Letters from Maine

Honey, I heard a heart murmur this morning!” I'm sure that every year hundreds of first-year medical students share this educational revelation with their spouses and significant others, but when a 60-year-old pediatrician is tempted to e-mail the same message to his wife, one has to wonder.

When I was a medical student, I struggled to hear the bruits that my instructors were waxing so eloquently about. As a house officer, I delighted in hearing murmurs that my peers had missed, and in my first few years of practice, it seemed as though every third or fourth patient had a cardiac sound worthy of comment.

Over the last 20 years, though, heart murmurs have silently crept onto my list of endangered physical findings. Thinking back over the last 2 days, I can't recall recording a single murmur on one of my patient's charts. During a quiet moment I pondered the possible causes for this threatened extinction.

My first thought was that I wasn't discovering as many murmurs because age has clearly taken a heavy toll on my hearing. This may be true to some extent, but my relative deafness doesn't explain why my two younger partners aren't documenting any more murmurs than I am. Furthermore, I think I still continue to hear rales, rhonchi, and diminished breath sounds in the appropriate situations, and my patients haven't suffered from an unusual number of auscultatory oversights.

Could it be that heart murmurs have simply joined nephrotic syndrome, observation hip, epiglottitis, and bacterial meningitis on the list of rarities in my pediatric neighborhood? Since murmurs can be caused by a wide variety of anatomic variations, I find this explanation untenable.

Prenatal diagnosis of congenital heart disease certainly has siphoned off most of the clinically significant murmurs to the cardiologists and surgeons before they get to my office, but the bulk of the murmurs I was noticing a generation ago were benign flow murmurs that, by definition, were insignificant.

Therein, I think, lies the critical clue to the mystery of the missing murmurs. It doesn't take very many years of barking up empty trees before one's definition of normal broadens to the point that physical findings that once appeared as bright blips on the radar screen fade into the background static.

There are also significant disincentives to acknowledging the presence of a benign flow murmur.

In the interest of complete disclosure, I used to compulsively share my observations with parents, but explaining the difference between “slightly out of the ordinary” and abnormal was time consuming and sometimes so unnerving that I would have to do a cardiogram to quell the fires of anxiety I had kindled with my good intentions. There were also the scores of phone calls from dentists' offices wanting to know if our mutual, inadequately informed patient with a benign flow murmur needed antibiotic coverage.

There is one more possible explanation. Like most physicians, I do the chest auscultation at the beginning of my exam, so an insignificant murmur often gets forgotten or pushed off the agenda by other findings or questions by the time I scribble my office notes. As our friends in the risk management business tell us: If it wasn't documented, it didn't exist.

So there you have it. Like the ivory-billed woodpecker, cardiac murmurs have not gone extinct. They still lurk in the dark swampy recesses of our subconscious, occasionally swooping out to surprise us when we decide to pay attention.

Honey, I heard a heart murmur this morning!” I'm sure that every year hundreds of first-year medical students share this educational revelation with their spouses and significant others, but when a 60-year-old pediatrician is tempted to e-mail the same message to his wife, one has to wonder.

When I was a medical student, I struggled to hear the bruits that my instructors were waxing so eloquently about. As a house officer, I delighted in hearing murmurs that my peers had missed, and in my first few years of practice, it seemed as though every third or fourth patient had a cardiac sound worthy of comment.

Over the last 20 years, though, heart murmurs have silently crept onto my list of endangered physical findings. Thinking back over the last 2 days, I can't recall recording a single murmur on one of my patient's charts. During a quiet moment I pondered the possible causes for this threatened extinction.

My first thought was that I wasn't discovering as many murmurs because age has clearly taken a heavy toll on my hearing. This may be true to some extent, but my relative deafness doesn't explain why my two younger partners aren't documenting any more murmurs than I am. Furthermore, I think I still continue to hear rales, rhonchi, and diminished breath sounds in the appropriate situations, and my patients haven't suffered from an unusual number of auscultatory oversights.

Could it be that heart murmurs have simply joined nephrotic syndrome, observation hip, epiglottitis, and bacterial meningitis on the list of rarities in my pediatric neighborhood? Since murmurs can be caused by a wide variety of anatomic variations, I find this explanation untenable.

Prenatal diagnosis of congenital heart disease certainly has siphoned off most of the clinically significant murmurs to the cardiologists and surgeons before they get to my office, but the bulk of the murmurs I was noticing a generation ago were benign flow murmurs that, by definition, were insignificant.

Therein, I think, lies the critical clue to the mystery of the missing murmurs. It doesn't take very many years of barking up empty trees before one's definition of normal broadens to the point that physical findings that once appeared as bright blips on the radar screen fade into the background static.

There are also significant disincentives to acknowledging the presence of a benign flow murmur.

In the interest of complete disclosure, I used to compulsively share my observations with parents, but explaining the difference between “slightly out of the ordinary” and abnormal was time consuming and sometimes so unnerving that I would have to do a cardiogram to quell the fires of anxiety I had kindled with my good intentions. There were also the scores of phone calls from dentists' offices wanting to know if our mutual, inadequately informed patient with a benign flow murmur needed antibiotic coverage.

There is one more possible explanation. Like most physicians, I do the chest auscultation at the beginning of my exam, so an insignificant murmur often gets forgotten or pushed off the agenda by other findings or questions by the time I scribble my office notes. As our friends in the risk management business tell us: If it wasn't documented, it didn't exist.

So there you have it. Like the ivory-billed woodpecker, cardiac murmurs have not gone extinct. They still lurk in the dark swampy recesses of our subconscious, occasionally swooping out to surprise us when we decide to pay attention.

Honey, I heard a heart murmur this morning!” I'm sure that every year hundreds of first-year medical students share this educational revelation with their spouses and significant others, but when a 60-year-old pediatrician is tempted to e-mail the same message to his wife, one has to wonder.

When I was a medical student, I struggled to hear the bruits that my instructors were waxing so eloquently about. As a house officer, I delighted in hearing murmurs that my peers had missed, and in my first few years of practice, it seemed as though every third or fourth patient had a cardiac sound worthy of comment.

Over the last 20 years, though, heart murmurs have silently crept onto my list of endangered physical findings. Thinking back over the last 2 days, I can't recall recording a single murmur on one of my patient's charts. During a quiet moment I pondered the possible causes for this threatened extinction.

My first thought was that I wasn't discovering as many murmurs because age has clearly taken a heavy toll on my hearing. This may be true to some extent, but my relative deafness doesn't explain why my two younger partners aren't documenting any more murmurs than I am. Furthermore, I think I still continue to hear rales, rhonchi, and diminished breath sounds in the appropriate situations, and my patients haven't suffered from an unusual number of auscultatory oversights.

Could it be that heart murmurs have simply joined nephrotic syndrome, observation hip, epiglottitis, and bacterial meningitis on the list of rarities in my pediatric neighborhood? Since murmurs can be caused by a wide variety of anatomic variations, I find this explanation untenable.

Prenatal diagnosis of congenital heart disease certainly has siphoned off most of the clinically significant murmurs to the cardiologists and surgeons before they get to my office, but the bulk of the murmurs I was noticing a generation ago were benign flow murmurs that, by definition, were insignificant.

Therein, I think, lies the critical clue to the mystery of the missing murmurs. It doesn't take very many years of barking up empty trees before one's definition of normal broadens to the point that physical findings that once appeared as bright blips on the radar screen fade into the background static.

There are also significant disincentives to acknowledging the presence of a benign flow murmur.

In the interest of complete disclosure, I used to compulsively share my observations with parents, but explaining the difference between “slightly out of the ordinary” and abnormal was time consuming and sometimes so unnerving that I would have to do a cardiogram to quell the fires of anxiety I had kindled with my good intentions. There were also the scores of phone calls from dentists' offices wanting to know if our mutual, inadequately informed patient with a benign flow murmur needed antibiotic coverage.

There is one more possible explanation. Like most physicians, I do the chest auscultation at the beginning of my exam, so an insignificant murmur often gets forgotten or pushed off the agenda by other findings or questions by the time I scribble my office notes. As our friends in the risk management business tell us: If it wasn't documented, it didn't exist.

So there you have it. Like the ivory-billed woodpecker, cardiac murmurs have not gone extinct. They still lurk in the dark swampy recesses of our subconscious, occasionally swooping out to surprise us when we decide to pay attention.

Since we first met when I was in high school, Will Shakespeare and I have never been what you would call close. From time to time, though, I bump into an observation of his that suits my mood. One such passage, I'm told, comes from Macbeth:

Sleep that knits up the raveled sleave of care, The death of each day's life, sore labour's bath, Balm of hurt minds, great nature's second course, Chief nourisher in life's feast.

Like the presidential candidate who had to keep reminding himself that it was the economy that concerned the voters, we pediatricians should continually remind ourselves that sleep deserves a spot at the top of our priority lists. And I'm not talking about getting house officers more sleep-friendly schedules or about building barricades of algorithms with which nurses can shield us from worried parents in the middle of the night. I'm urging that we acknowledge that sleep deprivation is the cause of many of our patients' complaints and problems.

Homo sapiens are not a nocturnal species, as witnessed by the fact that we have poor night vision, but since the opening of the first 'round-the-clock power plant in New York City in 1882 we have been artificially pushing back the night and eroding our opportunities for restorative sleep. A poll by the National Sleep Foundation found that adult Americans are now averaging 6.8 hours of sleep on week nights, which is more than an hour less than most sleep experts believe we need.

Quoted in an article in Harvard Magazine, Dr. Robert Stickgold, a cognitive neuroscientist specializing in sleep research at Harvard University said, “We are living in the middle of history's greatest experiment in sleep deprivation. … It's not inconceivable to me that we will discover that there are major social, economic, and health consequences to that experiment” (“Deep into Sleep,” July-August 2005;107:25–33; available online at www.harvardmagazine.com/on-line/070587.html

A sleep researcher at the University of Chicago discovered that sleep-deprived students produce half the number of antibodies in response to a viral challenge in the form of a flu vaccine. I'm not sure where she found a control group of well-rested college students, but I'm not surprised by her data.

The same sleep-deprived subjects also had evidence of insulin resistance and reduced levels of leptin, an endogenous appetite inhibitor. It makes one wonder how much of our obesity problem and the emergence of metabolic syndrome in children may be the result of sleep deprivation.

Hyperactivity, irritability, and reduced attention span are all symptoms of sleep deprivation.

We shouldn't be surprised that stimulant medications have become so popular with parents and educators. An improvement in a student's performance when he starts taking amphetamines doesn't necessarily mean that medication was the best first choice.

Not wanting to get out of bed in the morning can be a symptom of depression, but depression is also a major symptom of sleep deprivation.

This can be a difficult chicken-and-egg situation to sort out, but, again, it makes me suspect that some of the surge in mental illness that I have witnessed during the last 30 years is the result of our inability to create and enforce sleep-friendly schedules for ourselves and our children.

In my experience, nocturnal and late-day leg pains—the kind that were once incorrectly labeled “growing pains”—are clearly the result of sleep deprivation. The same is true of migraine headaches and cyclic vomiting. So far, I have never had to prescribe Imitrex (sumatriptan) because an aggressive approach to sleep and lifestyle management has always succeeded in those families who have made a serious effort to change the way they spend their days and nights.

It hasn't been easy for them, though. The erosion of our sleep has been so insidious that most parents don't realize that their families' schedules are providing insufficient opportunity for sleep.

School administrators and the organizers of extracurricular activities often seem oblivious to the situation and think nothing of scheduling activities, games, and practices at an hour that makes it impossible for children to get an adequate night's sleep (and a meal with their families).

Those of you who are regular readers of these epistles know that sleep deprivation is one of my favorite bandwagons. But the recent data about sleep-deprived metabolic syndrome and the relationship between sleep deprivation and immunity have prompted me to issue another reminder that we pediatricians should be taking thorough sleep histories and advocating for more sleep-friendly schedules for our young patients.

Since we first met when I was in high school, Will Shakespeare and I have never been what you would call close. From time to time, though, I bump into an observation of his that suits my mood. One such passage, I'm told, comes from Macbeth:

Sleep that knits up the raveled sleave of care, The death of each day's life, sore labour's bath, Balm of hurt minds, great nature's second course, Chief nourisher in life's feast.

Like the presidential candidate who had to keep reminding himself that it was the economy that concerned the voters, we pediatricians should continually remind ourselves that sleep deserves a spot at the top of our priority lists. And I'm not talking about getting house officers more sleep-friendly schedules or about building barricades of algorithms with which nurses can shield us from worried parents in the middle of the night. I'm urging that we acknowledge that sleep deprivation is the cause of many of our patients' complaints and problems.

Homo sapiens are not a nocturnal species, as witnessed by the fact that we have poor night vision, but since the opening of the first 'round-the-clock power plant in New York City in 1882 we have been artificially pushing back the night and eroding our opportunities for restorative sleep. A poll by the National Sleep Foundation found that adult Americans are now averaging 6.8 hours of sleep on week nights, which is more than an hour less than most sleep experts believe we need.

Quoted in an article in Harvard Magazine, Dr. Robert Stickgold, a cognitive neuroscientist specializing in sleep research at Harvard University said, “We are living in the middle of history's greatest experiment in sleep deprivation. … It's not inconceivable to me that we will discover that there are major social, economic, and health consequences to that experiment” (“Deep into Sleep,” July-August 2005;107:25–33; available online at www.harvardmagazine.com/on-line/070587.html

A sleep researcher at the University of Chicago discovered that sleep-deprived students produce half the number of antibodies in response to a viral challenge in the form of a flu vaccine. I'm not sure where she found a control group of well-rested college students, but I'm not surprised by her data.

The same sleep-deprived subjects also had evidence of insulin resistance and reduced levels of leptin, an endogenous appetite inhibitor. It makes one wonder how much of our obesity problem and the emergence of metabolic syndrome in children may be the result of sleep deprivation.

Hyperactivity, irritability, and reduced attention span are all symptoms of sleep deprivation.

We shouldn't be surprised that stimulant medications have become so popular with parents and educators. An improvement in a student's performance when he starts taking amphetamines doesn't necessarily mean that medication was the best first choice.

Not wanting to get out of bed in the morning can be a symptom of depression, but depression is also a major symptom of sleep deprivation.

This can be a difficult chicken-and-egg situation to sort out, but, again, it makes me suspect that some of the surge in mental illness that I have witnessed during the last 30 years is the result of our inability to create and enforce sleep-friendly schedules for ourselves and our children.

In my experience, nocturnal and late-day leg pains—the kind that were once incorrectly labeled “growing pains”—are clearly the result of sleep deprivation. The same is true of migraine headaches and cyclic vomiting. So far, I have never had to prescribe Imitrex (sumatriptan) because an aggressive approach to sleep and lifestyle management has always succeeded in those families who have made a serious effort to change the way they spend their days and nights.

It hasn't been easy for them, though. The erosion of our sleep has been so insidious that most parents don't realize that their families' schedules are providing insufficient opportunity for sleep.

School administrators and the organizers of extracurricular activities often seem oblivious to the situation and think nothing of scheduling activities, games, and practices at an hour that makes it impossible for children to get an adequate night's sleep (and a meal with their families).

Those of you who are regular readers of these epistles know that sleep deprivation is one of my favorite bandwagons. But the recent data about sleep-deprived metabolic syndrome and the relationship between sleep deprivation and immunity have prompted me to issue another reminder that we pediatricians should be taking thorough sleep histories and advocating for more sleep-friendly schedules for our young patients.

Since we first met when I was in high school, Will Shakespeare and I have never been what you would call close. From time to time, though, I bump into an observation of his that suits my mood. One such passage, I'm told, comes from Macbeth:

Sleep that knits up the raveled sleave of care, The death of each day's life, sore labour's bath, Balm of hurt minds, great nature's second course, Chief nourisher in life's feast.

Like the presidential candidate who had to keep reminding himself that it was the economy that concerned the voters, we pediatricians should continually remind ourselves that sleep deserves a spot at the top of our priority lists. And I'm not talking about getting house officers more sleep-friendly schedules or about building barricades of algorithms with which nurses can shield us from worried parents in the middle of the night. I'm urging that we acknowledge that sleep deprivation is the cause of many of our patients' complaints and problems.

Homo sapiens are not a nocturnal species, as witnessed by the fact that we have poor night vision, but since the opening of the first 'round-the-clock power plant in New York City in 1882 we have been artificially pushing back the night and eroding our opportunities for restorative sleep. A poll by the National Sleep Foundation found that adult Americans are now averaging 6.8 hours of sleep on week nights, which is more than an hour less than most sleep experts believe we need.

Quoted in an article in Harvard Magazine, Dr. Robert Stickgold, a cognitive neuroscientist specializing in sleep research at Harvard University said, “We are living in the middle of history's greatest experiment in sleep deprivation. … It's not inconceivable to me that we will discover that there are major social, economic, and health consequences to that experiment” (“Deep into Sleep,” July-August 2005;107:25–33; available online at www.harvardmagazine.com/on-line/070587.html

A sleep researcher at the University of Chicago discovered that sleep-deprived students produce half the number of antibodies in response to a viral challenge in the form of a flu vaccine. I'm not sure where she found a control group of well-rested college students, but I'm not surprised by her data.

The same sleep-deprived subjects also had evidence of insulin resistance and reduced levels of leptin, an endogenous appetite inhibitor. It makes one wonder how much of our obesity problem and the emergence of metabolic syndrome in children may be the result of sleep deprivation.

Hyperactivity, irritability, and reduced attention span are all symptoms of sleep deprivation.

We shouldn't be surprised that stimulant medications have become so popular with parents and educators. An improvement in a student's performance when he starts taking amphetamines doesn't necessarily mean that medication was the best first choice.

Not wanting to get out of bed in the morning can be a symptom of depression, but depression is also a major symptom of sleep deprivation.

This can be a difficult chicken-and-egg situation to sort out, but, again, it makes me suspect that some of the surge in mental illness that I have witnessed during the last 30 years is the result of our inability to create and enforce sleep-friendly schedules for ourselves and our children.

In my experience, nocturnal and late-day leg pains—the kind that were once incorrectly labeled “growing pains”—are clearly the result of sleep deprivation. The same is true of migraine headaches and cyclic vomiting. So far, I have never had to prescribe Imitrex (sumatriptan) because an aggressive approach to sleep and lifestyle management has always succeeded in those families who have made a serious effort to change the way they spend their days and nights.

It hasn't been easy for them, though. The erosion of our sleep has been so insidious that most parents don't realize that their families' schedules are providing insufficient opportunity for sleep.

School administrators and the organizers of extracurricular activities often seem oblivious to the situation and think nothing of scheduling activities, games, and practices at an hour that makes it impossible for children to get an adequate night's sleep (and a meal with their families).

Those of you who are regular readers of these epistles know that sleep deprivation is one of my favorite bandwagons. But the recent data about sleep-deprived metabolic syndrome and the relationship between sleep deprivation and immunity have prompted me to issue another reminder that we pediatricians should be taking thorough sleep histories and advocating for more sleep-friendly schedules for our young patients.

It is quite unsettling enough to hear a physician exclaim, “We've never seen a case like this before,” but when the surgeon you've known for more than 2 decades is talking about your 2-kg, not-quite-33-week-gestational-age granddaughter, it's frightening.

Little Hannah Margaret's entry into the world had begun to get complicated when her mother developed massive polyhydramnios and an ultrasound suggested that the baby's stomach was enlarged. We knew that something might not be quite right with her GI tract, but we were relieved when the neonatologist could pass a tube easily into her stomach. We were even more relieved when a limited-contrast study demonstrated continuity well into her small bowel. But continuity is a relative thing, and it became clear that her stomach did not empty normally.

At endoscopy, the antral region of her stomach was swollen and inflamed, and the gastroenterologist could not enter or even adequately visualize the pylorus. Trying hard to be the silent and supportive grandparent, I listened patiently as the pediatric surgeon at our tertiary care medical center outlined for my son the options for dealing with what he suspected was a very rare antral web. Unclear exactly what would be found until they opened her abdomen, he couldn't predict what procedure they would perform, but there was a high likelihood that little Hannah would be left with a dysfunctional pylorus.

When I sensed that my son had asked all his questions, I asked in my most naive voice if there was any chance that this outlet obstruction could be dealt with endoscopically. The answer was no.

Because of some scheduling issues, we had several days to prepare ourselves emotionally for the surgery. For 30 years I had relied on the magical skills and astute decision making of these same pediatric surgeons to rescue my patients from a broad range of congenital anomalies and anatomic misadventures. However, the plan that they outlined for my own granddaughter made me very uncomfortable. The rarity of her condition and, hence, their inexperience, was unsettling.

But what was the best way to act on my concerns without seeming to be a meddling grandfather who felt that the surgical expertise that had been just fine for his patients for 30 years was not good enough for his own granddaughter?

Not wanting to disturb my son's confidence in the care his daughter was receiving, I decided to do my research under cover. I began by bouncing the scenario off my partner, who would eventually become Hannah's physician. I then spoke to a pediatric gastroenterologist in Boston with whom I have shared patients since my residency. Both physicians supported my concerns and were, in fact, more troubled than I was about the proposed plan.

But when it came time for me to suggest a second opinion to my son and his wife, I was hesitant because I didn't want to offend the people who had been my go-to guys for more than 3 decades.

Even though I know it is often in the best interest of the patient, maybe only because it will give the parents peace of mind, I don't like it when families question my diagnosis or therapeutic plan and ask for a second opinion. Many times they have sensed my own poorly disguised discomfort with the situation—the cases in which I'm planning to recommend another physician if things don't improve by the next office visit—and beaten me to the punch.

In my granddaughter's situation, I was able to step back into the shadows and allow my saintly partner to do the dirty work of arranging the trip to Boston. And I am happy to report that the story has a happy ending. Even though the big-city specialists could remember only one similar case, they were willing to attempt an endoscopic approach. You should be reading about her successful procedure in a medical journal next year.

It is quite unsettling enough to hear a physician exclaim, “We've never seen a case like this before,” but when the surgeon you've known for more than 2 decades is talking about your 2-kg, not-quite-33-week-gestational-age granddaughter, it's frightening.

Little Hannah Margaret's entry into the world had begun to get complicated when her mother developed massive polyhydramnios and an ultrasound suggested that the baby's stomach was enlarged. We knew that something might not be quite right with her GI tract, but we were relieved when the neonatologist could pass a tube easily into her stomach. We were even more relieved when a limited-contrast study demonstrated continuity well into her small bowel. But continuity is a relative thing, and it became clear that her stomach did not empty normally.

At endoscopy, the antral region of her stomach was swollen and inflamed, and the gastroenterologist could not enter or even adequately visualize the pylorus. Trying hard to be the silent and supportive grandparent, I listened patiently as the pediatric surgeon at our tertiary care medical center outlined for my son the options for dealing with what he suspected was a very rare antral web. Unclear exactly what would be found until they opened her abdomen, he couldn't predict what procedure they would perform, but there was a high likelihood that little Hannah would be left with a dysfunctional pylorus.

When I sensed that my son had asked all his questions, I asked in my most naive voice if there was any chance that this outlet obstruction could be dealt with endoscopically. The answer was no.

Because of some scheduling issues, we had several days to prepare ourselves emotionally for the surgery. For 30 years I had relied on the magical skills and astute decision making of these same pediatric surgeons to rescue my patients from a broad range of congenital anomalies and anatomic misadventures. However, the plan that they outlined for my own granddaughter made me very uncomfortable. The rarity of her condition and, hence, their inexperience, was unsettling.

But what was the best way to act on my concerns without seeming to be a meddling grandfather who felt that the surgical expertise that had been just fine for his patients for 30 years was not good enough for his own granddaughter?

Not wanting to disturb my son's confidence in the care his daughter was receiving, I decided to do my research under cover. I began by bouncing the scenario off my partner, who would eventually become Hannah's physician. I then spoke to a pediatric gastroenterologist in Boston with whom I have shared patients since my residency. Both physicians supported my concerns and were, in fact, more troubled than I was about the proposed plan.

But when it came time for me to suggest a second opinion to my son and his wife, I was hesitant because I didn't want to offend the people who had been my go-to guys for more than 3 decades.

Even though I know it is often in the best interest of the patient, maybe only because it will give the parents peace of mind, I don't like it when families question my diagnosis or therapeutic plan and ask for a second opinion. Many times they have sensed my own poorly disguised discomfort with the situation—the cases in which I'm planning to recommend another physician if things don't improve by the next office visit—and beaten me to the punch.

In my granddaughter's situation, I was able to step back into the shadows and allow my saintly partner to do the dirty work of arranging the trip to Boston. And I am happy to report that the story has a happy ending. Even though the big-city specialists could remember only one similar case, they were willing to attempt an endoscopic approach. You should be reading about her successful procedure in a medical journal next year.

It is quite unsettling enough to hear a physician exclaim, “We've never seen a case like this before,” but when the surgeon you've known for more than 2 decades is talking about your 2-kg, not-quite-33-week-gestational-age granddaughter, it's frightening.

Little Hannah Margaret's entry into the world had begun to get complicated when her mother developed massive polyhydramnios and an ultrasound suggested that the baby's stomach was enlarged. We knew that something might not be quite right with her GI tract, but we were relieved when the neonatologist could pass a tube easily into her stomach. We were even more relieved when a limited-contrast study demonstrated continuity well into her small bowel. But continuity is a relative thing, and it became clear that her stomach did not empty normally.

At endoscopy, the antral region of her stomach was swollen and inflamed, and the gastroenterologist could not enter or even adequately visualize the pylorus. Trying hard to be the silent and supportive grandparent, I listened patiently as the pediatric surgeon at our tertiary care medical center outlined for my son the options for dealing with what he suspected was a very rare antral web. Unclear exactly what would be found until they opened her abdomen, he couldn't predict what procedure they would perform, but there was a high likelihood that little Hannah would be left with a dysfunctional pylorus.

When I sensed that my son had asked all his questions, I asked in my most naive voice if there was any chance that this outlet obstruction could be dealt with endoscopically. The answer was no.

Because of some scheduling issues, we had several days to prepare ourselves emotionally for the surgery. For 30 years I had relied on the magical skills and astute decision making of these same pediatric surgeons to rescue my patients from a broad range of congenital anomalies and anatomic misadventures. However, the plan that they outlined for my own granddaughter made me very uncomfortable. The rarity of her condition and, hence, their inexperience, was unsettling.

But what was the best way to act on my concerns without seeming to be a meddling grandfather who felt that the surgical expertise that had been just fine for his patients for 30 years was not good enough for his own granddaughter?

Not wanting to disturb my son's confidence in the care his daughter was receiving, I decided to do my research under cover. I began by bouncing the scenario off my partner, who would eventually become Hannah's physician. I then spoke to a pediatric gastroenterologist in Boston with whom I have shared patients since my residency. Both physicians supported my concerns and were, in fact, more troubled than I was about the proposed plan.

But when it came time for me to suggest a second opinion to my son and his wife, I was hesitant because I didn't want to offend the people who had been my go-to guys for more than 3 decades.

Even though I know it is often in the best interest of the patient, maybe only because it will give the parents peace of mind, I don't like it when families question my diagnosis or therapeutic plan and ask for a second opinion. Many times they have sensed my own poorly disguised discomfort with the situation—the cases in which I'm planning to recommend another physician if things don't improve by the next office visit—and beaten me to the punch.

In my granddaughter's situation, I was able to step back into the shadows and allow my saintly partner to do the dirty work of arranging the trip to Boston. And I am happy to report that the story has a happy ending. Even though the big-city specialists could remember only one similar case, they were willing to attempt an endoscopic approach. You should be reading about her successful procedure in a medical journal next year.

There are two societal phenomena that frustrate me to the point of hanging up my stethoscope and converting my garage into a boat-building shop. The first of these is the expanding collection of behavioral dysfunctions among America's children that are often mislabeled attention-deficit disorders. The other is the overweight epidemic among those same children.

In both cases, we pediatricians have accepted a hefty share of the challenge to fabricate medical solutions for what are primarily societal problems.

We didn't invent television, fast food, divorce, or overscheduled two-income families, but because the tsunamis generated by these realities are threatening to drown a generation of children, those of us committed to their welfare are logically viewed by ourselves and others as front-line soldiers.

But do we pediatricians have the weapons to wage these wars?

And where should the battles be fought?

One of the lead stories in last month's PEDIATRIC NEWS suggested that we can learn to counsel and administer behavioral treatments in our offices that will be effective against obesity (“Getting Through to Overweight Kids,” p. 1).

The pediatricians in the article may be making a difference for some of their patients, but I am skeptical about the applicability of their techniques for the rest of us, who are accustomed to the much higher success rates typical of asthma and pyelonephritis.

Only 37 of 73 families completed the counseling program, and the investigators admitted they didn't know how many families were initially asked to participate but declined.

Although I'm sure I could learn to do a better job of counseling, I have been talking—and listening—to parents about obesity and inactivity for several decades using similar techniques and have had frustratingly few successes.

But before I pack it in and retreat to my workshop, I feel I should give the challenge of obesity one more try.

Robert E. Holmberg Jr., M.D., a member of the American Academy of Pediatrics' task force on obesity, wrote in a recent editorial that, to be effective against the overweight phenomenon, we pediatricians must venture out of our offices and “embrace the community pediatric perspective and methods” (AAP News, July 2005, p. 32).

As one would expect from the clear-thinking, common-sense pediatrician from Maine that he is, Bob offers nine specific ways that a physician can “work with the community to develop projects to improve physical activity, nutrition and prevent [my italics] overweight in our children.”

I really like the concept of prevention because my attempts at mopping up the damage aren't working. Furthermore, I am pleased that his first suggestion is to “focus locally,” because I'm a think-small kind of guy.

But he also suggests that I form a “small steering group” and then a “community coalition” and eventually participate in my “coordinated school health council.” Whoa! Bob!

This is beginning to smell like a whole mess of meetings. You must not be reading my column very closely. I don't do meetings.

I knew that getting out of my office to battle obesity was going to take me away from what I do best, but this is sounding very uncomfortable.

Am I going to have to listen patiently while other concerned citizens voice their occasionally lame ideas?

Does this mean that instead of writing orders and prescriptions that are carried out without question, I might be writing grant applications that someone will edit and someone else might deny?

Bob, Bob, I'm all for a community team approach, but can't I please still be the captain?

I'm afraid I already know the answers. But damn it, the overweight crisis has really gotten to me, and I don't want anyone to accuse this old dog of not being able to learn a few new tricks.

Since I'm getting paid diddly-squat for counseling in the office anyway, I might as well go forth and embrace that community pediatric perspective at a few meetings out of the office where I won't get paid anything.

That wood I bought for the new boat should probably season in the garage for a few more years anyway.

There are two societal phenomena that frustrate me to the point of hanging up my stethoscope and converting my garage into a boat-building shop. The first of these is the expanding collection of behavioral dysfunctions among America's children that are often mislabeled attention-deficit disorders. The other is the overweight epidemic among those same children.

In both cases, we pediatricians have accepted a hefty share of the challenge to fabricate medical solutions for what are primarily societal problems.

We didn't invent television, fast food, divorce, or overscheduled two-income families, but because the tsunamis generated by these realities are threatening to drown a generation of children, those of us committed to their welfare are logically viewed by ourselves and others as front-line soldiers.

But do we pediatricians have the weapons to wage these wars?

And where should the battles be fought?

One of the lead stories in last month's PEDIATRIC NEWS suggested that we can learn to counsel and administer behavioral treatments in our offices that will be effective against obesity (“Getting Through to Overweight Kids,” p. 1).

The pediatricians in the article may be making a difference for some of their patients, but I am skeptical about the applicability of their techniques for the rest of us, who are accustomed to the much higher success rates typical of asthma and pyelonephritis.

Only 37 of 73 families completed the counseling program, and the investigators admitted they didn't know how many families were initially asked to participate but declined.

Although I'm sure I could learn to do a better job of counseling, I have been talking—and listening—to parents about obesity and inactivity for several decades using similar techniques and have had frustratingly few successes.

But before I pack it in and retreat to my workshop, I feel I should give the challenge of obesity one more try.

Robert E. Holmberg Jr., M.D., a member of the American Academy of Pediatrics' task force on obesity, wrote in a recent editorial that, to be effective against the overweight phenomenon, we pediatricians must venture out of our offices and “embrace the community pediatric perspective and methods” (AAP News, July 2005, p. 32).

As one would expect from the clear-thinking, common-sense pediatrician from Maine that he is, Bob offers nine specific ways that a physician can “work with the community to develop projects to improve physical activity, nutrition and prevent [my italics] overweight in our children.”

I really like the concept of prevention because my attempts at mopping up the damage aren't working. Furthermore, I am pleased that his first suggestion is to “focus locally,” because I'm a think-small kind of guy.

But he also suggests that I form a “small steering group” and then a “community coalition” and eventually participate in my “coordinated school health council.” Whoa! Bob!

This is beginning to smell like a whole mess of meetings. You must not be reading my column very closely. I don't do meetings.

I knew that getting out of my office to battle obesity was going to take me away from what I do best, but this is sounding very uncomfortable.

Am I going to have to listen patiently while other concerned citizens voice their occasionally lame ideas?

Does this mean that instead of writing orders and prescriptions that are carried out without question, I might be writing grant applications that someone will edit and someone else might deny?

Bob, Bob, I'm all for a community team approach, but can't I please still be the captain?

I'm afraid I already know the answers. But damn it, the overweight crisis has really gotten to me, and I don't want anyone to accuse this old dog of not being able to learn a few new tricks.

Since I'm getting paid diddly-squat for counseling in the office anyway, I might as well go forth and embrace that community pediatric perspective at a few meetings out of the office where I won't get paid anything.

That wood I bought for the new boat should probably season in the garage for a few more years anyway.

There are two societal phenomena that frustrate me to the point of hanging up my stethoscope and converting my garage into a boat-building shop. The first of these is the expanding collection of behavioral dysfunctions among America's children that are often mislabeled attention-deficit disorders. The other is the overweight epidemic among those same children.

In both cases, we pediatricians have accepted a hefty share of the challenge to fabricate medical solutions for what are primarily societal problems.

We didn't invent television, fast food, divorce, or overscheduled two-income families, but because the tsunamis generated by these realities are threatening to drown a generation of children, those of us committed to their welfare are logically viewed by ourselves and others as front-line soldiers.

But do we pediatricians have the weapons to wage these wars?

And where should the battles be fought?

One of the lead stories in last month's PEDIATRIC NEWS suggested that we can learn to counsel and administer behavioral treatments in our offices that will be effective against obesity (“Getting Through to Overweight Kids,” p. 1).

The pediatricians in the article may be making a difference for some of their patients, but I am skeptical about the applicability of their techniques for the rest of us, who are accustomed to the much higher success rates typical of asthma and pyelonephritis.

Only 37 of 73 families completed the counseling program, and the investigators admitted they didn't know how many families were initially asked to participate but declined.

Although I'm sure I could learn to do a better job of counseling, I have been talking—and listening—to parents about obesity and inactivity for several decades using similar techniques and have had frustratingly few successes.

But before I pack it in and retreat to my workshop, I feel I should give the challenge of obesity one more try.

Robert E. Holmberg Jr., M.D., a member of the American Academy of Pediatrics' task force on obesity, wrote in a recent editorial that, to be effective against the overweight phenomenon, we pediatricians must venture out of our offices and “embrace the community pediatric perspective and methods” (AAP News, July 2005, p. 32).

As one would expect from the clear-thinking, common-sense pediatrician from Maine that he is, Bob offers nine specific ways that a physician can “work with the community to develop projects to improve physical activity, nutrition and prevent [my italics] overweight in our children.”

I really like the concept of prevention because my attempts at mopping up the damage aren't working. Furthermore, I am pleased that his first suggestion is to “focus locally,” because I'm a think-small kind of guy.

But he also suggests that I form a “small steering group” and then a “community coalition” and eventually participate in my “coordinated school health council.” Whoa! Bob!

This is beginning to smell like a whole mess of meetings. You must not be reading my column very closely. I don't do meetings.

I knew that getting out of my office to battle obesity was going to take me away from what I do best, but this is sounding very uncomfortable.

Am I going to have to listen patiently while other concerned citizens voice their occasionally lame ideas?

Does this mean that instead of writing orders and prescriptions that are carried out without question, I might be writing grant applications that someone will edit and someone else might deny?

Bob, Bob, I'm all for a community team approach, but can't I please still be the captain?

I'm afraid I already know the answers. But damn it, the overweight crisis has really gotten to me, and I don't want anyone to accuse this old dog of not being able to learn a few new tricks.

Since I'm getting paid diddly-squat for counseling in the office anyway, I might as well go forth and embrace that community pediatric perspective at a few meetings out of the office where I won't get paid anything.

That wood I bought for the new boat should probably season in the garage for a few more years anyway.

The old highway sign—“Maine, the Way Life Should Be”—was hard to miss as one left the toll plaza in Kittery heading north toward Portland on I-95. Those of us fortunate enough to live here know that those words weren't simply a catch phrase cooked up by some big city PR firm.

With its rich supply of recreational opportunities and low population density, Maine is a beautiful and safe place to raise children. Like Montana and a few other heavenly places, though, we have trouble finding work for our adult children, and many of them are forced to leave this idyllic place to find employment that matches their education.

So you can imagine how excited Marilyn and I were when our son called to say he had landed a good job at L.L. Bean and would be moving back to Maine. In fact, he had already begun to look for a house here in Brunswick, and his wife was pregnant with our first grandchild.

As we proudly shared the good news with everyone who would listen, one of the most frequently asked questions was, “Well, who's going to be the baby's pediatrician?” In a few cases, the question was rhetorical, because our closest friends knew how uncomfortable I would be shouldering the responsibility of caring for my own grandchild.

But many of the questioners clearly didn't understand that being a pediatrician often requires a difficult and schizophrenic separation of one's natural instincts, even when the patient is neither a friend nor a relative. The ability to fluctuate between compassion and objectivity and still keep the whole process in balance isn't easy.

I recall an incident when I was an intern struggling to perform a lumbar puncture on a febrile 10-month-old girl. The gray-haired nurse who was holding the child for me said, “Will, you usually don't have this much trouble with LPs. Your daughter must be about the same age.”

She was correct. Fortunately, I was able to wall off my paternal emotions long enough to collect a clean sample of spinal fluid, but I knew that, had this little patient actually been my own daughter, I would have most likely bungled the tap or given up prematurely because I thought I was hurting her.

By the time I was a senior resident, I had promised myself that I wouldn't lift a therapeutic or diagnostic finger when one of my own children was ill. My steadfast adherence to this philosophy has meant that on several occasions, my poor wife had to drive for hours in rush-hour traffic to see the official pediatrician for what was obviously an otitis media. I may keep my good-luck stethoscope in my knapsack, but my otoscope always stays at the office. This eliminates any temptation to examine the ears of either kin or neighbor.

I've made a couple of exceptions over the years, with nearly disastrous results. The first incident involved my son's knee laceration, which I attempted to repair with inadequate anesthesia. Neither the scenario nor the result was pretty. In another episode, I nearly sent my daughter back to school with a fractured humerus after a cursory kitchen-table examination. Her mother saved the day and my ego by urging a second and wiser opinion.

Family and medicine don't mix well. Despite our best efforts to prevent it, some of our diagnostic and therapeutic procedures are painful. Under the best of circumstances, it is sometimes difficult to do the right thing, but when the patient is one's own child or grandchild, it may be impossible.

A good clinician must be able to submerge his own emotional attachment to the patient long enough to allow his rational decision-making skills to rise to the surface, while still demonstrating that he cares.

I know that when my grandchild arrives, I won't be able to suppress my own emotions. I just want to be his or her grandfather, and I hope I can let someone else be the pediatrician.

The old highway sign—“Maine, the Way Life Should Be”—was hard to miss as one left the toll plaza in Kittery heading north toward Portland on I-95. Those of us fortunate enough to live here know that those words weren't simply a catch phrase cooked up by some big city PR firm.

With its rich supply of recreational opportunities and low population density, Maine is a beautiful and safe place to raise children. Like Montana and a few other heavenly places, though, we have trouble finding work for our adult children, and many of them are forced to leave this idyllic place to find employment that matches their education.

So you can imagine how excited Marilyn and I were when our son called to say he had landed a good job at L.L. Bean and would be moving back to Maine. In fact, he had already begun to look for a house here in Brunswick, and his wife was pregnant with our first grandchild.

As we proudly shared the good news with everyone who would listen, one of the most frequently asked questions was, “Well, who's going to be the baby's pediatrician?” In a few cases, the question was rhetorical, because our closest friends knew how uncomfortable I would be shouldering the responsibility of caring for my own grandchild.

But many of the questioners clearly didn't understand that being a pediatrician often requires a difficult and schizophrenic separation of one's natural instincts, even when the patient is neither a friend nor a relative. The ability to fluctuate between compassion and objectivity and still keep the whole process in balance isn't easy.

I recall an incident when I was an intern struggling to perform a lumbar puncture on a febrile 10-month-old girl. The gray-haired nurse who was holding the child for me said, “Will, you usually don't have this much trouble with LPs. Your daughter must be about the same age.”

She was correct. Fortunately, I was able to wall off my paternal emotions long enough to collect a clean sample of spinal fluid, but I knew that, had this little patient actually been my own daughter, I would have most likely bungled the tap or given up prematurely because I thought I was hurting her.

By the time I was a senior resident, I had promised myself that I wouldn't lift a therapeutic or diagnostic finger when one of my own children was ill. My steadfast adherence to this philosophy has meant that on several occasions, my poor wife had to drive for hours in rush-hour traffic to see the official pediatrician for what was obviously an otitis media. I may keep my good-luck stethoscope in my knapsack, but my otoscope always stays at the office. This eliminates any temptation to examine the ears of either kin or neighbor.

I've made a couple of exceptions over the years, with nearly disastrous results. The first incident involved my son's knee laceration, which I attempted to repair with inadequate anesthesia. Neither the scenario nor the result was pretty. In another episode, I nearly sent my daughter back to school with a fractured humerus after a cursory kitchen-table examination. Her mother saved the day and my ego by urging a second and wiser opinion.

Family and medicine don't mix well. Despite our best efforts to prevent it, some of our diagnostic and therapeutic procedures are painful. Under the best of circumstances, it is sometimes difficult to do the right thing, but when the patient is one's own child or grandchild, it may be impossible.

A good clinician must be able to submerge his own emotional attachment to the patient long enough to allow his rational decision-making skills to rise to the surface, while still demonstrating that he cares.

I know that when my grandchild arrives, I won't be able to suppress my own emotions. I just want to be his or her grandfather, and I hope I can let someone else be the pediatrician.

The old highway sign—“Maine, the Way Life Should Be”—was hard to miss as one left the toll plaza in Kittery heading north toward Portland on I-95. Those of us fortunate enough to live here know that those words weren't simply a catch phrase cooked up by some big city PR firm.

With its rich supply of recreational opportunities and low population density, Maine is a beautiful and safe place to raise children. Like Montana and a few other heavenly places, though, we have trouble finding work for our adult children, and many of them are forced to leave this idyllic place to find employment that matches their education.

So you can imagine how excited Marilyn and I were when our son called to say he had landed a good job at L.L. Bean and would be moving back to Maine. In fact, he had already begun to look for a house here in Brunswick, and his wife was pregnant with our first grandchild.

As we proudly shared the good news with everyone who would listen, one of the most frequently asked questions was, “Well, who's going to be the baby's pediatrician?” In a few cases, the question was rhetorical, because our closest friends knew how uncomfortable I would be shouldering the responsibility of caring for my own grandchild.

But many of the questioners clearly didn't understand that being a pediatrician often requires a difficult and schizophrenic separation of one's natural instincts, even when the patient is neither a friend nor a relative. The ability to fluctuate between compassion and objectivity and still keep the whole process in balance isn't easy.

I recall an incident when I was an intern struggling to perform a lumbar puncture on a febrile 10-month-old girl. The gray-haired nurse who was holding the child for me said, “Will, you usually don't have this much trouble with LPs. Your daughter must be about the same age.”

She was correct. Fortunately, I was able to wall off my paternal emotions long enough to collect a clean sample of spinal fluid, but I knew that, had this little patient actually been my own daughter, I would have most likely bungled the tap or given up prematurely because I thought I was hurting her.

By the time I was a senior resident, I had promised myself that I wouldn't lift a therapeutic or diagnostic finger when one of my own children was ill. My steadfast adherence to this philosophy has meant that on several occasions, my poor wife had to drive for hours in rush-hour traffic to see the official pediatrician for what was obviously an otitis media. I may keep my good-luck stethoscope in my knapsack, but my otoscope always stays at the office. This eliminates any temptation to examine the ears of either kin or neighbor.

I've made a couple of exceptions over the years, with nearly disastrous results. The first incident involved my son's knee laceration, which I attempted to repair with inadequate anesthesia. Neither the scenario nor the result was pretty. In another episode, I nearly sent my daughter back to school with a fractured humerus after a cursory kitchen-table examination. Her mother saved the day and my ego by urging a second and wiser opinion.

Family and medicine don't mix well. Despite our best efforts to prevent it, some of our diagnostic and therapeutic procedures are painful. Under the best of circumstances, it is sometimes difficult to do the right thing, but when the patient is one's own child or grandchild, it may be impossible.

A good clinician must be able to submerge his own emotional attachment to the patient long enough to allow his rational decision-making skills to rise to the surface, while still demonstrating that he cares.

I know that when my grandchild arrives, I won't be able to suppress my own emotions. I just want to be his or her grandfather, and I hope I can let someone else be the pediatrician.

The receptionist usually scribbles an abbreviated version of the patient's chief complaint at the top of the billing form to give me a heads-up on the diagnostic challenge awaiting me, but Sheila was still learning the job and had left the space blank. It wasn't a big deal, but it meant I was going to enter the examining room blind.

As I eased the door open, however, my nose told me everything I needed to know before my eyes met the droopy gaze of the 12-year-old slouched on the exam table. The heavy, sweet odor told me this young man's mother was going to say her son had a sore throat, and it told me I was going to correctly predict that his rapid strep test would be positive.

Although the ears and eyes are the pediatrician's most powerful sensors, there are a few pediatric illnesses with distinctive odors that can lead the olfactorily sensitive physician to the right diagnosis. When I check the incubator each morning, I know instantly by the smell if we have a positive urine culture growing. An 8-year-old boy's smelly armpits prompt me to examine his genitalia, even though his chief complaint is a cough.

There are the 3-year-olds with bad breath and a little trickle from one nostril whose parents are surprised when I accurately anticipate that I am going to find a smelly little treasure hidden beneath a turbinate. And I must admit that I get a bit of perverse pleasure when I see the expression on the face of a squeamish parent of a 1-week-old after I lift up a previously undisturbed umbilical cord and release an invisible fetid cloud of aroma.

Other odors can alert me to a child-unfriendly home environment. When a 3-month-old smells like an ashtray, I can skip over my standard question about someone smoking. I move forward into a thorough investigation of exactly who is smoking and when and then begin looking for a remedy. The smoky smell puts me on alert for other things about the family that will put the baby at risk.

One of the most troubling odors I have encountered is alcohol on the breath of a father who had driven his child to the office for a well-child visit. This meant confronting him and then finding his wife so that she could become the designated driver. As uncomfortable as that encounter was, it did lead to a first stab at family counseling and a trip to Alcoholics Anonymous.

My nose reminds me that I live and practice in a community with socioeconomic diversity. Although they usually try to disguise their occupational odors, sometimes people just don't have enough time to do a thorough decontamination. The cattle and dairy farmers arrive with a hint of eau de barnyard, the woodcutters with a mixture of fresh sawdust and chainsaw oil. Fathers who have had to prime balky carburetors by hand to get the old family pickup truck going show up smelling of gasoline and axle grease. The lobstermen and sardine packers may arrive smelling of fish. But fortunately, we aren't too fashion conscious here in Maine, and I must rarely endure the overdoses of designer perfume that those of you in big cities encounter.

Although some of these odors are unpleasant even in small doses, the smell that bothers me the most is that of a well-cooked meal on a family when my lunch is a distant memory and dinner is still a waiting room full of patients away.

The receptionist usually scribbles an abbreviated version of the patient's chief complaint at the top of the billing form to give me a heads-up on the diagnostic challenge awaiting me, but Sheila was still learning the job and had left the space blank. It wasn't a big deal, but it meant I was going to enter the examining room blind.

As I eased the door open, however, my nose told me everything I needed to know before my eyes met the droopy gaze of the 12-year-old slouched on the exam table. The heavy, sweet odor told me this young man's mother was going to say her son had a sore throat, and it told me I was going to correctly predict that his rapid strep test would be positive.

Although the ears and eyes are the pediatrician's most powerful sensors, there are a few pediatric illnesses with distinctive odors that can lead the olfactorily sensitive physician to the right diagnosis. When I check the incubator each morning, I know instantly by the smell if we have a positive urine culture growing. An 8-year-old boy's smelly armpits prompt me to examine his genitalia, even though his chief complaint is a cough.

There are the 3-year-olds with bad breath and a little trickle from one nostril whose parents are surprised when I accurately anticipate that I am going to find a smelly little treasure hidden beneath a turbinate. And I must admit that I get a bit of perverse pleasure when I see the expression on the face of a squeamish parent of a 1-week-old after I lift up a previously undisturbed umbilical cord and release an invisible fetid cloud of aroma.

Other odors can alert me to a child-unfriendly home environment. When a 3-month-old smells like an ashtray, I can skip over my standard question about someone smoking. I move forward into a thorough investigation of exactly who is smoking and when and then begin looking for a remedy. The smoky smell puts me on alert for other things about the family that will put the baby at risk.

One of the most troubling odors I have encountered is alcohol on the breath of a father who had driven his child to the office for a well-child visit. This meant confronting him and then finding his wife so that she could become the designated driver. As uncomfortable as that encounter was, it did lead to a first stab at family counseling and a trip to Alcoholics Anonymous.

My nose reminds me that I live and practice in a community with socioeconomic diversity. Although they usually try to disguise their occupational odors, sometimes people just don't have enough time to do a thorough decontamination. The cattle and dairy farmers arrive with a hint of eau de barnyard, the woodcutters with a mixture of fresh sawdust and chainsaw oil. Fathers who have had to prime balky carburetors by hand to get the old family pickup truck going show up smelling of gasoline and axle grease. The lobstermen and sardine packers may arrive smelling of fish. But fortunately, we aren't too fashion conscious here in Maine, and I must rarely endure the overdoses of designer perfume that those of you in big cities encounter.

Although some of these odors are unpleasant even in small doses, the smell that bothers me the most is that of a well-cooked meal on a family when my lunch is a distant memory and dinner is still a waiting room full of patients away.

The receptionist usually scribbles an abbreviated version of the patient's chief complaint at the top of the billing form to give me a heads-up on the diagnostic challenge awaiting me, but Sheila was still learning the job and had left the space blank. It wasn't a big deal, but it meant I was going to enter the examining room blind.

As I eased the door open, however, my nose told me everything I needed to know before my eyes met the droopy gaze of the 12-year-old slouched on the exam table. The heavy, sweet odor told me this young man's mother was going to say her son had a sore throat, and it told me I was going to correctly predict that his rapid strep test would be positive.

Although the ears and eyes are the pediatrician's most powerful sensors, there are a few pediatric illnesses with distinctive odors that can lead the olfactorily sensitive physician to the right diagnosis. When I check the incubator each morning, I know instantly by the smell if we have a positive urine culture growing. An 8-year-old boy's smelly armpits prompt me to examine his genitalia, even though his chief complaint is a cough.

There are the 3-year-olds with bad breath and a little trickle from one nostril whose parents are surprised when I accurately anticipate that I am going to find a smelly little treasure hidden beneath a turbinate. And I must admit that I get a bit of perverse pleasure when I see the expression on the face of a squeamish parent of a 1-week-old after I lift up a previously undisturbed umbilical cord and release an invisible fetid cloud of aroma.

Other odors can alert me to a child-unfriendly home environment. When a 3-month-old smells like an ashtray, I can skip over my standard question about someone smoking. I move forward into a thorough investigation of exactly who is smoking and when and then begin looking for a remedy. The smoky smell puts me on alert for other things about the family that will put the baby at risk.

One of the most troubling odors I have encountered is alcohol on the breath of a father who had driven his child to the office for a well-child visit. This meant confronting him and then finding his wife so that she could become the designated driver. As uncomfortable as that encounter was, it did lead to a first stab at family counseling and a trip to Alcoholics Anonymous.

My nose reminds me that I live and practice in a community with socioeconomic diversity. Although they usually try to disguise their occupational odors, sometimes people just don't have enough time to do a thorough decontamination. The cattle and dairy farmers arrive with a hint of eau de barnyard, the woodcutters with a mixture of fresh sawdust and chainsaw oil. Fathers who have had to prime balky carburetors by hand to get the old family pickup truck going show up smelling of gasoline and axle grease. The lobstermen and sardine packers may arrive smelling of fish. But fortunately, we aren't too fashion conscious here in Maine, and I must rarely endure the overdoses of designer perfume that those of you in big cities encounter.

Although some of these odors are unpleasant even in small doses, the smell that bothers me the most is that of a well-cooked meal on a family when my lunch is a distant memory and dinner is still a waiting room full of patients away.

A few weeks ago I visited my favorite otolaryngologist. He's my favorite because he doesn't cut first and ask questions later. He is also very good at explaining things to parents. Bob is about my age and had already been in practice for a couple of years when I arrived in town in 1974.

My appointment was the first and last attempt to find a treatable cause for my dwindling hearing. I have long suspected that it is simply the result of years of auditory abuse, and reading the studies documenting that most pediatricians are exposed to noise levels deemed unsafe by the standards of the Occupational Safety and Health Administration only added to my suspicions. Although I feared that my difficulty catching every word in group conversations was the inevitable audiologic equivalent of presbyopia, I was in denial. I hoped that Bob could cure the problem by removing 35 years' worth of stethoscope-compacted cerumen.

After checking in with the receptionist, I spent a few minutes in his bare-bones waiting room catching up on Hollywood gossip and chatting with one of my teenage patients, who had just recovered from a bout of sinusitis-induced septicemia. When it was my turn, Bob ushered me into his small examining room and sat me down in what could have been an old barber chair. Since neither of us is a frequent attendee at hospital staff meetings, we had lots of catching up to do. The conversation ranged from children's weddings to our painful attempts at reacquiring tennis skills that had been allowed to atrophy over the last 2 decades.

After what seemed like less than 5 minutes of banter, he paused and said, “Well, the good news is that you don't have any wax in your ears. The bad news is that I bet you'll be wanting a hearing aid in a couple of years.” He then spent 10 minutes explaining the physiologic process that was eroding my hearing and what I could do to remedy the situation. We parted with an agreement to get together for some doubles in a couple of weeks.

As I climbed back into my truck for the trip home, I wondered how Bob could sound so confident about the cause of my deafness without even looking in my ears. The examination portion of the visit had flown by so quickly that I didn't remember him using an otoscope.

As I turned onto the highway, I attempted to reconstruct our encounter. He had moved so smoothly and efficiently through the exam that my focus had been on our conversation and not his invasion into every orifice in my head. I began to recall that he had not only looked in my ears, but he had also removed a small bit of cerumen and insufflated my tympanic membranes. He had looked past my turbinates, sterilized a mirror with an alcohol lamp, and taken a peek at my vocal cords. His fingers had nimbly danced over my thyroid and all the nodes above my clavicles.

As I thought about it, I realized that Bob had done an extremely thorough head and neck exam. Because of his efficiency, which came from more than 30 years of experience and the familiar surroundings of an office where every instrument was exactly where it was supposed to be, the process had taken no more than 4 or 5 minutes. Thirty years of trial and error guided his hands to find my tympanic membranes on the first pass and locate my vocal cords without triggering my gag reflex.

In the hands of an experienced clinician, a good, focused physical exam doesn't take much time. The true test of our clinical ability is not the speed at which we have learned to perform a thorough examination but what we do with the time we have saved. Do we reinvest it in the patient we have just examined by conveying to them what we have discovered in a manner that says we care? Or do we use the time we have gained through our efficiency to rush on to the next patient? Fortunately for me, Bob has chosen to do the former, and that's another reason he's my favorite.

A few weeks ago I visited my favorite otolaryngologist. He's my favorite because he doesn't cut first and ask questions later. He is also very good at explaining things to parents. Bob is about my age and had already been in practice for a couple of years when I arrived in town in 1974.

My appointment was the first and last attempt to find a treatable cause for my dwindling hearing. I have long suspected that it is simply the result of years of auditory abuse, and reading the studies documenting that most pediatricians are exposed to noise levels deemed unsafe by the standards of the Occupational Safety and Health Administration only added to my suspicions. Although I feared that my difficulty catching every word in group conversations was the inevitable audiologic equivalent of presbyopia, I was in denial. I hoped that Bob could cure the problem by removing 35 years' worth of stethoscope-compacted cerumen.

After checking in with the receptionist, I spent a few minutes in his bare-bones waiting room catching up on Hollywood gossip and chatting with one of my teenage patients, who had just recovered from a bout of sinusitis-induced septicemia. When it was my turn, Bob ushered me into his small examining room and sat me down in what could have been an old barber chair. Since neither of us is a frequent attendee at hospital staff meetings, we had lots of catching up to do. The conversation ranged from children's weddings to our painful attempts at reacquiring tennis skills that had been allowed to atrophy over the last 2 decades.

After what seemed like less than 5 minutes of banter, he paused and said, “Well, the good news is that you don't have any wax in your ears. The bad news is that I bet you'll be wanting a hearing aid in a couple of years.” He then spent 10 minutes explaining the physiologic process that was eroding my hearing and what I could do to remedy the situation. We parted with an agreement to get together for some doubles in a couple of weeks.

As I climbed back into my truck for the trip home, I wondered how Bob could sound so confident about the cause of my deafness without even looking in my ears. The examination portion of the visit had flown by so quickly that I didn't remember him using an otoscope.

As I turned onto the highway, I attempted to reconstruct our encounter. He had moved so smoothly and efficiently through the exam that my focus had been on our conversation and not his invasion into every orifice in my head. I began to recall that he had not only looked in my ears, but he had also removed a small bit of cerumen and insufflated my tympanic membranes. He had looked past my turbinates, sterilized a mirror with an alcohol lamp, and taken a peek at my vocal cords. His fingers had nimbly danced over my thyroid and all the nodes above my clavicles.

As I thought about it, I realized that Bob had done an extremely thorough head and neck exam. Because of his efficiency, which came from more than 30 years of experience and the familiar surroundings of an office where every instrument was exactly where it was supposed to be, the process had taken no more than 4 or 5 minutes. Thirty years of trial and error guided his hands to find my tympanic membranes on the first pass and locate my vocal cords without triggering my gag reflex.

In the hands of an experienced clinician, a good, focused physical exam doesn't take much time. The true test of our clinical ability is not the speed at which we have learned to perform a thorough examination but what we do with the time we have saved. Do we reinvest it in the patient we have just examined by conveying to them what we have discovered in a manner that says we care? Or do we use the time we have gained through our efficiency to rush on to the next patient? Fortunately for me, Bob has chosen to do the former, and that's another reason he's my favorite.

A few weeks ago I visited my favorite otolaryngologist. He's my favorite because he doesn't cut first and ask questions later. He is also very good at explaining things to parents. Bob is about my age and had already been in practice for a couple of years when I arrived in town in 1974.

My appointment was the first and last attempt to find a treatable cause for my dwindling hearing. I have long suspected that it is simply the result of years of auditory abuse, and reading the studies documenting that most pediatricians are exposed to noise levels deemed unsafe by the standards of the Occupational Safety and Health Administration only added to my suspicions. Although I feared that my difficulty catching every word in group conversations was the inevitable audiologic equivalent of presbyopia, I was in denial. I hoped that Bob could cure the problem by removing 35 years' worth of stethoscope-compacted cerumen.

After checking in with the receptionist, I spent a few minutes in his bare-bones waiting room catching up on Hollywood gossip and chatting with one of my teenage patients, who had just recovered from a bout of sinusitis-induced septicemia. When it was my turn, Bob ushered me into his small examining room and sat me down in what could have been an old barber chair. Since neither of us is a frequent attendee at hospital staff meetings, we had lots of catching up to do. The conversation ranged from children's weddings to our painful attempts at reacquiring tennis skills that had been allowed to atrophy over the last 2 decades.

After what seemed like less than 5 minutes of banter, he paused and said, “Well, the good news is that you don't have any wax in your ears. The bad news is that I bet you'll be wanting a hearing aid in a couple of years.” He then spent 10 minutes explaining the physiologic process that was eroding my hearing and what I could do to remedy the situation. We parted with an agreement to get together for some doubles in a couple of weeks.

As I climbed back into my truck for the trip home, I wondered how Bob could sound so confident about the cause of my deafness without even looking in my ears. The examination portion of the visit had flown by so quickly that I didn't remember him using an otoscope.

As I turned onto the highway, I attempted to reconstruct our encounter. He had moved so smoothly and efficiently through the exam that my focus had been on our conversation and not his invasion into every orifice in my head. I began to recall that he had not only looked in my ears, but he had also removed a small bit of cerumen and insufflated my tympanic membranes. He had looked past my turbinates, sterilized a mirror with an alcohol lamp, and taken a peek at my vocal cords. His fingers had nimbly danced over my thyroid and all the nodes above my clavicles.

As I thought about it, I realized that Bob had done an extremely thorough head and neck exam. Because of his efficiency, which came from more than 30 years of experience and the familiar surroundings of an office where every instrument was exactly where it was supposed to be, the process had taken no more than 4 or 5 minutes. Thirty years of trial and error guided his hands to find my tympanic membranes on the first pass and locate my vocal cords without triggering my gag reflex.

In the hands of an experienced clinician, a good, focused physical exam doesn't take much time. The true test of our clinical ability is not the speed at which we have learned to perform a thorough examination but what we do with the time we have saved. Do we reinvest it in the patient we have just examined by conveying to them what we have discovered in a manner that says we care? Or do we use the time we have gained through our efficiency to rush on to the next patient? Fortunately for me, Bob has chosen to do the former, and that's another reason he's my favorite.

One day last week, I forgot my key to the back door of the office and was forced to enter through the main entrance. As I passed the sign that stands out front, I noticed that more than 2 decades of sun and snow had taken a toll on my shingle.

Someone less enthusiastic about practicing pediatrics might interpret the fading and flaking of his name as a signal that it is time to hang up his stethoscope, but such is not the case for me. Rather, I viewed the decay as an opportunity to update my image and do some marketing.

Even when it was new, the black-on-white “William G. Wilkoff, M.D.—Pediatrics” just didn't have enough pizzazz. It's time for a bolder step. Color? A logo, perhaps? Something that says, “This guy is up to speed.” But what to choose? A caduceus is too traditional, and the snake might scare some of the toddlers. Brightly colored balloons or an arrangement of dolls and toy trucks would offend the preteens who now constitute the biggest cohort in my practice.

No, a logo isn't going to work. What I need is a few well-chosen words that will accurately describe me to the families who are looking for a new pediatrician. “Older but Wiser” pops into mind, but that would conflict with my plan to create a younger, more vital image. “Evidence-Based Medicine” has a very professional ring, but I'm afraid that I might be mistaken for a forensic pathologist.

What about “Holistic Medicine”? I've seen those words on a lot of shingles lately, but I'm never sure what they mean. Would I have to change my practice style? What exactly is a holistic physician doing that I'm not already doing?

I was trained to consider patients as people with emotions, families, and religious beliefs. I have learned to treat minds and bodies as single units. When a high school soccer player sprains his ankle, I examine both of his lower extremities and ask how I can help him deal with the anger and disappointment of having to miss the first game of the playoffs.

I consider the whole family when I am seeing a child, because I know that children of depressed mothers and unemployed fathers are more likely to have belly pain and headaches. I'm careful not to impose my own religious views on patients, but I encourage families to include faith-based resources in their search for solutions.

I support families who are searching for safe alternative therapies such as acupuncture, but if holistic means that I must embrace every unsubstantiated remedy that comes down the pike, I guess I'm not worthy of the label.

So here I am, back at square one, with a rotting shingle that isn't going to make it through another winter. I can't find a new-millennium label that fits, and a glitzy logo isn't going to work. I guess I'll just have to stick with the same old, same old. But since the guy who's going to paint the sign is charging me by the letter, I'll make one change. “Will Wilkoff, M.D.—Pediatrics.” It's four letters shorter, and it says it all.

One day last week, I forgot my key to the back door of the office and was forced to enter through the main entrance. As I passed the sign that stands out front, I noticed that more than 2 decades of sun and snow had taken a toll on my shingle.

Someone less enthusiastic about practicing pediatrics might interpret the fading and flaking of his name as a signal that it is time to hang up his stethoscope, but such is not the case for me. Rather, I viewed the decay as an opportunity to update my image and do some marketing.

Even when it was new, the black-on-white “William G. Wilkoff, M.D.—Pediatrics” just didn't have enough pizzazz. It's time for a bolder step. Color? A logo, perhaps? Something that says, “This guy is up to speed.” But what to choose? A caduceus is too traditional, and the snake might scare some of the toddlers. Brightly colored balloons or an arrangement of dolls and toy trucks would offend the preteens who now constitute the biggest cohort in my practice.

No, a logo isn't going to work. What I need is a few well-chosen words that will accurately describe me to the families who are looking for a new pediatrician. “Older but Wiser” pops into mind, but that would conflict with my plan to create a younger, more vital image. “Evidence-Based Medicine” has a very professional ring, but I'm afraid that I might be mistaken for a forensic pathologist.

What about “Holistic Medicine”? I've seen those words on a lot of shingles lately, but I'm never sure what they mean. Would I have to change my practice style? What exactly is a holistic physician doing that I'm not already doing?

I was trained to consider patients as people with emotions, families, and religious beliefs. I have learned to treat minds and bodies as single units. When a high school soccer player sprains his ankle, I examine both of his lower extremities and ask how I can help him deal with the anger and disappointment of having to miss the first game of the playoffs.

I consider the whole family when I am seeing a child, because I know that children of depressed mothers and unemployed fathers are more likely to have belly pain and headaches. I'm careful not to impose my own religious views on patients, but I encourage families to include faith-based resources in their search for solutions.

I support families who are searching for safe alternative therapies such as acupuncture, but if holistic means that I must embrace every unsubstantiated remedy that comes down the pike, I guess I'm not worthy of the label.

So here I am, back at square one, with a rotting shingle that isn't going to make it through another winter. I can't find a new-millennium label that fits, and a glitzy logo isn't going to work. I guess I'll just have to stick with the same old, same old. But since the guy who's going to paint the sign is charging me by the letter, I'll make one change. “Will Wilkoff, M.D.—Pediatrics.” It's four letters shorter, and it says it all.

One day last week, I forgot my key to the back door of the office and was forced to enter through the main entrance. As I passed the sign that stands out front, I noticed that more than 2 decades of sun and snow had taken a toll on my shingle.

Someone less enthusiastic about practicing pediatrics might interpret the fading and flaking of his name as a signal that it is time to hang up his stethoscope, but such is not the case for me. Rather, I viewed the decay as an opportunity to update my image and do some marketing.

Even when it was new, the black-on-white “William G. Wilkoff, M.D.—Pediatrics” just didn't have enough pizzazz. It's time for a bolder step. Color? A logo, perhaps? Something that says, “This guy is up to speed.” But what to choose? A caduceus is too traditional, and the snake might scare some of the toddlers. Brightly colored balloons or an arrangement of dolls and toy trucks would offend the preteens who now constitute the biggest cohort in my practice.

No, a logo isn't going to work. What I need is a few well-chosen words that will accurately describe me to the families who are looking for a new pediatrician. “Older but Wiser” pops into mind, but that would conflict with my plan to create a younger, more vital image. “Evidence-Based Medicine” has a very professional ring, but I'm afraid that I might be mistaken for a forensic pathologist.

What about “Holistic Medicine”? I've seen those words on a lot of shingles lately, but I'm never sure what they mean. Would I have to change my practice style? What exactly is a holistic physician doing that I'm not already doing?

I was trained to consider patients as people with emotions, families, and religious beliefs. I have learned to treat minds and bodies as single units. When a high school soccer player sprains his ankle, I examine both of his lower extremities and ask how I can help him deal with the anger and disappointment of having to miss the first game of the playoffs.

I consider the whole family when I am seeing a child, because I know that children of depressed mothers and unemployed fathers are more likely to have belly pain and headaches. I'm careful not to impose my own religious views on patients, but I encourage families to include faith-based resources in their search for solutions.

I support families who are searching for safe alternative therapies such as acupuncture, but if holistic means that I must embrace every unsubstantiated remedy that comes down the pike, I guess I'm not worthy of the label.

So here I am, back at square one, with a rotting shingle that isn't going to make it through another winter. I can't find a new-millennium label that fits, and a glitzy logo isn't going to work. I guess I'll just have to stick with the same old, same old. But since the guy who's going to paint the sign is charging me by the letter, I'll make one change. “Will Wilkoff, M.D.—Pediatrics.” It's four letters shorter, and it says it all.

Research that agrees with my anecdotal observations and supports my nonconforming practices always warms my heart, so the lead article in the December issue of Pediatrics really got my old cockles cooking.

After carefully evaluating 42 preventive interventions recommended by at least two national organizations concerned with child health, the investigators concluded that “limited direct evidence was found to support” these recommendations. So many interventions have been recommended and mandated, they also observed, that implementation of an unsupported recommendation by pediatricians could actually be harmful because it may displace “other beneficial activities” (Pediatrics 2004;114:1511–21).

What a bold and long overdue observation. Over the past 30 years, well-meaning groups from every nook and cranny of the child-oriented world have recommended that we pediatricians invest our hard-earned reputations and precious time promoting their pet ventures. It's time for us to say, “Whoa! Let's see if what you're asking us to do works.”

Even if the majority of these recommendations were well supported, their overwhelming volume would make implementation impossible even by the most efficient practitioner. When unproven interventions become mandated by state laws and regulations, those of us who dare to ignore them are vulnerable to financial penalties and, even worse, professional censure.

Obviously, this situation represents a serious challenge to our profession. We must demand that, regardless how valid they sound, all recommended interventions be evidence based.

Good research takes time, though, particularly when some of the outcomes may not be measurable until our patients reach adulthood. So what should we front-liners do for the next few decades while the researchers are gathering the evidence?

We must change our attitude toward well-child care. Health maintenance visits should be parent- and patient-driven. For too long, we and the committees that coach us have been writing the agendas for these visits.

This paternalistic attitude ignores the basic truth that our patients and their parents know best what is troubling them. Occasionally, we may need to help them articulate and focus their concerns, but it is the families and not the committees that should be writing the script for well-child visits. It's time for us to slide out from behind the steering wheel and begin riding shotgun. From our new seat on the passenger's side, we must keep our eyes on the road ahead and be prepared to warn parents when we see potholes in the path they have chosen.

We must replace our committee-driven interventions with open-ended questions that signal to parents that we are concerned about what concerns them. Then we must patiently wait for their answers. Instead of asking every family if they keep a gun in the house, we must become experts at reading body language and listening to the answers of simple questions like, “How are things going? Is your baby happy? Are you happy?” Dialogues that build on these open-ended questions will create the framework of a more valuable well-child visit.

If the parent is experienced and voices no concerns when offered the opportunity to express them, the visit may last just long enough for a good exam (though we may even find that part unnecessary) and some immunizations.

On the other hand, our apparent willingness to listen may encourage the depressed mother of a toddler to share her secret that she has been abusing the child. A well-child visit cannot be a one-size-fits-all event fabricated from a collection of committee-made parts.

We must acknowledge that the most important component of well-child care doesn't occur during the health maintenance visit. The three critical elements in keeping a child healthy are availability, availability, and availability. Parents already believe that pediatricians know a lot about children. Our challenge is to demonstrate that we care about their concerns and are eager to answer their questions not just at well-child visits, but at any time. An illness can be an excellent opportunity to get to know more about the patient and his family and to make it clear that we are good and concerned listeners.

It sounds like the medical home is the answer again.

Research that agrees with my anecdotal observations and supports my nonconforming practices always warms my heart, so the lead article in the December issue of Pediatrics really got my old cockles cooking.

After carefully evaluating 42 preventive interventions recommended by at least two national organizations concerned with child health, the investigators concluded that “limited direct evidence was found to support” these recommendations. So many interventions have been recommended and mandated, they also observed, that implementation of an unsupported recommendation by pediatricians could actually be harmful because it may displace “other beneficial activities” (Pediatrics 2004;114:1511–21).

What a bold and long overdue observation. Over the past 30 years, well-meaning groups from every nook and cranny of the child-oriented world have recommended that we pediatricians invest our hard-earned reputations and precious time promoting their pet ventures. It's time for us to say, “Whoa! Let's see if what you're asking us to do works.”

Even if the majority of these recommendations were well supported, their overwhelming volume would make implementation impossible even by the most efficient practitioner. When unproven interventions become mandated by state laws and regulations, those of us who dare to ignore them are vulnerable to financial penalties and, even worse, professional censure.

Obviously, this situation represents a serious challenge to our profession. We must demand that, regardless how valid they sound, all recommended interventions be evidence based.

Good research takes time, though, particularly when some of the outcomes may not be measurable until our patients reach adulthood. So what should we front-liners do for the next few decades while the researchers are gathering the evidence?

We must change our attitude toward well-child care. Health maintenance visits should be parent- and patient-driven. For too long, we and the committees that coach us have been writing the agendas for these visits.

This paternalistic attitude ignores the basic truth that our patients and their parents know best what is troubling them. Occasionally, we may need to help them articulate and focus their concerns, but it is the families and not the committees that should be writing the script for well-child visits. It's time for us to slide out from behind the steering wheel and begin riding shotgun. From our new seat on the passenger's side, we must keep our eyes on the road ahead and be prepared to warn parents when we see potholes in the path they have chosen.

We must replace our committee-driven interventions with open-ended questions that signal to parents that we are concerned about what concerns them. Then we must patiently wait for their answers. Instead of asking every family if they keep a gun in the house, we must become experts at reading body language and listening to the answers of simple questions like, “How are things going? Is your baby happy? Are you happy?” Dialogues that build on these open-ended questions will create the framework of a more valuable well-child visit.

If the parent is experienced and voices no concerns when offered the opportunity to express them, the visit may last just long enough for a good exam (though we may even find that part unnecessary) and some immunizations.

On the other hand, our apparent willingness to listen may encourage the depressed mother of a toddler to share her secret that she has been abusing the child. A well-child visit cannot be a one-size-fits-all event fabricated from a collection of committee-made parts.

We must acknowledge that the most important component of well-child care doesn't occur during the health maintenance visit. The three critical elements in keeping a child healthy are availability, availability, and availability. Parents already believe that pediatricians know a lot about children. Our challenge is to demonstrate that we care about their concerns and are eager to answer their questions not just at well-child visits, but at any time. An illness can be an excellent opportunity to get to know more about the patient and his family and to make it clear that we are good and concerned listeners.

It sounds like the medical home is the answer again.

Research that agrees with my anecdotal observations and supports my nonconforming practices always warms my heart, so the lead article in the December issue of Pediatrics really got my old cockles cooking.

After carefully evaluating 42 preventive interventions recommended by at least two national organizations concerned with child health, the investigators concluded that “limited direct evidence was found to support” these recommendations. So many interventions have been recommended and mandated, they also observed, that implementation of an unsupported recommendation by pediatricians could actually be harmful because it may displace “other beneficial activities” (Pediatrics 2004;114:1511–21).

What a bold and long overdue observation. Over the past 30 years, well-meaning groups from every nook and cranny of the child-oriented world have recommended that we pediatricians invest our hard-earned reputations and precious time promoting their pet ventures. It's time for us to say, “Whoa! Let's see if what you're asking us to do works.”

Even if the majority of these recommendations were well supported, their overwhelming volume would make implementation impossible even by the most efficient practitioner. When unproven interventions become mandated by state laws and regulations, those of us who dare to ignore them are vulnerable to financial penalties and, even worse, professional censure.

Obviously, this situation represents a serious challenge to our profession. We must demand that, regardless how valid they sound, all recommended interventions be evidence based.

Good research takes time, though, particularly when some of the outcomes may not be measurable until our patients reach adulthood. So what should we front-liners do for the next few decades while the researchers are gathering the evidence?

We must change our attitude toward well-child care. Health maintenance visits should be parent- and patient-driven. For too long, we and the committees that coach us have been writing the agendas for these visits.

This paternalistic attitude ignores the basic truth that our patients and their parents know best what is troubling them. Occasionally, we may need to help them articulate and focus their concerns, but it is the families and not the committees that should be writing the script for well-child visits. It's time for us to slide out from behind the steering wheel and begin riding shotgun. From our new seat on the passenger's side, we must keep our eyes on the road ahead and be prepared to warn parents when we see potholes in the path they have chosen.

We must replace our committee-driven interventions with open-ended questions that signal to parents that we are concerned about what concerns them. Then we must patiently wait for their answers. Instead of asking every family if they keep a gun in the house, we must become experts at reading body language and listening to the answers of simple questions like, “How are things going? Is your baby happy? Are you happy?” Dialogues that build on these open-ended questions will create the framework of a more valuable well-child visit.

If the parent is experienced and voices no concerns when offered the opportunity to express them, the visit may last just long enough for a good exam (though we may even find that part unnecessary) and some immunizations.

On the other hand, our apparent willingness to listen may encourage the depressed mother of a toddler to share her secret that she has been abusing the child. A well-child visit cannot be a one-size-fits-all event fabricated from a collection of committee-made parts.

We must acknowledge that the most important component of well-child care doesn't occur during the health maintenance visit. The three critical elements in keeping a child healthy are availability, availability, and availability. Parents already believe that pediatricians know a lot about children. Our challenge is to demonstrate that we care about their concerns and are eager to answer their questions not just at well-child visits, but at any time. An illness can be an excellent opportunity to get to know more about the patient and his family and to make it clear that we are good and concerned listeners.

It sounds like the medical home is the answer again.

As the garage door creaked up over my head, the rain promised for the afternoon began falling on the driveway in large heavy plops a good 5 hours ahead of schedule.

I muttered my favorite expletive and walked my old red bicycle back to her resting place against the trash cans. Returning to the mud room, I fumbled in the dark reaches of the sports-paraphernalia closet for an umbrella and then headed to work on foot. This minor meteorologic miscalculation would triple my commute time to 12 minutes, but I would still arrive well before our office's promised 8:30 call-in time.

As I strolled through the middle-class neighborhoods that border the office, I reflected on the group-wide provider meeting of the previous night. Some of the physicians clearly were discontented. Surprisingly, no one complained about the flatness of their income curves. Instead, time dominated their concerns. Did the group really need to continue offering evening and weekend office hours? The “less-contents” felt that office commitments were gobbling up the time they had hoped to spend with their families.

Splashing around and occasionally through the rapidly expanding puddles, I pondered the factors that sorted out the contents from the less-contents. One seemed to be commuting time. If I visualized a graph that plotted discontent against distance from the office, the relationship was almost linear. The longer a provider's commute, the less content he or she seemed to be.

Although many of us complain about our trips to and from work, I am surprised how few commuters accurately estimate the negative impact that travel time has on their lives and their families. A long commute at the end of the day often triggers a cascade of unfortunate dominos that can include a late dinner, an inadequate or nonexistent period of family reconnection, and an unhealthfully late bedtime for both child and parent.

The vicious cycle continues in the morning, when the sleep-deprived commuter must arise early enough to make it back to work on time. The relationship between sleep deprivation and accidents has received a bit more media attention recently, but sleeplessness continues to be a vastly underappreciated contributor to depression, headaches, and behavior problems, such as attention deficit hyperactivity disorder.

A physician who lives “only” 35 minutes from her office has an hour less each day to spend with her young children than I did. That adds up to an entire 24-hour day each month. In addition, she probably doesn't have the opportunity to zip home at lunch time to play with her toddlers before they go down for a nap the way I did. Those little noontime reconnections can make evening office hours much more palatable.

Unlike lawyers, who seem to be able to bill for their travel time, those of us in primary care have trouble making our commutes productive. Walking or bicycling to work can be counted as fitness maintenance time, and listening to educational tapes can earn us a few CME credits, but, for the most part, trips to and from the office feel like a waste of time.

Finding a place to live close to one's office can be difficult, and for those who choose to serve seriously underprivileged families, it may be impossible, but I wish that more of us would reconsider the advantages of shortening our commutes. No one is going to step forward and give us more time with our families. We have to make that time, and that may require renegotiating some of the compromises we have made with ourselves about where we live.

You can make any house a home, but you have to be there to do it. Regardless of how nice the house is when you finally arrive, it's hard to turn a long commute into anything but an exercise in frustration.

As the garage door creaked up over my head, the rain promised for the afternoon began falling on the driveway in large heavy plops a good 5 hours ahead of schedule.

I muttered my favorite expletive and walked my old red bicycle back to her resting place against the trash cans. Returning to the mud room, I fumbled in the dark reaches of the sports-paraphernalia closet for an umbrella and then headed to work on foot. This minor meteorologic miscalculation would triple my commute time to 12 minutes, but I would still arrive well before our office's promised 8:30 call-in time.

As I strolled through the middle-class neighborhoods that border the office, I reflected on the group-wide provider meeting of the previous night. Some of the physicians clearly were discontented. Surprisingly, no one complained about the flatness of their income curves. Instead, time dominated their concerns. Did the group really need to continue offering evening and weekend office hours? The “less-contents” felt that office commitments were gobbling up the time they had hoped to spend with their families.

Splashing around and occasionally through the rapidly expanding puddles, I pondered the factors that sorted out the contents from the less-contents. One seemed to be commuting time. If I visualized a graph that plotted discontent against distance from the office, the relationship was almost linear. The longer a provider's commute, the less content he or she seemed to be.

Although many of us complain about our trips to and from work, I am surprised how few commuters accurately estimate the negative impact that travel time has on their lives and their families. A long commute at the end of the day often triggers a cascade of unfortunate dominos that can include a late dinner, an inadequate or nonexistent period of family reconnection, and an unhealthfully late bedtime for both child and parent.

The vicious cycle continues in the morning, when the sleep-deprived commuter must arise early enough to make it back to work on time. The relationship between sleep deprivation and accidents has received a bit more media attention recently, but sleeplessness continues to be a vastly underappreciated contributor to depression, headaches, and behavior problems, such as attention deficit hyperactivity disorder.

A physician who lives “only” 35 minutes from her office has an hour less each day to spend with her young children than I did. That adds up to an entire 24-hour day each month. In addition, she probably doesn't have the opportunity to zip home at lunch time to play with her toddlers before they go down for a nap the way I did. Those little noontime reconnections can make evening office hours much more palatable.

Unlike lawyers, who seem to be able to bill for their travel time, those of us in primary care have trouble making our commutes productive. Walking or bicycling to work can be counted as fitness maintenance time, and listening to educational tapes can earn us a few CME credits, but, for the most part, trips to and from the office feel like a waste of time.

Finding a place to live close to one's office can be difficult, and for those who choose to serve seriously underprivileged families, it may be impossible, but I wish that more of us would reconsider the advantages of shortening our commutes. No one is going to step forward and give us more time with our families. We have to make that time, and that may require renegotiating some of the compromises we have made with ourselves about where we live.

You can make any house a home, but you have to be there to do it. Regardless of how nice the house is when you finally arrive, it's hard to turn a long commute into anything but an exercise in frustration.

As the garage door creaked up over my head, the rain promised for the afternoon began falling on the driveway in large heavy plops a good 5 hours ahead of schedule.

I muttered my favorite expletive and walked my old red bicycle back to her resting place against the trash cans. Returning to the mud room, I fumbled in the dark reaches of the sports-paraphernalia closet for an umbrella and then headed to work on foot. This minor meteorologic miscalculation would triple my commute time to 12 minutes, but I would still arrive well before our office's promised 8:30 call-in time.

As I strolled through the middle-class neighborhoods that border the office, I reflected on the group-wide provider meeting of the previous night. Some of the physicians clearly were discontented. Surprisingly, no one complained about the flatness of their income curves. Instead, time dominated their concerns. Did the group really need to continue offering evening and weekend office hours? The “less-contents” felt that office commitments were gobbling up the time they had hoped to spend with their families.

Splashing around and occasionally through the rapidly expanding puddles, I pondered the factors that sorted out the contents from the less-contents. One seemed to be commuting time. If I visualized a graph that plotted discontent against distance from the office, the relationship was almost linear. The longer a provider's commute, the less content he or she seemed to be.

Although many of us complain about our trips to and from work, I am surprised how few commuters accurately estimate the negative impact that travel time has on their lives and their families. A long commute at the end of the day often triggers a cascade of unfortunate dominos that can include a late dinner, an inadequate or nonexistent period of family reconnection, and an unhealthfully late bedtime for both child and parent.

The vicious cycle continues in the morning, when the sleep-deprived commuter must arise early enough to make it back to work on time. The relationship between sleep deprivation and accidents has received a bit more media attention recently, but sleeplessness continues to be a vastly underappreciated contributor to depression, headaches, and behavior problems, such as attention deficit hyperactivity disorder.

A physician who lives “only” 35 minutes from her office has an hour less each day to spend with her young children than I did. That adds up to an entire 24-hour day each month. In addition, she probably doesn't have the opportunity to zip home at lunch time to play with her toddlers before they go down for a nap the way I did. Those little noontime reconnections can make evening office hours much more palatable.

Unlike lawyers, who seem to be able to bill for their travel time, those of us in primary care have trouble making our commutes productive. Walking or bicycling to work can be counted as fitness maintenance time, and listening to educational tapes can earn us a few CME credits, but, for the most part, trips to and from the office feel like a waste of time.

Finding a place to live close to one's office can be difficult, and for those who choose to serve seriously underprivileged families, it may be impossible, but I wish that more of us would reconsider the advantages of shortening our commutes. No one is going to step forward and give us more time with our families. We have to make that time, and that may require renegotiating some of the compromises we have made with ourselves about where we live.

You can make any house a home, but you have to be there to do it. Regardless of how nice the house is when you finally arrive, it's hard to turn a long commute into anything but an exercise in frustration.