Letters from Maine

[email protected]

One of our newer physicians asked recently if I had any suggestions for increasing his efficiency. It's getting closer to the day his income will be based solely on productivity, and the handwriting on the wall is coming into clearer focus.

Never being bashful about pontificating, I began by suggesting that he move efficiency up his priority list to the same level as quality care and professional enjoyment. I continued by urging him to arrive early enough to make his call-backs and see his first patient on time. Playing catch-up isn't fun, and it certainly isn't efficient.

Then I said, “I've noticed that you do a lot of double-dipping.” His puzzled expression prompted me to explain that every time a physician leaves and returns to the examination room to see the same patient he must invest valuable time reestablishing the dialogue and the continuity of the visit. These return trips can be as costly as a full office visit, but of course the insurance companies don't reimburse for them.

A typical example involves a visit for a sore throat at which one does a rapid strep test. Before leaving the room with swab in hand, the efficient physician will have already discussed Plan A (test is positive) and Plan B (test is negative) with the patient and will have written a prescription for his choice of antibiotic so that his assistant can finish the visit. The experienced physician will have anticipated all of the usual questions and touched on them before exiting the room.

My student-for-the-moment said, “I can see what you mean, and I've been trying to get it all done with one trip into the exam room when I can. But, communication is important to me and I want to take advantage of every opportunity to achieve closure.”

Contorting my face into what I hoped was my wisest expression, I said, “Ah, closure—now there's a troubling concept.” Most training programs are in large metropolitan areas and serve outpatient populations that are often transient and economically disadvantaged. This fact, combined with the reality that house officers rotate and graduate, makes the establishment of a medical home model extremely difficult. I know that some programs work very hard to create continuity, but still most outpatient encounters exist in a vacuum. The physician-in-training and the patient understandably assume that they may never see or hear from each other again. In this dynamic, the physician's concern about achieving closure may squeeze common sense out of the picture.

Lab work is ordered to make sure that all the stones have been turned. Treatments of dubious value may be recommended and anxiety-provoking options are discussed unnecessarily because the practitioner is worried that he only has one chance to cover all his bases.

Many patients arrive at the physician's office in the early stages of an illness that is likely to be self-limited. Even the best diagnostician can't predict exactly where the process will go. Attempts at achieving closure in this fluid state are fruitless, time consuming, and potentially dangerous.

I urged my young associate to take full advantage of the fact that we live in a stable community of reasonably educated people. I suggested that he tell the patients that he is sure what they don't have, but that it is too early to be sure exactly what they do have or to expect the illness to have run its course.

I said, “Remind them that you and your partners are truly available by phone around the clock. Promise that you will call them the next day to see how things are going and then keep your promise. If you detect in your follow-up call even a hint of uncertainty, don't hesitate to have the patient return for another visit. That kind of double-dipping can teach you something, and you'll get paid to boot.”

As I rose to see my first patient of the afternoon 5 minutes late, I reminded my young associate that, “In a well-organized and compassionate outpatient setting, closure will come naturally. You won't have to waste time forcing it before it's ready to happen.”

[email protected]

One of our newer physicians asked recently if I had any suggestions for increasing his efficiency. It's getting closer to the day his income will be based solely on productivity, and the handwriting on the wall is coming into clearer focus.

Never being bashful about pontificating, I began by suggesting that he move efficiency up his priority list to the same level as quality care and professional enjoyment. I continued by urging him to arrive early enough to make his call-backs and see his first patient on time. Playing catch-up isn't fun, and it certainly isn't efficient.

Then I said, “I've noticed that you do a lot of double-dipping.” His puzzled expression prompted me to explain that every time a physician leaves and returns to the examination room to see the same patient he must invest valuable time reestablishing the dialogue and the continuity of the visit. These return trips can be as costly as a full office visit, but of course the insurance companies don't reimburse for them.

A typical example involves a visit for a sore throat at which one does a rapid strep test. Before leaving the room with swab in hand, the efficient physician will have already discussed Plan A (test is positive) and Plan B (test is negative) with the patient and will have written a prescription for his choice of antibiotic so that his assistant can finish the visit. The experienced physician will have anticipated all of the usual questions and touched on them before exiting the room.

My student-for-the-moment said, “I can see what you mean, and I've been trying to get it all done with one trip into the exam room when I can. But, communication is important to me and I want to take advantage of every opportunity to achieve closure.”

Contorting my face into what I hoped was my wisest expression, I said, “Ah, closure—now there's a troubling concept.” Most training programs are in large metropolitan areas and serve outpatient populations that are often transient and economically disadvantaged. This fact, combined with the reality that house officers rotate and graduate, makes the establishment of a medical home model extremely difficult. I know that some programs work very hard to create continuity, but still most outpatient encounters exist in a vacuum. The physician-in-training and the patient understandably assume that they may never see or hear from each other again. In this dynamic, the physician's concern about achieving closure may squeeze common sense out of the picture.

Lab work is ordered to make sure that all the stones have been turned. Treatments of dubious value may be recommended and anxiety-provoking options are discussed unnecessarily because the practitioner is worried that he only has one chance to cover all his bases.

Many patients arrive at the physician's office in the early stages of an illness that is likely to be self-limited. Even the best diagnostician can't predict exactly where the process will go. Attempts at achieving closure in this fluid state are fruitless, time consuming, and potentially dangerous.

I urged my young associate to take full advantage of the fact that we live in a stable community of reasonably educated people. I suggested that he tell the patients that he is sure what they don't have, but that it is too early to be sure exactly what they do have or to expect the illness to have run its course.

I said, “Remind them that you and your partners are truly available by phone around the clock. Promise that you will call them the next day to see how things are going and then keep your promise. If you detect in your follow-up call even a hint of uncertainty, don't hesitate to have the patient return for another visit. That kind of double-dipping can teach you something, and you'll get paid to boot.”

As I rose to see my first patient of the afternoon 5 minutes late, I reminded my young associate that, “In a well-organized and compassionate outpatient setting, closure will come naturally. You won't have to waste time forcing it before it's ready to happen.”

[email protected]

One of our newer physicians asked recently if I had any suggestions for increasing his efficiency. It's getting closer to the day his income will be based solely on productivity, and the handwriting on the wall is coming into clearer focus.

Never being bashful about pontificating, I began by suggesting that he move efficiency up his priority list to the same level as quality care and professional enjoyment. I continued by urging him to arrive early enough to make his call-backs and see his first patient on time. Playing catch-up isn't fun, and it certainly isn't efficient.

Then I said, “I've noticed that you do a lot of double-dipping.” His puzzled expression prompted me to explain that every time a physician leaves and returns to the examination room to see the same patient he must invest valuable time reestablishing the dialogue and the continuity of the visit. These return trips can be as costly as a full office visit, but of course the insurance companies don't reimburse for them.

A typical example involves a visit for a sore throat at which one does a rapid strep test. Before leaving the room with swab in hand, the efficient physician will have already discussed Plan A (test is positive) and Plan B (test is negative) with the patient and will have written a prescription for his choice of antibiotic so that his assistant can finish the visit. The experienced physician will have anticipated all of the usual questions and touched on them before exiting the room.

My student-for-the-moment said, “I can see what you mean, and I've been trying to get it all done with one trip into the exam room when I can. But, communication is important to me and I want to take advantage of every opportunity to achieve closure.”

Contorting my face into what I hoped was my wisest expression, I said, “Ah, closure—now there's a troubling concept.” Most training programs are in large metropolitan areas and serve outpatient populations that are often transient and economically disadvantaged. This fact, combined with the reality that house officers rotate and graduate, makes the establishment of a medical home model extremely difficult. I know that some programs work very hard to create continuity, but still most outpatient encounters exist in a vacuum. The physician-in-training and the patient understandably assume that they may never see or hear from each other again. In this dynamic, the physician's concern about achieving closure may squeeze common sense out of the picture.

Lab work is ordered to make sure that all the stones have been turned. Treatments of dubious value may be recommended and anxiety-provoking options are discussed unnecessarily because the practitioner is worried that he only has one chance to cover all his bases.

Many patients arrive at the physician's office in the early stages of an illness that is likely to be self-limited. Even the best diagnostician can't predict exactly where the process will go. Attempts at achieving closure in this fluid state are fruitless, time consuming, and potentially dangerous.

I urged my young associate to take full advantage of the fact that we live in a stable community of reasonably educated people. I suggested that he tell the patients that he is sure what they don't have, but that it is too early to be sure exactly what they do have or to expect the illness to have run its course.

I said, “Remind them that you and your partners are truly available by phone around the clock. Promise that you will call them the next day to see how things are going and then keep your promise. If you detect in your follow-up call even a hint of uncertainty, don't hesitate to have the patient return for another visit. That kind of double-dipping can teach you something, and you'll get paid to boot.”

As I rose to see my first patient of the afternoon 5 minutes late, I reminded my young associate that, “In a well-organized and compassionate outpatient setting, closure will come naturally. You won't have to waste time forcing it before it's ready to happen.”

[email protected]

Back in the Dark Ages, before Al Gore invented the Internet, there were hyperactive children. The most troublesome were sedated with tranquilizers, but eventually a counterintuitive discovery resulted in a more humane and successful management with amphetamines.

“Hyperactivity” morphed into a family of “attention-deficit hyperactivity disorders” when it became apparent that there were children whose minds jumped from distraction to distraction while their bodies remained relatively stationary.

In the 1980s most of us told parents that their children's attention-deficit hyperactivity disorder symptoms would abate during puberty so that medication could be discontinued. Of course, this prediction proved to be wrong in many cases.

In fact, some physicians and mental health workers began labeling previously undiagnosed adults as having ADHD and treating them with stimulants.

Should we pediatricians interpret this growing population of amphetamine-popping “ADHD adults” as an embarrassing diagnostic oversight and gear ourselves for a massive class-action suit by an entire generation of distracted and impulsive 30- or 40-somethings?

Do “ADHD adults” exist, and are we to blame?

Let me tell you what I think. It is pretty obvious to almost everyone who has watched a child mature that the attention span of a 15-year-old is significantly longer than that of a 15-month-old.

This is true even for those children whose nervous systems' chemical and structural arrangement makes it more difficult to pay attention.

And, it shouldn't surprise us that someone who was diagnosed as having ADHD as a child might remain on the distractible side of the bell-shaped curve of adults.

But, if our management of ADHD has been more comprehensive than simply writing Ritalin prescriptions, most of our patients should not require medication by the time they leave our practices.

It is unreasonable to ask educators and parents to adapt every child's environment to match his/her individual personality and learning style.

In the case of ADHD, stimulant medication can ease that round peg-square hole fit while we adults are helping the children find topics, activities, environments, and vocations that will keep their interest long enough to allow them to experience success. We can hope that medication will buy us some time while we wait for the natural process of maturity to come to our rescue. But, hoping isn't enough.

The educational process should include thoughtful and creative planning of curricula and learning spaces. Vocational experiences such as job shadowing and social skills coaching should be considered. Of course, these observations apply to any child whose learning style and capabilities are out of the mainstream. And certainly it doesn't happen enough.

Now, what about the 40-year-old college graduate who shows up in the internist's office complaining that he is having trouble concentrating, that he needs three cups of coffee just to get through the first hour at work, and that he never feels fulfilled in anything he does because he is always jumping from one thing to another? He's already taken a 10-question test that he found in a magazine and discovered that he has all the symptoms of adult ADHD.

Well, he got through college with prescription stimulants, so I think you and I can figure we are off the hook for a missed diagnosis. We can only hope that his internist understands that distractibility and impulsiveness can be symptoms of sleep deprivation and depression as well as the result of family and social turmoil.

It may be that this unfortunate guy has simply found himself with the wrong job and/or the wrong spouse. It's very possible that some stimulants stronger than his three morning cups of coffee will make him feel better for a while, but I suspect in the long run things won't improve without a broader approach.

We pediatricians know that just because Ritalin seems to improve some of the symptoms, it doesn't mean that our young patient has ADHD. In my opinion, if you need Ritalin to do your job, you need a new job.

There may be a few adult patients with “true” ADHD today who have escaped detection, but I can't imagine that anyone in the next generation will reach the age of 30 without a day care provider, teacher, or well-meaning aunt suggesting, “You should ask the doctor if he has ADHD.”

[email protected]

Back in the Dark Ages, before Al Gore invented the Internet, there were hyperactive children. The most troublesome were sedated with tranquilizers, but eventually a counterintuitive discovery resulted in a more humane and successful management with amphetamines.

“Hyperactivity” morphed into a family of “attention-deficit hyperactivity disorders” when it became apparent that there were children whose minds jumped from distraction to distraction while their bodies remained relatively stationary.

In the 1980s most of us told parents that their children's attention-deficit hyperactivity disorder symptoms would abate during puberty so that medication could be discontinued. Of course, this prediction proved to be wrong in many cases.

In fact, some physicians and mental health workers began labeling previously undiagnosed adults as having ADHD and treating them with stimulants.

Should we pediatricians interpret this growing population of amphetamine-popping “ADHD adults” as an embarrassing diagnostic oversight and gear ourselves for a massive class-action suit by an entire generation of distracted and impulsive 30- or 40-somethings?

Do “ADHD adults” exist, and are we to blame?

Let me tell you what I think. It is pretty obvious to almost everyone who has watched a child mature that the attention span of a 15-year-old is significantly longer than that of a 15-month-old.

This is true even for those children whose nervous systems' chemical and structural arrangement makes it more difficult to pay attention.

And, it shouldn't surprise us that someone who was diagnosed as having ADHD as a child might remain on the distractible side of the bell-shaped curve of adults.

But, if our management of ADHD has been more comprehensive than simply writing Ritalin prescriptions, most of our patients should not require medication by the time they leave our practices.

It is unreasonable to ask educators and parents to adapt every child's environment to match his/her individual personality and learning style.

In the case of ADHD, stimulant medication can ease that round peg-square hole fit while we adults are helping the children find topics, activities, environments, and vocations that will keep their interest long enough to allow them to experience success. We can hope that medication will buy us some time while we wait for the natural process of maturity to come to our rescue. But, hoping isn't enough.

The educational process should include thoughtful and creative planning of curricula and learning spaces. Vocational experiences such as job shadowing and social skills coaching should be considered. Of course, these observations apply to any child whose learning style and capabilities are out of the mainstream. And certainly it doesn't happen enough.

Now, what about the 40-year-old college graduate who shows up in the internist's office complaining that he is having trouble concentrating, that he needs three cups of coffee just to get through the first hour at work, and that he never feels fulfilled in anything he does because he is always jumping from one thing to another? He's already taken a 10-question test that he found in a magazine and discovered that he has all the symptoms of adult ADHD.

Well, he got through college with prescription stimulants, so I think you and I can figure we are off the hook for a missed diagnosis. We can only hope that his internist understands that distractibility and impulsiveness can be symptoms of sleep deprivation and depression as well as the result of family and social turmoil.

It may be that this unfortunate guy has simply found himself with the wrong job and/or the wrong spouse. It's very possible that some stimulants stronger than his three morning cups of coffee will make him feel better for a while, but I suspect in the long run things won't improve without a broader approach.

We pediatricians know that just because Ritalin seems to improve some of the symptoms, it doesn't mean that our young patient has ADHD. In my opinion, if you need Ritalin to do your job, you need a new job.

There may be a few adult patients with “true” ADHD today who have escaped detection, but I can't imagine that anyone in the next generation will reach the age of 30 without a day care provider, teacher, or well-meaning aunt suggesting, “You should ask the doctor if he has ADHD.”

[email protected]

Back in the Dark Ages, before Al Gore invented the Internet, there were hyperactive children. The most troublesome were sedated with tranquilizers, but eventually a counterintuitive discovery resulted in a more humane and successful management with amphetamines.

“Hyperactivity” morphed into a family of “attention-deficit hyperactivity disorders” when it became apparent that there were children whose minds jumped from distraction to distraction while their bodies remained relatively stationary.

In the 1980s most of us told parents that their children's attention-deficit hyperactivity disorder symptoms would abate during puberty so that medication could be discontinued. Of course, this prediction proved to be wrong in many cases.

In fact, some physicians and mental health workers began labeling previously undiagnosed adults as having ADHD and treating them with stimulants.

Should we pediatricians interpret this growing population of amphetamine-popping “ADHD adults” as an embarrassing diagnostic oversight and gear ourselves for a massive class-action suit by an entire generation of distracted and impulsive 30- or 40-somethings?

Do “ADHD adults” exist, and are we to blame?

Let me tell you what I think. It is pretty obvious to almost everyone who has watched a child mature that the attention span of a 15-year-old is significantly longer than that of a 15-month-old.

This is true even for those children whose nervous systems' chemical and structural arrangement makes it more difficult to pay attention.

And, it shouldn't surprise us that someone who was diagnosed as having ADHD as a child might remain on the distractible side of the bell-shaped curve of adults.

But, if our management of ADHD has been more comprehensive than simply writing Ritalin prescriptions, most of our patients should not require medication by the time they leave our practices.

It is unreasonable to ask educators and parents to adapt every child's environment to match his/her individual personality and learning style.

In the case of ADHD, stimulant medication can ease that round peg-square hole fit while we adults are helping the children find topics, activities, environments, and vocations that will keep their interest long enough to allow them to experience success. We can hope that medication will buy us some time while we wait for the natural process of maturity to come to our rescue. But, hoping isn't enough.

The educational process should include thoughtful and creative planning of curricula and learning spaces. Vocational experiences such as job shadowing and social skills coaching should be considered. Of course, these observations apply to any child whose learning style and capabilities are out of the mainstream. And certainly it doesn't happen enough.

Now, what about the 40-year-old college graduate who shows up in the internist's office complaining that he is having trouble concentrating, that he needs three cups of coffee just to get through the first hour at work, and that he never feels fulfilled in anything he does because he is always jumping from one thing to another? He's already taken a 10-question test that he found in a magazine and discovered that he has all the symptoms of adult ADHD.

Well, he got through college with prescription stimulants, so I think you and I can figure we are off the hook for a missed diagnosis. We can only hope that his internist understands that distractibility and impulsiveness can be symptoms of sleep deprivation and depression as well as the result of family and social turmoil.

It may be that this unfortunate guy has simply found himself with the wrong job and/or the wrong spouse. It's very possible that some stimulants stronger than his three morning cups of coffee will make him feel better for a while, but I suspect in the long run things won't improve without a broader approach.

We pediatricians know that just because Ritalin seems to improve some of the symptoms, it doesn't mean that our young patient has ADHD. In my opinion, if you need Ritalin to do your job, you need a new job.

There may be a few adult patients with “true” ADHD today who have escaped detection, but I can't imagine that anyone in the next generation will reach the age of 30 without a day care provider, teacher, or well-meaning aunt suggesting, “You should ask the doctor if he has ADHD.”

[email protected]

One of my partners has a bit of an issue with anxiety. She claims this is a congenital thing and isn't the least bit timid about owning up to her nervousness. As you might expect, she is quite clever at imagining worst-case scenarios, which is a handy skill to have when it comes to crafting a list of differential diagnoses.

But Deb's bigger problem is that she somehow manages to attract a larger number of worst-case scenarios than one would expect based strictly on chance. This unfortunate magnetism has earned her the title of “Disaster Deb,” a moniker she wears with considerable pride.

So you can imagine that when the call came for someone to head up our local pandemic preparedness posse, Disaster Deb was the logical choice … and not surprisingly, the only volunteer. Now she could spend what little free time she has worrying about worst- case scenarios on a level that makes toddlers with fevers and necks that “might be stiff” seem like child's play.

Now she could hang out and hobnob with people who get paid to worry on a national and even a global scale. My only concern about Deb accepting this position was that she might do some additional worrying—that she was having too much fun exploring worst-case scenarios.

But, she has managed to keep her anxiety within bounds—well, at least normal bounds for her—and has done a bang-up job of spreading the doom and gloom about pandemics. She has helped the hospital and our medical group begin thinking about what we might have to do to manage an outbreak of severe influenza. She gives excellent presentations of the Center for Disease Control and Prevention's version of what a pandemic could look like. At the end of her talk she always serves some of her home-baked cookies in a tasty but unsuccessful attempt at calming the nerves of audience members whom she has sent into a palm-sweating panic.

I'm pretty immune to the scary bits in her presentations because I find the likelihood of an influenza pandemic extremely remote. I just eat the cookies and worry that this whole pandemic preparedness extravaganza is a poor investment of our public health resources.

Deb tries to reassure me that the mental exercises she is leading us through now will carry over and help us in future pandemics and other disasters. But I'm sure that when this pandemic fails to materialize, most of those who have listened attentively will turn a deaf ear to subsequent warnings when the real disaster comes. Our society has a very short memory when it comes to near disasters. When the oil prices go up we tilt at a few windmills and buy a handful of hybrid cars, but within a month or two we're back to driving our SUVs at breakneck speeds.

I find the pandemic preparedness plans are drawn too narrowly. The real disasters are by definition unpredictable and hence one can't prepare for them. When the dome of seismic instability under Yellowstone Park finally erupts and darkens the skies for months (an event that might be as likely as an avian flu pandemic), the reams of paper generated by our flu preparations may be useful as a temporary fuel source, but that's about it.

When the doodoo really hits the fan, our survivability is going to depend on the strength of the moral fiber that binds us together as a society and on the intelligence, creativity, and charisma of the leaders we have chosen. So you can see why from time to time I join Disaster Deb in some serious recreational worrying.

[email protected]

One of my partners has a bit of an issue with anxiety. She claims this is a congenital thing and isn't the least bit timid about owning up to her nervousness. As you might expect, she is quite clever at imagining worst-case scenarios, which is a handy skill to have when it comes to crafting a list of differential diagnoses.

But Deb's bigger problem is that she somehow manages to attract a larger number of worst-case scenarios than one would expect based strictly on chance. This unfortunate magnetism has earned her the title of “Disaster Deb,” a moniker she wears with considerable pride.

So you can imagine that when the call came for someone to head up our local pandemic preparedness posse, Disaster Deb was the logical choice … and not surprisingly, the only volunteer. Now she could spend what little free time she has worrying about worst- case scenarios on a level that makes toddlers with fevers and necks that “might be stiff” seem like child's play.

Now she could hang out and hobnob with people who get paid to worry on a national and even a global scale. My only concern about Deb accepting this position was that she might do some additional worrying—that she was having too much fun exploring worst-case scenarios.

But, she has managed to keep her anxiety within bounds—well, at least normal bounds for her—and has done a bang-up job of spreading the doom and gloom about pandemics. She has helped the hospital and our medical group begin thinking about what we might have to do to manage an outbreak of severe influenza. She gives excellent presentations of the Center for Disease Control and Prevention's version of what a pandemic could look like. At the end of her talk she always serves some of her home-baked cookies in a tasty but unsuccessful attempt at calming the nerves of audience members whom she has sent into a palm-sweating panic.

I'm pretty immune to the scary bits in her presentations because I find the likelihood of an influenza pandemic extremely remote. I just eat the cookies and worry that this whole pandemic preparedness extravaganza is a poor investment of our public health resources.

Deb tries to reassure me that the mental exercises she is leading us through now will carry over and help us in future pandemics and other disasters. But I'm sure that when this pandemic fails to materialize, most of those who have listened attentively will turn a deaf ear to subsequent warnings when the real disaster comes. Our society has a very short memory when it comes to near disasters. When the oil prices go up we tilt at a few windmills and buy a handful of hybrid cars, but within a month or two we're back to driving our SUVs at breakneck speeds.

I find the pandemic preparedness plans are drawn too narrowly. The real disasters are by definition unpredictable and hence one can't prepare for them. When the dome of seismic instability under Yellowstone Park finally erupts and darkens the skies for months (an event that might be as likely as an avian flu pandemic), the reams of paper generated by our flu preparations may be useful as a temporary fuel source, but that's about it.

When the doodoo really hits the fan, our survivability is going to depend on the strength of the moral fiber that binds us together as a society and on the intelligence, creativity, and charisma of the leaders we have chosen. So you can see why from time to time I join Disaster Deb in some serious recreational worrying.

[email protected]

One of my partners has a bit of an issue with anxiety. She claims this is a congenital thing and isn't the least bit timid about owning up to her nervousness. As you might expect, she is quite clever at imagining worst-case scenarios, which is a handy skill to have when it comes to crafting a list of differential diagnoses.

But Deb's bigger problem is that she somehow manages to attract a larger number of worst-case scenarios than one would expect based strictly on chance. This unfortunate magnetism has earned her the title of “Disaster Deb,” a moniker she wears with considerable pride.

So you can imagine that when the call came for someone to head up our local pandemic preparedness posse, Disaster Deb was the logical choice … and not surprisingly, the only volunteer. Now she could spend what little free time she has worrying about worst- case scenarios on a level that makes toddlers with fevers and necks that “might be stiff” seem like child's play.

Now she could hang out and hobnob with people who get paid to worry on a national and even a global scale. My only concern about Deb accepting this position was that she might do some additional worrying—that she was having too much fun exploring worst-case scenarios.

But, she has managed to keep her anxiety within bounds—well, at least normal bounds for her—and has done a bang-up job of spreading the doom and gloom about pandemics. She has helped the hospital and our medical group begin thinking about what we might have to do to manage an outbreak of severe influenza. She gives excellent presentations of the Center for Disease Control and Prevention's version of what a pandemic could look like. At the end of her talk she always serves some of her home-baked cookies in a tasty but unsuccessful attempt at calming the nerves of audience members whom she has sent into a palm-sweating panic.

I'm pretty immune to the scary bits in her presentations because I find the likelihood of an influenza pandemic extremely remote. I just eat the cookies and worry that this whole pandemic preparedness extravaganza is a poor investment of our public health resources.

Deb tries to reassure me that the mental exercises she is leading us through now will carry over and help us in future pandemics and other disasters. But I'm sure that when this pandemic fails to materialize, most of those who have listened attentively will turn a deaf ear to subsequent warnings when the real disaster comes. Our society has a very short memory when it comes to near disasters. When the oil prices go up we tilt at a few windmills and buy a handful of hybrid cars, but within a month or two we're back to driving our SUVs at breakneck speeds.

I find the pandemic preparedness plans are drawn too narrowly. The real disasters are by definition unpredictable and hence one can't prepare for them. When the dome of seismic instability under Yellowstone Park finally erupts and darkens the skies for months (an event that might be as likely as an avian flu pandemic), the reams of paper generated by our flu preparations may be useful as a temporary fuel source, but that's about it.

When the doodoo really hits the fan, our survivability is going to depend on the strength of the moral fiber that binds us together as a society and on the intelligence, creativity, and charisma of the leaders we have chosen. So you can see why from time to time I join Disaster Deb in some serious recreational worrying.

[email protected]

“Sure, we can see your patient. How about 2 o'clock tomorrow? But if you think he needs to be seen sooner, send him right over and we can squeeze him in.” Those are words that can make any harassed and worried primary care pediatrician feel all warm and fuzzy inside.

Even if you are pretty sure the patient is healthy, it's a great relief when someone else agrees to share the burden of an overanxious parent. Unfortunately, none of us has the luxury of working above a completely impermeable safety net of willing and accessible subspecialists. A lot has been written and said about the “open access” practice model for primary care physicians. In theory, it makes sense, and with some simple modifications it has worked well in our office for more than a decade.

But for a variety of good and bad reasons, the easy-open-door policy doesn't seem to work well for most subspecialists. I can see why the depth and complexity of the problems they see may dictate that their initial office visits be time-consuming. Nonetheless, there are a few saintly and busy subspecializing physicians who are so well organized and/or compassionate that their receptionists can offer timely rescue service to my patients.

I'm not sure how they do this, but I suspect that they do what I do when I feel swamped: I temporarily suspend my usual practice of doing a complete exam and history on every new patient. I try to ferret out the patient's primary problem and his parents' overriding concern and begin the process of getting to the bottom of it. I reassure the family that when we have time I will address all of their concerns, but I tell them that to squeeze them in today I will have to temporarily narrow my focus. Most families are so happy to be seen promptly that they are more than happy to accept my triage approach.

When I stumble across busy but easy-access subspecialists, I try to treat them as I would fine wines. I call on them only for special occasions and send them concise and focused histories. They also receive thank-you notes and some of Marilyn's baked goods at Christmas.

But despite our careful husbandry, my partners and I still must live with critical shortages in some subspecialty areas. If you share our pain and frustration, I urge you to read Dr. Daniel Goodman's commentary, “The Pediatric Subspecialty Workforce: Time to Test Our Assumptions,” in the December 2006 issue of Pediatrics.

Dr. Goodman doesn't claim to offer any solutions. But he poses a collection of thought-provoking questions, the answers to which may lead us out of the woods. For example, he wonders if fellowships need to take 3 years or sometimes longer. Is a niche always so deep that a subspecialist in training must invest what could be productive time exploring every abstruse nook and cranny?

Could providers with a modest amount of training learn to care for the bulk of a subspecialty's patients? Unusual and complex patients could be bumped up the ladder to a few master subspecialists.

In selected subspecialties, why can't physicians who were originally trained to see adults broaden their practices to include children? I don't think we have to worry that this change would herald the demise of general pediatrics.

If we read Dr. Goodman's commentary with an open mind and join him in thinking outside the box, we may have some solutions to the subspecialist shortages. Until then, I'm going to continue writing effusive thank-you notes and encourage Marilyn to keep baking her scrumptious cookies.

[email protected]

“Sure, we can see your patient. How about 2 o'clock tomorrow? But if you think he needs to be seen sooner, send him right over and we can squeeze him in.” Those are words that can make any harassed and worried primary care pediatrician feel all warm and fuzzy inside.

Even if you are pretty sure the patient is healthy, it's a great relief when someone else agrees to share the burden of an overanxious parent. Unfortunately, none of us has the luxury of working above a completely impermeable safety net of willing and accessible subspecialists. A lot has been written and said about the “open access” practice model for primary care physicians. In theory, it makes sense, and with some simple modifications it has worked well in our office for more than a decade.

But for a variety of good and bad reasons, the easy-open-door policy doesn't seem to work well for most subspecialists. I can see why the depth and complexity of the problems they see may dictate that their initial office visits be time-consuming. Nonetheless, there are a few saintly and busy subspecializing physicians who are so well organized and/or compassionate that their receptionists can offer timely rescue service to my patients.

I'm not sure how they do this, but I suspect that they do what I do when I feel swamped: I temporarily suspend my usual practice of doing a complete exam and history on every new patient. I try to ferret out the patient's primary problem and his parents' overriding concern and begin the process of getting to the bottom of it. I reassure the family that when we have time I will address all of their concerns, but I tell them that to squeeze them in today I will have to temporarily narrow my focus. Most families are so happy to be seen promptly that they are more than happy to accept my triage approach.

When I stumble across busy but easy-access subspecialists, I try to treat them as I would fine wines. I call on them only for special occasions and send them concise and focused histories. They also receive thank-you notes and some of Marilyn's baked goods at Christmas.

But despite our careful husbandry, my partners and I still must live with critical shortages in some subspecialty areas. If you share our pain and frustration, I urge you to read Dr. Daniel Goodman's commentary, “The Pediatric Subspecialty Workforce: Time to Test Our Assumptions,” in the December 2006 issue of Pediatrics.

Dr. Goodman doesn't claim to offer any solutions. But he poses a collection of thought-provoking questions, the answers to which may lead us out of the woods. For example, he wonders if fellowships need to take 3 years or sometimes longer. Is a niche always so deep that a subspecialist in training must invest what could be productive time exploring every abstruse nook and cranny?

Could providers with a modest amount of training learn to care for the bulk of a subspecialty's patients? Unusual and complex patients could be bumped up the ladder to a few master subspecialists.

In selected subspecialties, why can't physicians who were originally trained to see adults broaden their practices to include children? I don't think we have to worry that this change would herald the demise of general pediatrics.

If we read Dr. Goodman's commentary with an open mind and join him in thinking outside the box, we may have some solutions to the subspecialist shortages. Until then, I'm going to continue writing effusive thank-you notes and encourage Marilyn to keep baking her scrumptious cookies.

[email protected]

“Sure, we can see your patient. How about 2 o'clock tomorrow? But if you think he needs to be seen sooner, send him right over and we can squeeze him in.” Those are words that can make any harassed and worried primary care pediatrician feel all warm and fuzzy inside.

Even if you are pretty sure the patient is healthy, it's a great relief when someone else agrees to share the burden of an overanxious parent. Unfortunately, none of us has the luxury of working above a completely impermeable safety net of willing and accessible subspecialists. A lot has been written and said about the “open access” practice model for primary care physicians. In theory, it makes sense, and with some simple modifications it has worked well in our office for more than a decade.

But for a variety of good and bad reasons, the easy-open-door policy doesn't seem to work well for most subspecialists. I can see why the depth and complexity of the problems they see may dictate that their initial office visits be time-consuming. Nonetheless, there are a few saintly and busy subspecializing physicians who are so well organized and/or compassionate that their receptionists can offer timely rescue service to my patients.

I'm not sure how they do this, but I suspect that they do what I do when I feel swamped: I temporarily suspend my usual practice of doing a complete exam and history on every new patient. I try to ferret out the patient's primary problem and his parents' overriding concern and begin the process of getting to the bottom of it. I reassure the family that when we have time I will address all of their concerns, but I tell them that to squeeze them in today I will have to temporarily narrow my focus. Most families are so happy to be seen promptly that they are more than happy to accept my triage approach.

When I stumble across busy but easy-access subspecialists, I try to treat them as I would fine wines. I call on them only for special occasions and send them concise and focused histories. They also receive thank-you notes and some of Marilyn's baked goods at Christmas.

But despite our careful husbandry, my partners and I still must live with critical shortages in some subspecialty areas. If you share our pain and frustration, I urge you to read Dr. Daniel Goodman's commentary, “The Pediatric Subspecialty Workforce: Time to Test Our Assumptions,” in the December 2006 issue of Pediatrics.

Dr. Goodman doesn't claim to offer any solutions. But he poses a collection of thought-provoking questions, the answers to which may lead us out of the woods. For example, he wonders if fellowships need to take 3 years or sometimes longer. Is a niche always so deep that a subspecialist in training must invest what could be productive time exploring every abstruse nook and cranny?

Could providers with a modest amount of training learn to care for the bulk of a subspecialty's patients? Unusual and complex patients could be bumped up the ladder to a few master subspecialists.

In selected subspecialties, why can't physicians who were originally trained to see adults broaden their practices to include children? I don't think we have to worry that this change would herald the demise of general pediatrics.

If we read Dr. Goodman's commentary with an open mind and join him in thinking outside the box, we may have some solutions to the subspecialist shortages. Until then, I'm going to continue writing effusive thank-you notes and encourage Marilyn to keep baking her scrumptious cookies.

[email protected]

The good news is that the flow of sick patients into the office has begun to slow. The viral gastroenteritis and the influenza-like illnesses that have plagued our community seem to be abating. We are now back to a more comfortable mix of slow-gaining breast-feeders, runnynosed toddlers, and limping teenaged athletes.

Physicians and staff are getting home in time to tuck their own children in for the night and sometimes even arriving before dinner is served. There are empty seats in the waiting room from time to time, and I no longer feel that I must begin each visit with an apology for running behind.

The rest of the good news is that weathering this 8-week siege of illness has forced everyone in the office to improve their efficiency so that now we are purring along like a well-oiled machine. Exam rooms are well supplied with otoscope pieces, tongue depressors, and ear curettes when the day begins because the nurses realize that once the patients start arriving, the window of opportunity to restock the drawers may not open again.

All the patients with vomiting or diarrhea are weighed before they see the physician. Children with urine complaints have already been coaxed into peeing and the results of their urinalyses are already on the chart before they are readied for an exam, and those with headaches or head bumps have had their blood pressures taken. The nurses who float over from the internist's pod from time to time are no longer wasting their time and irritating the patients by taking “routine” and meaningless temperatures.

The receptionists are asking more and better questions before they make appointments. After seeing a big influx of sicker-than-usual patients, they have witnessed multiple examples that support our office philosophy: Seeing the sicker patients early in the day helps things run more smoothly. Children with injuries that might require an x-ray are scheduled to come in when our in-house x-ray is staffed. Nearly all of the phone messages that arrive on the counter above the chart rack include sufficient information for the physician to give the correct advice without having to ask time-consuming follow-up questions.

The physicians are arriving in time to make their callbacks and are ready to sit down for our scheduled and promised call-in times. For some, this punctuality is a new habit spawned by the realization that when double-booking is the norm, there is no time to compensate for a late arrival.

The bad news is that 30 years of watching the ebb and flow of patient volume has taught me that after a few weeks of relative quiet, some old habits and inefficiencies will creep back into the routine. It's only natural. No one enjoys churning away at top speed, seeing patients in less time than they deserve.

For some staff members, this double-barreled outbreak was their first opportunity to see how busy a pediatric office can get. Of course, it also gave some of us old-timers the chance to tell a few “If you think this is busy …” stories. And I have grown to enjoy answering those, “Did you really see 85 patients in one day?” questions.

But there is even more good news. None of our permanent employees quit during the siege, and I think that most of our new employees now understand how some of our apparently trivial office policies came to be. When things are relatively quiet, it may not seem terribly important that each exam room always has an extra roll of paper towel under the sink. However, when a physician who is running 40 minutes behind finds herself out in the hall with wet hands instead of beginning her exam of a fussy and feverish 3-month-old, it isn't a pretty picture.

Office pediatrics will always be an unpredictable mix of chaos and calm. No one can write a practice manual that will make every day a stroll in the park. But, a well-run office can create commonsense policies that may help preserve the lessons that were so painfully learned in the heat of battle.

[email protected]

The good news is that the flow of sick patients into the office has begun to slow. The viral gastroenteritis and the influenza-like illnesses that have plagued our community seem to be abating. We are now back to a more comfortable mix of slow-gaining breast-feeders, runnynosed toddlers, and limping teenaged athletes.

Physicians and staff are getting home in time to tuck their own children in for the night and sometimes even arriving before dinner is served. There are empty seats in the waiting room from time to time, and I no longer feel that I must begin each visit with an apology for running behind.

The rest of the good news is that weathering this 8-week siege of illness has forced everyone in the office to improve their efficiency so that now we are purring along like a well-oiled machine. Exam rooms are well supplied with otoscope pieces, tongue depressors, and ear curettes when the day begins because the nurses realize that once the patients start arriving, the window of opportunity to restock the drawers may not open again.

All the patients with vomiting or diarrhea are weighed before they see the physician. Children with urine complaints have already been coaxed into peeing and the results of their urinalyses are already on the chart before they are readied for an exam, and those with headaches or head bumps have had their blood pressures taken. The nurses who float over from the internist's pod from time to time are no longer wasting their time and irritating the patients by taking “routine” and meaningless temperatures.

The receptionists are asking more and better questions before they make appointments. After seeing a big influx of sicker-than-usual patients, they have witnessed multiple examples that support our office philosophy: Seeing the sicker patients early in the day helps things run more smoothly. Children with injuries that might require an x-ray are scheduled to come in when our in-house x-ray is staffed. Nearly all of the phone messages that arrive on the counter above the chart rack include sufficient information for the physician to give the correct advice without having to ask time-consuming follow-up questions.

The physicians are arriving in time to make their callbacks and are ready to sit down for our scheduled and promised call-in times. For some, this punctuality is a new habit spawned by the realization that when double-booking is the norm, there is no time to compensate for a late arrival.

The bad news is that 30 years of watching the ebb and flow of patient volume has taught me that after a few weeks of relative quiet, some old habits and inefficiencies will creep back into the routine. It's only natural. No one enjoys churning away at top speed, seeing patients in less time than they deserve.

For some staff members, this double-barreled outbreak was their first opportunity to see how busy a pediatric office can get. Of course, it also gave some of us old-timers the chance to tell a few “If you think this is busy …” stories. And I have grown to enjoy answering those, “Did you really see 85 patients in one day?” questions.

But there is even more good news. None of our permanent employees quit during the siege, and I think that most of our new employees now understand how some of our apparently trivial office policies came to be. When things are relatively quiet, it may not seem terribly important that each exam room always has an extra roll of paper towel under the sink. However, when a physician who is running 40 minutes behind finds herself out in the hall with wet hands instead of beginning her exam of a fussy and feverish 3-month-old, it isn't a pretty picture.

Office pediatrics will always be an unpredictable mix of chaos and calm. No one can write a practice manual that will make every day a stroll in the park. But, a well-run office can create commonsense policies that may help preserve the lessons that were so painfully learned in the heat of battle.

[email protected]

The good news is that the flow of sick patients into the office has begun to slow. The viral gastroenteritis and the influenza-like illnesses that have plagued our community seem to be abating. We are now back to a more comfortable mix of slow-gaining breast-feeders, runnynosed toddlers, and limping teenaged athletes.

Physicians and staff are getting home in time to tuck their own children in for the night and sometimes even arriving before dinner is served. There are empty seats in the waiting room from time to time, and I no longer feel that I must begin each visit with an apology for running behind.

The rest of the good news is that weathering this 8-week siege of illness has forced everyone in the office to improve their efficiency so that now we are purring along like a well-oiled machine. Exam rooms are well supplied with otoscope pieces, tongue depressors, and ear curettes when the day begins because the nurses realize that once the patients start arriving, the window of opportunity to restock the drawers may not open again.

All the patients with vomiting or diarrhea are weighed before they see the physician. Children with urine complaints have already been coaxed into peeing and the results of their urinalyses are already on the chart before they are readied for an exam, and those with headaches or head bumps have had their blood pressures taken. The nurses who float over from the internist's pod from time to time are no longer wasting their time and irritating the patients by taking “routine” and meaningless temperatures.

The receptionists are asking more and better questions before they make appointments. After seeing a big influx of sicker-than-usual patients, they have witnessed multiple examples that support our office philosophy: Seeing the sicker patients early in the day helps things run more smoothly. Children with injuries that might require an x-ray are scheduled to come in when our in-house x-ray is staffed. Nearly all of the phone messages that arrive on the counter above the chart rack include sufficient information for the physician to give the correct advice without having to ask time-consuming follow-up questions.

The physicians are arriving in time to make their callbacks and are ready to sit down for our scheduled and promised call-in times. For some, this punctuality is a new habit spawned by the realization that when double-booking is the norm, there is no time to compensate for a late arrival.

The bad news is that 30 years of watching the ebb and flow of patient volume has taught me that after a few weeks of relative quiet, some old habits and inefficiencies will creep back into the routine. It's only natural. No one enjoys churning away at top speed, seeing patients in less time than they deserve.

For some staff members, this double-barreled outbreak was their first opportunity to see how busy a pediatric office can get. Of course, it also gave some of us old-timers the chance to tell a few “If you think this is busy …” stories. And I have grown to enjoy answering those, “Did you really see 85 patients in one day?” questions.

But there is even more good news. None of our permanent employees quit during the siege, and I think that most of our new employees now understand how some of our apparently trivial office policies came to be. When things are relatively quiet, it may not seem terribly important that each exam room always has an extra roll of paper towel under the sink. However, when a physician who is running 40 minutes behind finds herself out in the hall with wet hands instead of beginning her exam of a fussy and feverish 3-month-old, it isn't a pretty picture.

Office pediatrics will always be an unpredictable mix of chaos and calm. No one can write a practice manual that will make every day a stroll in the park. But, a well-run office can create commonsense policies that may help preserve the lessons that were so painfully learned in the heat of battle.

[email protected]

I have always prided myself on being a business-savvy and efficient practitioner. In fact, I'm a little bummed that the editor didn't choose me to write the Efficient Pediatrician Practices column that you will find near the back of each issue.

But to be honest, I don't think I could do nearly as good a job at collecting and presenting tips about running a pediatric office as Dr. Charles A. Scott is doing. His advice has the ring of common sense and is realistically doable.

Nonetheless, I can't resist the urge to share a few of my thoughts on coding and the advantages of creating one's personal bite-sized menu of diagnoses. Being a “think small” kind of guy, I have always striven to keep my list of codes and hence diagnoses as short as possible. Six or eight pretty much cover it.

Regardless of how complex the patients' problems may sound when one listens to their parents, I try to distill things into something simple such as “viral illness” or “fever.”

Keeping my diagnostic list as short as possible makes it easier for our staff members, who are already working at the limits of their capabilities.

I notice that my partners who enjoy splitting hairs and dredging up unusual diagnoses spend way too much time with the front office people trying to get the coding correct.

If the physician has written the diagnosis legibly, he or she has probably misspelled it. Even if the physician is lucky enough to have spelled it correctly, the receptionist may not know in which organ system to begin her search for the appropriate code.

I know that some practices have an exhaustive and intimidating list of “common” diagnoses and codes printed on their billing sheets. This usually creates a document that looks something like a page out of the phone book and is even harder to navigate.

Another issue is that at least half of my patients reach the checkout desk before I have gathered enough information to render an accurate and specific diagnosis. Rarely, I may be waiting for some lab work, but more than likely I'm just plain waiting. I'm pretty sure I know what the child doesn't have, and I've asked the parents to join me in a friendly game of wait-and-see until I call the next day.

I suspect my short-list approach to coding creates the impression that my patient mix is of low complexity. My numbers may make it look as though my professional life is rather boring. And I'm sure it would make in-office research projects fruitless. But, you and I know that it's the patients and not the diagnoses that make pediatrics interesting.

However, there are days when I wonder if my life might be easier if I expanded my diagnostic list just a bit. If I included “teething,” then I could hustle those parents of fussy infants and low-grade fevers out of the office more quickly. No need to make those time-consuming follow-up calls the next day.

Imagine how easy things would be if I could sign out all the cranky 2-month-olds as having “colic.” No more extended interviews to find out whether a new mother is depressed or sleep-deprived or both.

If I could move “sinusitis” from my seldom-used list to my short list, then scores of toddlers with green and yellow snot would be on the fast track out of the office and off to the pharmacy for antibiotics. “Growing pains” could become another giant wastebasket into which I could efficiently toss those annoying and sometimes mysterious cases of extremity aches.

But, I know the grand old masters of pediatrics who trained me would be spinning in their graves. I'm sure they would prefer that I stick to my current game plan. I think they would approve of my philosophy that no diagnosis is always better than the wrong one.

[email protected]

I have always prided myself on being a business-savvy and efficient practitioner. In fact, I'm a little bummed that the editor didn't choose me to write the Efficient Pediatrician Practices column that you will find near the back of each issue.

But to be honest, I don't think I could do nearly as good a job at collecting and presenting tips about running a pediatric office as Dr. Charles A. Scott is doing. His advice has the ring of common sense and is realistically doable.

Nonetheless, I can't resist the urge to share a few of my thoughts on coding and the advantages of creating one's personal bite-sized menu of diagnoses. Being a “think small” kind of guy, I have always striven to keep my list of codes and hence diagnoses as short as possible. Six or eight pretty much cover it.

Regardless of how complex the patients' problems may sound when one listens to their parents, I try to distill things into something simple such as “viral illness” or “fever.”

Keeping my diagnostic list as short as possible makes it easier for our staff members, who are already working at the limits of their capabilities.

I notice that my partners who enjoy splitting hairs and dredging up unusual diagnoses spend way too much time with the front office people trying to get the coding correct.

If the physician has written the diagnosis legibly, he or she has probably misspelled it. Even if the physician is lucky enough to have spelled it correctly, the receptionist may not know in which organ system to begin her search for the appropriate code.

I know that some practices have an exhaustive and intimidating list of “common” diagnoses and codes printed on their billing sheets. This usually creates a document that looks something like a page out of the phone book and is even harder to navigate.

Another issue is that at least half of my patients reach the checkout desk before I have gathered enough information to render an accurate and specific diagnosis. Rarely, I may be waiting for some lab work, but more than likely I'm just plain waiting. I'm pretty sure I know what the child doesn't have, and I've asked the parents to join me in a friendly game of wait-and-see until I call the next day.

I suspect my short-list approach to coding creates the impression that my patient mix is of low complexity. My numbers may make it look as though my professional life is rather boring. And I'm sure it would make in-office research projects fruitless. But, you and I know that it's the patients and not the diagnoses that make pediatrics interesting.

However, there are days when I wonder if my life might be easier if I expanded my diagnostic list just a bit. If I included “teething,” then I could hustle those parents of fussy infants and low-grade fevers out of the office more quickly. No need to make those time-consuming follow-up calls the next day.

Imagine how easy things would be if I could sign out all the cranky 2-month-olds as having “colic.” No more extended interviews to find out whether a new mother is depressed or sleep-deprived or both.

If I could move “sinusitis” from my seldom-used list to my short list, then scores of toddlers with green and yellow snot would be on the fast track out of the office and off to the pharmacy for antibiotics. “Growing pains” could become another giant wastebasket into which I could efficiently toss those annoying and sometimes mysterious cases of extremity aches.

But, I know the grand old masters of pediatrics who trained me would be spinning in their graves. I'm sure they would prefer that I stick to my current game plan. I think they would approve of my philosophy that no diagnosis is always better than the wrong one.

[email protected]

I have always prided myself on being a business-savvy and efficient practitioner. In fact, I'm a little bummed that the editor didn't choose me to write the Efficient Pediatrician Practices column that you will find near the back of each issue.

But to be honest, I don't think I could do nearly as good a job at collecting and presenting tips about running a pediatric office as Dr. Charles A. Scott is doing. His advice has the ring of common sense and is realistically doable.

Nonetheless, I can't resist the urge to share a few of my thoughts on coding and the advantages of creating one's personal bite-sized menu of diagnoses. Being a “think small” kind of guy, I have always striven to keep my list of codes and hence diagnoses as short as possible. Six or eight pretty much cover it.

Regardless of how complex the patients' problems may sound when one listens to their parents, I try to distill things into something simple such as “viral illness” or “fever.”

Keeping my diagnostic list as short as possible makes it easier for our staff members, who are already working at the limits of their capabilities.

I notice that my partners who enjoy splitting hairs and dredging up unusual diagnoses spend way too much time with the front office people trying to get the coding correct.

If the physician has written the diagnosis legibly, he or she has probably misspelled it. Even if the physician is lucky enough to have spelled it correctly, the receptionist may not know in which organ system to begin her search for the appropriate code.

I know that some practices have an exhaustive and intimidating list of “common” diagnoses and codes printed on their billing sheets. This usually creates a document that looks something like a page out of the phone book and is even harder to navigate.

Another issue is that at least half of my patients reach the checkout desk before I have gathered enough information to render an accurate and specific diagnosis. Rarely, I may be waiting for some lab work, but more than likely I'm just plain waiting. I'm pretty sure I know what the child doesn't have, and I've asked the parents to join me in a friendly game of wait-and-see until I call the next day.

I suspect my short-list approach to coding creates the impression that my patient mix is of low complexity. My numbers may make it look as though my professional life is rather boring. And I'm sure it would make in-office research projects fruitless. But, you and I know that it's the patients and not the diagnoses that make pediatrics interesting.

However, there are days when I wonder if my life might be easier if I expanded my diagnostic list just a bit. If I included “teething,” then I could hustle those parents of fussy infants and low-grade fevers out of the office more quickly. No need to make those time-consuming follow-up calls the next day.

Imagine how easy things would be if I could sign out all the cranky 2-month-olds as having “colic.” No more extended interviews to find out whether a new mother is depressed or sleep-deprived or both.

If I could move “sinusitis” from my seldom-used list to my short list, then scores of toddlers with green and yellow snot would be on the fast track out of the office and off to the pharmacy for antibiotics. “Growing pains” could become another giant wastebasket into which I could efficiently toss those annoying and sometimes mysterious cases of extremity aches.

But, I know the grand old masters of pediatrics who trained me would be spinning in their graves. I'm sure they would prefer that I stick to my current game plan. I think they would approve of my philosophy that no diagnosis is always better than the wrong one.

[email protected]

Ask a group of primary care pediatricians who are old enough to have children in college and they will tell you that the mix of patients in their offices has changed significantly since they opened their practices. The increase in mental health complaints and the decrease in serious bacterial infections such as meningitis and epiglottitis have been striking.

A less talked-about shift in traffic flow has been the decrease in the number of victims of minor trauma who limp or are carried across the threshold of the average general pediatrician's office.

There are several reasons for this decline in the bumps, cuts, and bruises. One is the advent of emergency medicine as a specialty and the resulting ubiquity of fully staffed emergency departments. A related phenomenon is the realization by hospitals that minor trauma and walk-in illnesses can generate income that can help fund the overhead costs for more serious trauma treatments.

Aggressive marketing by these hungry hospitals has convinced many parents that the hospital “ER” is the place to go when one's child is injured, regardless of how minor the trauma. The marketing has been so successful in our community that parents are often surprised that we can, and occasionally still do, perform suture repairs and simple casting in our office.

Some recently trained pediatricians may be less comfortable seeing minor trauma victims in the office setting, particularly if they don't have access to the security blankets of lab and x-ray.

Experienced physicians have learned that even a simple three-suture repair can throw their busy offices into chaos, and some may instruct their staff to triage every injured child to the emergency department just to keep some semblance of calm in the waiting room. Not surprisingly, it doesn't take long for parents to catch on that their pediatricians aren't interested in seeing injured children, and they will self-refer to the emergency department the next time their child trips and falls.

I suspect that another and more troubling reason that we are seeing fewer injured children in our offices is that there are fewer children who are active enough to sustain even minor trauma. I don't have any statistics to support this observation, but the math is pretty simple. We know that more children are spending more of their time doing nothing but sitting in front of a video screen.

Couch potatoes can get bruised if they roll off onto the floor, but those injuries don't seem to generate enough discomfort to get the little video addicts to turn off the TV and come to the office. Even the hyperactive kids, a group that I could count on for a steady supply of cuts and dings, are being throttled down with amphetamines.

It is so unusual to see a child with grass stains on his knees that some parents feel the need to apologize for this once commonplace physical finding. Of course, I reassure them that these stains and lower extremity bruises are signs of good health. But, their rarity is troubling.

We adults must certainly shoulder a large part of the blame for this drought in minor trauma. We continue to “make poor choices,” which is new millennium-speak for “do stupid things,” when it comes to raising our children. For example, many of you have heard that a school system in Massachusetts recently decided to ban from its playgrounds the game of “tag” because it was deemed a dangerous activity.

The trend toward this low-impact style of parenting is so prevalent that I suggest you sell your stock in Johnson & Johnson and invest in bubble wrap! Because I'm sure my great-grandchildren won't know what a Band-Aid is for, and their parents will be swaddling them in protective layers of bubble wrap before allowing them to leave the house. If indeed they are even allowed to step outside!

[email protected]

Ask a group of primary care pediatricians who are old enough to have children in college and they will tell you that the mix of patients in their offices has changed significantly since they opened their practices. The increase in mental health complaints and the decrease in serious bacterial infections such as meningitis and epiglottitis have been striking.

A less talked-about shift in traffic flow has been the decrease in the number of victims of minor trauma who limp or are carried across the threshold of the average general pediatrician's office.

There are several reasons for this decline in the bumps, cuts, and bruises. One is the advent of emergency medicine as a specialty and the resulting ubiquity of fully staffed emergency departments. A related phenomenon is the realization by hospitals that minor trauma and walk-in illnesses can generate income that can help fund the overhead costs for more serious trauma treatments.

Aggressive marketing by these hungry hospitals has convinced many parents that the hospital “ER” is the place to go when one's child is injured, regardless of how minor the trauma. The marketing has been so successful in our community that parents are often surprised that we can, and occasionally still do, perform suture repairs and simple casting in our office.

Some recently trained pediatricians may be less comfortable seeing minor trauma victims in the office setting, particularly if they don't have access to the security blankets of lab and x-ray.

Experienced physicians have learned that even a simple three-suture repair can throw their busy offices into chaos, and some may instruct their staff to triage every injured child to the emergency department just to keep some semblance of calm in the waiting room. Not surprisingly, it doesn't take long for parents to catch on that their pediatricians aren't interested in seeing injured children, and they will self-refer to the emergency department the next time their child trips and falls.

I suspect that another and more troubling reason that we are seeing fewer injured children in our offices is that there are fewer children who are active enough to sustain even minor trauma. I don't have any statistics to support this observation, but the math is pretty simple. We know that more children are spending more of their time doing nothing but sitting in front of a video screen.

Couch potatoes can get bruised if they roll off onto the floor, but those injuries don't seem to generate enough discomfort to get the little video addicts to turn off the TV and come to the office. Even the hyperactive kids, a group that I could count on for a steady supply of cuts and dings, are being throttled down with amphetamines.

It is so unusual to see a child with grass stains on his knees that some parents feel the need to apologize for this once commonplace physical finding. Of course, I reassure them that these stains and lower extremity bruises are signs of good health. But, their rarity is troubling.

We adults must certainly shoulder a large part of the blame for this drought in minor trauma. We continue to “make poor choices,” which is new millennium-speak for “do stupid things,” when it comes to raising our children. For example, many of you have heard that a school system in Massachusetts recently decided to ban from its playgrounds the game of “tag” because it was deemed a dangerous activity.

The trend toward this low-impact style of parenting is so prevalent that I suggest you sell your stock in Johnson & Johnson and invest in bubble wrap! Because I'm sure my great-grandchildren won't know what a Band-Aid is for, and their parents will be swaddling them in protective layers of bubble wrap before allowing them to leave the house. If indeed they are even allowed to step outside!

[email protected]

Ask a group of primary care pediatricians who are old enough to have children in college and they will tell you that the mix of patients in their offices has changed significantly since they opened their practices. The increase in mental health complaints and the decrease in serious bacterial infections such as meningitis and epiglottitis have been striking.

A less talked-about shift in traffic flow has been the decrease in the number of victims of minor trauma who limp or are carried across the threshold of the average general pediatrician's office.

There are several reasons for this decline in the bumps, cuts, and bruises. One is the advent of emergency medicine as a specialty and the resulting ubiquity of fully staffed emergency departments. A related phenomenon is the realization by hospitals that minor trauma and walk-in illnesses can generate income that can help fund the overhead costs for more serious trauma treatments.

Aggressive marketing by these hungry hospitals has convinced many parents that the hospital “ER” is the place to go when one's child is injured, regardless of how minor the trauma. The marketing has been so successful in our community that parents are often surprised that we can, and occasionally still do, perform suture repairs and simple casting in our office.

Some recently trained pediatricians may be less comfortable seeing minor trauma victims in the office setting, particularly if they don't have access to the security blankets of lab and x-ray.

Experienced physicians have learned that even a simple three-suture repair can throw their busy offices into chaos, and some may instruct their staff to triage every injured child to the emergency department just to keep some semblance of calm in the waiting room. Not surprisingly, it doesn't take long for parents to catch on that their pediatricians aren't interested in seeing injured children, and they will self-refer to the emergency department the next time their child trips and falls.

I suspect that another and more troubling reason that we are seeing fewer injured children in our offices is that there are fewer children who are active enough to sustain even minor trauma. I don't have any statistics to support this observation, but the math is pretty simple. We know that more children are spending more of their time doing nothing but sitting in front of a video screen.

Couch potatoes can get bruised if they roll off onto the floor, but those injuries don't seem to generate enough discomfort to get the little video addicts to turn off the TV and come to the office. Even the hyperactive kids, a group that I could count on for a steady supply of cuts and dings, are being throttled down with amphetamines.

It is so unusual to see a child with grass stains on his knees that some parents feel the need to apologize for this once commonplace physical finding. Of course, I reassure them that these stains and lower extremity bruises are signs of good health. But, their rarity is troubling.

We adults must certainly shoulder a large part of the blame for this drought in minor trauma. We continue to “make poor choices,” which is new millennium-speak for “do stupid things,” when it comes to raising our children. For example, many of you have heard that a school system in Massachusetts recently decided to ban from its playgrounds the game of “tag” because it was deemed a dangerous activity.

The trend toward this low-impact style of parenting is so prevalent that I suggest you sell your stock in Johnson & Johnson and invest in bubble wrap! Because I'm sure my great-grandchildren won't know what a Band-Aid is for, and their parents will be swaddling them in protective layers of bubble wrap before allowing them to leave the house. If indeed they are even allowed to step outside!

[email protected]

After practicing for more than 30 years in the same small town, one finds oneself draped in a wide variety of perceptions—some well deserved and some not. Among the ones I wear most proudly is: “If you are injured, Dr. Wilkoff is the guy to see when you want a note to return to sports participation ASAP.”

For as long as I can remember, sports have been woven into the fabric of my life. Like many boys who grew up in the 1950s, I dreamed of being a college football player. Making the high school team and earning a varsity letter were goals that required devotion that bordered on obsession. Being an athlete was critical to establishing and strengthening my puberty-challenged ego. The memory of those adolescent days has left me with great sympathy for junior high and high school athletes who find their careers interrupted by an injury.

I hope that my reputation among young athletes is the result of a holistic and compassionate approach to sports injuries and not a result of my being perceived as a rubber stamp. That management style has several key components. First, one must possess the skills and comfort level to determine when it is safe for the injured athlete to return to the specific challenges of the sport. This doesn't mean that one must be board certified in sports medicine. I certainly don't remember the names of all the muscle groups, nor can I recite or even spell the sometimes tongue-twisting names of all the ligaments and tendons that hold us together. But, determining the strength, stability, and range of motion is usually pretty straightforward and doesn't require x-rays or MRIs.

Second, the practitioner must ask the right questions to understand how the injury fits into the bigger picture—that is, the picture from the perspective of the young athletes: What positions do they play? Are they on the first string? How many weeks are left in the season? Is the team going to make the playoffs? When do they play their traditional rivals? Is this current sport their favorite or is it merely a way to stay fit until their favorite sport's season?

The responses to these questions are almost as important as is the answer to “Where does it hurt?” They provide me a window into my young patient's mind and can help me understand how the young athlete will accept my rehab plan and prediction of the healing time.

We all know that few decisions in medicine are as easy as telling black from white and rehabilitation schedules are seldom chiseled in stone. Of course we should never allow ourselves to recommend or allow a patient to risk permanent or serious injury. But, can I err on the side of liberalism if a playoff birth hinges on the next game(s)? Is the patient willing to accept the risk of aggravating an injury and missing even more games or the tryouts for a sport he considers his favorite? Entering into a dialogue with the patient and his family can help clarify which shade of gray suits this injury.

Unfortunately for the patient with a head injury, a concussion is not a condition that allows for compromise or negotiation. I have found that sharing a printed copy of my favorite set of head injury management guidelines can return the discussion to the clarity of black and white.

Finally, successful and compassionate management of an athletic injury should include a rehab plan that incorporates a list of things the patient can do that is at least as long as the prohibitions. Very few injuries require total inactivity. Keeping the uninjured extremities in motion can help maintain the athlete's cardiovascular conditioning, but most importantly it can protect his fragile emotions while he is waiting impatiently to get back on the field.

When it's time to return to the action, he may remember that I was one of the people who were on his side.

[email protected]

After practicing for more than 30 years in the same small town, one finds oneself draped in a wide variety of perceptions—some well deserved and some not. Among the ones I wear most proudly is: “If you are injured, Dr. Wilkoff is the guy to see when you want a note to return to sports participation ASAP.”

For as long as I can remember, sports have been woven into the fabric of my life. Like many boys who grew up in the 1950s, I dreamed of being a college football player. Making the high school team and earning a varsity letter were goals that required devotion that bordered on obsession. Being an athlete was critical to establishing and strengthening my puberty-challenged ego. The memory of those adolescent days has left me with great sympathy for junior high and high school athletes who find their careers interrupted by an injury.

I hope that my reputation among young athletes is the result of a holistic and compassionate approach to sports injuries and not a result of my being perceived as a rubber stamp. That management style has several key components. First, one must possess the skills and comfort level to determine when it is safe for the injured athlete to return to the specific challenges of the sport. This doesn't mean that one must be board certified in sports medicine. I certainly don't remember the names of all the muscle groups, nor can I recite or even spell the sometimes tongue-twisting names of all the ligaments and tendons that hold us together. But, determining the strength, stability, and range of motion is usually pretty straightforward and doesn't require x-rays or MRIs.

Second, the practitioner must ask the right questions to understand how the injury fits into the bigger picture—that is, the picture from the perspective of the young athletes: What positions do they play? Are they on the first string? How many weeks are left in the season? Is the team going to make the playoffs? When do they play their traditional rivals? Is this current sport their favorite or is it merely a way to stay fit until their favorite sport's season?

The responses to these questions are almost as important as is the answer to “Where does it hurt?” They provide me a window into my young patient's mind and can help me understand how the young athlete will accept my rehab plan and prediction of the healing time.

We all know that few decisions in medicine are as easy as telling black from white and rehabilitation schedules are seldom chiseled in stone. Of course we should never allow ourselves to recommend or allow a patient to risk permanent or serious injury. But, can I err on the side of liberalism if a playoff birth hinges on the next game(s)? Is the patient willing to accept the risk of aggravating an injury and missing even more games or the tryouts for a sport he considers his favorite? Entering into a dialogue with the patient and his family can help clarify which shade of gray suits this injury.

Unfortunately for the patient with a head injury, a concussion is not a condition that allows for compromise or negotiation. I have found that sharing a printed copy of my favorite set of head injury management guidelines can return the discussion to the clarity of black and white.

Finally, successful and compassionate management of an athletic injury should include a rehab plan that incorporates a list of things the patient can do that is at least as long as the prohibitions. Very few injuries require total inactivity. Keeping the uninjured extremities in motion can help maintain the athlete's cardiovascular conditioning, but most importantly it can protect his fragile emotions while he is waiting impatiently to get back on the field.

When it's time to return to the action, he may remember that I was one of the people who were on his side.

[email protected]

After practicing for more than 30 years in the same small town, one finds oneself draped in a wide variety of perceptions—some well deserved and some not. Among the ones I wear most proudly is: “If you are injured, Dr. Wilkoff is the guy to see when you want a note to return to sports participation ASAP.”

For as long as I can remember, sports have been woven into the fabric of my life. Like many boys who grew up in the 1950s, I dreamed of being a college football player. Making the high school team and earning a varsity letter were goals that required devotion that bordered on obsession. Being an athlete was critical to establishing and strengthening my puberty-challenged ego. The memory of those adolescent days has left me with great sympathy for junior high and high school athletes who find their careers interrupted by an injury.

I hope that my reputation among young athletes is the result of a holistic and compassionate approach to sports injuries and not a result of my being perceived as a rubber stamp. That management style has several key components. First, one must possess the skills and comfort level to determine when it is safe for the injured athlete to return to the specific challenges of the sport. This doesn't mean that one must be board certified in sports medicine. I certainly don't remember the names of all the muscle groups, nor can I recite or even spell the sometimes tongue-twisting names of all the ligaments and tendons that hold us together. But, determining the strength, stability, and range of motion is usually pretty straightforward and doesn't require x-rays or MRIs.

Second, the practitioner must ask the right questions to understand how the injury fits into the bigger picture—that is, the picture from the perspective of the young athletes: What positions do they play? Are they on the first string? How many weeks are left in the season? Is the team going to make the playoffs? When do they play their traditional rivals? Is this current sport their favorite or is it merely a way to stay fit until their favorite sport's season?

The responses to these questions are almost as important as is the answer to “Where does it hurt?” They provide me a window into my young patient's mind and can help me understand how the young athlete will accept my rehab plan and prediction of the healing time.

We all know that few decisions in medicine are as easy as telling black from white and rehabilitation schedules are seldom chiseled in stone. Of course we should never allow ourselves to recommend or allow a patient to risk permanent or serious injury. But, can I err on the side of liberalism if a playoff birth hinges on the next game(s)? Is the patient willing to accept the risk of aggravating an injury and missing even more games or the tryouts for a sport he considers his favorite? Entering into a dialogue with the patient and his family can help clarify which shade of gray suits this injury.

Unfortunately for the patient with a head injury, a concussion is not a condition that allows for compromise or negotiation. I have found that sharing a printed copy of my favorite set of head injury management guidelines can return the discussion to the clarity of black and white.

Finally, successful and compassionate management of an athletic injury should include a rehab plan that incorporates a list of things the patient can do that is at least as long as the prohibitions. Very few injuries require total inactivity. Keeping the uninjured extremities in motion can help maintain the athlete's cardiovascular conditioning, but most importantly it can protect his fragile emotions while he is waiting impatiently to get back on the field.

When it's time to return to the action, he may remember that I was one of the people who were on his side.

[email protected]

Here on the coast of Maine, the clam diggers fear a “red tide.” This natural phenomenon is the result of a toxic algal bloom that doesn't harm the clams, but makes them dangerously inedible to humans. Some pediatricians seem to have a similar, but less rational, fear of a “yellow tide” known as neonatal jaundice.

Currently, this natural phenomenon has prompted a yellow alert. Some physicians are recommending baseline bilirubin sampling on all newborns prior to discharge from the nursery. Others are suggesting that we test every newborn who appears yellow, regardless of age or nutritional status. Nursery nurses are being encouraged to be proactive and order bilirubin tests whenever they have any suspicion of jaundice.

The result of this yellow phobia is that hundreds of new families must remain in the hospital waiting for lab results. Scores of already anxious parents are being made more anxious by informational chats about jaundice with well-meaning nurses and physicians. Focus shifts from breast-feeding to battling the dread yellow tide. Who knows how many breast-feeding experiences have been jeopardized or destroyed by this unfortunate shift in attention?

Maintaining close physical contact between mother and baby is difficult and ad lib breast-feeding is impossible if phototherapy is prescribed. Marginal results may be achieved with daily trips to the lab, which are not fun for new mothers with sore bottoms or healing abdominal wounds. Mothers and babies who should be home sleeping and nursing find themselves sitting in hard plastic chairs in laboratory waiting areas.

In the 1970s, the yellow tide of worry ebbed as some sensible neonatologists cautioned the rest of us about irrational “vigintiphobia” (fear of bilirubin levels greater than 20) and many of us relaxed. I began ordering fewer bilirubin tests and started paying more attention to learning how I could better support breast-feeding. The “bili lights” moved into the storage room behind the nursery and were wheeled out only on rare occasions.

However, when economic forces shrunk hospital stays and some physicians failed to adequately compensate with timely outpatient follow-up visits, there was an increase in the number of very yellow babies. The tide of concern turned from ebb to flow, and along with it came the new recommendations for more aggressive testing.

I have resisted the encouragement from the various committees that pontificate on such matters of color and have continued to ignore the color of all but the most pumpkin-colored newborns. I admit that I have had a small and lingering worry that my color blindness may have prevented some of my patients from doing as well as their peers on the college SATs. But I have trouble imagining that a phenomenon as common as neonatal jaundice is something to fear.

Galloping onto the stage in their white hats to rescue me from nagging worry are T. B. Newman et al. from the University of California in San Francisco (N. Engl. J. Med. 2006;354:1889–900). They have collected 140 neonates with bilirubins greater than 25 (10 had levels of 30 or greater). When these neonates were compared with the control group, the investigators could find no significant difference in their scores on a collection of cognitive tests. There also was no difference in either the proportion of children with neurologic findings or the documented diagnoses of neurologic findings.

So there you have it. Will the yellow tide begin to recede? Will physicians and nursery nurses begin to shift their focus away from jaundice onto more important issues, such as providing new mothers the technical and emotional support they often need to make breast-feeding succeed? It's time to give our jaundiced eyes a rest and begin to listen to what new mothers want.

[email protected]

Here on the coast of Maine, the clam diggers fear a “red tide.” This natural phenomenon is the result of a toxic algal bloom that doesn't harm the clams, but makes them dangerously inedible to humans. Some pediatricians seem to have a similar, but less rational, fear of a “yellow tide” known as neonatal jaundice.

Currently, this natural phenomenon has prompted a yellow alert. Some physicians are recommending baseline bilirubin sampling on all newborns prior to discharge from the nursery. Others are suggesting that we test every newborn who appears yellow, regardless of age or nutritional status. Nursery nurses are being encouraged to be proactive and order bilirubin tests whenever they have any suspicion of jaundice.

The result of this yellow phobia is that hundreds of new families must remain in the hospital waiting for lab results. Scores of already anxious parents are being made more anxious by informational chats about jaundice with well-meaning nurses and physicians. Focus shifts from breast-feeding to battling the dread yellow tide. Who knows how many breast-feeding experiences have been jeopardized or destroyed by this unfortunate shift in attention?

Maintaining close physical contact between mother and baby is difficult and ad lib breast-feeding is impossible if phototherapy is prescribed. Marginal results may be achieved with daily trips to the lab, which are not fun for new mothers with sore bottoms or healing abdominal wounds. Mothers and babies who should be home sleeping and nursing find themselves sitting in hard plastic chairs in laboratory waiting areas.

In the 1970s, the yellow tide of worry ebbed as some sensible neonatologists cautioned the rest of us about irrational “vigintiphobia” (fear of bilirubin levels greater than 20) and many of us relaxed. I began ordering fewer bilirubin tests and started paying more attention to learning how I could better support breast-feeding. The “bili lights” moved into the storage room behind the nursery and were wheeled out only on rare occasions.

However, when economic forces shrunk hospital stays and some physicians failed to adequately compensate with timely outpatient follow-up visits, there was an increase in the number of very yellow babies. The tide of concern turned from ebb to flow, and along with it came the new recommendations for more aggressive testing.

I have resisted the encouragement from the various committees that pontificate on such matters of color and have continued to ignore the color of all but the most pumpkin-colored newborns. I admit that I have had a small and lingering worry that my color blindness may have prevented some of my patients from doing as well as their peers on the college SATs. But I have trouble imagining that a phenomenon as common as neonatal jaundice is something to fear.

Galloping onto the stage in their white hats to rescue me from nagging worry are T. B. Newman et al. from the University of California in San Francisco (N. Engl. J. Med. 2006;354:1889–900). They have collected 140 neonates with bilirubins greater than 25 (10 had levels of 30 or greater). When these neonates were compared with the control group, the investigators could find no significant difference in their scores on a collection of cognitive tests. There also was no difference in either the proportion of children with neurologic findings or the documented diagnoses of neurologic findings.

So there you have it. Will the yellow tide begin to recede? Will physicians and nursery nurses begin to shift their focus away from jaundice onto more important issues, such as providing new mothers the technical and emotional support they often need to make breast-feeding succeed? It's time to give our jaundiced eyes a rest and begin to listen to what new mothers want.

[email protected]

Here on the coast of Maine, the clam diggers fear a “red tide.” This natural phenomenon is the result of a toxic algal bloom that doesn't harm the clams, but makes them dangerously inedible to humans. Some pediatricians seem to have a similar, but less rational, fear of a “yellow tide” known as neonatal jaundice.

Currently, this natural phenomenon has prompted a yellow alert. Some physicians are recommending baseline bilirubin sampling on all newborns prior to discharge from the nursery. Others are suggesting that we test every newborn who appears yellow, regardless of age or nutritional status. Nursery nurses are being encouraged to be proactive and order bilirubin tests whenever they have any suspicion of jaundice.

The result of this yellow phobia is that hundreds of new families must remain in the hospital waiting for lab results. Scores of already anxious parents are being made more anxious by informational chats about jaundice with well-meaning nurses and physicians. Focus shifts from breast-feeding to battling the dread yellow tide. Who knows how many breast-feeding experiences have been jeopardized or destroyed by this unfortunate shift in attention?

Maintaining close physical contact between mother and baby is difficult and ad lib breast-feeding is impossible if phototherapy is prescribed. Marginal results may be achieved with daily trips to the lab, which are not fun for new mothers with sore bottoms or healing abdominal wounds. Mothers and babies who should be home sleeping and nursing find themselves sitting in hard plastic chairs in laboratory waiting areas.

In the 1970s, the yellow tide of worry ebbed as some sensible neonatologists cautioned the rest of us about irrational “vigintiphobia” (fear of bilirubin levels greater than 20) and many of us relaxed. I began ordering fewer bilirubin tests and started paying more attention to learning how I could better support breast-feeding. The “bili lights” moved into the storage room behind the nursery and were wheeled out only on rare occasions.

However, when economic forces shrunk hospital stays and some physicians failed to adequately compensate with timely outpatient follow-up visits, there was an increase in the number of very yellow babies. The tide of concern turned from ebb to flow, and along with it came the new recommendations for more aggressive testing.

I have resisted the encouragement from the various committees that pontificate on such matters of color and have continued to ignore the color of all but the most pumpkin-colored newborns. I admit that I have had a small and lingering worry that my color blindness may have prevented some of my patients from doing as well as their peers on the college SATs. But I have trouble imagining that a phenomenon as common as neonatal jaundice is something to fear.

Galloping onto the stage in their white hats to rescue me from nagging worry are T. B. Newman et al. from the University of California in San Francisco (N. Engl. J. Med. 2006;354:1889–900). They have collected 140 neonates with bilirubins greater than 25 (10 had levels of 30 or greater). When these neonates were compared with the control group, the investigators could find no significant difference in their scores on a collection of cognitive tests. There also was no difference in either the proportion of children with neurologic findings or the documented diagnoses of neurologic findings.

So there you have it. Will the yellow tide begin to recede? Will physicians and nursery nurses begin to shift their focus away from jaundice onto more important issues, such as providing new mothers the technical and emotional support they often need to make breast-feeding succeed? It's time to give our jaundiced eyes a rest and begin to listen to what new mothers want.

[email protected]

Practicing pediatrics is a lot like baking brownies.

I've been to enough picnics and to enough potluck suppers to know that everyone likes brownies.

And it is clear that every parent wants quality health care for their children.

The problem is that there are lots of ways to make a brownie. Do you like yours more like cake or more like fudge? From scratch or a mix? Nuts? On top or mixed in? Is store-bought in a cellophane bag good enough?

Likewise, everyone seems to have his or her own definition of quality health care. Of course you want your child's condition accurately diagnosed and treated with the most appropriate remedy. Just as chocolate, flour, and sugar are to a brownie, those are the essential ingredients of quality health care. But the ratios between the ingredients and the special additions to the recipe are what make one provider's approach to health care delivery more or less appealing to the appetite of the patients and their families.

In our group of four pediatricians, each of us has his or her particular style of delivering quality health care. We talk frequently among ourselves and see each other's charts many times during a typical day. We use the same rationale for choosing antibiotics and asthma medications. And, although we try to speak with one voice, we each have our own distinct accent that can put a different spin on the same message.

As the senior member of the group, I tend to rely on my age and an aura of experience to convince the patient's family that I have chosen the diagnosis and treatment wisely. Instead of ordering much lab work or x-rays, I use the unstated “because-I-said-so” rationale. While it's a defense that may not stand up in court, it works more often than not with most families who have chosen me as their primary care provider. I'm sure I don't spend as much time as my partners do explaining anatomy and physiology in great detail … but I do draw a lot of pictures.

But, there are some families for whom lab work and x-rays are part of their definition of quality health care. Just as there are some parents who prefer their medical care with a liberal dose of worry sprinkled on top. They will tend to choose one of my partners who shares their preference for looking at worst-case scenarios.

Please don't hear this as a judgmental observation. I completely understand why some people are comforted by hearing about all the ugly and unlikely possibilities that have been ruled out. It's just not the way I like to bake my brownies.

My usual health care delivery style is the pop-in-the-microwave-ready-to-serve version. I contend that in a blindfolded taste test the consumer couldn't tell the difference between mine and the baked-from-scratch version. It's got the essential ingredients of the correct diagnosis and treatment. And, surprisingly, many working parents with busy lives and overscheduled children like the quick turnaround time in the office. But, not surprisingly, other parents feel more comfortable when they know a diagnosis and treatment plan has baked in the oven for 15 or 20 minutes.

With four pediatricians in our group, the families who choose us can select a primary care provider whose style best fits their preferences.

But occasionally families will ask to see someone other than their primary care provider because on a particular day or with a particular complaint, they feel that a different style would be a better fit for their schedule or their emotional needs.

The challenge for physicians comes when we are on call and the only package on the shelf. Obviously, if there is time, I would like all families to receive the style of care they are most comfortable with. I can still bake them from scratch, add nuts, or make them sweet and fudgy, and I will. The challenge is figuring out just how each family likes its brownies.

[email protected]

Practicing pediatrics is a lot like baking brownies.

I've been to enough picnics and to enough potluck suppers to know that everyone likes brownies.

And it is clear that every parent wants quality health care for their children.

The problem is that there are lots of ways to make a brownie. Do you like yours more like cake or more like fudge? From scratch or a mix? Nuts? On top or mixed in? Is store-bought in a cellophane bag good enough?

Likewise, everyone seems to have his or her own definition of quality health care. Of course you want your child's condition accurately diagnosed and treated with the most appropriate remedy. Just as chocolate, flour, and sugar are to a brownie, those are the essential ingredients of quality health care. But the ratios between the ingredients and the special additions to the recipe are what make one provider's approach to health care delivery more or less appealing to the appetite of the patients and their families.

In our group of four pediatricians, each of us has his or her particular style of delivering quality health care. We talk frequently among ourselves and see each other's charts many times during a typical day. We use the same rationale for choosing antibiotics and asthma medications. And, although we try to speak with one voice, we each have our own distinct accent that can put a different spin on the same message.

As the senior member of the group, I tend to rely on my age and an aura of experience to convince the patient's family that I have chosen the diagnosis and treatment wisely. Instead of ordering much lab work or x-rays, I use the unstated “because-I-said-so” rationale. While it's a defense that may not stand up in court, it works more often than not with most families who have chosen me as their primary care provider. I'm sure I don't spend as much time as my partners do explaining anatomy and physiology in great detail … but I do draw a lot of pictures.

But, there are some families for whom lab work and x-rays are part of their definition of quality health care. Just as there are some parents who prefer their medical care with a liberal dose of worry sprinkled on top. They will tend to choose one of my partners who shares their preference for looking at worst-case scenarios.

Please don't hear this as a judgmental observation. I completely understand why some people are comforted by hearing about all the ugly and unlikely possibilities that have been ruled out. It's just not the way I like to bake my brownies.

My usual health care delivery style is the pop-in-the-microwave-ready-to-serve version. I contend that in a blindfolded taste test the consumer couldn't tell the difference between mine and the baked-from-scratch version. It's got the essential ingredients of the correct diagnosis and treatment. And, surprisingly, many working parents with busy lives and overscheduled children like the quick turnaround time in the office. But, not surprisingly, other parents feel more comfortable when they know a diagnosis and treatment plan has baked in the oven for 15 or 20 minutes.

With four pediatricians in our group, the families who choose us can select a primary care provider whose style best fits their preferences.

But occasionally families will ask to see someone other than their primary care provider because on a particular day or with a particular complaint, they feel that a different style would be a better fit for their schedule or their emotional needs.

The challenge for physicians comes when we are on call and the only package on the shelf. Obviously, if there is time, I would like all families to receive the style of care they are most comfortable with. I can still bake them from scratch, add nuts, or make them sweet and fudgy, and I will. The challenge is figuring out just how each family likes its brownies.

[email protected]

Practicing pediatrics is a lot like baking brownies.

I've been to enough picnics and to enough potluck suppers to know that everyone likes brownies.

And it is clear that every parent wants quality health care for their children.

The problem is that there are lots of ways to make a brownie. Do you like yours more like cake or more like fudge? From scratch or a mix? Nuts? On top or mixed in? Is store-bought in a cellophane bag good enough?

Likewise, everyone seems to have his or her own definition of quality health care. Of course you want your child's condition accurately diagnosed and treated with the most appropriate remedy. Just as chocolate, flour, and sugar are to a brownie, those are the essential ingredients of quality health care. But the ratios between the ingredients and the special additions to the recipe are what make one provider's approach to health care delivery more or less appealing to the appetite of the patients and their families.

In our group of four pediatricians, each of us has his or her particular style of delivering quality health care. We talk frequently among ourselves and see each other's charts many times during a typical day. We use the same rationale for choosing antibiotics and asthma medications. And, although we try to speak with one voice, we each have our own distinct accent that can put a different spin on the same message.

As the senior member of the group, I tend to rely on my age and an aura of experience to convince the patient's family that I have chosen the diagnosis and treatment wisely. Instead of ordering much lab work or x-rays, I use the unstated “because-I-said-so” rationale. While it's a defense that may not stand up in court, it works more often than not with most families who have chosen me as their primary care provider. I'm sure I don't spend as much time as my partners do explaining anatomy and physiology in great detail … but I do draw a lot of pictures.

But, there are some families for whom lab work and x-rays are part of their definition of quality health care. Just as there are some parents who prefer their medical care with a liberal dose of worry sprinkled on top. They will tend to choose one of my partners who shares their preference for looking at worst-case scenarios.

Please don't hear this as a judgmental observation. I completely understand why some people are comforted by hearing about all the ugly and unlikely possibilities that have been ruled out. It's just not the way I like to bake my brownies.

My usual health care delivery style is the pop-in-the-microwave-ready-to-serve version. I contend that in a blindfolded taste test the consumer couldn't tell the difference between mine and the baked-from-scratch version. It's got the essential ingredients of the correct diagnosis and treatment. And, surprisingly, many working parents with busy lives and overscheduled children like the quick turnaround time in the office. But, not surprisingly, other parents feel more comfortable when they know a diagnosis and treatment plan has baked in the oven for 15 or 20 minutes.

With four pediatricians in our group, the families who choose us can select a primary care provider whose style best fits their preferences.

But occasionally families will ask to see someone other than their primary care provider because on a particular day or with a particular complaint, they feel that a different style would be a better fit for their schedule or their emotional needs.

The challenge for physicians comes when we are on call and the only package on the shelf. Obviously, if there is time, I would like all families to receive the style of care they are most comfortable with. I can still bake them from scratch, add nuts, or make them sweet and fudgy, and I will. The challenge is figuring out just how each family likes its brownies.