Letters from Maine

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A couple of months ago I was invited to de-liver the commencement address at a small high school on Maryland's eastern shore. I was stumped for a topic, so my wife suggested that because I seem to be enjoying myself most of the time, I speak about happiness. Because I hear and read so much about burnout and professional dissatisfaction among physicians, I thought I would share with you what I discovered about happiness as I researched my address.

Of course, I would speak to the new graduates about the antidepressant effects of exercise, sunlight, and a good night's sleep. But because happiness is not merely the absence of depression, I needed more insight, so I aimed my computer mouse at Google and typed in “happiness.”

I quickly found that despite what the authors of our Declaration of Independence might have written, happiness is not something to pursue. Albert Camus has written, “You will never be happy if you continue to search for what happiness consists of.”

In the writing of the psychologist/physician Edward de Bono, I discovered his observation that “Unhappiness is best defined as a mismatch between our talents and expectations.” Every day, you and I see this phenomenon in new parents who have failed to accurately predict how much time and energy it takes to raise a child. Many of them think it will be just a tad more difficult than rearing a golden retriever.

But, how many of us realize that we may be suffering the unhappy consequences of similar miscalculations and choices? I have found it difficult to communicate to young would-be physicians how challenging it can be to see an economically profitable number of patients and still be the kind of physician they would like to be. If I did the math for them, I'm afraid I would discourage most of them from choosing outpatient pediatrics.

However, I learned from the Dalai Lama that being a pediatrician has great potential for providing happiness. He has said, “If you want others to be happy, practice compassion. If you want to be happy, practice compassion.” He also said, “It is hardly surprising that most of our happiness arises in the context of our relationship with others.” It is difficult to imagine many other professions that offer as many opportunities to interact with people and practice compassion as does pediatrics.

But even if you have discovered that pediatrics is the best fit between your talents and your expectations, doodoo happens. How you deal with these disappointments is a reflection of your happiness quotient. Helen Keller has written, “When one door of happiness closes, another one opens, but often we look so long at the door that is closed, we don't see the one that has opened for us.”

I read somewhere that happy people have a knack for always looking forward and not dwelling on the mistakes and misdeeds of others. Happy people tend to recall their successes and use them as a springboard to continue forward. I think this is what Albert Schweitzer was getting at when he said, “Happiness is nothing more than good health and a bad memory.” I would add that if we are smart we learn from our mistakes and the injustices we have received, but if we want to be happy, we quickly forget them and move on.

The last nugget about happiness that I discovered was from Matt Richey, who writes for the Motley Fool, a financial Web site. He has observed that “Contentment isn't a feeling or a mood, it is a decision. Only by choosing to be content with what you already have can you accomplish your goals. Without choosing happiness, you will be trapped by an ever-expanding appetite for money and all things it can purchase.”

That's more good news for us—I'm sure few of us have chosen pediatrics because we thought it would be a way to make a fast and easy buck.

[email protected]

A couple of months ago I was invited to de-liver the commencement address at a small high school on Maryland's eastern shore. I was stumped for a topic, so my wife suggested that because I seem to be enjoying myself most of the time, I speak about happiness. Because I hear and read so much about burnout and professional dissatisfaction among physicians, I thought I would share with you what I discovered about happiness as I researched my address.

Of course, I would speak to the new graduates about the antidepressant effects of exercise, sunlight, and a good night's sleep. But because happiness is not merely the absence of depression, I needed more insight, so I aimed my computer mouse at Google and typed in “happiness.”

I quickly found that despite what the authors of our Declaration of Independence might have written, happiness is not something to pursue. Albert Camus has written, “You will never be happy if you continue to search for what happiness consists of.”

In the writing of the psychologist/physician Edward de Bono, I discovered his observation that “Unhappiness is best defined as a mismatch between our talents and expectations.” Every day, you and I see this phenomenon in new parents who have failed to accurately predict how much time and energy it takes to raise a child. Many of them think it will be just a tad more difficult than rearing a golden retriever.

But, how many of us realize that we may be suffering the unhappy consequences of similar miscalculations and choices? I have found it difficult to communicate to young would-be physicians how challenging it can be to see an economically profitable number of patients and still be the kind of physician they would like to be. If I did the math for them, I'm afraid I would discourage most of them from choosing outpatient pediatrics.

However, I learned from the Dalai Lama that being a pediatrician has great potential for providing happiness. He has said, “If you want others to be happy, practice compassion. If you want to be happy, practice compassion.” He also said, “It is hardly surprising that most of our happiness arises in the context of our relationship with others.” It is difficult to imagine many other professions that offer as many opportunities to interact with people and practice compassion as does pediatrics.

But even if you have discovered that pediatrics is the best fit between your talents and your expectations, doodoo happens. How you deal with these disappointments is a reflection of your happiness quotient. Helen Keller has written, “When one door of happiness closes, another one opens, but often we look so long at the door that is closed, we don't see the one that has opened for us.”

I read somewhere that happy people have a knack for always looking forward and not dwelling on the mistakes and misdeeds of others. Happy people tend to recall their successes and use them as a springboard to continue forward. I think this is what Albert Schweitzer was getting at when he said, “Happiness is nothing more than good health and a bad memory.” I would add that if we are smart we learn from our mistakes and the injustices we have received, but if we want to be happy, we quickly forget them and move on.

The last nugget about happiness that I discovered was from Matt Richey, who writes for the Motley Fool, a financial Web site. He has observed that “Contentment isn't a feeling or a mood, it is a decision. Only by choosing to be content with what you already have can you accomplish your goals. Without choosing happiness, you will be trapped by an ever-expanding appetite for money and all things it can purchase.”

That's more good news for us—I'm sure few of us have chosen pediatrics because we thought it would be a way to make a fast and easy buck.

[email protected]

A couple of months ago I was invited to de-liver the commencement address at a small high school on Maryland's eastern shore. I was stumped for a topic, so my wife suggested that because I seem to be enjoying myself most of the time, I speak about happiness. Because I hear and read so much about burnout and professional dissatisfaction among physicians, I thought I would share with you what I discovered about happiness as I researched my address.

Of course, I would speak to the new graduates about the antidepressant effects of exercise, sunlight, and a good night's sleep. But because happiness is not merely the absence of depression, I needed more insight, so I aimed my computer mouse at Google and typed in “happiness.”

I quickly found that despite what the authors of our Declaration of Independence might have written, happiness is not something to pursue. Albert Camus has written, “You will never be happy if you continue to search for what happiness consists of.”

In the writing of the psychologist/physician Edward de Bono, I discovered his observation that “Unhappiness is best defined as a mismatch between our talents and expectations.” Every day, you and I see this phenomenon in new parents who have failed to accurately predict how much time and energy it takes to raise a child. Many of them think it will be just a tad more difficult than rearing a golden retriever.

But, how many of us realize that we may be suffering the unhappy consequences of similar miscalculations and choices? I have found it difficult to communicate to young would-be physicians how challenging it can be to see an economically profitable number of patients and still be the kind of physician they would like to be. If I did the math for them, I'm afraid I would discourage most of them from choosing outpatient pediatrics.

However, I learned from the Dalai Lama that being a pediatrician has great potential for providing happiness. He has said, “If you want others to be happy, practice compassion. If you want to be happy, practice compassion.” He also said, “It is hardly surprising that most of our happiness arises in the context of our relationship with others.” It is difficult to imagine many other professions that offer as many opportunities to interact with people and practice compassion as does pediatrics.

But even if you have discovered that pediatrics is the best fit between your talents and your expectations, doodoo happens. How you deal with these disappointments is a reflection of your happiness quotient. Helen Keller has written, “When one door of happiness closes, another one opens, but often we look so long at the door that is closed, we don't see the one that has opened for us.”

I read somewhere that happy people have a knack for always looking forward and not dwelling on the mistakes and misdeeds of others. Happy people tend to recall their successes and use them as a springboard to continue forward. I think this is what Albert Schweitzer was getting at when he said, “Happiness is nothing more than good health and a bad memory.” I would add that if we are smart we learn from our mistakes and the injustices we have received, but if we want to be happy, we quickly forget them and move on.

The last nugget about happiness that I discovered was from Matt Richey, who writes for the Motley Fool, a financial Web site. He has observed that “Contentment isn't a feeling or a mood, it is a decision. Only by choosing to be content with what you already have can you accomplish your goals. Without choosing happiness, you will be trapped by an ever-expanding appetite for money and all things it can purchase.”

That's more good news for us—I'm sure few of us have chosen pediatrics because we thought it would be a way to make a fast and easy buck.

Let me ask you a question. Your receptionist receives a call from the mother of a 7-month-old who has been feverish and irritable for 3 days. She is visiting from out of state and staying with a family whose three children have been your patients for 13 years. The mother is “pretty sure” that her insurance will cover an out-of-network visit.

Would your receptionist: (a) schedule an appointment, (b) ask you if it is okay to book the appointment and then warn the mother that she will have to pay at the time of the visit, or (c) suggest that the family take the child to the emergency department?

What would your answer be if the scenario included that this child from out of town also was the niece of one of your nurses?

I ask this question because the issue of how one manages visiting families comes up almost weekly in our office. Because our license plates here in Maine include the slogan “Vacationland” and because Brunswick sits on the shores of scenic Casco Bay, we have lots of visitors.

Our policy has always been to find an appointment slot for someone who tells us they are visiting from out of town regardless of whether they have been referred by a family that we know. I hope that the bulk of our motivation is just old-fashioned New England hospitality. But, a lot of it is just habit. In the not-so-good old days before there were such things as emergency department physicians, we were going to end up seeing the patients from out of town anyway. And it was usually more convenient for us to have them come to our office.

Even when staffed with well-trained physicians, an emergency department is usually not the optimal diagnostic or therapeutic setting for a moderately ill young child or infant. And most families who are accustomed to good office care at a medical home know this.

Although it's hard for me to imagine why anyone who lives in Vacationland would want to travel out of state, from time to time it does happen. And, when our patients' families return we occasionally hear horror stories of their attempts to find pediatric care. I recently had a mother tell me that a referral from a current patient and an offer to pay cash failed to unlock the tightly guarded pediatric office in the suburban community where she was visiting her parents.

I am sure that there are some communities with large transient populations in which our visitor-friendly office policy might be committing economic suicide. And, I suspect that many larger communities have emergency departments that can offer nonurgent pediatric care that would pass my “Is it good enough for my granddaughter?” test.

However, it troubles me to hear how shabbily some of our families are treated when they venture far from their children's medical home.

When we became fellows, the American Academy of Pediatrics didn't ask us to promise that we would see any patient who has a medical home supervised by one of our brother or sister pediatricians. Nor do any of us have written contracts with the families in our practices stating that we will agree to see any child who comes to visit them. But, if you have found yourself in a strange town with a sick child as I have, you know what you should do when a distraught mother visiting from out of town calls your office.

Let me ask you a question. Your receptionist receives a call from the mother of a 7-month-old who has been feverish and irritable for 3 days. She is visiting from out of state and staying with a family whose three children have been your patients for 13 years. The mother is “pretty sure” that her insurance will cover an out-of-network visit.

Would your receptionist: (a) schedule an appointment, (b) ask you if it is okay to book the appointment and then warn the mother that she will have to pay at the time of the visit, or (c) suggest that the family take the child to the emergency department?

What would your answer be if the scenario included that this child from out of town also was the niece of one of your nurses?

I ask this question because the issue of how one manages visiting families comes up almost weekly in our office. Because our license plates here in Maine include the slogan “Vacationland” and because Brunswick sits on the shores of scenic Casco Bay, we have lots of visitors.

Our policy has always been to find an appointment slot for someone who tells us they are visiting from out of town regardless of whether they have been referred by a family that we know. I hope that the bulk of our motivation is just old-fashioned New England hospitality. But, a lot of it is just habit. In the not-so-good old days before there were such things as emergency department physicians, we were going to end up seeing the patients from out of town anyway. And it was usually more convenient for us to have them come to our office.

Even when staffed with well-trained physicians, an emergency department is usually not the optimal diagnostic or therapeutic setting for a moderately ill young child or infant. And most families who are accustomed to good office care at a medical home know this.

Although it's hard for me to imagine why anyone who lives in Vacationland would want to travel out of state, from time to time it does happen. And, when our patients' families return we occasionally hear horror stories of their attempts to find pediatric care. I recently had a mother tell me that a referral from a current patient and an offer to pay cash failed to unlock the tightly guarded pediatric office in the suburban community where she was visiting her parents.

I am sure that there are some communities with large transient populations in which our visitor-friendly office policy might be committing economic suicide. And, I suspect that many larger communities have emergency departments that can offer nonurgent pediatric care that would pass my “Is it good enough for my granddaughter?” test.

However, it troubles me to hear how shabbily some of our families are treated when they venture far from their children's medical home.

When we became fellows, the American Academy of Pediatrics didn't ask us to promise that we would see any patient who has a medical home supervised by one of our brother or sister pediatricians. Nor do any of us have written contracts with the families in our practices stating that we will agree to see any child who comes to visit them. But, if you have found yourself in a strange town with a sick child as I have, you know what you should do when a distraught mother visiting from out of town calls your office.

Let me ask you a question. Your receptionist receives a call from the mother of a 7-month-old who has been feverish and irritable for 3 days. She is visiting from out of state and staying with a family whose three children have been your patients for 13 years. The mother is “pretty sure” that her insurance will cover an out-of-network visit.

Would your receptionist: (a) schedule an appointment, (b) ask you if it is okay to book the appointment and then warn the mother that she will have to pay at the time of the visit, or (c) suggest that the family take the child to the emergency department?

What would your answer be if the scenario included that this child from out of town also was the niece of one of your nurses?

I ask this question because the issue of how one manages visiting families comes up almost weekly in our office. Because our license plates here in Maine include the slogan “Vacationland” and because Brunswick sits on the shores of scenic Casco Bay, we have lots of visitors.

Our policy has always been to find an appointment slot for someone who tells us they are visiting from out of town regardless of whether they have been referred by a family that we know. I hope that the bulk of our motivation is just old-fashioned New England hospitality. But, a lot of it is just habit. In the not-so-good old days before there were such things as emergency department physicians, we were going to end up seeing the patients from out of town anyway. And it was usually more convenient for us to have them come to our office.

Even when staffed with well-trained physicians, an emergency department is usually not the optimal diagnostic or therapeutic setting for a moderately ill young child or infant. And most families who are accustomed to good office care at a medical home know this.

Although it's hard for me to imagine why anyone who lives in Vacationland would want to travel out of state, from time to time it does happen. And, when our patients' families return we occasionally hear horror stories of their attempts to find pediatric care. I recently had a mother tell me that a referral from a current patient and an offer to pay cash failed to unlock the tightly guarded pediatric office in the suburban community where she was visiting her parents.

I am sure that there are some communities with large transient populations in which our visitor-friendly office policy might be committing economic suicide. And, I suspect that many larger communities have emergency departments that can offer nonurgent pediatric care that would pass my “Is it good enough for my granddaughter?” test.

However, it troubles me to hear how shabbily some of our families are treated when they venture far from their children's medical home.

When we became fellows, the American Academy of Pediatrics didn't ask us to promise that we would see any patient who has a medical home supervised by one of our brother or sister pediatricians. Nor do any of us have written contracts with the families in our practices stating that we will agree to see any child who comes to visit them. But, if you have found yourself in a strange town with a sick child as I have, you know what you should do when a distraught mother visiting from out of town calls your office.

I recently stumbled across a reference to the fact that several colleges have felt the need to hire security guards to keep parents out of some freshman orientation activities. In a brief and unsuccessful attempt to find out exactly which colleges these were, I discovered that most other colleges offered flowery invitations to parents of incoming freshman to attend their own parent orientations. I suspect that in most cases these are attempts to distract the parents while the matriculating masses are hustled off to undisclosed locations for the real thing.

Regardless of whether they resort to uniformed guards or poorly disguised diversions, obviously college officials realize that one of their first challenges is to pry apart the Velcro attachments that bind many parents to their nearly adult children. This should not come as a surprise to those of us who practice general pediatrics. But it does represent a significant change in parenting styles over the last half century.

When I was in grade school there were no such things as parent-teacher conferences. Communication between my teacher and my parents consisted of a few handwritten phrases on the bottom of quarterly report cards. No one would have ever imagined that someday parents would receive weekly or even daily electronic reports on their children's activities.

Parents ventured inside schools only when summoned by the principal or the school nurse. If your parent was seen in the school, everyone knew that you had a big problem.

But that was back when a small-screen, black-and-white TV was a luxury few families could afford. Today, parental involvement has become an integral part of almost every school system. Fueled by budgetary shortfalls, volunteerism has been actively promoted and some parents play an important role as teachers' aides and classroom assistants. Many parents spend a half day or more every week in their children's classes.

Volunteering offers parents an opportunity to see exactly what and how their children are being taught. For some parents it is a step in the process of separating that may have been difficult, particularly if they had been practitioners of “attachment parenting.” Some parents have grown to see themselves as a friend and primary playmate for their child. I can imagine that for these parents the chance to spend a few hours in the child's classroom can be comforting.

But, parents volunteering in their children's classrooms can have a dark side. I suspect you have seen it in your own office. In some situations the presence of the child's parent inflames a preexisting classroom behavior problem. In other cases a usually well-behaved child will exhibit an uncharacteristic behavior when his parent is in the class. The child may appear unusually withdrawn and shy or may act out and misbehave.

Another more serious scenario occurs when a child is struggling with separation anxiety or school phobia. For these children, the goodbye at the bus stop in the morning has been a painful parting that they have mastered temporarily. Once in school with the support of a knowledgeable and compassionate teacher, the anxiety has abated. However, the arrival of the parent-volunteer in the classroom later in the morning is likely to fan the fading embers of uncertainty into a raging inferno of separation anxiety.

One of our newest and most difficult challenges as new-millennium pediatricians is to help parents learn to supervise without meddling. As soon as I e-mail this letter to the editor, I'm going to cc it to the school board and suggest that they continue to promote volunteerism. But, tactfully encourage parents to avoid regular assignments to their own children's classes. If I'm successful, maybe one less college will feel the need to call out the troops during freshman orientation.

I recently stumbled across a reference to the fact that several colleges have felt the need to hire security guards to keep parents out of some freshman orientation activities. In a brief and unsuccessful attempt to find out exactly which colleges these were, I discovered that most other colleges offered flowery invitations to parents of incoming freshman to attend their own parent orientations. I suspect that in most cases these are attempts to distract the parents while the matriculating masses are hustled off to undisclosed locations for the real thing.

Regardless of whether they resort to uniformed guards or poorly disguised diversions, obviously college officials realize that one of their first challenges is to pry apart the Velcro attachments that bind many parents to their nearly adult children. This should not come as a surprise to those of us who practice general pediatrics. But it does represent a significant change in parenting styles over the last half century.

When I was in grade school there were no such things as parent-teacher conferences. Communication between my teacher and my parents consisted of a few handwritten phrases on the bottom of quarterly report cards. No one would have ever imagined that someday parents would receive weekly or even daily electronic reports on their children's activities.

Parents ventured inside schools only when summoned by the principal or the school nurse. If your parent was seen in the school, everyone knew that you had a big problem.

But that was back when a small-screen, black-and-white TV was a luxury few families could afford. Today, parental involvement has become an integral part of almost every school system. Fueled by budgetary shortfalls, volunteerism has been actively promoted and some parents play an important role as teachers' aides and classroom assistants. Many parents spend a half day or more every week in their children's classes.

Volunteering offers parents an opportunity to see exactly what and how their children are being taught. For some parents it is a step in the process of separating that may have been difficult, particularly if they had been practitioners of “attachment parenting.” Some parents have grown to see themselves as a friend and primary playmate for their child. I can imagine that for these parents the chance to spend a few hours in the child's classroom can be comforting.

But, parents volunteering in their children's classrooms can have a dark side. I suspect you have seen it in your own office. In some situations the presence of the child's parent inflames a preexisting classroom behavior problem. In other cases a usually well-behaved child will exhibit an uncharacteristic behavior when his parent is in the class. The child may appear unusually withdrawn and shy or may act out and misbehave.

Another more serious scenario occurs when a child is struggling with separation anxiety or school phobia. For these children, the goodbye at the bus stop in the morning has been a painful parting that they have mastered temporarily. Once in school with the support of a knowledgeable and compassionate teacher, the anxiety has abated. However, the arrival of the parent-volunteer in the classroom later in the morning is likely to fan the fading embers of uncertainty into a raging inferno of separation anxiety.

One of our newest and most difficult challenges as new-millennium pediatricians is to help parents learn to supervise without meddling. As soon as I e-mail this letter to the editor, I'm going to cc it to the school board and suggest that they continue to promote volunteerism. But, tactfully encourage parents to avoid regular assignments to their own children's classes. If I'm successful, maybe one less college will feel the need to call out the troops during freshman orientation.

I recently stumbled across a reference to the fact that several colleges have felt the need to hire security guards to keep parents out of some freshman orientation activities. In a brief and unsuccessful attempt to find out exactly which colleges these were, I discovered that most other colleges offered flowery invitations to parents of incoming freshman to attend their own parent orientations. I suspect that in most cases these are attempts to distract the parents while the matriculating masses are hustled off to undisclosed locations for the real thing.

Regardless of whether they resort to uniformed guards or poorly disguised diversions, obviously college officials realize that one of their first challenges is to pry apart the Velcro attachments that bind many parents to their nearly adult children. This should not come as a surprise to those of us who practice general pediatrics. But it does represent a significant change in parenting styles over the last half century.

When I was in grade school there were no such things as parent-teacher conferences. Communication between my teacher and my parents consisted of a few handwritten phrases on the bottom of quarterly report cards. No one would have ever imagined that someday parents would receive weekly or even daily electronic reports on their children's activities.

Parents ventured inside schools only when summoned by the principal or the school nurse. If your parent was seen in the school, everyone knew that you had a big problem.

But that was back when a small-screen, black-and-white TV was a luxury few families could afford. Today, parental involvement has become an integral part of almost every school system. Fueled by budgetary shortfalls, volunteerism has been actively promoted and some parents play an important role as teachers' aides and classroom assistants. Many parents spend a half day or more every week in their children's classes.

Volunteering offers parents an opportunity to see exactly what and how their children are being taught. For some parents it is a step in the process of separating that may have been difficult, particularly if they had been practitioners of “attachment parenting.” Some parents have grown to see themselves as a friend and primary playmate for their child. I can imagine that for these parents the chance to spend a few hours in the child's classroom can be comforting.

But, parents volunteering in their children's classrooms can have a dark side. I suspect you have seen it in your own office. In some situations the presence of the child's parent inflames a preexisting classroom behavior problem. In other cases a usually well-behaved child will exhibit an uncharacteristic behavior when his parent is in the class. The child may appear unusually withdrawn and shy or may act out and misbehave.

Another more serious scenario occurs when a child is struggling with separation anxiety or school phobia. For these children, the goodbye at the bus stop in the morning has been a painful parting that they have mastered temporarily. Once in school with the support of a knowledgeable and compassionate teacher, the anxiety has abated. However, the arrival of the parent-volunteer in the classroom later in the morning is likely to fan the fading embers of uncertainty into a raging inferno of separation anxiety.

One of our newest and most difficult challenges as new-millennium pediatricians is to help parents learn to supervise without meddling. As soon as I e-mail this letter to the editor, I'm going to cc it to the school board and suggest that they continue to promote volunteerism. But, tactfully encourage parents to avoid regular assignments to their own children's classes. If I'm successful, maybe one less college will feel the need to call out the troops during freshman orientation.

Those of us practicing primary care pediatrics often refer to ourselves as “being in the trenches” or working on the “front lines.” But if one extends this battleground metaphor much further, it's clear that we are very poorly armed warriors indeed. The only standard-issue item we carry that could be construed as a weapon is a thin wooden stick only 6 inches long. It doesn't even have a sharp point. Despite its anemic appearance, a skilled practitioner can use it to pry open clenched teeth and reveal the deep recesses of the human body where lesser mortals fear to venture.

However, the longer I practice pediatrics the less I find that I need to use a tongue depressor as a pry bar. I suspect that my body language skills have improved so that more children are willing to open their mouths and utter a proper “aaahh.” Occasionally, I may need to use a throat stick to coax a tongue or buccal surface out of the way, but for the most part these little strips of birch just accumulate in my shirt pocket and eventually find their way into my sock drawer at home.

They seldom spend more than a few days slumbering in this miniature lumber yard in my bedroom, because tongue depressors have become my first choice for a wide variety of home projects. I use them to mix acrylic paints for my bird carvings, to blend body filler for my old World War II jeep restoration, to shim cranky kitchen drawers, and to scrape the mud off my work boots. Throat sticks are my default choice when my fingers can't do the job alone.

I have become so dependent on tongue depressors that I'm sure when I retire I will continue to make weekly trips back to the office to restock my sock drawer. Obviously, I'll pretend that I'm visiting to renew old acquaintances, but when I leave you can be sure that my pockets will be bulging with a few fistfuls of fresh throat sticks.

Of course, I could always drive up the road a couple of hours to Guilford, Maine, and buy direct from the Puritan Medical Products Company factory. Each year they produce approximately 268,000,000 tongue depressors, which is estimated to be about two-thirds of the American market and would fill quite a few sock drawers. The process requires about 1,400 cords of wood or 778,000 board feet of lumber.

I'm partial to our local Maine product. No wrapping, no flavoring, no logos. Just northern birch milled and sanded by solid men and women who don't need plastic bibs or instructions on a paper placemat when they eat “lobstah.”

But, for the foreseeable future, I'll still be getting my tongue depressors out of the drawers in my exam rooms. I also will continue to write phone numbers on them when I can't find a scrap of paper, and from time to time I will inadvertently insert one of these wooden mnemonics into a child's mouth and then cluelessly toss it into the trash.

Now that everyone from plumbers to drug dealers is carrying beepers and cell phones, a tongue depressor in my shirt pocket remains the only clear badge that identifies me as a physician. And, much to Marilyn's chagrin, I continue to wear one proudly at dinner parties, gallery openings, and concerts. Hey, you never know when you'll need to scrape something smelly off your shoes.

Those of us practicing primary care pediatrics often refer to ourselves as “being in the trenches” or working on the “front lines.” But if one extends this battleground metaphor much further, it's clear that we are very poorly armed warriors indeed. The only standard-issue item we carry that could be construed as a weapon is a thin wooden stick only 6 inches long. It doesn't even have a sharp point. Despite its anemic appearance, a skilled practitioner can use it to pry open clenched teeth and reveal the deep recesses of the human body where lesser mortals fear to venture.

However, the longer I practice pediatrics the less I find that I need to use a tongue depressor as a pry bar. I suspect that my body language skills have improved so that more children are willing to open their mouths and utter a proper “aaahh.” Occasionally, I may need to use a throat stick to coax a tongue or buccal surface out of the way, but for the most part these little strips of birch just accumulate in my shirt pocket and eventually find their way into my sock drawer at home.

They seldom spend more than a few days slumbering in this miniature lumber yard in my bedroom, because tongue depressors have become my first choice for a wide variety of home projects. I use them to mix acrylic paints for my bird carvings, to blend body filler for my old World War II jeep restoration, to shim cranky kitchen drawers, and to scrape the mud off my work boots. Throat sticks are my default choice when my fingers can't do the job alone.

I have become so dependent on tongue depressors that I'm sure when I retire I will continue to make weekly trips back to the office to restock my sock drawer. Obviously, I'll pretend that I'm visiting to renew old acquaintances, but when I leave you can be sure that my pockets will be bulging with a few fistfuls of fresh throat sticks.

Of course, I could always drive up the road a couple of hours to Guilford, Maine, and buy direct from the Puritan Medical Products Company factory. Each year they produce approximately 268,000,000 tongue depressors, which is estimated to be about two-thirds of the American market and would fill quite a few sock drawers. The process requires about 1,400 cords of wood or 778,000 board feet of lumber.

I'm partial to our local Maine product. No wrapping, no flavoring, no logos. Just northern birch milled and sanded by solid men and women who don't need plastic bibs or instructions on a paper placemat when they eat “lobstah.”

But, for the foreseeable future, I'll still be getting my tongue depressors out of the drawers in my exam rooms. I also will continue to write phone numbers on them when I can't find a scrap of paper, and from time to time I will inadvertently insert one of these wooden mnemonics into a child's mouth and then cluelessly toss it into the trash.

Now that everyone from plumbers to drug dealers is carrying beepers and cell phones, a tongue depressor in my shirt pocket remains the only clear badge that identifies me as a physician. And, much to Marilyn's chagrin, I continue to wear one proudly at dinner parties, gallery openings, and concerts. Hey, you never know when you'll need to scrape something smelly off your shoes.

Those of us practicing primary care pediatrics often refer to ourselves as “being in the trenches” or working on the “front lines.” But if one extends this battleground metaphor much further, it's clear that we are very poorly armed warriors indeed. The only standard-issue item we carry that could be construed as a weapon is a thin wooden stick only 6 inches long. It doesn't even have a sharp point. Despite its anemic appearance, a skilled practitioner can use it to pry open clenched teeth and reveal the deep recesses of the human body where lesser mortals fear to venture.

However, the longer I practice pediatrics the less I find that I need to use a tongue depressor as a pry bar. I suspect that my body language skills have improved so that more children are willing to open their mouths and utter a proper “aaahh.” Occasionally, I may need to use a throat stick to coax a tongue or buccal surface out of the way, but for the most part these little strips of birch just accumulate in my shirt pocket and eventually find their way into my sock drawer at home.

They seldom spend more than a few days slumbering in this miniature lumber yard in my bedroom, because tongue depressors have become my first choice for a wide variety of home projects. I use them to mix acrylic paints for my bird carvings, to blend body filler for my old World War II jeep restoration, to shim cranky kitchen drawers, and to scrape the mud off my work boots. Throat sticks are my default choice when my fingers can't do the job alone.

I have become so dependent on tongue depressors that I'm sure when I retire I will continue to make weekly trips back to the office to restock my sock drawer. Obviously, I'll pretend that I'm visiting to renew old acquaintances, but when I leave you can be sure that my pockets will be bulging with a few fistfuls of fresh throat sticks.

Of course, I could always drive up the road a couple of hours to Guilford, Maine, and buy direct from the Puritan Medical Products Company factory. Each year they produce approximately 268,000,000 tongue depressors, which is estimated to be about two-thirds of the American market and would fill quite a few sock drawers. The process requires about 1,400 cords of wood or 778,000 board feet of lumber.

I'm partial to our local Maine product. No wrapping, no flavoring, no logos. Just northern birch milled and sanded by solid men and women who don't need plastic bibs or instructions on a paper placemat when they eat “lobstah.”

But, for the foreseeable future, I'll still be getting my tongue depressors out of the drawers in my exam rooms. I also will continue to write phone numbers on them when I can't find a scrap of paper, and from time to time I will inadvertently insert one of these wooden mnemonics into a child's mouth and then cluelessly toss it into the trash.

Now that everyone from plumbers to drug dealers is carrying beepers and cell phones, a tongue depressor in my shirt pocket remains the only clear badge that identifies me as a physician. And, much to Marilyn's chagrin, I continue to wear one proudly at dinner parties, gallery openings, and concerts. Hey, you never know when you'll need to scrape something smelly off your shoes.

While in the past I have criticized the American Board of Pediatrics for adopting a proctored, closed-book exam format, I remain deeply appreciative of the board's decision to “grandfather” me and excuse me from the burden of recertification.

Although I suspect that the decision is based primarily on the old-dog-new-tricks myth, I hope the board also is giving me some partial credit for maturity. Maturity that might allow me to be trusted to keep my clinical skills current without the threat of recertification. Likewise, I hope that my choice of continuing education activities supports the wisdom of the board's decision.

Although the Bureau of Licensure here in Maine requires me to participate in 50 hours of category I educational experiences each year, it doesn't seem to care whether I am learning anything relevant to my practice. In fact, I am sure the bureau would be ecstatic if I went to Fiji and took a 2-week course in the Cosmetic Botoxification of Septuagenarians.

But, as a conscientious grandfather, I have tried to choose activities that are relevant to my daily clinical challenges. However, I am also a bit of a tightwad and hence don't want to invest much money or time in my continuing education activities. Expensive junkets to beautiful vacation spots to sit inside taking classes that may or may not be well taught have lost their appeal.

Being a rather distractible sort as well, I have learned that I can't tolerate the pain and frustration of being cooped up in a classroom (with or without windows) when I know there are recreational activities waiting outside just a few steps away. The odds that I won't stick around after the first coffee break are too high to make traveling for CME courses worth the time and expense.

The three CME activities I have chosen for myself are cheap, handy, and focused. The backbone of my curriculum is Pediatric Notes, the bimonthly letter founded by the late Dr. Sydney Gellis. In its well-chosen and smoothly written abstracts and commentary, I usually find one or two articles that are very relevant to my clinical situation. The open-book tests at the end of the year aren't painless, but at least I can work at my own pace in the comfort of my favorite rocker.

More painful and less relevant are my monthly copies of the American Academy of Pediatrics' Pediatrics in Review. I know that it is important to refresh the withering roots of my basic science education, but it hurts.

As soon as they arrive, I toss them in an old wooden bucket next to my rocker until it's time to subject myself to the torture of modern air travel. The accumulated Reviews give me something to read during those long airport layovers.

On one hand, I view reading them as a masochistic combination of more pain on top of pain. On the other, I see it as paying my dues for the privilege of bicycling on the quiet country roads of southern France.

The newest addition to my CME curriculum doesn't earn me any reportable credits. But, it is probably the most relevant and the most fun. The class meets once a week on Tuesday, when I have a standing invitation to visit my granddaughter, Hannah, who lives a short 10-minute walk away.

There also are numerous unscheduled seminar and lab sessions that meet throughout the week.

Although I see scores of little children each week in the office, it's been 30 years since I have had the chance to observe an infant in the relaxed atmosphere of a home environment.

Last month I relearned how infants learn to solve the problem of getting small bits of food into their mouths. This week's class is dealing with the advanced infantry crawl.

Because I am still struggling not to impose my parenting philosophy on my son and his wife, class participation is limited to tickling, knee-bouncing, and a wide variety of animal sound imitations. Each session is a wonderful opportunity to see if my timeworn advice to other parents still makes sense. And I've discovered some of it doesn't.

I don't know whether the American Board of Pediatrics would consider the changes I have made in my practice style as the result of my CME sessions with little Hannah to be “evidence based.” But then, I don't really care because I've truly been grandfathered.

While in the past I have criticized the American Board of Pediatrics for adopting a proctored, closed-book exam format, I remain deeply appreciative of the board's decision to “grandfather” me and excuse me from the burden of recertification.

Although I suspect that the decision is based primarily on the old-dog-new-tricks myth, I hope the board also is giving me some partial credit for maturity. Maturity that might allow me to be trusted to keep my clinical skills current without the threat of recertification. Likewise, I hope that my choice of continuing education activities supports the wisdom of the board's decision.

Although the Bureau of Licensure here in Maine requires me to participate in 50 hours of category I educational experiences each year, it doesn't seem to care whether I am learning anything relevant to my practice. In fact, I am sure the bureau would be ecstatic if I went to Fiji and took a 2-week course in the Cosmetic Botoxification of Septuagenarians.

But, as a conscientious grandfather, I have tried to choose activities that are relevant to my daily clinical challenges. However, I am also a bit of a tightwad and hence don't want to invest much money or time in my continuing education activities. Expensive junkets to beautiful vacation spots to sit inside taking classes that may or may not be well taught have lost their appeal.

Being a rather distractible sort as well, I have learned that I can't tolerate the pain and frustration of being cooped up in a classroom (with or without windows) when I know there are recreational activities waiting outside just a few steps away. The odds that I won't stick around after the first coffee break are too high to make traveling for CME courses worth the time and expense.

The three CME activities I have chosen for myself are cheap, handy, and focused. The backbone of my curriculum is Pediatric Notes, the bimonthly letter founded by the late Dr. Sydney Gellis. In its well-chosen and smoothly written abstracts and commentary, I usually find one or two articles that are very relevant to my clinical situation. The open-book tests at the end of the year aren't painless, but at least I can work at my own pace in the comfort of my favorite rocker.

More painful and less relevant are my monthly copies of the American Academy of Pediatrics' Pediatrics in Review. I know that it is important to refresh the withering roots of my basic science education, but it hurts.

As soon as they arrive, I toss them in an old wooden bucket next to my rocker until it's time to subject myself to the torture of modern air travel. The accumulated Reviews give me something to read during those long airport layovers.

On one hand, I view reading them as a masochistic combination of more pain on top of pain. On the other, I see it as paying my dues for the privilege of bicycling on the quiet country roads of southern France.

The newest addition to my CME curriculum doesn't earn me any reportable credits. But, it is probably the most relevant and the most fun. The class meets once a week on Tuesday, when I have a standing invitation to visit my granddaughter, Hannah, who lives a short 10-minute walk away.

There also are numerous unscheduled seminar and lab sessions that meet throughout the week.

Although I see scores of little children each week in the office, it's been 30 years since I have had the chance to observe an infant in the relaxed atmosphere of a home environment.

Last month I relearned how infants learn to solve the problem of getting small bits of food into their mouths. This week's class is dealing with the advanced infantry crawl.

Because I am still struggling not to impose my parenting philosophy on my son and his wife, class participation is limited to tickling, knee-bouncing, and a wide variety of animal sound imitations. Each session is a wonderful opportunity to see if my timeworn advice to other parents still makes sense. And I've discovered some of it doesn't.

I don't know whether the American Board of Pediatrics would consider the changes I have made in my practice style as the result of my CME sessions with little Hannah to be “evidence based.” But then, I don't really care because I've truly been grandfathered.

While in the past I have criticized the American Board of Pediatrics for adopting a proctored, closed-book exam format, I remain deeply appreciative of the board's decision to “grandfather” me and excuse me from the burden of recertification.

Although I suspect that the decision is based primarily on the old-dog-new-tricks myth, I hope the board also is giving me some partial credit for maturity. Maturity that might allow me to be trusted to keep my clinical skills current without the threat of recertification. Likewise, I hope that my choice of continuing education activities supports the wisdom of the board's decision.

Although the Bureau of Licensure here in Maine requires me to participate in 50 hours of category I educational experiences each year, it doesn't seem to care whether I am learning anything relevant to my practice. In fact, I am sure the bureau would be ecstatic if I went to Fiji and took a 2-week course in the Cosmetic Botoxification of Septuagenarians.

But, as a conscientious grandfather, I have tried to choose activities that are relevant to my daily clinical challenges. However, I am also a bit of a tightwad and hence don't want to invest much money or time in my continuing education activities. Expensive junkets to beautiful vacation spots to sit inside taking classes that may or may not be well taught have lost their appeal.

Being a rather distractible sort as well, I have learned that I can't tolerate the pain and frustration of being cooped up in a classroom (with or without windows) when I know there are recreational activities waiting outside just a few steps away. The odds that I won't stick around after the first coffee break are too high to make traveling for CME courses worth the time and expense.

The three CME activities I have chosen for myself are cheap, handy, and focused. The backbone of my curriculum is Pediatric Notes, the bimonthly letter founded by the late Dr. Sydney Gellis. In its well-chosen and smoothly written abstracts and commentary, I usually find one or two articles that are very relevant to my clinical situation. The open-book tests at the end of the year aren't painless, but at least I can work at my own pace in the comfort of my favorite rocker.

More painful and less relevant are my monthly copies of the American Academy of Pediatrics' Pediatrics in Review. I know that it is important to refresh the withering roots of my basic science education, but it hurts.

As soon as they arrive, I toss them in an old wooden bucket next to my rocker until it's time to subject myself to the torture of modern air travel. The accumulated Reviews give me something to read during those long airport layovers.

On one hand, I view reading them as a masochistic combination of more pain on top of pain. On the other, I see it as paying my dues for the privilege of bicycling on the quiet country roads of southern France.

The newest addition to my CME curriculum doesn't earn me any reportable credits. But, it is probably the most relevant and the most fun. The class meets once a week on Tuesday, when I have a standing invitation to visit my granddaughter, Hannah, who lives a short 10-minute walk away.

There also are numerous unscheduled seminar and lab sessions that meet throughout the week.

Although I see scores of little children each week in the office, it's been 30 years since I have had the chance to observe an infant in the relaxed atmosphere of a home environment.

Last month I relearned how infants learn to solve the problem of getting small bits of food into their mouths. This week's class is dealing with the advanced infantry crawl.

Because I am still struggling not to impose my parenting philosophy on my son and his wife, class participation is limited to tickling, knee-bouncing, and a wide variety of animal sound imitations. Each session is a wonderful opportunity to see if my timeworn advice to other parents still makes sense. And I've discovered some of it doesn't.

I don't know whether the American Board of Pediatrics would consider the changes I have made in my practice style as the result of my CME sessions with little Hannah to be “evidence based.” But then, I don't really care because I've truly been grandfathered.

The good, the bad, and the ugly—to everything there is a season. I would put school and camp forms among the ugly, and their seasons are approaching.

For college and summer camp forms it's May and June. In July and August, it's time for fall sports and kindergarten entry. September brings only a brief hiatus, though, because with each new sports season, would-be athletes will discover crumpled, candy bar-stained permission forms in the bottoms of their backpacks a few hours or days before their first practices.

It's not the volume of these seasonal paper inundations that I find so troubling. After all, I am happy to learn that so many of my patients have been successful enough to be admitted to a college or have chosen to leave their televisions and video games for a few hours to participate in athletics.

The problem is that the cursed forms that must accompany my patients on these academic and recreational adventures ask questions whose answers have little or no bearing on what these children will be doing. Furthermore, I suspect that no one ever reads even a third of the information that I've taken the time to provide.

Does a summer camp really need to know the height, weight, and blood pressure of my patient? Are they planning on using the measurements I have provided to order t-shirts for the campers? Are they considering putting some campers on a low-salt diet? Is an Ivy League college going to use my patient's urine specific gravity for their budget calculation for water usage?

From time to time, I see the occasional antique camp form that still asks, “Nits?” I am tempted to reply, “Yes!” to see if Camp Nurse Ratched calls me to ask what I've done about the lice. One highly respected and selective eastern university demands cholesterol levels on its form. Are they planning on restricting my patient to the salad bar? It's more likely that someone in their medical school is collecting data for a research project.

I can understand why international study programs and organizations that offer unusual physical challenges might want detailed information. I suspect that they have been burned in the past when participants have arrived unfit for rigorous activity or too mentally fragile to thrive away from their usual support systems.

But the vast majority of schools and camps don't need to know even a tenth of the information that they ask for. Even when I encounter the rare question that deserves an answer, I'm faced with a space barely big enough to scribble my initials.

The staff and provider time required to complete these camp and school forms is staggering. It is certainly an unnecessary distraction from the real business of helping our patients get and remain healthy.

I know that some practitioners charge for completing forms, but I can't bring myself to take this step. There is a better solution. Some colleges have already begun to produce forms that don't insult my intelligence, and now it's time for the other colleges, schools, and camps to follow suit. A standard form should simply state, “We have already asked your patient/parents a whole bunch of questions. Is there anything we here at Camp Intelligent should know about him/her so that we can provide him/her with a safe and successful educational/camp experience? Here are 20 comfortably spaced lines for your reply. Please write legibly and include a copy of his/her immunizations.”

Now here's the rub. If we physicians are to be given credit for the intelligence to respond to these broad and open-ended questions, then we must come up with honest and complete answers about our patients' health, particularly their mental health.

For our patients with chronic diseases such as asthma, this also means providing an accurate, up-to-date, and unambiguous action or management plan. Freed from the shackles of answering dumb questions about the 85% of our patients who are healthy, this should be a piece of cake.

The good, the bad, and the ugly—to everything there is a season. I would put school and camp forms among the ugly, and their seasons are approaching.

For college and summer camp forms it's May and June. In July and August, it's time for fall sports and kindergarten entry. September brings only a brief hiatus, though, because with each new sports season, would-be athletes will discover crumpled, candy bar-stained permission forms in the bottoms of their backpacks a few hours or days before their first practices.

It's not the volume of these seasonal paper inundations that I find so troubling. After all, I am happy to learn that so many of my patients have been successful enough to be admitted to a college or have chosen to leave their televisions and video games for a few hours to participate in athletics.

The problem is that the cursed forms that must accompany my patients on these academic and recreational adventures ask questions whose answers have little or no bearing on what these children will be doing. Furthermore, I suspect that no one ever reads even a third of the information that I've taken the time to provide.

Does a summer camp really need to know the height, weight, and blood pressure of my patient? Are they planning on using the measurements I have provided to order t-shirts for the campers? Are they considering putting some campers on a low-salt diet? Is an Ivy League college going to use my patient's urine specific gravity for their budget calculation for water usage?

From time to time, I see the occasional antique camp form that still asks, “Nits?” I am tempted to reply, “Yes!” to see if Camp Nurse Ratched calls me to ask what I've done about the lice. One highly respected and selective eastern university demands cholesterol levels on its form. Are they planning on restricting my patient to the salad bar? It's more likely that someone in their medical school is collecting data for a research project.

I can understand why international study programs and organizations that offer unusual physical challenges might want detailed information. I suspect that they have been burned in the past when participants have arrived unfit for rigorous activity or too mentally fragile to thrive away from their usual support systems.

But the vast majority of schools and camps don't need to know even a tenth of the information that they ask for. Even when I encounter the rare question that deserves an answer, I'm faced with a space barely big enough to scribble my initials.

The staff and provider time required to complete these camp and school forms is staggering. It is certainly an unnecessary distraction from the real business of helping our patients get and remain healthy.

I know that some practitioners charge for completing forms, but I can't bring myself to take this step. There is a better solution. Some colleges have already begun to produce forms that don't insult my intelligence, and now it's time for the other colleges, schools, and camps to follow suit. A standard form should simply state, “We have already asked your patient/parents a whole bunch of questions. Is there anything we here at Camp Intelligent should know about him/her so that we can provide him/her with a safe and successful educational/camp experience? Here are 20 comfortably spaced lines for your reply. Please write legibly and include a copy of his/her immunizations.”

Now here's the rub. If we physicians are to be given credit for the intelligence to respond to these broad and open-ended questions, then we must come up with honest and complete answers about our patients' health, particularly their mental health.

For our patients with chronic diseases such as asthma, this also means providing an accurate, up-to-date, and unambiguous action or management plan. Freed from the shackles of answering dumb questions about the 85% of our patients who are healthy, this should be a piece of cake.

The good, the bad, and the ugly—to everything there is a season. I would put school and camp forms among the ugly, and their seasons are approaching.

For college and summer camp forms it's May and June. In July and August, it's time for fall sports and kindergarten entry. September brings only a brief hiatus, though, because with each new sports season, would-be athletes will discover crumpled, candy bar-stained permission forms in the bottoms of their backpacks a few hours or days before their first practices.

It's not the volume of these seasonal paper inundations that I find so troubling. After all, I am happy to learn that so many of my patients have been successful enough to be admitted to a college or have chosen to leave their televisions and video games for a few hours to participate in athletics.

The problem is that the cursed forms that must accompany my patients on these academic and recreational adventures ask questions whose answers have little or no bearing on what these children will be doing. Furthermore, I suspect that no one ever reads even a third of the information that I've taken the time to provide.

Does a summer camp really need to know the height, weight, and blood pressure of my patient? Are they planning on using the measurements I have provided to order t-shirts for the campers? Are they considering putting some campers on a low-salt diet? Is an Ivy League college going to use my patient's urine specific gravity for their budget calculation for water usage?

From time to time, I see the occasional antique camp form that still asks, “Nits?” I am tempted to reply, “Yes!” to see if Camp Nurse Ratched calls me to ask what I've done about the lice. One highly respected and selective eastern university demands cholesterol levels on its form. Are they planning on restricting my patient to the salad bar? It's more likely that someone in their medical school is collecting data for a research project.

I can understand why international study programs and organizations that offer unusual physical challenges might want detailed information. I suspect that they have been burned in the past when participants have arrived unfit for rigorous activity or too mentally fragile to thrive away from their usual support systems.

But the vast majority of schools and camps don't need to know even a tenth of the information that they ask for. Even when I encounter the rare question that deserves an answer, I'm faced with a space barely big enough to scribble my initials.

The staff and provider time required to complete these camp and school forms is staggering. It is certainly an unnecessary distraction from the real business of helping our patients get and remain healthy.

I know that some practitioners charge for completing forms, but I can't bring myself to take this step. There is a better solution. Some colleges have already begun to produce forms that don't insult my intelligence, and now it's time for the other colleges, schools, and camps to follow suit. A standard form should simply state, “We have already asked your patient/parents a whole bunch of questions. Is there anything we here at Camp Intelligent should know about him/her so that we can provide him/her with a safe and successful educational/camp experience? Here are 20 comfortably spaced lines for your reply. Please write legibly and include a copy of his/her immunizations.”

Now here's the rub. If we physicians are to be given credit for the intelligence to respond to these broad and open-ended questions, then we must come up with honest and complete answers about our patients' health, particularly their mental health.

For our patients with chronic diseases such as asthma, this also means providing an accurate, up-to-date, and unambiguous action or management plan. Freed from the shackles of answering dumb questions about the 85% of our patients who are healthy, this should be a piece of cake.

When the view from your living room includes hundreds of lobster trap buoys, out-of-town visitors expect to be served lobster for dinner. It often comes as an unnerving surprise to our guests, though, when they hear the clattering death throes of unfortunate crustaceans entering the steaming pot.

Inevitably, this terminal event shifts the conversation to the concept of who or what can feel pain. Marilyn and I try to reassure the squeamish that scientific research (probably funded by the state of Maine) has shown lobsters to lack the neurologic equipment to feel pain.

Pain has also become a hot topic in medicine, and “pain management” has joined the pantheon of medical buzzwords for the new millennium. The mantra at our hospitals seems to have become, “No pain shall go unmeasured or unmedicated.” It has even crept out of the hospital. I have heard parents asking their toddlers, for whom counting is a recitation of 10 words they don't understand, to rate their pain on a scale from 1 to 10. This exercise in quantification is only slightly more futile than pointing to an array of pictograms with smiley and grumpy faces.

Sometimes, this well-intentioned passion to measure and eliminate pain can go awry and actually interrupt the timely discovery of the correct diagnosis. It may even interfere with a patient's ability to access other forms of comfort, such as the soft words and gentle touch of a parent.

Now, don't get me wrong. I am not advocating that we return to the bad old days when pain was seriously undertreated because we physicians harbored an irrational fear of creating drug addicts. Most of us, myself included, still have a lot to learn about the pharmacologic management of pain, particularly in patients with terminal illnesses.

I think, however, that we should all look more closely at nonpharmacologic solutions and try harder to understand why some patients appear to experience more pain than others. There must be genetic and biochemical components to these differences in pain tolerance, but in the last few decades it has become obvious to me that uncertainty and depression are two critical factors in making pain less tolerable. Fortunately, these are things that I as a physician can influence with a combination of clinical skills and medications that are not usually considered analgesics.

A few years ago, for example, a urologist had to rescue me from my own inattention. At one point, he explained to me that, over the next 8 hours, I would be experiencing what could be very painful bladder spasms. He described their cause and assured me that they would be temporary. He encouraged me to ask for pain medication, but he also mentioned that it might temporarily slow my recovery.

Comforted by his confident and detailed explanation of what I was going to experience, I elected not to take any medication. He was correct about everything, including the severity of the pain, but because of its spasmodic nature and because I knew what to expect, it was tolerable. In effect, my skilled physician had used his own version of the Lamaze technique to help him manage my pain.

Ever since that experience I have tried whenever practical to tell a patient as much about his or her pain as I can: what is causing it, how long it will last, and what we can do to ameliorate it. Over the last few years, my efforts to dispel uncertainty seem to have made a positive difference for many of my patients. Ferreting out and treating the depression component have been more difficult tasks than educating and reassuring, particularly when the pain appears acutely and the patient is a child I don't know very well. However, by at least considering the role of depression in my patients' diminished pain tolerance, I can often get us started on the path toward the correct long-term solution.

Fortunately, for Marilyn and me, by the time the lobsters are ready to eat, the discussion has usually drifted away from pain management. Then it's time for a short course in crustacean anatomy and how to find the succulent meat hidden inside those crimson shells.

When the view from your living room includes hundreds of lobster trap buoys, out-of-town visitors expect to be served lobster for dinner. It often comes as an unnerving surprise to our guests, though, when they hear the clattering death throes of unfortunate crustaceans entering the steaming pot.

Inevitably, this terminal event shifts the conversation to the concept of who or what can feel pain. Marilyn and I try to reassure the squeamish that scientific research (probably funded by the state of Maine) has shown lobsters to lack the neurologic equipment to feel pain.

Pain has also become a hot topic in medicine, and “pain management” has joined the pantheon of medical buzzwords for the new millennium. The mantra at our hospitals seems to have become, “No pain shall go unmeasured or unmedicated.” It has even crept out of the hospital. I have heard parents asking their toddlers, for whom counting is a recitation of 10 words they don't understand, to rate their pain on a scale from 1 to 10. This exercise in quantification is only slightly more futile than pointing to an array of pictograms with smiley and grumpy faces.

Sometimes, this well-intentioned passion to measure and eliminate pain can go awry and actually interrupt the timely discovery of the correct diagnosis. It may even interfere with a patient's ability to access other forms of comfort, such as the soft words and gentle touch of a parent.

Now, don't get me wrong. I am not advocating that we return to the bad old days when pain was seriously undertreated because we physicians harbored an irrational fear of creating drug addicts. Most of us, myself included, still have a lot to learn about the pharmacologic management of pain, particularly in patients with terminal illnesses.

I think, however, that we should all look more closely at nonpharmacologic solutions and try harder to understand why some patients appear to experience more pain than others. There must be genetic and biochemical components to these differences in pain tolerance, but in the last few decades it has become obvious to me that uncertainty and depression are two critical factors in making pain less tolerable. Fortunately, these are things that I as a physician can influence with a combination of clinical skills and medications that are not usually considered analgesics.

A few years ago, for example, a urologist had to rescue me from my own inattention. At one point, he explained to me that, over the next 8 hours, I would be experiencing what could be very painful bladder spasms. He described their cause and assured me that they would be temporary. He encouraged me to ask for pain medication, but he also mentioned that it might temporarily slow my recovery.

Comforted by his confident and detailed explanation of what I was going to experience, I elected not to take any medication. He was correct about everything, including the severity of the pain, but because of its spasmodic nature and because I knew what to expect, it was tolerable. In effect, my skilled physician had used his own version of the Lamaze technique to help him manage my pain.

Ever since that experience I have tried whenever practical to tell a patient as much about his or her pain as I can: what is causing it, how long it will last, and what we can do to ameliorate it. Over the last few years, my efforts to dispel uncertainty seem to have made a positive difference for many of my patients. Ferreting out and treating the depression component have been more difficult tasks than educating and reassuring, particularly when the pain appears acutely and the patient is a child I don't know very well. However, by at least considering the role of depression in my patients' diminished pain tolerance, I can often get us started on the path toward the correct long-term solution.

Fortunately, for Marilyn and me, by the time the lobsters are ready to eat, the discussion has usually drifted away from pain management. Then it's time for a short course in crustacean anatomy and how to find the succulent meat hidden inside those crimson shells.

When the view from your living room includes hundreds of lobster trap buoys, out-of-town visitors expect to be served lobster for dinner. It often comes as an unnerving surprise to our guests, though, when they hear the clattering death throes of unfortunate crustaceans entering the steaming pot.

Inevitably, this terminal event shifts the conversation to the concept of who or what can feel pain. Marilyn and I try to reassure the squeamish that scientific research (probably funded by the state of Maine) has shown lobsters to lack the neurologic equipment to feel pain.

Pain has also become a hot topic in medicine, and “pain management” has joined the pantheon of medical buzzwords for the new millennium. The mantra at our hospitals seems to have become, “No pain shall go unmeasured or unmedicated.” It has even crept out of the hospital. I have heard parents asking their toddlers, for whom counting is a recitation of 10 words they don't understand, to rate their pain on a scale from 1 to 10. This exercise in quantification is only slightly more futile than pointing to an array of pictograms with smiley and grumpy faces.

Sometimes, this well-intentioned passion to measure and eliminate pain can go awry and actually interrupt the timely discovery of the correct diagnosis. It may even interfere with a patient's ability to access other forms of comfort, such as the soft words and gentle touch of a parent.

Now, don't get me wrong. I am not advocating that we return to the bad old days when pain was seriously undertreated because we physicians harbored an irrational fear of creating drug addicts. Most of us, myself included, still have a lot to learn about the pharmacologic management of pain, particularly in patients with terminal illnesses.

I think, however, that we should all look more closely at nonpharmacologic solutions and try harder to understand why some patients appear to experience more pain than others. There must be genetic and biochemical components to these differences in pain tolerance, but in the last few decades it has become obvious to me that uncertainty and depression are two critical factors in making pain less tolerable. Fortunately, these are things that I as a physician can influence with a combination of clinical skills and medications that are not usually considered analgesics.

A few years ago, for example, a urologist had to rescue me from my own inattention. At one point, he explained to me that, over the next 8 hours, I would be experiencing what could be very painful bladder spasms. He described their cause and assured me that they would be temporary. He encouraged me to ask for pain medication, but he also mentioned that it might temporarily slow my recovery.

Comforted by his confident and detailed explanation of what I was going to experience, I elected not to take any medication. He was correct about everything, including the severity of the pain, but because of its spasmodic nature and because I knew what to expect, it was tolerable. In effect, my skilled physician had used his own version of the Lamaze technique to help him manage my pain.

Ever since that experience I have tried whenever practical to tell a patient as much about his or her pain as I can: what is causing it, how long it will last, and what we can do to ameliorate it. Over the last few years, my efforts to dispel uncertainty seem to have made a positive difference for many of my patients. Ferreting out and treating the depression component have been more difficult tasks than educating and reassuring, particularly when the pain appears acutely and the patient is a child I don't know very well. However, by at least considering the role of depression in my patients' diminished pain tolerance, I can often get us started on the path toward the correct long-term solution.

Fortunately, for Marilyn and me, by the time the lobsters are ready to eat, the discussion has usually drifted away from pain management. Then it's time for a short course in crustacean anatomy and how to find the succulent meat hidden inside those crimson shells.

If you have a minute—and I suggest that you not invest much more than a minute—turn to the commentary section in the back of the December 2005 issue of Pediatrics.

There you will find an article by a physical therapist, Margaret M. Plack, Ed.D., and a physician, Dr. Larrie Greenberg, titled “The Reflective Practitioner: Reaching for Excellence in Practice” (Pediatrics 2005;116:1546–52). It's pretty heavy stuff, full of words like “constitutive” and “contextualize.”

One sentence is 74 words long. One reference, they say, compares “good evidence to a DNA double helix.” Now there's an analogy that's guaranteed to clarify. It turns out that there are so many definitions of reflection that another pair of researchers felt the need to subject them to metaanalysis.

Don't worry, though, because I've done the heavy lifting for you. For some reason, as yet undetermined, I read the whole damn article and learned that “reflection is more than just stopping to think and act based on what we already know.” It turns out that, while you and I have been in the trenches promoting health, waging war against disease, and trying to stay out of the lawyers' crosshairs, someone slipped another cornerstone into the foundation of medical education. It's called reflection, and it's sitting right next to that other newcomer, evidence-based decision making.

Now, I may be oversimplifying what Dr. Plack and Dr. Greenberg have to say, but it sounds as though all of us at every level of pediatric training and practice should be taking the time to think about what we've been doing, why we've been doing it, and whether it makes sense to keep doing it. It's hard to argue with their rationale, but there is that bothersome little piece about the time.

Stimulated by my plunge into the cold and deep waters of educational erudition, a few nights ago I found myself feet up, favorite locally brewed beverage within reach, considering how I would reinvent medical education. Who knows, I may have been reflecting. I even may have been epiphanating. Whatever you choose to call my condition, it's clear I shouldn't have been operating heavy machinery or seeing patients.

So here are my thoughts. I would mandate that all college students considering a career in medicine major in one of the humanities. History, art, music, religion—you get the picture. My decision to major in art history is one I have never regretted.

During the summer, these premeds must have a real job, preferably one in which they must interact with or serve the public, or work shoulder to shoulder with people who haven't and aren't planning to go to college. I am continually disappointed to learn how many young physicians don't really understand the everyday microeconomic challenges faced by their patients. I am also troubled by how many physicians don't have a clue about basic rules of customer service that could be learned by working for any successful shopkeeper or restaurateur.

Once these future physicians are in medical school, I would encourage them to shadow a wide variety of doctors from many specialties. As often as possible, these visits should include sharing an evening meal in the physicians' homes so that the student could get a more multidimensional picture of a physician's life. These glimpses can be valuable aids in both career modeling and pitfall avoidance.

After postgraduate training has begun, I would encourage new physicians to see as many patients as they can. Hidden in the commentary on reflection was at least one kernel of truth: “Experience is at the core of learning in medical education.” We can ask a student to read, discuss, and reflect on a single case of scarlet fever until the cows come home, but that student is going to be a much more effective clinician once he or she has had the opportunity to see so many scarlatiniform rashes that the sight diagnosis becomes second nature.

Freed from the diagnostic fumbling that comes with inexperience, students can spend their time and energy exploring the nuances of how individual patients deal with disease. Familiarity with the commonplace makes sorting out the unusual much easier, but experience means seeing 15 patients with scarlet fever, looking at 2,000 tympanic membranes, and listening to a dozen depressed teenagers tell their stories.

The problem is that we're back to that troubling piece about time. Sufficient time for physicians in training to see enough patients is in short supply these days, particularly if we have decided that it is important to protect them from sleep deprivation. Fatigue or experience? Now there's a dilemma worthy of some deep reflection.

If you have a minute—and I suggest that you not invest much more than a minute—turn to the commentary section in the back of the December 2005 issue of Pediatrics.

There you will find an article by a physical therapist, Margaret M. Plack, Ed.D., and a physician, Dr. Larrie Greenberg, titled “The Reflective Practitioner: Reaching for Excellence in Practice” (Pediatrics 2005;116:1546–52). It's pretty heavy stuff, full of words like “constitutive” and “contextualize.”

One sentence is 74 words long. One reference, they say, compares “good evidence to a DNA double helix.” Now there's an analogy that's guaranteed to clarify. It turns out that there are so many definitions of reflection that another pair of researchers felt the need to subject them to metaanalysis.

Don't worry, though, because I've done the heavy lifting for you. For some reason, as yet undetermined, I read the whole damn article and learned that “reflection is more than just stopping to think and act based on what we already know.” It turns out that, while you and I have been in the trenches promoting health, waging war against disease, and trying to stay out of the lawyers' crosshairs, someone slipped another cornerstone into the foundation of medical education. It's called reflection, and it's sitting right next to that other newcomer, evidence-based decision making.

Now, I may be oversimplifying what Dr. Plack and Dr. Greenberg have to say, but it sounds as though all of us at every level of pediatric training and practice should be taking the time to think about what we've been doing, why we've been doing it, and whether it makes sense to keep doing it. It's hard to argue with their rationale, but there is that bothersome little piece about the time.

Stimulated by my plunge into the cold and deep waters of educational erudition, a few nights ago I found myself feet up, favorite locally brewed beverage within reach, considering how I would reinvent medical education. Who knows, I may have been reflecting. I even may have been epiphanating. Whatever you choose to call my condition, it's clear I shouldn't have been operating heavy machinery or seeing patients.

So here are my thoughts. I would mandate that all college students considering a career in medicine major in one of the humanities. History, art, music, religion—you get the picture. My decision to major in art history is one I have never regretted.

During the summer, these premeds must have a real job, preferably one in which they must interact with or serve the public, or work shoulder to shoulder with people who haven't and aren't planning to go to college. I am continually disappointed to learn how many young physicians don't really understand the everyday microeconomic challenges faced by their patients. I am also troubled by how many physicians don't have a clue about basic rules of customer service that could be learned by working for any successful shopkeeper or restaurateur.

Once these future physicians are in medical school, I would encourage them to shadow a wide variety of doctors from many specialties. As often as possible, these visits should include sharing an evening meal in the physicians' homes so that the student could get a more multidimensional picture of a physician's life. These glimpses can be valuable aids in both career modeling and pitfall avoidance.

After postgraduate training has begun, I would encourage new physicians to see as many patients as they can. Hidden in the commentary on reflection was at least one kernel of truth: “Experience is at the core of learning in medical education.” We can ask a student to read, discuss, and reflect on a single case of scarlet fever until the cows come home, but that student is going to be a much more effective clinician once he or she has had the opportunity to see so many scarlatiniform rashes that the sight diagnosis becomes second nature.

Freed from the diagnostic fumbling that comes with inexperience, students can spend their time and energy exploring the nuances of how individual patients deal with disease. Familiarity with the commonplace makes sorting out the unusual much easier, but experience means seeing 15 patients with scarlet fever, looking at 2,000 tympanic membranes, and listening to a dozen depressed teenagers tell their stories.

The problem is that we're back to that troubling piece about time. Sufficient time for physicians in training to see enough patients is in short supply these days, particularly if we have decided that it is important to protect them from sleep deprivation. Fatigue or experience? Now there's a dilemma worthy of some deep reflection.

If you have a minute—and I suggest that you not invest much more than a minute—turn to the commentary section in the back of the December 2005 issue of Pediatrics.

There you will find an article by a physical therapist, Margaret M. Plack, Ed.D., and a physician, Dr. Larrie Greenberg, titled “The Reflective Practitioner: Reaching for Excellence in Practice” (Pediatrics 2005;116:1546–52). It's pretty heavy stuff, full of words like “constitutive” and “contextualize.”

One sentence is 74 words long. One reference, they say, compares “good evidence to a DNA double helix.” Now there's an analogy that's guaranteed to clarify. It turns out that there are so many definitions of reflection that another pair of researchers felt the need to subject them to metaanalysis.

Don't worry, though, because I've done the heavy lifting for you. For some reason, as yet undetermined, I read the whole damn article and learned that “reflection is more than just stopping to think and act based on what we already know.” It turns out that, while you and I have been in the trenches promoting health, waging war against disease, and trying to stay out of the lawyers' crosshairs, someone slipped another cornerstone into the foundation of medical education. It's called reflection, and it's sitting right next to that other newcomer, evidence-based decision making.

Now, I may be oversimplifying what Dr. Plack and Dr. Greenberg have to say, but it sounds as though all of us at every level of pediatric training and practice should be taking the time to think about what we've been doing, why we've been doing it, and whether it makes sense to keep doing it. It's hard to argue with their rationale, but there is that bothersome little piece about the time.

Stimulated by my plunge into the cold and deep waters of educational erudition, a few nights ago I found myself feet up, favorite locally brewed beverage within reach, considering how I would reinvent medical education. Who knows, I may have been reflecting. I even may have been epiphanating. Whatever you choose to call my condition, it's clear I shouldn't have been operating heavy machinery or seeing patients.

So here are my thoughts. I would mandate that all college students considering a career in medicine major in one of the humanities. History, art, music, religion—you get the picture. My decision to major in art history is one I have never regretted.

During the summer, these premeds must have a real job, preferably one in which they must interact with or serve the public, or work shoulder to shoulder with people who haven't and aren't planning to go to college. I am continually disappointed to learn how many young physicians don't really understand the everyday microeconomic challenges faced by their patients. I am also troubled by how many physicians don't have a clue about basic rules of customer service that could be learned by working for any successful shopkeeper or restaurateur.

Once these future physicians are in medical school, I would encourage them to shadow a wide variety of doctors from many specialties. As often as possible, these visits should include sharing an evening meal in the physicians' homes so that the student could get a more multidimensional picture of a physician's life. These glimpses can be valuable aids in both career modeling and pitfall avoidance.

After postgraduate training has begun, I would encourage new physicians to see as many patients as they can. Hidden in the commentary on reflection was at least one kernel of truth: “Experience is at the core of learning in medical education.” We can ask a student to read, discuss, and reflect on a single case of scarlet fever until the cows come home, but that student is going to be a much more effective clinician once he or she has had the opportunity to see so many scarlatiniform rashes that the sight diagnosis becomes second nature.

Freed from the diagnostic fumbling that comes with inexperience, students can spend their time and energy exploring the nuances of how individual patients deal with disease. Familiarity with the commonplace makes sorting out the unusual much easier, but experience means seeing 15 patients with scarlet fever, looking at 2,000 tympanic membranes, and listening to a dozen depressed teenagers tell their stories.

The problem is that we're back to that troubling piece about time. Sufficient time for physicians in training to see enough patients is in short supply these days, particularly if we have decided that it is important to protect them from sleep deprivation. Fatigue or experience? Now there's a dilemma worthy of some deep reflection.

As I sit at the receptionist's desk, watching a heavy wet snow blanket the trees and shrubs in front of the office, I can tell by the unusually deliberate pace of the cars creeping out of the staff parking lot that the roads have gotten dangerously greasy. Those of us who live close enough to walk home are holding down the fort and answering the phones for another hour.

Despite the treacherous traveling conditions that have been worsening since lunchtime, the patients have continued to trickle in. Some have had earaches and sore throats, but some were healthy toddlers returning for their 3-week ear rechecks.

I have always been intrigued by the senseless irony of the psychological forces that keep patients at home when it's raining but drive them out onto snow-covered and ice-slicked highways like lemmings.

Even before SUVs replaced minivans as the suburban chariots of choice, many parents were seduced by the challenge of winter driving. When asked why they would risk life, limb, and vehicular damage to bring their child to the pediatrician for a trivial problem, I suspect that they would offer the traditional mountain climber's response—“Because it's there.”

I must admit that as a foolish young man I enjoyed charging out into the teeth of blizzards in my old VW Bug. I had nowhere to go, but doing donuts in vacant parking lots was a hoot. I was cured of this idiocy more than 20 years ago, when I was returning from my old office in a neighboring town and slid through an unplowed intersection at slow speed. The only patient I had seen that day was a healthy 3-year-old with a scheduled ear recheck.

The resulting fender bender only cost me $150 to settle, but that incident was the straw that pushed me to dissolve that partnership and open a solo office within walking distance of my home. If parents were going to persist in making stupid decisions about driving to see me, I could at least minimize the risks to my own health and property.

If all of the children's symptoms were trivial, I could solve the problem by closing the office when the first snowflake stuck to the pavement. Serious illness, though, doesn't pay attention to storm alerts, and some of the phone calls that come during a burst of severe weather can tax my decision-making skills to the limit.

In these situations, I follow the same credo as most pediatricians: When in doubt, have the patient come in to be examined. Of course, this means that some days, most of the children I have encouraged to make the trek across town are just a little bit sick, if they are even ill at all.

Discouraging visits risks professional suicide. Even with 30 years of interviewing experience and intuition sharpening, I still encounter children for whom my telephone assessment has significantly underestimated the severity of their illnesses. In an attempt to prevent the disastrous consequences of the “seriously-ill-child-not-seen syndrome,” we have an open-door policy. The current buzz words are “open access.”

In good weather there is little downside to this approach, but when there are 2 inches of slick, hard-packed snow on the roads, one must consider whether the trip to the office is more dangerous for the child than the symptoms that his parents have just described to you. When I decide to have the child come to the office in a snowstorm, I don't rest comfortably until I'm sure he is safely tucked into a bed, whether it be back in his own bedroom or on the pediatric floor at the hospital.

As I sit at the receptionist's desk, watching a heavy wet snow blanket the trees and shrubs in front of the office, I can tell by the unusually deliberate pace of the cars creeping out of the staff parking lot that the roads have gotten dangerously greasy. Those of us who live close enough to walk home are holding down the fort and answering the phones for another hour.

Despite the treacherous traveling conditions that have been worsening since lunchtime, the patients have continued to trickle in. Some have had earaches and sore throats, but some were healthy toddlers returning for their 3-week ear rechecks.

I have always been intrigued by the senseless irony of the psychological forces that keep patients at home when it's raining but drive them out onto snow-covered and ice-slicked highways like lemmings.

Even before SUVs replaced minivans as the suburban chariots of choice, many parents were seduced by the challenge of winter driving. When asked why they would risk life, limb, and vehicular damage to bring their child to the pediatrician for a trivial problem, I suspect that they would offer the traditional mountain climber's response—“Because it's there.”

I must admit that as a foolish young man I enjoyed charging out into the teeth of blizzards in my old VW Bug. I had nowhere to go, but doing donuts in vacant parking lots was a hoot. I was cured of this idiocy more than 20 years ago, when I was returning from my old office in a neighboring town and slid through an unplowed intersection at slow speed. The only patient I had seen that day was a healthy 3-year-old with a scheduled ear recheck.

The resulting fender bender only cost me $150 to settle, but that incident was the straw that pushed me to dissolve that partnership and open a solo office within walking distance of my home. If parents were going to persist in making stupid decisions about driving to see me, I could at least minimize the risks to my own health and property.

If all of the children's symptoms were trivial, I could solve the problem by closing the office when the first snowflake stuck to the pavement. Serious illness, though, doesn't pay attention to storm alerts, and some of the phone calls that come during a burst of severe weather can tax my decision-making skills to the limit.

In these situations, I follow the same credo as most pediatricians: When in doubt, have the patient come in to be examined. Of course, this means that some days, most of the children I have encouraged to make the trek across town are just a little bit sick, if they are even ill at all.

Discouraging visits risks professional suicide. Even with 30 years of interviewing experience and intuition sharpening, I still encounter children for whom my telephone assessment has significantly underestimated the severity of their illnesses. In an attempt to prevent the disastrous consequences of the “seriously-ill-child-not-seen syndrome,” we have an open-door policy. The current buzz words are “open access.”

In good weather there is little downside to this approach, but when there are 2 inches of slick, hard-packed snow on the roads, one must consider whether the trip to the office is more dangerous for the child than the symptoms that his parents have just described to you. When I decide to have the child come to the office in a snowstorm, I don't rest comfortably until I'm sure he is safely tucked into a bed, whether it be back in his own bedroom or on the pediatric floor at the hospital.

As I sit at the receptionist's desk, watching a heavy wet snow blanket the trees and shrubs in front of the office, I can tell by the unusually deliberate pace of the cars creeping out of the staff parking lot that the roads have gotten dangerously greasy. Those of us who live close enough to walk home are holding down the fort and answering the phones for another hour.

Despite the treacherous traveling conditions that have been worsening since lunchtime, the patients have continued to trickle in. Some have had earaches and sore throats, but some were healthy toddlers returning for their 3-week ear rechecks.

I have always been intrigued by the senseless irony of the psychological forces that keep patients at home when it's raining but drive them out onto snow-covered and ice-slicked highways like lemmings.

Even before SUVs replaced minivans as the suburban chariots of choice, many parents were seduced by the challenge of winter driving. When asked why they would risk life, limb, and vehicular damage to bring their child to the pediatrician for a trivial problem, I suspect that they would offer the traditional mountain climber's response—“Because it's there.”

I must admit that as a foolish young man I enjoyed charging out into the teeth of blizzards in my old VW Bug. I had nowhere to go, but doing donuts in vacant parking lots was a hoot. I was cured of this idiocy more than 20 years ago, when I was returning from my old office in a neighboring town and slid through an unplowed intersection at slow speed. The only patient I had seen that day was a healthy 3-year-old with a scheduled ear recheck.

The resulting fender bender only cost me $150 to settle, but that incident was the straw that pushed me to dissolve that partnership and open a solo office within walking distance of my home. If parents were going to persist in making stupid decisions about driving to see me, I could at least minimize the risks to my own health and property.

If all of the children's symptoms were trivial, I could solve the problem by closing the office when the first snowflake stuck to the pavement. Serious illness, though, doesn't pay attention to storm alerts, and some of the phone calls that come during a burst of severe weather can tax my decision-making skills to the limit.

In these situations, I follow the same credo as most pediatricians: When in doubt, have the patient come in to be examined. Of course, this means that some days, most of the children I have encouraged to make the trek across town are just a little bit sick, if they are even ill at all.

Discouraging visits risks professional suicide. Even with 30 years of interviewing experience and intuition sharpening, I still encounter children for whom my telephone assessment has significantly underestimated the severity of their illnesses. In an attempt to prevent the disastrous consequences of the “seriously-ill-child-not-seen syndrome,” we have an open-door policy. The current buzz words are “open access.”

In good weather there is little downside to this approach, but when there are 2 inches of slick, hard-packed snow on the roads, one must consider whether the trip to the office is more dangerous for the child than the symptoms that his parents have just described to you. When I decide to have the child come to the office in a snowstorm, I don't rest comfortably until I'm sure he is safely tucked into a bed, whether it be back in his own bedroom or on the pediatric floor at the hospital.

One of the things that I enjoy most about practicing in semirural, subsuburban Maine is that it allows me the privilege of caring for children representing the entire socioeconomic spectrum. I may begin the morning peering into the sore throat of the daughter of a former governor and finish the day by putting a cast on the son of an underemployed bloodworm digger.

There are four pediatric groups here in Brunswick and, although my partners and I may quietly feel we provide the best care in town, the truth is that no practice is considered the office to visit by the economically blessed elite. Nor is any group thought to be on the wrong side of the tracks.

This diversity is intellectually stimulating and keeps us on our diagnostic toes. It also gives us the warm fuzzy feeling of being community servants. That fuzziness comes with a price, though, because it is no secret that state-funded reimbursement often falls short of our costs. The unfortunate families who have slipped into the cracks between private and public funding present an even more troubling challenge.

As you can imagine, this situation has not gone unnoticed by our CEO, who sends us regular e-mail reminders that our patient mix is getting too heavy on the Medicaid side. We tend to ignore his warnings because we all enjoy seeing infants and the bulk of the new babies seem to be coming from underfunded families.

When pressed to close my practice to Medicaid families, I have been able to negotiate a temporary compromise that limits new patients to those residing in Brunswick and any town that abuts us.

I imagine myself to be a new-millennium Robin Hood, venturing deep into the Sherwood Forest of community pediatrics bent on robbing Peter to pay Paul. By trying to provide the same high-quality care to every patient in the most cost-effective manner, I hope that the occasional overpayment by some third parties will offset the underfunding by the rest.

Those of you who still remember enough high school math to do your own taxes may fault my economic logic, but so far it works for me and allows me to continue seeing the exciting mix of patients that I enjoy.

What doesn't work for me is the concept of concierge care that was the focus of a recent PEDIATRIC NEWS article (“Concierge Care Gives Time for Kids,” September 2005, p. 1). This is a free country, and any of us can carve out a high-end economic niche if we choose to, but the notion of skimming off the rich cream of economically advantaged families troubles me.

The standard of care for outpatient pediatrics demands availability—availability that cuts across socioeconomic strata. Regardless of who funds their care, at 10 o'clock at night all patients registered in our practice will have the same access to me or my fellow pediatricians in the community. As I interpret concierge care, it ducks this challenge of providing quality pediatric care to all children of the community.

It smacks of elitism, and I suspect that, because of its narrow scope, concierge care actually fails to provide the quality and availability that it promises and that my partners and I offer without surcharge. We don't ask our patients' parents to sign a contract that includes coverage gaps for our vacations.

We encourage families to develop a close working relationship with one physician, but my partners and I work very hard to create as seamless a coverage arrangement as possible. This means maintaining close communication with each other and trying to standardize our care without shackling our unique clinical personalities.

I'm confident that the majority of families here in Brunswick will say that our system works. Concierge care, on the other hand, serves neither the community nor the subgroup it has isolated. In my view, it robs both Peter and Paul.

One of the things that I enjoy most about practicing in semirural, subsuburban Maine is that it allows me the privilege of caring for children representing the entire socioeconomic spectrum. I may begin the morning peering into the sore throat of the daughter of a former governor and finish the day by putting a cast on the son of an underemployed bloodworm digger.

There are four pediatric groups here in Brunswick and, although my partners and I may quietly feel we provide the best care in town, the truth is that no practice is considered the office to visit by the economically blessed elite. Nor is any group thought to be on the wrong side of the tracks.

This diversity is intellectually stimulating and keeps us on our diagnostic toes. It also gives us the warm fuzzy feeling of being community servants. That fuzziness comes with a price, though, because it is no secret that state-funded reimbursement often falls short of our costs. The unfortunate families who have slipped into the cracks between private and public funding present an even more troubling challenge.

As you can imagine, this situation has not gone unnoticed by our CEO, who sends us regular e-mail reminders that our patient mix is getting too heavy on the Medicaid side. We tend to ignore his warnings because we all enjoy seeing infants and the bulk of the new babies seem to be coming from underfunded families.

When pressed to close my practice to Medicaid families, I have been able to negotiate a temporary compromise that limits new patients to those residing in Brunswick and any town that abuts us.

I imagine myself to be a new-millennium Robin Hood, venturing deep into the Sherwood Forest of community pediatrics bent on robbing Peter to pay Paul. By trying to provide the same high-quality care to every patient in the most cost-effective manner, I hope that the occasional overpayment by some third parties will offset the underfunding by the rest.

Those of you who still remember enough high school math to do your own taxes may fault my economic logic, but so far it works for me and allows me to continue seeing the exciting mix of patients that I enjoy.

What doesn't work for me is the concept of concierge care that was the focus of a recent PEDIATRIC NEWS article (“Concierge Care Gives Time for Kids,” September 2005, p. 1). This is a free country, and any of us can carve out a high-end economic niche if we choose to, but the notion of skimming off the rich cream of economically advantaged families troubles me.

The standard of care for outpatient pediatrics demands availability—availability that cuts across socioeconomic strata. Regardless of who funds their care, at 10 o'clock at night all patients registered in our practice will have the same access to me or my fellow pediatricians in the community. As I interpret concierge care, it ducks this challenge of providing quality pediatric care to all children of the community.

It smacks of elitism, and I suspect that, because of its narrow scope, concierge care actually fails to provide the quality and availability that it promises and that my partners and I offer without surcharge. We don't ask our patients' parents to sign a contract that includes coverage gaps for our vacations.

We encourage families to develop a close working relationship with one physician, but my partners and I work very hard to create as seamless a coverage arrangement as possible. This means maintaining close communication with each other and trying to standardize our care without shackling our unique clinical personalities.

I'm confident that the majority of families here in Brunswick will say that our system works. Concierge care, on the other hand, serves neither the community nor the subgroup it has isolated. In my view, it robs both Peter and Paul.

One of the things that I enjoy most about practicing in semirural, subsuburban Maine is that it allows me the privilege of caring for children representing the entire socioeconomic spectrum. I may begin the morning peering into the sore throat of the daughter of a former governor and finish the day by putting a cast on the son of an underemployed bloodworm digger.

There are four pediatric groups here in Brunswick and, although my partners and I may quietly feel we provide the best care in town, the truth is that no practice is considered the office to visit by the economically blessed elite. Nor is any group thought to be on the wrong side of the tracks.

This diversity is intellectually stimulating and keeps us on our diagnostic toes. It also gives us the warm fuzzy feeling of being community servants. That fuzziness comes with a price, though, because it is no secret that state-funded reimbursement often falls short of our costs. The unfortunate families who have slipped into the cracks between private and public funding present an even more troubling challenge.

As you can imagine, this situation has not gone unnoticed by our CEO, who sends us regular e-mail reminders that our patient mix is getting too heavy on the Medicaid side. We tend to ignore his warnings because we all enjoy seeing infants and the bulk of the new babies seem to be coming from underfunded families.

When pressed to close my practice to Medicaid families, I have been able to negotiate a temporary compromise that limits new patients to those residing in Brunswick and any town that abuts us.

I imagine myself to be a new-millennium Robin Hood, venturing deep into the Sherwood Forest of community pediatrics bent on robbing Peter to pay Paul. By trying to provide the same high-quality care to every patient in the most cost-effective manner, I hope that the occasional overpayment by some third parties will offset the underfunding by the rest.

Those of you who still remember enough high school math to do your own taxes may fault my economic logic, but so far it works for me and allows me to continue seeing the exciting mix of patients that I enjoy.

What doesn't work for me is the concept of concierge care that was the focus of a recent PEDIATRIC NEWS article (“Concierge Care Gives Time for Kids,” September 2005, p. 1). This is a free country, and any of us can carve out a high-end economic niche if we choose to, but the notion of skimming off the rich cream of economically advantaged families troubles me.

The standard of care for outpatient pediatrics demands availability—availability that cuts across socioeconomic strata. Regardless of who funds their care, at 10 o'clock at night all patients registered in our practice will have the same access to me or my fellow pediatricians in the community. As I interpret concierge care, it ducks this challenge of providing quality pediatric care to all children of the community.

It smacks of elitism, and I suspect that, because of its narrow scope, concierge care actually fails to provide the quality and availability that it promises and that my partners and I offer without surcharge. We don't ask our patients' parents to sign a contract that includes coverage gaps for our vacations.

We encourage families to develop a close working relationship with one physician, but my partners and I work very hard to create as seamless a coverage arrangement as possible. This means maintaining close communication with each other and trying to standardize our care without shackling our unique clinical personalities.

I'm confident that the majority of families here in Brunswick will say that our system works. Concierge care, on the other hand, serves neither the community nor the subgroup it has isolated. In my view, it robs both Peter and Paul.