William G. Wilkoff

pdnews@elsevier.com

“That's so borrrring!” How many times have you heard those words roll off the tongue of a teenager or preteen? For a decade or two, “boring” has been the description du jour for any activity that a young person doesn't want to or can't perform. Adolescents seem to be particularly vulnerable to this misuse of language. In part, it is the result of their position on the learning curve. But, just as often, teenagers are mirrors for adult behavior they see around them.

For example, I can recall seeing a 14-year-old boy whose office encounter sheet listed his chief complaint as “anxiety.” His mother began the visit by telling me that her son was doing poorly in school because school made him “anxious” and that he was having trouble paying attention.

I struggled for 20 minutes trying to discover what was creating this young man's anxiety. He denied fears about bullying, or using the toilet, or getting ill. He interacted easily with his peers and some teachers.

The only clue he gave me was that he became more anxious as the school day wore on and culminated in the last class of the day in which he was doing relatively well academically. Finally, I asked him the question I should have started with, “So, tell me what it feels like when you're anxious?” “Well,” he replied, “as it gets closer to the end of the day, I am just very anxious to get out of that place. It's so bad by the last period that I have trouble paying attention.”

So without pulling out my prescription pad, I was able to cure him of his anxiety disorder by pointing out that “anxious” can have a variety of meanings. I can't recall whether we eventually unearthed any learning disabilities. But I'm pretty sure we decided that he was simply suffering from garden-variety boredom, aggravated by the school system's recent conversion to 80-minute classes—a format that would have challenged my adolescent mind and still often tests my adult attention span.

As in this young man's case, boredom can be difficult to diagnose. Many parents attribute their child's misbehavior in school and poor academic performance to their belief that the school is failing to present material that is sufficiently challenging. Often the bigger problem is not boredom, but that the child's social skills aren't up to the challenge of a classroom setting.

But maybe we should not always consider boredom a challenge to be mastered. To my surprise, boredom has recently become the target of psychological and neuropsychological research. In a New York Times book review by Jennifer Schuessler entitled, “Our Boredom, Ourselves” (Jan. 24, 2010), the reviewer refers to a study in which healthy subjects were placed in a functional MRI scanner with nothing to do except lie there. The researchers discovered that the portion of the subject's brain that is believed to participate in thinking about what other people are feeling, thinking, and hypothesizing was firing actively. Their brains were consuming only slightly less energy than when they had been asked to perform basic tasks.

Parents who are allowing their children's brains to be continually bombarded by video displays are depriving them of something we all should value more—a little more time alone with our thoughts.

On the other hand, in a study of civil servants in England who reported being very bored at work, they were 2½ times more likely to die of cardiac causes, suggesting the old adage holds: You can have too much of a good thing.

pdnews@elsevier.com

“That's so borrrring!” How many times have you heard those words roll off the tongue of a teenager or preteen? For a decade or two, “boring” has been the description du jour for any activity that a young person doesn't want to or can't perform. Adolescents seem to be particularly vulnerable to this misuse of language. In part, it is the result of their position on the learning curve. But, just as often, teenagers are mirrors for adult behavior they see around them.

For example, I can recall seeing a 14-year-old boy whose office encounter sheet listed his chief complaint as “anxiety.” His mother began the visit by telling me that her son was doing poorly in school because school made him “anxious” and that he was having trouble paying attention.

I struggled for 20 minutes trying to discover what was creating this young man's anxiety. He denied fears about bullying, or using the toilet, or getting ill. He interacted easily with his peers and some teachers.

The only clue he gave me was that he became more anxious as the school day wore on and culminated in the last class of the day in which he was doing relatively well academically. Finally, I asked him the question I should have started with, “So, tell me what it feels like when you're anxious?” “Well,” he replied, “as it gets closer to the end of the day, I am just very anxious to get out of that place. It's so bad by the last period that I have trouble paying attention.”

So without pulling out my prescription pad, I was able to cure him of his anxiety disorder by pointing out that “anxious” can have a variety of meanings. I can't recall whether we eventually unearthed any learning disabilities. But I'm pretty sure we decided that he was simply suffering from garden-variety boredom, aggravated by the school system's recent conversion to 80-minute classes—a format that would have challenged my adolescent mind and still often tests my adult attention span.

As in this young man's case, boredom can be difficult to diagnose. Many parents attribute their child's misbehavior in school and poor academic performance to their belief that the school is failing to present material that is sufficiently challenging. Often the bigger problem is not boredom, but that the child's social skills aren't up to the challenge of a classroom setting.

But maybe we should not always consider boredom a challenge to be mastered. To my surprise, boredom has recently become the target of psychological and neuropsychological research. In a New York Times book review by Jennifer Schuessler entitled, “Our Boredom, Ourselves” (Jan. 24, 2010), the reviewer refers to a study in which healthy subjects were placed in a functional MRI scanner with nothing to do except lie there. The researchers discovered that the portion of the subject's brain that is believed to participate in thinking about what other people are feeling, thinking, and hypothesizing was firing actively. Their brains were consuming only slightly less energy than when they had been asked to perform basic tasks.

Parents who are allowing their children's brains to be continually bombarded by video displays are depriving them of something we all should value more—a little more time alone with our thoughts.

On the other hand, in a study of civil servants in England who reported being very bored at work, they were 2½ times more likely to die of cardiac causes, suggesting the old adage holds: You can have too much of a good thing.

pdnews@elsevier.com

“That's so borrrring!” How many times have you heard those words roll off the tongue of a teenager or preteen? For a decade or two, “boring” has been the description du jour for any activity that a young person doesn't want to or can't perform. Adolescents seem to be particularly vulnerable to this misuse of language. In part, it is the result of their position on the learning curve. But, just as often, teenagers are mirrors for adult behavior they see around them.

For example, I can recall seeing a 14-year-old boy whose office encounter sheet listed his chief complaint as “anxiety.” His mother began the visit by telling me that her son was doing poorly in school because school made him “anxious” and that he was having trouble paying attention.

I struggled for 20 minutes trying to discover what was creating this young man's anxiety. He denied fears about bullying, or using the toilet, or getting ill. He interacted easily with his peers and some teachers.

The only clue he gave me was that he became more anxious as the school day wore on and culminated in the last class of the day in which he was doing relatively well academically. Finally, I asked him the question I should have started with, “So, tell me what it feels like when you're anxious?” “Well,” he replied, “as it gets closer to the end of the day, I am just very anxious to get out of that place. It's so bad by the last period that I have trouble paying attention.”

So without pulling out my prescription pad, I was able to cure him of his anxiety disorder by pointing out that “anxious” can have a variety of meanings. I can't recall whether we eventually unearthed any learning disabilities. But I'm pretty sure we decided that he was simply suffering from garden-variety boredom, aggravated by the school system's recent conversion to 80-minute classes—a format that would have challenged my adolescent mind and still often tests my adult attention span.

As in this young man's case, boredom can be difficult to diagnose. Many parents attribute their child's misbehavior in school and poor academic performance to their belief that the school is failing to present material that is sufficiently challenging. Often the bigger problem is not boredom, but that the child's social skills aren't up to the challenge of a classroom setting.

But maybe we should not always consider boredom a challenge to be mastered. To my surprise, boredom has recently become the target of psychological and neuropsychological research. In a New York Times book review by Jennifer Schuessler entitled, “Our Boredom, Ourselves” (Jan. 24, 2010), the reviewer refers to a study in which healthy subjects were placed in a functional MRI scanner with nothing to do except lie there. The researchers discovered that the portion of the subject's brain that is believed to participate in thinking about what other people are feeling, thinking, and hypothesizing was firing actively. Their brains were consuming only slightly less energy than when they had been asked to perform basic tasks.

Parents who are allowing their children's brains to be continually bombarded by video displays are depriving them of something we all should value more—a little more time alone with our thoughts.

On the other hand, in a study of civil servants in England who reported being very bored at work, they were 2½ times more likely to die of cardiac causes, suggesting the old adage holds: You can have too much of a good thing.

pdnews@elsevier.com

If there is one quality that predominates among new parents, it is self-doubt. Fortunes have been made, (although not by me) in the publishing industry by tapping into the large and predictable market of confidence-deficient neo-parents. I suspect that to some extent it's always been this way. While familiarity may breed contempt, unfamiliarity has always bred trepidation.

The drive to make babies is a powerful force we are comfortable with because Mother Nature does the driving. But we often feel she has abandoned us the moment she hands us that wet, wailing, and totally dependent newborn.

While I am sure that back in the 1700's new parents worried, I suspect they suffered far less from self-doubt than new millennium parents. Several generations ago, new parents were surrounded by their families and grandparents who had been there, done that a dozen times. They grew up in large families and were familiar with what babies and children do.

Contrast this to the parents we see today. They are often geographically divorced from their own families. They come from small families, and may not have participated in raising their siblings, if they had them. They have delayed having children, and it may have been decades since they had any close contact with babies. Their only experience that is anywhere close to parenting has been raising a Labrador retriever. Although they may have been initially deluded that there will be some carryover, it takes only a few minutes to realize that parenting is a whole new ball game.

New parents are older and, to some extent, wiser. They have seen more and read more and know that the world presents much more to worry about than they imagined as teenagers. Of course, the media compounds this with horror stories about how even the most everyday events can go awry. We physicians unwittingly compound the situation with well-meaning suggestions about things like how long to breastfeed.

The bottom line is that new parents seriously need reassurance. Too few of them articulate this by asking, “Am I doing this right?” And too few of us answer the unasked question by unambiguously stating,” You're doing a great job!”

In a recent issue of AAP News (October 2009), Dr. Martin Stein and Dr. J. Lane Tanner reported on some findings from their study of 20 parent focus groups and 31 pediatric clinician focus groups. Among other things, they asked how an ideal pediatric practice would look. They observed, “Parents spoke to an issue that many doctors may be less aware of—how much they value the reassurance that the pediatrician or PNP can give, not only that their child is healthy, but also that they are doing a good job as parents.”

Sometimes we feel that saying, “That's a good weight gain” or complimenting parents on their child's cuteness is sufficient. But I've found that it's not. Parents hear those platitudes from their family and even strangers in the grocery store checkout line all the time. There is nothing more powerful than a respected child health provider saying, “I just want to tell you that you're doing a nice job!”

It's even more important when things aren't going well. Be reassuring during those first few weight checks in the office for the mother who's struggling with a marginal milk supply or who has terribly sore nipples. One doesn't have to be specific. “I know you're worried about how the breastfeeding is going, but you are doing a very good job of parenting.”

There are so few overconfident new parents that it is easy to recommend a shot of confidence at every well-child visit. I promise it won't hurt.

pdnews@elsevier.com

If there is one quality that predominates among new parents, it is self-doubt. Fortunes have been made, (although not by me) in the publishing industry by tapping into the large and predictable market of confidence-deficient neo-parents. I suspect that to some extent it's always been this way. While familiarity may breed contempt, unfamiliarity has always bred trepidation.

The drive to make babies is a powerful force we are comfortable with because Mother Nature does the driving. But we often feel she has abandoned us the moment she hands us that wet, wailing, and totally dependent newborn.

While I am sure that back in the 1700's new parents worried, I suspect they suffered far less from self-doubt than new millennium parents. Several generations ago, new parents were surrounded by their families and grandparents who had been there, done that a dozen times. They grew up in large families and were familiar with what babies and children do.

Contrast this to the parents we see today. They are often geographically divorced from their own families. They come from small families, and may not have participated in raising their siblings, if they had them. They have delayed having children, and it may have been decades since they had any close contact with babies. Their only experience that is anywhere close to parenting has been raising a Labrador retriever. Although they may have been initially deluded that there will be some carryover, it takes only a few minutes to realize that parenting is a whole new ball game.

New parents are older and, to some extent, wiser. They have seen more and read more and know that the world presents much more to worry about than they imagined as teenagers. Of course, the media compounds this with horror stories about how even the most everyday events can go awry. We physicians unwittingly compound the situation with well-meaning suggestions about things like how long to breastfeed.

The bottom line is that new parents seriously need reassurance. Too few of them articulate this by asking, “Am I doing this right?” And too few of us answer the unasked question by unambiguously stating,” You're doing a great job!”

In a recent issue of AAP News (October 2009), Dr. Martin Stein and Dr. J. Lane Tanner reported on some findings from their study of 20 parent focus groups and 31 pediatric clinician focus groups. Among other things, they asked how an ideal pediatric practice would look. They observed, “Parents spoke to an issue that many doctors may be less aware of—how much they value the reassurance that the pediatrician or PNP can give, not only that their child is healthy, but also that they are doing a good job as parents.”

Sometimes we feel that saying, “That's a good weight gain” or complimenting parents on their child's cuteness is sufficient. But I've found that it's not. Parents hear those platitudes from their family and even strangers in the grocery store checkout line all the time. There is nothing more powerful than a respected child health provider saying, “I just want to tell you that you're doing a nice job!”

It's even more important when things aren't going well. Be reassuring during those first few weight checks in the office for the mother who's struggling with a marginal milk supply or who has terribly sore nipples. One doesn't have to be specific. “I know you're worried about how the breastfeeding is going, but you are doing a very good job of parenting.”

There are so few overconfident new parents that it is easy to recommend a shot of confidence at every well-child visit. I promise it won't hurt.

pdnews@elsevier.com

If there is one quality that predominates among new parents, it is self-doubt. Fortunes have been made, (although not by me) in the publishing industry by tapping into the large and predictable market of confidence-deficient neo-parents. I suspect that to some extent it's always been this way. While familiarity may breed contempt, unfamiliarity has always bred trepidation.

The drive to make babies is a powerful force we are comfortable with because Mother Nature does the driving. But we often feel she has abandoned us the moment she hands us that wet, wailing, and totally dependent newborn.

While I am sure that back in the 1700's new parents worried, I suspect they suffered far less from self-doubt than new millennium parents. Several generations ago, new parents were surrounded by their families and grandparents who had been there, done that a dozen times. They grew up in large families and were familiar with what babies and children do.

Contrast this to the parents we see today. They are often geographically divorced from their own families. They come from small families, and may not have participated in raising their siblings, if they had them. They have delayed having children, and it may have been decades since they had any close contact with babies. Their only experience that is anywhere close to parenting has been raising a Labrador retriever. Although they may have been initially deluded that there will be some carryover, it takes only a few minutes to realize that parenting is a whole new ball game.

New parents are older and, to some extent, wiser. They have seen more and read more and know that the world presents much more to worry about than they imagined as teenagers. Of course, the media compounds this with horror stories about how even the most everyday events can go awry. We physicians unwittingly compound the situation with well-meaning suggestions about things like how long to breastfeed.

The bottom line is that new parents seriously need reassurance. Too few of them articulate this by asking, “Am I doing this right?” And too few of us answer the unasked question by unambiguously stating,” You're doing a great job!”

In a recent issue of AAP News (October 2009), Dr. Martin Stein and Dr. J. Lane Tanner reported on some findings from their study of 20 parent focus groups and 31 pediatric clinician focus groups. Among other things, they asked how an ideal pediatric practice would look. They observed, “Parents spoke to an issue that many doctors may be less aware of—how much they value the reassurance that the pediatrician or PNP can give, not only that their child is healthy, but also that they are doing a good job as parents.”

Sometimes we feel that saying, “That's a good weight gain” or complimenting parents on their child's cuteness is sufficient. But I've found that it's not. Parents hear those platitudes from their family and even strangers in the grocery store checkout line all the time. There is nothing more powerful than a respected child health provider saying, “I just want to tell you that you're doing a nice job!”

It's even more important when things aren't going well. Be reassuring during those first few weight checks in the office for the mother who's struggling with a marginal milk supply or who has terribly sore nipples. One doesn't have to be specific. “I know you're worried about how the breastfeeding is going, but you are doing a very good job of parenting.”

There are so few overconfident new parents that it is easy to recommend a shot of confidence at every well-child visit. I promise it won't hurt.

pdnews@elsevier.com

I snaked my way between the crowded tables of Friday evening revelers, late again. Despite continuous tweaking and re-tweaking of our schedules, we still manage to run late at least 25% of the time. If your goal is to never be too busy, you'll never be busy enough to pay the bills.

“Hey, Willis, how many lives did you save today?” The familiar voice told me I was nearing our table of regulars. I mulled over the perfunctory greeting I had received.

How many lives had I saved today? None! In fact I couldn't remember the last time I had actually saved a life. Sure, every time I give an immunization I am protecting the herd. And two or three times every year I have to jump start a newborn who had had a particularly harrowing obstetrical adventure.

But I don't consider that saving lives, certainly not like in the gold old days when Haemophilus influenzae stalked the infants and toddlers and new diabetics stayed in town instead of being shipped to the big city before the urine dipstick had dried. So who or what am I saving?

I thought back over the high points of the day I had just completed. Late in the morning I had seen a 6-year-old who had fallen on the playground and gotten a big goose egg on his forehead. Luckily his mother arrived at the school just before the ambulance did, and she had the good sense to call our office. The 15-minute visit did not include a head CT. In addition to saving him the radiation dose, I saved someone a $2,000 emergency room bill.

Just after lunch I saw a child whose left arm was hanging limply at his side. Within 2 minutes he was using it to reach eagerly for a sticker held over his head. I know that half of my partners would have ordered an x-ray before attempting a reduction, and I am sure that, had he been seen in an emergency room, he would have had the x-ray and maybe an orthopedic consult. Savings for this child were somewhere between $150 and $1,000.

At 3:15 p.m., I saw a new mother with a 2-week-old who was finally doing well at the breast and gaining weight. It had been a struggle over several visits that nearly exhausted my bag of tricks. Now the mom was confident and ready to nurse for at least 6 months. Savings to that family would be at least $600 in formula costs alone.

The last patient of the afternoon was an 18-month-old I had never seen before. His record documented several ear infections. He had a new cold and had been a bit fussy. His parents were convinced that he had another ear infection or that the last one was still bothering him. They had already been on the Internet and found an ear, nose, and throat specialist in Boston and were planning on having him insert pressure equalization tubes. The child's tympanic membranes were transparent and moved briskly on insufflation, a procedure the parents had never seen before.

Although it was late on a Friday afternoon, I decided to share with the family what I knew about the natural history of otitis media and the role of surgical management in its management. It's too early to tell, but I think I may have saved them a trip to Boston. Cost of travel, parking, and lost time at work could easily have run to $250.

So as my pint of ale arrived I did a little quick math. I had saved these four families at least $3,000. So, I guess when it comes to saving these days, at least for the primary care physician it's all about the money. For a pediatrician, though, the bulk of the rewards comes from intangibles like watching parents relax and seeing children grow into happy, productive adults.

pdnews@elsevier.com

I snaked my way between the crowded tables of Friday evening revelers, late again. Despite continuous tweaking and re-tweaking of our schedules, we still manage to run late at least 25% of the time. If your goal is to never be too busy, you'll never be busy enough to pay the bills.

“Hey, Willis, how many lives did you save today?” The familiar voice told me I was nearing our table of regulars. I mulled over the perfunctory greeting I had received.

How many lives had I saved today? None! In fact I couldn't remember the last time I had actually saved a life. Sure, every time I give an immunization I am protecting the herd. And two or three times every year I have to jump start a newborn who had had a particularly harrowing obstetrical adventure.

But I don't consider that saving lives, certainly not like in the gold old days when Haemophilus influenzae stalked the infants and toddlers and new diabetics stayed in town instead of being shipped to the big city before the urine dipstick had dried. So who or what am I saving?

I thought back over the high points of the day I had just completed. Late in the morning I had seen a 6-year-old who had fallen on the playground and gotten a big goose egg on his forehead. Luckily his mother arrived at the school just before the ambulance did, and she had the good sense to call our office. The 15-minute visit did not include a head CT. In addition to saving him the radiation dose, I saved someone a $2,000 emergency room bill.

Just after lunch I saw a child whose left arm was hanging limply at his side. Within 2 minutes he was using it to reach eagerly for a sticker held over his head. I know that half of my partners would have ordered an x-ray before attempting a reduction, and I am sure that, had he been seen in an emergency room, he would have had the x-ray and maybe an orthopedic consult. Savings for this child were somewhere between $150 and $1,000.

At 3:15 p.m., I saw a new mother with a 2-week-old who was finally doing well at the breast and gaining weight. It had been a struggle over several visits that nearly exhausted my bag of tricks. Now the mom was confident and ready to nurse for at least 6 months. Savings to that family would be at least $600 in formula costs alone.

The last patient of the afternoon was an 18-month-old I had never seen before. His record documented several ear infections. He had a new cold and had been a bit fussy. His parents were convinced that he had another ear infection or that the last one was still bothering him. They had already been on the Internet and found an ear, nose, and throat specialist in Boston and were planning on having him insert pressure equalization tubes. The child's tympanic membranes were transparent and moved briskly on insufflation, a procedure the parents had never seen before.

Although it was late on a Friday afternoon, I decided to share with the family what I knew about the natural history of otitis media and the role of surgical management in its management. It's too early to tell, but I think I may have saved them a trip to Boston. Cost of travel, parking, and lost time at work could easily have run to $250.

So as my pint of ale arrived I did a little quick math. I had saved these four families at least $3,000. So, I guess when it comes to saving these days, at least for the primary care physician it's all about the money. For a pediatrician, though, the bulk of the rewards comes from intangibles like watching parents relax and seeing children grow into happy, productive adults.

pdnews@elsevier.com

I snaked my way between the crowded tables of Friday evening revelers, late again. Despite continuous tweaking and re-tweaking of our schedules, we still manage to run late at least 25% of the time. If your goal is to never be too busy, you'll never be busy enough to pay the bills.

“Hey, Willis, how many lives did you save today?” The familiar voice told me I was nearing our table of regulars. I mulled over the perfunctory greeting I had received.

How many lives had I saved today? None! In fact I couldn't remember the last time I had actually saved a life. Sure, every time I give an immunization I am protecting the herd. And two or three times every year I have to jump start a newborn who had had a particularly harrowing obstetrical adventure.

But I don't consider that saving lives, certainly not like in the gold old days when Haemophilus influenzae stalked the infants and toddlers and new diabetics stayed in town instead of being shipped to the big city before the urine dipstick had dried. So who or what am I saving?

I thought back over the high points of the day I had just completed. Late in the morning I had seen a 6-year-old who had fallen on the playground and gotten a big goose egg on his forehead. Luckily his mother arrived at the school just before the ambulance did, and she had the good sense to call our office. The 15-minute visit did not include a head CT. In addition to saving him the radiation dose, I saved someone a $2,000 emergency room bill.

Just after lunch I saw a child whose left arm was hanging limply at his side. Within 2 minutes he was using it to reach eagerly for a sticker held over his head. I know that half of my partners would have ordered an x-ray before attempting a reduction, and I am sure that, had he been seen in an emergency room, he would have had the x-ray and maybe an orthopedic consult. Savings for this child were somewhere between $150 and $1,000.

At 3:15 p.m., I saw a new mother with a 2-week-old who was finally doing well at the breast and gaining weight. It had been a struggle over several visits that nearly exhausted my bag of tricks. Now the mom was confident and ready to nurse for at least 6 months. Savings to that family would be at least $600 in formula costs alone.

The last patient of the afternoon was an 18-month-old I had never seen before. His record documented several ear infections. He had a new cold and had been a bit fussy. His parents were convinced that he had another ear infection or that the last one was still bothering him. They had already been on the Internet and found an ear, nose, and throat specialist in Boston and were planning on having him insert pressure equalization tubes. The child's tympanic membranes were transparent and moved briskly on insufflation, a procedure the parents had never seen before.

Although it was late on a Friday afternoon, I decided to share with the family what I knew about the natural history of otitis media and the role of surgical management in its management. It's too early to tell, but I think I may have saved them a trip to Boston. Cost of travel, parking, and lost time at work could easily have run to $250.

So as my pint of ale arrived I did a little quick math. I had saved these four families at least $3,000. So, I guess when it comes to saving these days, at least for the primary care physician it's all about the money. For a pediatrician, though, the bulk of the rewards comes from intangibles like watching parents relax and seeing children grow into happy, productive adults.

pdnews@elsevier.com

It was getting to be a long day. Starting at 5:30 a.m. with an hour-long row on the glassy waters of Harpswell Sound meant that I would have to sacrifice my lunchtime bike ride. Without this energy booster, I was beginning to drag by 6 p.m. when the evening shift of receptionists arrived.

On paper, or more accurately on the computer screen, the patient mix for the evening didn't look too challenging. The prescheduled checkups were low-maintenance old friends. So far the acute visits were listed as “rashes.” Usually, I know what they are with one glance, but if not they will present a stimulating challenge to my powers of deductive reasoning.

But, as the evening progressed, more blue folders kept appearing in the chart rack. I was keeping ahead of the tide, but just barely. By 7:50 p.m. I was done, but it had been a frustrating couple of hours. To try and figure out why I hadn't been having as much fun as usual I did a little math.

Among the other assorted patients, I had seen four patients all over the age of 2 who had been sick for a total of 12 hours. That's not average; that's T-O-T-A-L. One patient had been ill for 4 hours, two for 3 hours each, and one for just short of 2 hours. They all had fevers of 101 or higher, but the grand total of their symptoms not including fever was three: vomiting, headache, and possible sore throat in one patient each (an 8-year-old had eventually answered yes to sore throat in an extensive parental survey); the fourth patient had only fever.

Like most pediatricians, I have seen a few deathly ill children with septicemia who by parental history have been ill for only a couple of hours. But, it's a rare occurrence. Now, I fancy myself a fairly capable diagnostician, but, give me a break. I need more than a few hours of accumulated symptoms to even take a stab at a diagnosis.

Premature visits are a fact of life for the new millennium pediatrician, and this evening's cluster got me thinking about why they are so prevalent. Certainly, a prime factor is our open access appointment policy. If you're open and coach receptionists to be receptive, the patients will come. But, why would the parent of a 4-year-old who doesn't have a chronic disease think about calling for 2 hours of fever and “looks a bit off?”

In some cases, the child has been in day care or with the “other” parent. A combination of guilt and uncertainty will often prompt a call. In other cases it is the result of educational failure. Grandma didn't do her job, and we pediatricians didn't provide sufficient anticipatory guidance. The media are more than happy to fill this void with dramatic stories about the rare and disastrous complication of common illness.

Some parents are compelled to call by their own anxiety that goes deeper than the normal parental anxiety we all have. But, whatever the cause of these premature visits, I am left gazing into my cloudy crystal ball. I must choose my words carefully. I don't want to be accused of being the doctor who “said there was nothing wrong.” I don't want to sound condescending, but I would like to prevent another premature visit.

I will suggest an algorithm that I hope guarantees that the child will be brought back when the symptoms warrant reevaluation. But, I don't want to paint so many scenarios I create more anxiety than already exists. In the end, I fall back on the pediatrician's old friend, and I promise to call the next morning to check in.

As frustrating as these premature visits are, of course, I wouldn't trade one of these parents who call too early for one who calls too late. It's those parents who keep me awake at night.

pdnews@elsevier.com

It was getting to be a long day. Starting at 5:30 a.m. with an hour-long row on the glassy waters of Harpswell Sound meant that I would have to sacrifice my lunchtime bike ride. Without this energy booster, I was beginning to drag by 6 p.m. when the evening shift of receptionists arrived.

On paper, or more accurately on the computer screen, the patient mix for the evening didn't look too challenging. The prescheduled checkups were low-maintenance old friends. So far the acute visits were listed as “rashes.” Usually, I know what they are with one glance, but if not they will present a stimulating challenge to my powers of deductive reasoning.

But, as the evening progressed, more blue folders kept appearing in the chart rack. I was keeping ahead of the tide, but just barely. By 7:50 p.m. I was done, but it had been a frustrating couple of hours. To try and figure out why I hadn't been having as much fun as usual I did a little math.

Among the other assorted patients, I had seen four patients all over the age of 2 who had been sick for a total of 12 hours. That's not average; that's T-O-T-A-L. One patient had been ill for 4 hours, two for 3 hours each, and one for just short of 2 hours. They all had fevers of 101 or higher, but the grand total of their symptoms not including fever was three: vomiting, headache, and possible sore throat in one patient each (an 8-year-old had eventually answered yes to sore throat in an extensive parental survey); the fourth patient had only fever.

Like most pediatricians, I have seen a few deathly ill children with septicemia who by parental history have been ill for only a couple of hours. But, it's a rare occurrence. Now, I fancy myself a fairly capable diagnostician, but, give me a break. I need more than a few hours of accumulated symptoms to even take a stab at a diagnosis.

Premature visits are a fact of life for the new millennium pediatrician, and this evening's cluster got me thinking about why they are so prevalent. Certainly, a prime factor is our open access appointment policy. If you're open and coach receptionists to be receptive, the patients will come. But, why would the parent of a 4-year-old who doesn't have a chronic disease think about calling for 2 hours of fever and “looks a bit off?”

In some cases, the child has been in day care or with the “other” parent. A combination of guilt and uncertainty will often prompt a call. In other cases it is the result of educational failure. Grandma didn't do her job, and we pediatricians didn't provide sufficient anticipatory guidance. The media are more than happy to fill this void with dramatic stories about the rare and disastrous complication of common illness.

Some parents are compelled to call by their own anxiety that goes deeper than the normal parental anxiety we all have. But, whatever the cause of these premature visits, I am left gazing into my cloudy crystal ball. I must choose my words carefully. I don't want to be accused of being the doctor who “said there was nothing wrong.” I don't want to sound condescending, but I would like to prevent another premature visit.

I will suggest an algorithm that I hope guarantees that the child will be brought back when the symptoms warrant reevaluation. But, I don't want to paint so many scenarios I create more anxiety than already exists. In the end, I fall back on the pediatrician's old friend, and I promise to call the next morning to check in.

As frustrating as these premature visits are, of course, I wouldn't trade one of these parents who call too early for one who calls too late. It's those parents who keep me awake at night.

pdnews@elsevier.com

It was getting to be a long day. Starting at 5:30 a.m. with an hour-long row on the glassy waters of Harpswell Sound meant that I would have to sacrifice my lunchtime bike ride. Without this energy booster, I was beginning to drag by 6 p.m. when the evening shift of receptionists arrived.

On paper, or more accurately on the computer screen, the patient mix for the evening didn't look too challenging. The prescheduled checkups were low-maintenance old friends. So far the acute visits were listed as “rashes.” Usually, I know what they are with one glance, but if not they will present a stimulating challenge to my powers of deductive reasoning.

But, as the evening progressed, more blue folders kept appearing in the chart rack. I was keeping ahead of the tide, but just barely. By 7:50 p.m. I was done, but it had been a frustrating couple of hours. To try and figure out why I hadn't been having as much fun as usual I did a little math.

Among the other assorted patients, I had seen four patients all over the age of 2 who had been sick for a total of 12 hours. That's not average; that's T-O-T-A-L. One patient had been ill for 4 hours, two for 3 hours each, and one for just short of 2 hours. They all had fevers of 101 or higher, but the grand total of their symptoms not including fever was three: vomiting, headache, and possible sore throat in one patient each (an 8-year-old had eventually answered yes to sore throat in an extensive parental survey); the fourth patient had only fever.

Like most pediatricians, I have seen a few deathly ill children with septicemia who by parental history have been ill for only a couple of hours. But, it's a rare occurrence. Now, I fancy myself a fairly capable diagnostician, but, give me a break. I need more than a few hours of accumulated symptoms to even take a stab at a diagnosis.

Premature visits are a fact of life for the new millennium pediatrician, and this evening's cluster got me thinking about why they are so prevalent. Certainly, a prime factor is our open access appointment policy. If you're open and coach receptionists to be receptive, the patients will come. But, why would the parent of a 4-year-old who doesn't have a chronic disease think about calling for 2 hours of fever and “looks a bit off?”

In some cases, the child has been in day care or with the “other” parent. A combination of guilt and uncertainty will often prompt a call. In other cases it is the result of educational failure. Grandma didn't do her job, and we pediatricians didn't provide sufficient anticipatory guidance. The media are more than happy to fill this void with dramatic stories about the rare and disastrous complication of common illness.

Some parents are compelled to call by their own anxiety that goes deeper than the normal parental anxiety we all have. But, whatever the cause of these premature visits, I am left gazing into my cloudy crystal ball. I must choose my words carefully. I don't want to be accused of being the doctor who “said there was nothing wrong.” I don't want to sound condescending, but I would like to prevent another premature visit.

I will suggest an algorithm that I hope guarantees that the child will be brought back when the symptoms warrant reevaluation. But, I don't want to paint so many scenarios I create more anxiety than already exists. In the end, I fall back on the pediatrician's old friend, and I promise to call the next morning to check in.

As frustrating as these premature visits are, of course, I wouldn't trade one of these parents who call too early for one who calls too late. It's those parents who keep me awake at night.

pdnews@elsevier.com

One of my plans for this year is to read more widely and think more deeply. As part of that plan I read a column by New York Times columnist David Brooks. In it he refers to “On Thinking Institutionally (On Politics)” (Boulder, Colo.: Paradigm, 2008)—a book by political scientist Hugh Heclo.

According to Mr. Heclo, we are all shaped by the institutions through which we navigate our lives. In this broad sense institutions include our family, the schools we attend, and eventually our profession.

The extent to which we internalize the rules and traditions of those institutions defines us as either an institutionalist or an individualist.

Those of us who revere the ones who preceded us and accumulated the rules that support the institution are thinking institutionally. According to Mr. Heclo, institutionalists “see themselves as debtors who owe something, not creditors to whom something is owed.”

You don't have to look very far to see that currently our society is tilting toward individualism. Chest-thumping end zone performances by egocentric professional football players and former senators who don't think paying taxes is important are all part of a phenomenon that has spilled over from the Me generation.

But, there remain a few high-profile figures who still revere the institutions in which they have thrived.

Mr. Brooks and Mr. Heclo quote Ryne Sandberg on the occasion of his induction into the Baseball Hall of Fame: “I didn't play the game right because I saw a reward at the end of the tunnel. I played it right because that's what you're supposed to do, play it right and with respect.…

“If this validates anything, it's that guys who taught me the game … did what they were supposed to do.”

Now it's time to start thinking more deeply. Do you see yourself more as an individualist or an institutionalist? What about your fellow physicians? Do they treat the practice of medicine with reverence? You may want to ask yourself, “What are the institutional values that define medicine?” Is it the Hippocratic oath? And, who were your physician models?

Ironically, it was probably the 10 years I was in solo practice that injected me with a reverence for the institution of pediatrics. Parents had other choices. They could have trusted the health, and on rare occasions, the lives of their children to someone else. But because I had adopted a set of skills and attitudes from the instructors in my training programs and through the mentorship of my former partner, and because I conformed to what parents viewed as the principles of the institution of pediatrics, they chose me.

Among my role models were two older surgeons. These gentlemen dressed in a manner that respected the sensibilities of their patients.

They introduced themselves with a handshake. They were instantly available when they were on call and never sounded as though my call for help was an imposition. There was never a hint that profit was a motive in their decisions to operate. They were classy and professional physicians who revered their profession.

Fortunately, there is room for creative thinking and action in most institutions. Great institutions like pediatrics not only tolerate but encourage their members to think outside the institutional box. And, luckily we have chosen a profession that still deserves our reverence. I hope you agree that we owe pediatrics far more than it owes us.

pdnews@elsevier.com

One of my plans for this year is to read more widely and think more deeply. As part of that plan I read a column by New York Times columnist David Brooks. In it he refers to “On Thinking Institutionally (On Politics)” (Boulder, Colo.: Paradigm, 2008)—a book by political scientist Hugh Heclo.

According to Mr. Heclo, we are all shaped by the institutions through which we navigate our lives. In this broad sense institutions include our family, the schools we attend, and eventually our profession.

The extent to which we internalize the rules and traditions of those institutions defines us as either an institutionalist or an individualist.

Those of us who revere the ones who preceded us and accumulated the rules that support the institution are thinking institutionally. According to Mr. Heclo, institutionalists “see themselves as debtors who owe something, not creditors to whom something is owed.”

You don't have to look very far to see that currently our society is tilting toward individualism. Chest-thumping end zone performances by egocentric professional football players and former senators who don't think paying taxes is important are all part of a phenomenon that has spilled over from the Me generation.

But, there remain a few high-profile figures who still revere the institutions in which they have thrived.

Mr. Brooks and Mr. Heclo quote Ryne Sandberg on the occasion of his induction into the Baseball Hall of Fame: “I didn't play the game right because I saw a reward at the end of the tunnel. I played it right because that's what you're supposed to do, play it right and with respect.…

“If this validates anything, it's that guys who taught me the game … did what they were supposed to do.”

Now it's time to start thinking more deeply. Do you see yourself more as an individualist or an institutionalist? What about your fellow physicians? Do they treat the practice of medicine with reverence? You may want to ask yourself, “What are the institutional values that define medicine?” Is it the Hippocratic oath? And, who were your physician models?

Ironically, it was probably the 10 years I was in solo practice that injected me with a reverence for the institution of pediatrics. Parents had other choices. They could have trusted the health, and on rare occasions, the lives of their children to someone else. But because I had adopted a set of skills and attitudes from the instructors in my training programs and through the mentorship of my former partner, and because I conformed to what parents viewed as the principles of the institution of pediatrics, they chose me.

Among my role models were two older surgeons. These gentlemen dressed in a manner that respected the sensibilities of their patients.

They introduced themselves with a handshake. They were instantly available when they were on call and never sounded as though my call for help was an imposition. There was never a hint that profit was a motive in their decisions to operate. They were classy and professional physicians who revered their profession.

Fortunately, there is room for creative thinking and action in most institutions. Great institutions like pediatrics not only tolerate but encourage their members to think outside the institutional box. And, luckily we have chosen a profession that still deserves our reverence. I hope you agree that we owe pediatrics far more than it owes us.

pdnews@elsevier.com

One of my plans for this year is to read more widely and think more deeply. As part of that plan I read a column by New York Times columnist David Brooks. In it he refers to “On Thinking Institutionally (On Politics)” (Boulder, Colo.: Paradigm, 2008)—a book by political scientist Hugh Heclo.

According to Mr. Heclo, we are all shaped by the institutions through which we navigate our lives. In this broad sense institutions include our family, the schools we attend, and eventually our profession.

The extent to which we internalize the rules and traditions of those institutions defines us as either an institutionalist or an individualist.

Those of us who revere the ones who preceded us and accumulated the rules that support the institution are thinking institutionally. According to Mr. Heclo, institutionalists “see themselves as debtors who owe something, not creditors to whom something is owed.”

You don't have to look very far to see that currently our society is tilting toward individualism. Chest-thumping end zone performances by egocentric professional football players and former senators who don't think paying taxes is important are all part of a phenomenon that has spilled over from the Me generation.

But, there remain a few high-profile figures who still revere the institutions in which they have thrived.

Mr. Brooks and Mr. Heclo quote Ryne Sandberg on the occasion of his induction into the Baseball Hall of Fame: “I didn't play the game right because I saw a reward at the end of the tunnel. I played it right because that's what you're supposed to do, play it right and with respect.…

“If this validates anything, it's that guys who taught me the game … did what they were supposed to do.”

Now it's time to start thinking more deeply. Do you see yourself more as an individualist or an institutionalist? What about your fellow physicians? Do they treat the practice of medicine with reverence? You may want to ask yourself, “What are the institutional values that define medicine?” Is it the Hippocratic oath? And, who were your physician models?

Ironically, it was probably the 10 years I was in solo practice that injected me with a reverence for the institution of pediatrics. Parents had other choices. They could have trusted the health, and on rare occasions, the lives of their children to someone else. But because I had adopted a set of skills and attitudes from the instructors in my training programs and through the mentorship of my former partner, and because I conformed to what parents viewed as the principles of the institution of pediatrics, they chose me.

Among my role models were two older surgeons. These gentlemen dressed in a manner that respected the sensibilities of their patients.

They introduced themselves with a handshake. They were instantly available when they were on call and never sounded as though my call for help was an imposition. There was never a hint that profit was a motive in their decisions to operate. They were classy and professional physicians who revered their profession.

Fortunately, there is room for creative thinking and action in most institutions. Great institutions like pediatrics not only tolerate but encourage their members to think outside the institutional box. And, luckily we have chosen a profession that still deserves our reverence. I hope you agree that we owe pediatrics far more than it owes us.

pdnews@elsevier.com

My lifestyle and preferences don't include much television viewing anymore. Certainly for the last 8 years I have completely avoided watching any presidential addresses because I found them very uncomfortable and embarrassing. But this week I found myself watching a rebroadcast of President Obama's address to the American Medical Association.

I like him, and like most Americans, I want him to do well. His speech touched all the bases in the health care ball game, and he was refreshingly frank in sharing his opinions. I wasn't embarrassed that I had voted for him, but some of the things he said made me a little uncomfortable.

I have already shared with you my concerns that electronification of health records is going to be a costly nightmare whose payback won't come until long after President Obama has left office—I'm counting on two terms. The basic premise is worthy, but the systems just aren't out there to do the job. When 40% of physicians are functioning as beta testers, it's going to get ugly.

A second, more subtle discomfort crept out of one of the president's statements that at first blush seems to be unarguable. He promises a system that allows you to be physicians “instead of administrators and accountants.” He adds: “You didn't enter this profession to be bean counters and paper pushers. You entered this profession to be healers.”

First, any physician who views himself primarily as a healer is suffering from severe ego inflation. But I'll forgive that as a slip of the tongue. However, some—including many physicians—could interpret Mr. Obama's first statement to mean that physicians will no longer need to concern themselves with the cost of the care we provide.

If you haven't read Atul Gawande's most recent article in the New Yorker (“The Cost Conundrum,” June 1, 2009), after you finish this column set down PEDIATRIC NEWS and immediately access the article on the Internet. Dr. Gawande explores why the cost of medical care in McAllen, Tex., is twice the national average and twice that in El Paso County, a similar geodemographic area. The quality of care in each area is similar.

What he discovers is that in McAllen, the culture of the medical community has shifted toward the entrepreneurial, health-care-for-profit end of the spectrum. Dr. Gawande observes correctly that physicians learn next to nothing about finance in medical school and that many physicians remain “oblivious to the financial implications of their decisions.” But in McAllen, a high percentage of physicians seems to have learned so much about making money in medicine that they have lost the focus on quality.

Good-quality health care doesn't necessarily cost more. In fact, the more I read and observe, the more I find that many expensive tests and interventions are proving to be worthless, and could and should be eliminated.

As appealing as President Obama's promise of financial obliviousness may sound, we don't want to lose sight of the costly ripples and tsunamis of our decisions and interventions. Those of us in solo practice and small groups must understand the concept of overhead to survive. But, even if you are buffered by layers of administration in a large corporation, you have an obligation to know what your patients are paying and why.

As Dr. Gawande observes, “The lesson of high-quality, low-cost care is that someone [I would add all physicians] has to be accountable for the totality of care.”

And that includes its cost.

pdnews@elsevier.com

My lifestyle and preferences don't include much television viewing anymore. Certainly for the last 8 years I have completely avoided watching any presidential addresses because I found them very uncomfortable and embarrassing. But this week I found myself watching a rebroadcast of President Obama's address to the American Medical Association.

I like him, and like most Americans, I want him to do well. His speech touched all the bases in the health care ball game, and he was refreshingly frank in sharing his opinions. I wasn't embarrassed that I had voted for him, but some of the things he said made me a little uncomfortable.

I have already shared with you my concerns that electronification of health records is going to be a costly nightmare whose payback won't come until long after President Obama has left office—I'm counting on two terms. The basic premise is worthy, but the systems just aren't out there to do the job. When 40% of physicians are functioning as beta testers, it's going to get ugly.

A second, more subtle discomfort crept out of one of the president's statements that at first blush seems to be unarguable. He promises a system that allows you to be physicians “instead of administrators and accountants.” He adds: “You didn't enter this profession to be bean counters and paper pushers. You entered this profession to be healers.”

First, any physician who views himself primarily as a healer is suffering from severe ego inflation. But I'll forgive that as a slip of the tongue. However, some—including many physicians—could interpret Mr. Obama's first statement to mean that physicians will no longer need to concern themselves with the cost of the care we provide.

If you haven't read Atul Gawande's most recent article in the New Yorker (“The Cost Conundrum,” June 1, 2009), after you finish this column set down PEDIATRIC NEWS and immediately access the article on the Internet. Dr. Gawande explores why the cost of medical care in McAllen, Tex., is twice the national average and twice that in El Paso County, a similar geodemographic area. The quality of care in each area is similar.

What he discovers is that in McAllen, the culture of the medical community has shifted toward the entrepreneurial, health-care-for-profit end of the spectrum. Dr. Gawande observes correctly that physicians learn next to nothing about finance in medical school and that many physicians remain “oblivious to the financial implications of their decisions.” But in McAllen, a high percentage of physicians seems to have learned so much about making money in medicine that they have lost the focus on quality.

Good-quality health care doesn't necessarily cost more. In fact, the more I read and observe, the more I find that many expensive tests and interventions are proving to be worthless, and could and should be eliminated.

As appealing as President Obama's promise of financial obliviousness may sound, we don't want to lose sight of the costly ripples and tsunamis of our decisions and interventions. Those of us in solo practice and small groups must understand the concept of overhead to survive. But, even if you are buffered by layers of administration in a large corporation, you have an obligation to know what your patients are paying and why.

As Dr. Gawande observes, “The lesson of high-quality, low-cost care is that someone [I would add all physicians] has to be accountable for the totality of care.”

And that includes its cost.

pdnews@elsevier.com

My lifestyle and preferences don't include much television viewing anymore. Certainly for the last 8 years I have completely avoided watching any presidential addresses because I found them very uncomfortable and embarrassing. But this week I found myself watching a rebroadcast of President Obama's address to the American Medical Association.

I like him, and like most Americans, I want him to do well. His speech touched all the bases in the health care ball game, and he was refreshingly frank in sharing his opinions. I wasn't embarrassed that I had voted for him, but some of the things he said made me a little uncomfortable.

I have already shared with you my concerns that electronification of health records is going to be a costly nightmare whose payback won't come until long after President Obama has left office—I'm counting on two terms. The basic premise is worthy, but the systems just aren't out there to do the job. When 40% of physicians are functioning as beta testers, it's going to get ugly.

A second, more subtle discomfort crept out of one of the president's statements that at first blush seems to be unarguable. He promises a system that allows you to be physicians “instead of administrators and accountants.” He adds: “You didn't enter this profession to be bean counters and paper pushers. You entered this profession to be healers.”

First, any physician who views himself primarily as a healer is suffering from severe ego inflation. But I'll forgive that as a slip of the tongue. However, some—including many physicians—could interpret Mr. Obama's first statement to mean that physicians will no longer need to concern themselves with the cost of the care we provide.

If you haven't read Atul Gawande's most recent article in the New Yorker (“The Cost Conundrum,” June 1, 2009), after you finish this column set down PEDIATRIC NEWS and immediately access the article on the Internet. Dr. Gawande explores why the cost of medical care in McAllen, Tex., is twice the national average and twice that in El Paso County, a similar geodemographic area. The quality of care in each area is similar.

What he discovers is that in McAllen, the culture of the medical community has shifted toward the entrepreneurial, health-care-for-profit end of the spectrum. Dr. Gawande observes correctly that physicians learn next to nothing about finance in medical school and that many physicians remain “oblivious to the financial implications of their decisions.” But in McAllen, a high percentage of physicians seems to have learned so much about making money in medicine that they have lost the focus on quality.

Good-quality health care doesn't necessarily cost more. In fact, the more I read and observe, the more I find that many expensive tests and interventions are proving to be worthless, and could and should be eliminated.

As appealing as President Obama's promise of financial obliviousness may sound, we don't want to lose sight of the costly ripples and tsunamis of our decisions and interventions. Those of us in solo practice and small groups must understand the concept of overhead to survive. But, even if you are buffered by layers of administration in a large corporation, you have an obligation to know what your patients are paying and why.

As Dr. Gawande observes, “The lesson of high-quality, low-cost care is that someone [I would add all physicians] has to be accountable for the totality of care.”

And that includes its cost.

pdnews@elsevier.com

Even if you are just a casual fan of professional football, you may have noticed this past season, on the back of every player's helmet, the letters “GU” and the number “63” in a dark circle. This commemorated Gene Upshaw, the long-time president of the National Football League Players Association, who died in August. Upshaw, a former NFL player himself, was a man of imposing stature and appearance. His efforts as an advocate for the players were so effective that it is not surprising that he was remembered with an unprecedented gesture.

During one of the numerous and annoying commercial breaks during the Super Bowl, I was on my way to the refrigerator when I had an epiphany of sorts: “Pediatrics needs a Gene Upshaw.”

Whenever sports fans saw Gene Upshaw on TV or in the newspaper, they knew he was there to represent the interests of professional football players. Whether the issue was salaries, drug testing, or safe playing conditions, he was their advocate and a darn good one. He was not just the voice but the face of professional football players.

Pediatricians' numbers are far greater and our mission is far more worthy, but we don't have a face—at least one that is recognizable on the national stage. From the standpoint of image, we are really a grassroots organization. We are the faces of pediatrics in our own communities. We usually live in the towns that we serve, and when we show up at meetings or on local TV, everyone knows that we are representing the interests of children.

The American Academy of Pediatrics can and will help us become more effective spokespersons by providing training sessions and coaching. From time to time, the AAP taps some of us to appear in the national media, but these are cameo appearances. We may recognize some of our brothers and sisters when we see them on the “Today Show,” but they will fade back into the obscurity of their day jobs and not become household words.

Our governance structure doesn't foster a lasting image. Our academy presidents serve a year of apprenticeship and then a year on the job before they exit the national stage. We do have a Washington office that works extremely hard to keep pediatric issues on the front burners of many legislators and federal administrators, but I suspect that our lobbying could be much more effective if pediatrics had a national face like Gene Upshaw's.

When Jesse Jackson appears at an event, he doesn't even have to say a word. I know he doesn't speak for all African Americans, but when I see his face I ask myself, “How is this situation going to affect people of color?” Wouldn't it be great if we could have a person whose appearance would say, “Think of the children!”

Where can we find someone like that? Does anyone like that even exist? Benjamin Spock certainly became a household word. T. Berry Brazelton's books and personal appearances have made him a trusted voice, but I think even he would admit that his age is a disadvantage. There are other prominent pediatricians, but most have special interests and may not be willing to moderate their positions so that they could speak for almost all of us.

Does our face have to belong to a pediatrician? Bob Keeshan—who was TV's Captain Kangaroo—would have been an excellent candidate, but sadly he is gone. Other celebrities have stepped forward to advocate for specific changes, but they all have their own careers and agendas.

So, I am at a bit of a loss. But we have serious national issues that need our voice and a recognizable face to go with it. Should the president of the AAP serve a longer term? Should we hire a PR firm to do a search for us? Until we find someone, each of us will have to be the Gene Upshaw in our own hometown.

pdnews@elsevier.com

Even if you are just a casual fan of professional football, you may have noticed this past season, on the back of every player's helmet, the letters “GU” and the number “63” in a dark circle. This commemorated Gene Upshaw, the long-time president of the National Football League Players Association, who died in August. Upshaw, a former NFL player himself, was a man of imposing stature and appearance. His efforts as an advocate for the players were so effective that it is not surprising that he was remembered with an unprecedented gesture.

During one of the numerous and annoying commercial breaks during the Super Bowl, I was on my way to the refrigerator when I had an epiphany of sorts: “Pediatrics needs a Gene Upshaw.”

Whenever sports fans saw Gene Upshaw on TV or in the newspaper, they knew he was there to represent the interests of professional football players. Whether the issue was salaries, drug testing, or safe playing conditions, he was their advocate and a darn good one. He was not just the voice but the face of professional football players.

Pediatricians' numbers are far greater and our mission is far more worthy, but we don't have a face—at least one that is recognizable on the national stage. From the standpoint of image, we are really a grassroots organization. We are the faces of pediatrics in our own communities. We usually live in the towns that we serve, and when we show up at meetings or on local TV, everyone knows that we are representing the interests of children.

The American Academy of Pediatrics can and will help us become more effective spokespersons by providing training sessions and coaching. From time to time, the AAP taps some of us to appear in the national media, but these are cameo appearances. We may recognize some of our brothers and sisters when we see them on the “Today Show,” but they will fade back into the obscurity of their day jobs and not become household words.

Our governance structure doesn't foster a lasting image. Our academy presidents serve a year of apprenticeship and then a year on the job before they exit the national stage. We do have a Washington office that works extremely hard to keep pediatric issues on the front burners of many legislators and federal administrators, but I suspect that our lobbying could be much more effective if pediatrics had a national face like Gene Upshaw's.

When Jesse Jackson appears at an event, he doesn't even have to say a word. I know he doesn't speak for all African Americans, but when I see his face I ask myself, “How is this situation going to affect people of color?” Wouldn't it be great if we could have a person whose appearance would say, “Think of the children!”

Where can we find someone like that? Does anyone like that even exist? Benjamin Spock certainly became a household word. T. Berry Brazelton's books and personal appearances have made him a trusted voice, but I think even he would admit that his age is a disadvantage. There are other prominent pediatricians, but most have special interests and may not be willing to moderate their positions so that they could speak for almost all of us.

Does our face have to belong to a pediatrician? Bob Keeshan—who was TV's Captain Kangaroo—would have been an excellent candidate, but sadly he is gone. Other celebrities have stepped forward to advocate for specific changes, but they all have their own careers and agendas.

So, I am at a bit of a loss. But we have serious national issues that need our voice and a recognizable face to go with it. Should the president of the AAP serve a longer term? Should we hire a PR firm to do a search for us? Until we find someone, each of us will have to be the Gene Upshaw in our own hometown.

pdnews@elsevier.com

Even if you are just a casual fan of professional football, you may have noticed this past season, on the back of every player's helmet, the letters “GU” and the number “63” in a dark circle. This commemorated Gene Upshaw, the long-time president of the National Football League Players Association, who died in August. Upshaw, a former NFL player himself, was a man of imposing stature and appearance. His efforts as an advocate for the players were so effective that it is not surprising that he was remembered with an unprecedented gesture.

During one of the numerous and annoying commercial breaks during the Super Bowl, I was on my way to the refrigerator when I had an epiphany of sorts: “Pediatrics needs a Gene Upshaw.”

Whenever sports fans saw Gene Upshaw on TV or in the newspaper, they knew he was there to represent the interests of professional football players. Whether the issue was salaries, drug testing, or safe playing conditions, he was their advocate and a darn good one. He was not just the voice but the face of professional football players.

Pediatricians' numbers are far greater and our mission is far more worthy, but we don't have a face—at least one that is recognizable on the national stage. From the standpoint of image, we are really a grassroots organization. We are the faces of pediatrics in our own communities. We usually live in the towns that we serve, and when we show up at meetings or on local TV, everyone knows that we are representing the interests of children.

The American Academy of Pediatrics can and will help us become more effective spokespersons by providing training sessions and coaching. From time to time, the AAP taps some of us to appear in the national media, but these are cameo appearances. We may recognize some of our brothers and sisters when we see them on the “Today Show,” but they will fade back into the obscurity of their day jobs and not become household words.

Our governance structure doesn't foster a lasting image. Our academy presidents serve a year of apprenticeship and then a year on the job before they exit the national stage. We do have a Washington office that works extremely hard to keep pediatric issues on the front burners of many legislators and federal administrators, but I suspect that our lobbying could be much more effective if pediatrics had a national face like Gene Upshaw's.

When Jesse Jackson appears at an event, he doesn't even have to say a word. I know he doesn't speak for all African Americans, but when I see his face I ask myself, “How is this situation going to affect people of color?” Wouldn't it be great if we could have a person whose appearance would say, “Think of the children!”

Where can we find someone like that? Does anyone like that even exist? Benjamin Spock certainly became a household word. T. Berry Brazelton's books and personal appearances have made him a trusted voice, but I think even he would admit that his age is a disadvantage. There are other prominent pediatricians, but most have special interests and may not be willing to moderate their positions so that they could speak for almost all of us.

Does our face have to belong to a pediatrician? Bob Keeshan—who was TV's Captain Kangaroo—would have been an excellent candidate, but sadly he is gone. Other celebrities have stepped forward to advocate for specific changes, but they all have their own careers and agendas.

So, I am at a bit of a loss. But we have serious national issues that need our voice and a recognizable face to go with it. Should the president of the AAP serve a longer term? Should we hire a PR firm to do a search for us? Until we find someone, each of us will have to be the Gene Upshaw in our own hometown.

pdnews@elsevier.com

The bad news is that the global economy has gone in the toilet. The good news is that most economists agree on something. They suggest that to winch ourselves out of this abyss, we (or our government) must do some serious spending. As a lifelong fiscal conservative, this notion makes me nervous.

However, a New York Times column by recent Nobel Prize recipient Paul Krugman helped me to realize that in a depression economy, we must operate by a different set of rules. Mr. Krugman feels that appropriately targeted spending in huge chunks is the best and only answer. If the economy overheats to the point of inflation, he says that we will have plenty of room to cool things down by increasing interest rates.

So … I'm ready to chime in with my own suggestions about how we should spend all that money we are going to print. It's hard to argue with the value of repairing and improving our roads, bridges, airports, etc. Maybe those of us who prefer to commute by bicycle will get a few more lanes of our own as part of this rehab of our infrastructure.

A comprehensive and totally federally funded immunization program also would be a nice addition. However, I suggest that we invest some of our stimulus package in something less tangible than bridges and vaccines—a plan that will stimulate our children to become more physically active.

The origins of our national epidemic of obesity are many and, in some cases, poorly defined, but it is clear that a sedentary lifestyle is a contributor. Although there are too few valid studies to draw a solid conclusion, intuition tells me that programs including increased physical activity must be beneficial. While I would like to see us take the simple and direct approach and blow up half the televisions in the United States, somehow I don't think Congress will buy it.

Although my friends who are educators have become increasingly frustrated as our public schools have become dumpsters for our society's ills, I am afraid it's time to toss our epidemic of physical inactivity on the pile.

A few primary school educators that I know have cleverly integrated physical activity into their curricula. However, I think the severity of the problem demands the more drastic step of adding an hour to the school day for every kindergarten-through-fifth-grade student in America. Obviously, this is a change with a big price tag. So this is where the stimulus bundle comes in. In the plan, each school that added an hour to the school day would receive a sizeable chunk of change to fund the cost of staff and building maintenance. The only stipulation would be that during that hour the students must be kept physically active.

Each school could use the money as its needs dictate. Upgrade playgrounds, modify classrooms to be activity friendly, pay stipends for teachers who wanted to work more hours—or even better, pay underemployed community members to be supervisors. Each school would be supplied with voluminous educational materials to stimulate creative solutions to fill that hour. For some schools, it may simply mean adding another and longer recess that promotes free play. For others, it could be adding nontraditional school activities such as dance and martial arts.

Presumably, the biggest health payoff for our investment would be a few decades away. For a quicker feedback, one could measure BMIs anonymously and compare them before and after initiating the program. Regardless of how much it bumps up our GDP, one less hour of inactivity will be good for our children.

pdnews@elsevier.com

The bad news is that the global economy has gone in the toilet. The good news is that most economists agree on something. They suggest that to winch ourselves out of this abyss, we (or our government) must do some serious spending. As a lifelong fiscal conservative, this notion makes me nervous.

However, a New York Times column by recent Nobel Prize recipient Paul Krugman helped me to realize that in a depression economy, we must operate by a different set of rules. Mr. Krugman feels that appropriately targeted spending in huge chunks is the best and only answer. If the economy overheats to the point of inflation, he says that we will have plenty of room to cool things down by increasing interest rates.

So … I'm ready to chime in with my own suggestions about how we should spend all that money we are going to print. It's hard to argue with the value of repairing and improving our roads, bridges, airports, etc. Maybe those of us who prefer to commute by bicycle will get a few more lanes of our own as part of this rehab of our infrastructure.

A comprehensive and totally federally funded immunization program also would be a nice addition. However, I suggest that we invest some of our stimulus package in something less tangible than bridges and vaccines—a plan that will stimulate our children to become more physically active.

The origins of our national epidemic of obesity are many and, in some cases, poorly defined, but it is clear that a sedentary lifestyle is a contributor. Although there are too few valid studies to draw a solid conclusion, intuition tells me that programs including increased physical activity must be beneficial. While I would like to see us take the simple and direct approach and blow up half the televisions in the United States, somehow I don't think Congress will buy it.

Although my friends who are educators have become increasingly frustrated as our public schools have become dumpsters for our society's ills, I am afraid it's time to toss our epidemic of physical inactivity on the pile.

A few primary school educators that I know have cleverly integrated physical activity into their curricula. However, I think the severity of the problem demands the more drastic step of adding an hour to the school day for every kindergarten-through-fifth-grade student in America. Obviously, this is a change with a big price tag. So this is where the stimulus bundle comes in. In the plan, each school that added an hour to the school day would receive a sizeable chunk of change to fund the cost of staff and building maintenance. The only stipulation would be that during that hour the students must be kept physically active.

Each school could use the money as its needs dictate. Upgrade playgrounds, modify classrooms to be activity friendly, pay stipends for teachers who wanted to work more hours—or even better, pay underemployed community members to be supervisors. Each school would be supplied with voluminous educational materials to stimulate creative solutions to fill that hour. For some schools, it may simply mean adding another and longer recess that promotes free play. For others, it could be adding nontraditional school activities such as dance and martial arts.

Presumably, the biggest health payoff for our investment would be a few decades away. For a quicker feedback, one could measure BMIs anonymously and compare them before and after initiating the program. Regardless of how much it bumps up our GDP, one less hour of inactivity will be good for our children.

pdnews@elsevier.com

The bad news is that the global economy has gone in the toilet. The good news is that most economists agree on something. They suggest that to winch ourselves out of this abyss, we (or our government) must do some serious spending. As a lifelong fiscal conservative, this notion makes me nervous.

However, a New York Times column by recent Nobel Prize recipient Paul Krugman helped me to realize that in a depression economy, we must operate by a different set of rules. Mr. Krugman feels that appropriately targeted spending in huge chunks is the best and only answer. If the economy overheats to the point of inflation, he says that we will have plenty of room to cool things down by increasing interest rates.

So … I'm ready to chime in with my own suggestions about how we should spend all that money we are going to print. It's hard to argue with the value of repairing and improving our roads, bridges, airports, etc. Maybe those of us who prefer to commute by bicycle will get a few more lanes of our own as part of this rehab of our infrastructure.

A comprehensive and totally federally funded immunization program also would be a nice addition. However, I suggest that we invest some of our stimulus package in something less tangible than bridges and vaccines—a plan that will stimulate our children to become more physically active.

The origins of our national epidemic of obesity are many and, in some cases, poorly defined, but it is clear that a sedentary lifestyle is a contributor. Although there are too few valid studies to draw a solid conclusion, intuition tells me that programs including increased physical activity must be beneficial. While I would like to see us take the simple and direct approach and blow up half the televisions in the United States, somehow I don't think Congress will buy it.

Although my friends who are educators have become increasingly frustrated as our public schools have become dumpsters for our society's ills, I am afraid it's time to toss our epidemic of physical inactivity on the pile.

A few primary school educators that I know have cleverly integrated physical activity into their curricula. However, I think the severity of the problem demands the more drastic step of adding an hour to the school day for every kindergarten-through-fifth-grade student in America. Obviously, this is a change with a big price tag. So this is where the stimulus bundle comes in. In the plan, each school that added an hour to the school day would receive a sizeable chunk of change to fund the cost of staff and building maintenance. The only stipulation would be that during that hour the students must be kept physically active.

Each school could use the money as its needs dictate. Upgrade playgrounds, modify classrooms to be activity friendly, pay stipends for teachers who wanted to work more hours—or even better, pay underemployed community members to be supervisors. Each school would be supplied with voluminous educational materials to stimulate creative solutions to fill that hour. For some schools, it may simply mean adding another and longer recess that promotes free play. For others, it could be adding nontraditional school activities such as dance and martial arts.

Presumably, the biggest health payoff for our investment would be a few decades away. For a quicker feedback, one could measure BMIs anonymously and compare them before and after initiating the program. Regardless of how much it bumps up our GDP, one less hour of inactivity will be good for our children.

pdnews@elsevier.com

If you have given more than a thousand intramuscular injections, you have probably hit bone at least once or twice. This is not the “Eureka!” kind of discovery that one gets from striking oil or seeing that crimson flashback from a successful and intentional arterial puncture. Pricking the periosteum is more of a fingernails-on-the-blackboard moment. Even if somehow you managed to ignore the bone-chilling vibrations that traveled up the syringe, the patient's response told you that going too deep is a bad thing.

In 2007, the Centers for Disease Control and Prevention released a set of guidelines that include a recommendation for longer needles when giving intramuscular injections (Epidemiology and Prevention of Immunization Practices: The Pink Book, 10th ed., Feb. 2007), up to 1 inch for the deltoid and 11/4 inch for the thigh. Their concern was that a failure to penetrate well into the muscle would result in suboptimal vaccine absorption.

At a lunchtime staff meeting that I somehow neglected to attend (it must have been a warm sunny day—or maybe just not raining) we decided that we should comply with the CDC's guidelines and we ordered a couple of boxes of longer needles. Trying to be a good soldier and a team player, I agreed to give these big boys a try. It was an ugly week.

One of my secrets for giving minimally painful injections is to prevent the patient and/or parent from seeing the business end of the syringe. However, even with my best sleight-of-hand techniques, I was having trouble hiding the longer needles. Whenever the patient caught a glimpse of these ice picks, the anxiety level in the room escalated and it was downhill from there.

With longer needles, I was uncomfortably out of control. Wielding an extra few millimeters of steel, I felt like a jousting knight of the Round Table galloping down the runway, my 10-foot lance wobbling in the wind, never quite sure if I was going to hit my intended target. When I did strike pay dirt, watching a 1-inch needle flexing back and forth in the thigh of a squirming toddler was more than I could take. I wasn't going to wait until I had performed an unintended bone marrow biopsy, and we halted the experiment.

It wasn't the first time I had ignored the CDC's recommendation, but I admit that I have harbored a few second thoughts. However, recently I have been rescued from my insecurity by William C. Lippert and Dr. Eric J. Wall, whose article, “Optimal Intramuscular Needle-Penetration Depth,” reassured me that I can stick with my shorter needles (Pediatrics 2008;122:e556–63). Using CT and MRI scans, they have determined that if one followed the CDC guidelines one would overpenetrate the thigh of 11% of the patients using a 1-inch needle and 39% of the patients if a 11/4-incher were used. For the deltoid, the numbers were more troubling. Overpenetration would occur 11% of the time with a 5/8-inch needle, 55% for a 7/8-inch, and a walloping 63% of the time with a 1-inch needle. Ouch!

The authors, neither of whom is a pediatrician, recommend shorter needles for thigh injections and offer weight- and gender-based guidelines to aid in selection of the correct length. In their opinion, the current CDC guidelines for deltoid injections were still appropriate. However, the CDC's Advisory Committee on Immunization Practices has decided to ignore this new creatively obtained evidence. (See story, page 8—Ed.) And so, I will continue to ignore the committees and inject to the beat of my own drummer. I will temper the new evidence with my own experience. In the discussion portion of the paper, Mr. Lippert and Dr. Wall buried a pearl that supports my rogue practice. They said that in light of the great variability in extremity dimensions, “clinical judgment be used and an assortment of different lengths be available.”

Three cheers for a combination of common sense and carefully done science.

pdnews@elsevier.com

If you have given more than a thousand intramuscular injections, you have probably hit bone at least once or twice. This is not the “Eureka!” kind of discovery that one gets from striking oil or seeing that crimson flashback from a successful and intentional arterial puncture. Pricking the periosteum is more of a fingernails-on-the-blackboard moment. Even if somehow you managed to ignore the bone-chilling vibrations that traveled up the syringe, the patient's response told you that going too deep is a bad thing.

In 2007, the Centers for Disease Control and Prevention released a set of guidelines that include a recommendation for longer needles when giving intramuscular injections (Epidemiology and Prevention of Immunization Practices: The Pink Book, 10th ed., Feb. 2007), up to 1 inch for the deltoid and 11/4 inch for the thigh. Their concern was that a failure to penetrate well into the muscle would result in suboptimal vaccine absorption.

At a lunchtime staff meeting that I somehow neglected to attend (it must have been a warm sunny day—or maybe just not raining) we decided that we should comply with the CDC's guidelines and we ordered a couple of boxes of longer needles. Trying to be a good soldier and a team player, I agreed to give these big boys a try. It was an ugly week.

One of my secrets for giving minimally painful injections is to prevent the patient and/or parent from seeing the business end of the syringe. However, even with my best sleight-of-hand techniques, I was having trouble hiding the longer needles. Whenever the patient caught a glimpse of these ice picks, the anxiety level in the room escalated and it was downhill from there.

With longer needles, I was uncomfortably out of control. Wielding an extra few millimeters of steel, I felt like a jousting knight of the Round Table galloping down the runway, my 10-foot lance wobbling in the wind, never quite sure if I was going to hit my intended target. When I did strike pay dirt, watching a 1-inch needle flexing back and forth in the thigh of a squirming toddler was more than I could take. I wasn't going to wait until I had performed an unintended bone marrow biopsy, and we halted the experiment.

It wasn't the first time I had ignored the CDC's recommendation, but I admit that I have harbored a few second thoughts. However, recently I have been rescued from my insecurity by William C. Lippert and Dr. Eric J. Wall, whose article, “Optimal Intramuscular Needle-Penetration Depth,” reassured me that I can stick with my shorter needles (Pediatrics 2008;122:e556–63). Using CT and MRI scans, they have determined that if one followed the CDC guidelines one would overpenetrate the thigh of 11% of the patients using a 1-inch needle and 39% of the patients if a 11/4-incher were used. For the deltoid, the numbers were more troubling. Overpenetration would occur 11% of the time with a 5/8-inch needle, 55% for a 7/8-inch, and a walloping 63% of the time with a 1-inch needle. Ouch!

The authors, neither of whom is a pediatrician, recommend shorter needles for thigh injections and offer weight- and gender-based guidelines to aid in selection of the correct length. In their opinion, the current CDC guidelines for deltoid injections were still appropriate. However, the CDC's Advisory Committee on Immunization Practices has decided to ignore this new creatively obtained evidence. (See story, page 8—Ed.) And so, I will continue to ignore the committees and inject to the beat of my own drummer. I will temper the new evidence with my own experience. In the discussion portion of the paper, Mr. Lippert and Dr. Wall buried a pearl that supports my rogue practice. They said that in light of the great variability in extremity dimensions, “clinical judgment be used and an assortment of different lengths be available.”

Three cheers for a combination of common sense and carefully done science.

pdnews@elsevier.com

If you have given more than a thousand intramuscular injections, you have probably hit bone at least once or twice. This is not the “Eureka!” kind of discovery that one gets from striking oil or seeing that crimson flashback from a successful and intentional arterial puncture. Pricking the periosteum is more of a fingernails-on-the-blackboard moment. Even if somehow you managed to ignore the bone-chilling vibrations that traveled up the syringe, the patient's response told you that going too deep is a bad thing.

In 2007, the Centers for Disease Control and Prevention released a set of guidelines that include a recommendation for longer needles when giving intramuscular injections (Epidemiology and Prevention of Immunization Practices: The Pink Book, 10th ed., Feb. 2007), up to 1 inch for the deltoid and 11/4 inch for the thigh. Their concern was that a failure to penetrate well into the muscle would result in suboptimal vaccine absorption.

At a lunchtime staff meeting that I somehow neglected to attend (it must have been a warm sunny day—or maybe just not raining) we decided that we should comply with the CDC's guidelines and we ordered a couple of boxes of longer needles. Trying to be a good soldier and a team player, I agreed to give these big boys a try. It was an ugly week.

One of my secrets for giving minimally painful injections is to prevent the patient and/or parent from seeing the business end of the syringe. However, even with my best sleight-of-hand techniques, I was having trouble hiding the longer needles. Whenever the patient caught a glimpse of these ice picks, the anxiety level in the room escalated and it was downhill from there.

With longer needles, I was uncomfortably out of control. Wielding an extra few millimeters of steel, I felt like a jousting knight of the Round Table galloping down the runway, my 10-foot lance wobbling in the wind, never quite sure if I was going to hit my intended target. When I did strike pay dirt, watching a 1-inch needle flexing back and forth in the thigh of a squirming toddler was more than I could take. I wasn't going to wait until I had performed an unintended bone marrow biopsy, and we halted the experiment.

It wasn't the first time I had ignored the CDC's recommendation, but I admit that I have harbored a few second thoughts. However, recently I have been rescued from my insecurity by William C. Lippert and Dr. Eric J. Wall, whose article, “Optimal Intramuscular Needle-Penetration Depth,” reassured me that I can stick with my shorter needles (Pediatrics 2008;122:e556–63). Using CT and MRI scans, they have determined that if one followed the CDC guidelines one would overpenetrate the thigh of 11% of the patients using a 1-inch needle and 39% of the patients if a 11/4-incher were used. For the deltoid, the numbers were more troubling. Overpenetration would occur 11% of the time with a 5/8-inch needle, 55% for a 7/8-inch, and a walloping 63% of the time with a 1-inch needle. Ouch!

The authors, neither of whom is a pediatrician, recommend shorter needles for thigh injections and offer weight- and gender-based guidelines to aid in selection of the correct length. In their opinion, the current CDC guidelines for deltoid injections were still appropriate. However, the CDC's Advisory Committee on Immunization Practices has decided to ignore this new creatively obtained evidence. (See story, page 8—Ed.) And so, I will continue to ignore the committees and inject to the beat of my own drummer. I will temper the new evidence with my own experience. In the discussion portion of the paper, Mr. Lippert and Dr. Wall buried a pearl that supports my rogue practice. They said that in light of the great variability in extremity dimensions, “clinical judgment be used and an assortment of different lengths be available.”

Three cheers for a combination of common sense and carefully done science.

pdnews@elsevier.com

I was about to enter an exam room to see my 30th patient of the day. “Dr. Wilkoff, her rapid strep test is negative.” Meredith is our newest PPS (patient placement specialist, a job category I invented several years ago), and she thought she was being helpful. But no one had told her that while one or two of my colleagues have asked their assistants to swab the throats of anyone complaining of sore throat, I prefer to do it myself after I have seen the patient.

There was nothing to be gained by holding my breath and turning purple. The water was over the dam. But now what was I going to do? The whole rhythm of this office visit would be thrown off. Like most people, I thrive on routine. When I am busy, routines and habits (good, bad, or ugly) help maintain my efficiency and sanity.

Of course, I have never sat down and written a script for my typical office visits, but over the years a standard plot pattern has evolved … a plot into which I weave as much drama as the scenario will allow. Each one-act play begins with an introduction during which I make a little small talk about the weather or comment on how well or poorly the Patriots or the Red Sox are doing.

Shifting to a more serious and thoughtful persona, I begin taking a history, scribbling illegibly, and sketching the painful body part. In most situations I am 94% confident that I know the diagnosis and have already begun developing my plan by the time I've heard the story. However, to build and maintain the suspense, I continue to contort my face to reflect curiosity and concern, and then I examine the patient.

In most cases I pause at the end of the exam and announce, “Let me do some more writing, and then we can talk about what might be going on and what we should do about it.” Occasionally, I add the apology that if I don't write things down immediately they will be forgotten. This is true, of course, but the real reason for this 60-second pause for documentation is that it will add even more suspense to the visit.

Hopefully, by the time I am ready to reveal my diagnosis, the patient is squirming with anticipation and will be more likely to accept without question my diagnosis of a simple URI requiring no specific treatment.

It is only in rare cases that my history and physical examination have not solidified the diagnosis. Then and only then is it time for some lab work. This may be an “old school” approach, but I think it is a tradition that serves us all well and not just because it can hype up the drama in a visit and make one feel professorial. Doing the lab work first devalues the two other components of a good clinical evaluation.

One need only look at a typical medical bill to see that the system already places a higher value on diagnostic studies (meaning lab and x-ray) than it does on a good history and physical. If we continue to request lab work and imaging studies before we have examined the patient, we will perpetuate this inequity.

Of course, there is always cost. Not infrequently the patient's chief complaint is so vague or so mangled by the person at the front desk that a routinely ordered preexamination lab or x-ray is unnecessary and makes no sense. I'm sure some of you must deal with orthopedists who demand MRIs before they examine certain patients. We're not talking the chump change of a rapid strep test here.

Finally, knowing the lab work before one examines the patient eliminates the intellectual gamesmanship that keeps me going. Looking at 50 sore throats a week can be a bit mind numbing. Guessing whether the rapid strep test is going to be positive or negative helps keep my head in the game.

pdnews@elsevier.com

I was about to enter an exam room to see my 30th patient of the day. “Dr. Wilkoff, her rapid strep test is negative.” Meredith is our newest PPS (patient placement specialist, a job category I invented several years ago), and she thought she was being helpful. But no one had told her that while one or two of my colleagues have asked their assistants to swab the throats of anyone complaining of sore throat, I prefer to do it myself after I have seen the patient.

There was nothing to be gained by holding my breath and turning purple. The water was over the dam. But now what was I going to do? The whole rhythm of this office visit would be thrown off. Like most people, I thrive on routine. When I am busy, routines and habits (good, bad, or ugly) help maintain my efficiency and sanity.

Of course, I have never sat down and written a script for my typical office visits, but over the years a standard plot pattern has evolved … a plot into which I weave as much drama as the scenario will allow. Each one-act play begins with an introduction during which I make a little small talk about the weather or comment on how well or poorly the Patriots or the Red Sox are doing.

Shifting to a more serious and thoughtful persona, I begin taking a history, scribbling illegibly, and sketching the painful body part. In most situations I am 94% confident that I know the diagnosis and have already begun developing my plan by the time I've heard the story. However, to build and maintain the suspense, I continue to contort my face to reflect curiosity and concern, and then I examine the patient.

In most cases I pause at the end of the exam and announce, “Let me do some more writing, and then we can talk about what might be going on and what we should do about it.” Occasionally, I add the apology that if I don't write things down immediately they will be forgotten. This is true, of course, but the real reason for this 60-second pause for documentation is that it will add even more suspense to the visit.

Hopefully, by the time I am ready to reveal my diagnosis, the patient is squirming with anticipation and will be more likely to accept without question my diagnosis of a simple URI requiring no specific treatment.

It is only in rare cases that my history and physical examination have not solidified the diagnosis. Then and only then is it time for some lab work. This may be an “old school” approach, but I think it is a tradition that serves us all well and not just because it can hype up the drama in a visit and make one feel professorial. Doing the lab work first devalues the two other components of a good clinical evaluation.

One need only look at a typical medical bill to see that the system already places a higher value on diagnostic studies (meaning lab and x-ray) than it does on a good history and physical. If we continue to request lab work and imaging studies before we have examined the patient, we will perpetuate this inequity.

Of course, there is always cost. Not infrequently the patient's chief complaint is so vague or so mangled by the person at the front desk that a routinely ordered preexamination lab or x-ray is unnecessary and makes no sense. I'm sure some of you must deal with orthopedists who demand MRIs before they examine certain patients. We're not talking the chump change of a rapid strep test here.

Finally, knowing the lab work before one examines the patient eliminates the intellectual gamesmanship that keeps me going. Looking at 50 sore throats a week can be a bit mind numbing. Guessing whether the rapid strep test is going to be positive or negative helps keep my head in the game.

pdnews@elsevier.com

I was about to enter an exam room to see my 30th patient of the day. “Dr. Wilkoff, her rapid strep test is negative.” Meredith is our newest PPS (patient placement specialist, a job category I invented several years ago), and she thought she was being helpful. But no one had told her that while one or two of my colleagues have asked their assistants to swab the throats of anyone complaining of sore throat, I prefer to do it myself after I have seen the patient.

There was nothing to be gained by holding my breath and turning purple. The water was over the dam. But now what was I going to do? The whole rhythm of this office visit would be thrown off. Like most people, I thrive on routine. When I am busy, routines and habits (good, bad, or ugly) help maintain my efficiency and sanity.

Of course, I have never sat down and written a script for my typical office visits, but over the years a standard plot pattern has evolved … a plot into which I weave as much drama as the scenario will allow. Each one-act play begins with an introduction during which I make a little small talk about the weather or comment on how well or poorly the Patriots or the Red Sox are doing.

Shifting to a more serious and thoughtful persona, I begin taking a history, scribbling illegibly, and sketching the painful body part. In most situations I am 94% confident that I know the diagnosis and have already begun developing my plan by the time I've heard the story. However, to build and maintain the suspense, I continue to contort my face to reflect curiosity and concern, and then I examine the patient.

In most cases I pause at the end of the exam and announce, “Let me do some more writing, and then we can talk about what might be going on and what we should do about it.” Occasionally, I add the apology that if I don't write things down immediately they will be forgotten. This is true, of course, but the real reason for this 60-second pause for documentation is that it will add even more suspense to the visit.

Hopefully, by the time I am ready to reveal my diagnosis, the patient is squirming with anticipation and will be more likely to accept without question my diagnosis of a simple URI requiring no specific treatment.

It is only in rare cases that my history and physical examination have not solidified the diagnosis. Then and only then is it time for some lab work. This may be an “old school” approach, but I think it is a tradition that serves us all well and not just because it can hype up the drama in a visit and make one feel professorial. Doing the lab work first devalues the two other components of a good clinical evaluation.

One need only look at a typical medical bill to see that the system already places a higher value on diagnostic studies (meaning lab and x-ray) than it does on a good history and physical. If we continue to request lab work and imaging studies before we have examined the patient, we will perpetuate this inequity.

Of course, there is always cost. Not infrequently the patient's chief complaint is so vague or so mangled by the person at the front desk that a routinely ordered preexamination lab or x-ray is unnecessary and makes no sense. I'm sure some of you must deal with orthopedists who demand MRIs before they examine certain patients. We're not talking the chump change of a rapid strep test here.

Finally, knowing the lab work before one examines the patient eliminates the intellectual gamesmanship that keeps me going. Looking at 50 sore throats a week can be a bit mind numbing. Guessing whether the rapid strep test is going to be positive or negative helps keep my head in the game.