William G. Wilkoff

pdnews@elsevier.com

A few months ago, I was invited to a retirement party for an old house-officer mate. He wasn't actually retiring, but he was calling it quits from active clinical practice. The food was good and the wine was very good, but the rest of the event left me feeling a bit sour.

The roasts and toasts began with the usual (and well-deserved) compliments by his coworkers. But one of the contributors spoke about how envious she was of my friend because she herself was eagerly anticipating a time when she would no longer have to deal with the stupid and inconsiderate (my words, not hers) patients and parents. She intended her observations to be humorous. However, her scenarios triggered a half-hour-long anecdote-sharing competition during which each physician who stood up tried to one-up his colleagues with a tale of how dumb patients can be. Or, how badly he had been abused by a thoughtless parent who called at an inconvenient time with what he felt was a trivial question.

I must admit that some of the stories made me chuckle until I stepped back and took a longer look at the tableau spread out before me. It bothered me for two reasons. First, we may not like to admit it, but almost every joke is “on” someone. And here I was listening to a bunch of physicians who in the frivolity of the moment were willing to make the patients they served into the butt of their humor.

Physicians must continually struggle with the “we-they” divide. On one hand, it can be important to maintain a reputation and demeanor that give our advice credibility. A patient or a parent facing the unknown of a serious disease is often looking for someone with more “authority” whom can be trusted. On the other hand, we must remember that “the sore throat in Room 7” belongs to another human being who, when all is said and done, is no different from us.

Almost every survey about medical care that I have seen in the last few years contains responses that make it clear that consumers, patients, clients—whoever—want good customer service. Nearly every week I find myself having to remind a receptionist or assistant to reconsider a response to a parent. “What would you have said if your daughter had been the patient?” I think it was Pogo the comic-strip possum who said, “We have met the enemy and he is us.” Customer service boils down to accepting the reality that we are all in this together and so we might as well treat each other as equals.

The second troubling concern that surfaced as I waited for the anecdote swapping to end was that this event had seemed to unroof a festering sore of dissatisfied physicians. Maybe I am reading more into this alcohol-enabled complaint session than I should. But, I have read somewhere that when older physicians are asked if they would encourage young people to enter medicine, many of them reply that they wouldn't.

What is it about being a physician in the new millennium that is making us such an unhappy bunch? Certainly, hassles with third-party payers and the ever-present threat of a malpractice suit can put a few dark clouds in your sky. But listening to these doctors, it sounds as though the day-in and day-out interaction with patients, or certainly with parents, might be a significant source of discontent among some of them.

I've always figured that medicine—and definitely pediatrics—is a people business. And we the people are a quirky sort. We do dumb things with great frequency, and from time to time even the most saintly among us behave inconsiderately. Failure to accept those basic facts of life might be at the root of some of our discontent.

And there might be a good argument for requiring all medical students to have a real job, such as waiting tables, before they start their formal medical education. It might just cut down on the whining.

pdnews@elsevier.com

A few months ago, I was invited to a retirement party for an old house-officer mate. He wasn't actually retiring, but he was calling it quits from active clinical practice. The food was good and the wine was very good, but the rest of the event left me feeling a bit sour.

The roasts and toasts began with the usual (and well-deserved) compliments by his coworkers. But one of the contributors spoke about how envious she was of my friend because she herself was eagerly anticipating a time when she would no longer have to deal with the stupid and inconsiderate (my words, not hers) patients and parents. She intended her observations to be humorous. However, her scenarios triggered a half-hour-long anecdote-sharing competition during which each physician who stood up tried to one-up his colleagues with a tale of how dumb patients can be. Or, how badly he had been abused by a thoughtless parent who called at an inconvenient time with what he felt was a trivial question.

I must admit that some of the stories made me chuckle until I stepped back and took a longer look at the tableau spread out before me. It bothered me for two reasons. First, we may not like to admit it, but almost every joke is “on” someone. And here I was listening to a bunch of physicians who in the frivolity of the moment were willing to make the patients they served into the butt of their humor.

Physicians must continually struggle with the “we-they” divide. On one hand, it can be important to maintain a reputation and demeanor that give our advice credibility. A patient or a parent facing the unknown of a serious disease is often looking for someone with more “authority” whom can be trusted. On the other hand, we must remember that “the sore throat in Room 7” belongs to another human being who, when all is said and done, is no different from us.

Almost every survey about medical care that I have seen in the last few years contains responses that make it clear that consumers, patients, clients—whoever—want good customer service. Nearly every week I find myself having to remind a receptionist or assistant to reconsider a response to a parent. “What would you have said if your daughter had been the patient?” I think it was Pogo the comic-strip possum who said, “We have met the enemy and he is us.” Customer service boils down to accepting the reality that we are all in this together and so we might as well treat each other as equals.

The second troubling concern that surfaced as I waited for the anecdote swapping to end was that this event had seemed to unroof a festering sore of dissatisfied physicians. Maybe I am reading more into this alcohol-enabled complaint session than I should. But, I have read somewhere that when older physicians are asked if they would encourage young people to enter medicine, many of them reply that they wouldn't.

What is it about being a physician in the new millennium that is making us such an unhappy bunch? Certainly, hassles with third-party payers and the ever-present threat of a malpractice suit can put a few dark clouds in your sky. But listening to these doctors, it sounds as though the day-in and day-out interaction with patients, or certainly with parents, might be a significant source of discontent among some of them.

I've always figured that medicine—and definitely pediatrics—is a people business. And we the people are a quirky sort. We do dumb things with great frequency, and from time to time even the most saintly among us behave inconsiderately. Failure to accept those basic facts of life might be at the root of some of our discontent.

And there might be a good argument for requiring all medical students to have a real job, such as waiting tables, before they start their formal medical education. It might just cut down on the whining.

pdnews@elsevier.com

A few months ago, I was invited to a retirement party for an old house-officer mate. He wasn't actually retiring, but he was calling it quits from active clinical practice. The food was good and the wine was very good, but the rest of the event left me feeling a bit sour.

The roasts and toasts began with the usual (and well-deserved) compliments by his coworkers. But one of the contributors spoke about how envious she was of my friend because she herself was eagerly anticipating a time when she would no longer have to deal with the stupid and inconsiderate (my words, not hers) patients and parents. She intended her observations to be humorous. However, her scenarios triggered a half-hour-long anecdote-sharing competition during which each physician who stood up tried to one-up his colleagues with a tale of how dumb patients can be. Or, how badly he had been abused by a thoughtless parent who called at an inconvenient time with what he felt was a trivial question.

I must admit that some of the stories made me chuckle until I stepped back and took a longer look at the tableau spread out before me. It bothered me for two reasons. First, we may not like to admit it, but almost every joke is “on” someone. And here I was listening to a bunch of physicians who in the frivolity of the moment were willing to make the patients they served into the butt of their humor.

Physicians must continually struggle with the “we-they” divide. On one hand, it can be important to maintain a reputation and demeanor that give our advice credibility. A patient or a parent facing the unknown of a serious disease is often looking for someone with more “authority” whom can be trusted. On the other hand, we must remember that “the sore throat in Room 7” belongs to another human being who, when all is said and done, is no different from us.

Almost every survey about medical care that I have seen in the last few years contains responses that make it clear that consumers, patients, clients—whoever—want good customer service. Nearly every week I find myself having to remind a receptionist or assistant to reconsider a response to a parent. “What would you have said if your daughter had been the patient?” I think it was Pogo the comic-strip possum who said, “We have met the enemy and he is us.” Customer service boils down to accepting the reality that we are all in this together and so we might as well treat each other as equals.

The second troubling concern that surfaced as I waited for the anecdote swapping to end was that this event had seemed to unroof a festering sore of dissatisfied physicians. Maybe I am reading more into this alcohol-enabled complaint session than I should. But, I have read somewhere that when older physicians are asked if they would encourage young people to enter medicine, many of them reply that they wouldn't.

What is it about being a physician in the new millennium that is making us such an unhappy bunch? Certainly, hassles with third-party payers and the ever-present threat of a malpractice suit can put a few dark clouds in your sky. But listening to these doctors, it sounds as though the day-in and day-out interaction with patients, or certainly with parents, might be a significant source of discontent among some of them.

I've always figured that medicine—and definitely pediatrics—is a people business. And we the people are a quirky sort. We do dumb things with great frequency, and from time to time even the most saintly among us behave inconsiderately. Failure to accept those basic facts of life might be at the root of some of our discontent.

And there might be a good argument for requiring all medical students to have a real job, such as waiting tables, before they start their formal medical education. It might just cut down on the whining.

pdnews@elsevier.com

Every pediatrician who is sensitive to the needs of his patients believes in the Tooth Fairy. But, do you believe in teething? Sure, we all know that somewhere between birth and their second birthday all children will have teeth erupt through their gums. But do you ever tell parents that their child's symptoms are the result of this eruption?

Many years ago, an old pediatrician told me that the only thing that teething caused was teeth. In the decades since he contributed that pearl to my necklace of inherited wisdom, I have failed to observe anything that makes me doubt his statement. However, I recently discovered that there is actually an ICD 9 code (520.7) called “teething syndrome” and worse yet, one of my colleagues has actually used it.

I vaguely remember reading where some study found a small but statistically significant association between the eruption of teeth and rhinorrhea, loose stools, and a very modest temperature elevation. But, I've never found that observation particularly helpful when I am trying to sort out what ails a fussy infant or toddler.

You have probably heard as many misattributions as I have: “My aunt said his fever of 103 was probably his teeth,” or “I thought his vomiting and blisters on his bottom were because he was teething.” Nearly every day I hear about unerupted or erupting teeth being linked to some constellation of symptoms for which they are blameless. Fortunately, I can't recall a case in which a child has died because life-saving treatment was delayed by a tragic therapeutic detour through a variety of teething remedies. But I fear that it has happened somewhere in this country.

If while relating the history of the current illness, a parent mentions that he has considered teething, I interrupt and correct the misperception. I know that if I don't, silence is often treated as agreement.

All normal 4-month-olds begin to drool in buckets and try to mouth everything then can get their chubby little fingers around. While this oral development stage probably has some remote relationship to eventual tooth eruption, most children don't cut teeth for at least another month or so.

Of course, from time to time some children may have a cranky day or night before a tooth eruption. But in my experience, a hard wood or rubber object for the child to chew on is as effective as any medicinal intervention. The problem comes when we allow this untreatable and benign teething behavior to creep onto our list of working diagnoses.

Even a figment of thought about teething can derail our rational deductive reasoning when we are facing a diagnostic enigma. Potentially serious and treatable conditions may never make it to the radar screen when the little voice in our head says, “It's probably just teething.” As difficult as it may be, the better tack is to come clean and tell the parents, “I'm not absolutely sure what's going on here, but I'm not worried about your child. I will call you tomorrow morning to check on her.”

I tell the parents if they want to think about teething, it should be so low on their list of diagnoses that by the time they have ruled out the other explanations, the problem has resolved. In other words, if teething deserves an ICD 9 code it should carry a footnote warning that it should only be used retrospectively and never as a working diagnosis.

pdnews@elsevier.com

Every pediatrician who is sensitive to the needs of his patients believes in the Tooth Fairy. But, do you believe in teething? Sure, we all know that somewhere between birth and their second birthday all children will have teeth erupt through their gums. But do you ever tell parents that their child's symptoms are the result of this eruption?

Many years ago, an old pediatrician told me that the only thing that teething caused was teeth. In the decades since he contributed that pearl to my necklace of inherited wisdom, I have failed to observe anything that makes me doubt his statement. However, I recently discovered that there is actually an ICD 9 code (520.7) called “teething syndrome” and worse yet, one of my colleagues has actually used it.

I vaguely remember reading where some study found a small but statistically significant association between the eruption of teeth and rhinorrhea, loose stools, and a very modest temperature elevation. But, I've never found that observation particularly helpful when I am trying to sort out what ails a fussy infant or toddler.

You have probably heard as many misattributions as I have: “My aunt said his fever of 103 was probably his teeth,” or “I thought his vomiting and blisters on his bottom were because he was teething.” Nearly every day I hear about unerupted or erupting teeth being linked to some constellation of symptoms for which they are blameless. Fortunately, I can't recall a case in which a child has died because life-saving treatment was delayed by a tragic therapeutic detour through a variety of teething remedies. But I fear that it has happened somewhere in this country.

If while relating the history of the current illness, a parent mentions that he has considered teething, I interrupt and correct the misperception. I know that if I don't, silence is often treated as agreement.

All normal 4-month-olds begin to drool in buckets and try to mouth everything then can get their chubby little fingers around. While this oral development stage probably has some remote relationship to eventual tooth eruption, most children don't cut teeth for at least another month or so.

Of course, from time to time some children may have a cranky day or night before a tooth eruption. But in my experience, a hard wood or rubber object for the child to chew on is as effective as any medicinal intervention. The problem comes when we allow this untreatable and benign teething behavior to creep onto our list of working diagnoses.

Even a figment of thought about teething can derail our rational deductive reasoning when we are facing a diagnostic enigma. Potentially serious and treatable conditions may never make it to the radar screen when the little voice in our head says, “It's probably just teething.” As difficult as it may be, the better tack is to come clean and tell the parents, “I'm not absolutely sure what's going on here, but I'm not worried about your child. I will call you tomorrow morning to check on her.”

I tell the parents if they want to think about teething, it should be so low on their list of diagnoses that by the time they have ruled out the other explanations, the problem has resolved. In other words, if teething deserves an ICD 9 code it should carry a footnote warning that it should only be used retrospectively and never as a working diagnosis.

pdnews@elsevier.com

Every pediatrician who is sensitive to the needs of his patients believes in the Tooth Fairy. But, do you believe in teething? Sure, we all know that somewhere between birth and their second birthday all children will have teeth erupt through their gums. But do you ever tell parents that their child's symptoms are the result of this eruption?

Many years ago, an old pediatrician told me that the only thing that teething caused was teeth. In the decades since he contributed that pearl to my necklace of inherited wisdom, I have failed to observe anything that makes me doubt his statement. However, I recently discovered that there is actually an ICD 9 code (520.7) called “teething syndrome” and worse yet, one of my colleagues has actually used it.

I vaguely remember reading where some study found a small but statistically significant association between the eruption of teeth and rhinorrhea, loose stools, and a very modest temperature elevation. But, I've never found that observation particularly helpful when I am trying to sort out what ails a fussy infant or toddler.

You have probably heard as many misattributions as I have: “My aunt said his fever of 103 was probably his teeth,” or “I thought his vomiting and blisters on his bottom were because he was teething.” Nearly every day I hear about unerupted or erupting teeth being linked to some constellation of symptoms for which they are blameless. Fortunately, I can't recall a case in which a child has died because life-saving treatment was delayed by a tragic therapeutic detour through a variety of teething remedies. But I fear that it has happened somewhere in this country.

If while relating the history of the current illness, a parent mentions that he has considered teething, I interrupt and correct the misperception. I know that if I don't, silence is often treated as agreement.

All normal 4-month-olds begin to drool in buckets and try to mouth everything then can get their chubby little fingers around. While this oral development stage probably has some remote relationship to eventual tooth eruption, most children don't cut teeth for at least another month or so.

Of course, from time to time some children may have a cranky day or night before a tooth eruption. But in my experience, a hard wood or rubber object for the child to chew on is as effective as any medicinal intervention. The problem comes when we allow this untreatable and benign teething behavior to creep onto our list of working diagnoses.

Even a figment of thought about teething can derail our rational deductive reasoning when we are facing a diagnostic enigma. Potentially serious and treatable conditions may never make it to the radar screen when the little voice in our head says, “It's probably just teething.” As difficult as it may be, the better tack is to come clean and tell the parents, “I'm not absolutely sure what's going on here, but I'm not worried about your child. I will call you tomorrow morning to check on her.”

I tell the parents if they want to think about teething, it should be so low on their list of diagnoses that by the time they have ruled out the other explanations, the problem has resolved. In other words, if teething deserves an ICD 9 code it should carry a footnote warning that it should only be used retrospectively and never as a working diagnosis.

pdnews@elsevier.com

On a low-lying landscape of inert couch potatoes, my longtime patient Jackson, 10 years old, is a refreshing peak of activity. However, sometimes activity leads to injury, and over the weekend he found himself in the emergency department following some head trauma that left him dazed for a minute or 2. He was now fine without any symptoms, but the ED personnel had told him to come to our office in 2 days regardless of how well he was feeling.

I learned from his father that while in the ED, Jackson had undergone a computed axial tomography (CAT, or CT) scan of his head. With mock surprise I asked, “Really? Did they warn you that this procedure involves a pretty hefty radiation dose?” His dad replied, “Actually, the doctor did mention that and said that it might be associated with an increased cancer risk. She was on the fence about ordering the study, but after Jackson vomited she decided to go ahead and have it done.” Heightening my concerns all the more, Dad recalled that Jackson had had another mild concussion 3 years earlier and had also received a CT scan on that ED visit.

Of course, the images then and now were normal. I have never seen a meaningful positive CT scan in a patient who was awake and conversant. It turns out Jackson's emesis was a single event in response to a well-meaning but ill-timed attempt to leave no pain untreated. A big slug of acetaminophen syrup hadn't sat well in his nerved-up stomach.

In a recent paper in the New England Journal of Medicine, the authors pointed out that the dose of radiation from a CT scan is significantly greater than that from a traditional radiograph. For example, an abdominal CT bombards the patient's stomach with 50 times more radiation than does a standard film (N. Engl. J. Med. 2007;357:2277-84).

Equally alarming was their citation of a survey finding that 75% of radiologists and ED physicians significantly underestimated the radiation dose of a CT scan (Radiology 2004;231:393-8). While the risk of cancer from CT scans is as yet unproved, it is troubling that 91% of these ED physicians did not believe that the scans were associated with an increased lifetime risk of cancer. Until we have all of the answers, ordering CT scans is an area in which it seems physicians should be prudent. Whatever happened to primum non nocere?

In a related discussion among pediatric radiologists, it was suggested that there is consensus that “somewhere around 30% of CT scans that we do are unnecessary” (Pediatr. Radiol. 2002;32:298-300). My observations suggest that this number is a serious underestimate, certainly when one is talking head injuries.

We older adults tend to be goofy most of the time. Children, on the other hand, tend to be far more transparent. By the time they present to us in the office or ED, what you see is what you get. It certainly is wise to have them sit around for an hour or 2 to make sure their mental status and physical exam are stable. But, the old nursery rhyme verse “bumped his head, went to bed, and couldn't get up in the morning” is a myth. As is the notion that vomiting is a predictor of intracranial injury (J. Pediatr. 2007;150:274-8).

Unfortunately, even a short observation period in an ED is expensive and can add to the chaos of gridlock. Sadly, for physicians who may not be as confident of their physical exam skills as they could be and who feel the hot breath of opportunistic lawyers on the backs of their necks, ordering a CT scan is the path of least anxiety.

We all must reevaluate use of CT scans and to support and educate those among us who are having the most difficulty being prudent in using these often unnecessary higher-dose imaging techniques.

pdnews@elsevier.com

On a low-lying landscape of inert couch potatoes, my longtime patient Jackson, 10 years old, is a refreshing peak of activity. However, sometimes activity leads to injury, and over the weekend he found himself in the emergency department following some head trauma that left him dazed for a minute or 2. He was now fine without any symptoms, but the ED personnel had told him to come to our office in 2 days regardless of how well he was feeling.

I learned from his father that while in the ED, Jackson had undergone a computed axial tomography (CAT, or CT) scan of his head. With mock surprise I asked, “Really? Did they warn you that this procedure involves a pretty hefty radiation dose?” His dad replied, “Actually, the doctor did mention that and said that it might be associated with an increased cancer risk. She was on the fence about ordering the study, but after Jackson vomited she decided to go ahead and have it done.” Heightening my concerns all the more, Dad recalled that Jackson had had another mild concussion 3 years earlier and had also received a CT scan on that ED visit.

Of course, the images then and now were normal. I have never seen a meaningful positive CT scan in a patient who was awake and conversant. It turns out Jackson's emesis was a single event in response to a well-meaning but ill-timed attempt to leave no pain untreated. A big slug of acetaminophen syrup hadn't sat well in his nerved-up stomach.

In a recent paper in the New England Journal of Medicine, the authors pointed out that the dose of radiation from a CT scan is significantly greater than that from a traditional radiograph. For example, an abdominal CT bombards the patient's stomach with 50 times more radiation than does a standard film (N. Engl. J. Med. 2007;357:2277-84).

Equally alarming was their citation of a survey finding that 75% of radiologists and ED physicians significantly underestimated the radiation dose of a CT scan (Radiology 2004;231:393-8). While the risk of cancer from CT scans is as yet unproved, it is troubling that 91% of these ED physicians did not believe that the scans were associated with an increased lifetime risk of cancer. Until we have all of the answers, ordering CT scans is an area in which it seems physicians should be prudent. Whatever happened to primum non nocere?

In a related discussion among pediatric radiologists, it was suggested that there is consensus that “somewhere around 30% of CT scans that we do are unnecessary” (Pediatr. Radiol. 2002;32:298-300). My observations suggest that this number is a serious underestimate, certainly when one is talking head injuries.

We older adults tend to be goofy most of the time. Children, on the other hand, tend to be far more transparent. By the time they present to us in the office or ED, what you see is what you get. It certainly is wise to have them sit around for an hour or 2 to make sure their mental status and physical exam are stable. But, the old nursery rhyme verse “bumped his head, went to bed, and couldn't get up in the morning” is a myth. As is the notion that vomiting is a predictor of intracranial injury (J. Pediatr. 2007;150:274-8).

Unfortunately, even a short observation period in an ED is expensive and can add to the chaos of gridlock. Sadly, for physicians who may not be as confident of their physical exam skills as they could be and who feel the hot breath of opportunistic lawyers on the backs of their necks, ordering a CT scan is the path of least anxiety.

We all must reevaluate use of CT scans and to support and educate those among us who are having the most difficulty being prudent in using these often unnecessary higher-dose imaging techniques.

pdnews@elsevier.com

On a low-lying landscape of inert couch potatoes, my longtime patient Jackson, 10 years old, is a refreshing peak of activity. However, sometimes activity leads to injury, and over the weekend he found himself in the emergency department following some head trauma that left him dazed for a minute or 2. He was now fine without any symptoms, but the ED personnel had told him to come to our office in 2 days regardless of how well he was feeling.

I learned from his father that while in the ED, Jackson had undergone a computed axial tomography (CAT, or CT) scan of his head. With mock surprise I asked, “Really? Did they warn you that this procedure involves a pretty hefty radiation dose?” His dad replied, “Actually, the doctor did mention that and said that it might be associated with an increased cancer risk. She was on the fence about ordering the study, but after Jackson vomited she decided to go ahead and have it done.” Heightening my concerns all the more, Dad recalled that Jackson had had another mild concussion 3 years earlier and had also received a CT scan on that ED visit.

Of course, the images then and now were normal. I have never seen a meaningful positive CT scan in a patient who was awake and conversant. It turns out Jackson's emesis was a single event in response to a well-meaning but ill-timed attempt to leave no pain untreated. A big slug of acetaminophen syrup hadn't sat well in his nerved-up stomach.

In a recent paper in the New England Journal of Medicine, the authors pointed out that the dose of radiation from a CT scan is significantly greater than that from a traditional radiograph. For example, an abdominal CT bombards the patient's stomach with 50 times more radiation than does a standard film (N. Engl. J. Med. 2007;357:2277-84).

Equally alarming was their citation of a survey finding that 75% of radiologists and ED physicians significantly underestimated the radiation dose of a CT scan (Radiology 2004;231:393-8). While the risk of cancer from CT scans is as yet unproved, it is troubling that 91% of these ED physicians did not believe that the scans were associated with an increased lifetime risk of cancer. Until we have all of the answers, ordering CT scans is an area in which it seems physicians should be prudent. Whatever happened to primum non nocere?

In a related discussion among pediatric radiologists, it was suggested that there is consensus that “somewhere around 30% of CT scans that we do are unnecessary” (Pediatr. Radiol. 2002;32:298-300). My observations suggest that this number is a serious underestimate, certainly when one is talking head injuries.

We older adults tend to be goofy most of the time. Children, on the other hand, tend to be far more transparent. By the time they present to us in the office or ED, what you see is what you get. It certainly is wise to have them sit around for an hour or 2 to make sure their mental status and physical exam are stable. But, the old nursery rhyme verse “bumped his head, went to bed, and couldn't get up in the morning” is a myth. As is the notion that vomiting is a predictor of intracranial injury (J. Pediatr. 2007;150:274-8).

Unfortunately, even a short observation period in an ED is expensive and can add to the chaos of gridlock. Sadly, for physicians who may not be as confident of their physical exam skills as they could be and who feel the hot breath of opportunistic lawyers on the backs of their necks, ordering a CT scan is the path of least anxiety.

We all must reevaluate use of CT scans and to support and educate those among us who are having the most difficulty being prudent in using these often unnecessary higher-dose imaging techniques.

pdnews@elsevier.com

That steady buzzing sound bugging me for the last couple of years has finally gotten so loud that I must write about the two words that are causing all the noise: Medical Home. How could one possibly argue with a concept that has such a nice apple-pie-and-motherhood ring to it?

The term was actually introduced by the American Academy of Pediatrics in 1967 before many of its active members were even born. Originally, “medical home” referred to the notion of archiving a child's medical record in a central location. Most children from traditional families now have what might be called a loosely centralized medical record, including reports from consultants and other providers, housed in the pediatrician's office.

In 2002, buoyed by this very modest success, the AAP expanded the concept to include more attributes of good care such as accessibility, continuity, comprehensiveness, and compassion. They also recommended that a medical home be family centered and culturally effective. With the exception of comprehensiveness, adopting these operational characteristics should be well within the reach of nearly every pediatrician regardless of the size or financial health of his or her practice. For some physicians, meeting this vision of a medical home may require some attitude adjustment about availability, but the upside is that these changes are likely to make their practices more attractive to consumers.

By 2007, the neighborhood around the medical home had become so attractive that the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association joined the AAP in claiming ownership and generated a document titled “Joint Principles of the Patient-Centered Medical Home.” This two-page document significantly expands the concept of a medical home, draping it with wordy garlands such as “physician directed,” “patient-centered,” “whole person orientation,” and “evidence-based.”

The new principles lean heavily on expensive improvements in information technology and quality assessment. Here is where there is more than a little devil lurking in the details, because I'm not confident that an electronic health record system exists that is up to the task as envisioned in these principles at any price.

Small practices like ours also can't generate enough data to allow for valid comparisons and conclusions. When our small group went looking for a system that would permit the data crunching and sharing that is necessary for quality improvement studies, we found that most of the users weren't as happy as we were with our old homegrown system. To make matters worse, sharing data requires that our computer system must be willing to talk with the other systems in our neighborhood. That degree of uniformity doesn't seem to exist yet.

Small practices also have much more difficulty providing the comprehensive services suggested in the advanced guidelines. For example, even if we had the room in our medical home for mental health providers, there aren't any around because they abandoned our neighborhood several years ago.

Although the term “medical home” has a nice “Little House on the Prairie” feel, the concept has morphed into one that favors larger, wealthier, and more highly structured practices. For us small players, return to a more modest definition makes the most sense.

How about, “The medical home, the first place to call for all of your child's health problems”? This may sound a little like the old “gatekeeper” mantra. But, the key difference is that instead of a family being forced to call to obtain access to the system, the availability, quality, and compassion of the medical home should make the decision of where to call an obvious one.

pdnews@elsevier.com

That steady buzzing sound bugging me for the last couple of years has finally gotten so loud that I must write about the two words that are causing all the noise: Medical Home. How could one possibly argue with a concept that has such a nice apple-pie-and-motherhood ring to it?

The term was actually introduced by the American Academy of Pediatrics in 1967 before many of its active members were even born. Originally, “medical home” referred to the notion of archiving a child's medical record in a central location. Most children from traditional families now have what might be called a loosely centralized medical record, including reports from consultants and other providers, housed in the pediatrician's office.

In 2002, buoyed by this very modest success, the AAP expanded the concept to include more attributes of good care such as accessibility, continuity, comprehensiveness, and compassion. They also recommended that a medical home be family centered and culturally effective. With the exception of comprehensiveness, adopting these operational characteristics should be well within the reach of nearly every pediatrician regardless of the size or financial health of his or her practice. For some physicians, meeting this vision of a medical home may require some attitude adjustment about availability, but the upside is that these changes are likely to make their practices more attractive to consumers.

By 2007, the neighborhood around the medical home had become so attractive that the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association joined the AAP in claiming ownership and generated a document titled “Joint Principles of the Patient-Centered Medical Home.” This two-page document significantly expands the concept of a medical home, draping it with wordy garlands such as “physician directed,” “patient-centered,” “whole person orientation,” and “evidence-based.”

The new principles lean heavily on expensive improvements in information technology and quality assessment. Here is where there is more than a little devil lurking in the details, because I'm not confident that an electronic health record system exists that is up to the task as envisioned in these principles at any price.

Small practices like ours also can't generate enough data to allow for valid comparisons and conclusions. When our small group went looking for a system that would permit the data crunching and sharing that is necessary for quality improvement studies, we found that most of the users weren't as happy as we were with our old homegrown system. To make matters worse, sharing data requires that our computer system must be willing to talk with the other systems in our neighborhood. That degree of uniformity doesn't seem to exist yet.

Small practices also have much more difficulty providing the comprehensive services suggested in the advanced guidelines. For example, even if we had the room in our medical home for mental health providers, there aren't any around because they abandoned our neighborhood several years ago.

Although the term “medical home” has a nice “Little House on the Prairie” feel, the concept has morphed into one that favors larger, wealthier, and more highly structured practices. For us small players, return to a more modest definition makes the most sense.

How about, “The medical home, the first place to call for all of your child's health problems”? This may sound a little like the old “gatekeeper” mantra. But, the key difference is that instead of a family being forced to call to obtain access to the system, the availability, quality, and compassion of the medical home should make the decision of where to call an obvious one.

pdnews@elsevier.com

That steady buzzing sound bugging me for the last couple of years has finally gotten so loud that I must write about the two words that are causing all the noise: Medical Home. How could one possibly argue with a concept that has such a nice apple-pie-and-motherhood ring to it?

The term was actually introduced by the American Academy of Pediatrics in 1967 before many of its active members were even born. Originally, “medical home” referred to the notion of archiving a child's medical record in a central location. Most children from traditional families now have what might be called a loosely centralized medical record, including reports from consultants and other providers, housed in the pediatrician's office.

In 2002, buoyed by this very modest success, the AAP expanded the concept to include more attributes of good care such as accessibility, continuity, comprehensiveness, and compassion. They also recommended that a medical home be family centered and culturally effective. With the exception of comprehensiveness, adopting these operational characteristics should be well within the reach of nearly every pediatrician regardless of the size or financial health of his or her practice. For some physicians, meeting this vision of a medical home may require some attitude adjustment about availability, but the upside is that these changes are likely to make their practices more attractive to consumers.

By 2007, the neighborhood around the medical home had become so attractive that the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association joined the AAP in claiming ownership and generated a document titled “Joint Principles of the Patient-Centered Medical Home.” This two-page document significantly expands the concept of a medical home, draping it with wordy garlands such as “physician directed,” “patient-centered,” “whole person orientation,” and “evidence-based.”

The new principles lean heavily on expensive improvements in information technology and quality assessment. Here is where there is more than a little devil lurking in the details, because I'm not confident that an electronic health record system exists that is up to the task as envisioned in these principles at any price.

Small practices like ours also can't generate enough data to allow for valid comparisons and conclusions. When our small group went looking for a system that would permit the data crunching and sharing that is necessary for quality improvement studies, we found that most of the users weren't as happy as we were with our old homegrown system. To make matters worse, sharing data requires that our computer system must be willing to talk with the other systems in our neighborhood. That degree of uniformity doesn't seem to exist yet.

Small practices also have much more difficulty providing the comprehensive services suggested in the advanced guidelines. For example, even if we had the room in our medical home for mental health providers, there aren't any around because they abandoned our neighborhood several years ago.

Although the term “medical home” has a nice “Little House on the Prairie” feel, the concept has morphed into one that favors larger, wealthier, and more highly structured practices. For us small players, return to a more modest definition makes the most sense.

How about, “The medical home, the first place to call for all of your child's health problems”? This may sound a little like the old “gatekeeper” mantra. But, the key difference is that instead of a family being forced to call to obtain access to the system, the availability, quality, and compassion of the medical home should make the decision of where to call an obvious one.

pdnews@elsevier.com

“My goodness, what is that?”

With the golden brown nugget that was the size of a pencil eraser still perched on my stainless magic wand, I waved it triumphantly and replied, “That, Mrs. Alcott, is a cerumen plug, manufactured by your little Jason and now a trophy we can all be proud of.”

“Is that normal?” she replied, still too concerned to bother complimenting me on my skillful extraction. It's happened before. We masters of wax removal have come to expect that our skills are often taken for granted. Fortunately, I have my own sense of satisfaction because for a busy pediatrician there aren't too many bigger highs than removing a big glob of wax in one piece.

Earwax is funny stuff. Most of the time, it's simply providing its owner protection from the elements. Rarely (mostly in teenage boys, it seems), it gets so dense and swollen that it interferes with hearing. More frequently, it serves as an annoying challenge to the assiduous pediatrician who at 4:45 p.m. on a Friday afternoon is trying to determine why an unappreciative 18-month-old has a fever.

When I was in medical school we were offered an hour lecture by someone—a neurologist, I believe—who included among his hobbies the study of earwax and would enlighten us on the topic. Because it was clear that we were never going to be tested on his message, and since it was even clearer that it was a comfortably warm and sunny Thursday afternoon, I opted for some tennis instead.

Had I only known how often my schedule, my emotions, my sense of self-esteem—in effect, my life—would be impacted by cerumen, I think I would have hung around the lecture hall and learned a bit more about my future adversary. But, that's water over the dam.

Once out in practice I learned quickly that if I was going to make good clinical decisions, I needed to see tympanic membranes, and to do this I needed to learn to remove earwax. During my training, no one really showed me how to use an ear curette.

Fortunately, my first partner had a good selection of curettes and I learned which one worked best for me. I learned how deep to go, how to feel with the curette and which way to scrape, how to have a firm hand on the patient and a soft hand on the curette, and certainly how to make sure the child was appropriately restrained. It meant frequent stops to visualize whether I had succeeded, and if not, where I needed to go next.

I learned that if I was unlucky or unskillful and there was some bleeding, that it was best to tell the family that they might see some blood later on, even though it wasn't evident at the moment. Anticipatory guidance saves a mess of evening phone calls.

Even if well done, removing cerumen can be uncomfortable for some patients. Sometimes it can't be avoided. This fact of life and inexperience deters many physicians from doing what is clinically correct and removing enough wax to get a good view of the tympanic membrane.

Every week I see children who were seen in an emergency department or another physician's office, or unfortunately on the floors of tertiary medical centers, whom I know couldn't have had their ears adequately examined. Because when I look in their ears there is a ton of wax, not just a few flakes that may have fallen off the walls of the canal overnight, but a serious amount of impacted wax.

Do I always get enough wax out on the first visit? Of course not, but if the clinical situation demands an adequate exam that day, I don't give up. Luckily there are many situations when I can have the patient return the next day when everyone is more rested.

There is a procedure code for removing cerumen. And if I have done more than scoop out a few flakes, I am not afraid to bill for the work because it appears that I have a skill that is in short supply.

pdnews@elsevier.com

“My goodness, what is that?”

With the golden brown nugget that was the size of a pencil eraser still perched on my stainless magic wand, I waved it triumphantly and replied, “That, Mrs. Alcott, is a cerumen plug, manufactured by your little Jason and now a trophy we can all be proud of.”

“Is that normal?” she replied, still too concerned to bother complimenting me on my skillful extraction. It's happened before. We masters of wax removal have come to expect that our skills are often taken for granted. Fortunately, I have my own sense of satisfaction because for a busy pediatrician there aren't too many bigger highs than removing a big glob of wax in one piece.

Earwax is funny stuff. Most of the time, it's simply providing its owner protection from the elements. Rarely (mostly in teenage boys, it seems), it gets so dense and swollen that it interferes with hearing. More frequently, it serves as an annoying challenge to the assiduous pediatrician who at 4:45 p.m. on a Friday afternoon is trying to determine why an unappreciative 18-month-old has a fever.

When I was in medical school we were offered an hour lecture by someone—a neurologist, I believe—who included among his hobbies the study of earwax and would enlighten us on the topic. Because it was clear that we were never going to be tested on his message, and since it was even clearer that it was a comfortably warm and sunny Thursday afternoon, I opted for some tennis instead.

Had I only known how often my schedule, my emotions, my sense of self-esteem—in effect, my life—would be impacted by cerumen, I think I would have hung around the lecture hall and learned a bit more about my future adversary. But, that's water over the dam.

Once out in practice I learned quickly that if I was going to make good clinical decisions, I needed to see tympanic membranes, and to do this I needed to learn to remove earwax. During my training, no one really showed me how to use an ear curette.

Fortunately, my first partner had a good selection of curettes and I learned which one worked best for me. I learned how deep to go, how to feel with the curette and which way to scrape, how to have a firm hand on the patient and a soft hand on the curette, and certainly how to make sure the child was appropriately restrained. It meant frequent stops to visualize whether I had succeeded, and if not, where I needed to go next.

I learned that if I was unlucky or unskillful and there was some bleeding, that it was best to tell the family that they might see some blood later on, even though it wasn't evident at the moment. Anticipatory guidance saves a mess of evening phone calls.

Even if well done, removing cerumen can be uncomfortable for some patients. Sometimes it can't be avoided. This fact of life and inexperience deters many physicians from doing what is clinically correct and removing enough wax to get a good view of the tympanic membrane.

Every week I see children who were seen in an emergency department or another physician's office, or unfortunately on the floors of tertiary medical centers, whom I know couldn't have had their ears adequately examined. Because when I look in their ears there is a ton of wax, not just a few flakes that may have fallen off the walls of the canal overnight, but a serious amount of impacted wax.

Do I always get enough wax out on the first visit? Of course not, but if the clinical situation demands an adequate exam that day, I don't give up. Luckily there are many situations when I can have the patient return the next day when everyone is more rested.

There is a procedure code for removing cerumen. And if I have done more than scoop out a few flakes, I am not afraid to bill for the work because it appears that I have a skill that is in short supply.

pdnews@elsevier.com

“My goodness, what is that?”

With the golden brown nugget that was the size of a pencil eraser still perched on my stainless magic wand, I waved it triumphantly and replied, “That, Mrs. Alcott, is a cerumen plug, manufactured by your little Jason and now a trophy we can all be proud of.”

“Is that normal?” she replied, still too concerned to bother complimenting me on my skillful extraction. It's happened before. We masters of wax removal have come to expect that our skills are often taken for granted. Fortunately, I have my own sense of satisfaction because for a busy pediatrician there aren't too many bigger highs than removing a big glob of wax in one piece.

Earwax is funny stuff. Most of the time, it's simply providing its owner protection from the elements. Rarely (mostly in teenage boys, it seems), it gets so dense and swollen that it interferes with hearing. More frequently, it serves as an annoying challenge to the assiduous pediatrician who at 4:45 p.m. on a Friday afternoon is trying to determine why an unappreciative 18-month-old has a fever.

When I was in medical school we were offered an hour lecture by someone—a neurologist, I believe—who included among his hobbies the study of earwax and would enlighten us on the topic. Because it was clear that we were never going to be tested on his message, and since it was even clearer that it was a comfortably warm and sunny Thursday afternoon, I opted for some tennis instead.

Had I only known how often my schedule, my emotions, my sense of self-esteem—in effect, my life—would be impacted by cerumen, I think I would have hung around the lecture hall and learned a bit more about my future adversary. But, that's water over the dam.

Once out in practice I learned quickly that if I was going to make good clinical decisions, I needed to see tympanic membranes, and to do this I needed to learn to remove earwax. During my training, no one really showed me how to use an ear curette.

Fortunately, my first partner had a good selection of curettes and I learned which one worked best for me. I learned how deep to go, how to feel with the curette and which way to scrape, how to have a firm hand on the patient and a soft hand on the curette, and certainly how to make sure the child was appropriately restrained. It meant frequent stops to visualize whether I had succeeded, and if not, where I needed to go next.

I learned that if I was unlucky or unskillful and there was some bleeding, that it was best to tell the family that they might see some blood later on, even though it wasn't evident at the moment. Anticipatory guidance saves a mess of evening phone calls.

Even if well done, removing cerumen can be uncomfortable for some patients. Sometimes it can't be avoided. This fact of life and inexperience deters many physicians from doing what is clinically correct and removing enough wax to get a good view of the tympanic membrane.

Every week I see children who were seen in an emergency department or another physician's office, or unfortunately on the floors of tertiary medical centers, whom I know couldn't have had their ears adequately examined. Because when I look in their ears there is a ton of wax, not just a few flakes that may have fallen off the walls of the canal overnight, but a serious amount of impacted wax.

Do I always get enough wax out on the first visit? Of course not, but if the clinical situation demands an adequate exam that day, I don't give up. Luckily there are many situations when I can have the patient return the next day when everyone is more rested.

There is a procedure code for removing cerumen. And if I have done more than scoop out a few flakes, I am not afraid to bill for the work because it appears that I have a skill that is in short supply.

pdnews@elsevier.com

Unless you've handed over the care of all of your sick patients to the hospitalists, you will have noticed cookbook medicine creeping into the care of your hospitalized patients. It comes clothed in several transparent disguises: “CareMaps,” “standardized orders,” and “algorithms” are the euphemisms for “recipe,” the term with which we here in Brunswick are most familiar.

Now, when I admit a patient to the hospital with the diagnosis of bronchiolitis or a baby has the misfortune of being born a bit on the heavy side, a printer somewhere at the nurses' station spits out a set of legible and detailed orders that will determine that child's care for his or her hospital stay. So long as I manage to get a history and physical into the chart and sign the orders, no one will bother me.

I'm not sure exactly where the trend began or who was responsible for getting this ball of red tape rolling. Most of the push for standardized orders seems to be coming from the nursing service. However, I wonder if the risk-management folks also might have a hand in the process. I vaguely remember sitting through several tedious meetings where the standard orders were discussed, but like most documents created by committee, these orders ended up being inclusive rather than thoughtful. Few of the items would successfully pass an evidence-based test of validity.

While I have never claimed that inpatient pediatrics is fun, standardized orders make the process less intellectually stimulating and more impersonal. Whenever I sign on the bottom line, I feel as though I am admitting that I haven't been paying attention during my CME exercises and that I'm too old to be trusted making clinical decisions about sick patients. It's safe to say that since their introduction I have never been a big fan of standardized orders.

However, one of my partners recently gave me an article from the Dec. 10, 2007, issue of the New Yorker magazine by Dr. Atul Gawande, a surgeon/author. (If you haven't read any of his writings, I urge you to start with his first book, “Complications.”) The article is titled “The Checklist” and describes how by developing a simple checklist for central line placement, Dr. Peter Pronovost, a Johns Hopkins University critical specialist, was able to prevent eight deaths from line infections and save $2 million in a single hospital in a single year.

The article goes on to describe how Dr. Pronovost has developed other evidence-based checklists, including one for the care of ventilated patients. The cost savings and life-sparing statistics are truly remarkable and have been effective in many other hospitals. Even the country of Spain has bought into the program and plans to implement it nationwide.

The ingredients in Dr. Pronovost's recipes are rather mundane and include such simple tasks as making sure the head of the bed is raised to 30 degrees for ventilator patients, that all ventilated patients receive antacids, and that any patient having a line placed has sterile drapes. Critical care units have such complex patients that rigorous attention to even the most basic factors is necessary to achieve a significantly improved outcome. As I read the article, I was reminded of the story of how a girl in Wisconsin was rescued from rabies by a combination of heavy sedation and scrupulous attention to life support.

I'm not sure how Dr. Pronovost's checklists for critical care units translate to my unsatisfying experience with the standard orders. I guess that for me, the big take-home message would be that checklists or recipes must be clearly evidence based, not just cobbled together by those of us at the grassroots. The results aren't going to be dramatic because I'm not dealing with critically ill patients, but after reading Dr. Gawande's article, I'm ready to try a few new recipes from a well-documented cookbook.

pdnews@elsevier.com

Unless you've handed over the care of all of your sick patients to the hospitalists, you will have noticed cookbook medicine creeping into the care of your hospitalized patients. It comes clothed in several transparent disguises: “CareMaps,” “standardized orders,” and “algorithms” are the euphemisms for “recipe,” the term with which we here in Brunswick are most familiar.

Now, when I admit a patient to the hospital with the diagnosis of bronchiolitis or a baby has the misfortune of being born a bit on the heavy side, a printer somewhere at the nurses' station spits out a set of legible and detailed orders that will determine that child's care for his or her hospital stay. So long as I manage to get a history and physical into the chart and sign the orders, no one will bother me.

I'm not sure exactly where the trend began or who was responsible for getting this ball of red tape rolling. Most of the push for standardized orders seems to be coming from the nursing service. However, I wonder if the risk-management folks also might have a hand in the process. I vaguely remember sitting through several tedious meetings where the standard orders were discussed, but like most documents created by committee, these orders ended up being inclusive rather than thoughtful. Few of the items would successfully pass an evidence-based test of validity.

While I have never claimed that inpatient pediatrics is fun, standardized orders make the process less intellectually stimulating and more impersonal. Whenever I sign on the bottom line, I feel as though I am admitting that I haven't been paying attention during my CME exercises and that I'm too old to be trusted making clinical decisions about sick patients. It's safe to say that since their introduction I have never been a big fan of standardized orders.

However, one of my partners recently gave me an article from the Dec. 10, 2007, issue of the New Yorker magazine by Dr. Atul Gawande, a surgeon/author. (If you haven't read any of his writings, I urge you to start with his first book, “Complications.”) The article is titled “The Checklist” and describes how by developing a simple checklist for central line placement, Dr. Peter Pronovost, a Johns Hopkins University critical specialist, was able to prevent eight deaths from line infections and save $2 million in a single hospital in a single year.

The article goes on to describe how Dr. Pronovost has developed other evidence-based checklists, including one for the care of ventilated patients. The cost savings and life-sparing statistics are truly remarkable and have been effective in many other hospitals. Even the country of Spain has bought into the program and plans to implement it nationwide.

The ingredients in Dr. Pronovost's recipes are rather mundane and include such simple tasks as making sure the head of the bed is raised to 30 degrees for ventilator patients, that all ventilated patients receive antacids, and that any patient having a line placed has sterile drapes. Critical care units have such complex patients that rigorous attention to even the most basic factors is necessary to achieve a significantly improved outcome. As I read the article, I was reminded of the story of how a girl in Wisconsin was rescued from rabies by a combination of heavy sedation and scrupulous attention to life support.

I'm not sure how Dr. Pronovost's checklists for critical care units translate to my unsatisfying experience with the standard orders. I guess that for me, the big take-home message would be that checklists or recipes must be clearly evidence based, not just cobbled together by those of us at the grassroots. The results aren't going to be dramatic because I'm not dealing with critically ill patients, but after reading Dr. Gawande's article, I'm ready to try a few new recipes from a well-documented cookbook.

pdnews@elsevier.com

Unless you've handed over the care of all of your sick patients to the hospitalists, you will have noticed cookbook medicine creeping into the care of your hospitalized patients. It comes clothed in several transparent disguises: “CareMaps,” “standardized orders,” and “algorithms” are the euphemisms for “recipe,” the term with which we here in Brunswick are most familiar.

Now, when I admit a patient to the hospital with the diagnosis of bronchiolitis or a baby has the misfortune of being born a bit on the heavy side, a printer somewhere at the nurses' station spits out a set of legible and detailed orders that will determine that child's care for his or her hospital stay. So long as I manage to get a history and physical into the chart and sign the orders, no one will bother me.

I'm not sure exactly where the trend began or who was responsible for getting this ball of red tape rolling. Most of the push for standardized orders seems to be coming from the nursing service. However, I wonder if the risk-management folks also might have a hand in the process. I vaguely remember sitting through several tedious meetings where the standard orders were discussed, but like most documents created by committee, these orders ended up being inclusive rather than thoughtful. Few of the items would successfully pass an evidence-based test of validity.

While I have never claimed that inpatient pediatrics is fun, standardized orders make the process less intellectually stimulating and more impersonal. Whenever I sign on the bottom line, I feel as though I am admitting that I haven't been paying attention during my CME exercises and that I'm too old to be trusted making clinical decisions about sick patients. It's safe to say that since their introduction I have never been a big fan of standardized orders.

However, one of my partners recently gave me an article from the Dec. 10, 2007, issue of the New Yorker magazine by Dr. Atul Gawande, a surgeon/author. (If you haven't read any of his writings, I urge you to start with his first book, “Complications.”) The article is titled “The Checklist” and describes how by developing a simple checklist for central line placement, Dr. Peter Pronovost, a Johns Hopkins University critical specialist, was able to prevent eight deaths from line infections and save $2 million in a single hospital in a single year.

The article goes on to describe how Dr. Pronovost has developed other evidence-based checklists, including one for the care of ventilated patients. The cost savings and life-sparing statistics are truly remarkable and have been effective in many other hospitals. Even the country of Spain has bought into the program and plans to implement it nationwide.

The ingredients in Dr. Pronovost's recipes are rather mundane and include such simple tasks as making sure the head of the bed is raised to 30 degrees for ventilator patients, that all ventilated patients receive antacids, and that any patient having a line placed has sterile drapes. Critical care units have such complex patients that rigorous attention to even the most basic factors is necessary to achieve a significantly improved outcome. As I read the article, I was reminded of the story of how a girl in Wisconsin was rescued from rabies by a combination of heavy sedation and scrupulous attention to life support.

I'm not sure how Dr. Pronovost's checklists for critical care units translate to my unsatisfying experience with the standard orders. I guess that for me, the big take-home message would be that checklists or recipes must be clearly evidence based, not just cobbled together by those of us at the grassroots. The results aren't going to be dramatic because I'm not dealing with critically ill patients, but after reading Dr. Gawande's article, I'm ready to try a few new recipes from a well-documented cookbook.

pdnews@elsevier.com

Since I had seen her last year, my 5-year-old patient Tiana had gained so much weight that I almost didn't recognize her. I knew that when I looked at her growth curve it would now include a steep upslope. The change had not caught her mother, Maria, by surprise. Tiana's weight was the first topic of her answer to my usual, “How are things goin'?”

Over the years we had had many discussions about how she might remedy the girls' sleep problems. Now we had a new issue to discuss: impending obesity.

My simplistic understanding of obesity has always been that if someone takes in more packets of energy than are burned, those packets will accumulate in the body as fat.

One must also account for genetic variation because it is clear that some of us are better at storing fat than others are.

Likewise, two automobiles of the same size may have dramatically different fuel efficiency ratings just because that's the way they were designed and built.

It seems, to those of who were blessed with lean parents, to be such a blatantly simple concept that we are easily frustrated by other families who “just don't get it.”

Which side of my simplistic equation had changed for Tiana?

Suspecting that it was an intake problem, I began to quiz Maria about the family's diet. It continues to be predominantly vegetables and grains, no soda, rare desserts. She admitted that there has been a slight increase in chips and snack food since she and her husband had taken over a mom-and-pop convenience store. But, the amounts didn't sound excessive.

I then began to explore the energy utilization side of the balance sheet.

“How much TV are the girls watching?” Here the answer was significantly different from the year before. The television was now on all the time.

“Why?” It turns out that since taking over the new business, Maria had been so busy keeping the books that she admitted using television as a babysitter. In the past, she would often take them outside and spend a good part of the day playing. But now the girls are full-time couch potatoes.

I told Maria what she had suspected herself: that the inactivity was the major contributor to Tiana's weight gain.

Digging deeper, I asked if there was a way that she could do the bookkeeping in the evening after the girls were asleep. The problem with that solution is that the younger child still sleeps poorly and Maria feels she must lie down with her whenever she wakes. She feels that she can't let her cry because it will interrupt her already sleep-deprived and overworked husband. With evenings consumed by sleep refusal, Maria must steal daytime from the girls to do the books. So we were back to talking about sleep, the same issue that Maria and I had batted around for the last 4 years.

Although growth curves as dramatic as Tiana's are unusual, when they do occur they reopen my eyes to the complexity of the obesity problem.

Sometimes the steep rise in body mass index is the result of a cookie-baking grandmother assuming the full-time day-care responsibilities. In other cases, opportunities for activity are lost and dietary supervision gets lost in the family shuffle.

In any case, obesity is one of those rare situations where my simplistic survival tool fails me.

pdnews@elsevier.com

Since I had seen her last year, my 5-year-old patient Tiana had gained so much weight that I almost didn't recognize her. I knew that when I looked at her growth curve it would now include a steep upslope. The change had not caught her mother, Maria, by surprise. Tiana's weight was the first topic of her answer to my usual, “How are things goin'?”

Over the years we had had many discussions about how she might remedy the girls' sleep problems. Now we had a new issue to discuss: impending obesity.

My simplistic understanding of obesity has always been that if someone takes in more packets of energy than are burned, those packets will accumulate in the body as fat.

One must also account for genetic variation because it is clear that some of us are better at storing fat than others are.

Likewise, two automobiles of the same size may have dramatically different fuel efficiency ratings just because that's the way they were designed and built.

It seems, to those of who were blessed with lean parents, to be such a blatantly simple concept that we are easily frustrated by other families who “just don't get it.”

Which side of my simplistic equation had changed for Tiana?

Suspecting that it was an intake problem, I began to quiz Maria about the family's diet. It continues to be predominantly vegetables and grains, no soda, rare desserts. She admitted that there has been a slight increase in chips and snack food since she and her husband had taken over a mom-and-pop convenience store. But, the amounts didn't sound excessive.

I then began to explore the energy utilization side of the balance sheet.

“How much TV are the girls watching?” Here the answer was significantly different from the year before. The television was now on all the time.

“Why?” It turns out that since taking over the new business, Maria had been so busy keeping the books that she admitted using television as a babysitter. In the past, she would often take them outside and spend a good part of the day playing. But now the girls are full-time couch potatoes.

I told Maria what she had suspected herself: that the inactivity was the major contributor to Tiana's weight gain.

Digging deeper, I asked if there was a way that she could do the bookkeeping in the evening after the girls were asleep. The problem with that solution is that the younger child still sleeps poorly and Maria feels she must lie down with her whenever she wakes. She feels that she can't let her cry because it will interrupt her already sleep-deprived and overworked husband. With evenings consumed by sleep refusal, Maria must steal daytime from the girls to do the books. So we were back to talking about sleep, the same issue that Maria and I had batted around for the last 4 years.

Although growth curves as dramatic as Tiana's are unusual, when they do occur they reopen my eyes to the complexity of the obesity problem.

Sometimes the steep rise in body mass index is the result of a cookie-baking grandmother assuming the full-time day-care responsibilities. In other cases, opportunities for activity are lost and dietary supervision gets lost in the family shuffle.

In any case, obesity is one of those rare situations where my simplistic survival tool fails me.

pdnews@elsevier.com

Since I had seen her last year, my 5-year-old patient Tiana had gained so much weight that I almost didn't recognize her. I knew that when I looked at her growth curve it would now include a steep upslope. The change had not caught her mother, Maria, by surprise. Tiana's weight was the first topic of her answer to my usual, “How are things goin'?”

Over the years we had had many discussions about how she might remedy the girls' sleep problems. Now we had a new issue to discuss: impending obesity.

My simplistic understanding of obesity has always been that if someone takes in more packets of energy than are burned, those packets will accumulate in the body as fat.

One must also account for genetic variation because it is clear that some of us are better at storing fat than others are.

Likewise, two automobiles of the same size may have dramatically different fuel efficiency ratings just because that's the way they were designed and built.

It seems, to those of who were blessed with lean parents, to be such a blatantly simple concept that we are easily frustrated by other families who “just don't get it.”

Which side of my simplistic equation had changed for Tiana?

Suspecting that it was an intake problem, I began to quiz Maria about the family's diet. It continues to be predominantly vegetables and grains, no soda, rare desserts. She admitted that there has been a slight increase in chips and snack food since she and her husband had taken over a mom-and-pop convenience store. But, the amounts didn't sound excessive.

I then began to explore the energy utilization side of the balance sheet.

“How much TV are the girls watching?” Here the answer was significantly different from the year before. The television was now on all the time.

“Why?” It turns out that since taking over the new business, Maria had been so busy keeping the books that she admitted using television as a babysitter. In the past, she would often take them outside and spend a good part of the day playing. But now the girls are full-time couch potatoes.

I told Maria what she had suspected herself: that the inactivity was the major contributor to Tiana's weight gain.

Digging deeper, I asked if there was a way that she could do the bookkeeping in the evening after the girls were asleep. The problem with that solution is that the younger child still sleeps poorly and Maria feels she must lie down with her whenever she wakes. She feels that she can't let her cry because it will interrupt her already sleep-deprived and overworked husband. With evenings consumed by sleep refusal, Maria must steal daytime from the girls to do the books. So we were back to talking about sleep, the same issue that Maria and I had batted around for the last 4 years.

Although growth curves as dramatic as Tiana's are unusual, when they do occur they reopen my eyes to the complexity of the obesity problem.

Sometimes the steep rise in body mass index is the result of a cookie-baking grandmother assuming the full-time day-care responsibilities. In other cases, opportunities for activity are lost and dietary supervision gets lost in the family shuffle.

In any case, obesity is one of those rare situations where my simplistic survival tool fails me.

pdnews@elsevier.com

No one who knows me well would ever describe me as a political animal. As a registered Independent, I switch allegiances based on my gut response to a candidate's stated position, his voting record … and, of course, his or her hairstyle and sartorial choices. When forced to choose based solely on the issues, I tend to side with those who claim that less government is better.

However, from time to time, this attitude of “just leave us alone and we'll sort it out ourselves” just doesn't work. A frightening example in which market forces and communal altruism have failed us is the current shambles we have made of our national vaccine program.

I had already begun to write this letter when Dr. Michael Pichichero's I.D. Consult column appeared in the February issue of PEDIATRIC NEWS (“Feds Should Help Bring Vaccines to U.S. Market”). He knows far more than I do about the details of how the system works and fails. And, he offers some rational solutions to at least some of the problems. But I can't resist the temptation to add my less knowledgeable and more emotional 2 cents' worth to his observations.

First, let me restate his frustration and concern about the current state of our vaccine supplies. While I admit that when it comes to remembering PIN numbers and passwords, age has taken its toll on my memory, I think I still qualify for a “pretty sharp” rating in most categories. But I have thrown in the towel when it comes to keeping up to date with the latest recommended vaccine schedule and its many addenda.

I now rely totally on our nurses to compare the patient's immunization records with the newest guidelines and our fluctuating vaccine supply and then come up with the best fit. The process is so time consuming for our clinical staff that I routinely room more than 50% of my patients. The patients and their parents may at times be flattered when the doctor summons them from the waiting room himself. And it does add a bit more of a homey quality to our medical home. But clearly it is not the most efficient way of providing medical care.

Vaccine costs and the inscrutable, unscrupulous, and variable reimbursement practices of the third-party payers has left us gun-shy when it comes to adding new vaccines to our offerings. We stay clear of the cutting edge of vaccine technology to avoid being shredded to ribbons and left holding a very expensive bag of immunizations. As someone who remembers when Haemophilus influenzae meningitis sat at the top of the rule-out diagnoses for a young child with fever, the Hib vaccine shortage makes me very nervous.

It is clear to even the less-government-is-better folks like myself that the federal government must step into the arena and ensure that vaccines are not only safe, but available. It must also create and maintain sufficient financial incentives to keep the private sector enthusiastic about vaccine research and development.

Regardless of whom we elect this November, the year 2009 should provide an excellent opportunity for change. Dr. Pichichero's recommendations take advantage of the current system, but I think we need to think bigger. Let's raise vaccine supply and safety issues to the cabinet level.

It's time for a Vaccine Czar, a Godfather (or Godmother) of Immunization. Someone who has the president's ear every day. Someone armed with a sharp knife that cuts red tape like warm butter. Someone who carries a big stick to whack the kneecaps of the insurance companies. And someone with an ample supply of carrots to keep the pharmaceutical companies drooling for the profits of newly developed vaccines.

I fell under the spell of Obama Charisma many months ago, but I think any of the top candidates can be convinced that vaccine supply is a critical issue. We just need to start yelling louder and they'll hear us.

pdnews@elsevier.com

No one who knows me well would ever describe me as a political animal. As a registered Independent, I switch allegiances based on my gut response to a candidate's stated position, his voting record … and, of course, his or her hairstyle and sartorial choices. When forced to choose based solely on the issues, I tend to side with those who claim that less government is better.

However, from time to time, this attitude of “just leave us alone and we'll sort it out ourselves” just doesn't work. A frightening example in which market forces and communal altruism have failed us is the current shambles we have made of our national vaccine program.

I had already begun to write this letter when Dr. Michael Pichichero's I.D. Consult column appeared in the February issue of PEDIATRIC NEWS (“Feds Should Help Bring Vaccines to U.S. Market”). He knows far more than I do about the details of how the system works and fails. And, he offers some rational solutions to at least some of the problems. But I can't resist the temptation to add my less knowledgeable and more emotional 2 cents' worth to his observations.

First, let me restate his frustration and concern about the current state of our vaccine supplies. While I admit that when it comes to remembering PIN numbers and passwords, age has taken its toll on my memory, I think I still qualify for a “pretty sharp” rating in most categories. But I have thrown in the towel when it comes to keeping up to date with the latest recommended vaccine schedule and its many addenda.

I now rely totally on our nurses to compare the patient's immunization records with the newest guidelines and our fluctuating vaccine supply and then come up with the best fit. The process is so time consuming for our clinical staff that I routinely room more than 50% of my patients. The patients and their parents may at times be flattered when the doctor summons them from the waiting room himself. And it does add a bit more of a homey quality to our medical home. But clearly it is not the most efficient way of providing medical care.

Vaccine costs and the inscrutable, unscrupulous, and variable reimbursement practices of the third-party payers has left us gun-shy when it comes to adding new vaccines to our offerings. We stay clear of the cutting edge of vaccine technology to avoid being shredded to ribbons and left holding a very expensive bag of immunizations. As someone who remembers when Haemophilus influenzae meningitis sat at the top of the rule-out diagnoses for a young child with fever, the Hib vaccine shortage makes me very nervous.

It is clear to even the less-government-is-better folks like myself that the federal government must step into the arena and ensure that vaccines are not only safe, but available. It must also create and maintain sufficient financial incentives to keep the private sector enthusiastic about vaccine research and development.

Regardless of whom we elect this November, the year 2009 should provide an excellent opportunity for change. Dr. Pichichero's recommendations take advantage of the current system, but I think we need to think bigger. Let's raise vaccine supply and safety issues to the cabinet level.

It's time for a Vaccine Czar, a Godfather (or Godmother) of Immunization. Someone who has the president's ear every day. Someone armed with a sharp knife that cuts red tape like warm butter. Someone who carries a big stick to whack the kneecaps of the insurance companies. And someone with an ample supply of carrots to keep the pharmaceutical companies drooling for the profits of newly developed vaccines.

I fell under the spell of Obama Charisma many months ago, but I think any of the top candidates can be convinced that vaccine supply is a critical issue. We just need to start yelling louder and they'll hear us.

pdnews@elsevier.com

No one who knows me well would ever describe me as a political animal. As a registered Independent, I switch allegiances based on my gut response to a candidate's stated position, his voting record … and, of course, his or her hairstyle and sartorial choices. When forced to choose based solely on the issues, I tend to side with those who claim that less government is better.

However, from time to time, this attitude of “just leave us alone and we'll sort it out ourselves” just doesn't work. A frightening example in which market forces and communal altruism have failed us is the current shambles we have made of our national vaccine program.

I had already begun to write this letter when Dr. Michael Pichichero's I.D. Consult column appeared in the February issue of PEDIATRIC NEWS (“Feds Should Help Bring Vaccines to U.S. Market”). He knows far more than I do about the details of how the system works and fails. And, he offers some rational solutions to at least some of the problems. But I can't resist the temptation to add my less knowledgeable and more emotional 2 cents' worth to his observations.

First, let me restate his frustration and concern about the current state of our vaccine supplies. While I admit that when it comes to remembering PIN numbers and passwords, age has taken its toll on my memory, I think I still qualify for a “pretty sharp” rating in most categories. But I have thrown in the towel when it comes to keeping up to date with the latest recommended vaccine schedule and its many addenda.

I now rely totally on our nurses to compare the patient's immunization records with the newest guidelines and our fluctuating vaccine supply and then come up with the best fit. The process is so time consuming for our clinical staff that I routinely room more than 50% of my patients. The patients and their parents may at times be flattered when the doctor summons them from the waiting room himself. And it does add a bit more of a homey quality to our medical home. But clearly it is not the most efficient way of providing medical care.

Vaccine costs and the inscrutable, unscrupulous, and variable reimbursement practices of the third-party payers has left us gun-shy when it comes to adding new vaccines to our offerings. We stay clear of the cutting edge of vaccine technology to avoid being shredded to ribbons and left holding a very expensive bag of immunizations. As someone who remembers when Haemophilus influenzae meningitis sat at the top of the rule-out diagnoses for a young child with fever, the Hib vaccine shortage makes me very nervous.

It is clear to even the less-government-is-better folks like myself that the federal government must step into the arena and ensure that vaccines are not only safe, but available. It must also create and maintain sufficient financial incentives to keep the private sector enthusiastic about vaccine research and development.

Regardless of whom we elect this November, the year 2009 should provide an excellent opportunity for change. Dr. Pichichero's recommendations take advantage of the current system, but I think we need to think bigger. Let's raise vaccine supply and safety issues to the cabinet level.

It's time for a Vaccine Czar, a Godfather (or Godmother) of Immunization. Someone who has the president's ear every day. Someone armed with a sharp knife that cuts red tape like warm butter. Someone who carries a big stick to whack the kneecaps of the insurance companies. And someone with an ample supply of carrots to keep the pharmaceutical companies drooling for the profits of newly developed vaccines.

I fell under the spell of Obama Charisma many months ago, but I think any of the top candidates can be convinced that vaccine supply is a critical issue. We just need to start yelling louder and they'll hear us.

pdnews@elsevier.com

Feet up on my desk, with my phone headset glued to my better ear, I was just extricating myself from the last call of the morning's half-hour call time. Sensing a presence behind me, I turned to find Allison, our newest receptionist, patiently waiting with a sheaf of unsigned health forms in her hand.

“I was eavesdropping on your last two calls,” she said. “It sounds like you're not very worried about all this stuff I read about lead-containing toys from China.”

“I guess I'm not disguising my impatience with the silliness of the whole thing,” I replied. “Let me tell you a little story that might help explain my lack of enthusiasm for the current lead flap.”

The story went something like this: When I was a preschooler, I and many of my peers played with toy soldiers made out of lead. But I was really into these little hand-painted warriors. I suspect that I had an army of at least 200 soldiers representing several different nations. I would line them up in a variety of battle formations and have them flank and outflank each other for hours. My father built me several elaborate storage trays as my collection grew. With heavy use, many of their hand-painted uniforms chipped off, exposing their lead bodies.

By the time I was 11, my interest had shifted to sports and building boat and airplane models. For one project, I needed some ballast, and I knew that lead had the weight-to-volume ratio that I wanted. So, I built myself some little ½-by-½-by-2-inch molds out of scrap wood I found in the basement. I asked my mother if I could borrow one of her old saucepans and I proceeded to melt down a third of my lead soldier collection on the kitchen stove. I carefully poured the molten lead into my molds and my little homemade ingots came out exactly as I had planned. And I continued to use them for a variety of projects over the next several years. My father was very upset because I had destroyed what he correctly suspected would have become a valuable collection in 20 years. Neither of my parents expressed any concern about my health.

While I never got straight A's in school, I still managed to graduate from college and an accredited medical school. In recent years, I have wondered how well I might have done had I not dabbled in metallurgy as a youngster, but I don't think I can blame lead for any of my numerous shortcomings.

So you can see that the tiny amounts of lead that have been getting so much attention don't get me very excited. However, when asked, I do suggest that parents toss out or return any toys that appear on the lead-tainted recall list. Not so much because I'm concerned about the lead, but because many of the toys are media driven and encourage more TV viewing.

Sadly, some of the parents who have become concerned about these toys also have been withholding valuable and potentially lifesaving vaccines based on irrational and unsubstantiated concerns about the safety of another heavy metal, mercury. But, don't get me wrong. Lead can be and still is a serious problem for some young children.

Fortunately, the young families who are buying and rehabbing old farmhouses here in Maine are generally well-educated and very aware of the risks of lead paint chips, dust, and plumbing. However, we still encounter problems with unscrupulous landlords who rent lead-contaminated apartments to economically disadvantaged families. We try to stay ahead of the problem with our screening tests, but we aren't perfect. Even when we identify a child at risk, the family often moves on, the apartment remains a problem, and another unsuspecting family moves in and the cycle goes on.

I could sense Allison was beginning to lose interest in my harangue. But, she politely thanked me for the anecdote and reminded me to “remember to please sign these forms.”

pdnews@elsevier.com

Feet up on my desk, with my phone headset glued to my better ear, I was just extricating myself from the last call of the morning's half-hour call time. Sensing a presence behind me, I turned to find Allison, our newest receptionist, patiently waiting with a sheaf of unsigned health forms in her hand.

“I was eavesdropping on your last two calls,” she said. “It sounds like you're not very worried about all this stuff I read about lead-containing toys from China.”

“I guess I'm not disguising my impatience with the silliness of the whole thing,” I replied. “Let me tell you a little story that might help explain my lack of enthusiasm for the current lead flap.”

The story went something like this: When I was a preschooler, I and many of my peers played with toy soldiers made out of lead. But I was really into these little hand-painted warriors. I suspect that I had an army of at least 200 soldiers representing several different nations. I would line them up in a variety of battle formations and have them flank and outflank each other for hours. My father built me several elaborate storage trays as my collection grew. With heavy use, many of their hand-painted uniforms chipped off, exposing their lead bodies.

By the time I was 11, my interest had shifted to sports and building boat and airplane models. For one project, I needed some ballast, and I knew that lead had the weight-to-volume ratio that I wanted. So, I built myself some little ½-by-½-by-2-inch molds out of scrap wood I found in the basement. I asked my mother if I could borrow one of her old saucepans and I proceeded to melt down a third of my lead soldier collection on the kitchen stove. I carefully poured the molten lead into my molds and my little homemade ingots came out exactly as I had planned. And I continued to use them for a variety of projects over the next several years. My father was very upset because I had destroyed what he correctly suspected would have become a valuable collection in 20 years. Neither of my parents expressed any concern about my health.

While I never got straight A's in school, I still managed to graduate from college and an accredited medical school. In recent years, I have wondered how well I might have done had I not dabbled in metallurgy as a youngster, but I don't think I can blame lead for any of my numerous shortcomings.

So you can see that the tiny amounts of lead that have been getting so much attention don't get me very excited. However, when asked, I do suggest that parents toss out or return any toys that appear on the lead-tainted recall list. Not so much because I'm concerned about the lead, but because many of the toys are media driven and encourage more TV viewing.

Sadly, some of the parents who have become concerned about these toys also have been withholding valuable and potentially lifesaving vaccines based on irrational and unsubstantiated concerns about the safety of another heavy metal, mercury. But, don't get me wrong. Lead can be and still is a serious problem for some young children.

Fortunately, the young families who are buying and rehabbing old farmhouses here in Maine are generally well-educated and very aware of the risks of lead paint chips, dust, and plumbing. However, we still encounter problems with unscrupulous landlords who rent lead-contaminated apartments to economically disadvantaged families. We try to stay ahead of the problem with our screening tests, but we aren't perfect. Even when we identify a child at risk, the family often moves on, the apartment remains a problem, and another unsuspecting family moves in and the cycle goes on.

I could sense Allison was beginning to lose interest in my harangue. But, she politely thanked me for the anecdote and reminded me to “remember to please sign these forms.”

pdnews@elsevier.com

Feet up on my desk, with my phone headset glued to my better ear, I was just extricating myself from the last call of the morning's half-hour call time. Sensing a presence behind me, I turned to find Allison, our newest receptionist, patiently waiting with a sheaf of unsigned health forms in her hand.

“I was eavesdropping on your last two calls,” she said. “It sounds like you're not very worried about all this stuff I read about lead-containing toys from China.”

“I guess I'm not disguising my impatience with the silliness of the whole thing,” I replied. “Let me tell you a little story that might help explain my lack of enthusiasm for the current lead flap.”

The story went something like this: When I was a preschooler, I and many of my peers played with toy soldiers made out of lead. But I was really into these little hand-painted warriors. I suspect that I had an army of at least 200 soldiers representing several different nations. I would line them up in a variety of battle formations and have them flank and outflank each other for hours. My father built me several elaborate storage trays as my collection grew. With heavy use, many of their hand-painted uniforms chipped off, exposing their lead bodies.

By the time I was 11, my interest had shifted to sports and building boat and airplane models. For one project, I needed some ballast, and I knew that lead had the weight-to-volume ratio that I wanted. So, I built myself some little ½-by-½-by-2-inch molds out of scrap wood I found in the basement. I asked my mother if I could borrow one of her old saucepans and I proceeded to melt down a third of my lead soldier collection on the kitchen stove. I carefully poured the molten lead into my molds and my little homemade ingots came out exactly as I had planned. And I continued to use them for a variety of projects over the next several years. My father was very upset because I had destroyed what he correctly suspected would have become a valuable collection in 20 years. Neither of my parents expressed any concern about my health.

While I never got straight A's in school, I still managed to graduate from college and an accredited medical school. In recent years, I have wondered how well I might have done had I not dabbled in metallurgy as a youngster, but I don't think I can blame lead for any of my numerous shortcomings.

So you can see that the tiny amounts of lead that have been getting so much attention don't get me very excited. However, when asked, I do suggest that parents toss out or return any toys that appear on the lead-tainted recall list. Not so much because I'm concerned about the lead, but because many of the toys are media driven and encourage more TV viewing.

Sadly, some of the parents who have become concerned about these toys also have been withholding valuable and potentially lifesaving vaccines based on irrational and unsubstantiated concerns about the safety of another heavy metal, mercury. But, don't get me wrong. Lead can be and still is a serious problem for some young children.

Fortunately, the young families who are buying and rehabbing old farmhouses here in Maine are generally well-educated and very aware of the risks of lead paint chips, dust, and plumbing. However, we still encounter problems with unscrupulous landlords who rent lead-contaminated apartments to economically disadvantaged families. We try to stay ahead of the problem with our screening tests, but we aren't perfect. Even when we identify a child at risk, the family often moves on, the apartment remains a problem, and another unsuspecting family moves in and the cycle goes on.

I could sense Allison was beginning to lose interest in my harangue. But, she politely thanked me for the anecdote and reminded me to “remember to please sign these forms.”

pdnews@elsevier.com

I glanced at the chief complaint scribbled on the top of the billing sheet before I entered the exam room. I usually ignore these little “heads-ups” from the receptionists because they often bear little if any resemblance to the parent's real concern or the patient's problem.

In this case, I was hoping the “?development” was one of those red herrings.

The patient I was about to see was a 16-month-old whom I had examined at least nine times since his birth, and I couldn't recall receiving bad vibes on any of those previous health maintenance visits.

So, I took a deep breath and gave my nose the habitual rub before entering a patient encounter, and opened the door carefully because one can never tell where a toddler might be motoring. Fortunately, the history spilled out quickly.

It turns out that a friend of a sister-in-law of the child's day-care provider is a recently trained occupational therapist. She had paid a social call at the day-care center one day the previous week and after a 20-minute informal observation, had shared her concerns about this young man's development.

Apparently, she was troubled by how he rose from sitting to standing and by the fact that he was totally uninterested in television. The day-care provider felt obligated to share these unsolicited observations with the parents and voila, we have an office visit.

I re-asked a handful of questions from the previous two well-child visits as I watched this little rascal cavort around the room. I then took him for a run down the hall and examined him.

Luckily, the parents were already skeptical about the off-the-cuff appraisal they had received secondhand. They readily accepted my qualified reassurances, including, “I don't know whether he is going to graduate first in his class, but I don't have any worries about your son's development.”

The scenario could have been much different. At any one moment, there are three or four infants and toddlers with soft signs of developmental delay circulating in my subconscious. I haven't shared my concerns with their parents because I know that within 12 months, the tincture of time will have coaxed 90% of these little outliers back under the safe umbrella of the bell-shaped curve.

Of course, once or twice a year it will become obvious that things haven't moved along as well as I had hoped, and I must begin the careful process of sharing my concerns with the parents.

I'm sure that people who equate early intervention with motherhood and apple pie will feel that by keeping my worries to myself for a few months, I have done irreparable harm to these patients and their families.

Trust me, I would much prefer to cleanse my mind of all those private worries I harbor about my patients. But, it is just part of being a physician. One can minimize some of these worries by ordering unnecessary but reassuring lab work and CT scans. But when the worry is about something as nebulous as a subtle developmental delay, the lab and the imaging department can't bail me out. Only time will tell, and I choose to keep my tongue clenched firmly between my teeth while I wait.

To do otherwise can open a can of worms that has parental angst written all over it. When I finally say, “Mrs. James, I'm just a teeny bit concerned because your baby is just a little bit floppy,” I had better be ready for several long discussions about what this can mean and have a plan of how we are going to move forward with evaluations and therapy.

If I'm lucky, the parents will say, “We're glad you mentioned that because we were just beginning to wonder about his development ourselves.”

Timing is everything.

pdnews@elsevier.com

I glanced at the chief complaint scribbled on the top of the billing sheet before I entered the exam room. I usually ignore these little “heads-ups” from the receptionists because they often bear little if any resemblance to the parent's real concern or the patient's problem.

In this case, I was hoping the “?development” was one of those red herrings.

The patient I was about to see was a 16-month-old whom I had examined at least nine times since his birth, and I couldn't recall receiving bad vibes on any of those previous health maintenance visits.

So, I took a deep breath and gave my nose the habitual rub before entering a patient encounter, and opened the door carefully because one can never tell where a toddler might be motoring. Fortunately, the history spilled out quickly.

It turns out that a friend of a sister-in-law of the child's day-care provider is a recently trained occupational therapist. She had paid a social call at the day-care center one day the previous week and after a 20-minute informal observation, had shared her concerns about this young man's development.

Apparently, she was troubled by how he rose from sitting to standing and by the fact that he was totally uninterested in television. The day-care provider felt obligated to share these unsolicited observations with the parents and voila, we have an office visit.

I re-asked a handful of questions from the previous two well-child visits as I watched this little rascal cavort around the room. I then took him for a run down the hall and examined him.

Luckily, the parents were already skeptical about the off-the-cuff appraisal they had received secondhand. They readily accepted my qualified reassurances, including, “I don't know whether he is going to graduate first in his class, but I don't have any worries about your son's development.”

The scenario could have been much different. At any one moment, there are three or four infants and toddlers with soft signs of developmental delay circulating in my subconscious. I haven't shared my concerns with their parents because I know that within 12 months, the tincture of time will have coaxed 90% of these little outliers back under the safe umbrella of the bell-shaped curve.

Of course, once or twice a year it will become obvious that things haven't moved along as well as I had hoped, and I must begin the careful process of sharing my concerns with the parents.

I'm sure that people who equate early intervention with motherhood and apple pie will feel that by keeping my worries to myself for a few months, I have done irreparable harm to these patients and their families.

Trust me, I would much prefer to cleanse my mind of all those private worries I harbor about my patients. But, it is just part of being a physician. One can minimize some of these worries by ordering unnecessary but reassuring lab work and CT scans. But when the worry is about something as nebulous as a subtle developmental delay, the lab and the imaging department can't bail me out. Only time will tell, and I choose to keep my tongue clenched firmly between my teeth while I wait.

To do otherwise can open a can of worms that has parental angst written all over it. When I finally say, “Mrs. James, I'm just a teeny bit concerned because your baby is just a little bit floppy,” I had better be ready for several long discussions about what this can mean and have a plan of how we are going to move forward with evaluations and therapy.

If I'm lucky, the parents will say, “We're glad you mentioned that because we were just beginning to wonder about his development ourselves.”

Timing is everything.

pdnews@elsevier.com

I glanced at the chief complaint scribbled on the top of the billing sheet before I entered the exam room. I usually ignore these little “heads-ups” from the receptionists because they often bear little if any resemblance to the parent's real concern or the patient's problem.

In this case, I was hoping the “?development” was one of those red herrings.

The patient I was about to see was a 16-month-old whom I had examined at least nine times since his birth, and I couldn't recall receiving bad vibes on any of those previous health maintenance visits.

So, I took a deep breath and gave my nose the habitual rub before entering a patient encounter, and opened the door carefully because one can never tell where a toddler might be motoring. Fortunately, the history spilled out quickly.

It turns out that a friend of a sister-in-law of the child's day-care provider is a recently trained occupational therapist. She had paid a social call at the day-care center one day the previous week and after a 20-minute informal observation, had shared her concerns about this young man's development.

Apparently, she was troubled by how he rose from sitting to standing and by the fact that he was totally uninterested in television. The day-care provider felt obligated to share these unsolicited observations with the parents and voila, we have an office visit.

I re-asked a handful of questions from the previous two well-child visits as I watched this little rascal cavort around the room. I then took him for a run down the hall and examined him.

Luckily, the parents were already skeptical about the off-the-cuff appraisal they had received secondhand. They readily accepted my qualified reassurances, including, “I don't know whether he is going to graduate first in his class, but I don't have any worries about your son's development.”

The scenario could have been much different. At any one moment, there are three or four infants and toddlers with soft signs of developmental delay circulating in my subconscious. I haven't shared my concerns with their parents because I know that within 12 months, the tincture of time will have coaxed 90% of these little outliers back under the safe umbrella of the bell-shaped curve.

Of course, once or twice a year it will become obvious that things haven't moved along as well as I had hoped, and I must begin the careful process of sharing my concerns with the parents.

I'm sure that people who equate early intervention with motherhood and apple pie will feel that by keeping my worries to myself for a few months, I have done irreparable harm to these patients and their families.

Trust me, I would much prefer to cleanse my mind of all those private worries I harbor about my patients. But, it is just part of being a physician. One can minimize some of these worries by ordering unnecessary but reassuring lab work and CT scans. But when the worry is about something as nebulous as a subtle developmental delay, the lab and the imaging department can't bail me out. Only time will tell, and I choose to keep my tongue clenched firmly between my teeth while I wait.

To do otherwise can open a can of worms that has parental angst written all over it. When I finally say, “Mrs. James, I'm just a teeny bit concerned because your baby is just a little bit floppy,” I had better be ready for several long discussions about what this can mean and have a plan of how we are going to move forward with evaluations and therapy.

If I'm lucky, the parents will say, “We're glad you mentioned that because we were just beginning to wonder about his development ourselves.”

Timing is everything.