William G. Wilkoff, MD

 

It rolls off your tongue so easily. See-one, do-one, teach-one has been the mantra recited to doctors-in-training for hundreds of years. It purports to characterize the process by which technical skills are passed from one generation of physicians to the next. However, you know as well as I do that the process of learning a skill such as performing a lumbar puncture on a squirming 6-month-old almost never conforms to the see-one, do-one, teach-one dictum.

Although I recall that it was not until my 7th birthday that I could consistently and confidently tie my own shoes, I consider myself reasonably dexterous. As a woodcarver, I was comfortable around sharp instruments, but that comfort zone quickly disappeared when it came to poking and cutting another human being who had nerves and blood vessels.

Even though the procedure may have looked effortless and easy in the hands of my instructors, when it came time for me to begin the do-one part of the process, the sweat began flowing from every pore on my body. I still had enough ego left to deal with the high likelihood of failure. But, how much damage and pain was I going to inflict on the unfortunate patient during my failed attempt or, more likely, multiple attempts? Where did that “at first do no harm” thing fit in here? Shouldn’t there really be a “try some” in middle of that training mantra? And that raises the question of, How many is “some”?

In a Pediatric Perspective in the June 2017 issue of Pediatrics, two anesthesiologists at Texas Children’s Hospital in Houston and the Children’s Hospital of Philadelphia address that question of, How many tries is reasonable for a physician attempting to learn a new technique (“When Should Trainees Call for Help with Invasive Procedures?” Pediatrics. 2017, June. doi: 10.1542/peds.2016-3673)? They illustrate their insightful discussion with the gruesome image of the wrist of an infant who had endured 21 attempts at percutaneous arterial line placement.

In addition to direct supervision, the authors recommend that instructors engage the trainee in a preprocedure discussion that includes setting a predetermined number of unsuccessful attempts at which the trainee will stop and ask for help. They suggest that the “trainee should be taught the self-insight to summon a more experienced provider or perhaps just a fresh pair of hands.”

For the general pediatrician or family physician, many of the technical skills we learned in training are likely to fade from disuse in the real world of office practice. However, learning when and how to step back in the face of multiple failures is a skill that every physician will continue to use regardless of where he or she is on his or her professional trajectory.

It isn’t always easy. It challenges our egos to ask for help when we have failed at making the diagnosis or not chosen the most effective therapy. At a minimum, stepping back and taking a deep breath (or three) may allow us a window through which we can finally see outside the box we find ourselves in.

Persistence is an attribute that allowed us to navigate the long and challenging path of our medical education. But, there are situations when it gets in the way of good medical care.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

 

It rolls off your tongue so easily. See-one, do-one, teach-one has been the mantra recited to doctors-in-training for hundreds of years. It purports to characterize the process by which technical skills are passed from one generation of physicians to the next. However, you know as well as I do that the process of learning a skill such as performing a lumbar puncture on a squirming 6-month-old almost never conforms to the see-one, do-one, teach-one dictum.

Although I recall that it was not until my 7th birthday that I could consistently and confidently tie my own shoes, I consider myself reasonably dexterous. As a woodcarver, I was comfortable around sharp instruments, but that comfort zone quickly disappeared when it came to poking and cutting another human being who had nerves and blood vessels.

Even though the procedure may have looked effortless and easy in the hands of my instructors, when it came time for me to begin the do-one part of the process, the sweat began flowing from every pore on my body. I still had enough ego left to deal with the high likelihood of failure. But, how much damage and pain was I going to inflict on the unfortunate patient during my failed attempt or, more likely, multiple attempts? Where did that “at first do no harm” thing fit in here? Shouldn’t there really be a “try some” in middle of that training mantra? And that raises the question of, How many is “some”?

In a Pediatric Perspective in the June 2017 issue of Pediatrics, two anesthesiologists at Texas Children’s Hospital in Houston and the Children’s Hospital of Philadelphia address that question of, How many tries is reasonable for a physician attempting to learn a new technique (“When Should Trainees Call for Help with Invasive Procedures?” Pediatrics. 2017, June. doi: 10.1542/peds.2016-3673)? They illustrate their insightful discussion with the gruesome image of the wrist of an infant who had endured 21 attempts at percutaneous arterial line placement.

In addition to direct supervision, the authors recommend that instructors engage the trainee in a preprocedure discussion that includes setting a predetermined number of unsuccessful attempts at which the trainee will stop and ask for help. They suggest that the “trainee should be taught the self-insight to summon a more experienced provider or perhaps just a fresh pair of hands.”

For the general pediatrician or family physician, many of the technical skills we learned in training are likely to fade from disuse in the real world of office practice. However, learning when and how to step back in the face of multiple failures is a skill that every physician will continue to use regardless of where he or she is on his or her professional trajectory.

It isn’t always easy. It challenges our egos to ask for help when we have failed at making the diagnosis or not chosen the most effective therapy. At a minimum, stepping back and taking a deep breath (or three) may allow us a window through which we can finally see outside the box we find ourselves in.

Persistence is an attribute that allowed us to navigate the long and challenging path of our medical education. But, there are situations when it gets in the way of good medical care.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

 

It rolls off your tongue so easily. See-one, do-one, teach-one has been the mantra recited to doctors-in-training for hundreds of years. It purports to characterize the process by which technical skills are passed from one generation of physicians to the next. However, you know as well as I do that the process of learning a skill such as performing a lumbar puncture on a squirming 6-month-old almost never conforms to the see-one, do-one, teach-one dictum.

Although I recall that it was not until my 7th birthday that I could consistently and confidently tie my own shoes, I consider myself reasonably dexterous. As a woodcarver, I was comfortable around sharp instruments, but that comfort zone quickly disappeared when it came to poking and cutting another human being who had nerves and blood vessels.

Even though the procedure may have looked effortless and easy in the hands of my instructors, when it came time for me to begin the do-one part of the process, the sweat began flowing from every pore on my body. I still had enough ego left to deal with the high likelihood of failure. But, how much damage and pain was I going to inflict on the unfortunate patient during my failed attempt or, more likely, multiple attempts? Where did that “at first do no harm” thing fit in here? Shouldn’t there really be a “try some” in middle of that training mantra? And that raises the question of, How many is “some”?

In a Pediatric Perspective in the June 2017 issue of Pediatrics, two anesthesiologists at Texas Children’s Hospital in Houston and the Children’s Hospital of Philadelphia address that question of, How many tries is reasonable for a physician attempting to learn a new technique (“When Should Trainees Call for Help with Invasive Procedures?” Pediatrics. 2017, June. doi: 10.1542/peds.2016-3673)? They illustrate their insightful discussion with the gruesome image of the wrist of an infant who had endured 21 attempts at percutaneous arterial line placement.

In addition to direct supervision, the authors recommend that instructors engage the trainee in a preprocedure discussion that includes setting a predetermined number of unsuccessful attempts at which the trainee will stop and ask for help. They suggest that the “trainee should be taught the self-insight to summon a more experienced provider or perhaps just a fresh pair of hands.”

For the general pediatrician or family physician, many of the technical skills we learned in training are likely to fade from disuse in the real world of office practice. However, learning when and how to step back in the face of multiple failures is a skill that every physician will continue to use regardless of where he or she is on his or her professional trajectory.

It isn’t always easy. It challenges our egos to ask for help when we have failed at making the diagnosis or not chosen the most effective therapy. At a minimum, stepping back and taking a deep breath (or three) may allow us a window through which we can finally see outside the box we find ourselves in.

Persistence is an attribute that allowed us to navigate the long and challenging path of our medical education. But, there are situations when it gets in the way of good medical care.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

 

The headline in a Portland, Maine, newspaper read, “Standish man sentenced to serve 15 years in prison for death of his 3-month-old son” (Edward Murphy, May 23, 2017). I suspect that many of the folks who read the story under the headline feel that the sentence was too light. Others are asking themselves how a 21-year-old man could beat a fragile 5-pound infant to death. What kind of evil monster is this guy?

However, even with the snatches of information provided in the 500-word newspaper story, the unfortunate scenario makes sense, and the child’s death is a tragic culmination of a series of events that shouldn’t surprise any pediatrician. It turns out the infant was a twin who, with his sister, had been born at 30 weeks’ gestation. He had spent a month or more in the hospital, and his sister was still in neonatal ICU at the time of his death. While it is unclear from the newspaper article whether the twins’ parents were married, they were living in a house with eight other adults and some other children. The mother was out of the home working while the father was left to care for his son.

The newspaper article outlined that the father had a troubled childhood. According to his lawyer, as a child, the father and his siblings had been locked in their bedroom by their mother while she watched television. He and a younger brother were relinquished to the care of the state when he was 9 years old. He then bounced between nine foster homes until he was 18. Also, the fact that the surviving twin has been adopted by her grandparents suggests that their mother had her own struggles with parenting.

I am sure that the neonatologists and social workers at the hospital where the twins were born were aware of at least some of the red flags that waved over this unfortunate family. I also am confident that they did what they could to assure this infant a safe home environment when it was time for his discharge from the NICU. However, risks factors may have been missed that now seem obvious in retrospect. We should all realize by now from our experience with domestic terrorism that simply appearing on someone’s radar doesn’t mean that preemptive action can or will be taken. Short of keeping the parents of high-risk neonates under constant surveillance for a year or 2, there are few other workable options to prevent every tragedy like this one.

This case is another example of the erosive power of a baby’s cry. Most pediatricians have developed a filtering mechanism that allows us to function in a cacophonous environment dominated by a screaming infant. However, even adults without this young father’s deprived background crack under the stress when they are confined in a space with a crying child. The risk of decompensation is compounded when the adult also feels some responsibility for the child’s welfare. I don’t think we can condone what the father did in this tragic scenario, but we can certainly understand how the dominoes fell.

We are all potential child abusers. When faced with the right, or I guess the wrong, set of circumstances we might lash out to stop the crying. Luckily, most of us are several body lengths from the end of that rope.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

 

The headline in a Portland, Maine, newspaper read, “Standish man sentenced to serve 15 years in prison for death of his 3-month-old son” (Edward Murphy, May 23, 2017). I suspect that many of the folks who read the story under the headline feel that the sentence was too light. Others are asking themselves how a 21-year-old man could beat a fragile 5-pound infant to death. What kind of evil monster is this guy?

However, even with the snatches of information provided in the 500-word newspaper story, the unfortunate scenario makes sense, and the child’s death is a tragic culmination of a series of events that shouldn’t surprise any pediatrician. It turns out the infant was a twin who, with his sister, had been born at 30 weeks’ gestation. He had spent a month or more in the hospital, and his sister was still in neonatal ICU at the time of his death. While it is unclear from the newspaper article whether the twins’ parents were married, they were living in a house with eight other adults and some other children. The mother was out of the home working while the father was left to care for his son.

The newspaper article outlined that the father had a troubled childhood. According to his lawyer, as a child, the father and his siblings had been locked in their bedroom by their mother while she watched television. He and a younger brother were relinquished to the care of the state when he was 9 years old. He then bounced between nine foster homes until he was 18. Also, the fact that the surviving twin has been adopted by her grandparents suggests that their mother had her own struggles with parenting.

I am sure that the neonatologists and social workers at the hospital where the twins were born were aware of at least some of the red flags that waved over this unfortunate family. I also am confident that they did what they could to assure this infant a safe home environment when it was time for his discharge from the NICU. However, risks factors may have been missed that now seem obvious in retrospect. We should all realize by now from our experience with domestic terrorism that simply appearing on someone’s radar doesn’t mean that preemptive action can or will be taken. Short of keeping the parents of high-risk neonates under constant surveillance for a year or 2, there are few other workable options to prevent every tragedy like this one.

This case is another example of the erosive power of a baby’s cry. Most pediatricians have developed a filtering mechanism that allows us to function in a cacophonous environment dominated by a screaming infant. However, even adults without this young father’s deprived background crack under the stress when they are confined in a space with a crying child. The risk of decompensation is compounded when the adult also feels some responsibility for the child’s welfare. I don’t think we can condone what the father did in this tragic scenario, but we can certainly understand how the dominoes fell.

We are all potential child abusers. When faced with the right, or I guess the wrong, set of circumstances we might lash out to stop the crying. Luckily, most of us are several body lengths from the end of that rope.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

 

The headline in a Portland, Maine, newspaper read, “Standish man sentenced to serve 15 years in prison for death of his 3-month-old son” (Edward Murphy, May 23, 2017). I suspect that many of the folks who read the story under the headline feel that the sentence was too light. Others are asking themselves how a 21-year-old man could beat a fragile 5-pound infant to death. What kind of evil monster is this guy?

However, even with the snatches of information provided in the 500-word newspaper story, the unfortunate scenario makes sense, and the child’s death is a tragic culmination of a series of events that shouldn’t surprise any pediatrician. It turns out the infant was a twin who, with his sister, had been born at 30 weeks’ gestation. He had spent a month or more in the hospital, and his sister was still in neonatal ICU at the time of his death. While it is unclear from the newspaper article whether the twins’ parents were married, they were living in a house with eight other adults and some other children. The mother was out of the home working while the father was left to care for his son.

The newspaper article outlined that the father had a troubled childhood. According to his lawyer, as a child, the father and his siblings had been locked in their bedroom by their mother while she watched television. He and a younger brother were relinquished to the care of the state when he was 9 years old. He then bounced between nine foster homes until he was 18. Also, the fact that the surviving twin has been adopted by her grandparents suggests that their mother had her own struggles with parenting.

I am sure that the neonatologists and social workers at the hospital where the twins were born were aware of at least some of the red flags that waved over this unfortunate family. I also am confident that they did what they could to assure this infant a safe home environment when it was time for his discharge from the NICU. However, risks factors may have been missed that now seem obvious in retrospect. We should all realize by now from our experience with domestic terrorism that simply appearing on someone’s radar doesn’t mean that preemptive action can or will be taken. Short of keeping the parents of high-risk neonates under constant surveillance for a year or 2, there are few other workable options to prevent every tragedy like this one.

This case is another example of the erosive power of a baby’s cry. Most pediatricians have developed a filtering mechanism that allows us to function in a cacophonous environment dominated by a screaming infant. However, even adults without this young father’s deprived background crack under the stress when they are confined in a space with a crying child. The risk of decompensation is compounded when the adult also feels some responsibility for the child’s welfare. I don’t think we can condone what the father did in this tragic scenario, but we can certainly understand how the dominoes fell.

We are all potential child abusers. When faced with the right, or I guess the wrong, set of circumstances we might lash out to stop the crying. Luckily, most of us are several body lengths from the end of that rope.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

 

You all know the statistics or at least have a sense of the scope of the problem. While 85% of mothers in this country intend to breastfeed their infants exclusively for at least 3 months, only slightly more than 30% achieve this goal. Among the dozens of reasons for this unfortunate shortfall is what some experts view as inadequate support by primary care physicians and their offices. In the May 2017 Pediatrics, two members of the American Academy of Pediatrics Section on Breastfeeding offer a clinical report that hopes to remedy this situation (“The Breastfeeding-Friendly Pediatric Office Practice.” Pediatrics. 2017 May. 139[5]:e20170647). It is a document that begins with an excellent review of the background and epidemiology of breastfeeding in the United States and a survey of the current initiatives targeted at improving our dismal performance. What follows is an extensive set of 19 evidence-based recommendations for the pediatric outpatient practice that hopes to “meet or exceed the AAP recommendations.”

One certainly can’t fault the authors for their thoroughness, but therein lies the problem. Their list of 19 recommendations (I’m surprised that they couldn’t find one more to make a nice round number) includes everything from the obvious of allowing and encouraging mothers to breastfeed in the office waiting room to the difficult challenge of monitoring the “breastfeeding initiation and duration rates in the pediatric practice” that is probably already overburdened with a data hungry and clunky EMR system. Buried in the last third of this flurry of guidelines is No. 14 that begins “Train staff to follow telephone protocols to address breastfeeding concerns.” From my experience, it is at this critical patient-telephone-office interface that most practices fail to be truly breastfeeding friendly, and, as a result, salvageable nursing experiences crash.

A large part of the problem is the failure of the point person in the office, usually the receptionist, to realize that a tearful call from a new mother who is struggling with breastfeeding is an emergency, one that demands a response in minutes … not hours. Even when the call is eventually routed to someone with a compassionate voice who will call back with the right answers, if that process takes just an hour or two, that is enough time for a mother with a screaming and hungry newborn to reach for a bottle of formula.

copyright Jupiterimages/thinkstockphotos.com

There are very few babies who will refuse that first bottle of formula; in fact, most will avidly take it. It’s only natural, an instinct for survival. The crying will stop, and the sleep-deprived, anxious, and frazzled new mother can relax with the knowledge that her baby isn’t going to starve to death. This scenario is less likely if the hospital and pediatrician’s office have been careful to avoid providing sample packs of formula. However, there are convenience stores and inexperienced, impatient, and vulnerable husbands, grandmothers, aunts, and neighbors who are more than willing to make that short trip on what they see as a rescue mission. In too many cases the relief that comes with this bottle of formula closes the book on breastfeeding.

I urge you to read this exhaustive clinical report in Pediatrics because it is very likely you will come across some things that you can include in your office practice to make it more breastfeeding friendly. However, remember that a call from a new mother struggling with breastfeeding is time sensitive. Even if you and your staff have the right advice, this is not a situation of “better late than never.”

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

 

You all know the statistics or at least have a sense of the scope of the problem. While 85% of mothers in this country intend to breastfeed their infants exclusively for at least 3 months, only slightly more than 30% achieve this goal. Among the dozens of reasons for this unfortunate shortfall is what some experts view as inadequate support by primary care physicians and their offices. In the May 2017 Pediatrics, two members of the American Academy of Pediatrics Section on Breastfeeding offer a clinical report that hopes to remedy this situation (“The Breastfeeding-Friendly Pediatric Office Practice.” Pediatrics. 2017 May. 139[5]:e20170647). It is a document that begins with an excellent review of the background and epidemiology of breastfeeding in the United States and a survey of the current initiatives targeted at improving our dismal performance. What follows is an extensive set of 19 evidence-based recommendations for the pediatric outpatient practice that hopes to “meet or exceed the AAP recommendations.”

One certainly can’t fault the authors for their thoroughness, but therein lies the problem. Their list of 19 recommendations (I’m surprised that they couldn’t find one more to make a nice round number) includes everything from the obvious of allowing and encouraging mothers to breastfeed in the office waiting room to the difficult challenge of monitoring the “breastfeeding initiation and duration rates in the pediatric practice” that is probably already overburdened with a data hungry and clunky EMR system. Buried in the last third of this flurry of guidelines is No. 14 that begins “Train staff to follow telephone protocols to address breastfeeding concerns.” From my experience, it is at this critical patient-telephone-office interface that most practices fail to be truly breastfeeding friendly, and, as a result, salvageable nursing experiences crash.

A large part of the problem is the failure of the point person in the office, usually the receptionist, to realize that a tearful call from a new mother who is struggling with breastfeeding is an emergency, one that demands a response in minutes … not hours. Even when the call is eventually routed to someone with a compassionate voice who will call back with the right answers, if that process takes just an hour or two, that is enough time for a mother with a screaming and hungry newborn to reach for a bottle of formula.

copyright Jupiterimages/thinkstockphotos.com

There are very few babies who will refuse that first bottle of formula; in fact, most will avidly take it. It’s only natural, an instinct for survival. The crying will stop, and the sleep-deprived, anxious, and frazzled new mother can relax with the knowledge that her baby isn’t going to starve to death. This scenario is less likely if the hospital and pediatrician’s office have been careful to avoid providing sample packs of formula. However, there are convenience stores and inexperienced, impatient, and vulnerable husbands, grandmothers, aunts, and neighbors who are more than willing to make that short trip on what they see as a rescue mission. In too many cases the relief that comes with this bottle of formula closes the book on breastfeeding.

I urge you to read this exhaustive clinical report in Pediatrics because it is very likely you will come across some things that you can include in your office practice to make it more breastfeeding friendly. However, remember that a call from a new mother struggling with breastfeeding is time sensitive. Even if you and your staff have the right advice, this is not a situation of “better late than never.”

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

 

You all know the statistics or at least have a sense of the scope of the problem. While 85% of mothers in this country intend to breastfeed their infants exclusively for at least 3 months, only slightly more than 30% achieve this goal. Among the dozens of reasons for this unfortunate shortfall is what some experts view as inadequate support by primary care physicians and their offices. In the May 2017 Pediatrics, two members of the American Academy of Pediatrics Section on Breastfeeding offer a clinical report that hopes to remedy this situation (“The Breastfeeding-Friendly Pediatric Office Practice.” Pediatrics. 2017 May. 139[5]:e20170647). It is a document that begins with an excellent review of the background and epidemiology of breastfeeding in the United States and a survey of the current initiatives targeted at improving our dismal performance. What follows is an extensive set of 19 evidence-based recommendations for the pediatric outpatient practice that hopes to “meet or exceed the AAP recommendations.”

One certainly can’t fault the authors for their thoroughness, but therein lies the problem. Their list of 19 recommendations (I’m surprised that they couldn’t find one more to make a nice round number) includes everything from the obvious of allowing and encouraging mothers to breastfeed in the office waiting room to the difficult challenge of monitoring the “breastfeeding initiation and duration rates in the pediatric practice” that is probably already overburdened with a data hungry and clunky EMR system. Buried in the last third of this flurry of guidelines is No. 14 that begins “Train staff to follow telephone protocols to address breastfeeding concerns.” From my experience, it is at this critical patient-telephone-office interface that most practices fail to be truly breastfeeding friendly, and, as a result, salvageable nursing experiences crash.

A large part of the problem is the failure of the point person in the office, usually the receptionist, to realize that a tearful call from a new mother who is struggling with breastfeeding is an emergency, one that demands a response in minutes … not hours. Even when the call is eventually routed to someone with a compassionate voice who will call back with the right answers, if that process takes just an hour or two, that is enough time for a mother with a screaming and hungry newborn to reach for a bottle of formula.

copyright Jupiterimages/thinkstockphotos.com

There are very few babies who will refuse that first bottle of formula; in fact, most will avidly take it. It’s only natural, an instinct for survival. The crying will stop, and the sleep-deprived, anxious, and frazzled new mother can relax with the knowledge that her baby isn’t going to starve to death. This scenario is less likely if the hospital and pediatrician’s office have been careful to avoid providing sample packs of formula. However, there are convenience stores and inexperienced, impatient, and vulnerable husbands, grandmothers, aunts, and neighbors who are more than willing to make that short trip on what they see as a rescue mission. In too many cases the relief that comes with this bottle of formula closes the book on breastfeeding.

I urge you to read this exhaustive clinical report in Pediatrics because it is very likely you will come across some things that you can include in your office practice to make it more breastfeeding friendly. However, remember that a call from a new mother struggling with breastfeeding is time sensitive. Even if you and your staff have the right advice, this is not a situation of “better late than never.”

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

 

If you consider yourself a busy pediatrician and haven’t seen a Fidget Spinner, you are either a neonatologist or have been on maternity leave for the last 3 months. Because I no longer see patients, my introduction to Fidget Spinners came via my 10-year-old grandson, Peter. Last week, I was tasked with meeting him after school and accompanying him on his bike ride to our house. Instead of a hi-grampy-smile he shouted, “Look what Jonah gave me!”

Peter held in his hand a collection of stainless steel nuts, a bolt, and a pair of roller blade wheel bearings that had been epoxified together so that they would spin with the flick of a finger. This was a homemade Fidget. This wasn’t a “gadget,” a term that would imply to me that it might have some function. No, this was a Fidget, and its sole purpose was to keep the user’s hands busy, usually by spinning it.

Before we climbed on our bikes for the ride home, Peter pointed out a half-dozen schoolmates who were twirling store-bought (or more likely Internet-purchased) Fidgets. According to Peter, Fidgets first appeared in his school after the recent spring break, and they were now all the rage.

Of course ,within days of my enlightening, I discovered articles about the Fidget tsunami in several national newspapers. The most complete chronology of the Fidget’s trajectory from its unheralded birth in the 1990s to its explosive entry on grade school scene in the last 6 months appeared in the New York Times. (Alex Williams. “How Fidget Spinners Became the Hula-Hoop for Generation Z.” May 6, 2017).

For a brief period of time, Fidget Spinners were touted by some “experts” as calming devices for both adults and children who have been labeled with ADHD. I assume this unsubstantiated benefit was in part based on the aphorism attributed to St. Jerome that “idle hands are the Devil’s workshop.” However, when Fidgets escaped from their niche for the distractable and inattentive and entered the mainstream, educators and school administrators quickly realized that, what might have been a cure for some students, can become an intolerable distraction for the entire classroom. Not surprisingly, hastily enacted rules and restrictions have only made the spinners even more popular, must-have items.

While Fidget Spinners are the latest rage for the grade-school crowd, the attraction between palm-sized objects and young children has probably existed since the first Neanderthal infant picked up a shiny stream-polished pebble or a dried seed pod that rattled. I suspect that, if you begin keeping a record, you will discover that, on an average day, at least half of your patients under the age of 4 years have arrived with some temporarily treasured object clutched in their hands – a smooth stone, a matchbox truck, or a Lego or Playmobil figure. These treasures are not to be confused with the plushy and soft security or transition objects that are primarily sleep associated.

What I’m talking about are the recently found items that fulfill a primordial need of little hands to hold something ... anything. For the most part, they are ephemeral and will be replaced in a day or a week with another palm-sized tactile companion.

This compulsion to hold something seems to persist longer in boys and becomes stronger when they are exposed to objects that spin, roll, or make noise. Even Peter, at age 10, invariably shows up at a restaurant with a fidgetable item in his hand to help him endure the interminable wait for his pasta or pizza to arrive at the table. As distracting as it may be to his fellow diners, it certainly beats the alternative of kicking his sister under the table.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

 

If you consider yourself a busy pediatrician and haven’t seen a Fidget Spinner, you are either a neonatologist or have been on maternity leave for the last 3 months. Because I no longer see patients, my introduction to Fidget Spinners came via my 10-year-old grandson, Peter. Last week, I was tasked with meeting him after school and accompanying him on his bike ride to our house. Instead of a hi-grampy-smile he shouted, “Look what Jonah gave me!”

Peter held in his hand a collection of stainless steel nuts, a bolt, and a pair of roller blade wheel bearings that had been epoxified together so that they would spin with the flick of a finger. This was a homemade Fidget. This wasn’t a “gadget,” a term that would imply to me that it might have some function. No, this was a Fidget, and its sole purpose was to keep the user’s hands busy, usually by spinning it.

Before we climbed on our bikes for the ride home, Peter pointed out a half-dozen schoolmates who were twirling store-bought (or more likely Internet-purchased) Fidgets. According to Peter, Fidgets first appeared in his school after the recent spring break, and they were now all the rage.

Of course ,within days of my enlightening, I discovered articles about the Fidget tsunami in several national newspapers. The most complete chronology of the Fidget’s trajectory from its unheralded birth in the 1990s to its explosive entry on grade school scene in the last 6 months appeared in the New York Times. (Alex Williams. “How Fidget Spinners Became the Hula-Hoop for Generation Z.” May 6, 2017).

For a brief period of time, Fidget Spinners were touted by some “experts” as calming devices for both adults and children who have been labeled with ADHD. I assume this unsubstantiated benefit was in part based on the aphorism attributed to St. Jerome that “idle hands are the Devil’s workshop.” However, when Fidgets escaped from their niche for the distractable and inattentive and entered the mainstream, educators and school administrators quickly realized that, what might have been a cure for some students, can become an intolerable distraction for the entire classroom. Not surprisingly, hastily enacted rules and restrictions have only made the spinners even more popular, must-have items.

While Fidget Spinners are the latest rage for the grade-school crowd, the attraction between palm-sized objects and young children has probably existed since the first Neanderthal infant picked up a shiny stream-polished pebble or a dried seed pod that rattled. I suspect that, if you begin keeping a record, you will discover that, on an average day, at least half of your patients under the age of 4 years have arrived with some temporarily treasured object clutched in their hands – a smooth stone, a matchbox truck, or a Lego or Playmobil figure. These treasures are not to be confused with the plushy and soft security or transition objects that are primarily sleep associated.

What I’m talking about are the recently found items that fulfill a primordial need of little hands to hold something ... anything. For the most part, they are ephemeral and will be replaced in a day or a week with another palm-sized tactile companion.

This compulsion to hold something seems to persist longer in boys and becomes stronger when they are exposed to objects that spin, roll, or make noise. Even Peter, at age 10, invariably shows up at a restaurant with a fidgetable item in his hand to help him endure the interminable wait for his pasta or pizza to arrive at the table. As distracting as it may be to his fellow diners, it certainly beats the alternative of kicking his sister under the table.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

 

If you consider yourself a busy pediatrician and haven’t seen a Fidget Spinner, you are either a neonatologist or have been on maternity leave for the last 3 months. Because I no longer see patients, my introduction to Fidget Spinners came via my 10-year-old grandson, Peter. Last week, I was tasked with meeting him after school and accompanying him on his bike ride to our house. Instead of a hi-grampy-smile he shouted, “Look what Jonah gave me!”

Peter held in his hand a collection of stainless steel nuts, a bolt, and a pair of roller blade wheel bearings that had been epoxified together so that they would spin with the flick of a finger. This was a homemade Fidget. This wasn’t a “gadget,” a term that would imply to me that it might have some function. No, this was a Fidget, and its sole purpose was to keep the user’s hands busy, usually by spinning it.

Before we climbed on our bikes for the ride home, Peter pointed out a half-dozen schoolmates who were twirling store-bought (or more likely Internet-purchased) Fidgets. According to Peter, Fidgets first appeared in his school after the recent spring break, and they were now all the rage.

Of course ,within days of my enlightening, I discovered articles about the Fidget tsunami in several national newspapers. The most complete chronology of the Fidget’s trajectory from its unheralded birth in the 1990s to its explosive entry on grade school scene in the last 6 months appeared in the New York Times. (Alex Williams. “How Fidget Spinners Became the Hula-Hoop for Generation Z.” May 6, 2017).

For a brief period of time, Fidget Spinners were touted by some “experts” as calming devices for both adults and children who have been labeled with ADHD. I assume this unsubstantiated benefit was in part based on the aphorism attributed to St. Jerome that “idle hands are the Devil’s workshop.” However, when Fidgets escaped from their niche for the distractable and inattentive and entered the mainstream, educators and school administrators quickly realized that, what might have been a cure for some students, can become an intolerable distraction for the entire classroom. Not surprisingly, hastily enacted rules and restrictions have only made the spinners even more popular, must-have items.

While Fidget Spinners are the latest rage for the grade-school crowd, the attraction between palm-sized objects and young children has probably existed since the first Neanderthal infant picked up a shiny stream-polished pebble or a dried seed pod that rattled. I suspect that, if you begin keeping a record, you will discover that, on an average day, at least half of your patients under the age of 4 years have arrived with some temporarily treasured object clutched in their hands – a smooth stone, a matchbox truck, or a Lego or Playmobil figure. These treasures are not to be confused with the plushy and soft security or transition objects that are primarily sleep associated.

What I’m talking about are the recently found items that fulfill a primordial need of little hands to hold something ... anything. For the most part, they are ephemeral and will be replaced in a day or a week with another palm-sized tactile companion.

This compulsion to hold something seems to persist longer in boys and becomes stronger when they are exposed to objects that spin, roll, or make noise. Even Peter, at age 10, invariably shows up at a restaurant with a fidgetable item in his hand to help him endure the interminable wait for his pasta or pizza to arrive at the table. As distracting as it may be to his fellow diners, it certainly beats the alternative of kicking his sister under the table.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

 

I’m a little concerned about my grandchildren. I worry that when they are in their twenties, no one will want them as trivia teammates. Or when they are hanging out with other 40-something couples, they will fade into the wallpaper when the conversation turns to, “Remember that episode of Big Bang Theory when ... .”

The 5½-year-old and the 8-year-old have grown up in a household that has never had a TV, and the 10- and 12-year-old are surviving with a cable connection so basic that it barely gets more than a few shopping channels and the local school board meetings.

This situation is not the direct result of the TV environments in which their parents grew up. While we were among the last families in the neighborhood with a color TV, we did watch TV. We did put some limits on TV viewing, and our children were in their late teens before they realized that our TV was capable of receiving cartoons on Saturday mornings. They thought this kind of special connection existed only in motel rooms. Other than putting a few restrictions on TV viewing, we weren’t militant supervisors of our children’s viewing habits.

Our children were just too busy doing things to watch much TV. Now as adults they have been paying attention to what they have heard and read about the potential negative influence that TV may have on their own children, and imposed restrictions far more severe than those under which they were raised. It has been interesting to watch how their children are responding to these TV-deprived environments.

For the most part, there has been no whining or begging to turn on the TV. The younger two have no other option and don’t realize what they are missing. The older two, who watched some Sesame Street as toddlers, have been similarly disinterested, although my 10-year-old grandson enjoys watching some sports when the opportunity arises.

So what do my grandchildren do with the 28 hours each week that their peers are spending in front of a TV (“Television and Children,” University of Michigan Medical School/Michigan Medicine website)? The two older girls are voracious readers. One spends hours drawing, and with her younger sister, always has a craft project or two going. The older two are skillful board and card game players, and they play musical instruments. All four are involved in at least one sport per season, and when asked, they would prefer to be playing something outside. And they go to bed at a healthy hour.

In a recent article in AAP News (“How to provide evidence-based pediatric care for the digital age,” May 2017), Michael O. Rich, MD, a member of the American Academy of Pediatrics Council on Communications and Media, writes, “Our traditional advice to limit screen time and restrict content is no longer relevant and often unheard by families.” I agree that for many years that AAP advice had been too focused on content. However, seeing my grandchildren thrive in an environment of what many might consider an extreme screen time restriction has further reinforced my previous observations that the critical issue with screen time is that it replaces health-promoting active alternatives. Even screen time that requires some interaction relegates the child to the role of a sedentary spectator.

Although Dr. Rich is to be commended for suggesting that we look at evidence-based studies as we decide how to counsel parents about screen time, I am always skeptical about the validity of short-term “evidence.” I fear that some of the evidence-based studies are being used to excuse or rationalize an already unhealthy situation. At some point we need to step back and take the longer look. Would you rather see your grandchildren hunched over a screen or couched in front of a television watching other people doing things, or would you prefer that they be physically active doers and creators themselves?
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

 

I’m a little concerned about my grandchildren. I worry that when they are in their twenties, no one will want them as trivia teammates. Or when they are hanging out with other 40-something couples, they will fade into the wallpaper when the conversation turns to, “Remember that episode of Big Bang Theory when ... .”

The 5½-year-old and the 8-year-old have grown up in a household that has never had a TV, and the 10- and 12-year-old are surviving with a cable connection so basic that it barely gets more than a few shopping channels and the local school board meetings.

This situation is not the direct result of the TV environments in which their parents grew up. While we were among the last families in the neighborhood with a color TV, we did watch TV. We did put some limits on TV viewing, and our children were in their late teens before they realized that our TV was capable of receiving cartoons on Saturday mornings. They thought this kind of special connection existed only in motel rooms. Other than putting a few restrictions on TV viewing, we weren’t militant supervisors of our children’s viewing habits.

Our children were just too busy doing things to watch much TV. Now as adults they have been paying attention to what they have heard and read about the potential negative influence that TV may have on their own children, and imposed restrictions far more severe than those under which they were raised. It has been interesting to watch how their children are responding to these TV-deprived environments.

For the most part, there has been no whining or begging to turn on the TV. The younger two have no other option and don’t realize what they are missing. The older two, who watched some Sesame Street as toddlers, have been similarly disinterested, although my 10-year-old grandson enjoys watching some sports when the opportunity arises.

So what do my grandchildren do with the 28 hours each week that their peers are spending in front of a TV (“Television and Children,” University of Michigan Medical School/Michigan Medicine website)? The two older girls are voracious readers. One spends hours drawing, and with her younger sister, always has a craft project or two going. The older two are skillful board and card game players, and they play musical instruments. All four are involved in at least one sport per season, and when asked, they would prefer to be playing something outside. And they go to bed at a healthy hour.

In a recent article in AAP News (“How to provide evidence-based pediatric care for the digital age,” May 2017), Michael O. Rich, MD, a member of the American Academy of Pediatrics Council on Communications and Media, writes, “Our traditional advice to limit screen time and restrict content is no longer relevant and often unheard by families.” I agree that for many years that AAP advice had been too focused on content. However, seeing my grandchildren thrive in an environment of what many might consider an extreme screen time restriction has further reinforced my previous observations that the critical issue with screen time is that it replaces health-promoting active alternatives. Even screen time that requires some interaction relegates the child to the role of a sedentary spectator.

Although Dr. Rich is to be commended for suggesting that we look at evidence-based studies as we decide how to counsel parents about screen time, I am always skeptical about the validity of short-term “evidence.” I fear that some of the evidence-based studies are being used to excuse or rationalize an already unhealthy situation. At some point we need to step back and take the longer look. Would you rather see your grandchildren hunched over a screen or couched in front of a television watching other people doing things, or would you prefer that they be physically active doers and creators themselves?
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

 

I’m a little concerned about my grandchildren. I worry that when they are in their twenties, no one will want them as trivia teammates. Or when they are hanging out with other 40-something couples, they will fade into the wallpaper when the conversation turns to, “Remember that episode of Big Bang Theory when ... .”

The 5½-year-old and the 8-year-old have grown up in a household that has never had a TV, and the 10- and 12-year-old are surviving with a cable connection so basic that it barely gets more than a few shopping channels and the local school board meetings.

This situation is not the direct result of the TV environments in which their parents grew up. While we were among the last families in the neighborhood with a color TV, we did watch TV. We did put some limits on TV viewing, and our children were in their late teens before they realized that our TV was capable of receiving cartoons on Saturday mornings. They thought this kind of special connection existed only in motel rooms. Other than putting a few restrictions on TV viewing, we weren’t militant supervisors of our children’s viewing habits.

Our children were just too busy doing things to watch much TV. Now as adults they have been paying attention to what they have heard and read about the potential negative influence that TV may have on their own children, and imposed restrictions far more severe than those under which they were raised. It has been interesting to watch how their children are responding to these TV-deprived environments.

For the most part, there has been no whining or begging to turn on the TV. The younger two have no other option and don’t realize what they are missing. The older two, who watched some Sesame Street as toddlers, have been similarly disinterested, although my 10-year-old grandson enjoys watching some sports when the opportunity arises.

So what do my grandchildren do with the 28 hours each week that their peers are spending in front of a TV (“Television and Children,” University of Michigan Medical School/Michigan Medicine website)? The two older girls are voracious readers. One spends hours drawing, and with her younger sister, always has a craft project or two going. The older two are skillful board and card game players, and they play musical instruments. All four are involved in at least one sport per season, and when asked, they would prefer to be playing something outside. And they go to bed at a healthy hour.

In a recent article in AAP News (“How to provide evidence-based pediatric care for the digital age,” May 2017), Michael O. Rich, MD, a member of the American Academy of Pediatrics Council on Communications and Media, writes, “Our traditional advice to limit screen time and restrict content is no longer relevant and often unheard by families.” I agree that for many years that AAP advice had been too focused on content. However, seeing my grandchildren thrive in an environment of what many might consider an extreme screen time restriction has further reinforced my previous observations that the critical issue with screen time is that it replaces health-promoting active alternatives. Even screen time that requires some interaction relegates the child to the role of a sedentary spectator.

Although Dr. Rich is to be commended for suggesting that we look at evidence-based studies as we decide how to counsel parents about screen time, I am always skeptical about the validity of short-term “evidence.” I fear that some of the evidence-based studies are being used to excuse or rationalize an already unhealthy situation. At some point we need to step back and take the longer look. Would you rather see your grandchildren hunched over a screen or couched in front of a television watching other people doing things, or would you prefer that they be physically active doers and creators themselves?
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

 

I have a repertoire of about a dozen soups that I enjoy preparing, but I certainly don’t consider myself a gourmet chef. However, I can legitimately claim to be a master of the microwave. Hand me a potentially edible substance, and I will nuke it to a palatable temperature in one step. This skill comes from 30 years of practice and requires a sixth sense that includes factoring in the object’s water content, shape, and density, and knowing whether I am starting from the frozen state, refrigerator cool, or room temperature.

Sadly, our 30-some-year-old microwave nuked its last leftover in a shower of sparks a few weeks ago, and I have been forced to recalibrate my technique with a new machine. Not to worry, I am just one or two more rewarmed meals away from returning to my old “nukelear” mastery.

I recently learned that Amana introduced the first countertop microwave in 1967, the same year that Pediatric News began publication (Susan Strasser. “What’s in Your Microwave Oven?” The New York Times. April 14, 2017). Over those ensuing 50 years, the microwave has been one of the major forces molding what, when, and how North Americans eat. It has been a tremendous time-saver for those saddled with the task of preparing family meals. The microwave oven also has allowed millions of adults and children without even the most basic kitchen skills or equipment to prepare themselves warm and nutritious meals at any time they choose or when their schedules allow.

Unfortunately, as with any new technology, the ubiquity of countertop microwave ovens has come with some downsides. While they do offer the cooking challenged among us a broad choice of foods we can prepare in minutes or seconds, the choices we make are not always nutritiously sound.

The microwave oven and single-serving prepared frozen meals have been a great boon to people who live alone or live or work on schedules out of sync with their families’ meal schedule. However, there is a point when this technologically-enabled nutritional independence begins to take precedence over communal dining. The family meal slips on to the endangered species list. Although there is some debate about whether family meals are any more valuable as character-building exercises than other shared family experiences, there is no question that children in families who dine together on a regular basis enjoy substantial health benefits, such as less depressive symptoms, more healthy foods, fewer weight problems, and less delinquency.

The forces that have driven the family meal into decline are numerous and powerful. However, we should not underestimate the role that the microwave oven has had in greasing this path toward extinction. Even if the family has one member with the time, skills, and commitment to create nutritious and complete meals, the microwave oven offers even the youngest member an easy way to opt out of sharing it with the rest of his family. A parent who must work late can rewarm his serving at 9:00 p.m. when he or she gets home. The high school thespian can nuke her own prepared frozen dinner at 5 p.m. so she can get to a rehearsal at 6 p.m. And, the 4-year-old picky eater who won’t touch anything green can have his treasured mac ‘n cheese warmed to his taste while everyone else is enjoying fish tacos. And, there you have it. Poof! With the touch of a couple buttons, the opportunity for a family to enjoy a meal together and share their experiences of the day has vanished into thin air along with a valuable lesson in cooperation and compromise.

But, we needn’t worry about those family members who are dining separately getting lonely because more than likely they each have their own electronic companion to keep them company while they eat their microwaved meal.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

 

I have a repertoire of about a dozen soups that I enjoy preparing, but I certainly don’t consider myself a gourmet chef. However, I can legitimately claim to be a master of the microwave. Hand me a potentially edible substance, and I will nuke it to a palatable temperature in one step. This skill comes from 30 years of practice and requires a sixth sense that includes factoring in the object’s water content, shape, and density, and knowing whether I am starting from the frozen state, refrigerator cool, or room temperature.

Sadly, our 30-some-year-old microwave nuked its last leftover in a shower of sparks a few weeks ago, and I have been forced to recalibrate my technique with a new machine. Not to worry, I am just one or two more rewarmed meals away from returning to my old “nukelear” mastery.

I recently learned that Amana introduced the first countertop microwave in 1967, the same year that Pediatric News began publication (Susan Strasser. “What’s in Your Microwave Oven?” The New York Times. April 14, 2017). Over those ensuing 50 years, the microwave has been one of the major forces molding what, when, and how North Americans eat. It has been a tremendous time-saver for those saddled with the task of preparing family meals. The microwave oven also has allowed millions of adults and children without even the most basic kitchen skills or equipment to prepare themselves warm and nutritious meals at any time they choose or when their schedules allow.

Unfortunately, as with any new technology, the ubiquity of countertop microwave ovens has come with some downsides. While they do offer the cooking challenged among us a broad choice of foods we can prepare in minutes or seconds, the choices we make are not always nutritiously sound.

The microwave oven and single-serving prepared frozen meals have been a great boon to people who live alone or live or work on schedules out of sync with their families’ meal schedule. However, there is a point when this technologically-enabled nutritional independence begins to take precedence over communal dining. The family meal slips on to the endangered species list. Although there is some debate about whether family meals are any more valuable as character-building exercises than other shared family experiences, there is no question that children in families who dine together on a regular basis enjoy substantial health benefits, such as less depressive symptoms, more healthy foods, fewer weight problems, and less delinquency.

The forces that have driven the family meal into decline are numerous and powerful. However, we should not underestimate the role that the microwave oven has had in greasing this path toward extinction. Even if the family has one member with the time, skills, and commitment to create nutritious and complete meals, the microwave oven offers even the youngest member an easy way to opt out of sharing it with the rest of his family. A parent who must work late can rewarm his serving at 9:00 p.m. when he or she gets home. The high school thespian can nuke her own prepared frozen dinner at 5 p.m. so she can get to a rehearsal at 6 p.m. And, the 4-year-old picky eater who won’t touch anything green can have his treasured mac ‘n cheese warmed to his taste while everyone else is enjoying fish tacos. And, there you have it. Poof! With the touch of a couple buttons, the opportunity for a family to enjoy a meal together and share their experiences of the day has vanished into thin air along with a valuable lesson in cooperation and compromise.

But, we needn’t worry about those family members who are dining separately getting lonely because more than likely they each have their own electronic companion to keep them company while they eat their microwaved meal.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

 

I have a repertoire of about a dozen soups that I enjoy preparing, but I certainly don’t consider myself a gourmet chef. However, I can legitimately claim to be a master of the microwave. Hand me a potentially edible substance, and I will nuke it to a palatable temperature in one step. This skill comes from 30 years of practice and requires a sixth sense that includes factoring in the object’s water content, shape, and density, and knowing whether I am starting from the frozen state, refrigerator cool, or room temperature.

Sadly, our 30-some-year-old microwave nuked its last leftover in a shower of sparks a few weeks ago, and I have been forced to recalibrate my technique with a new machine. Not to worry, I am just one or two more rewarmed meals away from returning to my old “nukelear” mastery.

I recently learned that Amana introduced the first countertop microwave in 1967, the same year that Pediatric News began publication (Susan Strasser. “What’s in Your Microwave Oven?” The New York Times. April 14, 2017). Over those ensuing 50 years, the microwave has been one of the major forces molding what, when, and how North Americans eat. It has been a tremendous time-saver for those saddled with the task of preparing family meals. The microwave oven also has allowed millions of adults and children without even the most basic kitchen skills or equipment to prepare themselves warm and nutritious meals at any time they choose or when their schedules allow.

Unfortunately, as with any new technology, the ubiquity of countertop microwave ovens has come with some downsides. While they do offer the cooking challenged among us a broad choice of foods we can prepare in minutes or seconds, the choices we make are not always nutritiously sound.

The microwave oven and single-serving prepared frozen meals have been a great boon to people who live alone or live or work on schedules out of sync with their families’ meal schedule. However, there is a point when this technologically-enabled nutritional independence begins to take precedence over communal dining. The family meal slips on to the endangered species list. Although there is some debate about whether family meals are any more valuable as character-building exercises than other shared family experiences, there is no question that children in families who dine together on a regular basis enjoy substantial health benefits, such as less depressive symptoms, more healthy foods, fewer weight problems, and less delinquency.

The forces that have driven the family meal into decline are numerous and powerful. However, we should not underestimate the role that the microwave oven has had in greasing this path toward extinction. Even if the family has one member with the time, skills, and commitment to create nutritious and complete meals, the microwave oven offers even the youngest member an easy way to opt out of sharing it with the rest of his family. A parent who must work late can rewarm his serving at 9:00 p.m. when he or she gets home. The high school thespian can nuke her own prepared frozen dinner at 5 p.m. so she can get to a rehearsal at 6 p.m. And, the 4-year-old picky eater who won’t touch anything green can have his treasured mac ‘n cheese warmed to his taste while everyone else is enjoying fish tacos. And, there you have it. Poof! With the touch of a couple buttons, the opportunity for a family to enjoy a meal together and share their experiences of the day has vanished into thin air along with a valuable lesson in cooperation and compromise.

But, we needn’t worry about those family members who are dining separately getting lonely because more than likely they each have their own electronic companion to keep them company while they eat their microwaved meal.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

 

Those of you who were in high school or middle school in 1987, when the DSM II-R first included “Attention Deficit Disorder With and Without Hyperactivity” for the first time, missed out on the “discovery,” and subsequent commercialization, of a condition that had been percolating under physicians’ noses for hundreds of years.

You may have wondered what primary care physicians did with their time before they were inundated with requests for evaluations and medications to treat ADHD. You may not realize that we didn’t always have ADHD specialists to help us or several dozen stimulant concoctions from which to choose. In the beginning, ADHD specialists had to invent themselves while the pharmaceutical companies scrambled to meet the demand for drugs that were longer lasting and more palatable.

Don’t worry that you missed out on the birth of a medical phenomena. You and your fellow physicians are fortunate to have front row seats to watch the discovery and commercialization process repeat itself as the field of concussion management struggles with its own growing pains. Just like ADHD, concussions always have been there. We’ve just lowered the bar on their diagnosis and wondered, with more concern, whether we have been managing them correctly.

The increasing popularity of professional contact sports is probably what we have to thank for sharpening this focus on head injury. I suspect that, for the general population, there are no more concussions occurring today than there were 50 years ago. However, in the subgroup of professional and elite college athletes, the players’ increasing speed, size, and flagrant ignorance of the rules have resulted in more significant head injuries. When a highly paid megastar athlete must sit out key games, the management of his head injury generates a lot of attention and discussion.

I am sure that there also has been an increase in concussions among young women who now have more opportunities to participate in contact sports. However, I suspect that most of the apparent increase in the diagnosis among high school and younger athletes of both sexes is primarily the result of heightened awareness. I don’t know of data to support or refute this opinion.

I may be wrong about lack of a real increase in concussion injuries, but there can be no arguing about the explosion in the number of clinics and providers who advertise themselves as concussion specialists. Neurologists, psychologists, chiropractors, orthopedists, and sports medicine practitioners and trainers all have climbed on the bandwagon to satisfy the demand generated by this country’s new concussion awareness.

The problem is that, just as in the early days after the “discovery” of ADHD, the science behind much of the advice and management strategies for concussion just isn’t there. For example, resting the brain after a head injury sounds like a good idea. After all, it works for a torn hamstring. However, “sounds like” and “is” are two very different things.

In an excellent article in this publication (“Spotlight shifts to active treatment for concussions,” by Christine Kilgore), I found some comforting news that concussion management may be taking some baby steps into the realm of evidence-based decision management. The original results came from a pediatric population, but it now appears that prolonged rest, which is routinely recommended, can be counterproductive in many concussed patients. The physicians quoted in this article suggest that their experience is pointing to the need for active management in patients with a variety of postconcussion symptoms. Brian Hainline, MD, a clinical professor of neurology at New York University and Indiana University, Indianapolis, observes, “It’s rare that prolonged rest is the answer. Look at stroke – you don’t have patients resting indefinitely. You have to get their nervous systems re-engaged.”

Of course, the science is still lagging behind and the observations by the physicians quoted in this article are based on small series, but their agreement deserves our attention. I urge you to take a look at this article to get an idea of where the management of concussion appears to be going. Not surprisingly, no two concussion patients are the same, and their management should be tailored to their needs. Reliance on overly simplistic guidelines not only doesn’t work but can do harm. It’s that old Hippocratic Oath thing again.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

 

Those of you who were in high school or middle school in 1987, when the DSM II-R first included “Attention Deficit Disorder With and Without Hyperactivity” for the first time, missed out on the “discovery,” and subsequent commercialization, of a condition that had been percolating under physicians’ noses for hundreds of years.

You may have wondered what primary care physicians did with their time before they were inundated with requests for evaluations and medications to treat ADHD. You may not realize that we didn’t always have ADHD specialists to help us or several dozen stimulant concoctions from which to choose. In the beginning, ADHD specialists had to invent themselves while the pharmaceutical companies scrambled to meet the demand for drugs that were longer lasting and more palatable.

Don’t worry that you missed out on the birth of a medical phenomena. You and your fellow physicians are fortunate to have front row seats to watch the discovery and commercialization process repeat itself as the field of concussion management struggles with its own growing pains. Just like ADHD, concussions always have been there. We’ve just lowered the bar on their diagnosis and wondered, with more concern, whether we have been managing them correctly.

The increasing popularity of professional contact sports is probably what we have to thank for sharpening this focus on head injury. I suspect that, for the general population, there are no more concussions occurring today than there were 50 years ago. However, in the subgroup of professional and elite college athletes, the players’ increasing speed, size, and flagrant ignorance of the rules have resulted in more significant head injuries. When a highly paid megastar athlete must sit out key games, the management of his head injury generates a lot of attention and discussion.

I am sure that there also has been an increase in concussions among young women who now have more opportunities to participate in contact sports. However, I suspect that most of the apparent increase in the diagnosis among high school and younger athletes of both sexes is primarily the result of heightened awareness. I don’t know of data to support or refute this opinion.

I may be wrong about lack of a real increase in concussion injuries, but there can be no arguing about the explosion in the number of clinics and providers who advertise themselves as concussion specialists. Neurologists, psychologists, chiropractors, orthopedists, and sports medicine practitioners and trainers all have climbed on the bandwagon to satisfy the demand generated by this country’s new concussion awareness.

The problem is that, just as in the early days after the “discovery” of ADHD, the science behind much of the advice and management strategies for concussion just isn’t there. For example, resting the brain after a head injury sounds like a good idea. After all, it works for a torn hamstring. However, “sounds like” and “is” are two very different things.

In an excellent article in this publication (“Spotlight shifts to active treatment for concussions,” by Christine Kilgore), I found some comforting news that concussion management may be taking some baby steps into the realm of evidence-based decision management. The original results came from a pediatric population, but it now appears that prolonged rest, which is routinely recommended, can be counterproductive in many concussed patients. The physicians quoted in this article suggest that their experience is pointing to the need for active management in patients with a variety of postconcussion symptoms. Brian Hainline, MD, a clinical professor of neurology at New York University and Indiana University, Indianapolis, observes, “It’s rare that prolonged rest is the answer. Look at stroke – you don’t have patients resting indefinitely. You have to get their nervous systems re-engaged.”

Of course, the science is still lagging behind and the observations by the physicians quoted in this article are based on small series, but their agreement deserves our attention. I urge you to take a look at this article to get an idea of where the management of concussion appears to be going. Not surprisingly, no two concussion patients are the same, and their management should be tailored to their needs. Reliance on overly simplistic guidelines not only doesn’t work but can do harm. It’s that old Hippocratic Oath thing again.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

 

Those of you who were in high school or middle school in 1987, when the DSM II-R first included “Attention Deficit Disorder With and Without Hyperactivity” for the first time, missed out on the “discovery,” and subsequent commercialization, of a condition that had been percolating under physicians’ noses for hundreds of years.

You may have wondered what primary care physicians did with their time before they were inundated with requests for evaluations and medications to treat ADHD. You may not realize that we didn’t always have ADHD specialists to help us or several dozen stimulant concoctions from which to choose. In the beginning, ADHD specialists had to invent themselves while the pharmaceutical companies scrambled to meet the demand for drugs that were longer lasting and more palatable.

Don’t worry that you missed out on the birth of a medical phenomena. You and your fellow physicians are fortunate to have front row seats to watch the discovery and commercialization process repeat itself as the field of concussion management struggles with its own growing pains. Just like ADHD, concussions always have been there. We’ve just lowered the bar on their diagnosis and wondered, with more concern, whether we have been managing them correctly.

The increasing popularity of professional contact sports is probably what we have to thank for sharpening this focus on head injury. I suspect that, for the general population, there are no more concussions occurring today than there were 50 years ago. However, in the subgroup of professional and elite college athletes, the players’ increasing speed, size, and flagrant ignorance of the rules have resulted in more significant head injuries. When a highly paid megastar athlete must sit out key games, the management of his head injury generates a lot of attention and discussion.

I am sure that there also has been an increase in concussions among young women who now have more opportunities to participate in contact sports. However, I suspect that most of the apparent increase in the diagnosis among high school and younger athletes of both sexes is primarily the result of heightened awareness. I don’t know of data to support or refute this opinion.

I may be wrong about lack of a real increase in concussion injuries, but there can be no arguing about the explosion in the number of clinics and providers who advertise themselves as concussion specialists. Neurologists, psychologists, chiropractors, orthopedists, and sports medicine practitioners and trainers all have climbed on the bandwagon to satisfy the demand generated by this country’s new concussion awareness.

The problem is that, just as in the early days after the “discovery” of ADHD, the science behind much of the advice and management strategies for concussion just isn’t there. For example, resting the brain after a head injury sounds like a good idea. After all, it works for a torn hamstring. However, “sounds like” and “is” are two very different things.

In an excellent article in this publication (“Spotlight shifts to active treatment for concussions,” by Christine Kilgore), I found some comforting news that concussion management may be taking some baby steps into the realm of evidence-based decision management. The original results came from a pediatric population, but it now appears that prolonged rest, which is routinely recommended, can be counterproductive in many concussed patients. The physicians quoted in this article suggest that their experience is pointing to the need for active management in patients with a variety of postconcussion symptoms. Brian Hainline, MD, a clinical professor of neurology at New York University and Indiana University, Indianapolis, observes, “It’s rare that prolonged rest is the answer. Look at stroke – you don’t have patients resting indefinitely. You have to get their nervous systems re-engaged.”

Of course, the science is still lagging behind and the observations by the physicians quoted in this article are based on small series, but their agreement deserves our attention. I urge you to take a look at this article to get an idea of where the management of concussion appears to be going. Not surprisingly, no two concussion patients are the same, and their management should be tailored to their needs. Reliance on overly simplistic guidelines not only doesn’t work but can do harm. It’s that old Hippocratic Oath thing again.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

“Honey, does this town make me look fat?”

“Yes, Dear, I’m afraid it does.”

No, that really wasn’t a typo in the first line. I intended to type “town” and not “gown.” A recent article by Dionysus Powell in healthcareinamerica.us has prompted me to think a bit more about the relationship between obesity and the communities we inhabit (“Fit Cities vs. Fat Cities – What available data can tell us about the difference in lifestyle and obesity between cities,” by Dionysus Powell, March 28, 2017). The author is a biotech researcher who has collected readily available Centers for Disease Control and Prevention data on body mass index (BMI) and self-reported sedentary behavior in almost 200 U.S. cities. He then sliced and diced these numbers with each cities’ walkability score, which is a crude measure of how easily citizens and visitors on foot can reach a variety of destinations such as shops, schools, churches, libraries, and municipal offices. You can easily find your own town’s score by going to walkscore.com.

He then resliced and -diced those numbers with CDC data on health outcomes and ethnic diversity, and resorted using meteorologic data on humidity and temperature using a multivariate analysis technique called multiple linear regression. The article is illustrated with one map and six scatter graphs.

Not surprisingly, the author discovered that “differences in obesity rates between cities can largely be explained by differences in physical activity.” Of course, there is a point at which a community has sufficient walkable infrastructure so that its obesity rate is a result of the citizens choosing not to walk rather than the community’s failure to provide pedestrians with enough connectivity to do their daily errands on foot. That threshold point appears to be a walkability score of 50, yet Mr. Powell observes that most American cities fail to reach even that minimum.

Although rich people tend to have better health outcomes than poor people, and there is a “general trend for richer cities to be more physically active than poorer cities,” Mr. Powell could not find a relationship between a city’s median income and its walkability.

If, like most of us, you have been frustrated in your efforts to lower the BMI of your patients, it may be time to emerge from the confines of your office and take a look at your town’s walkability score. If it is less than 50, you and your fellow concerned citizens and officials have some work to do. It may mean advocating for improved pedestrian infrastructure and/or dismantling the physical and zoning barriers to pedestrian connectivity. For example, maybe your community should be adding more pedestrian-activated crossing signals or tapping into federal and state safe routes to school programs or adopting zoning ordinances that require sidewalks in all new developments.

Here in Brunswick, we have a very enviable walkability score of 87, meaning “most errands can be accomplished on foot.” We have a bicycle and pedestrian advisory committee that reports to the town council and works with the town engineer to advocate for infrastructure improvements that encourage pedestrian connectivity. However, funding these improvements in walkability is always a challenge. But as the analysis in this recent study suggestions, our biggest challenge continues to be encouraging our citizens to take advantage of our existing pedestrian infrastructure.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

“Honey, does this town make me look fat?”

“Yes, Dear, I’m afraid it does.”

No, that really wasn’t a typo in the first line. I intended to type “town” and not “gown.” A recent article by Dionysus Powell in healthcareinamerica.us has prompted me to think a bit more about the relationship between obesity and the communities we inhabit (“Fit Cities vs. Fat Cities – What available data can tell us about the difference in lifestyle and obesity between cities,” by Dionysus Powell, March 28, 2017). The author is a biotech researcher who has collected readily available Centers for Disease Control and Prevention data on body mass index (BMI) and self-reported sedentary behavior in almost 200 U.S. cities. He then sliced and diced these numbers with each cities’ walkability score, which is a crude measure of how easily citizens and visitors on foot can reach a variety of destinations such as shops, schools, churches, libraries, and municipal offices. You can easily find your own town’s score by going to walkscore.com.

He then resliced and -diced those numbers with CDC data on health outcomes and ethnic diversity, and resorted using meteorologic data on humidity and temperature using a multivariate analysis technique called multiple linear regression. The article is illustrated with one map and six scatter graphs.

Not surprisingly, the author discovered that “differences in obesity rates between cities can largely be explained by differences in physical activity.” Of course, there is a point at which a community has sufficient walkable infrastructure so that its obesity rate is a result of the citizens choosing not to walk rather than the community’s failure to provide pedestrians with enough connectivity to do their daily errands on foot. That threshold point appears to be a walkability score of 50, yet Mr. Powell observes that most American cities fail to reach even that minimum.

Although rich people tend to have better health outcomes than poor people, and there is a “general trend for richer cities to be more physically active than poorer cities,” Mr. Powell could not find a relationship between a city’s median income and its walkability.

If, like most of us, you have been frustrated in your efforts to lower the BMI of your patients, it may be time to emerge from the confines of your office and take a look at your town’s walkability score. If it is less than 50, you and your fellow concerned citizens and officials have some work to do. It may mean advocating for improved pedestrian infrastructure and/or dismantling the physical and zoning barriers to pedestrian connectivity. For example, maybe your community should be adding more pedestrian-activated crossing signals or tapping into federal and state safe routes to school programs or adopting zoning ordinances that require sidewalks in all new developments.

Here in Brunswick, we have a very enviable walkability score of 87, meaning “most errands can be accomplished on foot.” We have a bicycle and pedestrian advisory committee that reports to the town council and works with the town engineer to advocate for infrastructure improvements that encourage pedestrian connectivity. However, funding these improvements in walkability is always a challenge. But as the analysis in this recent study suggestions, our biggest challenge continues to be encouraging our citizens to take advantage of our existing pedestrian infrastructure.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

“Honey, does this town make me look fat?”

“Yes, Dear, I’m afraid it does.”

No, that really wasn’t a typo in the first line. I intended to type “town” and not “gown.” A recent article by Dionysus Powell in healthcareinamerica.us has prompted me to think a bit more about the relationship between obesity and the communities we inhabit (“Fit Cities vs. Fat Cities – What available data can tell us about the difference in lifestyle and obesity between cities,” by Dionysus Powell, March 28, 2017). The author is a biotech researcher who has collected readily available Centers for Disease Control and Prevention data on body mass index (BMI) and self-reported sedentary behavior in almost 200 U.S. cities. He then sliced and diced these numbers with each cities’ walkability score, which is a crude measure of how easily citizens and visitors on foot can reach a variety of destinations such as shops, schools, churches, libraries, and municipal offices. You can easily find your own town’s score by going to walkscore.com.

He then resliced and -diced those numbers with CDC data on health outcomes and ethnic diversity, and resorted using meteorologic data on humidity and temperature using a multivariate analysis technique called multiple linear regression. The article is illustrated with one map and six scatter graphs.

Not surprisingly, the author discovered that “differences in obesity rates between cities can largely be explained by differences in physical activity.” Of course, there is a point at which a community has sufficient walkable infrastructure so that its obesity rate is a result of the citizens choosing not to walk rather than the community’s failure to provide pedestrians with enough connectivity to do their daily errands on foot. That threshold point appears to be a walkability score of 50, yet Mr. Powell observes that most American cities fail to reach even that minimum.

Although rich people tend to have better health outcomes than poor people, and there is a “general trend for richer cities to be more physically active than poorer cities,” Mr. Powell could not find a relationship between a city’s median income and its walkability.

If, like most of us, you have been frustrated in your efforts to lower the BMI of your patients, it may be time to emerge from the confines of your office and take a look at your town’s walkability score. If it is less than 50, you and your fellow concerned citizens and officials have some work to do. It may mean advocating for improved pedestrian infrastructure and/or dismantling the physical and zoning barriers to pedestrian connectivity. For example, maybe your community should be adding more pedestrian-activated crossing signals or tapping into federal and state safe routes to school programs or adopting zoning ordinances that require sidewalks in all new developments.

Here in Brunswick, we have a very enviable walkability score of 87, meaning “most errands can be accomplished on foot.” We have a bicycle and pedestrian advisory committee that reports to the town council and works with the town engineer to advocate for infrastructure improvements that encourage pedestrian connectivity. However, funding these improvements in walkability is always a challenge. But as the analysis in this recent study suggestions, our biggest challenge continues to be encouraging our citizens to take advantage of our existing pedestrian infrastructure.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

 

In a feature article in Pediatric News entitled “What do doctors want from health reform,” Alicia Gallegos reports on the results of a recent online Frontline Medical News poll of 390 physicians who were asked what one thing about the ACA they would change. The answers were scattered, but “Stabilize premiums and out of pocket expenses for patients” garnered 50% of the votes.

I suspect that this result was an anguished cry for some leadership in Washington. It could come from the left or the right or, even better, from a coalition. But please, we just need some clear leadership, some direction, and a plan that would allow all of us – physicians, patients, hospitals, and insurance companies – to get on with our various missions.

If asked what one thing about the ACA I would change, as the article did, I would have replied, “Are you kidding me? Just one thing?” Let’s go back to square one. Although “ACA” is the Affordable Care Act, most of the discussion has not been about the affordability of care but about the affordability of insurance coverage. I would like to see the discussion refocus on the cost of care because, if it goes up, the cost of insurance coverage must follow. The notion that merging smaller medical groups into larger conglomerates will create saving by an economy of scale has not worked out. The survivors may have been biggest, but they have not been the fittest nor the most cost effective in some part because the larger conglomerates aren’t as agile and able to respond to change as are the smaller groups.

The cost of medication is another major driver of health care cost. Any new plan or adjustments to the ACA should more forcefully rein in or outright eliminate the pharmacy benefit managers who needlessly add cost to medication. Although most of us grumble when faced with cookbook recipes for care that constrain our prescribing choices, we must accept that, in most cases, these evidence-based guidelines are necessary evils. At the same time, we should vigorously support and cooperate with the efforts to discipline the flagrant overprescribers in our midst.

It is not surprising that the ACA has had difficulty attracting young healthy people to buy health insurance that is costly even at a discount. Offering a lower price, no frills, catastrophic care option might be more appealing to young people who still see themselves as invincible. While, as pediatricians, we can see the benefit of immunizations and preventive care in the first year of life, it may be time for a more critical look at the cost benefit ratio for other preventive initiatives in older age groups that may sound good but are making health insurance more expensive.

Finally, an improved ACA should make reduction of the administrative burden of prior authorizations a high priority. Michael L. Munger, MD, president-elect of the American Academy of Family Physicians, suggests that a standard process for both private and publicly funded patients would allow physicians to focus their time and talents on more efficient patient care. The failure of the ACA to mandate even basic standardization for electronic health records has left us with a nonsystem made up of mini-systems that are neither user friendly nor capable of effectively communicating with one another.

It appears that this country doesn’t yet have the stomach for a single payer model. While I usually believe that compromise will yield a good result, the ACA is an example of when a leadership vacuum can result in a collection of bad compromises.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

 

[polldaddy:9708248]

 

In a feature article in Pediatric News entitled “What do doctors want from health reform,” Alicia Gallegos reports on the results of a recent online Frontline Medical News poll of 390 physicians who were asked what one thing about the ACA they would change. The answers were scattered, but “Stabilize premiums and out of pocket expenses for patients” garnered 50% of the votes.

I suspect that this result was an anguished cry for some leadership in Washington. It could come from the left or the right or, even better, from a coalition. But please, we just need some clear leadership, some direction, and a plan that would allow all of us – physicians, patients, hospitals, and insurance companies – to get on with our various missions.

If asked what one thing about the ACA I would change, as the article did, I would have replied, “Are you kidding me? Just one thing?” Let’s go back to square one. Although “ACA” is the Affordable Care Act, most of the discussion has not been about the affordability of care but about the affordability of insurance coverage. I would like to see the discussion refocus on the cost of care because, if it goes up, the cost of insurance coverage must follow. The notion that merging smaller medical groups into larger conglomerates will create saving by an economy of scale has not worked out. The survivors may have been biggest, but they have not been the fittest nor the most cost effective in some part because the larger conglomerates aren’t as agile and able to respond to change as are the smaller groups.

The cost of medication is another major driver of health care cost. Any new plan or adjustments to the ACA should more forcefully rein in or outright eliminate the pharmacy benefit managers who needlessly add cost to medication. Although most of us grumble when faced with cookbook recipes for care that constrain our prescribing choices, we must accept that, in most cases, these evidence-based guidelines are necessary evils. At the same time, we should vigorously support and cooperate with the efforts to discipline the flagrant overprescribers in our midst.

It is not surprising that the ACA has had difficulty attracting young healthy people to buy health insurance that is costly even at a discount. Offering a lower price, no frills, catastrophic care option might be more appealing to young people who still see themselves as invincible. While, as pediatricians, we can see the benefit of immunizations and preventive care in the first year of life, it may be time for a more critical look at the cost benefit ratio for other preventive initiatives in older age groups that may sound good but are making health insurance more expensive.

Finally, an improved ACA should make reduction of the administrative burden of prior authorizations a high priority. Michael L. Munger, MD, president-elect of the American Academy of Family Physicians, suggests that a standard process for both private and publicly funded patients would allow physicians to focus their time and talents on more efficient patient care. The failure of the ACA to mandate even basic standardization for electronic health records has left us with a nonsystem made up of mini-systems that are neither user friendly nor capable of effectively communicating with one another.

It appears that this country doesn’t yet have the stomach for a single payer model. While I usually believe that compromise will yield a good result, the ACA is an example of when a leadership vacuum can result in a collection of bad compromises.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

 

[polldaddy:9708248]

 

In a feature article in Pediatric News entitled “What do doctors want from health reform,” Alicia Gallegos reports on the results of a recent online Frontline Medical News poll of 390 physicians who were asked what one thing about the ACA they would change. The answers were scattered, but “Stabilize premiums and out of pocket expenses for patients” garnered 50% of the votes.

I suspect that this result was an anguished cry for some leadership in Washington. It could come from the left or the right or, even better, from a coalition. But please, we just need some clear leadership, some direction, and a plan that would allow all of us – physicians, patients, hospitals, and insurance companies – to get on with our various missions.

If asked what one thing about the ACA I would change, as the article did, I would have replied, “Are you kidding me? Just one thing?” Let’s go back to square one. Although “ACA” is the Affordable Care Act, most of the discussion has not been about the affordability of care but about the affordability of insurance coverage. I would like to see the discussion refocus on the cost of care because, if it goes up, the cost of insurance coverage must follow. The notion that merging smaller medical groups into larger conglomerates will create saving by an economy of scale has not worked out. The survivors may have been biggest, but they have not been the fittest nor the most cost effective in some part because the larger conglomerates aren’t as agile and able to respond to change as are the smaller groups.

The cost of medication is another major driver of health care cost. Any new plan or adjustments to the ACA should more forcefully rein in or outright eliminate the pharmacy benefit managers who needlessly add cost to medication. Although most of us grumble when faced with cookbook recipes for care that constrain our prescribing choices, we must accept that, in most cases, these evidence-based guidelines are necessary evils. At the same time, we should vigorously support and cooperate with the efforts to discipline the flagrant overprescribers in our midst.

It is not surprising that the ACA has had difficulty attracting young healthy people to buy health insurance that is costly even at a discount. Offering a lower price, no frills, catastrophic care option might be more appealing to young people who still see themselves as invincible. While, as pediatricians, we can see the benefit of immunizations and preventive care in the first year of life, it may be time for a more critical look at the cost benefit ratio for other preventive initiatives in older age groups that may sound good but are making health insurance more expensive.

Finally, an improved ACA should make reduction of the administrative burden of prior authorizations a high priority. Michael L. Munger, MD, president-elect of the American Academy of Family Physicians, suggests that a standard process for both private and publicly funded patients would allow physicians to focus their time and talents on more efficient patient care. The failure of the ACA to mandate even basic standardization for electronic health records has left us with a nonsystem made up of mini-systems that are neither user friendly nor capable of effectively communicating with one another.

It appears that this country doesn’t yet have the stomach for a single payer model. While I usually believe that compromise will yield a good result, the ACA is an example of when a leadership vacuum can result in a collection of bad compromises.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

 

[polldaddy:9708248]

 

You walk into an examining room and discover a 3-year-old in his underpants wearing a fireman’s hat and what must be his older sister’s rubber boots. You have to ask: “Are you going to be a firefighter when you grow up?” If he is a sensitive kid he will resist answering, “What do you think, Dr. Obvious?” and instead he politely replies, “Yes, and an EMT [emergency medical technician] too.”

Adults, even ones who have devoted their professional lives to the care of children, can’t seem to stifle the urge ask every young person they meet about his or her career plans. It is a strange sort of obsession, and may simply reflect the fact that most adults are at a loss for conversation starters when it comes to talking with young people. Children don’t seem to have much concern about the weather. And most of them don’t have opinions about the current political situation. They don’t have stories about their grandchildren they would love to bore you with. You could ask if the child has a pet, but that may be picking the scab of an unresolved family issue.

Most adults realize that their career plans prior to adolescence have no relationship to their present situation. Thinking back on this disconnect in their own lives may provide them with a good chuckle. But they also may hope to store away the child’s naive answer as ammunition for a future embarrassing challenge. “Do you remember that you once told me you were going to be a forest ranger?”

It may be that the child’s answer will give the adults an opportunity to share their “wisdom” based on their own career decisions. How lucky for the child who has stumbled on an unsolicited life coach.

For the most part, these interrogations about career planning are just idle banter. But as children get older, reality begins shining its harsh light on choices and decisions. What was once a seemingly harmless question about the distant future may no longer be so innocuous. I try to sound apologetic when I say to high school juniors and seniors, “I’m sure everyone is asking you, but what about college?” However, after reading a story in The Wall Street Journal, I now wonder whether I should be skipping the apology and just simply not raising the subject of college (“What’s Worse Than Waiting to Hear From Colleges? Getting Interrogated About It,” by Sue Shellenbarger, March 8, 2017).

In communities where most high school graduates have been on a college track since middle school, tension and anxiety hangs over the older adolescents like a cloud that darkens as application deadlines herald the long and painful wait for acceptance/rejection letters and emails. High school seniors are tired of thinking about the process and certainly don’t want to talk about. They consider questions about their future an invasion of their privacy. Redbubble, an online marketplace based in Australia, is seeing rising sales of T-shirts that read “Don’t ask me about college. Thanks.”

The unwelcome interrogations don’t stop with college acceptance. Adults want to know, “Have you chosen a major?” And as college graduation nears they can’t resist asking, “Do you have any job offers?”

Most adolescents and many 20-somethings don’t seem to have a career goal. It may be that they are afraid that the process of setting a goal will make them more vulnerable to failure. It also may be that revealing, “I’ve always wanted to be a ...” will label them as being a bit childish and weird.

Where does all this adolescent discomfort with the near future leave us pediatricians? The complete evaluation of a high school–age patient should include a question or questions about how our patient is weathering the college and career planning process. The challenge is how to present those questions in a manner that makes it clear that we aren’t just another one of those career-obsessed nosy adults.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

 

You walk into an examining room and discover a 3-year-old in his underpants wearing a fireman’s hat and what must be his older sister’s rubber boots. You have to ask: “Are you going to be a firefighter when you grow up?” If he is a sensitive kid he will resist answering, “What do you think, Dr. Obvious?” and instead he politely replies, “Yes, and an EMT [emergency medical technician] too.”

Adults, even ones who have devoted their professional lives to the care of children, can’t seem to stifle the urge ask every young person they meet about his or her career plans. It is a strange sort of obsession, and may simply reflect the fact that most adults are at a loss for conversation starters when it comes to talking with young people. Children don’t seem to have much concern about the weather. And most of them don’t have opinions about the current political situation. They don’t have stories about their grandchildren they would love to bore you with. You could ask if the child has a pet, but that may be picking the scab of an unresolved family issue.

Most adults realize that their career plans prior to adolescence have no relationship to their present situation. Thinking back on this disconnect in their own lives may provide them with a good chuckle. But they also may hope to store away the child’s naive answer as ammunition for a future embarrassing challenge. “Do you remember that you once told me you were going to be a forest ranger?”

It may be that the child’s answer will give the adults an opportunity to share their “wisdom” based on their own career decisions. How lucky for the child who has stumbled on an unsolicited life coach.

For the most part, these interrogations about career planning are just idle banter. But as children get older, reality begins shining its harsh light on choices and decisions. What was once a seemingly harmless question about the distant future may no longer be so innocuous. I try to sound apologetic when I say to high school juniors and seniors, “I’m sure everyone is asking you, but what about college?” However, after reading a story in The Wall Street Journal, I now wonder whether I should be skipping the apology and just simply not raising the subject of college (“What’s Worse Than Waiting to Hear From Colleges? Getting Interrogated About It,” by Sue Shellenbarger, March 8, 2017).

In communities where most high school graduates have been on a college track since middle school, tension and anxiety hangs over the older adolescents like a cloud that darkens as application deadlines herald the long and painful wait for acceptance/rejection letters and emails. High school seniors are tired of thinking about the process and certainly don’t want to talk about. They consider questions about their future an invasion of their privacy. Redbubble, an online marketplace based in Australia, is seeing rising sales of T-shirts that read “Don’t ask me about college. Thanks.”

The unwelcome interrogations don’t stop with college acceptance. Adults want to know, “Have you chosen a major?” And as college graduation nears they can’t resist asking, “Do you have any job offers?”

Most adolescents and many 20-somethings don’t seem to have a career goal. It may be that they are afraid that the process of setting a goal will make them more vulnerable to failure. It also may be that revealing, “I’ve always wanted to be a ...” will label them as being a bit childish and weird.

Where does all this adolescent discomfort with the near future leave us pediatricians? The complete evaluation of a high school–age patient should include a question or questions about how our patient is weathering the college and career planning process. The challenge is how to present those questions in a manner that makes it clear that we aren’t just another one of those career-obsessed nosy adults.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

 

You walk into an examining room and discover a 3-year-old in his underpants wearing a fireman’s hat and what must be his older sister’s rubber boots. You have to ask: “Are you going to be a firefighter when you grow up?” If he is a sensitive kid he will resist answering, “What do you think, Dr. Obvious?” and instead he politely replies, “Yes, and an EMT [emergency medical technician] too.”

Adults, even ones who have devoted their professional lives to the care of children, can’t seem to stifle the urge ask every young person they meet about his or her career plans. It is a strange sort of obsession, and may simply reflect the fact that most adults are at a loss for conversation starters when it comes to talking with young people. Children don’t seem to have much concern about the weather. And most of them don’t have opinions about the current political situation. They don’t have stories about their grandchildren they would love to bore you with. You could ask if the child has a pet, but that may be picking the scab of an unresolved family issue.

Most adults realize that their career plans prior to adolescence have no relationship to their present situation. Thinking back on this disconnect in their own lives may provide them with a good chuckle. But they also may hope to store away the child’s naive answer as ammunition for a future embarrassing challenge. “Do you remember that you once told me you were going to be a forest ranger?”

It may be that the child’s answer will give the adults an opportunity to share their “wisdom” based on their own career decisions. How lucky for the child who has stumbled on an unsolicited life coach.

For the most part, these interrogations about career planning are just idle banter. But as children get older, reality begins shining its harsh light on choices and decisions. What was once a seemingly harmless question about the distant future may no longer be so innocuous. I try to sound apologetic when I say to high school juniors and seniors, “I’m sure everyone is asking you, but what about college?” However, after reading a story in The Wall Street Journal, I now wonder whether I should be skipping the apology and just simply not raising the subject of college (“What’s Worse Than Waiting to Hear From Colleges? Getting Interrogated About It,” by Sue Shellenbarger, March 8, 2017).

In communities where most high school graduates have been on a college track since middle school, tension and anxiety hangs over the older adolescents like a cloud that darkens as application deadlines herald the long and painful wait for acceptance/rejection letters and emails. High school seniors are tired of thinking about the process and certainly don’t want to talk about. They consider questions about their future an invasion of their privacy. Redbubble, an online marketplace based in Australia, is seeing rising sales of T-shirts that read “Don’t ask me about college. Thanks.”

The unwelcome interrogations don’t stop with college acceptance. Adults want to know, “Have you chosen a major?” And as college graduation nears they can’t resist asking, “Do you have any job offers?”

Most adolescents and many 20-somethings don’t seem to have a career goal. It may be that they are afraid that the process of setting a goal will make them more vulnerable to failure. It also may be that revealing, “I’ve always wanted to be a ...” will label them as being a bit childish and weird.

Where does all this adolescent discomfort with the near future leave us pediatricians? The complete evaluation of a high school–age patient should include a question or questions about how our patient is weathering the college and career planning process. The challenge is how to present those questions in a manner that makes it clear that we aren’t just another one of those career-obsessed nosy adults.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.