William G. Wilkoff

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.

pdnews@elsevier.com

I know that I've opined and whined about electronic health records several times in the last year and a half, but it's an issue, a big issue that just isn't going away. And it isn't being realistically addressed in either the professional or the lay press.

Just to remind you, I am not a Luddite. We've had a computer in our home since Apple first started selling them. Our office has had its own homegrown electronic health record (EHR) system for a decade. It was embraced by all of us, but for a variety of reasons – some good and some bad – it was retired. We purchased an off-the-shelf model from one of the largest purveyors of EHRs.

The last time I wrote, I was still on the steep part of the learning curve, but was optimistic that I could adapt to its quirks and clumsiness. My biggest gripe then was that the new system didn't allow me to enhance the record with my self-drawn illustrations. As I write today more than 4 months later, I'm resting somewhat uncomfortably on the plateau above the curve, curled up in a fetal position with my thumb in my mouth.

I have created a manageable number of shortcuts to create authentic text with just a few keystrokes. I can navigate the redundant screens with a minimum of mouse clicks. I haven't seen anyone in the group who can chart electronically faster than I can. However, even at the top of my game, it takes me at least 3 minutes longer to complete an encounter with a patient than it did using our old system.

Where did this time go? To begin with, I quickly discovered that if I want to maintain eye contact with the patient, I will have to suspend my charting until they or I have left the exam room. When I was writing by hand, I could scribble a phrase or check a box or two and still be looking at the patient or parent 90% of the time. Even if the screen is well positioned, I still find that my eyes will be on it and not the patient. In situations in which I don't know the patient well or his or her problems are very complex, I will try to review the record before I enter the exam room to minimize my screen time with the patient.

When the visit is over, there is some awkwardness. They were accustomed to my leaving the room first or walking with them to the front desk. Now I just want them to leave me alone with the computer so I can do my charting before I forget what I wanted to write. I have resorted to giving them a bogus piece of paper and asking them to give it to the receptionist on their way out. But the old system of last-in-first-out still prompts many families to linger uncomfortably. The trade-off is that I know that I am at least more visually attentive to patients.

So what about those 3 minutes? I suspect that to the program and system developers this doesn't seem like a big deal. Most of them aren't physicians, and the few who were have been so distracted by their algorithms that they haven't seen a patient in years. But just do the math. If you only see 20 patients a day, an extra 3 minutes per patient is 60 minutes, known to most of us as 1 hour. And that's what most of us in the office have found we've lost. We are spending nearly 1 hour more per day charting or, if our pocketbooks can absorb the associated loss, we are seeing fewer patients.

I am sure this ugly reality has been experienced by thousands of other physicians who have been electronified. The government is creating financial incentives to adopt EHRs, but if I were faced with the decision now, I would wait, wait, wait. If time is important to you, I don't think there is a system out there yet that will save you any time, and most will lose you at least 3 minutes per patient of that precious stuff you can't recoup once it's lost.

pdnews@elsevier.com

I know that I've opined and whined about electronic health records several times in the last year and a half, but it's an issue, a big issue that just isn't going away. And it isn't being realistically addressed in either the professional or the lay press.

Just to remind you, I am not a Luddite. We've had a computer in our home since Apple first started selling them. Our office has had its own homegrown electronic health record (EHR) system for a decade. It was embraced by all of us, but for a variety of reasons – some good and some bad – it was retired. We purchased an off-the-shelf model from one of the largest purveyors of EHRs.

The last time I wrote, I was still on the steep part of the learning curve, but was optimistic that I could adapt to its quirks and clumsiness. My biggest gripe then was that the new system didn't allow me to enhance the record with my self-drawn illustrations. As I write today more than 4 months later, I'm resting somewhat uncomfortably on the plateau above the curve, curled up in a fetal position with my thumb in my mouth.

I have created a manageable number of shortcuts to create authentic text with just a few keystrokes. I can navigate the redundant screens with a minimum of mouse clicks. I haven't seen anyone in the group who can chart electronically faster than I can. However, even at the top of my game, it takes me at least 3 minutes longer to complete an encounter with a patient than it did using our old system.

Where did this time go? To begin with, I quickly discovered that if I want to maintain eye contact with the patient, I will have to suspend my charting until they or I have left the exam room. When I was writing by hand, I could scribble a phrase or check a box or two and still be looking at the patient or parent 90% of the time. Even if the screen is well positioned, I still find that my eyes will be on it and not the patient. In situations in which I don't know the patient well or his or her problems are very complex, I will try to review the record before I enter the exam room to minimize my screen time with the patient.

When the visit is over, there is some awkwardness. They were accustomed to my leaving the room first or walking with them to the front desk. Now I just want them to leave me alone with the computer so I can do my charting before I forget what I wanted to write. I have resorted to giving them a bogus piece of paper and asking them to give it to the receptionist on their way out. But the old system of last-in-first-out still prompts many families to linger uncomfortably. The trade-off is that I know that I am at least more visually attentive to patients.

So what about those 3 minutes? I suspect that to the program and system developers this doesn't seem like a big deal. Most of them aren't physicians, and the few who were have been so distracted by their algorithms that they haven't seen a patient in years. But just do the math. If you only see 20 patients a day, an extra 3 minutes per patient is 60 minutes, known to most of us as 1 hour. And that's what most of us in the office have found we've lost. We are spending nearly 1 hour more per day charting or, if our pocketbooks can absorb the associated loss, we are seeing fewer patients.

I am sure this ugly reality has been experienced by thousands of other physicians who have been electronified. The government is creating financial incentives to adopt EHRs, but if I were faced with the decision now, I would wait, wait, wait. If time is important to you, I don't think there is a system out there yet that will save you any time, and most will lose you at least 3 minutes per patient of that precious stuff you can't recoup once it's lost.

pdnews@elsevier.com

I know that I've opined and whined about electronic health records several times in the last year and a half, but it's an issue, a big issue that just isn't going away. And it isn't being realistically addressed in either the professional or the lay press.

Just to remind you, I am not a Luddite. We've had a computer in our home since Apple first started selling them. Our office has had its own homegrown electronic health record (EHR) system for a decade. It was embraced by all of us, but for a variety of reasons – some good and some bad – it was retired. We purchased an off-the-shelf model from one of the largest purveyors of EHRs.

The last time I wrote, I was still on the steep part of the learning curve, but was optimistic that I could adapt to its quirks and clumsiness. My biggest gripe then was that the new system didn't allow me to enhance the record with my self-drawn illustrations. As I write today more than 4 months later, I'm resting somewhat uncomfortably on the plateau above the curve, curled up in a fetal position with my thumb in my mouth.

I have created a manageable number of shortcuts to create authentic text with just a few keystrokes. I can navigate the redundant screens with a minimum of mouse clicks. I haven't seen anyone in the group who can chart electronically faster than I can. However, even at the top of my game, it takes me at least 3 minutes longer to complete an encounter with a patient than it did using our old system.

Where did this time go? To begin with, I quickly discovered that if I want to maintain eye contact with the patient, I will have to suspend my charting until they or I have left the exam room. When I was writing by hand, I could scribble a phrase or check a box or two and still be looking at the patient or parent 90% of the time. Even if the screen is well positioned, I still find that my eyes will be on it and not the patient. In situations in which I don't know the patient well or his or her problems are very complex, I will try to review the record before I enter the exam room to minimize my screen time with the patient.

When the visit is over, there is some awkwardness. They were accustomed to my leaving the room first or walking with them to the front desk. Now I just want them to leave me alone with the computer so I can do my charting before I forget what I wanted to write. I have resorted to giving them a bogus piece of paper and asking them to give it to the receptionist on their way out. But the old system of last-in-first-out still prompts many families to linger uncomfortably. The trade-off is that I know that I am at least more visually attentive to patients.

So what about those 3 minutes? I suspect that to the program and system developers this doesn't seem like a big deal. Most of them aren't physicians, and the few who were have been so distracted by their algorithms that they haven't seen a patient in years. But just do the math. If you only see 20 patients a day, an extra 3 minutes per patient is 60 minutes, known to most of us as 1 hour. And that's what most of us in the office have found we've lost. We are spending nearly 1 hour more per day charting or, if our pocketbooks can absorb the associated loss, we are seeing fewer patients.

I am sure this ugly reality has been experienced by thousands of other physicians who have been electronified. The government is creating financial incentives to adopt EHRs, but if I were faced with the decision now, I would wait, wait, wait. If time is important to you, I don't think there is a system out there yet that will save you any time, and most will lose you at least 3 minutes per patient of that precious stuff you can't recoup once it's lost.

pdnews@elsevier.com

“Sarah, your son is doing very well. It looks like you are enjoying being a mother. Unless you are having trouble I won't be seeing you until Clay's 4-month visit. I know you said at the last visit that you had your day care plans in order. Are they still solid?”

“Well … Dr. Wilkoff, being a mother has been much more fun than I expected. It is going to be very hard for me to go back to work and leave Clay with someone else. I've enjoyed nursing and although the schedule that my boss has agreed to should allow me to keep nursing, I just don't want to look back a year or 2 from now and regret having missed this special time.

“I never guessed that it would be like this. I enjoy my job. I never ever considered not going back to it. Jason and I have talked and looked at the numbers. He says he's pretty sure we can make it on one income, and he thinks we should try it with me staying home. But I don't know. I'm worried we won't make it, and I don't want to have to ask our parents for help. What do you think, Dr. Wilkoff?”

I have stood at these crossroads that Sarah and Jason are facing dozens of times in my career. Usually, I am an interested, but mute bystander. But, every now and then I will be asked for my 2 cents.

Obviously, it's difficult to give advice without knowing the details of a young family's finances. Because in the end it is all about the money. Are they already living in a house with a mortgage that gobbles up too much of their incomes? Do they have other debt? Whose job is helping fund their health insurance?

But actually it isn't all about the money. It's about some important intangibles. How creative can this young couple be in cutting their expenses? Can they think far enough outside the box to get by with just one vehicle and no cable television? Will Jason have enough stamina to work more hours or find a part-time job? It sounds as though he is committed to the concept of Sarah's staying home. His positive attitude alone suggests to me that this experiment is going to work.

Will Sarah have the stamina after a full day of mothering to work a few hours in the evening a couple of hours a week? Can she accept a part-time job that is well beneath her training and experience?

Even if they can make the new numbers work, will Sarah find a peer group that will support her decision to stay home? Thirty years ago I wouldn't have thought to consider this question. But over the decades I have spoken to enough young mothers who have stayed home to hear that it can feel lonely at times without other women who share their perspective on the frustrations, fears, and successes of parenting.

If Sarah decides to quit her job and stay home, depending on her neighborhood, she will find herself in a small minority, maybe even alone. Will she find enough support to balance what she might perceive as a loss of status associated with stepping away from her career? I may be able to help by reminding her at each visit of the “firsts” she has witnessed by staying at home. And the control she has over things like Clay's sleep schedule and TV exposure.

So what did I tell Sarah today? First, I reminded her that past performance is no guarantee of success, but that whenever family members have shared with me their concerns about this kind of decision it has always worked out. It's not easy swimming against the societal norm, but I had a strong feeling that Sarah and Jason and Clay were going to make it work.

In the interest of gender equality, I must add that the arrangement can work well when the father is the parent who stays home.

pdnews@elsevier.com

“Sarah, your son is doing very well. It looks like you are enjoying being a mother. Unless you are having trouble I won't be seeing you until Clay's 4-month visit. I know you said at the last visit that you had your day care plans in order. Are they still solid?”

“Well … Dr. Wilkoff, being a mother has been much more fun than I expected. It is going to be very hard for me to go back to work and leave Clay with someone else. I've enjoyed nursing and although the schedule that my boss has agreed to should allow me to keep nursing, I just don't want to look back a year or 2 from now and regret having missed this special time.

“I never guessed that it would be like this. I enjoy my job. I never ever considered not going back to it. Jason and I have talked and looked at the numbers. He says he's pretty sure we can make it on one income, and he thinks we should try it with me staying home. But I don't know. I'm worried we won't make it, and I don't want to have to ask our parents for help. What do you think, Dr. Wilkoff?”

I have stood at these crossroads that Sarah and Jason are facing dozens of times in my career. Usually, I am an interested, but mute bystander. But, every now and then I will be asked for my 2 cents.

Obviously, it's difficult to give advice without knowing the details of a young family's finances. Because in the end it is all about the money. Are they already living in a house with a mortgage that gobbles up too much of their incomes? Do they have other debt? Whose job is helping fund their health insurance?

But actually it isn't all about the money. It's about some important intangibles. How creative can this young couple be in cutting their expenses? Can they think far enough outside the box to get by with just one vehicle and no cable television? Will Jason have enough stamina to work more hours or find a part-time job? It sounds as though he is committed to the concept of Sarah's staying home. His positive attitude alone suggests to me that this experiment is going to work.

Will Sarah have the stamina after a full day of mothering to work a few hours in the evening a couple of hours a week? Can she accept a part-time job that is well beneath her training and experience?

Even if they can make the new numbers work, will Sarah find a peer group that will support her decision to stay home? Thirty years ago I wouldn't have thought to consider this question. But over the decades I have spoken to enough young mothers who have stayed home to hear that it can feel lonely at times without other women who share their perspective on the frustrations, fears, and successes of parenting.

If Sarah decides to quit her job and stay home, depending on her neighborhood, she will find herself in a small minority, maybe even alone. Will she find enough support to balance what she might perceive as a loss of status associated with stepping away from her career? I may be able to help by reminding her at each visit of the “firsts” she has witnessed by staying at home. And the control she has over things like Clay's sleep schedule and TV exposure.

So what did I tell Sarah today? First, I reminded her that past performance is no guarantee of success, but that whenever family members have shared with me their concerns about this kind of decision it has always worked out. It's not easy swimming against the societal norm, but I had a strong feeling that Sarah and Jason and Clay were going to make it work.

In the interest of gender equality, I must add that the arrangement can work well when the father is the parent who stays home.

pdnews@elsevier.com

“Sarah, your son is doing very well. It looks like you are enjoying being a mother. Unless you are having trouble I won't be seeing you until Clay's 4-month visit. I know you said at the last visit that you had your day care plans in order. Are they still solid?”

“Well … Dr. Wilkoff, being a mother has been much more fun than I expected. It is going to be very hard for me to go back to work and leave Clay with someone else. I've enjoyed nursing and although the schedule that my boss has agreed to should allow me to keep nursing, I just don't want to look back a year or 2 from now and regret having missed this special time.

“I never guessed that it would be like this. I enjoy my job. I never ever considered not going back to it. Jason and I have talked and looked at the numbers. He says he's pretty sure we can make it on one income, and he thinks we should try it with me staying home. But I don't know. I'm worried we won't make it, and I don't want to have to ask our parents for help. What do you think, Dr. Wilkoff?”

I have stood at these crossroads that Sarah and Jason are facing dozens of times in my career. Usually, I am an interested, but mute bystander. But, every now and then I will be asked for my 2 cents.

Obviously, it's difficult to give advice without knowing the details of a young family's finances. Because in the end it is all about the money. Are they already living in a house with a mortgage that gobbles up too much of their incomes? Do they have other debt? Whose job is helping fund their health insurance?

But actually it isn't all about the money. It's about some important intangibles. How creative can this young couple be in cutting their expenses? Can they think far enough outside the box to get by with just one vehicle and no cable television? Will Jason have enough stamina to work more hours or find a part-time job? It sounds as though he is committed to the concept of Sarah's staying home. His positive attitude alone suggests to me that this experiment is going to work.

Will Sarah have the stamina after a full day of mothering to work a few hours in the evening a couple of hours a week? Can she accept a part-time job that is well beneath her training and experience?

Even if they can make the new numbers work, will Sarah find a peer group that will support her decision to stay home? Thirty years ago I wouldn't have thought to consider this question. But over the decades I have spoken to enough young mothers who have stayed home to hear that it can feel lonely at times without other women who share their perspective on the frustrations, fears, and successes of parenting.

If Sarah decides to quit her job and stay home, depending on her neighborhood, she will find herself in a small minority, maybe even alone. Will she find enough support to balance what she might perceive as a loss of status associated with stepping away from her career? I may be able to help by reminding her at each visit of the “firsts” she has witnessed by staying at home. And the control she has over things like Clay's sleep schedule and TV exposure.

So what did I tell Sarah today? First, I reminded her that past performance is no guarantee of success, but that whenever family members have shared with me their concerns about this kind of decision it has always worked out. It's not easy swimming against the societal norm, but I had a strong feeling that Sarah and Jason and Clay were going to make it work.

In the interest of gender equality, I must add that the arrangement can work well when the father is the parent who stays home.

pdnews@elsevier.com

How do you sleep when you're on call? To those of you who are hospital-based physicians or part of a very large and busy call group, this sounds like a silly question. Your answer will be that you are so busy that anything more than a 5-minute catnap while you are waiting for an x-ray is not an option. But, for those of us who may only get one or two calls after midnight – or some nights never have a call – getting sleep can present an awkward dilemma.

On one hand, we must be prepared to respond to a real, or usually just perceived, emergency. We must be able to speak intelligently (and intelligibly), think rationally, and perform fine motor tasks accurately after being aroused from any REM or non-REM state. On the other hand, we will be expected to show up at the office the next morning apparently well rested and prepared to make a few dozen clinical decisions in a thoughtful and compassionate manner. Can you do it? How do you do it?

I recently met with two physicians whom I hadn't seen in a while. Whenever aging physicians get together, the conversation eventually touches on the burden of taking call. One said he really could never sleep when he was on call, and the other said that he sleeps very poorly when it is his night in the barrel.

Strategies for a Good Night's Sleep

These revelations surprised me a bit coming from two physicians with a combined experience of nearly 60 years. I often hear from my partners who are 25 years younger that they can't sleep when they are on call. I try to reassure them that, as they did for me, things will get better, and they will learn or assimilate strategies that will allow them to get enough restorative sleep on the nights when they have drawn the short straw.

For example, I never let a patient leave the office until I am comfortable that I've have done everything I should (not could) in this clinical situation. If I think of something after we've all gone home, I'm not embarrassed to call to recheck the situation or tell them to go to the hospital lab for the lab work I've forgotten. Or tell them I will meet them in the ER so that I can have one more look before I go to bed. Shakespeare may have believed that sleep “knits up the raveled sleeves of care.” But if you go to bed with too many loose ends, you'll never get to sleep.

Experience should teach us to give better and better anticipatory guidance. The more questions and bumps in the road a physician can head off with a few preemptive and reassuring words when he/she is face to face with the parent, the more sleep everyone will get.

When I go to bed, I turn off my beeper and tell the answering service to have the parents call my home phone whose ringer has been muted with duct tape so it doesn't disturb Marilyn. This means no fumbling for a light or a pen. It eliminates those embarrassing misdialed numbers at 2 a.m. that begin, “This is Doctor Wilkoff.” It also makes parents consider one more time whether their question is worth waking me at home.

But, there is only so much we pediatricians can do to improve our chances of getting a good night's sleep. The most frustrating calls come from someone on the obstetrics floor who just wants to give me a “heads up” about some meconium-stained fluid or an expected preterm delivery. Unless the situation is so unusual I am going to need to hunt for some special equipment or consultant, I'm not sure how this information is going to help matters. Maybe it's just one of those “misery loves company” deals. But, I can guarantee one thing: It's certainly going to ruin my night's sleep.

pdnews@elsevier.com

How do you sleep when you're on call? To those of you who are hospital-based physicians or part of a very large and busy call group, this sounds like a silly question. Your answer will be that you are so busy that anything more than a 5-minute catnap while you are waiting for an x-ray is not an option. But, for those of us who may only get one or two calls after midnight – or some nights never have a call – getting sleep can present an awkward dilemma.

On one hand, we must be prepared to respond to a real, or usually just perceived, emergency. We must be able to speak intelligently (and intelligibly), think rationally, and perform fine motor tasks accurately after being aroused from any REM or non-REM state. On the other hand, we will be expected to show up at the office the next morning apparently well rested and prepared to make a few dozen clinical decisions in a thoughtful and compassionate manner. Can you do it? How do you do it?

I recently met with two physicians whom I hadn't seen in a while. Whenever aging physicians get together, the conversation eventually touches on the burden of taking call. One said he really could never sleep when he was on call, and the other said that he sleeps very poorly when it is his night in the barrel.

Strategies for a Good Night's Sleep

These revelations surprised me a bit coming from two physicians with a combined experience of nearly 60 years. I often hear from my partners who are 25 years younger that they can't sleep when they are on call. I try to reassure them that, as they did for me, things will get better, and they will learn or assimilate strategies that will allow them to get enough restorative sleep on the nights when they have drawn the short straw.

For example, I never let a patient leave the office until I am comfortable that I've have done everything I should (not could) in this clinical situation. If I think of something after we've all gone home, I'm not embarrassed to call to recheck the situation or tell them to go to the hospital lab for the lab work I've forgotten. Or tell them I will meet them in the ER so that I can have one more look before I go to bed. Shakespeare may have believed that sleep “knits up the raveled sleeves of care.” But if you go to bed with too many loose ends, you'll never get to sleep.

Experience should teach us to give better and better anticipatory guidance. The more questions and bumps in the road a physician can head off with a few preemptive and reassuring words when he/she is face to face with the parent, the more sleep everyone will get.

When I go to bed, I turn off my beeper and tell the answering service to have the parents call my home phone whose ringer has been muted with duct tape so it doesn't disturb Marilyn. This means no fumbling for a light or a pen. It eliminates those embarrassing misdialed numbers at 2 a.m. that begin, “This is Doctor Wilkoff.” It also makes parents consider one more time whether their question is worth waking me at home.

But, there is only so much we pediatricians can do to improve our chances of getting a good night's sleep. The most frustrating calls come from someone on the obstetrics floor who just wants to give me a “heads up” about some meconium-stained fluid or an expected preterm delivery. Unless the situation is so unusual I am going to need to hunt for some special equipment or consultant, I'm not sure how this information is going to help matters. Maybe it's just one of those “misery loves company” deals. But, I can guarantee one thing: It's certainly going to ruin my night's sleep.

pdnews@elsevier.com

How do you sleep when you're on call? To those of you who are hospital-based physicians or part of a very large and busy call group, this sounds like a silly question. Your answer will be that you are so busy that anything more than a 5-minute catnap while you are waiting for an x-ray is not an option. But, for those of us who may only get one or two calls after midnight – or some nights never have a call – getting sleep can present an awkward dilemma.

On one hand, we must be prepared to respond to a real, or usually just perceived, emergency. We must be able to speak intelligently (and intelligibly), think rationally, and perform fine motor tasks accurately after being aroused from any REM or non-REM state. On the other hand, we will be expected to show up at the office the next morning apparently well rested and prepared to make a few dozen clinical decisions in a thoughtful and compassionate manner. Can you do it? How do you do it?

I recently met with two physicians whom I hadn't seen in a while. Whenever aging physicians get together, the conversation eventually touches on the burden of taking call. One said he really could never sleep when he was on call, and the other said that he sleeps very poorly when it is his night in the barrel.

Strategies for a Good Night's Sleep

These revelations surprised me a bit coming from two physicians with a combined experience of nearly 60 years. I often hear from my partners who are 25 years younger that they can't sleep when they are on call. I try to reassure them that, as they did for me, things will get better, and they will learn or assimilate strategies that will allow them to get enough restorative sleep on the nights when they have drawn the short straw.

For example, I never let a patient leave the office until I am comfortable that I've have done everything I should (not could) in this clinical situation. If I think of something after we've all gone home, I'm not embarrassed to call to recheck the situation or tell them to go to the hospital lab for the lab work I've forgotten. Or tell them I will meet them in the ER so that I can have one more look before I go to bed. Shakespeare may have believed that sleep “knits up the raveled sleeves of care.” But if you go to bed with too many loose ends, you'll never get to sleep.

Experience should teach us to give better and better anticipatory guidance. The more questions and bumps in the road a physician can head off with a few preemptive and reassuring words when he/she is face to face with the parent, the more sleep everyone will get.

When I go to bed, I turn off my beeper and tell the answering service to have the parents call my home phone whose ringer has been muted with duct tape so it doesn't disturb Marilyn. This means no fumbling for a light or a pen. It eliminates those embarrassing misdialed numbers at 2 a.m. that begin, “This is Doctor Wilkoff.” It also makes parents consider one more time whether their question is worth waking me at home.

But, there is only so much we pediatricians can do to improve our chances of getting a good night's sleep. The most frustrating calls come from someone on the obstetrics floor who just wants to give me a “heads up” about some meconium-stained fluid or an expected preterm delivery. Unless the situation is so unusual I am going to need to hunt for some special equipment or consultant, I'm not sure how this information is going to help matters. Maybe it's just one of those “misery loves company” deals. But, I can guarantee one thing: It's certainly going to ruin my night's sleep.

Let me begin by saying that I agree with those who feel our decision-making habits could use some spiffing up. We should not be choosing medications based on what our local pharmaceutical representatives tell us over a sumptuous meal at a nice little French restaurant. Nor should we be ordering lab tests out of fear that we will be sued for missing a rare and extremely unlikely disease. Nor should we continue to recommend a certain therapy because that's the way we've been doing it since we finished our residencies.

I agree that medical decisions (and probably all of our decisions) should reflect the best evidence available. However, I am having trouble wrapping my mind and my heart around many of the strategies that I encounter in articles about how I might practice evidence-based medicine. For the most part, they seem unrealistic and impractical.

Let's start with the initial premise that there is enough good evidence out there to support my decisions. New studies are being performed at such a rate that what seems to be correct information today may well be hogwash tomorrow. Yes, there are statistical manipulations that can help sort out the wheat from the chaff, none with a clear advantage. But I don't think that someone can reasonably expect most primary care pediatricians to carry these kinds of analytical skills in our decision-making “tool boxes.”

It's not that we are stupid. It's just that we don't have the time to stop the merry-go-round long enough to do the footwork to perform these analyses. A computer can help, but I'm sure you have discovered that once you open up the Internet, time flies. An extra click here or there and before you know it a half an hour has zipped by.

So how can we make more rational decisions? First, many of the good evidence-based studies I have read (and trust) often suggest that what we've been doing out of habit and tradition isn't achieving our goals. The authors usually suggest further studies, but for the moment doing nothing sounds like the better course of action for those of us in the trenches. Therefore, I recommend we begin teaching medical students how to do nothing.

This isn't as crazy as it sounds. The therapeutic nihilists who trained me are long gone, so this will mean a new core curriculum that teaches young doctors how to just stand there instead of doing something for which there is no good evidence. One must learn the best body language to adopt while standing inert, and some comforting and reassuring words to say that can help parents understand and accept our inaction. Nihilism also can save money and lives by minimizing expensive tests and risky interventions.

A second and related strategy involves learning how to stop the clock. A recent article posed a scenario in which a primary care physician is consulted by an ENT specialist about the safety of doing elective surgery on a child with both a personal and family history that suggests a bleeding disorder (Pediatr. Rev. 2009;30:317–22).

The recommended approach included searching for several articles and then applying a formula to determine probability and likelihood ratios. The issue of time was never raised in the article, but in my experience, the real scenario would have to include the fact that the call from the ENT came at 4:30 in the afternoon and surgery was scheduled for 7:30 the next morning. Why? Because that's the way it always is.

Good decisions can take time and searching for evidence can take even more time. A shortage of time can contribute to bad decisions. Sometimes we need to be bolder about asking for more time to make our decisions. If I were faced with this scenario I would have picked up the phone and asked Ann, my saintly hematologist friend down in Portland, what she would do.

Let me begin by saying that I agree with those who feel our decision-making habits could use some spiffing up. We should not be choosing medications based on what our local pharmaceutical representatives tell us over a sumptuous meal at a nice little French restaurant. Nor should we be ordering lab tests out of fear that we will be sued for missing a rare and extremely unlikely disease. Nor should we continue to recommend a certain therapy because that's the way we've been doing it since we finished our residencies.

I agree that medical decisions (and probably all of our decisions) should reflect the best evidence available. However, I am having trouble wrapping my mind and my heart around many of the strategies that I encounter in articles about how I might practice evidence-based medicine. For the most part, they seem unrealistic and impractical.

Let's start with the initial premise that there is enough good evidence out there to support my decisions. New studies are being performed at such a rate that what seems to be correct information today may well be hogwash tomorrow. Yes, there are statistical manipulations that can help sort out the wheat from the chaff, none with a clear advantage. But I don't think that someone can reasonably expect most primary care pediatricians to carry these kinds of analytical skills in our decision-making “tool boxes.”

It's not that we are stupid. It's just that we don't have the time to stop the merry-go-round long enough to do the footwork to perform these analyses. A computer can help, but I'm sure you have discovered that once you open up the Internet, time flies. An extra click here or there and before you know it a half an hour has zipped by.

So how can we make more rational decisions? First, many of the good evidence-based studies I have read (and trust) often suggest that what we've been doing out of habit and tradition isn't achieving our goals. The authors usually suggest further studies, but for the moment doing nothing sounds like the better course of action for those of us in the trenches. Therefore, I recommend we begin teaching medical students how to do nothing.

This isn't as crazy as it sounds. The therapeutic nihilists who trained me are long gone, so this will mean a new core curriculum that teaches young doctors how to just stand there instead of doing something for which there is no good evidence. One must learn the best body language to adopt while standing inert, and some comforting and reassuring words to say that can help parents understand and accept our inaction. Nihilism also can save money and lives by minimizing expensive tests and risky interventions.

A second and related strategy involves learning how to stop the clock. A recent article posed a scenario in which a primary care physician is consulted by an ENT specialist about the safety of doing elective surgery on a child with both a personal and family history that suggests a bleeding disorder (Pediatr. Rev. 2009;30:317–22).

The recommended approach included searching for several articles and then applying a formula to determine probability and likelihood ratios. The issue of time was never raised in the article, but in my experience, the real scenario would have to include the fact that the call from the ENT came at 4:30 in the afternoon and surgery was scheduled for 7:30 the next morning. Why? Because that's the way it always is.

Good decisions can take time and searching for evidence can take even more time. A shortage of time can contribute to bad decisions. Sometimes we need to be bolder about asking for more time to make our decisions. If I were faced with this scenario I would have picked up the phone and asked Ann, my saintly hematologist friend down in Portland, what she would do.

Let me begin by saying that I agree with those who feel our decision-making habits could use some spiffing up. We should not be choosing medications based on what our local pharmaceutical representatives tell us over a sumptuous meal at a nice little French restaurant. Nor should we be ordering lab tests out of fear that we will be sued for missing a rare and extremely unlikely disease. Nor should we continue to recommend a certain therapy because that's the way we've been doing it since we finished our residencies.

I agree that medical decisions (and probably all of our decisions) should reflect the best evidence available. However, I am having trouble wrapping my mind and my heart around many of the strategies that I encounter in articles about how I might practice evidence-based medicine. For the most part, they seem unrealistic and impractical.

Let's start with the initial premise that there is enough good evidence out there to support my decisions. New studies are being performed at such a rate that what seems to be correct information today may well be hogwash tomorrow. Yes, there are statistical manipulations that can help sort out the wheat from the chaff, none with a clear advantage. But I don't think that someone can reasonably expect most primary care pediatricians to carry these kinds of analytical skills in our decision-making “tool boxes.”

It's not that we are stupid. It's just that we don't have the time to stop the merry-go-round long enough to do the footwork to perform these analyses. A computer can help, but I'm sure you have discovered that once you open up the Internet, time flies. An extra click here or there and before you know it a half an hour has zipped by.

So how can we make more rational decisions? First, many of the good evidence-based studies I have read (and trust) often suggest that what we've been doing out of habit and tradition isn't achieving our goals. The authors usually suggest further studies, but for the moment doing nothing sounds like the better course of action for those of us in the trenches. Therefore, I recommend we begin teaching medical students how to do nothing.

This isn't as crazy as it sounds. The therapeutic nihilists who trained me are long gone, so this will mean a new core curriculum that teaches young doctors how to just stand there instead of doing something for which there is no good evidence. One must learn the best body language to adopt while standing inert, and some comforting and reassuring words to say that can help parents understand and accept our inaction. Nihilism also can save money and lives by minimizing expensive tests and risky interventions.

A second and related strategy involves learning how to stop the clock. A recent article posed a scenario in which a primary care physician is consulted by an ENT specialist about the safety of doing elective surgery on a child with both a personal and family history that suggests a bleeding disorder (Pediatr. Rev. 2009;30:317–22).

The recommended approach included searching for several articles and then applying a formula to determine probability and likelihood ratios. The issue of time was never raised in the article, but in my experience, the real scenario would have to include the fact that the call from the ENT came at 4:30 in the afternoon and surgery was scheduled for 7:30 the next morning. Why? Because that's the way it always is.

Good decisions can take time and searching for evidence can take even more time. A shortage of time can contribute to bad decisions. Sometimes we need to be bolder about asking for more time to make our decisions. If I were faced with this scenario I would have picked up the phone and asked Ann, my saintly hematologist friend down in Portland, what she would do.

pdnews@elsevier.com

Hx: runny nose × 3 d—fever 101 ax yest afternoon—very fussy last night'some cough—no Breakfast—no V or D

PE: Well—N.A.D. sl fussy—orients to Mom—Chest clear—Rt TM honey colored opaque bulging—Lt creamy fluid level 2/3 immobile

Dx: B.O.M.

Plan: Amox 250 tid × 10 d/Ret 3 wks

Does this look familiar? It's a typical note that has been scanned into a patient's electronic medical record. It was originally handwritten and includes a small schematic diagram of a tympanic membrane. But it could have been typed or dictated with a system such as Dragonspeak.

Does it seem skimpy? How does it compare to your own office records or those you receive from an emergency room? Is the format familiar?

You may wonder why I don't use the SOAP format (subjective, objective, assessment, plan). I was already a few steps into my training when SOAP was introduced and promoted. One of those old dog/new tricks deals. But a more philosophic answer is that I have some real reservations about the objectivity of most physical exams, my own included.

Look at our poor track record in observing and recording the appearance of tympanic membranes or heart murmurs or lung sounds. How many of us are disciplined enough to describe a skin eruption beyond reporting it as “maculopapular”? If we were to change the “O” in SOAP to “observation” instead of “objective,” I could buy it. Otherwise a physical exam is in the eye of the beholder. The only objective portions are the vital signs and the lab work. And I have my doubts about the accuracy of weights and BPs coming out of many offices and emergency rooms. My notes are divided into history, physical exam, diagnosis (or assessment), and plan. If the child has multiple problems, I number them and match them with similarly numbered plans.

If you can accept my old-school format, can you accept my note's skimpiness? You may ask, “Where are the pertinent negatives?” Good question. But here's a better question: What is the value of listing pertinent negatives?

When we were medical students, a list of pertinent negatives proved that we had taken a thorough history and done a complete exam. My colleagues who cover for me know how thoroughly I interview and examine patients. I owe them a thumbnail sketch of how sick the child looked and a description of the positives in case it's helpful for comparison at a subsequent visit. I include “chest clear” out of habit, but otherwise I try to spare my busy brother and sister pediatricians the tedium of a laundry list of negatives.

Two groups retain a perverse curiosity about what I haven't seen or heard: the lawyers and the third-party bean counters. They remain zealous believers in the myth that, “if you didn't document it, it did not happen.” Obviously this is rubbish, but they wield power (mostly financial), and unfortunately that power has influenced, and I fear will continue to influence, the format and style of electronic medical records. Templates, drop-down lists, and preprogrammed phrases will become the norm. The busy physician will click or tap with a stylus to create a voluminous list of negatives, pertinent and otherwise, that only a medical school instructor would care about.

Navigating these electronic shortcuts is not as easy as it sounds. The extensive lists they generate mean more wasted time for a covering physician. The finished note's spell-checked and laser-printed clarity doesn't guarantee that the right questions have been asked or that the exam was expertly done.

pdnews@elsevier.com

Hx: runny nose × 3 d—fever 101 ax yest afternoon—very fussy last night'some cough—no Breakfast—no V or D

PE: Well—N.A.D. sl fussy—orients to Mom—Chest clear—Rt TM honey colored opaque bulging—Lt creamy fluid level 2/3 immobile

Dx: B.O.M.

Plan: Amox 250 tid × 10 d/Ret 3 wks

Does this look familiar? It's a typical note that has been scanned into a patient's electronic medical record. It was originally handwritten and includes a small schematic diagram of a tympanic membrane. But it could have been typed or dictated with a system such as Dragonspeak.

Does it seem skimpy? How does it compare to your own office records or those you receive from an emergency room? Is the format familiar?

You may wonder why I don't use the SOAP format (subjective, objective, assessment, plan). I was already a few steps into my training when SOAP was introduced and promoted. One of those old dog/new tricks deals. But a more philosophic answer is that I have some real reservations about the objectivity of most physical exams, my own included.

Look at our poor track record in observing and recording the appearance of tympanic membranes or heart murmurs or lung sounds. How many of us are disciplined enough to describe a skin eruption beyond reporting it as “maculopapular”? If we were to change the “O” in SOAP to “observation” instead of “objective,” I could buy it. Otherwise a physical exam is in the eye of the beholder. The only objective portions are the vital signs and the lab work. And I have my doubts about the accuracy of weights and BPs coming out of many offices and emergency rooms. My notes are divided into history, physical exam, diagnosis (or assessment), and plan. If the child has multiple problems, I number them and match them with similarly numbered plans.

If you can accept my old-school format, can you accept my note's skimpiness? You may ask, “Where are the pertinent negatives?” Good question. But here's a better question: What is the value of listing pertinent negatives?

When we were medical students, a list of pertinent negatives proved that we had taken a thorough history and done a complete exam. My colleagues who cover for me know how thoroughly I interview and examine patients. I owe them a thumbnail sketch of how sick the child looked and a description of the positives in case it's helpful for comparison at a subsequent visit. I include “chest clear” out of habit, but otherwise I try to spare my busy brother and sister pediatricians the tedium of a laundry list of negatives.

Two groups retain a perverse curiosity about what I haven't seen or heard: the lawyers and the third-party bean counters. They remain zealous believers in the myth that, “if you didn't document it, it did not happen.” Obviously this is rubbish, but they wield power (mostly financial), and unfortunately that power has influenced, and I fear will continue to influence, the format and style of electronic medical records. Templates, drop-down lists, and preprogrammed phrases will become the norm. The busy physician will click or tap with a stylus to create a voluminous list of negatives, pertinent and otherwise, that only a medical school instructor would care about.

Navigating these electronic shortcuts is not as easy as it sounds. The extensive lists they generate mean more wasted time for a covering physician. The finished note's spell-checked and laser-printed clarity doesn't guarantee that the right questions have been asked or that the exam was expertly done.

pdnews@elsevier.com

Hx: runny nose × 3 d—fever 101 ax yest afternoon—very fussy last night'some cough—no Breakfast—no V or D

PE: Well—N.A.D. sl fussy—orients to Mom—Chest clear—Rt TM honey colored opaque bulging—Lt creamy fluid level 2/3 immobile

Dx: B.O.M.

Plan: Amox 250 tid × 10 d/Ret 3 wks

Does this look familiar? It's a typical note that has been scanned into a patient's electronic medical record. It was originally handwritten and includes a small schematic diagram of a tympanic membrane. But it could have been typed or dictated with a system such as Dragonspeak.

Does it seem skimpy? How does it compare to your own office records or those you receive from an emergency room? Is the format familiar?

You may wonder why I don't use the SOAP format (subjective, objective, assessment, plan). I was already a few steps into my training when SOAP was introduced and promoted. One of those old dog/new tricks deals. But a more philosophic answer is that I have some real reservations about the objectivity of most physical exams, my own included.

Look at our poor track record in observing and recording the appearance of tympanic membranes or heart murmurs or lung sounds. How many of us are disciplined enough to describe a skin eruption beyond reporting it as “maculopapular”? If we were to change the “O” in SOAP to “observation” instead of “objective,” I could buy it. Otherwise a physical exam is in the eye of the beholder. The only objective portions are the vital signs and the lab work. And I have my doubts about the accuracy of weights and BPs coming out of many offices and emergency rooms. My notes are divided into history, physical exam, diagnosis (or assessment), and plan. If the child has multiple problems, I number them and match them with similarly numbered plans.

If you can accept my old-school format, can you accept my note's skimpiness? You may ask, “Where are the pertinent negatives?” Good question. But here's a better question: What is the value of listing pertinent negatives?

When we were medical students, a list of pertinent negatives proved that we had taken a thorough history and done a complete exam. My colleagues who cover for me know how thoroughly I interview and examine patients. I owe them a thumbnail sketch of how sick the child looked and a description of the positives in case it's helpful for comparison at a subsequent visit. I include “chest clear” out of habit, but otherwise I try to spare my busy brother and sister pediatricians the tedium of a laundry list of negatives.

Two groups retain a perverse curiosity about what I haven't seen or heard: the lawyers and the third-party bean counters. They remain zealous believers in the myth that, “if you didn't document it, it did not happen.” Obviously this is rubbish, but they wield power (mostly financial), and unfortunately that power has influenced, and I fear will continue to influence, the format and style of electronic medical records. Templates, drop-down lists, and preprogrammed phrases will become the norm. The busy physician will click or tap with a stylus to create a voluminous list of negatives, pertinent and otherwise, that only a medical school instructor would care about.

Navigating these electronic shortcuts is not as easy as it sounds. The extensive lists they generate mean more wasted time for a covering physician. The finished note's spell-checked and laser-printed clarity doesn't guarantee that the right questions have been asked or that the exam was expertly done.

pdnews@elsevier.com

I've been a bit grumpy the last couple of weeks. We had to put down our 10-year-old electronic medical record system, and I am still working through the grieving process.

She was getting long in the tooth. Homemade by one of our doctors, she had served us well. Everybody loved her from Day 1. But keeping her healthy had become expensive and frustrating. She didn't interface with our off-the-shelf billing and prescribing platforms. She had to go.

What we pediatricians had liked about her was that she allowed us to handwrite our notes and scan them in quickly. Our new system is point and click or type in free text boxes. Dictation just doesn't fit our practice styles. For me, typing isn't much of an issue. In one of her wiser moments, my mom decided that I wasn't going to waste the entire summer of my 11th year at the town swimming pool. She taped over the keys of one of my Dad's old typewriters; gave me a water-stained copy of a learn-to-type book and set me to transcribing Reader's Digest articles. The result is that I am a fast but inaccurate typist whose brain is littered with deep pockets of useless knowledge and anecdotes.

I am trying to learn to keep my eyes off the keyboard and the screen. It's a struggle but I know I can make the adjustment. The reason for my persistent grumpiness is that while the keyboard can replace my handwriting (and probably should have years ago) it can't replace the scores of drawings that decorate my charts.

I have always been a drawer. Ask me for directions and I'll draw you a map. Ask me any question and the odds are 2:1 that I will pull out my pen and illustrate my answer on an old envelope or a paper napkin. It must be genetic. My mom was trained to be an art teacher. My dad always designed and made our Christmas cards. My sister is a whiz with fine-tipped colored markers. My college major was art history. I'm just a visual guy.

It's always been easier for me to draw the distribution of a rash than to describe it. “It hurts here” is more efficiently sketched than written about. The size, shape, and location of laceration are unmistakable when I can draw the wound. A quick outline of the tympanic membrane allows me to remember how much and where the fluid was collecting.

While I am a prolific medical illustrator, the quality of my work is spotty. I have certain favorites and strengths. I am particularly proud of my renderings of legs, fingers, trunks, and genitalia. My sketches of faces and noses are good, my tongues and tonsils are fair. Profiles, ankles, and teeth are pretty shaky but always unmistakable. Even my worst work offers our medical record staff multiple opportunities for a good laugh at the end of a long day.

I have never warmed up to the concept of adding my own lines and dots to the preprinted anatomically correct drawings available on off-the-shelf forms. Somehow it makes me feel that I am prostituting my artistic talents.

There is technology out there that might allow me to draw on the computer, but I've been told it won't be finding its way to our little corner of Maine for quite awhile. So I will be struggling to describe what I have been drawing for years. My vocabulary of anatomical names, which has atrophied from disuse, will have to be rebuilt. For decades I have relied on my sketches and shoddy penmanship to disguise my spelling deficiencies.

But in my darkest hours of grumpiness I am reassured that I will still need my pen and paper to illustrate my mini lectures for patients and parents. They need to “see” what a middle ear looks like and how an inguinal hernia forms. Or why a swollen prepatellar bursa is not as serious as an intra-articular effusion.

Every picture is worth a thousand words … at least.

pdnews@elsevier.com

I've been a bit grumpy the last couple of weeks. We had to put down our 10-year-old electronic medical record system, and I am still working through the grieving process.

She was getting long in the tooth. Homemade by one of our doctors, she had served us well. Everybody loved her from Day 1. But keeping her healthy had become expensive and frustrating. She didn't interface with our off-the-shelf billing and prescribing platforms. She had to go.

What we pediatricians had liked about her was that she allowed us to handwrite our notes and scan them in quickly. Our new system is point and click or type in free text boxes. Dictation just doesn't fit our practice styles. For me, typing isn't much of an issue. In one of her wiser moments, my mom decided that I wasn't going to waste the entire summer of my 11th year at the town swimming pool. She taped over the keys of one of my Dad's old typewriters; gave me a water-stained copy of a learn-to-type book and set me to transcribing Reader's Digest articles. The result is that I am a fast but inaccurate typist whose brain is littered with deep pockets of useless knowledge and anecdotes.

I am trying to learn to keep my eyes off the keyboard and the screen. It's a struggle but I know I can make the adjustment. The reason for my persistent grumpiness is that while the keyboard can replace my handwriting (and probably should have years ago) it can't replace the scores of drawings that decorate my charts.

I have always been a drawer. Ask me for directions and I'll draw you a map. Ask me any question and the odds are 2:1 that I will pull out my pen and illustrate my answer on an old envelope or a paper napkin. It must be genetic. My mom was trained to be an art teacher. My dad always designed and made our Christmas cards. My sister is a whiz with fine-tipped colored markers. My college major was art history. I'm just a visual guy.

It's always been easier for me to draw the distribution of a rash than to describe it. “It hurts here” is more efficiently sketched than written about. The size, shape, and location of laceration are unmistakable when I can draw the wound. A quick outline of the tympanic membrane allows me to remember how much and where the fluid was collecting.

While I am a prolific medical illustrator, the quality of my work is spotty. I have certain favorites and strengths. I am particularly proud of my renderings of legs, fingers, trunks, and genitalia. My sketches of faces and noses are good, my tongues and tonsils are fair. Profiles, ankles, and teeth are pretty shaky but always unmistakable. Even my worst work offers our medical record staff multiple opportunities for a good laugh at the end of a long day.

I have never warmed up to the concept of adding my own lines and dots to the preprinted anatomically correct drawings available on off-the-shelf forms. Somehow it makes me feel that I am prostituting my artistic talents.

There is technology out there that might allow me to draw on the computer, but I've been told it won't be finding its way to our little corner of Maine for quite awhile. So I will be struggling to describe what I have been drawing for years. My vocabulary of anatomical names, which has atrophied from disuse, will have to be rebuilt. For decades I have relied on my sketches and shoddy penmanship to disguise my spelling deficiencies.

But in my darkest hours of grumpiness I am reassured that I will still need my pen and paper to illustrate my mini lectures for patients and parents. They need to “see” what a middle ear looks like and how an inguinal hernia forms. Or why a swollen prepatellar bursa is not as serious as an intra-articular effusion.

Every picture is worth a thousand words … at least.

pdnews@elsevier.com

I've been a bit grumpy the last couple of weeks. We had to put down our 10-year-old electronic medical record system, and I am still working through the grieving process.

She was getting long in the tooth. Homemade by one of our doctors, she had served us well. Everybody loved her from Day 1. But keeping her healthy had become expensive and frustrating. She didn't interface with our off-the-shelf billing and prescribing platforms. She had to go.

What we pediatricians had liked about her was that she allowed us to handwrite our notes and scan them in quickly. Our new system is point and click or type in free text boxes. Dictation just doesn't fit our practice styles. For me, typing isn't much of an issue. In one of her wiser moments, my mom decided that I wasn't going to waste the entire summer of my 11th year at the town swimming pool. She taped over the keys of one of my Dad's old typewriters; gave me a water-stained copy of a learn-to-type book and set me to transcribing Reader's Digest articles. The result is that I am a fast but inaccurate typist whose brain is littered with deep pockets of useless knowledge and anecdotes.

I am trying to learn to keep my eyes off the keyboard and the screen. It's a struggle but I know I can make the adjustment. The reason for my persistent grumpiness is that while the keyboard can replace my handwriting (and probably should have years ago) it can't replace the scores of drawings that decorate my charts.

I have always been a drawer. Ask me for directions and I'll draw you a map. Ask me any question and the odds are 2:1 that I will pull out my pen and illustrate my answer on an old envelope or a paper napkin. It must be genetic. My mom was trained to be an art teacher. My dad always designed and made our Christmas cards. My sister is a whiz with fine-tipped colored markers. My college major was art history. I'm just a visual guy.

It's always been easier for me to draw the distribution of a rash than to describe it. “It hurts here” is more efficiently sketched than written about. The size, shape, and location of laceration are unmistakable when I can draw the wound. A quick outline of the tympanic membrane allows me to remember how much and where the fluid was collecting.

While I am a prolific medical illustrator, the quality of my work is spotty. I have certain favorites and strengths. I am particularly proud of my renderings of legs, fingers, trunks, and genitalia. My sketches of faces and noses are good, my tongues and tonsils are fair. Profiles, ankles, and teeth are pretty shaky but always unmistakable. Even my worst work offers our medical record staff multiple opportunities for a good laugh at the end of a long day.

I have never warmed up to the concept of adding my own lines and dots to the preprinted anatomically correct drawings available on off-the-shelf forms. Somehow it makes me feel that I am prostituting my artistic talents.

There is technology out there that might allow me to draw on the computer, but I've been told it won't be finding its way to our little corner of Maine for quite awhile. So I will be struggling to describe what I have been drawing for years. My vocabulary of anatomical names, which has atrophied from disuse, will have to be rebuilt. For decades I have relied on my sketches and shoddy penmanship to disguise my spelling deficiencies.

But in my darkest hours of grumpiness I am reassured that I will still need my pen and paper to illustrate my mini lectures for patients and parents. They need to “see” what a middle ear looks like and how an inguinal hernia forms. Or why a swollen prepatellar bursa is not as serious as an intra-articular effusion.

Every picture is worth a thousand words … at least.

Quality of life. Now there's a hot topic. It seems that everyone under the age of 45 with a marketable skill is looking for it. And every head hunter, real estate agent, and chamber of commerce claims they know where to find it. But, quality of life isn't something to market or buy. Nor is it something that's going to fall into our laps just because we behave well and have nice hair.

Quality of life is something we have to build for ourselves. And it must begin with a plan—one that is realistic, matches our capabilities and personalities, and is reasonably achievable in the current economy. It must be adjustable because stuff happens; every plan A should include at least options B and C.

It must be built from quality materials that include a vocation that satisfies our need to be productive and contribute to a cause outside of ourselves. Choosing a position primarily because it offers more free time runs the risk of our accepting unfulfilling hours of drudgery with our eyes glued to our watch and calendar. Location can be very important but without a supportive partner and/or a comfortable collection of friends, anywhere can lose its charm. The right job in the right place surrounded by the right people still can't guarantee a good quality of life because being a physician comes with stressors that can erode even the most artfully constructed life. Having watched scores of physicians and myself struggle to maintain balance in their lives, it appears that the ability to compartmentalize one's life is a critical skill.

If Robert Frost was correct about good fences and good neighbors, then the physician who can build good walls between his professional and personal lives is more likely to be living a good quality life. It takes practice for a compassionate doctor to successfully leave patients' problems in the office at the end of a long day. But it must be done. It means learning how to minimize our errors of omission so that we can sleep at night knowing we have dotted all of the i's and crossed all of the of t's. If we want to live in the community where we practice, it will mean learning how to politely deflect the occasional impertinent questions in the grocery store checkout line. At times we must adopt two personas, one for the office and one for the outside world.

Although I suspect that most practice consultants today will agree with me that compartmentalization is a strategy to aim for, it hasn't always been the model for physicians. I recently read about the death of Dr. Martin F. Randolph, a 92-year-old pediatrician who practiced in Danbury, Conn., from 1948 to 1997 (“With the Death of a Physician, An Era Fades” by Peter Applebome, The New York Times, March 25, 2010). That's 50 years of pediatric practice, folks! His office was in his home. His wife worked with him as a nurse. He saw patients at all hours including weekends. He was the school system's first physician, and he was often seen bicycling around town. I think it would be safe to say that Dr. Randolph didn't build many walls between his private and professional lives. Instead, he chose to be a weaver and wove his pediatric practice into the fabric of his life. It would seem that he did a damn good job of it. And, I'll bet you he was pretty happy with the quality of life he achieved.

Quality of life. Now there's a hot topic. It seems that everyone under the age of 45 with a marketable skill is looking for it. And every head hunter, real estate agent, and chamber of commerce claims they know where to find it. But, quality of life isn't something to market or buy. Nor is it something that's going to fall into our laps just because we behave well and have nice hair.

Quality of life is something we have to build for ourselves. And it must begin with a plan—one that is realistic, matches our capabilities and personalities, and is reasonably achievable in the current economy. It must be adjustable because stuff happens; every plan A should include at least options B and C.

It must be built from quality materials that include a vocation that satisfies our need to be productive and contribute to a cause outside of ourselves. Choosing a position primarily because it offers more free time runs the risk of our accepting unfulfilling hours of drudgery with our eyes glued to our watch and calendar. Location can be very important but without a supportive partner and/or a comfortable collection of friends, anywhere can lose its charm. The right job in the right place surrounded by the right people still can't guarantee a good quality of life because being a physician comes with stressors that can erode even the most artfully constructed life. Having watched scores of physicians and myself struggle to maintain balance in their lives, it appears that the ability to compartmentalize one's life is a critical skill.

If Robert Frost was correct about good fences and good neighbors, then the physician who can build good walls between his professional and personal lives is more likely to be living a good quality life. It takes practice for a compassionate doctor to successfully leave patients' problems in the office at the end of a long day. But it must be done. It means learning how to minimize our errors of omission so that we can sleep at night knowing we have dotted all of the i's and crossed all of the of t's. If we want to live in the community where we practice, it will mean learning how to politely deflect the occasional impertinent questions in the grocery store checkout line. At times we must adopt two personas, one for the office and one for the outside world.

Although I suspect that most practice consultants today will agree with me that compartmentalization is a strategy to aim for, it hasn't always been the model for physicians. I recently read about the death of Dr. Martin F. Randolph, a 92-year-old pediatrician who practiced in Danbury, Conn., from 1948 to 1997 (“With the Death of a Physician, An Era Fades” by Peter Applebome, The New York Times, March 25, 2010). That's 50 years of pediatric practice, folks! His office was in his home. His wife worked with him as a nurse. He saw patients at all hours including weekends. He was the school system's first physician, and he was often seen bicycling around town. I think it would be safe to say that Dr. Randolph didn't build many walls between his private and professional lives. Instead, he chose to be a weaver and wove his pediatric practice into the fabric of his life. It would seem that he did a damn good job of it. And, I'll bet you he was pretty happy with the quality of life he achieved.

Quality of life. Now there's a hot topic. It seems that everyone under the age of 45 with a marketable skill is looking for it. And every head hunter, real estate agent, and chamber of commerce claims they know where to find it. But, quality of life isn't something to market or buy. Nor is it something that's going to fall into our laps just because we behave well and have nice hair.

Quality of life is something we have to build for ourselves. And it must begin with a plan—one that is realistic, matches our capabilities and personalities, and is reasonably achievable in the current economy. It must be adjustable because stuff happens; every plan A should include at least options B and C.

It must be built from quality materials that include a vocation that satisfies our need to be productive and contribute to a cause outside of ourselves. Choosing a position primarily because it offers more free time runs the risk of our accepting unfulfilling hours of drudgery with our eyes glued to our watch and calendar. Location can be very important but without a supportive partner and/or a comfortable collection of friends, anywhere can lose its charm. The right job in the right place surrounded by the right people still can't guarantee a good quality of life because being a physician comes with stressors that can erode even the most artfully constructed life. Having watched scores of physicians and myself struggle to maintain balance in their lives, it appears that the ability to compartmentalize one's life is a critical skill.

If Robert Frost was correct about good fences and good neighbors, then the physician who can build good walls between his professional and personal lives is more likely to be living a good quality life. It takes practice for a compassionate doctor to successfully leave patients' problems in the office at the end of a long day. But it must be done. It means learning how to minimize our errors of omission so that we can sleep at night knowing we have dotted all of the i's and crossed all of the of t's. If we want to live in the community where we practice, it will mean learning how to politely deflect the occasional impertinent questions in the grocery store checkout line. At times we must adopt two personas, one for the office and one for the outside world.

Although I suspect that most practice consultants today will agree with me that compartmentalization is a strategy to aim for, it hasn't always been the model for physicians. I recently read about the death of Dr. Martin F. Randolph, a 92-year-old pediatrician who practiced in Danbury, Conn., from 1948 to 1997 (“With the Death of a Physician, An Era Fades” by Peter Applebome, The New York Times, March 25, 2010). That's 50 years of pediatric practice, folks! His office was in his home. His wife worked with him as a nurse. He saw patients at all hours including weekends. He was the school system's first physician, and he was often seen bicycling around town. I think it would be safe to say that Dr. Randolph didn't build many walls between his private and professional lives. Instead, he chose to be a weaver and wove his pediatric practice into the fabric of his life. It would seem that he did a damn good job of it. And, I'll bet you he was pretty happy with the quality of life he achieved.

pdnews@elsevier.com

“Oops” is probably my most frequently used subject when creating e-mails. The recipient is immediately alerted that in the text they are going to find an extensive mea culpa. Often I am apologizing for forgetting to attend a meeting. Although “forgetting” may not be the most accurate word when it comes to group exercises destined to go nowhere slowly.

Warriors have their own versions of “oops.” Both conjure up horrible and tragic images of death and destruction. One is “friendly fire.” The other is “collateral damage,” a term that refers to devastation outside the expected target area.

A few months ago I opened the Sunday morning paper and encountered an explosive event on page 4. You have probably read or heard other versions of the story of a 56-year-old pediatrician from Lewes, Del., who is in jail awaiting prosecution for a 471-count indictment for sexually molesting some of his patients over at least 11 years in practice.

The details of the case that have come to light so far are complex and terribly disturbing. The ground zero for this horrible explosion is predictably the children who were molested, particularly those who have some memory of the events. Sharing the epicenter are their parents whose anger is directed outward to the alleged perpetrator. And inward at themselves for not acting on the occasional uneasy feeling that the physician whom they had trusted with their children seemed a little too weird.

We can only hope that with time both parents and children will find a physician with whom they can feel comfortable. For some I am sure it will take many years to repair the damage. But, because we live in an age of instant and global communication, this horrible bomb of mistrust is radiating and will continue to radiate damage far beyond the borders of that tiny town on the Delaware Coast.

Parents from Portland, Maine, to San Diego will be looking at their pediatricians with a new and suspicious eye. “Does he seem overly interested in my daughter's private parts?” “Does she spend too much time trying to find my 8-month-old son's testicle?” “Doesn't that beard make him seem just a little too weird?” Those of us who wear oversized polka dot bow ties or occasionally don red clown noses to put our patients at ease may be in for special scrutiny.

Although some of us may feel we need to traditionalize our attire, sartorial alterations are relatively easy to make. Behavioral adjustments will present more of a problem. Doctoring can and at times must be hands on. In some circumstances private places must be carefully inspected. Complicating matters is the fact that even on our most hectic days we don't just tolerate our patients. We like them.

There are times when this genuine affection emerges in a big hug for the 4-year-old who has weathered his preschool shots with only a glint of a tear in his eyes. Or a pat on the head for a 3-year-old who has finally mastered the skill of holding still for an ear exam. Two-month-old infants can be too cute not to cradle in one's arms.

But because of the alleged and horribly inappropriate behavior of one of our number, some things will have to change. We will always have to explain what and why we are doing the sensitive portions of our exams. We can no longer assume that because we are pediatricians, our behavior will be interpreted as appropriate.

But what won't and mustn't change is our affection for our patients. However, we may have to begin asking permission for some things that once came so naturally. Unfortunately, the spontaneous hug may have become a casualty of collateral damage.

pdnews@elsevier.com

“Oops” is probably my most frequently used subject when creating e-mails. The recipient is immediately alerted that in the text they are going to find an extensive mea culpa. Often I am apologizing for forgetting to attend a meeting. Although “forgetting” may not be the most accurate word when it comes to group exercises destined to go nowhere slowly.

Warriors have their own versions of “oops.” Both conjure up horrible and tragic images of death and destruction. One is “friendly fire.” The other is “collateral damage,” a term that refers to devastation outside the expected target area.

A few months ago I opened the Sunday morning paper and encountered an explosive event on page 4. You have probably read or heard other versions of the story of a 56-year-old pediatrician from Lewes, Del., who is in jail awaiting prosecution for a 471-count indictment for sexually molesting some of his patients over at least 11 years in practice.

The details of the case that have come to light so far are complex and terribly disturbing. The ground zero for this horrible explosion is predictably the children who were molested, particularly those who have some memory of the events. Sharing the epicenter are their parents whose anger is directed outward to the alleged perpetrator. And inward at themselves for not acting on the occasional uneasy feeling that the physician whom they had trusted with their children seemed a little too weird.

We can only hope that with time both parents and children will find a physician with whom they can feel comfortable. For some I am sure it will take many years to repair the damage. But, because we live in an age of instant and global communication, this horrible bomb of mistrust is radiating and will continue to radiate damage far beyond the borders of that tiny town on the Delaware Coast.

Parents from Portland, Maine, to San Diego will be looking at their pediatricians with a new and suspicious eye. “Does he seem overly interested in my daughter's private parts?” “Does she spend too much time trying to find my 8-month-old son's testicle?” “Doesn't that beard make him seem just a little too weird?” Those of us who wear oversized polka dot bow ties or occasionally don red clown noses to put our patients at ease may be in for special scrutiny.

Although some of us may feel we need to traditionalize our attire, sartorial alterations are relatively easy to make. Behavioral adjustments will present more of a problem. Doctoring can and at times must be hands on. In some circumstances private places must be carefully inspected. Complicating matters is the fact that even on our most hectic days we don't just tolerate our patients. We like them.

There are times when this genuine affection emerges in a big hug for the 4-year-old who has weathered his preschool shots with only a glint of a tear in his eyes. Or a pat on the head for a 3-year-old who has finally mastered the skill of holding still for an ear exam. Two-month-old infants can be too cute not to cradle in one's arms.

But because of the alleged and horribly inappropriate behavior of one of our number, some things will have to change. We will always have to explain what and why we are doing the sensitive portions of our exams. We can no longer assume that because we are pediatricians, our behavior will be interpreted as appropriate.

But what won't and mustn't change is our affection for our patients. However, we may have to begin asking permission for some things that once came so naturally. Unfortunately, the spontaneous hug may have become a casualty of collateral damage.

pdnews@elsevier.com

“Oops” is probably my most frequently used subject when creating e-mails. The recipient is immediately alerted that in the text they are going to find an extensive mea culpa. Often I am apologizing for forgetting to attend a meeting. Although “forgetting” may not be the most accurate word when it comes to group exercises destined to go nowhere slowly.

Warriors have their own versions of “oops.” Both conjure up horrible and tragic images of death and destruction. One is “friendly fire.” The other is “collateral damage,” a term that refers to devastation outside the expected target area.

A few months ago I opened the Sunday morning paper and encountered an explosive event on page 4. You have probably read or heard other versions of the story of a 56-year-old pediatrician from Lewes, Del., who is in jail awaiting prosecution for a 471-count indictment for sexually molesting some of his patients over at least 11 years in practice.

The details of the case that have come to light so far are complex and terribly disturbing. The ground zero for this horrible explosion is predictably the children who were molested, particularly those who have some memory of the events. Sharing the epicenter are their parents whose anger is directed outward to the alleged perpetrator. And inward at themselves for not acting on the occasional uneasy feeling that the physician whom they had trusted with their children seemed a little too weird.

We can only hope that with time both parents and children will find a physician with whom they can feel comfortable. For some I am sure it will take many years to repair the damage. But, because we live in an age of instant and global communication, this horrible bomb of mistrust is radiating and will continue to radiate damage far beyond the borders of that tiny town on the Delaware Coast.

Parents from Portland, Maine, to San Diego will be looking at their pediatricians with a new and suspicious eye. “Does he seem overly interested in my daughter's private parts?” “Does she spend too much time trying to find my 8-month-old son's testicle?” “Doesn't that beard make him seem just a little too weird?” Those of us who wear oversized polka dot bow ties or occasionally don red clown noses to put our patients at ease may be in for special scrutiny.

Although some of us may feel we need to traditionalize our attire, sartorial alterations are relatively easy to make. Behavioral adjustments will present more of a problem. Doctoring can and at times must be hands on. In some circumstances private places must be carefully inspected. Complicating matters is the fact that even on our most hectic days we don't just tolerate our patients. We like them.

There are times when this genuine affection emerges in a big hug for the 4-year-old who has weathered his preschool shots with only a glint of a tear in his eyes. Or a pat on the head for a 3-year-old who has finally mastered the skill of holding still for an ear exam. Two-month-old infants can be too cute not to cradle in one's arms.

But because of the alleged and horribly inappropriate behavior of one of our number, some things will have to change. We will always have to explain what and why we are doing the sensitive portions of our exams. We can no longer assume that because we are pediatricians, our behavior will be interpreted as appropriate.

But what won't and mustn't change is our affection for our patients. However, we may have to begin asking permission for some things that once came so naturally. Unfortunately, the spontaneous hug may have become a casualty of collateral damage.

pdnews@elsevier.com

Do you use templates? If you haven't stepped over the threshold into the costly world of electronic health records, you may not understand the question.

In the old days, a template was a pattern or gauge for accurately creating a product. A stencil is a template. In addition to ensuring accuracy, a template allows its user to replicate the original product more efficiently.

Even if you haven't begun using electronic templates but practice in a group, you probably have adopted standard forms for a variety of patient interactions—for example, ones for sick visits, which may be disease specific, or for well visits, which may be age specific. Obviously, standardization can make it easier for practicing physicians and their staffs to find information through documentation guided by templates. These forms can be bought off the shelf or developed internally by members of the group after what can be contentious negotiations between providers. Those of us who practiced by ourselves quickly became wedded to the formats we developed ourselves. When one joins a group, it can be difficult to leave our old favorite forms. And, when new editions are proposed, tugs-of-war can erupt over where to position, and how big to make, the boxes.

Some physicians prefer detailed and exhaustive checklists; others like myself prefer broad categories with plenty of elbow room to scribble and create anatomically incorrect drawings. We don't like being fenced in by a myriad of little boxes. Instead we crave the wide-open spaces to create and express our individuality.

Should a template dictate practice? Is it the purpose of the form to remind, coach, or arm twist the practitioner into asking certain questions or performing certain tests? There is certainly mounting evidence that checklists for procedures can improve outcomes. But when we are talking about an office visit encounter, one could ask, “Is the form the boss of me? Or is it merely a tool to guide my documentation so that my coworkers can find and understand what I have done?”

When templates become electronic, they can become tools for replicating documents of dubious quality. For example, when one clicks on a box that says “normal pharynx,” the computer may spit out a stored bit of dialogue that includes “uvula midline, tonsils not enlarged.” In reality the child may have a bifid uvula and his tonsils may have been surgically removed. Although these inaccuracies may be trivial, one can easily imagine others that are not so innocuous.

How many of us really carefully read the final documents generated by our clicks or wand taps? How many of us remember what the computer is going to say when we click “normal”? This kind of error by click is most obvious in emergency department records, which read like textbooks. Having spent more time in emergency departments than I care to remember, I know that the computer-generated record often bears little resemblance to what was actually examined.

Few of us intend to deceive when we document our findings, but a computerized template can make it easy to do so inadvertently.

Even more troubling is the phenomenon in which templates become too narrow and disease specific. All children with earaches are not made equal.

The diagnosis may not be otitis media but school avoidance or anxiety. If the office staff has already loaded in a template specific for otitis, the practitioner may be influenced away from other diagnoses.

A template that functions too much like a cookie cutter can discourage a broader assessment of the patient as a unique individual.

pdnews@elsevier.com

Do you use templates? If you haven't stepped over the threshold into the costly world of electronic health records, you may not understand the question.

In the old days, a template was a pattern or gauge for accurately creating a product. A stencil is a template. In addition to ensuring accuracy, a template allows its user to replicate the original product more efficiently.

Even if you haven't begun using electronic templates but practice in a group, you probably have adopted standard forms for a variety of patient interactions—for example, ones for sick visits, which may be disease specific, or for well visits, which may be age specific. Obviously, standardization can make it easier for practicing physicians and their staffs to find information through documentation guided by templates. These forms can be bought off the shelf or developed internally by members of the group after what can be contentious negotiations between providers. Those of us who practiced by ourselves quickly became wedded to the formats we developed ourselves. When one joins a group, it can be difficult to leave our old favorite forms. And, when new editions are proposed, tugs-of-war can erupt over where to position, and how big to make, the boxes.

Some physicians prefer detailed and exhaustive checklists; others like myself prefer broad categories with plenty of elbow room to scribble and create anatomically incorrect drawings. We don't like being fenced in by a myriad of little boxes. Instead we crave the wide-open spaces to create and express our individuality.

Should a template dictate practice? Is it the purpose of the form to remind, coach, or arm twist the practitioner into asking certain questions or performing certain tests? There is certainly mounting evidence that checklists for procedures can improve outcomes. But when we are talking about an office visit encounter, one could ask, “Is the form the boss of me? Or is it merely a tool to guide my documentation so that my coworkers can find and understand what I have done?”

When templates become electronic, they can become tools for replicating documents of dubious quality. For example, when one clicks on a box that says “normal pharynx,” the computer may spit out a stored bit of dialogue that includes “uvula midline, tonsils not enlarged.” In reality the child may have a bifid uvula and his tonsils may have been surgically removed. Although these inaccuracies may be trivial, one can easily imagine others that are not so innocuous.

How many of us really carefully read the final documents generated by our clicks or wand taps? How many of us remember what the computer is going to say when we click “normal”? This kind of error by click is most obvious in emergency department records, which read like textbooks. Having spent more time in emergency departments than I care to remember, I know that the computer-generated record often bears little resemblance to what was actually examined.

Few of us intend to deceive when we document our findings, but a computerized template can make it easy to do so inadvertently.

Even more troubling is the phenomenon in which templates become too narrow and disease specific. All children with earaches are not made equal.

The diagnosis may not be otitis media but school avoidance or anxiety. If the office staff has already loaded in a template specific for otitis, the practitioner may be influenced away from other diagnoses.

A template that functions too much like a cookie cutter can discourage a broader assessment of the patient as a unique individual.

pdnews@elsevier.com

Do you use templates? If you haven't stepped over the threshold into the costly world of electronic health records, you may not understand the question.

In the old days, a template was a pattern or gauge for accurately creating a product. A stencil is a template. In addition to ensuring accuracy, a template allows its user to replicate the original product more efficiently.

Even if you haven't begun using electronic templates but practice in a group, you probably have adopted standard forms for a variety of patient interactions—for example, ones for sick visits, which may be disease specific, or for well visits, which may be age specific. Obviously, standardization can make it easier for practicing physicians and their staffs to find information through documentation guided by templates. These forms can be bought off the shelf or developed internally by members of the group after what can be contentious negotiations between providers. Those of us who practiced by ourselves quickly became wedded to the formats we developed ourselves. When one joins a group, it can be difficult to leave our old favorite forms. And, when new editions are proposed, tugs-of-war can erupt over where to position, and how big to make, the boxes.

Some physicians prefer detailed and exhaustive checklists; others like myself prefer broad categories with plenty of elbow room to scribble and create anatomically incorrect drawings. We don't like being fenced in by a myriad of little boxes. Instead we crave the wide-open spaces to create and express our individuality.

Should a template dictate practice? Is it the purpose of the form to remind, coach, or arm twist the practitioner into asking certain questions or performing certain tests? There is certainly mounting evidence that checklists for procedures can improve outcomes. But when we are talking about an office visit encounter, one could ask, “Is the form the boss of me? Or is it merely a tool to guide my documentation so that my coworkers can find and understand what I have done?”

When templates become electronic, they can become tools for replicating documents of dubious quality. For example, when one clicks on a box that says “normal pharynx,” the computer may spit out a stored bit of dialogue that includes “uvula midline, tonsils not enlarged.” In reality the child may have a bifid uvula and his tonsils may have been surgically removed. Although these inaccuracies may be trivial, one can easily imagine others that are not so innocuous.

How many of us really carefully read the final documents generated by our clicks or wand taps? How many of us remember what the computer is going to say when we click “normal”? This kind of error by click is most obvious in emergency department records, which read like textbooks. Having spent more time in emergency departments than I care to remember, I know that the computer-generated record often bears little resemblance to what was actually examined.

Few of us intend to deceive when we document our findings, but a computerized template can make it easy to do so inadvertently.

Even more troubling is the phenomenon in which templates become too narrow and disease specific. All children with earaches are not made equal.

The diagnosis may not be otitis media but school avoidance or anxiety. If the office staff has already loaded in a template specific for otitis, the practitioner may be influenced away from other diagnoses.

A template that functions too much like a cookie cutter can discourage a broader assessment of the patient as a unique individual.