William G. Wilkoff

If you manage to struggle your way to the back of the October 2014 Pediatrics, you will find a clinical report authored by members of the American Academy of Pediatrics Section on Integrative Medicine Executive Committee and the AAP Committee on Practice and Ambulatory Medicine (Pediatrics 2014;134:830-35 [doi: 10.1542/peds.2014-2278]). Under the title Physician Health and Wellness, the authors have carved out an approach to physician burnout, not by addressing its treatment but instead addressing it from the perspective of prevention.

Although the authors refer to two systems-based initiatives that have been launched in the last several years, unfortunately they shy away from making any specific recommendations themselves.

Not surprisingly, they observe that a mentally healthy physician is usually a physically healthy physician who eats well, sleeps well, and exercises regularly. He probably has supportive friends and/or family, and knows how to partition his life in a way that allows him time for one or two pursuits that he enjoys outside of his professional activities. Unless, of course, he is one of those lucky few who derives enough enjoyment from his patients. I would add that a mentally healthy, burnout-resistant physician is one whose expectations for his life are well within his abilities and the situation in which he finds himself.

But, why not give us some specifics on how we might guide young physicians onto paths that will maximize their resistance to burnout while it is still a preventable condition? For starters, why not consider a potential medical student’s ability to make healthy lifestyle choices? How many medical school admissions officers ask about the applicant’s exercise and sleep history ... and hobbies? An urban legend has it that the admissions director where I attended medical school occasionally performed his own little stress tests by among other things, asking the interviewee to open a window that had been painted shut. His efforts may have been crude and cruel, but why not give more attention to seeking out medical students who have already demonstrated some ability to find balance in their lives?

Once in medical school, students should have mentors or coaches who are good role models of wellness and who have the commitment to meet with the students on a regular basis. Encourage medical students to keep and share with their mentors diaries that include their exercise, sleep, and dietary schedules as well as observations on their own mental health. It’s gotta be easy on a smart phone. This may sound like smothering with mothering, but the magnitude of the problem of burnout deserves a more hands-on approach.

As students approach the last 2 years of school, they should be coached on what to expect from postgraduate training and the career paths they are considering. They should be encouraged to consider their own strengths and vulnerabilities, and how these will mesh with the realities of life as a practicing physician.

In the generation just ahead of me, some of the elite house officer training programs required that their house officers be single, because the program administrators felt that the life of a house officer was not compatible with married life. I’m not suggesting that we return to those monastic days, but medical students and young physicians need to be coached on how to be more realistic when making career choices and family planning decisions. One survey noted by the authors of this report has shown that not having minor children in the home was associated with less stress.

The authors offer “mindfulness” as an avenue worthy of consideration. It is a concept that I have trouble grasping, other than seeing it as a reminder to folks to stop just going through the motions and make a broad and honest assessment of their current situations. I guess if it helps a young physician to realize that if he moved a half-hour closer to work he would gain an hour a day with his family, “mindfulness” makes sense.

Finally, this AAP clinical report ignores one of the most serious contributors to physician burnout: electronic medical records. Everyone on the front lines knows it and talks about it. But, for the decision makers it continues to be the elephant in the room. It may take someone with a heavy hand and some common sense, but with good leadership a national electronic health record system that works is within reach.

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.” E-mail him at pdnews@frontlinemedcom.com.

If you manage to struggle your way to the back of the October 2014 Pediatrics, you will find a clinical report authored by members of the American Academy of Pediatrics Section on Integrative Medicine Executive Committee and the AAP Committee on Practice and Ambulatory Medicine (Pediatrics 2014;134:830-35 [doi: 10.1542/peds.2014-2278]). Under the title Physician Health and Wellness, the authors have carved out an approach to physician burnout, not by addressing its treatment but instead addressing it from the perspective of prevention.

Although the authors refer to two systems-based initiatives that have been launched in the last several years, unfortunately they shy away from making any specific recommendations themselves.

Not surprisingly, they observe that a mentally healthy physician is usually a physically healthy physician who eats well, sleeps well, and exercises regularly. He probably has supportive friends and/or family, and knows how to partition his life in a way that allows him time for one or two pursuits that he enjoys outside of his professional activities. Unless, of course, he is one of those lucky few who derives enough enjoyment from his patients. I would add that a mentally healthy, burnout-resistant physician is one whose expectations for his life are well within his abilities and the situation in which he finds himself.

But, why not give us some specifics on how we might guide young physicians onto paths that will maximize their resistance to burnout while it is still a preventable condition? For starters, why not consider a potential medical student’s ability to make healthy lifestyle choices? How many medical school admissions officers ask about the applicant’s exercise and sleep history ... and hobbies? An urban legend has it that the admissions director where I attended medical school occasionally performed his own little stress tests by among other things, asking the interviewee to open a window that had been painted shut. His efforts may have been crude and cruel, but why not give more attention to seeking out medical students who have already demonstrated some ability to find balance in their lives?

Once in medical school, students should have mentors or coaches who are good role models of wellness and who have the commitment to meet with the students on a regular basis. Encourage medical students to keep and share with their mentors diaries that include their exercise, sleep, and dietary schedules as well as observations on their own mental health. It’s gotta be easy on a smart phone. This may sound like smothering with mothering, but the magnitude of the problem of burnout deserves a more hands-on approach.

As students approach the last 2 years of school, they should be coached on what to expect from postgraduate training and the career paths they are considering. They should be encouraged to consider their own strengths and vulnerabilities, and how these will mesh with the realities of life as a practicing physician.

In the generation just ahead of me, some of the elite house officer training programs required that their house officers be single, because the program administrators felt that the life of a house officer was not compatible with married life. I’m not suggesting that we return to those monastic days, but medical students and young physicians need to be coached on how to be more realistic when making career choices and family planning decisions. One survey noted by the authors of this report has shown that not having minor children in the home was associated with less stress.

The authors offer “mindfulness” as an avenue worthy of consideration. It is a concept that I have trouble grasping, other than seeing it as a reminder to folks to stop just going through the motions and make a broad and honest assessment of their current situations. I guess if it helps a young physician to realize that if he moved a half-hour closer to work he would gain an hour a day with his family, “mindfulness” makes sense.

Finally, this AAP clinical report ignores one of the most serious contributors to physician burnout: electronic medical records. Everyone on the front lines knows it and talks about it. But, for the decision makers it continues to be the elephant in the room. It may take someone with a heavy hand and some common sense, but with good leadership a national electronic health record system that works is within reach.

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.” E-mail him at pdnews@frontlinemedcom.com.

If you manage to struggle your way to the back of the October 2014 Pediatrics, you will find a clinical report authored by members of the American Academy of Pediatrics Section on Integrative Medicine Executive Committee and the AAP Committee on Practice and Ambulatory Medicine (Pediatrics 2014;134:830-35 [doi: 10.1542/peds.2014-2278]). Under the title Physician Health and Wellness, the authors have carved out an approach to physician burnout, not by addressing its treatment but instead addressing it from the perspective of prevention.

Although the authors refer to two systems-based initiatives that have been launched in the last several years, unfortunately they shy away from making any specific recommendations themselves.

Not surprisingly, they observe that a mentally healthy physician is usually a physically healthy physician who eats well, sleeps well, and exercises regularly. He probably has supportive friends and/or family, and knows how to partition his life in a way that allows him time for one or two pursuits that he enjoys outside of his professional activities. Unless, of course, he is one of those lucky few who derives enough enjoyment from his patients. I would add that a mentally healthy, burnout-resistant physician is one whose expectations for his life are well within his abilities and the situation in which he finds himself.

But, why not give us some specifics on how we might guide young physicians onto paths that will maximize their resistance to burnout while it is still a preventable condition? For starters, why not consider a potential medical student’s ability to make healthy lifestyle choices? How many medical school admissions officers ask about the applicant’s exercise and sleep history ... and hobbies? An urban legend has it that the admissions director where I attended medical school occasionally performed his own little stress tests by among other things, asking the interviewee to open a window that had been painted shut. His efforts may have been crude and cruel, but why not give more attention to seeking out medical students who have already demonstrated some ability to find balance in their lives?

Once in medical school, students should have mentors or coaches who are good role models of wellness and who have the commitment to meet with the students on a regular basis. Encourage medical students to keep and share with their mentors diaries that include their exercise, sleep, and dietary schedules as well as observations on their own mental health. It’s gotta be easy on a smart phone. This may sound like smothering with mothering, but the magnitude of the problem of burnout deserves a more hands-on approach.

As students approach the last 2 years of school, they should be coached on what to expect from postgraduate training and the career paths they are considering. They should be encouraged to consider their own strengths and vulnerabilities, and how these will mesh with the realities of life as a practicing physician.

In the generation just ahead of me, some of the elite house officer training programs required that their house officers be single, because the program administrators felt that the life of a house officer was not compatible with married life. I’m not suggesting that we return to those monastic days, but medical students and young physicians need to be coached on how to be more realistic when making career choices and family planning decisions. One survey noted by the authors of this report has shown that not having minor children in the home was associated with less stress.

The authors offer “mindfulness” as an avenue worthy of consideration. It is a concept that I have trouble grasping, other than seeing it as a reminder to folks to stop just going through the motions and make a broad and honest assessment of their current situations. I guess if it helps a young physician to realize that if he moved a half-hour closer to work he would gain an hour a day with his family, “mindfulness” makes sense.

Finally, this AAP clinical report ignores one of the most serious contributors to physician burnout: electronic medical records. Everyone on the front lines knows it and talks about it. But, for the decision makers it continues to be the elephant in the room. It may take someone with a heavy hand and some common sense, but with good leadership a national electronic health record system that works is within reach.

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.” E-mail him at pdnews@frontlinemedcom.com.

It was nearly 20 years ago that I first learned about the efforts to delay school start time in hopes that it might help sleep deprived teenagers become better students. From its epicenter in greater Minneapolis, this low amplitude groundswell has rattled a few school districts to change their schedules. But, it hasn’t really caught on. When it was considered here in Brunswick about 15 years ago, parents and school board members were sympathetic to the plight of teenagers suffering from morning drowsiness. But, the cascade of schedule disruptions that would be triggered by tinkering with high school start times was too daunting, and the issue faded on everyone’s radar screens.

However, according to an article in the New York Times ("To Keep Teenagers Alert, Schools Let Them Sleep In," Jan Hoffman, March 13, 2014), the movement has rumbled to life in a variety of school districts across the country. Some of the resurgence in interest may be the result of recent data collected by researchers at the University of Minnesota. They found that teenagers who took advantage of the delayed starts by getting more sleep performed better academically and were involved in fewer motor vehicle crashes.

There is now a growing body of evidence linking sleep deprivation to a variety of ills including depression, hyperactivity, inattention, and migraine headaches, just to name a few. Research at Brown University by Mary Carskadon, Ph.D., suggests that the adolescent brain is chemically and structurally vulnerable to changes in sleep onset and duration. In her studies on humans and a variety of small mammals Dr. Carskadon has demonstrated that while the adolescent brain is more capable at staying awake later in the day, it still requires the same amount of sleep as it did during prepuberty. In other words, if we allow teenagers to push back their bedtimes by 2 hours but continue to demand that they be in school at 7:30 in the morning, we will continue to see the behavioral and physiologic damage related to sleep deprivation. This is clearly a case of watching a generation of candles burning at both ends. The efforts to delay school start times address only the smoldering at one end of the candle.

While Dr. Carskadon’s research suggests that it is physiologically easier for teenagers to stay up later, it doesn’t mean that we need fan the flame by making it any easier. The result of one study has shown that teenagers got more sleep if their parents had set a bedtime ... even if it wasn’t enforced. They got even more if it was enforced.

In the recent University of Minnesota studies, 88% of the students had cell phones in their bedrooms. Other studies have shown that having a television or other electronic distraction in the bedroom delays sleep onset and shortens sleep duration. Clearly, there is abundance of room for change in the sleep onset side of equation if we want our teenagers to be less sleep deprived. But, parents need to initiate the change.

Unfortunately, some of this research has spawned a myth that teenagers are biologically predestined to stay up late and sleep late, and, there’s nothing we can do about it. The armed services have disproved this myth many times over. I’m not suggesting we turn our schools into boot camps. But, any community that is considering a delayed high school start time should make it part of broad and frank discussion about sleep hygiene. Merely allowing teenagers to sleep an extra hour doesn’t even address half of the problem of sleep deprivation.

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."

It was nearly 20 years ago that I first learned about the efforts to delay school start time in hopes that it might help sleep deprived teenagers become better students. From its epicenter in greater Minneapolis, this low amplitude groundswell has rattled a few school districts to change their schedules. But, it hasn’t really caught on. When it was considered here in Brunswick about 15 years ago, parents and school board members were sympathetic to the plight of teenagers suffering from morning drowsiness. But, the cascade of schedule disruptions that would be triggered by tinkering with high school start times was too daunting, and the issue faded on everyone’s radar screens.

However, according to an article in the New York Times ("To Keep Teenagers Alert, Schools Let Them Sleep In," Jan Hoffman, March 13, 2014), the movement has rumbled to life in a variety of school districts across the country. Some of the resurgence in interest may be the result of recent data collected by researchers at the University of Minnesota. They found that teenagers who took advantage of the delayed starts by getting more sleep performed better academically and were involved in fewer motor vehicle crashes.

There is now a growing body of evidence linking sleep deprivation to a variety of ills including depression, hyperactivity, inattention, and migraine headaches, just to name a few. Research at Brown University by Mary Carskadon, Ph.D., suggests that the adolescent brain is chemically and structurally vulnerable to changes in sleep onset and duration. In her studies on humans and a variety of small mammals Dr. Carskadon has demonstrated that while the adolescent brain is more capable at staying awake later in the day, it still requires the same amount of sleep as it did during prepuberty. In other words, if we allow teenagers to push back their bedtimes by 2 hours but continue to demand that they be in school at 7:30 in the morning, we will continue to see the behavioral and physiologic damage related to sleep deprivation. This is clearly a case of watching a generation of candles burning at both ends. The efforts to delay school start times address only the smoldering at one end of the candle.

While Dr. Carskadon’s research suggests that it is physiologically easier for teenagers to stay up later, it doesn’t mean that we need fan the flame by making it any easier. The result of one study has shown that teenagers got more sleep if their parents had set a bedtime ... even if it wasn’t enforced. They got even more if it was enforced.

In the recent University of Minnesota studies, 88% of the students had cell phones in their bedrooms. Other studies have shown that having a television or other electronic distraction in the bedroom delays sleep onset and shortens sleep duration. Clearly, there is abundance of room for change in the sleep onset side of equation if we want our teenagers to be less sleep deprived. But, parents need to initiate the change.

Unfortunately, some of this research has spawned a myth that teenagers are biologically predestined to stay up late and sleep late, and, there’s nothing we can do about it. The armed services have disproved this myth many times over. I’m not suggesting we turn our schools into boot camps. But, any community that is considering a delayed high school start time should make it part of broad and frank discussion about sleep hygiene. Merely allowing teenagers to sleep an extra hour doesn’t even address half of the problem of sleep deprivation.

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."

It was nearly 20 years ago that I first learned about the efforts to delay school start time in hopes that it might help sleep deprived teenagers become better students. From its epicenter in greater Minneapolis, this low amplitude groundswell has rattled a few school districts to change their schedules. But, it hasn’t really caught on. When it was considered here in Brunswick about 15 years ago, parents and school board members were sympathetic to the plight of teenagers suffering from morning drowsiness. But, the cascade of schedule disruptions that would be triggered by tinkering with high school start times was too daunting, and the issue faded on everyone’s radar screens.

However, according to an article in the New York Times ("To Keep Teenagers Alert, Schools Let Them Sleep In," Jan Hoffman, March 13, 2014), the movement has rumbled to life in a variety of school districts across the country. Some of the resurgence in interest may be the result of recent data collected by researchers at the University of Minnesota. They found that teenagers who took advantage of the delayed starts by getting more sleep performed better academically and were involved in fewer motor vehicle crashes.

There is now a growing body of evidence linking sleep deprivation to a variety of ills including depression, hyperactivity, inattention, and migraine headaches, just to name a few. Research at Brown University by Mary Carskadon, Ph.D., suggests that the adolescent brain is chemically and structurally vulnerable to changes in sleep onset and duration. In her studies on humans and a variety of small mammals Dr. Carskadon has demonstrated that while the adolescent brain is more capable at staying awake later in the day, it still requires the same amount of sleep as it did during prepuberty. In other words, if we allow teenagers to push back their bedtimes by 2 hours but continue to demand that they be in school at 7:30 in the morning, we will continue to see the behavioral and physiologic damage related to sleep deprivation. This is clearly a case of watching a generation of candles burning at both ends. The efforts to delay school start times address only the smoldering at one end of the candle.

While Dr. Carskadon’s research suggests that it is physiologically easier for teenagers to stay up later, it doesn’t mean that we need fan the flame by making it any easier. The result of one study has shown that teenagers got more sleep if their parents had set a bedtime ... even if it wasn’t enforced. They got even more if it was enforced.

In the recent University of Minnesota studies, 88% of the students had cell phones in their bedrooms. Other studies have shown that having a television or other electronic distraction in the bedroom delays sleep onset and shortens sleep duration. Clearly, there is abundance of room for change in the sleep onset side of equation if we want our teenagers to be less sleep deprived. But, parents need to initiate the change.

Unfortunately, some of this research has spawned a myth that teenagers are biologically predestined to stay up late and sleep late, and, there’s nothing we can do about it. The armed services have disproved this myth many times over. I’m not suggesting we turn our schools into boot camps. But, any community that is considering a delayed high school start time should make it part of broad and frank discussion about sleep hygiene. Merely allowing teenagers to sleep an extra hour doesn’t even address half of the problem of sleep deprivation.

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."

Would you tell your children to eliminate the practice of medicine from their list of potential career paths? It’s not a question I ever needed to consider. Although my three children are bright and have a good work ethic, none of them considered becoming a doctor. At least if they did, I wasn’t consulted. Two of them have always been squeamish about body fluids, and that was probably a deal breaker for them. It certainly wasn’t because I complained about my job. I don’t recall ever grumbling about being a pediatrician. Although my considerably less-than-perfect attendance at dinner and their sporting events may have prompted them to seek a more family-friendly profession.

In a recent column, Dr. Allan M. Block wrote a piece titled "Why I’m happy my kids don’t want to be doctors"(January 2014, p. 16). In his sad-but-true commentary, he imagines how uncomfortable it must be to leave medical school with nearly a quarter of a million dollars in debt, a burden that must affect how young doctors choose what and how they practice. While none of us planned to practice rogue medicine, Dr. Block also bemoans the fact that "people who know nothing about medicine try to tell us what we can or can’t do."

Is his commentary merely a burnout candidate’s last rant before the flames reach his vital organs? Or, is he speaking for the many physicians who have worked long enough to realize that the practice of medicine has moved perilously close to the point where the cost/benefit ratio has tipped to the "it-isn’t-worth-it" side?

While none of my children sought my opinion on medicine as a career path, scores of my patients have shared their dreams of becoming physicians. Whenever this has happened, I egotistically hope that in some way I may have served as a positive role model they wish to emulate. But, I have learned that there are usually more potent motivators lurking in the background. While still puffed up with undeserved pride, I also assume that they are asking for my opinion on their plans . . . which of course they are not.

I ignore the obvious and offer, "Well, it may not be as much fun as it was 20 years ago, but being a pediatrician is still a lot of fun." Of course, this begs the question, If I were in their shoes today, would I apply to medical school?

Hesitant to throw too much cold water on their enthusiasm, I am sure to reassure them that I think they would make wonderful doctors. But, I add that becoming a physician is a long and expensive process. I hope that they are still listening when I add, "You know that nurse practitioners and physician assistants get to do almost all of the cool things I enjoy the most about being a pediatrician, . . . and the training is certainly shorter and less costly."

Of course, choosing either of these nonphysician career paths will rob their parents of the opportunity to introduce them at cocktail parties as "Our daughter, the doctor." But, the trade-off is that they will be more likely to be content with their jobs.

While my observations may be good advice for some of my patients, it leaves unanswered what to do about the malaise that hangs over Dr. Block and many of our colleagues. Educational debt has robbed some young doctors of their entrepreneurial spirit. Pressures from the government and third-party payers have nibbled away at our autonomy. And, the threat of malpractice action has smothered many of us in a blanket of fear.

Even in the face of all this gloom, if one of my grandchildren told me that they really wanted to be a pediatrician and expressed no interest in the nurse practitioner option, I would be candid in describing the erosion that has occurred over the course of my career. But, I would challenge them to tell me another job that could offer them even half of the opportunities to feel needed and appreciated that I have enjoyed. Hopefully, at least some of the frustrating downsides of medicine today will be reversed by the time they enter practice.

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." E-mail him at pdnews@frontlinemedcom.com.

Would you tell your children to eliminate the practice of medicine from their list of potential career paths? It’s not a question I ever needed to consider. Although my three children are bright and have a good work ethic, none of them considered becoming a doctor. At least if they did, I wasn’t consulted. Two of them have always been squeamish about body fluids, and that was probably a deal breaker for them. It certainly wasn’t because I complained about my job. I don’t recall ever grumbling about being a pediatrician. Although my considerably less-than-perfect attendance at dinner and their sporting events may have prompted them to seek a more family-friendly profession.

In a recent column, Dr. Allan M. Block wrote a piece titled "Why I’m happy my kids don’t want to be doctors"(January 2014, p. 16). In his sad-but-true commentary, he imagines how uncomfortable it must be to leave medical school with nearly a quarter of a million dollars in debt, a burden that must affect how young doctors choose what and how they practice. While none of us planned to practice rogue medicine, Dr. Block also bemoans the fact that "people who know nothing about medicine try to tell us what we can or can’t do."

Is his commentary merely a burnout candidate’s last rant before the flames reach his vital organs? Or, is he speaking for the many physicians who have worked long enough to realize that the practice of medicine has moved perilously close to the point where the cost/benefit ratio has tipped to the "it-isn’t-worth-it" side?

While none of my children sought my opinion on medicine as a career path, scores of my patients have shared their dreams of becoming physicians. Whenever this has happened, I egotistically hope that in some way I may have served as a positive role model they wish to emulate. But, I have learned that there are usually more potent motivators lurking in the background. While still puffed up with undeserved pride, I also assume that they are asking for my opinion on their plans . . . which of course they are not.

I ignore the obvious and offer, "Well, it may not be as much fun as it was 20 years ago, but being a pediatrician is still a lot of fun." Of course, this begs the question, If I were in their shoes today, would I apply to medical school?

Hesitant to throw too much cold water on their enthusiasm, I am sure to reassure them that I think they would make wonderful doctors. But, I add that becoming a physician is a long and expensive process. I hope that they are still listening when I add, "You know that nurse practitioners and physician assistants get to do almost all of the cool things I enjoy the most about being a pediatrician, . . . and the training is certainly shorter and less costly."

Of course, choosing either of these nonphysician career paths will rob their parents of the opportunity to introduce them at cocktail parties as "Our daughter, the doctor." But, the trade-off is that they will be more likely to be content with their jobs.

While my observations may be good advice for some of my patients, it leaves unanswered what to do about the malaise that hangs over Dr. Block and many of our colleagues. Educational debt has robbed some young doctors of their entrepreneurial spirit. Pressures from the government and third-party payers have nibbled away at our autonomy. And, the threat of malpractice action has smothered many of us in a blanket of fear.

Even in the face of all this gloom, if one of my grandchildren told me that they really wanted to be a pediatrician and expressed no interest in the nurse practitioner option, I would be candid in describing the erosion that has occurred over the course of my career. But, I would challenge them to tell me another job that could offer them even half of the opportunities to feel needed and appreciated that I have enjoyed. Hopefully, at least some of the frustrating downsides of medicine today will be reversed by the time they enter practice.

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." E-mail him at pdnews@frontlinemedcom.com.

Would you tell your children to eliminate the practice of medicine from their list of potential career paths? It’s not a question I ever needed to consider. Although my three children are bright and have a good work ethic, none of them considered becoming a doctor. At least if they did, I wasn’t consulted. Two of them have always been squeamish about body fluids, and that was probably a deal breaker for them. It certainly wasn’t because I complained about my job. I don’t recall ever grumbling about being a pediatrician. Although my considerably less-than-perfect attendance at dinner and their sporting events may have prompted them to seek a more family-friendly profession.

In a recent column, Dr. Allan M. Block wrote a piece titled "Why I’m happy my kids don’t want to be doctors"(January 2014, p. 16). In his sad-but-true commentary, he imagines how uncomfortable it must be to leave medical school with nearly a quarter of a million dollars in debt, a burden that must affect how young doctors choose what and how they practice. While none of us planned to practice rogue medicine, Dr. Block also bemoans the fact that "people who know nothing about medicine try to tell us what we can or can’t do."

Is his commentary merely a burnout candidate’s last rant before the flames reach his vital organs? Or, is he speaking for the many physicians who have worked long enough to realize that the practice of medicine has moved perilously close to the point where the cost/benefit ratio has tipped to the "it-isn’t-worth-it" side?

While none of my children sought my opinion on medicine as a career path, scores of my patients have shared their dreams of becoming physicians. Whenever this has happened, I egotistically hope that in some way I may have served as a positive role model they wish to emulate. But, I have learned that there are usually more potent motivators lurking in the background. While still puffed up with undeserved pride, I also assume that they are asking for my opinion on their plans . . . which of course they are not.

I ignore the obvious and offer, "Well, it may not be as much fun as it was 20 years ago, but being a pediatrician is still a lot of fun." Of course, this begs the question, If I were in their shoes today, would I apply to medical school?

Hesitant to throw too much cold water on their enthusiasm, I am sure to reassure them that I think they would make wonderful doctors. But, I add that becoming a physician is a long and expensive process. I hope that they are still listening when I add, "You know that nurse practitioners and physician assistants get to do almost all of the cool things I enjoy the most about being a pediatrician, . . . and the training is certainly shorter and less costly."

Of course, choosing either of these nonphysician career paths will rob their parents of the opportunity to introduce them at cocktail parties as "Our daughter, the doctor." But, the trade-off is that they will be more likely to be content with their jobs.

While my observations may be good advice for some of my patients, it leaves unanswered what to do about the malaise that hangs over Dr. Block and many of our colleagues. Educational debt has robbed some young doctors of their entrepreneurial spirit. Pressures from the government and third-party payers have nibbled away at our autonomy. And, the threat of malpractice action has smothered many of us in a blanket of fear.

Even in the face of all this gloom, if one of my grandchildren told me that they really wanted to be a pediatrician and expressed no interest in the nurse practitioner option, I would be candid in describing the erosion that has occurred over the course of my career. But, I would challenge them to tell me another job that could offer them even half of the opportunities to feel needed and appreciated that I have enjoyed. Hopefully, at least some of the frustrating downsides of medicine today will be reversed by the time they enter practice.

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." E-mail him at pdnews@frontlinemedcom.com.

Some of the darkest hours during my house officer training (and there were more than a few) came when it was my job to extract a blood sample from a young child or infant, or even worse, a preemie. Those were the days before multiport indwelling catheters had been invented. Finding an unused vein could take an hour. Eventually, one might resort to a femoral stick or the infamous internal jugular approach.

Even in hospitals devoted to the care of children, laboratories often asked for samples that if successfully obtained would result in an iatrogenic anemia or exsanguination. For house officers, the three most dreaded letters were Q-N-S on a lab slip.

Some tests had been successfully miniaturized, but even getting a free-flowing finger or heel stick in a sick infant isn’t easy. Heavy-handed attempts at getting blood out of one of these little turnips often resulted in a useless hemolyzed sample.

It’s not surprising that pediatricians in my demographic are often loath to order lab tests. Posttraumatic stress can be a potent behavior modifier. But, I’m sure that despite advances in lab diagnostics and phlebotomy techniques, those of you who were trained in the last 20 years have also had your share of frustrating experiences getting blood from your smallest patients.

However, it appears that the next generation of house officers isn’t going to have any phlebotomy war stories to share. The woman who promises to put an end to this bloodletting torture that my patients and I endured is a 29-year-old who dropped out of Stanford at 19, cashed in her parents’ education trust, and started her own bioscience company, now known as Theranos.

After 10 years of research and development Elizabeth Holmes says she now has a system that can provide accurate results for more than a thousand tests on a blood sample the size of a raindrop. And, the results will be ready "in as little as 2 hours" ("Elizabeth Holmes: The Breakthrough of Instant Diagnosis," by Joseph Rago, Wall Street Journal, Sept. 8, 2013). And, she claims the results will be more accurate than current lab techniques, in part because of reduced bench and handling time. And, and ... there’s more. The tests will be half the cost and could save Medicare and Medicaid $150 billion over a 10-year period.

Ms. Holmes has already entered into an arrangement with Walgreens to develop in-store sample collection centers. Her long-term goal is to provide her service "within 5 miles of virtually every American home."

Hmmm. Maybe it’s time for us to pause and take a breath. Listen. Is that creaking sound I hear the rusty hinges of Pandora’s box opening? It’s hard to argue with cutting health care costs, improving accuracy, and shortening the anxiety-provoking wait that many patients endure waiting for their lab results to reach them. But, this "breakthrough" sounds like it has the potential for creating a tsunami of TMI (too much information).

Physicians already order too many lab tests, in many cases a defensive strategy. Often physicians don’t know what to do with borderline results. The temptation is to retest, and soon the doctor finds herself in unfamiliar waters chasing an elusive school of red herring. The Theranos technology promises to make ordering blood tests cheaper and easier, and, predictably, physicians will respond by ordering more of them.

We know that pathologists and the folks who run for-profit laboratories are going to balk at this new system. But, the rest of us will need to figure out how we can deal with the glut of data and help our patients benefit from what promises to be a significant upside of this breakthrough technology.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He continues to monitor and comment on anything pediatric. E-mail him at pdnews@frontlinemedcom.com.

Some of the darkest hours during my house officer training (and there were more than a few) came when it was my job to extract a blood sample from a young child or infant, or even worse, a preemie. Those were the days before multiport indwelling catheters had been invented. Finding an unused vein could take an hour. Eventually, one might resort to a femoral stick or the infamous internal jugular approach.

Even in hospitals devoted to the care of children, laboratories often asked for samples that if successfully obtained would result in an iatrogenic anemia or exsanguination. For house officers, the three most dreaded letters were Q-N-S on a lab slip.

Some tests had been successfully miniaturized, but even getting a free-flowing finger or heel stick in a sick infant isn’t easy. Heavy-handed attempts at getting blood out of one of these little turnips often resulted in a useless hemolyzed sample.

It’s not surprising that pediatricians in my demographic are often loath to order lab tests. Posttraumatic stress can be a potent behavior modifier. But, I’m sure that despite advances in lab diagnostics and phlebotomy techniques, those of you who were trained in the last 20 years have also had your share of frustrating experiences getting blood from your smallest patients.

However, it appears that the next generation of house officers isn’t going to have any phlebotomy war stories to share. The woman who promises to put an end to this bloodletting torture that my patients and I endured is a 29-year-old who dropped out of Stanford at 19, cashed in her parents’ education trust, and started her own bioscience company, now known as Theranos.

After 10 years of research and development Elizabeth Holmes says she now has a system that can provide accurate results for more than a thousand tests on a blood sample the size of a raindrop. And, the results will be ready "in as little as 2 hours" ("Elizabeth Holmes: The Breakthrough of Instant Diagnosis," by Joseph Rago, Wall Street Journal, Sept. 8, 2013). And, she claims the results will be more accurate than current lab techniques, in part because of reduced bench and handling time. And, and ... there’s more. The tests will be half the cost and could save Medicare and Medicaid $150 billion over a 10-year period.

Ms. Holmes has already entered into an arrangement with Walgreens to develop in-store sample collection centers. Her long-term goal is to provide her service "within 5 miles of virtually every American home."

Hmmm. Maybe it’s time for us to pause and take a breath. Listen. Is that creaking sound I hear the rusty hinges of Pandora’s box opening? It’s hard to argue with cutting health care costs, improving accuracy, and shortening the anxiety-provoking wait that many patients endure waiting for their lab results to reach them. But, this "breakthrough" sounds like it has the potential for creating a tsunami of TMI (too much information).

Physicians already order too many lab tests, in many cases a defensive strategy. Often physicians don’t know what to do with borderline results. The temptation is to retest, and soon the doctor finds herself in unfamiliar waters chasing an elusive school of red herring. The Theranos technology promises to make ordering blood tests cheaper and easier, and, predictably, physicians will respond by ordering more of them.

We know that pathologists and the folks who run for-profit laboratories are going to balk at this new system. But, the rest of us will need to figure out how we can deal with the glut of data and help our patients benefit from what promises to be a significant upside of this breakthrough technology.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He continues to monitor and comment on anything pediatric. E-mail him at pdnews@frontlinemedcom.com.

Some of the darkest hours during my house officer training (and there were more than a few) came when it was my job to extract a blood sample from a young child or infant, or even worse, a preemie. Those were the days before multiport indwelling catheters had been invented. Finding an unused vein could take an hour. Eventually, one might resort to a femoral stick or the infamous internal jugular approach.

Even in hospitals devoted to the care of children, laboratories often asked for samples that if successfully obtained would result in an iatrogenic anemia or exsanguination. For house officers, the three most dreaded letters were Q-N-S on a lab slip.

Some tests had been successfully miniaturized, but even getting a free-flowing finger or heel stick in a sick infant isn’t easy. Heavy-handed attempts at getting blood out of one of these little turnips often resulted in a useless hemolyzed sample.

It’s not surprising that pediatricians in my demographic are often loath to order lab tests. Posttraumatic stress can be a potent behavior modifier. But, I’m sure that despite advances in lab diagnostics and phlebotomy techniques, those of you who were trained in the last 20 years have also had your share of frustrating experiences getting blood from your smallest patients.

However, it appears that the next generation of house officers isn’t going to have any phlebotomy war stories to share. The woman who promises to put an end to this bloodletting torture that my patients and I endured is a 29-year-old who dropped out of Stanford at 19, cashed in her parents’ education trust, and started her own bioscience company, now known as Theranos.

After 10 years of research and development Elizabeth Holmes says she now has a system that can provide accurate results for more than a thousand tests on a blood sample the size of a raindrop. And, the results will be ready "in as little as 2 hours" ("Elizabeth Holmes: The Breakthrough of Instant Diagnosis," by Joseph Rago, Wall Street Journal, Sept. 8, 2013). And, she claims the results will be more accurate than current lab techniques, in part because of reduced bench and handling time. And, and ... there’s more. The tests will be half the cost and could save Medicare and Medicaid $150 billion over a 10-year period.

Ms. Holmes has already entered into an arrangement with Walgreens to develop in-store sample collection centers. Her long-term goal is to provide her service "within 5 miles of virtually every American home."

Hmmm. Maybe it’s time for us to pause and take a breath. Listen. Is that creaking sound I hear the rusty hinges of Pandora’s box opening? It’s hard to argue with cutting health care costs, improving accuracy, and shortening the anxiety-provoking wait that many patients endure waiting for their lab results to reach them. But, this "breakthrough" sounds like it has the potential for creating a tsunami of TMI (too much information).

Physicians already order too many lab tests, in many cases a defensive strategy. Often physicians don’t know what to do with borderline results. The temptation is to retest, and soon the doctor finds herself in unfamiliar waters chasing an elusive school of red herring. The Theranos technology promises to make ordering blood tests cheaper and easier, and, predictably, physicians will respond by ordering more of them.

We know that pathologists and the folks who run for-profit laboratories are going to balk at this new system. But, the rest of us will need to figure out how we can deal with the glut of data and help our patients benefit from what promises to be a significant upside of this breakthrough technology.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He continues to monitor and comment on anything pediatric. E-mail him at pdnews@frontlinemedcom.com.

Recently my primary computer began to act sick off and on. I took it to the folks behind the tech support bar at the corporate store who were eager to help. They ran a bunch of diagnostic tests that were inconclusive. They couldn’t be sure whether it was a hard drive or a software issue, so they reloaded a clean copy of the software and wished me luck. They warned me that the hardware was too old for them to work should the problem recur.

Well, it did. So on a rainy weekend afternoon, I found myself visiting the independent computer mechanic who had been recommended. After a half an hour of running some more tests and a bit of head scratching, he stood up, leaned over the computer, and put his ear against the back of the panel for about a minute and a half. "I could do a bunch more tests tomorrow, but when the hard drive in these babies begins to fail, they make a different sound," he said. He told me I needed a new hard drive. I got one, and was soon back in business.

Two articles reinforce what I relearned during my visit with the computer doctor: A well-trained ear is a valuable tool, and more testing often doesn’t result in a more accurate diagnosis. Nor does it correlate with better quality care.

Dr. Todd A. Florin and his fellow investigators found that emergency departments that used more tests to diagnose and manage community-acquired pneumonia had higher hospitalization rates and were no more likely to experience revisitations than were lower utilizing EDs (Pediatrics 2013;132:237-44).

In the other study, Dr. Jane F. Knapp and her associates observed that pediatric-focused EDs used significantly fewer chest x-rays to diagnose asthma than did general EDs (Pediatrics 2013;132:245-52).

Neither of these groups examined the factors that might have influenced the differences in utilization that they observed. It is unlikely that standard lab and x-ray resources are any less available at the kind of institutions they were studying. Could it be that physicians practicing in pediatric-focused EDs somehow feel more insulated from the threat of a malpractice suit? Are they "better" trained? And if so, what was it about that training that allowed these physicians to rely more on their history taking and physical exams to arrive at a diagnosis? Or is there some test-ordering virus that has infected the culture of certain hospitals while sparing others?

Of course, one of the explanations may be that physicians who limit their practices to children are more likely to acquire a comfort level with diagnosing community-acquired pneumonia, because it represents a higher percentage of the volume of illness that they see. If a physician is well mentored, familiarity can breed competency.

I suspect that if the investigators in these studies had examined the relationship between physician age and resource utilization, they would have found that older physicians ordered fewer lab tests and x-rays. Forty or 50 years ago, physicians were more likely to practice in settings geographically separated from hospitals, and as such were less likely to have ready access to lab and x-ray equipment. Out of necessity, they had to become comfortable using their eyes and ears to make a diagnosis. As physicians huddled together in groups and/or became extensions of hospitals, diagnostic equipment became more available. And when it gets built, it will get used, particularly if it can provide some income.

Community-acquired pneumonia is usually not a difficult diagnosis to make. If I hear crackles in a febrile child, do I need to know his exact temperature or his white count? If the x-ray is normal, will I withhold antibiotics? Not if I know that x-ray images can lag behind reality.

However, if there has been a recent choking episode or the child looks sick enough to hospitalize, I would like more information before I treat. Or if a phone call from my office staff the next day isn’t reassuring, it may be time for some tests. But one phone call is cheaper than a complete blood count and emits far less radiation than a chest x-ray.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at pdnews@frontlinemedcom.com.

Updated: 10/8/2013

Recently my primary computer began to act sick off and on. I took it to the folks behind the tech support bar at the corporate store who were eager to help. They ran a bunch of diagnostic tests that were inconclusive. They couldn’t be sure whether it was a hard drive or a software issue, so they reloaded a clean copy of the software and wished me luck. They warned me that the hardware was too old for them to work should the problem recur.

Well, it did. So on a rainy weekend afternoon, I found myself visiting the independent computer mechanic who had been recommended. After a half an hour of running some more tests and a bit of head scratching, he stood up, leaned over the computer, and put his ear against the back of the panel for about a minute and a half. "I could do a bunch more tests tomorrow, but when the hard drive in these babies begins to fail, they make a different sound," he said. He told me I needed a new hard drive. I got one, and was soon back in business.

Two articles reinforce what I relearned during my visit with the computer doctor: A well-trained ear is a valuable tool, and more testing often doesn’t result in a more accurate diagnosis. Nor does it correlate with better quality care.

Dr. Todd A. Florin and his fellow investigators found that emergency departments that used more tests to diagnose and manage community-acquired pneumonia had higher hospitalization rates and were no more likely to experience revisitations than were lower utilizing EDs (Pediatrics 2013;132:237-44).

In the other study, Dr. Jane F. Knapp and her associates observed that pediatric-focused EDs used significantly fewer chest x-rays to diagnose asthma than did general EDs (Pediatrics 2013;132:245-52).

Neither of these groups examined the factors that might have influenced the differences in utilization that they observed. It is unlikely that standard lab and x-ray resources are any less available at the kind of institutions they were studying. Could it be that physicians practicing in pediatric-focused EDs somehow feel more insulated from the threat of a malpractice suit? Are they "better" trained? And if so, what was it about that training that allowed these physicians to rely more on their history taking and physical exams to arrive at a diagnosis? Or is there some test-ordering virus that has infected the culture of certain hospitals while sparing others?

Of course, one of the explanations may be that physicians who limit their practices to children are more likely to acquire a comfort level with diagnosing community-acquired pneumonia, because it represents a higher percentage of the volume of illness that they see. If a physician is well mentored, familiarity can breed competency.

I suspect that if the investigators in these studies had examined the relationship between physician age and resource utilization, they would have found that older physicians ordered fewer lab tests and x-rays. Forty or 50 years ago, physicians were more likely to practice in settings geographically separated from hospitals, and as such were less likely to have ready access to lab and x-ray equipment. Out of necessity, they had to become comfortable using their eyes and ears to make a diagnosis. As physicians huddled together in groups and/or became extensions of hospitals, diagnostic equipment became more available. And when it gets built, it will get used, particularly if it can provide some income.

Community-acquired pneumonia is usually not a difficult diagnosis to make. If I hear crackles in a febrile child, do I need to know his exact temperature or his white count? If the x-ray is normal, will I withhold antibiotics? Not if I know that x-ray images can lag behind reality.

However, if there has been a recent choking episode or the child looks sick enough to hospitalize, I would like more information before I treat. Or if a phone call from my office staff the next day isn’t reassuring, it may be time for some tests. But one phone call is cheaper than a complete blood count and emits far less radiation than a chest x-ray.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at pdnews@frontlinemedcom.com.

Updated: 10/8/2013

Recently my primary computer began to act sick off and on. I took it to the folks behind the tech support bar at the corporate store who were eager to help. They ran a bunch of diagnostic tests that were inconclusive. They couldn’t be sure whether it was a hard drive or a software issue, so they reloaded a clean copy of the software and wished me luck. They warned me that the hardware was too old for them to work should the problem recur.

Well, it did. So on a rainy weekend afternoon, I found myself visiting the independent computer mechanic who had been recommended. After a half an hour of running some more tests and a bit of head scratching, he stood up, leaned over the computer, and put his ear against the back of the panel for about a minute and a half. "I could do a bunch more tests tomorrow, but when the hard drive in these babies begins to fail, they make a different sound," he said. He told me I needed a new hard drive. I got one, and was soon back in business.

Two articles reinforce what I relearned during my visit with the computer doctor: A well-trained ear is a valuable tool, and more testing often doesn’t result in a more accurate diagnosis. Nor does it correlate with better quality care.

Dr. Todd A. Florin and his fellow investigators found that emergency departments that used more tests to diagnose and manage community-acquired pneumonia had higher hospitalization rates and were no more likely to experience revisitations than were lower utilizing EDs (Pediatrics 2013;132:237-44).

In the other study, Dr. Jane F. Knapp and her associates observed that pediatric-focused EDs used significantly fewer chest x-rays to diagnose asthma than did general EDs (Pediatrics 2013;132:245-52).

Neither of these groups examined the factors that might have influenced the differences in utilization that they observed. It is unlikely that standard lab and x-ray resources are any less available at the kind of institutions they were studying. Could it be that physicians practicing in pediatric-focused EDs somehow feel more insulated from the threat of a malpractice suit? Are they "better" trained? And if so, what was it about that training that allowed these physicians to rely more on their history taking and physical exams to arrive at a diagnosis? Or is there some test-ordering virus that has infected the culture of certain hospitals while sparing others?

Of course, one of the explanations may be that physicians who limit their practices to children are more likely to acquire a comfort level with diagnosing community-acquired pneumonia, because it represents a higher percentage of the volume of illness that they see. If a physician is well mentored, familiarity can breed competency.

I suspect that if the investigators in these studies had examined the relationship between physician age and resource utilization, they would have found that older physicians ordered fewer lab tests and x-rays. Forty or 50 years ago, physicians were more likely to practice in settings geographically separated from hospitals, and as such were less likely to have ready access to lab and x-ray equipment. Out of necessity, they had to become comfortable using their eyes and ears to make a diagnosis. As physicians huddled together in groups and/or became extensions of hospitals, diagnostic equipment became more available. And when it gets built, it will get used, particularly if it can provide some income.

Community-acquired pneumonia is usually not a difficult diagnosis to make. If I hear crackles in a febrile child, do I need to know his exact temperature or his white count? If the x-ray is normal, will I withhold antibiotics? Not if I know that x-ray images can lag behind reality.

However, if there has been a recent choking episode or the child looks sick enough to hospitalize, I would like more information before I treat. Or if a phone call from my office staff the next day isn’t reassuring, it may be time for some tests. But one phone call is cheaper than a complete blood count and emits far less radiation than a chest x-ray.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at pdnews@frontlinemedcom.com.

Updated: 10/8/2013

If a physician focuses on his patients and their responses to illness rather than the illness itself, he is less likely find the practice of general pediatrics boring. However, there are days when a steady diet of runny noses, ear infections, depressed teenagers, and rule-out-attention-deficit/hyperactivity disorder can numb the senses of even the most patient-centered pediatrician.

Half a century ago, pediatricians saw a wider variety of illnesses and injuries in their offices than they do now. For various reasons, the scope of practice for most pediatricians has narrowed. Residency programs churned out subspecialists, who then moved into communities that had previously been "underserved." Alert parents interested in the "best" care options could now bypass the general pediatrician and self-refer for problems that he had been successfully managing himself.

Newly trained pediatricians accustomed to having easy access to subspecialists during their residency may become more likely to reach for the phone and a quick-and-easy referral instead of tackling a problem that their older colleagues would have managed on their own. While necessity was once the mother of invention, an abundance of subspecialists eager to market their skills has fathered a generation of physicians hesitant to venture beyond a narrow comfort zone. Of course, the perceived threat of malpractice suits has amplified this shift toward specialty dependence.

Twenty-five years ago, hospitals and pharmacy chains began to realize that opening urgent care centers and walk-in clinics could be profitable or at least function as attractive portals to their other income streams. Some physicians welcomed these new kids on the block. But even pediatricians who encouraged families with minor emergencies to come to their offices, and who offered extended office hours, faced stiff competition from hospital walk-in clinics with hefty advertising budgets.

The end result of these forces of competition and short-sighted self-pruning is that many families no longer think of their pediatrician’s office as the place to go for minor injuries. With less exposure, a physician and his staff can become increasingly uncomfortable with these simple problems.

A report in the Journal of Pediatric Orthopedics (2012;32:732-6) documents how far this trend to avoidance has gone. Of more than 500 new referrals to a hospital-based orthopedic clinic, the investigators determined that nearly half of the patients had a problem that a health care provider with "basic musculoskeletal education and experience can manage." The list of conditions included undisplaced finger fractures, displaced single bone upper extremity fractures, femoral anteversion, and radial buckle fractures.

I was lucky enough to have been trained by physicians who assumed that I wouldn’t have ready access to orthopedists. This left me with some very basic skills that have allowed me to enjoy a more balanced diet of presenting complaints in the office. Primary care orthopedics is not rocket science or neurosurgery. Children’s bones heal quickly. Splinting and casting is hands-on fun with rewarding results. And parents appreciate the convenience of one-stop shopping.

If you want to build a medical home that provides you with a more stimulating variety of chief complaints and offers families an attractive place to get good care, it’s time to bone up on your basic musculoskeletal education.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at pdnews@frontlinemedcom.com.

If a physician focuses on his patients and their responses to illness rather than the illness itself, he is less likely find the practice of general pediatrics boring. However, there are days when a steady diet of runny noses, ear infections, depressed teenagers, and rule-out-attention-deficit/hyperactivity disorder can numb the senses of even the most patient-centered pediatrician.

Half a century ago, pediatricians saw a wider variety of illnesses and injuries in their offices than they do now. For various reasons, the scope of practice for most pediatricians has narrowed. Residency programs churned out subspecialists, who then moved into communities that had previously been "underserved." Alert parents interested in the "best" care options could now bypass the general pediatrician and self-refer for problems that he had been successfully managing himself.

Newly trained pediatricians accustomed to having easy access to subspecialists during their residency may become more likely to reach for the phone and a quick-and-easy referral instead of tackling a problem that their older colleagues would have managed on their own. While necessity was once the mother of invention, an abundance of subspecialists eager to market their skills has fathered a generation of physicians hesitant to venture beyond a narrow comfort zone. Of course, the perceived threat of malpractice suits has amplified this shift toward specialty dependence.

Twenty-five years ago, hospitals and pharmacy chains began to realize that opening urgent care centers and walk-in clinics could be profitable or at least function as attractive portals to their other income streams. Some physicians welcomed these new kids on the block. But even pediatricians who encouraged families with minor emergencies to come to their offices, and who offered extended office hours, faced stiff competition from hospital walk-in clinics with hefty advertising budgets.

The end result of these forces of competition and short-sighted self-pruning is that many families no longer think of their pediatrician’s office as the place to go for minor injuries. With less exposure, a physician and his staff can become increasingly uncomfortable with these simple problems.

A report in the Journal of Pediatric Orthopedics (2012;32:732-6) documents how far this trend to avoidance has gone. Of more than 500 new referrals to a hospital-based orthopedic clinic, the investigators determined that nearly half of the patients had a problem that a health care provider with "basic musculoskeletal education and experience can manage." The list of conditions included undisplaced finger fractures, displaced single bone upper extremity fractures, femoral anteversion, and radial buckle fractures.

I was lucky enough to have been trained by physicians who assumed that I wouldn’t have ready access to orthopedists. This left me with some very basic skills that have allowed me to enjoy a more balanced diet of presenting complaints in the office. Primary care orthopedics is not rocket science or neurosurgery. Children’s bones heal quickly. Splinting and casting is hands-on fun with rewarding results. And parents appreciate the convenience of one-stop shopping.

If you want to build a medical home that provides you with a more stimulating variety of chief complaints and offers families an attractive place to get good care, it’s time to bone up on your basic musculoskeletal education.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at pdnews@frontlinemedcom.com.

If a physician focuses on his patients and their responses to illness rather than the illness itself, he is less likely find the practice of general pediatrics boring. However, there are days when a steady diet of runny noses, ear infections, depressed teenagers, and rule-out-attention-deficit/hyperactivity disorder can numb the senses of even the most patient-centered pediatrician.

Half a century ago, pediatricians saw a wider variety of illnesses and injuries in their offices than they do now. For various reasons, the scope of practice for most pediatricians has narrowed. Residency programs churned out subspecialists, who then moved into communities that had previously been "underserved." Alert parents interested in the "best" care options could now bypass the general pediatrician and self-refer for problems that he had been successfully managing himself.

Newly trained pediatricians accustomed to having easy access to subspecialists during their residency may become more likely to reach for the phone and a quick-and-easy referral instead of tackling a problem that their older colleagues would have managed on their own. While necessity was once the mother of invention, an abundance of subspecialists eager to market their skills has fathered a generation of physicians hesitant to venture beyond a narrow comfort zone. Of course, the perceived threat of malpractice suits has amplified this shift toward specialty dependence.

Twenty-five years ago, hospitals and pharmacy chains began to realize that opening urgent care centers and walk-in clinics could be profitable or at least function as attractive portals to their other income streams. Some physicians welcomed these new kids on the block. But even pediatricians who encouraged families with minor emergencies to come to their offices, and who offered extended office hours, faced stiff competition from hospital walk-in clinics with hefty advertising budgets.

The end result of these forces of competition and short-sighted self-pruning is that many families no longer think of their pediatrician’s office as the place to go for minor injuries. With less exposure, a physician and his staff can become increasingly uncomfortable with these simple problems.

A report in the Journal of Pediatric Orthopedics (2012;32:732-6) documents how far this trend to avoidance has gone. Of more than 500 new referrals to a hospital-based orthopedic clinic, the investigators determined that nearly half of the patients had a problem that a health care provider with "basic musculoskeletal education and experience can manage." The list of conditions included undisplaced finger fractures, displaced single bone upper extremity fractures, femoral anteversion, and radial buckle fractures.

I was lucky enough to have been trained by physicians who assumed that I wouldn’t have ready access to orthopedists. This left me with some very basic skills that have allowed me to enjoy a more balanced diet of presenting complaints in the office. Primary care orthopedics is not rocket science or neurosurgery. Children’s bones heal quickly. Splinting and casting is hands-on fun with rewarding results. And parents appreciate the convenience of one-stop shopping.

If you want to build a medical home that provides you with a more stimulating variety of chief complaints and offers families an attractive place to get good care, it’s time to bone up on your basic musculoskeletal education.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at pdnews@frontlinemedcom.com.

If you are wondering why the Affordable Care Act fails to address the role of defensive medicine in the cost of health care, I have two answers, but there may be more.

The first reason is that I suspect the lobby representing the trial lawyers had some influence. Of course I don’t have the research staff at my fingertips to prove this allegation, but I have my suspicions.

The second reason that malpractice reform was swept off the negotiating table is that well-meaning advisers were influenced by the studies, which have shown that states that enacted reforms have experienced a 2%-5% reduction in health care spending. The authors of one of these often-cited studies devaluing defensive medicine have recently rethought their position.

Amitabh Chandra, Dr. Anupam B. Jena, and Seth A. Seabury, professors of public health care policy at Harvard and the University of Southern California, wrote in the Wall Street Journal that they have reexamined the available data and question their original conclusions ("Defensive Medicine May Be Costlier Than It Seems," Feb. 7, 2013).

They wrote, "even in reform states, doctors continue to practice defensive medicine. The changes in the malpractice system have done little to change physicians’ perceptions of the risk of being sued."

The authors cited a study that found that in the five states with highest malpractice risk, 68% physicians self-reported practicing defensive medicine. Sixty-four percent of the physicians in the five states with the lowest risk of being sued similarly reported that they also ordered tests and consultations to "avoid the appearance of malpractice." This difference seems to be rather small and of little significance.

Professors Chandra, Jena, and Seabury postulate that malpractice reforms have done little to influence the defensive behavior of physicians because most reforms have focused on "restricting the size of damages without necessarily targeting the frequency of malpractice claims." As a malpractice suit survivor, I can tell you firsthand that it made no difference to me whether the award was going to be $500,000 or $5,000,000. The money involved was so far above any resources at my personal disposal that I never gave it a thought.

The problem was that I was being sued, and my professional skills and integrity were being challenged. Every day for the 7 years that it took the legal machinery to grind out a result in my favor, the dark cloud of that suit followed me around. A cap on the damages might have saved the insurance company some money had I been found negligent, but it wasn’t going to make my professional or personal life any easier.

Are there reforms that might decrease the frequency of suits? The authors suggest that the "adoption of national rather than local standards" to help juries determine negligence might be start. They also suggest "disclosure-and-offer" programs that encourage prompt and candid disclosure when mistakes occur. To determine the "true extent of defensive medicine" they recommend a large scale "safe-harbor" program in which physicians who could demonstrate that they have followed accepted guidelines would be exempt from liability.

Professors Chandra, Jena, and Seabury have done us a great service by acknowledging that their original work may have resulted in flawed conclusions. As physicians we must do a better a job of policing our own, creating realistic best practice guidelines and helping each other achieve them.

If nearly two-thirds of physicians admit to practicing defensive medicine, I am sure that is a serious underestimate of the real number. The dollar figure of the unnecessary tests and consultations that we are ordering every year in an attempt to shield ourselves from the threat of frequent suits is beyond any health policy planner’s wildest dreams.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at pdnews@frontlinemedcom.com.

If you are wondering why the Affordable Care Act fails to address the role of defensive medicine in the cost of health care, I have two answers, but there may be more.

The first reason is that I suspect the lobby representing the trial lawyers had some influence. Of course I don’t have the research staff at my fingertips to prove this allegation, but I have my suspicions.

The second reason that malpractice reform was swept off the negotiating table is that well-meaning advisers were influenced by the studies, which have shown that states that enacted reforms have experienced a 2%-5% reduction in health care spending. The authors of one of these often-cited studies devaluing defensive medicine have recently rethought their position.

Amitabh Chandra, Dr. Anupam B. Jena, and Seth A. Seabury, professors of public health care policy at Harvard and the University of Southern California, wrote in the Wall Street Journal that they have reexamined the available data and question their original conclusions ("Defensive Medicine May Be Costlier Than It Seems," Feb. 7, 2013).

They wrote, "even in reform states, doctors continue to practice defensive medicine. The changes in the malpractice system have done little to change physicians’ perceptions of the risk of being sued."

The authors cited a study that found that in the five states with highest malpractice risk, 68% physicians self-reported practicing defensive medicine. Sixty-four percent of the physicians in the five states with the lowest risk of being sued similarly reported that they also ordered tests and consultations to "avoid the appearance of malpractice." This difference seems to be rather small and of little significance.

Professors Chandra, Jena, and Seabury postulate that malpractice reforms have done little to influence the defensive behavior of physicians because most reforms have focused on "restricting the size of damages without necessarily targeting the frequency of malpractice claims." As a malpractice suit survivor, I can tell you firsthand that it made no difference to me whether the award was going to be $500,000 or $5,000,000. The money involved was so far above any resources at my personal disposal that I never gave it a thought.

The problem was that I was being sued, and my professional skills and integrity were being challenged. Every day for the 7 years that it took the legal machinery to grind out a result in my favor, the dark cloud of that suit followed me around. A cap on the damages might have saved the insurance company some money had I been found negligent, but it wasn’t going to make my professional or personal life any easier.

Are there reforms that might decrease the frequency of suits? The authors suggest that the "adoption of national rather than local standards" to help juries determine negligence might be start. They also suggest "disclosure-and-offer" programs that encourage prompt and candid disclosure when mistakes occur. To determine the "true extent of defensive medicine" they recommend a large scale "safe-harbor" program in which physicians who could demonstrate that they have followed accepted guidelines would be exempt from liability.

Professors Chandra, Jena, and Seabury have done us a great service by acknowledging that their original work may have resulted in flawed conclusions. As physicians we must do a better a job of policing our own, creating realistic best practice guidelines and helping each other achieve them.

If nearly two-thirds of physicians admit to practicing defensive medicine, I am sure that is a serious underestimate of the real number. The dollar figure of the unnecessary tests and consultations that we are ordering every year in an attempt to shield ourselves from the threat of frequent suits is beyond any health policy planner’s wildest dreams.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at pdnews@frontlinemedcom.com.

If you are wondering why the Affordable Care Act fails to address the role of defensive medicine in the cost of health care, I have two answers, but there may be more.

The first reason is that I suspect the lobby representing the trial lawyers had some influence. Of course I don’t have the research staff at my fingertips to prove this allegation, but I have my suspicions.

The second reason that malpractice reform was swept off the negotiating table is that well-meaning advisers were influenced by the studies, which have shown that states that enacted reforms have experienced a 2%-5% reduction in health care spending. The authors of one of these often-cited studies devaluing defensive medicine have recently rethought their position.

Amitabh Chandra, Dr. Anupam B. Jena, and Seth A. Seabury, professors of public health care policy at Harvard and the University of Southern California, wrote in the Wall Street Journal that they have reexamined the available data and question their original conclusions ("Defensive Medicine May Be Costlier Than It Seems," Feb. 7, 2013).

They wrote, "even in reform states, doctors continue to practice defensive medicine. The changes in the malpractice system have done little to change physicians’ perceptions of the risk of being sued."

The authors cited a study that found that in the five states with highest malpractice risk, 68% physicians self-reported practicing defensive medicine. Sixty-four percent of the physicians in the five states with the lowest risk of being sued similarly reported that they also ordered tests and consultations to "avoid the appearance of malpractice." This difference seems to be rather small and of little significance.

Professors Chandra, Jena, and Seabury postulate that malpractice reforms have done little to influence the defensive behavior of physicians because most reforms have focused on "restricting the size of damages without necessarily targeting the frequency of malpractice claims." As a malpractice suit survivor, I can tell you firsthand that it made no difference to me whether the award was going to be $500,000 or $5,000,000. The money involved was so far above any resources at my personal disposal that I never gave it a thought.

The problem was that I was being sued, and my professional skills and integrity were being challenged. Every day for the 7 years that it took the legal machinery to grind out a result in my favor, the dark cloud of that suit followed me around. A cap on the damages might have saved the insurance company some money had I been found negligent, but it wasn’t going to make my professional or personal life any easier.

Are there reforms that might decrease the frequency of suits? The authors suggest that the "adoption of national rather than local standards" to help juries determine negligence might be start. They also suggest "disclosure-and-offer" programs that encourage prompt and candid disclosure when mistakes occur. To determine the "true extent of defensive medicine" they recommend a large scale "safe-harbor" program in which physicians who could demonstrate that they have followed accepted guidelines would be exempt from liability.

Professors Chandra, Jena, and Seabury have done us a great service by acknowledging that their original work may have resulted in flawed conclusions. As physicians we must do a better a job of policing our own, creating realistic best practice guidelines and helping each other achieve them.

If nearly two-thirds of physicians admit to practicing defensive medicine, I am sure that is a serious underestimate of the real number. The dollar figure of the unnecessary tests and consultations that we are ordering every year in an attempt to shield ourselves from the threat of frequent suits is beyond any health policy planner’s wildest dreams.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at pdnews@frontlinemedcom.com.

A restaurant owner in Pennsylvania recently stopped allowing children younger than 6 years to dine at his establishment. As you might imagine, this change in policy touched off a flurry of comments. What might surprise you (but shouldn't) is that he reports that his e-mails, which number more than 2,000, are running 11-1 in favor of his restrictive policy. In a local television station survey of more than 10,000 respondents, 64% supported his decision. And he seems to be busier than before he stopped seating young children.

Is this scenario simply a reflection of one of our shifting demographics, as millions of baby boomers age into grumpy old men and women who don't want their dinners disturbed? Or is it a statement by a larger silent majority who believe that American parents have dropped the ball when it comes to discipline?

As with most societal hot buttons, the answer lies somewhere in the middle. Demographics certainly play a role, but it's not just the growing population of older folks, some of whom can be irritated by even the normal buzz that radiates from well-behaved children. The other growing segment of the population is that of families in which both parents work out of the home. When our children were young, we didn't take them to restaurants. We couldn't afford it. A stop at a hotdog cart or an ice cream stand was about it for extramural dining experiences.

Modern two-income families have fewer meals at home and, in some cases, have more disposable income to spend at restaurants. Dining has become another opportunity for young families to snatch some precious time together, and this often means dining at an hour when my children would have been in bed. The result can be an uncomfortable clash of cultures at a restaurant.

Compounding the collision of dining expectations has been the unfortunate emergence of the notion that meals must include some stimulating amusement. When I was young, we were entertained by each other's reports of how our days had gone. But today, the television has won a place at the dinner table in many homes. More and more restaurants (and not just fast-food places) have recreation areas and video-game consoles to fill those awkward moments of silence that can occur between bites.

However, I suspect that the response that surfaced at that small Pennsylvania restaurant also reflects a broader discontent by those who see the unruly behavior of young children in restaurants as just the tip of the iceberg of parents who have not mastered the skill of saying no to their children.

It's clear from my experiences in the office that most parents realize they need help with discipline, and they are eager to learn. The fact that of the four books I've written, the one that has been translated into two foreign languages (Polish and Italian) is titled “How to Say No to Your Toddler” suggests that this appetite for help is not limited to North American parents.

While the American Academy of Pediatrics should probably avoid setting age guidelines for dining establishments, the issue of unruly young children in restaurants is one that often bounces into our court as primary care pediatricians. Helping parents to set age-appropriate limits and develop humane and effective consequences is primarily about safety, but it is also the cornerstone in the development of civility. A healthy society is one in which all age groups can coexist, but sometimes that just can't happen in a nice restaurant at 7:30 in the evening.

I am interested in what you all think about this issue. If you respond, please include your age.

A restaurant owner in Pennsylvania recently stopped allowing children younger than 6 years to dine at his establishment. As you might imagine, this change in policy touched off a flurry of comments. What might surprise you (but shouldn't) is that he reports that his e-mails, which number more than 2,000, are running 11-1 in favor of his restrictive policy. In a local television station survey of more than 10,000 respondents, 64% supported his decision. And he seems to be busier than before he stopped seating young children.

Is this scenario simply a reflection of one of our shifting demographics, as millions of baby boomers age into grumpy old men and women who don't want their dinners disturbed? Or is it a statement by a larger silent majority who believe that American parents have dropped the ball when it comes to discipline?

As with most societal hot buttons, the answer lies somewhere in the middle. Demographics certainly play a role, but it's not just the growing population of older folks, some of whom can be irritated by even the normal buzz that radiates from well-behaved children. The other growing segment of the population is that of families in which both parents work out of the home. When our children were young, we didn't take them to restaurants. We couldn't afford it. A stop at a hotdog cart or an ice cream stand was about it for extramural dining experiences.

Modern two-income families have fewer meals at home and, in some cases, have more disposable income to spend at restaurants. Dining has become another opportunity for young families to snatch some precious time together, and this often means dining at an hour when my children would have been in bed. The result can be an uncomfortable clash of cultures at a restaurant.

Compounding the collision of dining expectations has been the unfortunate emergence of the notion that meals must include some stimulating amusement. When I was young, we were entertained by each other's reports of how our days had gone. But today, the television has won a place at the dinner table in many homes. More and more restaurants (and not just fast-food places) have recreation areas and video-game consoles to fill those awkward moments of silence that can occur between bites.

However, I suspect that the response that surfaced at that small Pennsylvania restaurant also reflects a broader discontent by those who see the unruly behavior of young children in restaurants as just the tip of the iceberg of parents who have not mastered the skill of saying no to their children.

It's clear from my experiences in the office that most parents realize they need help with discipline, and they are eager to learn. The fact that of the four books I've written, the one that has been translated into two foreign languages (Polish and Italian) is titled “How to Say No to Your Toddler” suggests that this appetite for help is not limited to North American parents.

While the American Academy of Pediatrics should probably avoid setting age guidelines for dining establishments, the issue of unruly young children in restaurants is one that often bounces into our court as primary care pediatricians. Helping parents to set age-appropriate limits and develop humane and effective consequences is primarily about safety, but it is also the cornerstone in the development of civility. A healthy society is one in which all age groups can coexist, but sometimes that just can't happen in a nice restaurant at 7:30 in the evening.

I am interested in what you all think about this issue. If you respond, please include your age.

A restaurant owner in Pennsylvania recently stopped allowing children younger than 6 years to dine at his establishment. As you might imagine, this change in policy touched off a flurry of comments. What might surprise you (but shouldn't) is that he reports that his e-mails, which number more than 2,000, are running 11-1 in favor of his restrictive policy. In a local television station survey of more than 10,000 respondents, 64% supported his decision. And he seems to be busier than before he stopped seating young children.

Is this scenario simply a reflection of one of our shifting demographics, as millions of baby boomers age into grumpy old men and women who don't want their dinners disturbed? Or is it a statement by a larger silent majority who believe that American parents have dropped the ball when it comes to discipline?

As with most societal hot buttons, the answer lies somewhere in the middle. Demographics certainly play a role, but it's not just the growing population of older folks, some of whom can be irritated by even the normal buzz that radiates from well-behaved children. The other growing segment of the population is that of families in which both parents work out of the home. When our children were young, we didn't take them to restaurants. We couldn't afford it. A stop at a hotdog cart or an ice cream stand was about it for extramural dining experiences.

Modern two-income families have fewer meals at home and, in some cases, have more disposable income to spend at restaurants. Dining has become another opportunity for young families to snatch some precious time together, and this often means dining at an hour when my children would have been in bed. The result can be an uncomfortable clash of cultures at a restaurant.

Compounding the collision of dining expectations has been the unfortunate emergence of the notion that meals must include some stimulating amusement. When I was young, we were entertained by each other's reports of how our days had gone. But today, the television has won a place at the dinner table in many homes. More and more restaurants (and not just fast-food places) have recreation areas and video-game consoles to fill those awkward moments of silence that can occur between bites.

However, I suspect that the response that surfaced at that small Pennsylvania restaurant also reflects a broader discontent by those who see the unruly behavior of young children in restaurants as just the tip of the iceberg of parents who have not mastered the skill of saying no to their children.

It's clear from my experiences in the office that most parents realize they need help with discipline, and they are eager to learn. The fact that of the four books I've written, the one that has been translated into two foreign languages (Polish and Italian) is titled “How to Say No to Your Toddler” suggests that this appetite for help is not limited to North American parents.

While the American Academy of Pediatrics should probably avoid setting age guidelines for dining establishments, the issue of unruly young children in restaurants is one that often bounces into our court as primary care pediatricians. Helping parents to set age-appropriate limits and develop humane and effective consequences is primarily about safety, but it is also the cornerstone in the development of civility. A healthy society is one in which all age groups can coexist, but sometimes that just can't happen in a nice restaurant at 7:30 in the evening.

I am interested in what you all think about this issue. If you respond, please include your age.

One of my goals has always been to keep both feet firmly planted on this side of the provider-patient divide. But every now and then, stuff happens.

A couple months ago, one of my usual colonic polyps appeared in a location that made it unapproachable by any kind of scope. I was told that I should ready myself for some good old-fashioned knife-and-forceps surgery. I preferred to have this assault take place at a major teaching hospital in the big city. So, I packed myself off to Boston.

As part of the registration process I was handed a glossy two-color brochure describing my rights and their protection on the federal HIPAA (Health Insurance Portability and Accountability Act) regulations. I signed the form acknowledging my understanding, not sure what would happen should one decline.

Not being a sheik from an oil-rich state, I knew I wouldn’t be staying in one of the sumptuous suites not listed on the button panel in the elevator. Nor was it anticipated that I would be sick enough to warrant a private room. And so I entered the self-contradictory realm of semi-privacy.

My first roommate was a young guy in his 30s who had been stabbed multiple times in his abdomen by his "girlfriend." As he said with a wink on one of his shirtless trips to the bathroom, "She got me pretty good."

Obviously, this knifing was not his first social misadventure, and his family seemed to have evaporated. Listening to the nurses and social workers struggle to find someone to retrieve him was sadly humorous.

My second roommate came at a bad time, the night of my ileus, a complication I had struggled, but failed, to avoid. He was a guy probably in his mid-60s. I was never clear what brought him into the hospital. I wasn’t alone. The unfortunate staff physician assigned to do his work-up seemed confused as well. The guy had a totally positive but vaguely recalled past history and review of systems. "Mr. Fergus, have you ever had purple bowel movements?" "Well, I’m pretty sure I have. Maybe it was around the time I had that whaddya-call-it autoimmune thing? Have I told you about that?"

This interview went on for what seemed like hours as my gut continued to fill with air and fluid. Mercifully, the doctor decided that he had better decide on a working diagnosis and chose, randomly it seemed, to ship my roommate to the coronary care unit. Just in time for me to be rescued by a nasogastric tube the size of a garden hose.

After a day of partial solitude, my third roommate arrived. Another guy in his mid-60s, he also suffered from what was probably a chronic case of vagueness. I suspect he was a college professor from a family that had come over on the Mayflower. Somewhere, they had lost their ability for self-help and, again, the discharge team spent hours attempting to get him to focus on the notion that he couldn’t stay in the hospital until it might be a good day for his wife at home to find the time to call a car service.

The medical information that my roommates and I shared didn’t stop with dialogue. We all had our own beeping monitors that would alarm when leads fell off or IV bags ran dry. Even when ours were silent, alarms from adjacent rooms on the hall penetrated the walls. As they seemed to convey little critical information, the staff seldom responded to the cacophony in a timely fashion.

But I’m home now and mending in silence. I’ve always had my doubts about the value of many of the HIPAA regulations. However, my recent experience on the dark side has made me wonder whether we should expand HIPAA. In addition to protecting my health information, how about some rules that protect me from everyone else’s medical facts? As it stands now, HIPAA in a semi-private world is bad joke.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine.

One of my goals has always been to keep both feet firmly planted on this side of the provider-patient divide. But every now and then, stuff happens.

A couple months ago, one of my usual colonic polyps appeared in a location that made it unapproachable by any kind of scope. I was told that I should ready myself for some good old-fashioned knife-and-forceps surgery. I preferred to have this assault take place at a major teaching hospital in the big city. So, I packed myself off to Boston.

As part of the registration process I was handed a glossy two-color brochure describing my rights and their protection on the federal HIPAA (Health Insurance Portability and Accountability Act) regulations. I signed the form acknowledging my understanding, not sure what would happen should one decline.

Not being a sheik from an oil-rich state, I knew I wouldn’t be staying in one of the sumptuous suites not listed on the button panel in the elevator. Nor was it anticipated that I would be sick enough to warrant a private room. And so I entered the self-contradictory realm of semi-privacy.

My first roommate was a young guy in his 30s who had been stabbed multiple times in his abdomen by his "girlfriend." As he said with a wink on one of his shirtless trips to the bathroom, "She got me pretty good."

Obviously, this knifing was not his first social misadventure, and his family seemed to have evaporated. Listening to the nurses and social workers struggle to find someone to retrieve him was sadly humorous.

My second roommate came at a bad time, the night of my ileus, a complication I had struggled, but failed, to avoid. He was a guy probably in his mid-60s. I was never clear what brought him into the hospital. I wasn’t alone. The unfortunate staff physician assigned to do his work-up seemed confused as well. The guy had a totally positive but vaguely recalled past history and review of systems. "Mr. Fergus, have you ever had purple bowel movements?" "Well, I’m pretty sure I have. Maybe it was around the time I had that whaddya-call-it autoimmune thing? Have I told you about that?"

This interview went on for what seemed like hours as my gut continued to fill with air and fluid. Mercifully, the doctor decided that he had better decide on a working diagnosis and chose, randomly it seemed, to ship my roommate to the coronary care unit. Just in time for me to be rescued by a nasogastric tube the size of a garden hose.

After a day of partial solitude, my third roommate arrived. Another guy in his mid-60s, he also suffered from what was probably a chronic case of vagueness. I suspect he was a college professor from a family that had come over on the Mayflower. Somewhere, they had lost their ability for self-help and, again, the discharge team spent hours attempting to get him to focus on the notion that he couldn’t stay in the hospital until it might be a good day for his wife at home to find the time to call a car service.

The medical information that my roommates and I shared didn’t stop with dialogue. We all had our own beeping monitors that would alarm when leads fell off or IV bags ran dry. Even when ours were silent, alarms from adjacent rooms on the hall penetrated the walls. As they seemed to convey little critical information, the staff seldom responded to the cacophony in a timely fashion.

But I’m home now and mending in silence. I’ve always had my doubts about the value of many of the HIPAA regulations. However, my recent experience on the dark side has made me wonder whether we should expand HIPAA. In addition to protecting my health information, how about some rules that protect me from everyone else’s medical facts? As it stands now, HIPAA in a semi-private world is bad joke.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine.

One of my goals has always been to keep both feet firmly planted on this side of the provider-patient divide. But every now and then, stuff happens.

A couple months ago, one of my usual colonic polyps appeared in a location that made it unapproachable by any kind of scope. I was told that I should ready myself for some good old-fashioned knife-and-forceps surgery. I preferred to have this assault take place at a major teaching hospital in the big city. So, I packed myself off to Boston.

As part of the registration process I was handed a glossy two-color brochure describing my rights and their protection on the federal HIPAA (Health Insurance Portability and Accountability Act) regulations. I signed the form acknowledging my understanding, not sure what would happen should one decline.

Not being a sheik from an oil-rich state, I knew I wouldn’t be staying in one of the sumptuous suites not listed on the button panel in the elevator. Nor was it anticipated that I would be sick enough to warrant a private room. And so I entered the self-contradictory realm of semi-privacy.

My first roommate was a young guy in his 30s who had been stabbed multiple times in his abdomen by his "girlfriend." As he said with a wink on one of his shirtless trips to the bathroom, "She got me pretty good."

Obviously, this knifing was not his first social misadventure, and his family seemed to have evaporated. Listening to the nurses and social workers struggle to find someone to retrieve him was sadly humorous.

My second roommate came at a bad time, the night of my ileus, a complication I had struggled, but failed, to avoid. He was a guy probably in his mid-60s. I was never clear what brought him into the hospital. I wasn’t alone. The unfortunate staff physician assigned to do his work-up seemed confused as well. The guy had a totally positive but vaguely recalled past history and review of systems. "Mr. Fergus, have you ever had purple bowel movements?" "Well, I’m pretty sure I have. Maybe it was around the time I had that whaddya-call-it autoimmune thing? Have I told you about that?"

This interview went on for what seemed like hours as my gut continued to fill with air and fluid. Mercifully, the doctor decided that he had better decide on a working diagnosis and chose, randomly it seemed, to ship my roommate to the coronary care unit. Just in time for me to be rescued by a nasogastric tube the size of a garden hose.

After a day of partial solitude, my third roommate arrived. Another guy in his mid-60s, he also suffered from what was probably a chronic case of vagueness. I suspect he was a college professor from a family that had come over on the Mayflower. Somewhere, they had lost their ability for self-help and, again, the discharge team spent hours attempting to get him to focus on the notion that he couldn’t stay in the hospital until it might be a good day for his wife at home to find the time to call a car service.

The medical information that my roommates and I shared didn’t stop with dialogue. We all had our own beeping monitors that would alarm when leads fell off or IV bags ran dry. Even when ours were silent, alarms from adjacent rooms on the hall penetrated the walls. As they seemed to convey little critical information, the staff seldom responded to the cacophony in a timely fashion.

But I’m home now and mending in silence. I’ve always had my doubts about the value of many of the HIPAA regulations. However, my recent experience on the dark side has made me wonder whether we should expand HIPAA. In addition to protecting my health information, how about some rules that protect me from everyone else’s medical facts? As it stands now, HIPAA in a semi-private world is bad joke.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine.

One of my goals has always been to keep both feet firmly planted on this side of the provider-patient divide. But every now and then, stuff happens.

A couple months ago, one of my usual colonic polyps appeared in a location that made it unapproachable by any kind of scope. I was told that I should ready myself for some good old-fashioned knife-and-forceps surgery. I preferred to have this assault take place at a major teaching hospital in the big city. So, I packed myself off to Boston.

As part of the registration process I was handed a glossy two-color brochure describing my rights and their protection on the federal HIPAA (Health Insurance Portability and Accountability Act) regulations. I signed the form acknowledging my understanding, not sure what would happen should one decline.

Not being a sheik from an oil-rich state, I knew I wouldn’t be staying in one of the sumptuous suites not listed on the button panel in the elevator. Nor was it anticipated that I would be sick enough to warrant a private room. And so I entered the self-contradictory realm of semi-privacy.

My first roommate was a young guy in his 30s who had been stabbed multiple times in his abdomen by his "girlfriend." As he said with a wink on one of his shirtless trips to the bathroom, "She got me pretty good."

Obviously, this knifing was not his first social misadventure, and his family seemed to have evaporated. Listening to the nurses and social workers struggle to find someone to retrieve him was sadly humorous.

My second roommate came at a bad time, the night of my ileus, a complication I had struggled, but failed, to avoid. He was a guy probably in his mid-60s. I was never clear what brought him into the hospital. I wasn’t alone. The unfortunate staff physician assigned to do his work-up seemed confused as well. The guy had a totally positive but vaguely recalled past history and review of systems. "Mr. Fergus, have you ever had purple bowel movements?" "Well, I’m pretty sure I have. Maybe it was around the time I had that whaddya-call-it autoimmune thing? Have I told you about that?"

This interview went on for what seemed like hours as my gut continued to fill with air and fluid. Mercifully, the doctor decided that he had better decide on a working diagnosis and chose, randomly it seemed, to ship my roommate to the coronary care unit. Just in time for me to be rescued by a nasogastric tube the size of a garden hose.

After a day of partial solitude, my third roommate arrived. Another guy in his mid-60s, he also suffered from what was probably a chronic case of vagueness. I suspect he was a college professor from a family that had come over on the Mayflower. Somewhere, they had lost their ability for self-help and, again, the discharge team spent hours attempting to get him to focus on the notion that he couldn’t stay in the hospital until it might be a good day for his wife at home to find the time to call a car service.

The medical information that my roommates and I shared didn’t stop with dialogue. We all had our own beeping monitors that would alarm when leads fell off or IV bags ran dry. Even when ours were silent, alarms from adjacent rooms on the hall penetrated the walls. As they seemed to convey little critical information, the staff seldom responded to the cacophony in a timely fashion.

But I’m home now and mending in silence. I’ve always had my doubts about the value of many of the HIPAA regulations. However, my recent experience on the dark side has made me wonder whether we should expand HIPAA. In addition to protecting my health information, how about some rules that protect me from everyone else’s medical facts? As it stands now, HIPAA in a semi-private world is bad joke.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. 

One of my goals has always been to keep both feet firmly planted on this side of the provider-patient divide. But every now and then, stuff happens.

A couple months ago, one of my usual colonic polyps appeared in a location that made it unapproachable by any kind of scope. I was told that I should ready myself for some good old-fashioned knife-and-forceps surgery. I preferred to have this assault take place at a major teaching hospital in the big city. So, I packed myself off to Boston.

As part of the registration process I was handed a glossy two-color brochure describing my rights and their protection on the federal HIPAA (Health Insurance Portability and Accountability Act) regulations. I signed the form acknowledging my understanding, not sure what would happen should one decline.

Not being a sheik from an oil-rich state, I knew I wouldn’t be staying in one of the sumptuous suites not listed on the button panel in the elevator. Nor was it anticipated that I would be sick enough to warrant a private room. And so I entered the self-contradictory realm of semi-privacy.

My first roommate was a young guy in his 30s who had been stabbed multiple times in his abdomen by his "girlfriend." As he said with a wink on one of his shirtless trips to the bathroom, "She got me pretty good."

Obviously, this knifing was not his first social misadventure, and his family seemed to have evaporated. Listening to the nurses and social workers struggle to find someone to retrieve him was sadly humorous.

My second roommate came at a bad time, the night of my ileus, a complication I had struggled, but failed, to avoid. He was a guy probably in his mid-60s. I was never clear what brought him into the hospital. I wasn’t alone. The unfortunate staff physician assigned to do his work-up seemed confused as well. The guy had a totally positive but vaguely recalled past history and review of systems. "Mr. Fergus, have you ever had purple bowel movements?" "Well, I’m pretty sure I have. Maybe it was around the time I had that whaddya-call-it autoimmune thing? Have I told you about that?"

This interview went on for what seemed like hours as my gut continued to fill with air and fluid. Mercifully, the doctor decided that he had better decide on a working diagnosis and chose, randomly it seemed, to ship my roommate to the coronary care unit. Just in time for me to be rescued by a nasogastric tube the size of a garden hose.

After a day of partial solitude, my third roommate arrived. Another guy in his mid-60s, he also suffered from what was probably a chronic case of vagueness. I suspect he was a college professor from a family that had come over on the Mayflower. Somewhere, they had lost their ability for self-help and, again, the discharge team spent hours attempting to get him to focus on the notion that he couldn’t stay in the hospital until it might be a good day for his wife at home to find the time to call a car service.

The medical information that my roommates and I shared didn’t stop with dialogue. We all had our own beeping monitors that would alarm when leads fell off or IV bags ran dry. Even when ours were silent, alarms from adjacent rooms on the hall penetrated the walls. As they seemed to convey little critical information, the staff seldom responded to the cacophony in a timely fashion.

But I’m home now and mending in silence. I’ve always had my doubts about the value of many of the HIPAA regulations. However, my recent experience on the dark side has made me wonder whether we should expand HIPAA. In addition to protecting my health information, how about some rules that protect me from everyone else’s medical facts? As it stands now, HIPAA in a semi-private world is bad joke.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. 

One of my goals has always been to keep both feet firmly planted on this side of the provider-patient divide. But every now and then, stuff happens.

A couple months ago, one of my usual colonic polyps appeared in a location that made it unapproachable by any kind of scope. I was told that I should ready myself for some good old-fashioned knife-and-forceps surgery. I preferred to have this assault take place at a major teaching hospital in the big city. So, I packed myself off to Boston.

As part of the registration process I was handed a glossy two-color brochure describing my rights and their protection on the federal HIPAA (Health Insurance Portability and Accountability Act) regulations. I signed the form acknowledging my understanding, not sure what would happen should one decline.

Not being a sheik from an oil-rich state, I knew I wouldn’t be staying in one of the sumptuous suites not listed on the button panel in the elevator. Nor was it anticipated that I would be sick enough to warrant a private room. And so I entered the self-contradictory realm of semi-privacy.

My first roommate was a young guy in his 30s who had been stabbed multiple times in his abdomen by his "girlfriend." As he said with a wink on one of his shirtless trips to the bathroom, "She got me pretty good."

Obviously, this knifing was not his first social misadventure, and his family seemed to have evaporated. Listening to the nurses and social workers struggle to find someone to retrieve him was sadly humorous.

My second roommate came at a bad time, the night of my ileus, a complication I had struggled, but failed, to avoid. He was a guy probably in his mid-60s. I was never clear what brought him into the hospital. I wasn’t alone. The unfortunate staff physician assigned to do his work-up seemed confused as well. The guy had a totally positive but vaguely recalled past history and review of systems. "Mr. Fergus, have you ever had purple bowel movements?" "Well, I’m pretty sure I have. Maybe it was around the time I had that whaddya-call-it autoimmune thing? Have I told you about that?"

This interview went on for what seemed like hours as my gut continued to fill with air and fluid. Mercifully, the doctor decided that he had better decide on a working diagnosis and chose, randomly it seemed, to ship my roommate to the coronary care unit. Just in time for me to be rescued by a nasogastric tube the size of a garden hose.

After a day of partial solitude, my third roommate arrived. Another guy in his mid-60s, he also suffered from what was probably a chronic case of vagueness. I suspect he was a college professor from a family that had come over on the Mayflower. Somewhere, they had lost their ability for self-help and, again, the discharge team spent hours attempting to get him to focus on the notion that he couldn’t stay in the hospital until it might be a good day for his wife at home to find the time to call a car service.

The medical information that my roommates and I shared didn’t stop with dialogue. We all had our own beeping monitors that would alarm when leads fell off or IV bags ran dry. Even when ours were silent, alarms from adjacent rooms on the hall penetrated the walls. As they seemed to convey little critical information, the staff seldom responded to the cacophony in a timely fashion.

But I’m home now and mending in silence. I’ve always had my doubts about the value of many of the HIPAA regulations. However, my recent experience on the dark side has made me wonder whether we should expand HIPAA. In addition to protecting my health information, how about some rules that protect me from everyone else’s medical facts? As it stands now, HIPAA in a semi-private world is bad joke.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine.