William G. Wilkoff

The good, the bad, and the ugly—to everything there is a season. I would put school and camp forms among the ugly, and their seasons are approaching.

For college and summer camp forms it's May and June. In July and August, it's time for fall sports and kindergarten entry. September brings only a brief hiatus, though, because with each new sports season, would-be athletes will discover crumpled, candy bar-stained permission forms in the bottoms of their backpacks a few hours or days before their first practices.

It's not the volume of these seasonal paper inundations that I find so troubling. After all, I am happy to learn that so many of my patients have been successful enough to be admitted to a college or have chosen to leave their televisions and video games for a few hours to participate in athletics.

The problem is that the cursed forms that must accompany my patients on these academic and recreational adventures ask questions whose answers have little or no bearing on what these children will be doing. Furthermore, I suspect that no one ever reads even a third of the information that I've taken the time to provide.

Does a summer camp really need to know the height, weight, and blood pressure of my patient? Are they planning on using the measurements I have provided to order t-shirts for the campers? Are they considering putting some campers on a low-salt diet? Is an Ivy League college going to use my patient's urine specific gravity for their budget calculation for water usage?

From time to time, I see the occasional antique camp form that still asks, “Nits?” I am tempted to reply, “Yes!” to see if Camp Nurse Ratched calls me to ask what I've done about the lice. One highly respected and selective eastern university demands cholesterol levels on its form. Are they planning on restricting my patient to the salad bar? It's more likely that someone in their medical school is collecting data for a research project.

I can understand why international study programs and organizations that offer unusual physical challenges might want detailed information. I suspect that they have been burned in the past when participants have arrived unfit for rigorous activity or too mentally fragile to thrive away from their usual support systems.

But the vast majority of schools and camps don't need to know even a tenth of the information that they ask for. Even when I encounter the rare question that deserves an answer, I'm faced with a space barely big enough to scribble my initials.

The staff and provider time required to complete these camp and school forms is staggering. It is certainly an unnecessary distraction from the real business of helping our patients get and remain healthy.

I know that some practitioners charge for completing forms, but I can't bring myself to take this step. There is a better solution. Some colleges have already begun to produce forms that don't insult my intelligence, and now it's time for the other colleges, schools, and camps to follow suit. A standard form should simply state, “We have already asked your patient/parents a whole bunch of questions. Is there anything we here at Camp Intelligent should know about him/her so that we can provide him/her with a safe and successful educational/camp experience? Here are 20 comfortably spaced lines for your reply. Please write legibly and include a copy of his/her immunizations.”

Now here's the rub. If we physicians are to be given credit for the intelligence to respond to these broad and open-ended questions, then we must come up with honest and complete answers about our patients' health, particularly their mental health.

For our patients with chronic diseases such as asthma, this also means providing an accurate, up-to-date, and unambiguous action or management plan. Freed from the shackles of answering dumb questions about the 85% of our patients who are healthy, this should be a piece of cake.

The good, the bad, and the ugly—to everything there is a season. I would put school and camp forms among the ugly, and their seasons are approaching.

For college and summer camp forms it's May and June. In July and August, it's time for fall sports and kindergarten entry. September brings only a brief hiatus, though, because with each new sports season, would-be athletes will discover crumpled, candy bar-stained permission forms in the bottoms of their backpacks a few hours or days before their first practices.

It's not the volume of these seasonal paper inundations that I find so troubling. After all, I am happy to learn that so many of my patients have been successful enough to be admitted to a college or have chosen to leave their televisions and video games for a few hours to participate in athletics.

The problem is that the cursed forms that must accompany my patients on these academic and recreational adventures ask questions whose answers have little or no bearing on what these children will be doing. Furthermore, I suspect that no one ever reads even a third of the information that I've taken the time to provide.

Does a summer camp really need to know the height, weight, and blood pressure of my patient? Are they planning on using the measurements I have provided to order t-shirts for the campers? Are they considering putting some campers on a low-salt diet? Is an Ivy League college going to use my patient's urine specific gravity for their budget calculation for water usage?

From time to time, I see the occasional antique camp form that still asks, “Nits?” I am tempted to reply, “Yes!” to see if Camp Nurse Ratched calls me to ask what I've done about the lice. One highly respected and selective eastern university demands cholesterol levels on its form. Are they planning on restricting my patient to the salad bar? It's more likely that someone in their medical school is collecting data for a research project.

I can understand why international study programs and organizations that offer unusual physical challenges might want detailed information. I suspect that they have been burned in the past when participants have arrived unfit for rigorous activity or too mentally fragile to thrive away from their usual support systems.

But the vast majority of schools and camps don't need to know even a tenth of the information that they ask for. Even when I encounter the rare question that deserves an answer, I'm faced with a space barely big enough to scribble my initials.

The staff and provider time required to complete these camp and school forms is staggering. It is certainly an unnecessary distraction from the real business of helping our patients get and remain healthy.

I know that some practitioners charge for completing forms, but I can't bring myself to take this step. There is a better solution. Some colleges have already begun to produce forms that don't insult my intelligence, and now it's time for the other colleges, schools, and camps to follow suit. A standard form should simply state, “We have already asked your patient/parents a whole bunch of questions. Is there anything we here at Camp Intelligent should know about him/her so that we can provide him/her with a safe and successful educational/camp experience? Here are 20 comfortably spaced lines for your reply. Please write legibly and include a copy of his/her immunizations.”

Now here's the rub. If we physicians are to be given credit for the intelligence to respond to these broad and open-ended questions, then we must come up with honest and complete answers about our patients' health, particularly their mental health.

For our patients with chronic diseases such as asthma, this also means providing an accurate, up-to-date, and unambiguous action or management plan. Freed from the shackles of answering dumb questions about the 85% of our patients who are healthy, this should be a piece of cake.

The good, the bad, and the ugly—to everything there is a season. I would put school and camp forms among the ugly, and their seasons are approaching.

For college and summer camp forms it's May and June. In July and August, it's time for fall sports and kindergarten entry. September brings only a brief hiatus, though, because with each new sports season, would-be athletes will discover crumpled, candy bar-stained permission forms in the bottoms of their backpacks a few hours or days before their first practices.

It's not the volume of these seasonal paper inundations that I find so troubling. After all, I am happy to learn that so many of my patients have been successful enough to be admitted to a college or have chosen to leave their televisions and video games for a few hours to participate in athletics.

The problem is that the cursed forms that must accompany my patients on these academic and recreational adventures ask questions whose answers have little or no bearing on what these children will be doing. Furthermore, I suspect that no one ever reads even a third of the information that I've taken the time to provide.

Does a summer camp really need to know the height, weight, and blood pressure of my patient? Are they planning on using the measurements I have provided to order t-shirts for the campers? Are they considering putting some campers on a low-salt diet? Is an Ivy League college going to use my patient's urine specific gravity for their budget calculation for water usage?

From time to time, I see the occasional antique camp form that still asks, “Nits?” I am tempted to reply, “Yes!” to see if Camp Nurse Ratched calls me to ask what I've done about the lice. One highly respected and selective eastern university demands cholesterol levels on its form. Are they planning on restricting my patient to the salad bar? It's more likely that someone in their medical school is collecting data for a research project.

I can understand why international study programs and organizations that offer unusual physical challenges might want detailed information. I suspect that they have been burned in the past when participants have arrived unfit for rigorous activity or too mentally fragile to thrive away from their usual support systems.

But the vast majority of schools and camps don't need to know even a tenth of the information that they ask for. Even when I encounter the rare question that deserves an answer, I'm faced with a space barely big enough to scribble my initials.

The staff and provider time required to complete these camp and school forms is staggering. It is certainly an unnecessary distraction from the real business of helping our patients get and remain healthy.

I know that some practitioners charge for completing forms, but I can't bring myself to take this step. There is a better solution. Some colleges have already begun to produce forms that don't insult my intelligence, and now it's time for the other colleges, schools, and camps to follow suit. A standard form should simply state, “We have already asked your patient/parents a whole bunch of questions. Is there anything we here at Camp Intelligent should know about him/her so that we can provide him/her with a safe and successful educational/camp experience? Here are 20 comfortably spaced lines for your reply. Please write legibly and include a copy of his/her immunizations.”

Now here's the rub. If we physicians are to be given credit for the intelligence to respond to these broad and open-ended questions, then we must come up with honest and complete answers about our patients' health, particularly their mental health.

For our patients with chronic diseases such as asthma, this also means providing an accurate, up-to-date, and unambiguous action or management plan. Freed from the shackles of answering dumb questions about the 85% of our patients who are healthy, this should be a piece of cake.

When the view from your living room includes hundreds of lobster trap buoys, out-of-town visitors expect to be served lobster for dinner. It often comes as an unnerving surprise to our guests, though, when they hear the clattering death throes of unfortunate crustaceans entering the steaming pot.

Inevitably, this terminal event shifts the conversation to the concept of who or what can feel pain. Marilyn and I try to reassure the squeamish that scientific research (probably funded by the state of Maine) has shown lobsters to lack the neurologic equipment to feel pain.

Pain has also become a hot topic in medicine, and “pain management” has joined the pantheon of medical buzzwords for the new millennium. The mantra at our hospitals seems to have become, “No pain shall go unmeasured or unmedicated.” It has even crept out of the hospital. I have heard parents asking their toddlers, for whom counting is a recitation of 10 words they don't understand, to rate their pain on a scale from 1 to 10. This exercise in quantification is only slightly more futile than pointing to an array of pictograms with smiley and grumpy faces.

Sometimes, this well-intentioned passion to measure and eliminate pain can go awry and actually interrupt the timely discovery of the correct diagnosis. It may even interfere with a patient's ability to access other forms of comfort, such as the soft words and gentle touch of a parent.

Now, don't get me wrong. I am not advocating that we return to the bad old days when pain was seriously undertreated because we physicians harbored an irrational fear of creating drug addicts. Most of us, myself included, still have a lot to learn about the pharmacologic management of pain, particularly in patients with terminal illnesses.

I think, however, that we should all look more closely at nonpharmacologic solutions and try harder to understand why some patients appear to experience more pain than others. There must be genetic and biochemical components to these differences in pain tolerance, but in the last few decades it has become obvious to me that uncertainty and depression are two critical factors in making pain less tolerable. Fortunately, these are things that I as a physician can influence with a combination of clinical skills and medications that are not usually considered analgesics.

A few years ago, for example, a urologist had to rescue me from my own inattention. At one point, he explained to me that, over the next 8 hours, I would be experiencing what could be very painful bladder spasms. He described their cause and assured me that they would be temporary. He encouraged me to ask for pain medication, but he also mentioned that it might temporarily slow my recovery.

Comforted by his confident and detailed explanation of what I was going to experience, I elected not to take any medication. He was correct about everything, including the severity of the pain, but because of its spasmodic nature and because I knew what to expect, it was tolerable. In effect, my skilled physician had used his own version of the Lamaze technique to help him manage my pain.

Ever since that experience I have tried whenever practical to tell a patient as much about his or her pain as I can: what is causing it, how long it will last, and what we can do to ameliorate it. Over the last few years, my efforts to dispel uncertainty seem to have made a positive difference for many of my patients. Ferreting out and treating the depression component have been more difficult tasks than educating and reassuring, particularly when the pain appears acutely and the patient is a child I don't know very well. However, by at least considering the role of depression in my patients' diminished pain tolerance, I can often get us started on the path toward the correct long-term solution.

Fortunately, for Marilyn and me, by the time the lobsters are ready to eat, the discussion has usually drifted away from pain management. Then it's time for a short course in crustacean anatomy and how to find the succulent meat hidden inside those crimson shells.

When the view from your living room includes hundreds of lobster trap buoys, out-of-town visitors expect to be served lobster for dinner. It often comes as an unnerving surprise to our guests, though, when they hear the clattering death throes of unfortunate crustaceans entering the steaming pot.

Inevitably, this terminal event shifts the conversation to the concept of who or what can feel pain. Marilyn and I try to reassure the squeamish that scientific research (probably funded by the state of Maine) has shown lobsters to lack the neurologic equipment to feel pain.

Pain has also become a hot topic in medicine, and “pain management” has joined the pantheon of medical buzzwords for the new millennium. The mantra at our hospitals seems to have become, “No pain shall go unmeasured or unmedicated.” It has even crept out of the hospital. I have heard parents asking their toddlers, for whom counting is a recitation of 10 words they don't understand, to rate their pain on a scale from 1 to 10. This exercise in quantification is only slightly more futile than pointing to an array of pictograms with smiley and grumpy faces.

Sometimes, this well-intentioned passion to measure and eliminate pain can go awry and actually interrupt the timely discovery of the correct diagnosis. It may even interfere with a patient's ability to access other forms of comfort, such as the soft words and gentle touch of a parent.

Now, don't get me wrong. I am not advocating that we return to the bad old days when pain was seriously undertreated because we physicians harbored an irrational fear of creating drug addicts. Most of us, myself included, still have a lot to learn about the pharmacologic management of pain, particularly in patients with terminal illnesses.

I think, however, that we should all look more closely at nonpharmacologic solutions and try harder to understand why some patients appear to experience more pain than others. There must be genetic and biochemical components to these differences in pain tolerance, but in the last few decades it has become obvious to me that uncertainty and depression are two critical factors in making pain less tolerable. Fortunately, these are things that I as a physician can influence with a combination of clinical skills and medications that are not usually considered analgesics.

A few years ago, for example, a urologist had to rescue me from my own inattention. At one point, he explained to me that, over the next 8 hours, I would be experiencing what could be very painful bladder spasms. He described their cause and assured me that they would be temporary. He encouraged me to ask for pain medication, but he also mentioned that it might temporarily slow my recovery.

Comforted by his confident and detailed explanation of what I was going to experience, I elected not to take any medication. He was correct about everything, including the severity of the pain, but because of its spasmodic nature and because I knew what to expect, it was tolerable. In effect, my skilled physician had used his own version of the Lamaze technique to help him manage my pain.

Ever since that experience I have tried whenever practical to tell a patient as much about his or her pain as I can: what is causing it, how long it will last, and what we can do to ameliorate it. Over the last few years, my efforts to dispel uncertainty seem to have made a positive difference for many of my patients. Ferreting out and treating the depression component have been more difficult tasks than educating and reassuring, particularly when the pain appears acutely and the patient is a child I don't know very well. However, by at least considering the role of depression in my patients' diminished pain tolerance, I can often get us started on the path toward the correct long-term solution.

Fortunately, for Marilyn and me, by the time the lobsters are ready to eat, the discussion has usually drifted away from pain management. Then it's time for a short course in crustacean anatomy and how to find the succulent meat hidden inside those crimson shells.

When the view from your living room includes hundreds of lobster trap buoys, out-of-town visitors expect to be served lobster for dinner. It often comes as an unnerving surprise to our guests, though, when they hear the clattering death throes of unfortunate crustaceans entering the steaming pot.

Inevitably, this terminal event shifts the conversation to the concept of who or what can feel pain. Marilyn and I try to reassure the squeamish that scientific research (probably funded by the state of Maine) has shown lobsters to lack the neurologic equipment to feel pain.

Pain has also become a hot topic in medicine, and “pain management” has joined the pantheon of medical buzzwords for the new millennium. The mantra at our hospitals seems to have become, “No pain shall go unmeasured or unmedicated.” It has even crept out of the hospital. I have heard parents asking their toddlers, for whom counting is a recitation of 10 words they don't understand, to rate their pain on a scale from 1 to 10. This exercise in quantification is only slightly more futile than pointing to an array of pictograms with smiley and grumpy faces.

Sometimes, this well-intentioned passion to measure and eliminate pain can go awry and actually interrupt the timely discovery of the correct diagnosis. It may even interfere with a patient's ability to access other forms of comfort, such as the soft words and gentle touch of a parent.

Now, don't get me wrong. I am not advocating that we return to the bad old days when pain was seriously undertreated because we physicians harbored an irrational fear of creating drug addicts. Most of us, myself included, still have a lot to learn about the pharmacologic management of pain, particularly in patients with terminal illnesses.

I think, however, that we should all look more closely at nonpharmacologic solutions and try harder to understand why some patients appear to experience more pain than others. There must be genetic and biochemical components to these differences in pain tolerance, but in the last few decades it has become obvious to me that uncertainty and depression are two critical factors in making pain less tolerable. Fortunately, these are things that I as a physician can influence with a combination of clinical skills and medications that are not usually considered analgesics.

A few years ago, for example, a urologist had to rescue me from my own inattention. At one point, he explained to me that, over the next 8 hours, I would be experiencing what could be very painful bladder spasms. He described their cause and assured me that they would be temporary. He encouraged me to ask for pain medication, but he also mentioned that it might temporarily slow my recovery.

Comforted by his confident and detailed explanation of what I was going to experience, I elected not to take any medication. He was correct about everything, including the severity of the pain, but because of its spasmodic nature and because I knew what to expect, it was tolerable. In effect, my skilled physician had used his own version of the Lamaze technique to help him manage my pain.

Ever since that experience I have tried whenever practical to tell a patient as much about his or her pain as I can: what is causing it, how long it will last, and what we can do to ameliorate it. Over the last few years, my efforts to dispel uncertainty seem to have made a positive difference for many of my patients. Ferreting out and treating the depression component have been more difficult tasks than educating and reassuring, particularly when the pain appears acutely and the patient is a child I don't know very well. However, by at least considering the role of depression in my patients' diminished pain tolerance, I can often get us started on the path toward the correct long-term solution.

Fortunately, for Marilyn and me, by the time the lobsters are ready to eat, the discussion has usually drifted away from pain management. Then it's time for a short course in crustacean anatomy and how to find the succulent meat hidden inside those crimson shells.

If you have a minute—and I suggest that you not invest much more than a minute—turn to the commentary section in the back of the December 2005 issue of Pediatrics.

There you will find an article by a physical therapist, Margaret M. Plack, Ed.D., and a physician, Dr. Larrie Greenberg, titled “The Reflective Practitioner: Reaching for Excellence in Practice” (Pediatrics 2005;116:1546–52). It's pretty heavy stuff, full of words like “constitutive” and “contextualize.”

One sentence is 74 words long. One reference, they say, compares “good evidence to a DNA double helix.” Now there's an analogy that's guaranteed to clarify. It turns out that there are so many definitions of reflection that another pair of researchers felt the need to subject them to metaanalysis.

Don't worry, though, because I've done the heavy lifting for you. For some reason, as yet undetermined, I read the whole damn article and learned that “reflection is more than just stopping to think and act based on what we already know.” It turns out that, while you and I have been in the trenches promoting health, waging war against disease, and trying to stay out of the lawyers' crosshairs, someone slipped another cornerstone into the foundation of medical education. It's called reflection, and it's sitting right next to that other newcomer, evidence-based decision making.

Now, I may be oversimplifying what Dr. Plack and Dr. Greenberg have to say, but it sounds as though all of us at every level of pediatric training and practice should be taking the time to think about what we've been doing, why we've been doing it, and whether it makes sense to keep doing it. It's hard to argue with their rationale, but there is that bothersome little piece about the time.

Stimulated by my plunge into the cold and deep waters of educational erudition, a few nights ago I found myself feet up, favorite locally brewed beverage within reach, considering how I would reinvent medical education. Who knows, I may have been reflecting. I even may have been epiphanating. Whatever you choose to call my condition, it's clear I shouldn't have been operating heavy machinery or seeing patients.

So here are my thoughts. I would mandate that all college students considering a career in medicine major in one of the humanities. History, art, music, religion—you get the picture. My decision to major in art history is one I have never regretted.

During the summer, these premeds must have a real job, preferably one in which they must interact with or serve the public, or work shoulder to shoulder with people who haven't and aren't planning to go to college. I am continually disappointed to learn how many young physicians don't really understand the everyday microeconomic challenges faced by their patients. I am also troubled by how many physicians don't have a clue about basic rules of customer service that could be learned by working for any successful shopkeeper or restaurateur.

Once these future physicians are in medical school, I would encourage them to shadow a wide variety of doctors from many specialties. As often as possible, these visits should include sharing an evening meal in the physicians' homes so that the student could get a more multidimensional picture of a physician's life. These glimpses can be valuable aids in both career modeling and pitfall avoidance.

After postgraduate training has begun, I would encourage new physicians to see as many patients as they can. Hidden in the commentary on reflection was at least one kernel of truth: “Experience is at the core of learning in medical education.” We can ask a student to read, discuss, and reflect on a single case of scarlet fever until the cows come home, but that student is going to be a much more effective clinician once he or she has had the opportunity to see so many scarlatiniform rashes that the sight diagnosis becomes second nature.

Freed from the diagnostic fumbling that comes with inexperience, students can spend their time and energy exploring the nuances of how individual patients deal with disease. Familiarity with the commonplace makes sorting out the unusual much easier, but experience means seeing 15 patients with scarlet fever, looking at 2,000 tympanic membranes, and listening to a dozen depressed teenagers tell their stories.

The problem is that we're back to that troubling piece about time. Sufficient time for physicians in training to see enough patients is in short supply these days, particularly if we have decided that it is important to protect them from sleep deprivation. Fatigue or experience? Now there's a dilemma worthy of some deep reflection.

If you have a minute—and I suggest that you not invest much more than a minute—turn to the commentary section in the back of the December 2005 issue of Pediatrics.

There you will find an article by a physical therapist, Margaret M. Plack, Ed.D., and a physician, Dr. Larrie Greenberg, titled “The Reflective Practitioner: Reaching for Excellence in Practice” (Pediatrics 2005;116:1546–52). It's pretty heavy stuff, full of words like “constitutive” and “contextualize.”

One sentence is 74 words long. One reference, they say, compares “good evidence to a DNA double helix.” Now there's an analogy that's guaranteed to clarify. It turns out that there are so many definitions of reflection that another pair of researchers felt the need to subject them to metaanalysis.

Don't worry, though, because I've done the heavy lifting for you. For some reason, as yet undetermined, I read the whole damn article and learned that “reflection is more than just stopping to think and act based on what we already know.” It turns out that, while you and I have been in the trenches promoting health, waging war against disease, and trying to stay out of the lawyers' crosshairs, someone slipped another cornerstone into the foundation of medical education. It's called reflection, and it's sitting right next to that other newcomer, evidence-based decision making.

Now, I may be oversimplifying what Dr. Plack and Dr. Greenberg have to say, but it sounds as though all of us at every level of pediatric training and practice should be taking the time to think about what we've been doing, why we've been doing it, and whether it makes sense to keep doing it. It's hard to argue with their rationale, but there is that bothersome little piece about the time.

Stimulated by my plunge into the cold and deep waters of educational erudition, a few nights ago I found myself feet up, favorite locally brewed beverage within reach, considering how I would reinvent medical education. Who knows, I may have been reflecting. I even may have been epiphanating. Whatever you choose to call my condition, it's clear I shouldn't have been operating heavy machinery or seeing patients.

So here are my thoughts. I would mandate that all college students considering a career in medicine major in one of the humanities. History, art, music, religion—you get the picture. My decision to major in art history is one I have never regretted.

During the summer, these premeds must have a real job, preferably one in which they must interact with or serve the public, or work shoulder to shoulder with people who haven't and aren't planning to go to college. I am continually disappointed to learn how many young physicians don't really understand the everyday microeconomic challenges faced by their patients. I am also troubled by how many physicians don't have a clue about basic rules of customer service that could be learned by working for any successful shopkeeper or restaurateur.

Once these future physicians are in medical school, I would encourage them to shadow a wide variety of doctors from many specialties. As often as possible, these visits should include sharing an evening meal in the physicians' homes so that the student could get a more multidimensional picture of a physician's life. These glimpses can be valuable aids in both career modeling and pitfall avoidance.

After postgraduate training has begun, I would encourage new physicians to see as many patients as they can. Hidden in the commentary on reflection was at least one kernel of truth: “Experience is at the core of learning in medical education.” We can ask a student to read, discuss, and reflect on a single case of scarlet fever until the cows come home, but that student is going to be a much more effective clinician once he or she has had the opportunity to see so many scarlatiniform rashes that the sight diagnosis becomes second nature.

Freed from the diagnostic fumbling that comes with inexperience, students can spend their time and energy exploring the nuances of how individual patients deal with disease. Familiarity with the commonplace makes sorting out the unusual much easier, but experience means seeing 15 patients with scarlet fever, looking at 2,000 tympanic membranes, and listening to a dozen depressed teenagers tell their stories.

The problem is that we're back to that troubling piece about time. Sufficient time for physicians in training to see enough patients is in short supply these days, particularly if we have decided that it is important to protect them from sleep deprivation. Fatigue or experience? Now there's a dilemma worthy of some deep reflection.

If you have a minute—and I suggest that you not invest much more than a minute—turn to the commentary section in the back of the December 2005 issue of Pediatrics.

There you will find an article by a physical therapist, Margaret M. Plack, Ed.D., and a physician, Dr. Larrie Greenberg, titled “The Reflective Practitioner: Reaching for Excellence in Practice” (Pediatrics 2005;116:1546–52). It's pretty heavy stuff, full of words like “constitutive” and “contextualize.”

One sentence is 74 words long. One reference, they say, compares “good evidence to a DNA double helix.” Now there's an analogy that's guaranteed to clarify. It turns out that there are so many definitions of reflection that another pair of researchers felt the need to subject them to metaanalysis.

Don't worry, though, because I've done the heavy lifting for you. For some reason, as yet undetermined, I read the whole damn article and learned that “reflection is more than just stopping to think and act based on what we already know.” It turns out that, while you and I have been in the trenches promoting health, waging war against disease, and trying to stay out of the lawyers' crosshairs, someone slipped another cornerstone into the foundation of medical education. It's called reflection, and it's sitting right next to that other newcomer, evidence-based decision making.

Now, I may be oversimplifying what Dr. Plack and Dr. Greenberg have to say, but it sounds as though all of us at every level of pediatric training and practice should be taking the time to think about what we've been doing, why we've been doing it, and whether it makes sense to keep doing it. It's hard to argue with their rationale, but there is that bothersome little piece about the time.

Stimulated by my plunge into the cold and deep waters of educational erudition, a few nights ago I found myself feet up, favorite locally brewed beverage within reach, considering how I would reinvent medical education. Who knows, I may have been reflecting. I even may have been epiphanating. Whatever you choose to call my condition, it's clear I shouldn't have been operating heavy machinery or seeing patients.

So here are my thoughts. I would mandate that all college students considering a career in medicine major in one of the humanities. History, art, music, religion—you get the picture. My decision to major in art history is one I have never regretted.

During the summer, these premeds must have a real job, preferably one in which they must interact with or serve the public, or work shoulder to shoulder with people who haven't and aren't planning to go to college. I am continually disappointed to learn how many young physicians don't really understand the everyday microeconomic challenges faced by their patients. I am also troubled by how many physicians don't have a clue about basic rules of customer service that could be learned by working for any successful shopkeeper or restaurateur.

Once these future physicians are in medical school, I would encourage them to shadow a wide variety of doctors from many specialties. As often as possible, these visits should include sharing an evening meal in the physicians' homes so that the student could get a more multidimensional picture of a physician's life. These glimpses can be valuable aids in both career modeling and pitfall avoidance.

After postgraduate training has begun, I would encourage new physicians to see as many patients as they can. Hidden in the commentary on reflection was at least one kernel of truth: “Experience is at the core of learning in medical education.” We can ask a student to read, discuss, and reflect on a single case of scarlet fever until the cows come home, but that student is going to be a much more effective clinician once he or she has had the opportunity to see so many scarlatiniform rashes that the sight diagnosis becomes second nature.

Freed from the diagnostic fumbling that comes with inexperience, students can spend their time and energy exploring the nuances of how individual patients deal with disease. Familiarity with the commonplace makes sorting out the unusual much easier, but experience means seeing 15 patients with scarlet fever, looking at 2,000 tympanic membranes, and listening to a dozen depressed teenagers tell their stories.

The problem is that we're back to that troubling piece about time. Sufficient time for physicians in training to see enough patients is in short supply these days, particularly if we have decided that it is important to protect them from sleep deprivation. Fatigue or experience? Now there's a dilemma worthy of some deep reflection.

As I sit at the receptionist's desk, watching a heavy wet snow blanket the trees and shrubs in front of the office, I can tell by the unusually deliberate pace of the cars creeping out of the staff parking lot that the roads have gotten dangerously greasy. Those of us who live close enough to walk home are holding down the fort and answering the phones for another hour.

Despite the treacherous traveling conditions that have been worsening since lunchtime, the patients have continued to trickle in. Some have had earaches and sore throats, but some were healthy toddlers returning for their 3-week ear rechecks.

I have always been intrigued by the senseless irony of the psychological forces that keep patients at home when it's raining but drive them out onto snow-covered and ice-slicked highways like lemmings.

Even before SUVs replaced minivans as the suburban chariots of choice, many parents were seduced by the challenge of winter driving. When asked why they would risk life, limb, and vehicular damage to bring their child to the pediatrician for a trivial problem, I suspect that they would offer the traditional mountain climber's response—“Because it's there.”

I must admit that as a foolish young man I enjoyed charging out into the teeth of blizzards in my old VW Bug. I had nowhere to go, but doing donuts in vacant parking lots was a hoot. I was cured of this idiocy more than 20 years ago, when I was returning from my old office in a neighboring town and slid through an unplowed intersection at slow speed. The only patient I had seen that day was a healthy 3-year-old with a scheduled ear recheck.

The resulting fender bender only cost me $150 to settle, but that incident was the straw that pushed me to dissolve that partnership and open a solo office within walking distance of my home. If parents were going to persist in making stupid decisions about driving to see me, I could at least minimize the risks to my own health and property.

If all of the children's symptoms were trivial, I could solve the problem by closing the office when the first snowflake stuck to the pavement. Serious illness, though, doesn't pay attention to storm alerts, and some of the phone calls that come during a burst of severe weather can tax my decision-making skills to the limit.

In these situations, I follow the same credo as most pediatricians: When in doubt, have the patient come in to be examined. Of course, this means that some days, most of the children I have encouraged to make the trek across town are just a little bit sick, if they are even ill at all.

Discouraging visits risks professional suicide. Even with 30 years of interviewing experience and intuition sharpening, I still encounter children for whom my telephone assessment has significantly underestimated the severity of their illnesses. In an attempt to prevent the disastrous consequences of the “seriously-ill-child-not-seen syndrome,” we have an open-door policy. The current buzz words are “open access.”

In good weather there is little downside to this approach, but when there are 2 inches of slick, hard-packed snow on the roads, one must consider whether the trip to the office is more dangerous for the child than the symptoms that his parents have just described to you. When I decide to have the child come to the office in a snowstorm, I don't rest comfortably until I'm sure he is safely tucked into a bed, whether it be back in his own bedroom or on the pediatric floor at the hospital.

As I sit at the receptionist's desk, watching a heavy wet snow blanket the trees and shrubs in front of the office, I can tell by the unusually deliberate pace of the cars creeping out of the staff parking lot that the roads have gotten dangerously greasy. Those of us who live close enough to walk home are holding down the fort and answering the phones for another hour.

Despite the treacherous traveling conditions that have been worsening since lunchtime, the patients have continued to trickle in. Some have had earaches and sore throats, but some were healthy toddlers returning for their 3-week ear rechecks.

I have always been intrigued by the senseless irony of the psychological forces that keep patients at home when it's raining but drive them out onto snow-covered and ice-slicked highways like lemmings.

Even before SUVs replaced minivans as the suburban chariots of choice, many parents were seduced by the challenge of winter driving. When asked why they would risk life, limb, and vehicular damage to bring their child to the pediatrician for a trivial problem, I suspect that they would offer the traditional mountain climber's response—“Because it's there.”

I must admit that as a foolish young man I enjoyed charging out into the teeth of blizzards in my old VW Bug. I had nowhere to go, but doing donuts in vacant parking lots was a hoot. I was cured of this idiocy more than 20 years ago, when I was returning from my old office in a neighboring town and slid through an unplowed intersection at slow speed. The only patient I had seen that day was a healthy 3-year-old with a scheduled ear recheck.

The resulting fender bender only cost me $150 to settle, but that incident was the straw that pushed me to dissolve that partnership and open a solo office within walking distance of my home. If parents were going to persist in making stupid decisions about driving to see me, I could at least minimize the risks to my own health and property.

If all of the children's symptoms were trivial, I could solve the problem by closing the office when the first snowflake stuck to the pavement. Serious illness, though, doesn't pay attention to storm alerts, and some of the phone calls that come during a burst of severe weather can tax my decision-making skills to the limit.

In these situations, I follow the same credo as most pediatricians: When in doubt, have the patient come in to be examined. Of course, this means that some days, most of the children I have encouraged to make the trek across town are just a little bit sick, if they are even ill at all.

Discouraging visits risks professional suicide. Even with 30 years of interviewing experience and intuition sharpening, I still encounter children for whom my telephone assessment has significantly underestimated the severity of their illnesses. In an attempt to prevent the disastrous consequences of the “seriously-ill-child-not-seen syndrome,” we have an open-door policy. The current buzz words are “open access.”

In good weather there is little downside to this approach, but when there are 2 inches of slick, hard-packed snow on the roads, one must consider whether the trip to the office is more dangerous for the child than the symptoms that his parents have just described to you. When I decide to have the child come to the office in a snowstorm, I don't rest comfortably until I'm sure he is safely tucked into a bed, whether it be back in his own bedroom or on the pediatric floor at the hospital.

As I sit at the receptionist's desk, watching a heavy wet snow blanket the trees and shrubs in front of the office, I can tell by the unusually deliberate pace of the cars creeping out of the staff parking lot that the roads have gotten dangerously greasy. Those of us who live close enough to walk home are holding down the fort and answering the phones for another hour.

Despite the treacherous traveling conditions that have been worsening since lunchtime, the patients have continued to trickle in. Some have had earaches and sore throats, but some were healthy toddlers returning for their 3-week ear rechecks.

I have always been intrigued by the senseless irony of the psychological forces that keep patients at home when it's raining but drive them out onto snow-covered and ice-slicked highways like lemmings.

Even before SUVs replaced minivans as the suburban chariots of choice, many parents were seduced by the challenge of winter driving. When asked why they would risk life, limb, and vehicular damage to bring their child to the pediatrician for a trivial problem, I suspect that they would offer the traditional mountain climber's response—“Because it's there.”

I must admit that as a foolish young man I enjoyed charging out into the teeth of blizzards in my old VW Bug. I had nowhere to go, but doing donuts in vacant parking lots was a hoot. I was cured of this idiocy more than 20 years ago, when I was returning from my old office in a neighboring town and slid through an unplowed intersection at slow speed. The only patient I had seen that day was a healthy 3-year-old with a scheduled ear recheck.

The resulting fender bender only cost me $150 to settle, but that incident was the straw that pushed me to dissolve that partnership and open a solo office within walking distance of my home. If parents were going to persist in making stupid decisions about driving to see me, I could at least minimize the risks to my own health and property.

If all of the children's symptoms were trivial, I could solve the problem by closing the office when the first snowflake stuck to the pavement. Serious illness, though, doesn't pay attention to storm alerts, and some of the phone calls that come during a burst of severe weather can tax my decision-making skills to the limit.

In these situations, I follow the same credo as most pediatricians: When in doubt, have the patient come in to be examined. Of course, this means that some days, most of the children I have encouraged to make the trek across town are just a little bit sick, if they are even ill at all.

Discouraging visits risks professional suicide. Even with 30 years of interviewing experience and intuition sharpening, I still encounter children for whom my telephone assessment has significantly underestimated the severity of their illnesses. In an attempt to prevent the disastrous consequences of the “seriously-ill-child-not-seen syndrome,” we have an open-door policy. The current buzz words are “open access.”

In good weather there is little downside to this approach, but when there are 2 inches of slick, hard-packed snow on the roads, one must consider whether the trip to the office is more dangerous for the child than the symptoms that his parents have just described to you. When I decide to have the child come to the office in a snowstorm, I don't rest comfortably until I'm sure he is safely tucked into a bed, whether it be back in his own bedroom or on the pediatric floor at the hospital.

One of the things that I enjoy most about practicing in semirural, subsuburban Maine is that it allows me the privilege of caring for children representing the entire socioeconomic spectrum. I may begin the morning peering into the sore throat of the daughter of a former governor and finish the day by putting a cast on the son of an underemployed bloodworm digger.

There are four pediatric groups here in Brunswick and, although my partners and I may quietly feel we provide the best care in town, the truth is that no practice is considered the office to visit by the economically blessed elite. Nor is any group thought to be on the wrong side of the tracks.

This diversity is intellectually stimulating and keeps us on our diagnostic toes. It also gives us the warm fuzzy feeling of being community servants. That fuzziness comes with a price, though, because it is no secret that state-funded reimbursement often falls short of our costs. The unfortunate families who have slipped into the cracks between private and public funding present an even more troubling challenge.

As you can imagine, this situation has not gone unnoticed by our CEO, who sends us regular e-mail reminders that our patient mix is getting too heavy on the Medicaid side. We tend to ignore his warnings because we all enjoy seeing infants and the bulk of the new babies seem to be coming from underfunded families.

When pressed to close my practice to Medicaid families, I have been able to negotiate a temporary compromise that limits new patients to those residing in Brunswick and any town that abuts us.

I imagine myself to be a new-millennium Robin Hood, venturing deep into the Sherwood Forest of community pediatrics bent on robbing Peter to pay Paul. By trying to provide the same high-quality care to every patient in the most cost-effective manner, I hope that the occasional overpayment by some third parties will offset the underfunding by the rest.

Those of you who still remember enough high school math to do your own taxes may fault my economic logic, but so far it works for me and allows me to continue seeing the exciting mix of patients that I enjoy.

What doesn't work for me is the concept of concierge care that was the focus of a recent PEDIATRIC NEWS article (“Concierge Care Gives Time for Kids,” September 2005, p. 1). This is a free country, and any of us can carve out a high-end economic niche if we choose to, but the notion of skimming off the rich cream of economically advantaged families troubles me.

The standard of care for outpatient pediatrics demands availability—availability that cuts across socioeconomic strata. Regardless of who funds their care, at 10 o'clock at night all patients registered in our practice will have the same access to me or my fellow pediatricians in the community. As I interpret concierge care, it ducks this challenge of providing quality pediatric care to all children of the community.

It smacks of elitism, and I suspect that, because of its narrow scope, concierge care actually fails to provide the quality and availability that it promises and that my partners and I offer without surcharge. We don't ask our patients' parents to sign a contract that includes coverage gaps for our vacations.

We encourage families to develop a close working relationship with one physician, but my partners and I work very hard to create as seamless a coverage arrangement as possible. This means maintaining close communication with each other and trying to standardize our care without shackling our unique clinical personalities.

I'm confident that the majority of families here in Brunswick will say that our system works. Concierge care, on the other hand, serves neither the community nor the subgroup it has isolated. In my view, it robs both Peter and Paul.

One of the things that I enjoy most about practicing in semirural, subsuburban Maine is that it allows me the privilege of caring for children representing the entire socioeconomic spectrum. I may begin the morning peering into the sore throat of the daughter of a former governor and finish the day by putting a cast on the son of an underemployed bloodworm digger.

There are four pediatric groups here in Brunswick and, although my partners and I may quietly feel we provide the best care in town, the truth is that no practice is considered the office to visit by the economically blessed elite. Nor is any group thought to be on the wrong side of the tracks.

This diversity is intellectually stimulating and keeps us on our diagnostic toes. It also gives us the warm fuzzy feeling of being community servants. That fuzziness comes with a price, though, because it is no secret that state-funded reimbursement often falls short of our costs. The unfortunate families who have slipped into the cracks between private and public funding present an even more troubling challenge.

As you can imagine, this situation has not gone unnoticed by our CEO, who sends us regular e-mail reminders that our patient mix is getting too heavy on the Medicaid side. We tend to ignore his warnings because we all enjoy seeing infants and the bulk of the new babies seem to be coming from underfunded families.

When pressed to close my practice to Medicaid families, I have been able to negotiate a temporary compromise that limits new patients to those residing in Brunswick and any town that abuts us.

I imagine myself to be a new-millennium Robin Hood, venturing deep into the Sherwood Forest of community pediatrics bent on robbing Peter to pay Paul. By trying to provide the same high-quality care to every patient in the most cost-effective manner, I hope that the occasional overpayment by some third parties will offset the underfunding by the rest.

Those of you who still remember enough high school math to do your own taxes may fault my economic logic, but so far it works for me and allows me to continue seeing the exciting mix of patients that I enjoy.

What doesn't work for me is the concept of concierge care that was the focus of a recent PEDIATRIC NEWS article (“Concierge Care Gives Time for Kids,” September 2005, p. 1). This is a free country, and any of us can carve out a high-end economic niche if we choose to, but the notion of skimming off the rich cream of economically advantaged families troubles me.

The standard of care for outpatient pediatrics demands availability—availability that cuts across socioeconomic strata. Regardless of who funds their care, at 10 o'clock at night all patients registered in our practice will have the same access to me or my fellow pediatricians in the community. As I interpret concierge care, it ducks this challenge of providing quality pediatric care to all children of the community.

It smacks of elitism, and I suspect that, because of its narrow scope, concierge care actually fails to provide the quality and availability that it promises and that my partners and I offer without surcharge. We don't ask our patients' parents to sign a contract that includes coverage gaps for our vacations.

We encourage families to develop a close working relationship with one physician, but my partners and I work very hard to create as seamless a coverage arrangement as possible. This means maintaining close communication with each other and trying to standardize our care without shackling our unique clinical personalities.

I'm confident that the majority of families here in Brunswick will say that our system works. Concierge care, on the other hand, serves neither the community nor the subgroup it has isolated. In my view, it robs both Peter and Paul.

One of the things that I enjoy most about practicing in semirural, subsuburban Maine is that it allows me the privilege of caring for children representing the entire socioeconomic spectrum. I may begin the morning peering into the sore throat of the daughter of a former governor and finish the day by putting a cast on the son of an underemployed bloodworm digger.

There are four pediatric groups here in Brunswick and, although my partners and I may quietly feel we provide the best care in town, the truth is that no practice is considered the office to visit by the economically blessed elite. Nor is any group thought to be on the wrong side of the tracks.

This diversity is intellectually stimulating and keeps us on our diagnostic toes. It also gives us the warm fuzzy feeling of being community servants. That fuzziness comes with a price, though, because it is no secret that state-funded reimbursement often falls short of our costs. The unfortunate families who have slipped into the cracks between private and public funding present an even more troubling challenge.

As you can imagine, this situation has not gone unnoticed by our CEO, who sends us regular e-mail reminders that our patient mix is getting too heavy on the Medicaid side. We tend to ignore his warnings because we all enjoy seeing infants and the bulk of the new babies seem to be coming from underfunded families.

When pressed to close my practice to Medicaid families, I have been able to negotiate a temporary compromise that limits new patients to those residing in Brunswick and any town that abuts us.

I imagine myself to be a new-millennium Robin Hood, venturing deep into the Sherwood Forest of community pediatrics bent on robbing Peter to pay Paul. By trying to provide the same high-quality care to every patient in the most cost-effective manner, I hope that the occasional overpayment by some third parties will offset the underfunding by the rest.

Those of you who still remember enough high school math to do your own taxes may fault my economic logic, but so far it works for me and allows me to continue seeing the exciting mix of patients that I enjoy.

What doesn't work for me is the concept of concierge care that was the focus of a recent PEDIATRIC NEWS article (“Concierge Care Gives Time for Kids,” September 2005, p. 1). This is a free country, and any of us can carve out a high-end economic niche if we choose to, but the notion of skimming off the rich cream of economically advantaged families troubles me.

The standard of care for outpatient pediatrics demands availability—availability that cuts across socioeconomic strata. Regardless of who funds their care, at 10 o'clock at night all patients registered in our practice will have the same access to me or my fellow pediatricians in the community. As I interpret concierge care, it ducks this challenge of providing quality pediatric care to all children of the community.

It smacks of elitism, and I suspect that, because of its narrow scope, concierge care actually fails to provide the quality and availability that it promises and that my partners and I offer without surcharge. We don't ask our patients' parents to sign a contract that includes coverage gaps for our vacations.

We encourage families to develop a close working relationship with one physician, but my partners and I work very hard to create as seamless a coverage arrangement as possible. This means maintaining close communication with each other and trying to standardize our care without shackling our unique clinical personalities.

I'm confident that the majority of families here in Brunswick will say that our system works. Concierge care, on the other hand, serves neither the community nor the subgroup it has isolated. In my view, it robs both Peter and Paul.

Honey, I heard a heart murmur this morning!” I'm sure that every year hundreds of first-year medical students share this educational revelation with their spouses and significant others, but when a 60-year-old pediatrician is tempted to e-mail the same message to his wife, one has to wonder.

When I was a medical student, I struggled to hear the bruits that my instructors were waxing so eloquently about. As a house officer, I delighted in hearing murmurs that my peers had missed, and in my first few years of practice, it seemed as though every third or fourth patient had a cardiac sound worthy of comment.

Over the last 20 years, though, heart murmurs have silently crept onto my list of endangered physical findings. Thinking back over the last 2 days, I can't recall recording a single murmur on one of my patient's charts. During a quiet moment I pondered the possible causes for this threatened extinction.

My first thought was that I wasn't discovering as many murmurs because age has clearly taken a heavy toll on my hearing. This may be true to some extent, but my relative deafness doesn't explain why my two younger partners aren't documenting any more murmurs than I am. Furthermore, I think I still continue to hear rales, rhonchi, and diminished breath sounds in the appropriate situations, and my patients haven't suffered from an unusual number of auscultatory oversights.

Could it be that heart murmurs have simply joined nephrotic syndrome, observation hip, epiglottitis, and bacterial meningitis on the list of rarities in my pediatric neighborhood? Since murmurs can be caused by a wide variety of anatomic variations, I find this explanation untenable.

Prenatal diagnosis of congenital heart disease certainly has siphoned off most of the clinically significant murmurs to the cardiologists and surgeons before they get to my office, but the bulk of the murmurs I was noticing a generation ago were benign flow murmurs that, by definition, were insignificant.

Therein, I think, lies the critical clue to the mystery of the missing murmurs. It doesn't take very many years of barking up empty trees before one's definition of normal broadens to the point that physical findings that once appeared as bright blips on the radar screen fade into the background static.

There are also significant disincentives to acknowledging the presence of a benign flow murmur.

In the interest of complete disclosure, I used to compulsively share my observations with parents, but explaining the difference between “slightly out of the ordinary” and abnormal was time consuming and sometimes so unnerving that I would have to do a cardiogram to quell the fires of anxiety I had kindled with my good intentions. There were also the scores of phone calls from dentists' offices wanting to know if our mutual, inadequately informed patient with a benign flow murmur needed antibiotic coverage.

There is one more possible explanation. Like most physicians, I do the chest auscultation at the beginning of my exam, so an insignificant murmur often gets forgotten or pushed off the agenda by other findings or questions by the time I scribble my office notes. As our friends in the risk management business tell us: If it wasn't documented, it didn't exist.

So there you have it. Like the ivory-billed woodpecker, cardiac murmurs have not gone extinct. They still lurk in the dark swampy recesses of our subconscious, occasionally swooping out to surprise us when we decide to pay attention.

Honey, I heard a heart murmur this morning!” I'm sure that every year hundreds of first-year medical students share this educational revelation with their spouses and significant others, but when a 60-year-old pediatrician is tempted to e-mail the same message to his wife, one has to wonder.

When I was a medical student, I struggled to hear the bruits that my instructors were waxing so eloquently about. As a house officer, I delighted in hearing murmurs that my peers had missed, and in my first few years of practice, it seemed as though every third or fourth patient had a cardiac sound worthy of comment.

Over the last 20 years, though, heart murmurs have silently crept onto my list of endangered physical findings. Thinking back over the last 2 days, I can't recall recording a single murmur on one of my patient's charts. During a quiet moment I pondered the possible causes for this threatened extinction.

My first thought was that I wasn't discovering as many murmurs because age has clearly taken a heavy toll on my hearing. This may be true to some extent, but my relative deafness doesn't explain why my two younger partners aren't documenting any more murmurs than I am. Furthermore, I think I still continue to hear rales, rhonchi, and diminished breath sounds in the appropriate situations, and my patients haven't suffered from an unusual number of auscultatory oversights.

Could it be that heart murmurs have simply joined nephrotic syndrome, observation hip, epiglottitis, and bacterial meningitis on the list of rarities in my pediatric neighborhood? Since murmurs can be caused by a wide variety of anatomic variations, I find this explanation untenable.

Prenatal diagnosis of congenital heart disease certainly has siphoned off most of the clinically significant murmurs to the cardiologists and surgeons before they get to my office, but the bulk of the murmurs I was noticing a generation ago were benign flow murmurs that, by definition, were insignificant.

Therein, I think, lies the critical clue to the mystery of the missing murmurs. It doesn't take very many years of barking up empty trees before one's definition of normal broadens to the point that physical findings that once appeared as bright blips on the radar screen fade into the background static.

There are also significant disincentives to acknowledging the presence of a benign flow murmur.

In the interest of complete disclosure, I used to compulsively share my observations with parents, but explaining the difference between “slightly out of the ordinary” and abnormal was time consuming and sometimes so unnerving that I would have to do a cardiogram to quell the fires of anxiety I had kindled with my good intentions. There were also the scores of phone calls from dentists' offices wanting to know if our mutual, inadequately informed patient with a benign flow murmur needed antibiotic coverage.

There is one more possible explanation. Like most physicians, I do the chest auscultation at the beginning of my exam, so an insignificant murmur often gets forgotten or pushed off the agenda by other findings or questions by the time I scribble my office notes. As our friends in the risk management business tell us: If it wasn't documented, it didn't exist.

So there you have it. Like the ivory-billed woodpecker, cardiac murmurs have not gone extinct. They still lurk in the dark swampy recesses of our subconscious, occasionally swooping out to surprise us when we decide to pay attention.

Honey, I heard a heart murmur this morning!” I'm sure that every year hundreds of first-year medical students share this educational revelation with their spouses and significant others, but when a 60-year-old pediatrician is tempted to e-mail the same message to his wife, one has to wonder.

When I was a medical student, I struggled to hear the bruits that my instructors were waxing so eloquently about. As a house officer, I delighted in hearing murmurs that my peers had missed, and in my first few years of practice, it seemed as though every third or fourth patient had a cardiac sound worthy of comment.

Over the last 20 years, though, heart murmurs have silently crept onto my list of endangered physical findings. Thinking back over the last 2 days, I can't recall recording a single murmur on one of my patient's charts. During a quiet moment I pondered the possible causes for this threatened extinction.

My first thought was that I wasn't discovering as many murmurs because age has clearly taken a heavy toll on my hearing. This may be true to some extent, but my relative deafness doesn't explain why my two younger partners aren't documenting any more murmurs than I am. Furthermore, I think I still continue to hear rales, rhonchi, and diminished breath sounds in the appropriate situations, and my patients haven't suffered from an unusual number of auscultatory oversights.

Could it be that heart murmurs have simply joined nephrotic syndrome, observation hip, epiglottitis, and bacterial meningitis on the list of rarities in my pediatric neighborhood? Since murmurs can be caused by a wide variety of anatomic variations, I find this explanation untenable.

Prenatal diagnosis of congenital heart disease certainly has siphoned off most of the clinically significant murmurs to the cardiologists and surgeons before they get to my office, but the bulk of the murmurs I was noticing a generation ago were benign flow murmurs that, by definition, were insignificant.

Therein, I think, lies the critical clue to the mystery of the missing murmurs. It doesn't take very many years of barking up empty trees before one's definition of normal broadens to the point that physical findings that once appeared as bright blips on the radar screen fade into the background static.

There are also significant disincentives to acknowledging the presence of a benign flow murmur.

In the interest of complete disclosure, I used to compulsively share my observations with parents, but explaining the difference between “slightly out of the ordinary” and abnormal was time consuming and sometimes so unnerving that I would have to do a cardiogram to quell the fires of anxiety I had kindled with my good intentions. There were also the scores of phone calls from dentists' offices wanting to know if our mutual, inadequately informed patient with a benign flow murmur needed antibiotic coverage.

There is one more possible explanation. Like most physicians, I do the chest auscultation at the beginning of my exam, so an insignificant murmur often gets forgotten or pushed off the agenda by other findings or questions by the time I scribble my office notes. As our friends in the risk management business tell us: If it wasn't documented, it didn't exist.

So there you have it. Like the ivory-billed woodpecker, cardiac murmurs have not gone extinct. They still lurk in the dark swampy recesses of our subconscious, occasionally swooping out to surprise us when we decide to pay attention.

Since we first met when I was in high school, Will Shakespeare and I have never been what you would call close. From time to time, though, I bump into an observation of his that suits my mood. One such passage, I'm told, comes from Macbeth:

Sleep that knits up the raveled sleave of care, The death of each day's life, sore labour's bath, Balm of hurt minds, great nature's second course, Chief nourisher in life's feast.

Like the presidential candidate who had to keep reminding himself that it was the economy that concerned the voters, we pediatricians should continually remind ourselves that sleep deserves a spot at the top of our priority lists. And I'm not talking about getting house officers more sleep-friendly schedules or about building barricades of algorithms with which nurses can shield us from worried parents in the middle of the night. I'm urging that we acknowledge that sleep deprivation is the cause of many of our patients' complaints and problems.

Homo sapiens are not a nocturnal species, as witnessed by the fact that we have poor night vision, but since the opening of the first 'round-the-clock power plant in New York City in 1882 we have been artificially pushing back the night and eroding our opportunities for restorative sleep. A poll by the National Sleep Foundation found that adult Americans are now averaging 6.8 hours of sleep on week nights, which is more than an hour less than most sleep experts believe we need.

Quoted in an article in Harvard Magazine, Dr. Robert Stickgold, a cognitive neuroscientist specializing in sleep research at Harvard University said, “We are living in the middle of history's greatest experiment in sleep deprivation. … It's not inconceivable to me that we will discover that there are major social, economic, and health consequences to that experiment” (“Deep into Sleep,” July-August 2005;107:25–33; available online at www.harvardmagazine.com/on-line/070587.html

A sleep researcher at the University of Chicago discovered that sleep-deprived students produce half the number of antibodies in response to a viral challenge in the form of a flu vaccine. I'm not sure where she found a control group of well-rested college students, but I'm not surprised by her data.

The same sleep-deprived subjects also had evidence of insulin resistance and reduced levels of leptin, an endogenous appetite inhibitor. It makes one wonder how much of our obesity problem and the emergence of metabolic syndrome in children may be the result of sleep deprivation.

Hyperactivity, irritability, and reduced attention span are all symptoms of sleep deprivation.

We shouldn't be surprised that stimulant medications have become so popular with parents and educators. An improvement in a student's performance when he starts taking amphetamines doesn't necessarily mean that medication was the best first choice.

Not wanting to get out of bed in the morning can be a symptom of depression, but depression is also a major symptom of sleep deprivation.

This can be a difficult chicken-and-egg situation to sort out, but, again, it makes me suspect that some of the surge in mental illness that I have witnessed during the last 30 years is the result of our inability to create and enforce sleep-friendly schedules for ourselves and our children.

In my experience, nocturnal and late-day leg pains—the kind that were once incorrectly labeled “growing pains”—are clearly the result of sleep deprivation. The same is true of migraine headaches and cyclic vomiting. So far, I have never had to prescribe Imitrex (sumatriptan) because an aggressive approach to sleep and lifestyle management has always succeeded in those families who have made a serious effort to change the way they spend their days and nights.

It hasn't been easy for them, though. The erosion of our sleep has been so insidious that most parents don't realize that their families' schedules are providing insufficient opportunity for sleep.

School administrators and the organizers of extracurricular activities often seem oblivious to the situation and think nothing of scheduling activities, games, and practices at an hour that makes it impossible for children to get an adequate night's sleep (and a meal with their families).

Those of you who are regular readers of these epistles know that sleep deprivation is one of my favorite bandwagons. But the recent data about sleep-deprived metabolic syndrome and the relationship between sleep deprivation and immunity have prompted me to issue another reminder that we pediatricians should be taking thorough sleep histories and advocating for more sleep-friendly schedules for our young patients.

Since we first met when I was in high school, Will Shakespeare and I have never been what you would call close. From time to time, though, I bump into an observation of his that suits my mood. One such passage, I'm told, comes from Macbeth:

Sleep that knits up the raveled sleave of care, The death of each day's life, sore labour's bath, Balm of hurt minds, great nature's second course, Chief nourisher in life's feast.

Like the presidential candidate who had to keep reminding himself that it was the economy that concerned the voters, we pediatricians should continually remind ourselves that sleep deserves a spot at the top of our priority lists. And I'm not talking about getting house officers more sleep-friendly schedules or about building barricades of algorithms with which nurses can shield us from worried parents in the middle of the night. I'm urging that we acknowledge that sleep deprivation is the cause of many of our patients' complaints and problems.

Homo sapiens are not a nocturnal species, as witnessed by the fact that we have poor night vision, but since the opening of the first 'round-the-clock power plant in New York City in 1882 we have been artificially pushing back the night and eroding our opportunities for restorative sleep. A poll by the National Sleep Foundation found that adult Americans are now averaging 6.8 hours of sleep on week nights, which is more than an hour less than most sleep experts believe we need.

Quoted in an article in Harvard Magazine, Dr. Robert Stickgold, a cognitive neuroscientist specializing in sleep research at Harvard University said, “We are living in the middle of history's greatest experiment in sleep deprivation. … It's not inconceivable to me that we will discover that there are major social, economic, and health consequences to that experiment” (“Deep into Sleep,” July-August 2005;107:25–33; available online at www.harvardmagazine.com/on-line/070587.html

A sleep researcher at the University of Chicago discovered that sleep-deprived students produce half the number of antibodies in response to a viral challenge in the form of a flu vaccine. I'm not sure where she found a control group of well-rested college students, but I'm not surprised by her data.

The same sleep-deprived subjects also had evidence of insulin resistance and reduced levels of leptin, an endogenous appetite inhibitor. It makes one wonder how much of our obesity problem and the emergence of metabolic syndrome in children may be the result of sleep deprivation.

Hyperactivity, irritability, and reduced attention span are all symptoms of sleep deprivation.

We shouldn't be surprised that stimulant medications have become so popular with parents and educators. An improvement in a student's performance when he starts taking amphetamines doesn't necessarily mean that medication was the best first choice.

Not wanting to get out of bed in the morning can be a symptom of depression, but depression is also a major symptom of sleep deprivation.

This can be a difficult chicken-and-egg situation to sort out, but, again, it makes me suspect that some of the surge in mental illness that I have witnessed during the last 30 years is the result of our inability to create and enforce sleep-friendly schedules for ourselves and our children.

In my experience, nocturnal and late-day leg pains—the kind that were once incorrectly labeled “growing pains”—are clearly the result of sleep deprivation. The same is true of migraine headaches and cyclic vomiting. So far, I have never had to prescribe Imitrex (sumatriptan) because an aggressive approach to sleep and lifestyle management has always succeeded in those families who have made a serious effort to change the way they spend their days and nights.

It hasn't been easy for them, though. The erosion of our sleep has been so insidious that most parents don't realize that their families' schedules are providing insufficient opportunity for sleep.

School administrators and the organizers of extracurricular activities often seem oblivious to the situation and think nothing of scheduling activities, games, and practices at an hour that makes it impossible for children to get an adequate night's sleep (and a meal with their families).

Those of you who are regular readers of these epistles know that sleep deprivation is one of my favorite bandwagons. But the recent data about sleep-deprived metabolic syndrome and the relationship between sleep deprivation and immunity have prompted me to issue another reminder that we pediatricians should be taking thorough sleep histories and advocating for more sleep-friendly schedules for our young patients.

Since we first met when I was in high school, Will Shakespeare and I have never been what you would call close. From time to time, though, I bump into an observation of his that suits my mood. One such passage, I'm told, comes from Macbeth:

Sleep that knits up the raveled sleave of care, The death of each day's life, sore labour's bath, Balm of hurt minds, great nature's second course, Chief nourisher in life's feast.

Like the presidential candidate who had to keep reminding himself that it was the economy that concerned the voters, we pediatricians should continually remind ourselves that sleep deserves a spot at the top of our priority lists. And I'm not talking about getting house officers more sleep-friendly schedules or about building barricades of algorithms with which nurses can shield us from worried parents in the middle of the night. I'm urging that we acknowledge that sleep deprivation is the cause of many of our patients' complaints and problems.

Homo sapiens are not a nocturnal species, as witnessed by the fact that we have poor night vision, but since the opening of the first 'round-the-clock power plant in New York City in 1882 we have been artificially pushing back the night and eroding our opportunities for restorative sleep. A poll by the National Sleep Foundation found that adult Americans are now averaging 6.8 hours of sleep on week nights, which is more than an hour less than most sleep experts believe we need.

Quoted in an article in Harvard Magazine, Dr. Robert Stickgold, a cognitive neuroscientist specializing in sleep research at Harvard University said, “We are living in the middle of history's greatest experiment in sleep deprivation. … It's not inconceivable to me that we will discover that there are major social, economic, and health consequences to that experiment” (“Deep into Sleep,” July-August 2005;107:25–33; available online at www.harvardmagazine.com/on-line/070587.html

A sleep researcher at the University of Chicago discovered that sleep-deprived students produce half the number of antibodies in response to a viral challenge in the form of a flu vaccine. I'm not sure where she found a control group of well-rested college students, but I'm not surprised by her data.

The same sleep-deprived subjects also had evidence of insulin resistance and reduced levels of leptin, an endogenous appetite inhibitor. It makes one wonder how much of our obesity problem and the emergence of metabolic syndrome in children may be the result of sleep deprivation.

Hyperactivity, irritability, and reduced attention span are all symptoms of sleep deprivation.

We shouldn't be surprised that stimulant medications have become so popular with parents and educators. An improvement in a student's performance when he starts taking amphetamines doesn't necessarily mean that medication was the best first choice.

Not wanting to get out of bed in the morning can be a symptom of depression, but depression is also a major symptom of sleep deprivation.

This can be a difficult chicken-and-egg situation to sort out, but, again, it makes me suspect that some of the surge in mental illness that I have witnessed during the last 30 years is the result of our inability to create and enforce sleep-friendly schedules for ourselves and our children.

In my experience, nocturnal and late-day leg pains—the kind that were once incorrectly labeled “growing pains”—are clearly the result of sleep deprivation. The same is true of migraine headaches and cyclic vomiting. So far, I have never had to prescribe Imitrex (sumatriptan) because an aggressive approach to sleep and lifestyle management has always succeeded in those families who have made a serious effort to change the way they spend their days and nights.

It hasn't been easy for them, though. The erosion of our sleep has been so insidious that most parents don't realize that their families' schedules are providing insufficient opportunity for sleep.

School administrators and the organizers of extracurricular activities often seem oblivious to the situation and think nothing of scheduling activities, games, and practices at an hour that makes it impossible for children to get an adequate night's sleep (and a meal with their families).

Those of you who are regular readers of these epistles know that sleep deprivation is one of my favorite bandwagons. But the recent data about sleep-deprived metabolic syndrome and the relationship between sleep deprivation and immunity have prompted me to issue another reminder that we pediatricians should be taking thorough sleep histories and advocating for more sleep-friendly schedules for our young patients.

It is quite unsettling enough to hear a physician exclaim, “We've never seen a case like this before,” but when the surgeon you've known for more than 2 decades is talking about your 2-kg, not-quite-33-week-gestational-age granddaughter, it's frightening.

Little Hannah Margaret's entry into the world had begun to get complicated when her mother developed massive polyhydramnios and an ultrasound suggested that the baby's stomach was enlarged. We knew that something might not be quite right with her GI tract, but we were relieved when the neonatologist could pass a tube easily into her stomach. We were even more relieved when a limited-contrast study demonstrated continuity well into her small bowel. But continuity is a relative thing, and it became clear that her stomach did not empty normally.

At endoscopy, the antral region of her stomach was swollen and inflamed, and the gastroenterologist could not enter or even adequately visualize the pylorus. Trying hard to be the silent and supportive grandparent, I listened patiently as the pediatric surgeon at our tertiary care medical center outlined for my son the options for dealing with what he suspected was a very rare antral web. Unclear exactly what would be found until they opened her abdomen, he couldn't predict what procedure they would perform, but there was a high likelihood that little Hannah would be left with a dysfunctional pylorus.

When I sensed that my son had asked all his questions, I asked in my most naive voice if there was any chance that this outlet obstruction could be dealt with endoscopically. The answer was no.

Because of some scheduling issues, we had several days to prepare ourselves emotionally for the surgery. For 30 years I had relied on the magical skills and astute decision making of these same pediatric surgeons to rescue my patients from a broad range of congenital anomalies and anatomic misadventures. However, the plan that they outlined for my own granddaughter made me very uncomfortable. The rarity of her condition and, hence, their inexperience, was unsettling.

But what was the best way to act on my concerns without seeming to be a meddling grandfather who felt that the surgical expertise that had been just fine for his patients for 30 years was not good enough for his own granddaughter?

Not wanting to disturb my son's confidence in the care his daughter was receiving, I decided to do my research under cover. I began by bouncing the scenario off my partner, who would eventually become Hannah's physician. I then spoke to a pediatric gastroenterologist in Boston with whom I have shared patients since my residency. Both physicians supported my concerns and were, in fact, more troubled than I was about the proposed plan.

But when it came time for me to suggest a second opinion to my son and his wife, I was hesitant because I didn't want to offend the people who had been my go-to guys for more than 3 decades.

Even though I know it is often in the best interest of the patient, maybe only because it will give the parents peace of mind, I don't like it when families question my diagnosis or therapeutic plan and ask for a second opinion. Many times they have sensed my own poorly disguised discomfort with the situation—the cases in which I'm planning to recommend another physician if things don't improve by the next office visit—and beaten me to the punch.

In my granddaughter's situation, I was able to step back into the shadows and allow my saintly partner to do the dirty work of arranging the trip to Boston. And I am happy to report that the story has a happy ending. Even though the big-city specialists could remember only one similar case, they were willing to attempt an endoscopic approach. You should be reading about her successful procedure in a medical journal next year.

It is quite unsettling enough to hear a physician exclaim, “We've never seen a case like this before,” but when the surgeon you've known for more than 2 decades is talking about your 2-kg, not-quite-33-week-gestational-age granddaughter, it's frightening.

Little Hannah Margaret's entry into the world had begun to get complicated when her mother developed massive polyhydramnios and an ultrasound suggested that the baby's stomach was enlarged. We knew that something might not be quite right with her GI tract, but we were relieved when the neonatologist could pass a tube easily into her stomach. We were even more relieved when a limited-contrast study demonstrated continuity well into her small bowel. But continuity is a relative thing, and it became clear that her stomach did not empty normally.

At endoscopy, the antral region of her stomach was swollen and inflamed, and the gastroenterologist could not enter or even adequately visualize the pylorus. Trying hard to be the silent and supportive grandparent, I listened patiently as the pediatric surgeon at our tertiary care medical center outlined for my son the options for dealing with what he suspected was a very rare antral web. Unclear exactly what would be found until they opened her abdomen, he couldn't predict what procedure they would perform, but there was a high likelihood that little Hannah would be left with a dysfunctional pylorus.

When I sensed that my son had asked all his questions, I asked in my most naive voice if there was any chance that this outlet obstruction could be dealt with endoscopically. The answer was no.

Because of some scheduling issues, we had several days to prepare ourselves emotionally for the surgery. For 30 years I had relied on the magical skills and astute decision making of these same pediatric surgeons to rescue my patients from a broad range of congenital anomalies and anatomic misadventures. However, the plan that they outlined for my own granddaughter made me very uncomfortable. The rarity of her condition and, hence, their inexperience, was unsettling.

But what was the best way to act on my concerns without seeming to be a meddling grandfather who felt that the surgical expertise that had been just fine for his patients for 30 years was not good enough for his own granddaughter?

Not wanting to disturb my son's confidence in the care his daughter was receiving, I decided to do my research under cover. I began by bouncing the scenario off my partner, who would eventually become Hannah's physician. I then spoke to a pediatric gastroenterologist in Boston with whom I have shared patients since my residency. Both physicians supported my concerns and were, in fact, more troubled than I was about the proposed plan.

But when it came time for me to suggest a second opinion to my son and his wife, I was hesitant because I didn't want to offend the people who had been my go-to guys for more than 3 decades.

Even though I know it is often in the best interest of the patient, maybe only because it will give the parents peace of mind, I don't like it when families question my diagnosis or therapeutic plan and ask for a second opinion. Many times they have sensed my own poorly disguised discomfort with the situation—the cases in which I'm planning to recommend another physician if things don't improve by the next office visit—and beaten me to the punch.

In my granddaughter's situation, I was able to step back into the shadows and allow my saintly partner to do the dirty work of arranging the trip to Boston. And I am happy to report that the story has a happy ending. Even though the big-city specialists could remember only one similar case, they were willing to attempt an endoscopic approach. You should be reading about her successful procedure in a medical journal next year.

It is quite unsettling enough to hear a physician exclaim, “We've never seen a case like this before,” but when the surgeon you've known for more than 2 decades is talking about your 2-kg, not-quite-33-week-gestational-age granddaughter, it's frightening.

Little Hannah Margaret's entry into the world had begun to get complicated when her mother developed massive polyhydramnios and an ultrasound suggested that the baby's stomach was enlarged. We knew that something might not be quite right with her GI tract, but we were relieved when the neonatologist could pass a tube easily into her stomach. We were even more relieved when a limited-contrast study demonstrated continuity well into her small bowel. But continuity is a relative thing, and it became clear that her stomach did not empty normally.

At endoscopy, the antral region of her stomach was swollen and inflamed, and the gastroenterologist could not enter or even adequately visualize the pylorus. Trying hard to be the silent and supportive grandparent, I listened patiently as the pediatric surgeon at our tertiary care medical center outlined for my son the options for dealing with what he suspected was a very rare antral web. Unclear exactly what would be found until they opened her abdomen, he couldn't predict what procedure they would perform, but there was a high likelihood that little Hannah would be left with a dysfunctional pylorus.

When I sensed that my son had asked all his questions, I asked in my most naive voice if there was any chance that this outlet obstruction could be dealt with endoscopically. The answer was no.

Because of some scheduling issues, we had several days to prepare ourselves emotionally for the surgery. For 30 years I had relied on the magical skills and astute decision making of these same pediatric surgeons to rescue my patients from a broad range of congenital anomalies and anatomic misadventures. However, the plan that they outlined for my own granddaughter made me very uncomfortable. The rarity of her condition and, hence, their inexperience, was unsettling.

But what was the best way to act on my concerns without seeming to be a meddling grandfather who felt that the surgical expertise that had been just fine for his patients for 30 years was not good enough for his own granddaughter?

Not wanting to disturb my son's confidence in the care his daughter was receiving, I decided to do my research under cover. I began by bouncing the scenario off my partner, who would eventually become Hannah's physician. I then spoke to a pediatric gastroenterologist in Boston with whom I have shared patients since my residency. Both physicians supported my concerns and were, in fact, more troubled than I was about the proposed plan.

But when it came time for me to suggest a second opinion to my son and his wife, I was hesitant because I didn't want to offend the people who had been my go-to guys for more than 3 decades.

Even though I know it is often in the best interest of the patient, maybe only because it will give the parents peace of mind, I don't like it when families question my diagnosis or therapeutic plan and ask for a second opinion. Many times they have sensed my own poorly disguised discomfort with the situation—the cases in which I'm planning to recommend another physician if things don't improve by the next office visit—and beaten me to the punch.

In my granddaughter's situation, I was able to step back into the shadows and allow my saintly partner to do the dirty work of arranging the trip to Boston. And I am happy to report that the story has a happy ending. Even though the big-city specialists could remember only one similar case, they were willing to attempt an endoscopic approach. You should be reading about her successful procedure in a medical journal next year.

There are two societal phenomena that frustrate me to the point of hanging up my stethoscope and converting my garage into a boat-building shop. The first of these is the expanding collection of behavioral dysfunctions among America's children that are often mislabeled attention-deficit disorders. The other is the overweight epidemic among those same children.

In both cases, we pediatricians have accepted a hefty share of the challenge to fabricate medical solutions for what are primarily societal problems.

We didn't invent television, fast food, divorce, or overscheduled two-income families, but because the tsunamis generated by these realities are threatening to drown a generation of children, those of us committed to their welfare are logically viewed by ourselves and others as front-line soldiers.

But do we pediatricians have the weapons to wage these wars?

And where should the battles be fought?

One of the lead stories in last month's PEDIATRIC NEWS suggested that we can learn to counsel and administer behavioral treatments in our offices that will be effective against obesity (“Getting Through to Overweight Kids,” p. 1).

The pediatricians in the article may be making a difference for some of their patients, but I am skeptical about the applicability of their techniques for the rest of us, who are accustomed to the much higher success rates typical of asthma and pyelonephritis.

Only 37 of 73 families completed the counseling program, and the investigators admitted they didn't know how many families were initially asked to participate but declined.

Although I'm sure I could learn to do a better job of counseling, I have been talking—and listening—to parents about obesity and inactivity for several decades using similar techniques and have had frustratingly few successes.

But before I pack it in and retreat to my workshop, I feel I should give the challenge of obesity one more try.

Robert E. Holmberg Jr., M.D., a member of the American Academy of Pediatrics' task force on obesity, wrote in a recent editorial that, to be effective against the overweight phenomenon, we pediatricians must venture out of our offices and “embrace the community pediatric perspective and methods” (AAP News, July 2005, p. 32).

As one would expect from the clear-thinking, common-sense pediatrician from Maine that he is, Bob offers nine specific ways that a physician can “work with the community to develop projects to improve physical activity, nutrition and prevent [my italics] overweight in our children.”

I really like the concept of prevention because my attempts at mopping up the damage aren't working. Furthermore, I am pleased that his first suggestion is to “focus locally,” because I'm a think-small kind of guy.

But he also suggests that I form a “small steering group” and then a “community coalition” and eventually participate in my “coordinated school health council.” Whoa! Bob!

This is beginning to smell like a whole mess of meetings. You must not be reading my column very closely. I don't do meetings.

I knew that getting out of my office to battle obesity was going to take me away from what I do best, but this is sounding very uncomfortable.

Am I going to have to listen patiently while other concerned citizens voice their occasionally lame ideas?

Does this mean that instead of writing orders and prescriptions that are carried out without question, I might be writing grant applications that someone will edit and someone else might deny?

Bob, Bob, I'm all for a community team approach, but can't I please still be the captain?

I'm afraid I already know the answers. But damn it, the overweight crisis has really gotten to me, and I don't want anyone to accuse this old dog of not being able to learn a few new tricks.

Since I'm getting paid diddly-squat for counseling in the office anyway, I might as well go forth and embrace that community pediatric perspective at a few meetings out of the office where I won't get paid anything.

That wood I bought for the new boat should probably season in the garage for a few more years anyway.

There are two societal phenomena that frustrate me to the point of hanging up my stethoscope and converting my garage into a boat-building shop. The first of these is the expanding collection of behavioral dysfunctions among America's children that are often mislabeled attention-deficit disorders. The other is the overweight epidemic among those same children.

In both cases, we pediatricians have accepted a hefty share of the challenge to fabricate medical solutions for what are primarily societal problems.

We didn't invent television, fast food, divorce, or overscheduled two-income families, but because the tsunamis generated by these realities are threatening to drown a generation of children, those of us committed to their welfare are logically viewed by ourselves and others as front-line soldiers.

But do we pediatricians have the weapons to wage these wars?

And where should the battles be fought?

One of the lead stories in last month's PEDIATRIC NEWS suggested that we can learn to counsel and administer behavioral treatments in our offices that will be effective against obesity (“Getting Through to Overweight Kids,” p. 1).

The pediatricians in the article may be making a difference for some of their patients, but I am skeptical about the applicability of their techniques for the rest of us, who are accustomed to the much higher success rates typical of asthma and pyelonephritis.

Only 37 of 73 families completed the counseling program, and the investigators admitted they didn't know how many families were initially asked to participate but declined.

Although I'm sure I could learn to do a better job of counseling, I have been talking—and listening—to parents about obesity and inactivity for several decades using similar techniques and have had frustratingly few successes.

But before I pack it in and retreat to my workshop, I feel I should give the challenge of obesity one more try.

Robert E. Holmberg Jr., M.D., a member of the American Academy of Pediatrics' task force on obesity, wrote in a recent editorial that, to be effective against the overweight phenomenon, we pediatricians must venture out of our offices and “embrace the community pediatric perspective and methods” (AAP News, July 2005, p. 32).

As one would expect from the clear-thinking, common-sense pediatrician from Maine that he is, Bob offers nine specific ways that a physician can “work with the community to develop projects to improve physical activity, nutrition and prevent [my italics] overweight in our children.”

I really like the concept of prevention because my attempts at mopping up the damage aren't working. Furthermore, I am pleased that his first suggestion is to “focus locally,” because I'm a think-small kind of guy.

But he also suggests that I form a “small steering group” and then a “community coalition” and eventually participate in my “coordinated school health council.” Whoa! Bob!

This is beginning to smell like a whole mess of meetings. You must not be reading my column very closely. I don't do meetings.

I knew that getting out of my office to battle obesity was going to take me away from what I do best, but this is sounding very uncomfortable.

Am I going to have to listen patiently while other concerned citizens voice their occasionally lame ideas?

Does this mean that instead of writing orders and prescriptions that are carried out without question, I might be writing grant applications that someone will edit and someone else might deny?

Bob, Bob, I'm all for a community team approach, but can't I please still be the captain?

I'm afraid I already know the answers. But damn it, the overweight crisis has really gotten to me, and I don't want anyone to accuse this old dog of not being able to learn a few new tricks.

Since I'm getting paid diddly-squat for counseling in the office anyway, I might as well go forth and embrace that community pediatric perspective at a few meetings out of the office where I won't get paid anything.

That wood I bought for the new boat should probably season in the garage for a few more years anyway.

There are two societal phenomena that frustrate me to the point of hanging up my stethoscope and converting my garage into a boat-building shop. The first of these is the expanding collection of behavioral dysfunctions among America's children that are often mislabeled attention-deficit disorders. The other is the overweight epidemic among those same children.

In both cases, we pediatricians have accepted a hefty share of the challenge to fabricate medical solutions for what are primarily societal problems.

We didn't invent television, fast food, divorce, or overscheduled two-income families, but because the tsunamis generated by these realities are threatening to drown a generation of children, those of us committed to their welfare are logically viewed by ourselves and others as front-line soldiers.

But do we pediatricians have the weapons to wage these wars?

And where should the battles be fought?

One of the lead stories in last month's PEDIATRIC NEWS suggested that we can learn to counsel and administer behavioral treatments in our offices that will be effective against obesity (“Getting Through to Overweight Kids,” p. 1).

The pediatricians in the article may be making a difference for some of their patients, but I am skeptical about the applicability of their techniques for the rest of us, who are accustomed to the much higher success rates typical of asthma and pyelonephritis.

Only 37 of 73 families completed the counseling program, and the investigators admitted they didn't know how many families were initially asked to participate but declined.

Although I'm sure I could learn to do a better job of counseling, I have been talking—and listening—to parents about obesity and inactivity for several decades using similar techniques and have had frustratingly few successes.

But before I pack it in and retreat to my workshop, I feel I should give the challenge of obesity one more try.

Robert E. Holmberg Jr., M.D., a member of the American Academy of Pediatrics' task force on obesity, wrote in a recent editorial that, to be effective against the overweight phenomenon, we pediatricians must venture out of our offices and “embrace the community pediatric perspective and methods” (AAP News, July 2005, p. 32).

As one would expect from the clear-thinking, common-sense pediatrician from Maine that he is, Bob offers nine specific ways that a physician can “work with the community to develop projects to improve physical activity, nutrition and prevent [my italics] overweight in our children.”

I really like the concept of prevention because my attempts at mopping up the damage aren't working. Furthermore, I am pleased that his first suggestion is to “focus locally,” because I'm a think-small kind of guy.

But he also suggests that I form a “small steering group” and then a “community coalition” and eventually participate in my “coordinated school health council.” Whoa! Bob!

This is beginning to smell like a whole mess of meetings. You must not be reading my column very closely. I don't do meetings.

I knew that getting out of my office to battle obesity was going to take me away from what I do best, but this is sounding very uncomfortable.

Am I going to have to listen patiently while other concerned citizens voice their occasionally lame ideas?

Does this mean that instead of writing orders and prescriptions that are carried out without question, I might be writing grant applications that someone will edit and someone else might deny?

Bob, Bob, I'm all for a community team approach, but can't I please still be the captain?

I'm afraid I already know the answers. But damn it, the overweight crisis has really gotten to me, and I don't want anyone to accuse this old dog of not being able to learn a few new tricks.

Since I'm getting paid diddly-squat for counseling in the office anyway, I might as well go forth and embrace that community pediatric perspective at a few meetings out of the office where I won't get paid anything.

That wood I bought for the new boat should probably season in the garage for a few more years anyway.

The old highway sign—“Maine, the Way Life Should Be”—was hard to miss as one left the toll plaza in Kittery heading north toward Portland on I-95. Those of us fortunate enough to live here know that those words weren't simply a catch phrase cooked up by some big city PR firm.

With its rich supply of recreational opportunities and low population density, Maine is a beautiful and safe place to raise children. Like Montana and a few other heavenly places, though, we have trouble finding work for our adult children, and many of them are forced to leave this idyllic place to find employment that matches their education.

So you can imagine how excited Marilyn and I were when our son called to say he had landed a good job at L.L. Bean and would be moving back to Maine. In fact, he had already begun to look for a house here in Brunswick, and his wife was pregnant with our first grandchild.

As we proudly shared the good news with everyone who would listen, one of the most frequently asked questions was, “Well, who's going to be the baby's pediatrician?” In a few cases, the question was rhetorical, because our closest friends knew how uncomfortable I would be shouldering the responsibility of caring for my own grandchild.

But many of the questioners clearly didn't understand that being a pediatrician often requires a difficult and schizophrenic separation of one's natural instincts, even when the patient is neither a friend nor a relative. The ability to fluctuate between compassion and objectivity and still keep the whole process in balance isn't easy.

I recall an incident when I was an intern struggling to perform a lumbar puncture on a febrile 10-month-old girl. The gray-haired nurse who was holding the child for me said, “Will, you usually don't have this much trouble with LPs. Your daughter must be about the same age.”

She was correct. Fortunately, I was able to wall off my paternal emotions long enough to collect a clean sample of spinal fluid, but I knew that, had this little patient actually been my own daughter, I would have most likely bungled the tap or given up prematurely because I thought I was hurting her.

By the time I was a senior resident, I had promised myself that I wouldn't lift a therapeutic or diagnostic finger when one of my own children was ill. My steadfast adherence to this philosophy has meant that on several occasions, my poor wife had to drive for hours in rush-hour traffic to see the official pediatrician for what was obviously an otitis media. I may keep my good-luck stethoscope in my knapsack, but my otoscope always stays at the office. This eliminates any temptation to examine the ears of either kin or neighbor.

I've made a couple of exceptions over the years, with nearly disastrous results. The first incident involved my son's knee laceration, which I attempted to repair with inadequate anesthesia. Neither the scenario nor the result was pretty. In another episode, I nearly sent my daughter back to school with a fractured humerus after a cursory kitchen-table examination. Her mother saved the day and my ego by urging a second and wiser opinion.

Family and medicine don't mix well. Despite our best efforts to prevent it, some of our diagnostic and therapeutic procedures are painful. Under the best of circumstances, it is sometimes difficult to do the right thing, but when the patient is one's own child or grandchild, it may be impossible.

A good clinician must be able to submerge his own emotional attachment to the patient long enough to allow his rational decision-making skills to rise to the surface, while still demonstrating that he cares.

I know that when my grandchild arrives, I won't be able to suppress my own emotions. I just want to be his or her grandfather, and I hope I can let someone else be the pediatrician.

The old highway sign—“Maine, the Way Life Should Be”—was hard to miss as one left the toll plaza in Kittery heading north toward Portland on I-95. Those of us fortunate enough to live here know that those words weren't simply a catch phrase cooked up by some big city PR firm.

With its rich supply of recreational opportunities and low population density, Maine is a beautiful and safe place to raise children. Like Montana and a few other heavenly places, though, we have trouble finding work for our adult children, and many of them are forced to leave this idyllic place to find employment that matches their education.

So you can imagine how excited Marilyn and I were when our son called to say he had landed a good job at L.L. Bean and would be moving back to Maine. In fact, he had already begun to look for a house here in Brunswick, and his wife was pregnant with our first grandchild.

As we proudly shared the good news with everyone who would listen, one of the most frequently asked questions was, “Well, who's going to be the baby's pediatrician?” In a few cases, the question was rhetorical, because our closest friends knew how uncomfortable I would be shouldering the responsibility of caring for my own grandchild.

But many of the questioners clearly didn't understand that being a pediatrician often requires a difficult and schizophrenic separation of one's natural instincts, even when the patient is neither a friend nor a relative. The ability to fluctuate between compassion and objectivity and still keep the whole process in balance isn't easy.

I recall an incident when I was an intern struggling to perform a lumbar puncture on a febrile 10-month-old girl. The gray-haired nurse who was holding the child for me said, “Will, you usually don't have this much trouble with LPs. Your daughter must be about the same age.”

She was correct. Fortunately, I was able to wall off my paternal emotions long enough to collect a clean sample of spinal fluid, but I knew that, had this little patient actually been my own daughter, I would have most likely bungled the tap or given up prematurely because I thought I was hurting her.

By the time I was a senior resident, I had promised myself that I wouldn't lift a therapeutic or diagnostic finger when one of my own children was ill. My steadfast adherence to this philosophy has meant that on several occasions, my poor wife had to drive for hours in rush-hour traffic to see the official pediatrician for what was obviously an otitis media. I may keep my good-luck stethoscope in my knapsack, but my otoscope always stays at the office. This eliminates any temptation to examine the ears of either kin or neighbor.

I've made a couple of exceptions over the years, with nearly disastrous results. The first incident involved my son's knee laceration, which I attempted to repair with inadequate anesthesia. Neither the scenario nor the result was pretty. In another episode, I nearly sent my daughter back to school with a fractured humerus after a cursory kitchen-table examination. Her mother saved the day and my ego by urging a second and wiser opinion.

Family and medicine don't mix well. Despite our best efforts to prevent it, some of our diagnostic and therapeutic procedures are painful. Under the best of circumstances, it is sometimes difficult to do the right thing, but when the patient is one's own child or grandchild, it may be impossible.

A good clinician must be able to submerge his own emotional attachment to the patient long enough to allow his rational decision-making skills to rise to the surface, while still demonstrating that he cares.

I know that when my grandchild arrives, I won't be able to suppress my own emotions. I just want to be his or her grandfather, and I hope I can let someone else be the pediatrician.

The old highway sign—“Maine, the Way Life Should Be”—was hard to miss as one left the toll plaza in Kittery heading north toward Portland on I-95. Those of us fortunate enough to live here know that those words weren't simply a catch phrase cooked up by some big city PR firm.

With its rich supply of recreational opportunities and low population density, Maine is a beautiful and safe place to raise children. Like Montana and a few other heavenly places, though, we have trouble finding work for our adult children, and many of them are forced to leave this idyllic place to find employment that matches their education.

So you can imagine how excited Marilyn and I were when our son called to say he had landed a good job at L.L. Bean and would be moving back to Maine. In fact, he had already begun to look for a house here in Brunswick, and his wife was pregnant with our first grandchild.

As we proudly shared the good news with everyone who would listen, one of the most frequently asked questions was, “Well, who's going to be the baby's pediatrician?” In a few cases, the question was rhetorical, because our closest friends knew how uncomfortable I would be shouldering the responsibility of caring for my own grandchild.

But many of the questioners clearly didn't understand that being a pediatrician often requires a difficult and schizophrenic separation of one's natural instincts, even when the patient is neither a friend nor a relative. The ability to fluctuate between compassion and objectivity and still keep the whole process in balance isn't easy.

I recall an incident when I was an intern struggling to perform a lumbar puncture on a febrile 10-month-old girl. The gray-haired nurse who was holding the child for me said, “Will, you usually don't have this much trouble with LPs. Your daughter must be about the same age.”

She was correct. Fortunately, I was able to wall off my paternal emotions long enough to collect a clean sample of spinal fluid, but I knew that, had this little patient actually been my own daughter, I would have most likely bungled the tap or given up prematurely because I thought I was hurting her.

By the time I was a senior resident, I had promised myself that I wouldn't lift a therapeutic or diagnostic finger when one of my own children was ill. My steadfast adherence to this philosophy has meant that on several occasions, my poor wife had to drive for hours in rush-hour traffic to see the official pediatrician for what was obviously an otitis media. I may keep my good-luck stethoscope in my knapsack, but my otoscope always stays at the office. This eliminates any temptation to examine the ears of either kin or neighbor.

I've made a couple of exceptions over the years, with nearly disastrous results. The first incident involved my son's knee laceration, which I attempted to repair with inadequate anesthesia. Neither the scenario nor the result was pretty. In another episode, I nearly sent my daughter back to school with a fractured humerus after a cursory kitchen-table examination. Her mother saved the day and my ego by urging a second and wiser opinion.

Family and medicine don't mix well. Despite our best efforts to prevent it, some of our diagnostic and therapeutic procedures are painful. Under the best of circumstances, it is sometimes difficult to do the right thing, but when the patient is one's own child or grandchild, it may be impossible.

A good clinician must be able to submerge his own emotional attachment to the patient long enough to allow his rational decision-making skills to rise to the surface, while still demonstrating that he cares.

I know that when my grandchild arrives, I won't be able to suppress my own emotions. I just want to be his or her grandfather, and I hope I can let someone else be the pediatrician.