answers. But, my young appendage for the morning had no questions, just an observation: “You certainly have your patients well trained.”

This was not the first time a visitor to my practice has made this comment. And each time I hear it, I get a bit uncomfortable … and defensive.

No question about it. I see patients more quickly than the average clinician. And, I'm not embarrassed to admit that my approach to problems, health-related or otherwise, is pragmatic, no-nonsense, get-to-the-point. I am old enough that I introduce myself to patients and parents as “Doctor Wilkoff.” That's what everyone did when I started, and I've seen no reason to change.

But, I hope I'm not an ogre. My coworkers don't snap to attention and click their heels when I enter the room. I ask people what is bothering them in a way that I hope encourages the best answers, and I listen to their responses. So, it troubles me when someone makes an observation that suggests that I have patients and parents performing like a troupe of dancing bears.

Struggling to sound undefensive, I asked “What do you mean by well-trained?!!” Seeing through my thin disguise, the student replied, “No, no, I didn't mean it that way. I was just impressed how many calls you received during your call time. And, I don't remember that we were interrupted once while we were seeing patients. You told one of your partners you only got one call last night.”

I replied, “I was hoping that's what you would say. You know that every physician's patients are trained. … We are all just slaves to positive and negative reinforcement. Our patients know they can always reach us at a call time and they know we keep our promises to call them in the morning. In that sense, they are 'trained' to wait.”

A physician who always runs late will find that when he is on time his patients will be late. The physician who instructs his staff to take temperatures on every sick child and makes a big deal about the number is training parents to focus on fever and call him with frequent updates about each tenth-of-a-degree change.

Physicians who include teething in their diagnostic repertoires and fail to correct parents who use teething as an explanation for a variety of symptoms may be training those parents to be less accurate and safe observers of their children. The physician who is less than rigorous with his diagnostic criteria for otitis and/or who treats when observation would be a better course is training parents to expect a diagnosis and antibiotics when their children have fevers and runny noses.

I could have given my young tutee even more examples of how parent/patient behavior is a reflection of their physicians' behavior. But, it was pushing 12 o'clock and our patients are trained that for the next hour they can reach me, and that I'll be on my bicycle and out of breath when I answer my pager.

[email protected]

I had just finished a full morning of seeing patients with a third-year medical student who was beginning his second clinical rotation. His half day with me was billed as an “Introduction to Outpatient Community Pediatrics.” And, I thought I had given him a pretty good run for his 3-hour investment.

We sat down in my cluttered but homey office for a brief recap of the morning's experience. Unless it is a question about a physical finding that will vanish when the patient leaves, I usually ask students to hold most of their questions until the end of the half-day session, when we can have a more leisurely opportunity to explore the answers. But, my young appendage for the morning had no questions, just an observation: “You certainly have your patients well trained.”

This was not the first time a visitor to my practice has made this comment. And each time I hear it, I get a bit uncomfortable … and defensive.

No question about it. I see patients more quickly than the average clinician. And, I'm not embarrassed to admit that my approach to problems, health-related or otherwise, is pragmatic, no-nonsense, get-to-the-point. I am old enough that I introduce myself to patients and parents as “Doctor Wilkoff.” That's what everyone did when I started, and I've seen no reason to change.

But, I hope I'm not an ogre. My coworkers don't snap to attention and click their heels when I enter the room. I ask people what is bothering them in a way that I hope encourages the best answers, and I listen to their responses. So, it troubles me when someone makes an observation that suggests that I have patients and parents performing like a troupe of dancing bears.

Struggling to sound undefensive, I asked “What do you mean by well-trained?!!” Seeing through my thin disguise, the student replied, “No, no, I didn't mean it that way. I was just impressed how many calls you received during your call time. And, I don't remember that we were interrupted once while we were seeing patients. You told one of your partners you only got one call last night.”

I replied, “I was hoping that's what you would say. You know that every physician's patients are trained. … We are all just slaves to positive and negative reinforcement. Our patients know they can always reach us at a call time and they know we keep our promises to call them in the morning. In that sense, they are 'trained' to wait.”

A physician who always runs late will find that when he is on time his patients will be late. The physician who instructs his staff to take temperatures on every sick child and makes a big deal about the number is training parents to focus on fever and call him with frequent updates about each tenth-of-a-degree change.

Physicians who include teething in their diagnostic repertoires and fail to correct parents who use teething as an explanation for a variety of symptoms may be training those parents to be less accurate and safe observers of their children. The physician who is less than rigorous with his diagnostic criteria for otitis and/or who treats when observation would be a better course is training parents to expect a diagnosis and antibiotics when their children have fevers and runny noses.

I could have given my young tutee even more examples of how parent/patient behavior is a reflection of their physicians' behavior. But, it was pushing 12 o'clock and our patients are trained that for the next hour they can reach me, and that I'll be on my bicycle and out of breath when I answer my pager.

[email protected]

I had just finished a full morning of seeing patients with a third-year medical student who was beginning his second clinical rotation. His half day with me was billed as an “Introduction to Outpatient Community Pediatrics.” And, I thought I had given him a pretty good run for his 3-hour investment.

We sat down in my cluttered but homey office for a brief recap of the morning's experience. Unless it is a question about a physical finding that will vanish when the patient leaves, I usually ask students to hold most of their questions until the end of the half-day session, when we can have a more leisurely opportunity to explore the answers. But, my young appendage for the morning had no questions, just an observation: “You certainly have your patients well trained.”

This was not the first time a visitor to my practice has made this comment. And each time I hear it, I get a bit uncomfortable … and defensive.

No question about it. I see patients more quickly than the average clinician. And, I'm not embarrassed to admit that my approach to problems, health-related or otherwise, is pragmatic, no-nonsense, get-to-the-point. I am old enough that I introduce myself to patients and parents as “Doctor Wilkoff.” That's what everyone did when I started, and I've seen no reason to change.

But, I hope I'm not an ogre. My coworkers don't snap to attention and click their heels when I enter the room. I ask people what is bothering them in a way that I hope encourages the best answers, and I listen to their responses. So, it troubles me when someone makes an observation that suggests that I have patients and parents performing like a troupe of dancing bears.

Struggling to sound undefensive, I asked “What do you mean by well-trained?!!” Seeing through my thin disguise, the student replied, “No, no, I didn't mean it that way. I was just impressed how many calls you received during your call time. And, I don't remember that we were interrupted once while we were seeing patients. You told one of your partners you only got one call last night.”

I replied, “I was hoping that's what you would say. You know that every physician's patients are trained. … We are all just slaves to positive and negative reinforcement. Our patients know they can always reach us at a call time and they know we keep our promises to call them in the morning. In that sense, they are 'trained' to wait.”

A physician who always runs late will find that when he is on time his patients will be late. The physician who instructs his staff to take temperatures on every sick child and makes a big deal about the number is training parents to focus on fever and call him with frequent updates about each tenth-of-a-degree change.

Physicians who include teething in their diagnostic repertoires and fail to correct parents who use teething as an explanation for a variety of symptoms may be training those parents to be less accurate and safe observers of their children. The physician who is less than rigorous with his diagnostic criteria for otitis and/or who treats when observation would be a better course is training parents to expect a diagnosis and antibiotics when their children have fevers and runny noses.

I could have given my young tutee even more examples of how parent/patient behavior is a reflection of their physicians' behavior. But, it was pushing 12 o'clock and our patients are trained that for the next hour they can reach me, and that I'll be on my bicycle and out of breath when I answer my pager.

[email protected]

It would be an exaggeration to say that I have a love-hate relationship with meet-and-greet visits. Let's just say that I know that it can be very important to sit down with families who are shopping for a pediatrician. But, these investigatory sessions can throw my office schedule into a waiting room gridlock from which it may take hours to recover. Meet-and-greet visits are never the high point of my day.

When one or both parents-to-be are former patients, the visits may take just a few minutes. Their own parents have brainwashed them into believing that I am the best thing since sliced bread. The young and clueless couples have already decided to come to our office, and I simply feed them a few answers to the questions they have forgotten to ask.

Sometimes an “interrogation” can drag on for 30 minutes as we walk slowly through a laser-printed set of questions collected from Internet sites and books about how to be a skeptical parent. We have tried to shortcut some of the predictable biographic and procedural questions by handing out a printed sheet of answers to these FAQs. But, from time to time a receptionist will forget to pass out these sheets and I must spin a few extra yarns to make myself appear to be human and well trained.

One of the standard questions asked is whether my wife and I have children. Obviously, they want to know that I have “been there and done that.” It's silly because we all know one doesn't have to have had children to be an excellent pediatrician. To further impress my interrogators, I often add the reassurance that none of my three offspring is currently incarcerated or institutionalized.

The most time-devouring questions are the open-ended ones such as, “Do you prescribe antibiotics?” or “How do you feel about immunizations?” “Yes” and “Good” never seem to be sufficient answers. But, I've learned to toss these questions back at my inquisitors. Their answers to, “How do you feel about antibiotics and immunizations?” will give me some clues about how easy this family would be to work with.

While I still have control of the questioning, I ask a few more: “Do you have a birth plan and what does it include?” “Do you plan to breast-feed and do you have any concerns about how it will work?” The answers can highlight potential friction points and bumps in the road that can make the first few weeks of parenting unnecessarily disappointing and frustrating for all of us.

It's nice to know ahead of time that a family is planning to refuse the vitamin K shot and/or antibiotic eye drops. At least I will have a chance to tell my side of the story in the calm and rational setting of my office. And, it's just plain good medicine to establish even a small foundation for your professional relationship before the doodoo hits the fan. The only time I have been sued in more than 30 years involved a premature newborn and a family from out of state whom I had never met. Even a brief prenatal visit might have helped me stay out of the courtroom.

I can still remember how much easier it was to tell a couple that I was sure that their brand-new daughter had Down syndrome because I had suffered through a 15-minute meet-and-greet the previous month. Unfortunately, we continue to have trouble getting our obstetricians to see much value in pediatric prenatal visits. They want us there in a flash when things go sour, but somehow they can't remember to encourage their patients to visit and choose a pediatrician in the calm of the second trimester.

[email protected]

It would be an exaggeration to say that I have a love-hate relationship with meet-and-greet visits. Let's just say that I know that it can be very important to sit down with families who are shopping for a pediatrician. But, these investigatory sessions can throw my office schedule into a waiting room gridlock from which it may take hours to recover. Meet-and-greet visits are never the high point of my day.

When one or both parents-to-be are former patients, the visits may take just a few minutes. Their own parents have brainwashed them into believing that I am the best thing since sliced bread. The young and clueless couples have already decided to come to our office, and I simply feed them a few answers to the questions they have forgotten to ask.

Sometimes an “interrogation” can drag on for 30 minutes as we walk slowly through a laser-printed set of questions collected from Internet sites and books about how to be a skeptical parent. We have tried to shortcut some of the predictable biographic and procedural questions by handing out a printed sheet of answers to these FAQs. But, from time to time a receptionist will forget to pass out these sheets and I must spin a few extra yarns to make myself appear to be human and well trained.

One of the standard questions asked is whether my wife and I have children. Obviously, they want to know that I have “been there and done that.” It's silly because we all know one doesn't have to have had children to be an excellent pediatrician. To further impress my interrogators, I often add the reassurance that none of my three offspring is currently incarcerated or institutionalized.

The most time-devouring questions are the open-ended ones such as, “Do you prescribe antibiotics?” or “How do you feel about immunizations?” “Yes” and “Good” never seem to be sufficient answers. But, I've learned to toss these questions back at my inquisitors. Their answers to, “How do you feel about antibiotics and immunizations?” will give me some clues about how easy this family would be to work with.

While I still have control of the questioning, I ask a few more: “Do you have a birth plan and what does it include?” “Do you plan to breast-feed and do you have any concerns about how it will work?” The answers can highlight potential friction points and bumps in the road that can make the first few weeks of parenting unnecessarily disappointing and frustrating for all of us.

It's nice to know ahead of time that a family is planning to refuse the vitamin K shot and/or antibiotic eye drops. At least I will have a chance to tell my side of the story in the calm and rational setting of my office. And, it's just plain good medicine to establish even a small foundation for your professional relationship before the doodoo hits the fan. The only time I have been sued in more than 30 years involved a premature newborn and a family from out of state whom I had never met. Even a brief prenatal visit might have helped me stay out of the courtroom.

I can still remember how much easier it was to tell a couple that I was sure that their brand-new daughter had Down syndrome because I had suffered through a 15-minute meet-and-greet the previous month. Unfortunately, we continue to have trouble getting our obstetricians to see much value in pediatric prenatal visits. They want us there in a flash when things go sour, but somehow they can't remember to encourage their patients to visit and choose a pediatrician in the calm of the second trimester.

[email protected]

It would be an exaggeration to say that I have a love-hate relationship with meet-and-greet visits. Let's just say that I know that it can be very important to sit down with families who are shopping for a pediatrician. But, these investigatory sessions can throw my office schedule into a waiting room gridlock from which it may take hours to recover. Meet-and-greet visits are never the high point of my day.

When one or both parents-to-be are former patients, the visits may take just a few minutes. Their own parents have brainwashed them into believing that I am the best thing since sliced bread. The young and clueless couples have already decided to come to our office, and I simply feed them a few answers to the questions they have forgotten to ask.

Sometimes an “interrogation” can drag on for 30 minutes as we walk slowly through a laser-printed set of questions collected from Internet sites and books about how to be a skeptical parent. We have tried to shortcut some of the predictable biographic and procedural questions by handing out a printed sheet of answers to these FAQs. But, from time to time a receptionist will forget to pass out these sheets and I must spin a few extra yarns to make myself appear to be human and well trained.

One of the standard questions asked is whether my wife and I have children. Obviously, they want to know that I have “been there and done that.” It's silly because we all know one doesn't have to have had children to be an excellent pediatrician. To further impress my interrogators, I often add the reassurance that none of my three offspring is currently incarcerated or institutionalized.

The most time-devouring questions are the open-ended ones such as, “Do you prescribe antibiotics?” or “How do you feel about immunizations?” “Yes” and “Good” never seem to be sufficient answers. But, I've learned to toss these questions back at my inquisitors. Their answers to, “How do you feel about antibiotics and immunizations?” will give me some clues about how easy this family would be to work with.

While I still have control of the questioning, I ask a few more: “Do you have a birth plan and what does it include?” “Do you plan to breast-feed and do you have any concerns about how it will work?” The answers can highlight potential friction points and bumps in the road that can make the first few weeks of parenting unnecessarily disappointing and frustrating for all of us.

It's nice to know ahead of time that a family is planning to refuse the vitamin K shot and/or antibiotic eye drops. At least I will have a chance to tell my side of the story in the calm and rational setting of my office. And, it's just plain good medicine to establish even a small foundation for your professional relationship before the doodoo hits the fan. The only time I have been sued in more than 30 years involved a premature newborn and a family from out of state whom I had never met. Even a brief prenatal visit might have helped me stay out of the courtroom.

I can still remember how much easier it was to tell a couple that I was sure that their brand-new daughter had Down syndrome because I had suffered through a 15-minute meet-and-greet the previous month. Unfortunately, we continue to have trouble getting our obstetricians to see much value in pediatric prenatal visits. They want us there in a flash when things go sour, but somehow they can't remember to encourage their patients to visit and choose a pediatrician in the calm of the second trimester.

[email protected]

“Welcome to the Bowdoin Medical Group, Mrs. Talbot. We're happy you've chosen to bring your children to see us. You look familiar. Have you been living here in Brunswick for a while?”

“Yes, we moved here about 6 years ago, but I got tired of never being sure which doctor my children would see when I took them to the XYZ Clinic. We've heard that will happen less frequently here with your group.”

Like “evidence-based,” “continuity” is one of those warm fuzzy concepts that we pediatricians have been told to clutch to our breasts and cuddle with when the cold winds of change are stinging our faces.

But, which evidence are we to believe and who among us has the stamina to volunteer to be available to our patients 24/7/365?

Continuity can create a sense of security that we all enjoy whether we are seeking reassurance about our health or merely picking up our dry cleaning.

I contend that the reason Mr. Peterson continued to return to Cheers was not because the beer was cold and plentiful, but because he was always greeted with a resounding welcome of “Norm!!” every time he walked through the door.

Familiarity breeds comfort, not contempt.

But when it comes to the delivery of medical care, familiarity and continuity also foster safety and efficiency.

When the same physician sees the patient, the history-taking part of the encounter takes far less time and documentation needs to be far less detailed.

Those fragments of social and family history that may hold the key to the patient's recurring abdominal pains surface more quickly for a familiar face but may never appear for the physician/stranger.

In a survey of surgery and internal medicine residents, one investigator discovered that after the Accreditation Council for Graduate Medical Education (ACGME) duty-hour restrictions came into effect, the residents felt that continuity had decreased significantly and the quality of care had suffered slightly. It appears that errors attributable to physician fatigue may have been replaced with those related to discontinuous care.

One may argue that from time to time a patient may benefit from having his/her concerns considered by another physician with a different perspective.

However, when all is said and done, patients prefer being seen by the same physician and, in my view, receive better care when it is continuous.

But, continuity is costly. How many physicians have found themselves smoldering on the pyre of colleagues burned out in an attempt to be available to their patients 24/7/365?

Even the illusion of continuity created by well-crafted coverage arrangements can be expensive.

Documentation must be accurate and available to the surrogate provider when the patient is seen. Quality transcription and electronic medical records don't come cheap.

Dividing a larger group into smaller working units can provide the familiarity that patients want and need.

But, chopping a practice into bite-sized teams works only if everyone on the team buys into the concept that continuity is important.

In our group we feel that we do a pretty good job at having our patients see the same physician as often as possible.

However, we struggle with continuity at the front desk.

Our 8 a.m. to 7 p.m. (or later) office hours mean that receptionists change shifts once or twice each day. We would like our patients to be welcomed by a familiar face when they arrive. But, it just isn't happening.

I guess I shouldn't fret too much—we must be doing well enough to have earned a reputation that attracted Mrs. Talbot.

[email protected]

“Welcome to the Bowdoin Medical Group, Mrs. Talbot. We're happy you've chosen to bring your children to see us. You look familiar. Have you been living here in Brunswick for a while?”

“Yes, we moved here about 6 years ago, but I got tired of never being sure which doctor my children would see when I took them to the XYZ Clinic. We've heard that will happen less frequently here with your group.”

Like “evidence-based,” “continuity” is one of those warm fuzzy concepts that we pediatricians have been told to clutch to our breasts and cuddle with when the cold winds of change are stinging our faces.

But, which evidence are we to believe and who among us has the stamina to volunteer to be available to our patients 24/7/365?

Continuity can create a sense of security that we all enjoy whether we are seeking reassurance about our health or merely picking up our dry cleaning.

I contend that the reason Mr. Peterson continued to return to Cheers was not because the beer was cold and plentiful, but because he was always greeted with a resounding welcome of “Norm!!” every time he walked through the door.

Familiarity breeds comfort, not contempt.

But when it comes to the delivery of medical care, familiarity and continuity also foster safety and efficiency.

When the same physician sees the patient, the history-taking part of the encounter takes far less time and documentation needs to be far less detailed.

Those fragments of social and family history that may hold the key to the patient's recurring abdominal pains surface more quickly for a familiar face but may never appear for the physician/stranger.

In a survey of surgery and internal medicine residents, one investigator discovered that after the Accreditation Council for Graduate Medical Education (ACGME) duty-hour restrictions came into effect, the residents felt that continuity had decreased significantly and the quality of care had suffered slightly. It appears that errors attributable to physician fatigue may have been replaced with those related to discontinuous care.

One may argue that from time to time a patient may benefit from having his/her concerns considered by another physician with a different perspective.

However, when all is said and done, patients prefer being seen by the same physician and, in my view, receive better care when it is continuous.

But, continuity is costly. How many physicians have found themselves smoldering on the pyre of colleagues burned out in an attempt to be available to their patients 24/7/365?

Even the illusion of continuity created by well-crafted coverage arrangements can be expensive.

Documentation must be accurate and available to the surrogate provider when the patient is seen. Quality transcription and electronic medical records don't come cheap.

Dividing a larger group into smaller working units can provide the familiarity that patients want and need.

But, chopping a practice into bite-sized teams works only if everyone on the team buys into the concept that continuity is important.

In our group we feel that we do a pretty good job at having our patients see the same physician as often as possible.

However, we struggle with continuity at the front desk.

Our 8 a.m. to 7 p.m. (or later) office hours mean that receptionists change shifts once or twice each day. We would like our patients to be welcomed by a familiar face when they arrive. But, it just isn't happening.

I guess I shouldn't fret too much—we must be doing well enough to have earned a reputation that attracted Mrs. Talbot.

[email protected]

“Welcome to the Bowdoin Medical Group, Mrs. Talbot. We're happy you've chosen to bring your children to see us. You look familiar. Have you been living here in Brunswick for a while?”

“Yes, we moved here about 6 years ago, but I got tired of never being sure which doctor my children would see when I took them to the XYZ Clinic. We've heard that will happen less frequently here with your group.”

Like “evidence-based,” “continuity” is one of those warm fuzzy concepts that we pediatricians have been told to clutch to our breasts and cuddle with when the cold winds of change are stinging our faces.

But, which evidence are we to believe and who among us has the stamina to volunteer to be available to our patients 24/7/365?

Continuity can create a sense of security that we all enjoy whether we are seeking reassurance about our health or merely picking up our dry cleaning.

I contend that the reason Mr. Peterson continued to return to Cheers was not because the beer was cold and plentiful, but because he was always greeted with a resounding welcome of “Norm!!” every time he walked through the door.

Familiarity breeds comfort, not contempt.

But when it comes to the delivery of medical care, familiarity and continuity also foster safety and efficiency.

When the same physician sees the patient, the history-taking part of the encounter takes far less time and documentation needs to be far less detailed.

Those fragments of social and family history that may hold the key to the patient's recurring abdominal pains surface more quickly for a familiar face but may never appear for the physician/stranger.

In a survey of surgery and internal medicine residents, one investigator discovered that after the Accreditation Council for Graduate Medical Education (ACGME) duty-hour restrictions came into effect, the residents felt that continuity had decreased significantly and the quality of care had suffered slightly. It appears that errors attributable to physician fatigue may have been replaced with those related to discontinuous care.

One may argue that from time to time a patient may benefit from having his/her concerns considered by another physician with a different perspective.

However, when all is said and done, patients prefer being seen by the same physician and, in my view, receive better care when it is continuous.

But, continuity is costly. How many physicians have found themselves smoldering on the pyre of colleagues burned out in an attempt to be available to their patients 24/7/365?

Even the illusion of continuity created by well-crafted coverage arrangements can be expensive.

Documentation must be accurate and available to the surrogate provider when the patient is seen. Quality transcription and electronic medical records don't come cheap.

Dividing a larger group into smaller working units can provide the familiarity that patients want and need.

But, chopping a practice into bite-sized teams works only if everyone on the team buys into the concept that continuity is important.

In our group we feel that we do a pretty good job at having our patients see the same physician as often as possible.

However, we struggle with continuity at the front desk.

Our 8 a.m. to 7 p.m. (or later) office hours mean that receptionists change shifts once or twice each day. We would like our patients to be welcomed by a familiar face when they arrive. But, it just isn't happening.

I guess I shouldn't fret too much—we must be doing well enough to have earned a reputation that attracted Mrs. Talbot.

[email protected]

I've written about it several times, and we have all experienced it. The inevitable erosion of technical skills starts the month you leave your hospital-based, high-acuity residency programs and begin practicing outpatient primary care. You've been warned to “use it or lose it.” You may try to stay sharp by taking some hands-on refresher courses, but the opportunities to use your technical skills are fewer and fewer with each month of disuse.

And, with less opportunity to experience success, one's confidence begins to dip to dysfunctional levels. Tackling a procedure with a serious debt of confidence is one of the best ways to ensure failure.

A few weeks ago when I was in a particularly dark valley of technical self-doubt, I took a mini-inventory of my few remaining skills. Despite the fact that I can't remember whether I started an IV last year, I still have just a smidge of confidence that in an emergency I could use an old-fashioned butterfly needle. But, of course, their rigid design significantly shortens their life span. Surprisingly, I have just a shade more confidence of my ability to do lumbar punctures. However, these little glimmers of confidence are just that, very tiny sparkles of light on a dark landscape of technical skill.

But, there are a few shining examples that I can be trusted with sharp instruments. Although I have infrequent opportunities to stick needles into blood vessels and other vital structures of varying size and visibility, I do a mess of injections. And, while administering immunizations may not sound like the most challenging technical skill, nonetheless it is a skill … and at the risk of sounding pompous, I must say I'm pretty darn good at it.

It's not unusual for a parent to say, “He didn't even cry.” Or for a preteen to ask, “Did you do it? That didn't hurt.” From my admittedly biased and self-promoting perspective, when it comes to giving injections I feel I'm near the top of the heap.

Just do the math. In the course of an average day that includes six or eight health maintenance visits, I could be administering 25 or 30 immunizations. If I have been paying attention only half of the time, I must be learning something that can make the process more comfortable for my patients.

First of all, I'm fast and prepared. I have a little understanding with the nurses in our office. If the injection materials aren't drawn up and ready in the room when I'm ready to give the shot, they have to give the injection. I'm not sure whether this strategy qualifies as a carrot or a stick, but it works extremely well.

Next, I make sure the patient is in a situation where he or she will be well restrained. This requires an accurate assessment of the parent's mindset and ability to hold the child. Sometimes, despite my best coaching, some 150-pound adults can't seem to hold even one extremity of someone weighing only 25 pounds.

Although I do a ritualistic alcohol swipe, I don't and never have drawn back on the syringe before the injection. I have read that this maneuver increases the discomfort and doesn't minimize the risk of an untoward consequence. I try to distract the child by squeezing or gently pinching another portion of the target extremity. I give the most painful injection last, a strategy that has recently been shown to decrease the pain of the first vaccine (Pediatric News, “In Vaccine '1–2 Punch,' the Second Hurts More,” June 2007, p. 13).

But most importantly, I try to be as matter-of-fact as I can be about the whole shot process. Unfortunately, many children arrive at their well-child visit in a high state of anxiety fueled by well-meaning parents and not-so-well-intentioned older siblings and schoolmates. Promises of gifts and trips for ice cream may have further inflamed the situation to a point that even a confident master technician like myself is going to fail to give a painless injection. In the words of my old lacrosse coach, “All you can do is give it your best shot.”

[email protected]

I've written about it several times, and we have all experienced it. The inevitable erosion of technical skills starts the month you leave your hospital-based, high-acuity residency programs and begin practicing outpatient primary care. You've been warned to “use it or lose it.” You may try to stay sharp by taking some hands-on refresher courses, but the opportunities to use your technical skills are fewer and fewer with each month of disuse.

And, with less opportunity to experience success, one's confidence begins to dip to dysfunctional levels. Tackling a procedure with a serious debt of confidence is one of the best ways to ensure failure.

A few weeks ago when I was in a particularly dark valley of technical self-doubt, I took a mini-inventory of my few remaining skills. Despite the fact that I can't remember whether I started an IV last year, I still have just a smidge of confidence that in an emergency I could use an old-fashioned butterfly needle. But, of course, their rigid design significantly shortens their life span. Surprisingly, I have just a shade more confidence of my ability to do lumbar punctures. However, these little glimmers of confidence are just that, very tiny sparkles of light on a dark landscape of technical skill.

But, there are a few shining examples that I can be trusted with sharp instruments. Although I have infrequent opportunities to stick needles into blood vessels and other vital structures of varying size and visibility, I do a mess of injections. And, while administering immunizations may not sound like the most challenging technical skill, nonetheless it is a skill … and at the risk of sounding pompous, I must say I'm pretty darn good at it.

It's not unusual for a parent to say, “He didn't even cry.” Or for a preteen to ask, “Did you do it? That didn't hurt.” From my admittedly biased and self-promoting perspective, when it comes to giving injections I feel I'm near the top of the heap.

Just do the math. In the course of an average day that includes six or eight health maintenance visits, I could be administering 25 or 30 immunizations. If I have been paying attention only half of the time, I must be learning something that can make the process more comfortable for my patients.

First of all, I'm fast and prepared. I have a little understanding with the nurses in our office. If the injection materials aren't drawn up and ready in the room when I'm ready to give the shot, they have to give the injection. I'm not sure whether this strategy qualifies as a carrot or a stick, but it works extremely well.

Next, I make sure the patient is in a situation where he or she will be well restrained. This requires an accurate assessment of the parent's mindset and ability to hold the child. Sometimes, despite my best coaching, some 150-pound adults can't seem to hold even one extremity of someone weighing only 25 pounds.

Although I do a ritualistic alcohol swipe, I don't and never have drawn back on the syringe before the injection. I have read that this maneuver increases the discomfort and doesn't minimize the risk of an untoward consequence. I try to distract the child by squeezing or gently pinching another portion of the target extremity. I give the most painful injection last, a strategy that has recently been shown to decrease the pain of the first vaccine (Pediatric News, “In Vaccine '1–2 Punch,' the Second Hurts More,” June 2007, p. 13).

But most importantly, I try to be as matter-of-fact as I can be about the whole shot process. Unfortunately, many children arrive at their well-child visit in a high state of anxiety fueled by well-meaning parents and not-so-well-intentioned older siblings and schoolmates. Promises of gifts and trips for ice cream may have further inflamed the situation to a point that even a confident master technician like myself is going to fail to give a painless injection. In the words of my old lacrosse coach, “All you can do is give it your best shot.”

[email protected]

I've written about it several times, and we have all experienced it. The inevitable erosion of technical skills starts the month you leave your hospital-based, high-acuity residency programs and begin practicing outpatient primary care. You've been warned to “use it or lose it.” You may try to stay sharp by taking some hands-on refresher courses, but the opportunities to use your technical skills are fewer and fewer with each month of disuse.

And, with less opportunity to experience success, one's confidence begins to dip to dysfunctional levels. Tackling a procedure with a serious debt of confidence is one of the best ways to ensure failure.

A few weeks ago when I was in a particularly dark valley of technical self-doubt, I took a mini-inventory of my few remaining skills. Despite the fact that I can't remember whether I started an IV last year, I still have just a smidge of confidence that in an emergency I could use an old-fashioned butterfly needle. But, of course, their rigid design significantly shortens their life span. Surprisingly, I have just a shade more confidence of my ability to do lumbar punctures. However, these little glimmers of confidence are just that, very tiny sparkles of light on a dark landscape of technical skill.

But, there are a few shining examples that I can be trusted with sharp instruments. Although I have infrequent opportunities to stick needles into blood vessels and other vital structures of varying size and visibility, I do a mess of injections. And, while administering immunizations may not sound like the most challenging technical skill, nonetheless it is a skill … and at the risk of sounding pompous, I must say I'm pretty darn good at it.

It's not unusual for a parent to say, “He didn't even cry.” Or for a preteen to ask, “Did you do it? That didn't hurt.” From my admittedly biased and self-promoting perspective, when it comes to giving injections I feel I'm near the top of the heap.

Just do the math. In the course of an average day that includes six or eight health maintenance visits, I could be administering 25 or 30 immunizations. If I have been paying attention only half of the time, I must be learning something that can make the process more comfortable for my patients.

First of all, I'm fast and prepared. I have a little understanding with the nurses in our office. If the injection materials aren't drawn up and ready in the room when I'm ready to give the shot, they have to give the injection. I'm not sure whether this strategy qualifies as a carrot or a stick, but it works extremely well.

Next, I make sure the patient is in a situation where he or she will be well restrained. This requires an accurate assessment of the parent's mindset and ability to hold the child. Sometimes, despite my best coaching, some 150-pound adults can't seem to hold even one extremity of someone weighing only 25 pounds.

Although I do a ritualistic alcohol swipe, I don't and never have drawn back on the syringe before the injection. I have read that this maneuver increases the discomfort and doesn't minimize the risk of an untoward consequence. I try to distract the child by squeezing or gently pinching another portion of the target extremity. I give the most painful injection last, a strategy that has recently been shown to decrease the pain of the first vaccine (Pediatric News, “In Vaccine '1–2 Punch,' the Second Hurts More,” June 2007, p. 13).

But most importantly, I try to be as matter-of-fact as I can be about the whole shot process. Unfortunately, many children arrive at their well-child visit in a high state of anxiety fueled by well-meaning parents and not-so-well-intentioned older siblings and schoolmates. Promises of gifts and trips for ice cream may have further inflamed the situation to a point that even a confident master technician like myself is going to fail to give a painless injection. In the words of my old lacrosse coach, “All you can do is give it your best shot.”

[email protected]

One of the perks that a maturing physician can enjoy is a declining frequency of unexpected clinical outcomes. As the face-to-face patient encounters accumulate over the years, repeating patterns begin to emerge. Ironically, while the older physician notices that his memory for specifics is declining, he may find himself saying more often, “I've seen something like this before.”

In fact, if he can remain objective and engaged with the passing multitude, the experienced physician may develop diagnostic skills that can make him appear psychic. Many years ago I remember being in awe of one of our older physicians who could arrive at the correct diagnosis in half the time and usually with none of the lab or x-ray studies that his young associates required. In addition, his therapeutic interventions seemed to fail far less often than mine.

Sadly, I haven't come close to achieving that old guy's uncanny diagnostic skills, but I've been seeing patients long enough to appreciate how easy things are when my experience includes the right stuff. And, how uncomfortable I feel when I am clueless and floundering even after taking a thorough history and physical.

There is no substitute for an accurate diagnosis or the correct answer to a parent's question. The wrong path can trigger an expensive and time-consuming cascade of lab tests, x-rays, and poorly focused consultations. Therapeutic interventions may be recommended that are likely to be ineffective or, worse yet, that tip their own domino slide of side effects and confusing symptoms.

For example, let's take the everyday scenario of the 18-month-old who is in the middle of the community-wide viral gastroenteritis. Her vomiting has subsided after 2 days but the diarrhea is still voluminous. Her physician does a thorough exam including a weight. He determines that there is no immediate danger of dehydration and suggests that the family continue the oral electrolyte solution and suggests a “bland diet.” Unfortunately, the physician fails to ask what the family is currently giving the child to eat and drink.

The parents, believing that the oral electrolyte solution is a medication, continue to give the child fruit juice as her primary beverage in addition to the solution. The diarrhea continues to rage and 2 days later the family returns to the emergency department after hours. The ED physician orders a battery of tests including stool cultures and a survey for intestinal parasites. The bill for the hospital services exceeds $400. And, when the family finally returns to the pediatrician, the child's bottom is raw and bleeding.

It is tempting to blame the parents for not considering that if the pediatrician had previously recommended fruit juice as a remedy for constipation, then juice would probably be a bad idea when the child has diarrhea. However, I have witnessed the scenario enough times to remove this from my list of basic assumptions. After several unfortunate experiences, I now ask all parents exactly what they are giving their children now and I specify what they should and should not give their children until the diarrhea subsides.

So what's the big deal? In the whole spectrum of medical mistakes, this physician's omission is so trivial that it will never appear as a statistic. But, it does make me shiver to think how big the iceberg of medical errors must be.

The dilemma I struggle with occurs when I am eavesdropping and I hear what I know is the wrong answer being given to a parent. Of course, when the error may result in pain or injury, I speak up promptly. However, when the fallout of the imperfect advice will be limited to a loss of time or money, I bite my tongue. And, I hope I will remember at some later time to tactfully discuss the scenario. The problem is that neither tact nor memory is my strong suit. I don't want to be seen as a nitpicking old codger … all the time.

[email protected]

One of the perks that a maturing physician can enjoy is a declining frequency of unexpected clinical outcomes. As the face-to-face patient encounters accumulate over the years, repeating patterns begin to emerge. Ironically, while the older physician notices that his memory for specifics is declining, he may find himself saying more often, “I've seen something like this before.”

In fact, if he can remain objective and engaged with the passing multitude, the experienced physician may develop diagnostic skills that can make him appear psychic. Many years ago I remember being in awe of one of our older physicians who could arrive at the correct diagnosis in half the time and usually with none of the lab or x-ray studies that his young associates required. In addition, his therapeutic interventions seemed to fail far less often than mine.

Sadly, I haven't come close to achieving that old guy's uncanny diagnostic skills, but I've been seeing patients long enough to appreciate how easy things are when my experience includes the right stuff. And, how uncomfortable I feel when I am clueless and floundering even after taking a thorough history and physical.

There is no substitute for an accurate diagnosis or the correct answer to a parent's question. The wrong path can trigger an expensive and time-consuming cascade of lab tests, x-rays, and poorly focused consultations. Therapeutic interventions may be recommended that are likely to be ineffective or, worse yet, that tip their own domino slide of side effects and confusing symptoms.

For example, let's take the everyday scenario of the 18-month-old who is in the middle of the community-wide viral gastroenteritis. Her vomiting has subsided after 2 days but the diarrhea is still voluminous. Her physician does a thorough exam including a weight. He determines that there is no immediate danger of dehydration and suggests that the family continue the oral electrolyte solution and suggests a “bland diet.” Unfortunately, the physician fails to ask what the family is currently giving the child to eat and drink.

The parents, believing that the oral electrolyte solution is a medication, continue to give the child fruit juice as her primary beverage in addition to the solution. The diarrhea continues to rage and 2 days later the family returns to the emergency department after hours. The ED physician orders a battery of tests including stool cultures and a survey for intestinal parasites. The bill for the hospital services exceeds $400. And, when the family finally returns to the pediatrician, the child's bottom is raw and bleeding.

It is tempting to blame the parents for not considering that if the pediatrician had previously recommended fruit juice as a remedy for constipation, then juice would probably be a bad idea when the child has diarrhea. However, I have witnessed the scenario enough times to remove this from my list of basic assumptions. After several unfortunate experiences, I now ask all parents exactly what they are giving their children now and I specify what they should and should not give their children until the diarrhea subsides.

So what's the big deal? In the whole spectrum of medical mistakes, this physician's omission is so trivial that it will never appear as a statistic. But, it does make me shiver to think how big the iceberg of medical errors must be.

The dilemma I struggle with occurs when I am eavesdropping and I hear what I know is the wrong answer being given to a parent. Of course, when the error may result in pain or injury, I speak up promptly. However, when the fallout of the imperfect advice will be limited to a loss of time or money, I bite my tongue. And, I hope I will remember at some later time to tactfully discuss the scenario. The problem is that neither tact nor memory is my strong suit. I don't want to be seen as a nitpicking old codger … all the time.

[email protected]

One of the perks that a maturing physician can enjoy is a declining frequency of unexpected clinical outcomes. As the face-to-face patient encounters accumulate over the years, repeating patterns begin to emerge. Ironically, while the older physician notices that his memory for specifics is declining, he may find himself saying more often, “I've seen something like this before.”

In fact, if he can remain objective and engaged with the passing multitude, the experienced physician may develop diagnostic skills that can make him appear psychic. Many years ago I remember being in awe of one of our older physicians who could arrive at the correct diagnosis in half the time and usually with none of the lab or x-ray studies that his young associates required. In addition, his therapeutic interventions seemed to fail far less often than mine.

Sadly, I haven't come close to achieving that old guy's uncanny diagnostic skills, but I've been seeing patients long enough to appreciate how easy things are when my experience includes the right stuff. And, how uncomfortable I feel when I am clueless and floundering even after taking a thorough history and physical.

There is no substitute for an accurate diagnosis or the correct answer to a parent's question. The wrong path can trigger an expensive and time-consuming cascade of lab tests, x-rays, and poorly focused consultations. Therapeutic interventions may be recommended that are likely to be ineffective or, worse yet, that tip their own domino slide of side effects and confusing symptoms.

For example, let's take the everyday scenario of the 18-month-old who is in the middle of the community-wide viral gastroenteritis. Her vomiting has subsided after 2 days but the diarrhea is still voluminous. Her physician does a thorough exam including a weight. He determines that there is no immediate danger of dehydration and suggests that the family continue the oral electrolyte solution and suggests a “bland diet.” Unfortunately, the physician fails to ask what the family is currently giving the child to eat and drink.

The parents, believing that the oral electrolyte solution is a medication, continue to give the child fruit juice as her primary beverage in addition to the solution. The diarrhea continues to rage and 2 days later the family returns to the emergency department after hours. The ED physician orders a battery of tests including stool cultures and a survey for intestinal parasites. The bill for the hospital services exceeds $400. And, when the family finally returns to the pediatrician, the child's bottom is raw and bleeding.

It is tempting to blame the parents for not considering that if the pediatrician had previously recommended fruit juice as a remedy for constipation, then juice would probably be a bad idea when the child has diarrhea. However, I have witnessed the scenario enough times to remove this from my list of basic assumptions. After several unfortunate experiences, I now ask all parents exactly what they are giving their children now and I specify what they should and should not give their children until the diarrhea subsides.

So what's the big deal? In the whole spectrum of medical mistakes, this physician's omission is so trivial that it will never appear as a statistic. But, it does make me shiver to think how big the iceberg of medical errors must be.

The dilemma I struggle with occurs when I am eavesdropping and I hear what I know is the wrong answer being given to a parent. Of course, when the error may result in pain or injury, I speak up promptly. However, when the fallout of the imperfect advice will be limited to a loss of time or money, I bite my tongue. And, I hope I will remember at some later time to tactfully discuss the scenario. The problem is that neither tact nor memory is my strong suit. I don't want to be seen as a nitpicking old codger … all the time.