Letters from Maine

There were days when I really didn’t like doing annual checkups, in fact, sometimes I hated it. I always enjoyed talking with the kids who wanted to engage, but I would wonder if the whole preventive care thing was just a bunch of bunk. There, I said it.

Stand back because at any moment lightning may strike me for coming out as a heretic. We pediatricians are supposed to be the preventive care standard-bearers. We are the immunizers. We are the growth-chart plotters. We are the ones toiling at ground zero, hoping to steer our little patients toward the paths of a healthy adulthood.

But, are annual checkups on well children really making a difference? The Society of General Internal Medicine has recently released a list of Five Things Physicians and Patients Should Question (Choose Wisely, an initiative of the ABIM Foundation). No. 2 on the list is "Don’t perform routine general health checks on asymptomatic adults." The authors observe that "annual visit have not shown to be effective in reducing morbidity, mortality, or hospitalization." Could the same claim be made for annual checkups on asymptomatic older children? Has anyone had the courage to ask the question?

Take a deep breath. Please don’t call the American Academy of Pediatrics and demand that they revoke my emeritus membership. Let me do some quick backpedaling. Yes, there were days when doing checkups on apparently healthy tight-lipped 10-year-olds who would rather be elsewhere made me feel worthless. But, children aren’t adults. Preverbal children can’t really be said to have "no complaints." Up to the point that a child has successfully negotiated kindergarten and first grade, they are dependent on us to find out if there is anything wrong with them. Annual or more often checkups makes sense.

But, for the school-age child who is growing well and doesn’t have any chronic conditions or genetic predispositions, do annual physical exams make sense? Let’s be honest. How many novel physical findings did you make last year in the course of doing hundreds of well-child exams on children without complaints. Of course, you found some concerning growth curves and a few elevated blood pressures. But wouldn’t a complete set of vital signs done at school been just as effective a screening device?

You might ask, "What about immunizations?" Couldn’t the school be a more efficient place to administer them? You might also question whether curtailing annual checkups might remove the office as a critical venue for health education. I think we have to be realistic here and admit that television, the Internet, and social medial sites are probably more powerful communicators.

Wouldn’t being more selective about doing annual exams narrow an important income stream for physicians? Just listen to the receptionists and nurse triage specialists in the average office struggle to deflect calls from concerned parents who would like to have their children seen promptly. Pediatricians could easily fill the appointment slots vacated by older children having needless checkups with the sick and the worried well who need and/or want to be seen. Two of the most frequent complaints we hear about physicians is that it’s "impossible" to get in for an appointment, and we don’t spend enough time with the patients.

As the ill conceived and poorly administered push to adopt electronic health records gobbles up more and more of the time physicians can spend with patients, we are going to have to be smarter and thoughtful about who we see. When there is a shortage of lubricant, the squeaky wheel should get the grease. The other three wheels are rolling along just fine.

If any of you have harbored the same heretical thoughts, please share them, anonymously if you choose.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say ‘No’ to Your Toddler." E-mail him at pdnews@frontlinemedcom.com.

There were days when I really didn’t like doing annual checkups, in fact, sometimes I hated it. I always enjoyed talking with the kids who wanted to engage, but I would wonder if the whole preventive care thing was just a bunch of bunk. There, I said it.

Stand back because at any moment lightning may strike me for coming out as a heretic. We pediatricians are supposed to be the preventive care standard-bearers. We are the immunizers. We are the growth-chart plotters. We are the ones toiling at ground zero, hoping to steer our little patients toward the paths of a healthy adulthood.

But, are annual checkups on well children really making a difference? The Society of General Internal Medicine has recently released a list of Five Things Physicians and Patients Should Question (Choose Wisely, an initiative of the ABIM Foundation). No. 2 on the list is "Don’t perform routine general health checks on asymptomatic adults." The authors observe that "annual visit have not shown to be effective in reducing morbidity, mortality, or hospitalization." Could the same claim be made for annual checkups on asymptomatic older children? Has anyone had the courage to ask the question?

Take a deep breath. Please don’t call the American Academy of Pediatrics and demand that they revoke my emeritus membership. Let me do some quick backpedaling. Yes, there were days when doing checkups on apparently healthy tight-lipped 10-year-olds who would rather be elsewhere made me feel worthless. But, children aren’t adults. Preverbal children can’t really be said to have "no complaints." Up to the point that a child has successfully negotiated kindergarten and first grade, they are dependent on us to find out if there is anything wrong with them. Annual or more often checkups makes sense.

But, for the school-age child who is growing well and doesn’t have any chronic conditions or genetic predispositions, do annual physical exams make sense? Let’s be honest. How many novel physical findings did you make last year in the course of doing hundreds of well-child exams on children without complaints. Of course, you found some concerning growth curves and a few elevated blood pressures. But wouldn’t a complete set of vital signs done at school been just as effective a screening device?

You might ask, "What about immunizations?" Couldn’t the school be a more efficient place to administer them? You might also question whether curtailing annual checkups might remove the office as a critical venue for health education. I think we have to be realistic here and admit that television, the Internet, and social medial sites are probably more powerful communicators.

Wouldn’t being more selective about doing annual exams narrow an important income stream for physicians? Just listen to the receptionists and nurse triage specialists in the average office struggle to deflect calls from concerned parents who would like to have their children seen promptly. Pediatricians could easily fill the appointment slots vacated by older children having needless checkups with the sick and the worried well who need and/or want to be seen. Two of the most frequent complaints we hear about physicians is that it’s "impossible" to get in for an appointment, and we don’t spend enough time with the patients.

As the ill conceived and poorly administered push to adopt electronic health records gobbles up more and more of the time physicians can spend with patients, we are going to have to be smarter and thoughtful about who we see. When there is a shortage of lubricant, the squeaky wheel should get the grease. The other three wheels are rolling along just fine.

If any of you have harbored the same heretical thoughts, please share them, anonymously if you choose.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say ‘No’ to Your Toddler." E-mail him at pdnews@frontlinemedcom.com.

There were days when I really didn’t like doing annual checkups, in fact, sometimes I hated it. I always enjoyed talking with the kids who wanted to engage, but I would wonder if the whole preventive care thing was just a bunch of bunk. There, I said it.

Stand back because at any moment lightning may strike me for coming out as a heretic. We pediatricians are supposed to be the preventive care standard-bearers. We are the immunizers. We are the growth-chart plotters. We are the ones toiling at ground zero, hoping to steer our little patients toward the paths of a healthy adulthood.

But, are annual checkups on well children really making a difference? The Society of General Internal Medicine has recently released a list of Five Things Physicians and Patients Should Question (Choose Wisely, an initiative of the ABIM Foundation). No. 2 on the list is "Don’t perform routine general health checks on asymptomatic adults." The authors observe that "annual visit have not shown to be effective in reducing morbidity, mortality, or hospitalization." Could the same claim be made for annual checkups on asymptomatic older children? Has anyone had the courage to ask the question?

Take a deep breath. Please don’t call the American Academy of Pediatrics and demand that they revoke my emeritus membership. Let me do some quick backpedaling. Yes, there were days when doing checkups on apparently healthy tight-lipped 10-year-olds who would rather be elsewhere made me feel worthless. But, children aren’t adults. Preverbal children can’t really be said to have "no complaints." Up to the point that a child has successfully negotiated kindergarten and first grade, they are dependent on us to find out if there is anything wrong with them. Annual or more often checkups makes sense.

But, for the school-age child who is growing well and doesn’t have any chronic conditions or genetic predispositions, do annual physical exams make sense? Let’s be honest. How many novel physical findings did you make last year in the course of doing hundreds of well-child exams on children without complaints. Of course, you found some concerning growth curves and a few elevated blood pressures. But wouldn’t a complete set of vital signs done at school been just as effective a screening device?

You might ask, "What about immunizations?" Couldn’t the school be a more efficient place to administer them? You might also question whether curtailing annual checkups might remove the office as a critical venue for health education. I think we have to be realistic here and admit that television, the Internet, and social medial sites are probably more powerful communicators.

Wouldn’t being more selective about doing annual exams narrow an important income stream for physicians? Just listen to the receptionists and nurse triage specialists in the average office struggle to deflect calls from concerned parents who would like to have their children seen promptly. Pediatricians could easily fill the appointment slots vacated by older children having needless checkups with the sick and the worried well who need and/or want to be seen. Two of the most frequent complaints we hear about physicians is that it’s "impossible" to get in for an appointment, and we don’t spend enough time with the patients.

As the ill conceived and poorly administered push to adopt electronic health records gobbles up more and more of the time physicians can spend with patients, we are going to have to be smarter and thoughtful about who we see. When there is a shortage of lubricant, the squeaky wheel should get the grease. The other three wheels are rolling along just fine.

If any of you have harbored the same heretical thoughts, please share them, anonymously if you choose.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say ‘No’ to Your Toddler." E-mail him at pdnews@frontlinemedcom.com.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

On Aug. 27, Dr. John Kennell died at the age of 91. I learned from his obituary in the New York Times that he was the guy who put maternal-infant bonding on the map. It was his observations as a neonatologist, when neonatology was in its infancy, that ended the common and unnatural practice of separating mother and infants for hours and in some sad cases even days, so that each could recover from the ordeal of an uncomplicated hospital childbirth.

In a book coauthored with Dr. Marshall Klaus in 1976 titled "Maternal-Infant Bonding," Dr. Kennell claimed that there was a critical period in the first few hours after delivery during which mothers were biochemically primed to form bonds with their infants. And, that these bonds were crucial for normal development. Over the next few decades, he nuanced his position. In fact, his most recent efforts were in support of doula care, which if poorly done could conceivably interfere with the bonding he had pioneered.

But, the damage was already done. At least two generations of parents still live in dread fear that they didn’t spend enough of the right kind of time with their newborns. For example, 2 years ago, I received a call from a friend whose daughter had recently delivered her second child by C-section. The baby was fine, but the mother nearly died of intrapartum group A beta-hemolytic sepsis. The ordeal included DIC [disseminated intravascular coagulation],multiorgan failure, and the partial amputation of a couple of digits.

Not surprisingly, this young woman was in no condition to interact with anyone for more than 2 weeks. The new grandmother’s call was prompted by the observation that now in the third week postpartum when her daughter was awake she seemed to have little interest in holding or nurturing the baby. And, she was more than willing to have nurses and family members do the hugging and cuddling.

I asked, "Is this about that bonding thing? If your daughter really wanted to have this baby, we could send her to Cleveland for 3 months and the two of them would still form a normal mother-daughter relationship." I could have added, "Let’s remember, we aren’t geese who will imprint on the first adult figure they see after hatching. Even if it is a 6-foot-tall researcher with a beard." This summer I got to meet this young woman and her daughter and could tell that the two made a beautifully adjusted dyad.

It is unfortunate that Dr. Kennell’s early work that was so critical to creating a more humane birthing experience had a dark side that sent a ripple of needless anxiety that still shakes parents 3 decades later. Tragically, there are cases of seriously disordered maternal-infant bonding so severe that they result in infanticide. But, in my experience these incidents are the result of a long or deep mental illness and are not caused by a few hours or days of separation immediately after birth.

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

Updated: 10/8/2013

On Aug. 27, Dr. John Kennell died at the age of 91. I learned from his obituary in the New York Times that he was the guy who put maternal-infant bonding on the map. It was his observations as a neonatologist, when neonatology was in its infancy, that ended the common and unnatural practice of separating mother and infants for hours and in some sad cases even days, so that each could recover from the ordeal of an uncomplicated hospital childbirth.

In a book coauthored with Dr. Marshall Klaus in 1976 titled "Maternal-Infant Bonding," Dr. Kennell claimed that there was a critical period in the first few hours after delivery during which mothers were biochemically primed to form bonds with their infants. And, that these bonds were crucial for normal development. Over the next few decades, he nuanced his position. In fact, his most recent efforts were in support of doula care, which if poorly done could conceivably interfere with the bonding he had pioneered.

But, the damage was already done. At least two generations of parents still live in dread fear that they didn’t spend enough of the right kind of time with their newborns. For example, 2 years ago, I received a call from a friend whose daughter had recently delivered her second child by C-section. The baby was fine, but the mother nearly died of intrapartum group A beta-hemolytic sepsis. The ordeal included DIC [disseminated intravascular coagulation],multiorgan failure, and the partial amputation of a couple of digits.

Not surprisingly, this young woman was in no condition to interact with anyone for more than 2 weeks. The new grandmother’s call was prompted by the observation that now in the third week postpartum when her daughter was awake she seemed to have little interest in holding or nurturing the baby. And, she was more than willing to have nurses and family members do the hugging and cuddling.

I asked, "Is this about that bonding thing? If your daughter really wanted to have this baby, we could send her to Cleveland for 3 months and the two of them would still form a normal mother-daughter relationship." I could have added, "Let’s remember, we aren’t geese who will imprint on the first adult figure they see after hatching. Even if it is a 6-foot-tall researcher with a beard." This summer I got to meet this young woman and her daughter and could tell that the two made a beautifully adjusted dyad.

It is unfortunate that Dr. Kennell’s early work that was so critical to creating a more humane birthing experience had a dark side that sent a ripple of needless anxiety that still shakes parents 3 decades later. Tragically, there are cases of seriously disordered maternal-infant bonding so severe that they result in infanticide. But, in my experience these incidents are the result of a long or deep mental illness and are not caused by a few hours or days of separation immediately after birth.

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

Updated: 10/8/2013

On Aug. 27, Dr. John Kennell died at the age of 91. I learned from his obituary in the New York Times that he was the guy who put maternal-infant bonding on the map. It was his observations as a neonatologist, when neonatology was in its infancy, that ended the common and unnatural practice of separating mother and infants for hours and in some sad cases even days, so that each could recover from the ordeal of an uncomplicated hospital childbirth.

In a book coauthored with Dr. Marshall Klaus in 1976 titled "Maternal-Infant Bonding," Dr. Kennell claimed that there was a critical period in the first few hours after delivery during which mothers were biochemically primed to form bonds with their infants. And, that these bonds were crucial for normal development. Over the next few decades, he nuanced his position. In fact, his most recent efforts were in support of doula care, which if poorly done could conceivably interfere with the bonding he had pioneered.

But, the damage was already done. At least two generations of parents still live in dread fear that they didn’t spend enough of the right kind of time with their newborns. For example, 2 years ago, I received a call from a friend whose daughter had recently delivered her second child by C-section. The baby was fine, but the mother nearly died of intrapartum group A beta-hemolytic sepsis. The ordeal included DIC [disseminated intravascular coagulation],multiorgan failure, and the partial amputation of a couple of digits.

Not surprisingly, this young woman was in no condition to interact with anyone for more than 2 weeks. The new grandmother’s call was prompted by the observation that now in the third week postpartum when her daughter was awake she seemed to have little interest in holding or nurturing the baby. And, she was more than willing to have nurses and family members do the hugging and cuddling.

I asked, "Is this about that bonding thing? If your daughter really wanted to have this baby, we could send her to Cleveland for 3 months and the two of them would still form a normal mother-daughter relationship." I could have added, "Let’s remember, we aren’t geese who will imprint on the first adult figure they see after hatching. Even if it is a 6-foot-tall researcher with a beard." This summer I got to meet this young woman and her daughter and could tell that the two made a beautifully adjusted dyad.

It is unfortunate that Dr. Kennell’s early work that was so critical to creating a more humane birthing experience had a dark side that sent a ripple of needless anxiety that still shakes parents 3 decades later. Tragically, there are cases of seriously disordered maternal-infant bonding so severe that they result in infanticide. But, in my experience these incidents are the result of a long or deep mental illness and are not caused by a few hours or days of separation immediately after birth.

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

Updated: 10/8/2013

Most days, I feel that the Affordable Care Act’s negatives outweigh its positives, but I’m not quite ready to throw out the baby with the bathwater. For example, I recently discovered that the ACA requires that all insurance companies pay for breast pumps and lactation counseling. Great idea! But, then I learned that the law neither specifies the type of breast pump nor defines who qualifies as a trained provider of lactation counseling services (Breast-Feeding Services Lag Behind the Law, Catherine Saint Louis, New York Times, Sept. 30, 2013). It turns out that with rare exceptions, finding a lactation consultant who is approved by the insurance company and then securing payment are fraught with delays that are measured in days or weeks. Of course, these delays and snafus come during a critical window for breastfeeding success.

A recent study by Wagner et al. (Breastfeeding Concerns at 3 and 7 Days Postpartum and Feeding Status at 2 Months; Pediatrics 2013;132:e865-e75) reports the obvious. Maternal concerns about their infant’s feeding difficulties, breastfeeding pain, and milk quantity were associated with early cessation of breastfeeding, with peaks at 3 and 7 days postpartum. The fact is that even mothers who had a solid intent to nurse their babies for at least 2 months worry. They become upset if they perceive that their babies are struggling to feed, or if they suspect that the babies aren’t getting enough to eat. And, they are just as vulnerable to pain as everyone else.

These concerns and worries occur in a compressed time frame of very few days and are magnified by the sleep deprivation that accompanies most deliveries. The correct advice provided by compassionate lactation consultants (and here I include pediatricians) can be critical to breastfeeding success. But, it must be provided on a time scale that matches the tempo of the lactation process. Here I am talking about hours, not days.

Interestingly and sadly, the hospital where Ms. Wagner and her colleagues collected their data doesn’t seem to understand that time-sensitive urgency. The investigators report that lactation consultants are "generally available on the maternity unit 6 days per week." Heaven help the poor mother and infant who are struggling with a poor latch on that 7th day. And, what does "generally available" mean? Folks, a new mother’s breastfeeding concerns require intensive care. The nurses and doctors in an ICU just aren’t "generally available."

The researchers also postulate that the increase in adverse outcomes later in the first week postpartum may be because "there is often a gap between hospital and community lactation services." Really? There’s the problem in a nutshell. If we want more babies to be breastfed, we have to treat the support services as critical and time sensitive. We have done a pretty good job of convincing mothers that breastfeeding is the best way to feed their newborns. Now we have to acknowledge their concerns and support them with quality advice 24/7.

Medical homes must function like homes. Your parents may have turned the lights out at 10:00 p.m., but they didn’t leave you alone and go to a motel for the night. To achieve the kind of seamless support net that new mothers need and deserve, pediatricians need to learn more about giving lactation advice themselves. They need to join with lactation consultants with whom they feel comfortable to provide 24/7 phone support and face-to-face visits on a 365/365 schedule.

The ACA appears to be offering us the opportunity to take breastfeeding support seriously. Obviously, it has some rough edges at this point. But, let’s take advantage of this chance by seeing that the support for our patients is provided in a time frame that matches the biology of breastfeeding.

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

Updated: 10/8/2013

Most days, I feel that the Affordable Care Act’s negatives outweigh its positives, but I’m not quite ready to throw out the baby with the bathwater. For example, I recently discovered that the ACA requires that all insurance companies pay for breast pumps and lactation counseling. Great idea! But, then I learned that the law neither specifies the type of breast pump nor defines who qualifies as a trained provider of lactation counseling services (Breast-Feeding Services Lag Behind the Law, Catherine Saint Louis, New York Times, Sept. 30, 2013). It turns out that with rare exceptions, finding a lactation consultant who is approved by the insurance company and then securing payment are fraught with delays that are measured in days or weeks. Of course, these delays and snafus come during a critical window for breastfeeding success.

A recent study by Wagner et al. (Breastfeeding Concerns at 3 and 7 Days Postpartum and Feeding Status at 2 Months; Pediatrics 2013;132:e865-e75) reports the obvious. Maternal concerns about their infant’s feeding difficulties, breastfeeding pain, and milk quantity were associated with early cessation of breastfeeding, with peaks at 3 and 7 days postpartum. The fact is that even mothers who had a solid intent to nurse their babies for at least 2 months worry. They become upset if they perceive that their babies are struggling to feed, or if they suspect that the babies aren’t getting enough to eat. And, they are just as vulnerable to pain as everyone else.

These concerns and worries occur in a compressed time frame of very few days and are magnified by the sleep deprivation that accompanies most deliveries. The correct advice provided by compassionate lactation consultants (and here I include pediatricians) can be critical to breastfeeding success. But, it must be provided on a time scale that matches the tempo of the lactation process. Here I am talking about hours, not days.

Interestingly and sadly, the hospital where Ms. Wagner and her colleagues collected their data doesn’t seem to understand that time-sensitive urgency. The investigators report that lactation consultants are "generally available on the maternity unit 6 days per week." Heaven help the poor mother and infant who are struggling with a poor latch on that 7th day. And, what does "generally available" mean? Folks, a new mother’s breastfeeding concerns require intensive care. The nurses and doctors in an ICU just aren’t "generally available."

The researchers also postulate that the increase in adverse outcomes later in the first week postpartum may be because "there is often a gap between hospital and community lactation services." Really? There’s the problem in a nutshell. If we want more babies to be breastfed, we have to treat the support services as critical and time sensitive. We have done a pretty good job of convincing mothers that breastfeeding is the best way to feed their newborns. Now we have to acknowledge their concerns and support them with quality advice 24/7.

Medical homes must function like homes. Your parents may have turned the lights out at 10:00 p.m., but they didn’t leave you alone and go to a motel for the night. To achieve the kind of seamless support net that new mothers need and deserve, pediatricians need to learn more about giving lactation advice themselves. They need to join with lactation consultants with whom they feel comfortable to provide 24/7 phone support and face-to-face visits on a 365/365 schedule.

The ACA appears to be offering us the opportunity to take breastfeeding support seriously. Obviously, it has some rough edges at this point. But, let’s take advantage of this chance by seeing that the support for our patients is provided in a time frame that matches the biology of breastfeeding.

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

Updated: 10/8/2013

Most days, I feel that the Affordable Care Act’s negatives outweigh its positives, but I’m not quite ready to throw out the baby with the bathwater. For example, I recently discovered that the ACA requires that all insurance companies pay for breast pumps and lactation counseling. Great idea! But, then I learned that the law neither specifies the type of breast pump nor defines who qualifies as a trained provider of lactation counseling services (Breast-Feeding Services Lag Behind the Law, Catherine Saint Louis, New York Times, Sept. 30, 2013). It turns out that with rare exceptions, finding a lactation consultant who is approved by the insurance company and then securing payment are fraught with delays that are measured in days or weeks. Of course, these delays and snafus come during a critical window for breastfeeding success.

A recent study by Wagner et al. (Breastfeeding Concerns at 3 and 7 Days Postpartum and Feeding Status at 2 Months; Pediatrics 2013;132:e865-e75) reports the obvious. Maternal concerns about their infant’s feeding difficulties, breastfeeding pain, and milk quantity were associated with early cessation of breastfeeding, with peaks at 3 and 7 days postpartum. The fact is that even mothers who had a solid intent to nurse their babies for at least 2 months worry. They become upset if they perceive that their babies are struggling to feed, or if they suspect that the babies aren’t getting enough to eat. And, they are just as vulnerable to pain as everyone else.

These concerns and worries occur in a compressed time frame of very few days and are magnified by the sleep deprivation that accompanies most deliveries. The correct advice provided by compassionate lactation consultants (and here I include pediatricians) can be critical to breastfeeding success. But, it must be provided on a time scale that matches the tempo of the lactation process. Here I am talking about hours, not days.

Interestingly and sadly, the hospital where Ms. Wagner and her colleagues collected their data doesn’t seem to understand that time-sensitive urgency. The investigators report that lactation consultants are "generally available on the maternity unit 6 days per week." Heaven help the poor mother and infant who are struggling with a poor latch on that 7th day. And, what does "generally available" mean? Folks, a new mother’s breastfeeding concerns require intensive care. The nurses and doctors in an ICU just aren’t "generally available."

The researchers also postulate that the increase in adverse outcomes later in the first week postpartum may be because "there is often a gap between hospital and community lactation services." Really? There’s the problem in a nutshell. If we want more babies to be breastfed, we have to treat the support services as critical and time sensitive. We have done a pretty good job of convincing mothers that breastfeeding is the best way to feed their newborns. Now we have to acknowledge their concerns and support them with quality advice 24/7.

Medical homes must function like homes. Your parents may have turned the lights out at 10:00 p.m., but they didn’t leave you alone and go to a motel for the night. To achieve the kind of seamless support net that new mothers need and deserve, pediatricians need to learn more about giving lactation advice themselves. They need to join with lactation consultants with whom they feel comfortable to provide 24/7 phone support and face-to-face visits on a 365/365 schedule.

The ACA appears to be offering us the opportunity to take breastfeeding support seriously. Obviously, it has some rough edges at this point. But, let’s take advantage of this chance by seeing that the support for our patients is provided in a time frame that matches the biology of breastfeeding.

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

Updated: 10/8/2013

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

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

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

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

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

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

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

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

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

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

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

Updated: 10/8/2013

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

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

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

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

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

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

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

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

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

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

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

Updated: 10/8/2013

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

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

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

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

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

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

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

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

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

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

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

Updated: 10/8/2013

Two of my physician friends recently had knee surgery. Both have had good outcomes, but during their hospital stays they struggled to defend themselves against the troops of the no-pain-goes-untreated army. They have been paying attention, and realize that every medication and intervention carries a downside. So when they were badgered into taking something for pain in the immediate postop period, their inclination was to decline.

Weakened by preop fatigue, each eventually relented and "took the damn pills." The result was for each of them the worst experience of their surgical adventure. One vomited and wisely declined anything more than acetaminophen. The other became so loopy and disoriented that his hospital stay was extended by a day as the physicians and nurses struggled to make sure he hadn’t suffered a stroke.

If you had asked each of my friends whether they were having pain, they would have answered, "Sure." But, if you had asked them to rate their pain on a scale of 1-10, they would have screwed up their faces and asked, "What are you talking about?" If you rephrased the question and asked, "How does this compare to the worst pain you have ever had?" they would reply, "I’m sorry, are we talking apples or oranges?"

Pain is one of those things that doesn’t fit into any definable category. Because of their commitment to helping patients be as comfortable as they can, nurses are eager to use the tools at their disposal. They have been taught that in most cases, early mobility results in a better outcome, and that pain can discourage patients from wanting to move or even participate in their own recovery.

In the last several decades, there has been a well-intentioned but misguided movement toward asking patients to quantify their pain. I wonder whether there is much good evidence to support this effort. But it sounds oh so terribly scientific to put a number on something. Suffering is such a personal experience that pain can’t really be distilled down to a number or a smiley face emoticon. Although it requires more time and skill, a better approach for caregivers is to engage the patient in a dialogue about his or her discomfort. I suspect that most of the best nurses do just that.

Some well-crafted questions delivered with an empathetic tone will detect confounding issues, such as anxiety. From my observations and personal experience, anxiety is a powerful multiplier of pain. The more the patient understands about what is causing his pain and the more realistic his expectations are about how long it will last, the more tolerable the pain can be. But finding out what is making the patient anxious, and explaining the management options, including likely side effects, take time. My physician friends who initially declined pain medications (and certainly will again) did so because they have seen scores of their own patients suffer similar side effects. I’m sure that they share my suspicion that reports of side effects seriously underestimate reality.

When it comes to very young children and unconscious adults, we are limited in our ability to have a dialogue about discomfort. In those cases, we are obligated to treat and accept the risk of side effects. We must make inferences from vital signs and other biophysical measurements that the patient is uncomfortable. However, for the patient who can communicate, I think we should put more stock in what the patient tells us about what is bothering him, and why, than in the tracings on a monitor or some sketchy number.

While dictionaries usually make little distinction between "pain" and "suffering," it may be time for those of us who treat patients to consider assigning each word its own working definition. Pain could be reserved for the neurophysiologists and described in terms of spike potentials and neurotransmitter levels. Suffering, on the other hand, would be a much broader term that is unique to each patient’s experience and takes into account factors such as anxiety and depression. We may find with this redefinition that we are using less medication and that patients are more comfortable.

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

 Updated 9/4/13, 10/8/2013

Two of my physician friends recently had knee surgery. Both have had good outcomes, but during their hospital stays they struggled to defend themselves against the troops of the no-pain-goes-untreated army. They have been paying attention, and realize that every medication and intervention carries a downside. So when they were badgered into taking something for pain in the immediate postop period, their inclination was to decline.

Weakened by preop fatigue, each eventually relented and "took the damn pills." The result was for each of them the worst experience of their surgical adventure. One vomited and wisely declined anything more than acetaminophen. The other became so loopy and disoriented that his hospital stay was extended by a day as the physicians and nurses struggled to make sure he hadn’t suffered a stroke.

If you had asked each of my friends whether they were having pain, they would have answered, "Sure." But, if you had asked them to rate their pain on a scale of 1-10, they would have screwed up their faces and asked, "What are you talking about?" If you rephrased the question and asked, "How does this compare to the worst pain you have ever had?" they would reply, "I’m sorry, are we talking apples or oranges?"

Pain is one of those things that doesn’t fit into any definable category. Because of their commitment to helping patients be as comfortable as they can, nurses are eager to use the tools at their disposal. They have been taught that in most cases, early mobility results in a better outcome, and that pain can discourage patients from wanting to move or even participate in their own recovery.

In the last several decades, there has been a well-intentioned but misguided movement toward asking patients to quantify their pain. I wonder whether there is much good evidence to support this effort. But it sounds oh so terribly scientific to put a number on something. Suffering is such a personal experience that pain can’t really be distilled down to a number or a smiley face emoticon. Although it requires more time and skill, a better approach for caregivers is to engage the patient in a dialogue about his or her discomfort. I suspect that most of the best nurses do just that.

Some well-crafted questions delivered with an empathetic tone will detect confounding issues, such as anxiety. From my observations and personal experience, anxiety is a powerful multiplier of pain. The more the patient understands about what is causing his pain and the more realistic his expectations are about how long it will last, the more tolerable the pain can be. But finding out what is making the patient anxious, and explaining the management options, including likely side effects, take time. My physician friends who initially declined pain medications (and certainly will again) did so because they have seen scores of their own patients suffer similar side effects. I’m sure that they share my suspicion that reports of side effects seriously underestimate reality.

When it comes to very young children and unconscious adults, we are limited in our ability to have a dialogue about discomfort. In those cases, we are obligated to treat and accept the risk of side effects. We must make inferences from vital signs and other biophysical measurements that the patient is uncomfortable. However, for the patient who can communicate, I think we should put more stock in what the patient tells us about what is bothering him, and why, than in the tracings on a monitor or some sketchy number.

While dictionaries usually make little distinction between "pain" and "suffering," it may be time for those of us who treat patients to consider assigning each word its own working definition. Pain could be reserved for the neurophysiologists and described in terms of spike potentials and neurotransmitter levels. Suffering, on the other hand, would be a much broader term that is unique to each patient’s experience and takes into account factors such as anxiety and depression. We may find with this redefinition that we are using less medication and that patients are more comfortable.

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

 Updated 9/4/13, 10/8/2013

Two of my physician friends recently had knee surgery. Both have had good outcomes, but during their hospital stays they struggled to defend themselves against the troops of the no-pain-goes-untreated army. They have been paying attention, and realize that every medication and intervention carries a downside. So when they were badgered into taking something for pain in the immediate postop period, their inclination was to decline.

Weakened by preop fatigue, each eventually relented and "took the damn pills." The result was for each of them the worst experience of their surgical adventure. One vomited and wisely declined anything more than acetaminophen. The other became so loopy and disoriented that his hospital stay was extended by a day as the physicians and nurses struggled to make sure he hadn’t suffered a stroke.

If you had asked each of my friends whether they were having pain, they would have answered, "Sure." But, if you had asked them to rate their pain on a scale of 1-10, they would have screwed up their faces and asked, "What are you talking about?" If you rephrased the question and asked, "How does this compare to the worst pain you have ever had?" they would reply, "I’m sorry, are we talking apples or oranges?"

Pain is one of those things that doesn’t fit into any definable category. Because of their commitment to helping patients be as comfortable as they can, nurses are eager to use the tools at their disposal. They have been taught that in most cases, early mobility results in a better outcome, and that pain can discourage patients from wanting to move or even participate in their own recovery.

In the last several decades, there has been a well-intentioned but misguided movement toward asking patients to quantify their pain. I wonder whether there is much good evidence to support this effort. But it sounds oh so terribly scientific to put a number on something. Suffering is such a personal experience that pain can’t really be distilled down to a number or a smiley face emoticon. Although it requires more time and skill, a better approach for caregivers is to engage the patient in a dialogue about his or her discomfort. I suspect that most of the best nurses do just that.

Some well-crafted questions delivered with an empathetic tone will detect confounding issues, such as anxiety. From my observations and personal experience, anxiety is a powerful multiplier of pain. The more the patient understands about what is causing his pain and the more realistic his expectations are about how long it will last, the more tolerable the pain can be. But finding out what is making the patient anxious, and explaining the management options, including likely side effects, take time. My physician friends who initially declined pain medications (and certainly will again) did so because they have seen scores of their own patients suffer similar side effects. I’m sure that they share my suspicion that reports of side effects seriously underestimate reality.

When it comes to very young children and unconscious adults, we are limited in our ability to have a dialogue about discomfort. In those cases, we are obligated to treat and accept the risk of side effects. We must make inferences from vital signs and other biophysical measurements that the patient is uncomfortable. However, for the patient who can communicate, I think we should put more stock in what the patient tells us about what is bothering him, and why, than in the tracings on a monitor or some sketchy number.

While dictionaries usually make little distinction between "pain" and "suffering," it may be time for those of us who treat patients to consider assigning each word its own working definition. Pain could be reserved for the neurophysiologists and described in terms of spike potentials and neurotransmitter levels. Suffering, on the other hand, would be a much broader term that is unique to each patient’s experience and takes into account factors such as anxiety and depression. We may find with this redefinition that we are using less medication and that patients are more comfortable.

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

 Updated 9/4/13, 10/8/2013

I grew up in a small town about 30 miles north of New York City. Back then, it was a quiet, semirural community proud of its excellent school system. It was a wonderful place for raising children and still affordable for families with modest means.

Like half of the other men in town, my father commuted into the city for his job. As a result, he spent more than 2 hours of his day travelling. My memories of how he looked and what he said when he arrived home in the evening convinced me that I would never allow commuting to gobble up a large chunk of my life. As commutes go, I guess his was relatively benign. Most nights he had a seat on the train and could read the newspaper and do the crossword.

My sister and I will be forever grateful for those sacrifices he made by commuting so that we could grow up in a safe and supportive community. But as I considered my options for work, I ruled out the subspecialties of pediatric dermatology and radiology, which suited my visual skills, because they would have required me to live in a city of several hundred thousand people. My preference for small town life and an aversion to commuting meant that happiness would be more likely if I worked and resided in the same town.

Until one of our hospitals moved 4 miles to the other side of town a few years ago, my commute consisted of a 5-minute bike ride or a 12-minute walk. When our children were young, it meant that, even though I might not be able to make it home for dinner or tuck-in time, we could have lunch and play ball in the yard before their afternoon naps.

As I have watched other parents struggle to fabricate quality time with their children, I wish that more of them could have made the decision my wife and I made when we chose to live and work in the same community. I know that this will never be a viable option for many families, particularly for those saintly folks who have chosen to provide health care to underserved inner city populations. However, I fear that too many families underestimate the toll that commuting can take on the fabric of their lives.

A parent exhausted by a long drive in rush-hour traffic is generally not the best parent he or she could be. Young children have trouble understanding why they need to wait for the weekend to spend time with their parents. Workdays inflated by lengthy commutes may nudge parents into making the unwise decision of delaying their children’s bedtimes to an unhealthy hour so that they can be part of the process.

I suspect that most of you have long ago made the big decisions about location and have either endured the consequences or made creative adjustments that have allowed you to comfortably bridge the gap between where you work and where you live. But for those of you who are on the threshold of your professional career or who are facing burnout fueled by too-few-hours-in-a-day, do the math. Imagine what you could do with the time you will be or have been investing in your commute. Are there things you could be doing to make the community where you work a place where you would also like to live? If you eliminate your commute you may have the time to do all sorts of wonderful things.

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

Updated 9/4/13, 10/8/13

I grew up in a small town about 30 miles north of New York City. Back then, it was a quiet, semirural community proud of its excellent school system. It was a wonderful place for raising children and still affordable for families with modest means.

Like half of the other men in town, my father commuted into the city for his job. As a result, he spent more than 2 hours of his day travelling. My memories of how he looked and what he said when he arrived home in the evening convinced me that I would never allow commuting to gobble up a large chunk of my life. As commutes go, I guess his was relatively benign. Most nights he had a seat on the train and could read the newspaper and do the crossword.

My sister and I will be forever grateful for those sacrifices he made by commuting so that we could grow up in a safe and supportive community. But as I considered my options for work, I ruled out the subspecialties of pediatric dermatology and radiology, which suited my visual skills, because they would have required me to live in a city of several hundred thousand people. My preference for small town life and an aversion to commuting meant that happiness would be more likely if I worked and resided in the same town.

Until one of our hospitals moved 4 miles to the other side of town a few years ago, my commute consisted of a 5-minute bike ride or a 12-minute walk. When our children were young, it meant that, even though I might not be able to make it home for dinner or tuck-in time, we could have lunch and play ball in the yard before their afternoon naps.

As I have watched other parents struggle to fabricate quality time with their children, I wish that more of them could have made the decision my wife and I made when we chose to live and work in the same community. I know that this will never be a viable option for many families, particularly for those saintly folks who have chosen to provide health care to underserved inner city populations. However, I fear that too many families underestimate the toll that commuting can take on the fabric of their lives.

A parent exhausted by a long drive in rush-hour traffic is generally not the best parent he or she could be. Young children have trouble understanding why they need to wait for the weekend to spend time with their parents. Workdays inflated by lengthy commutes may nudge parents into making the unwise decision of delaying their children’s bedtimes to an unhealthy hour so that they can be part of the process.

I suspect that most of you have long ago made the big decisions about location and have either endured the consequences or made creative adjustments that have allowed you to comfortably bridge the gap between where you work and where you live. But for those of you who are on the threshold of your professional career or who are facing burnout fueled by too-few-hours-in-a-day, do the math. Imagine what you could do with the time you will be or have been investing in your commute. Are there things you could be doing to make the community where you work a place where you would also like to live? If you eliminate your commute you may have the time to do all sorts of wonderful things.

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

Updated 9/4/13, 10/8/13

I grew up in a small town about 30 miles north of New York City. Back then, it was a quiet, semirural community proud of its excellent school system. It was a wonderful place for raising children and still affordable for families with modest means.

Like half of the other men in town, my father commuted into the city for his job. As a result, he spent more than 2 hours of his day travelling. My memories of how he looked and what he said when he arrived home in the evening convinced me that I would never allow commuting to gobble up a large chunk of my life. As commutes go, I guess his was relatively benign. Most nights he had a seat on the train and could read the newspaper and do the crossword.

My sister and I will be forever grateful for those sacrifices he made by commuting so that we could grow up in a safe and supportive community. But as I considered my options for work, I ruled out the subspecialties of pediatric dermatology and radiology, which suited my visual skills, because they would have required me to live in a city of several hundred thousand people. My preference for small town life and an aversion to commuting meant that happiness would be more likely if I worked and resided in the same town.

Until one of our hospitals moved 4 miles to the other side of town a few years ago, my commute consisted of a 5-minute bike ride or a 12-minute walk. When our children were young, it meant that, even though I might not be able to make it home for dinner or tuck-in time, we could have lunch and play ball in the yard before their afternoon naps.

As I have watched other parents struggle to fabricate quality time with their children, I wish that more of them could have made the decision my wife and I made when we chose to live and work in the same community. I know that this will never be a viable option for many families, particularly for those saintly folks who have chosen to provide health care to underserved inner city populations. However, I fear that too many families underestimate the toll that commuting can take on the fabric of their lives.

A parent exhausted by a long drive in rush-hour traffic is generally not the best parent he or she could be. Young children have trouble understanding why they need to wait for the weekend to spend time with their parents. Workdays inflated by lengthy commutes may nudge parents into making the unwise decision of delaying their children’s bedtimes to an unhealthy hour so that they can be part of the process.

I suspect that most of you have long ago made the big decisions about location and have either endured the consequences or made creative adjustments that have allowed you to comfortably bridge the gap between where you work and where you live. But for those of you who are on the threshold of your professional career or who are facing burnout fueled by too-few-hours-in-a-day, do the math. Imagine what you could do with the time you will be or have been investing in your commute. Are there things you could be doing to make the community where you work a place where you would also like to live? If you eliminate your commute you may have the time to do all sorts of wonderful things.

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

Updated 9/4/13, 10/8/13

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thirty years ago, I was transitioning from a two-doctor partnership to solo practice. I was desperately seeking advice about how to run a small business when I stumbled across a letter to the editor written by an older physician. He wrote that for 20 years he had pegged his office visit charge to the price of a first-class stamp ... a dollar for each penny of postage. He claimed that over 2 decades, it had allowed him to stay ahead of inflation and provided him a level of reimbursement that he felt was fair and equitable.

While at the time it seemed like a reasonable strategy, it obviously wouldn’t work now. Today, at $0.47 a stamp the United States Postal Service is losing money hand over fist. And, I don’t think there are many physicians today who are billing $47 dollars for a 99213. Although if the price of stamp reflected the real costs, that old guy’s formula might still hold up.

As long as I practiced by myself, I was acutely aware of my expenses and my charges. While most families I saw had some level of third-party coverage, there were plenty of lobsterman, carpenters, and other small business owners who were paying out of pocket. Often, on the weekend, I was the only one in the office. I had to be comfortable with saying, as I looked a parent in the eye, "If you want to pay for the visit today, it’ll be $23." Many of the families were friends and all of them were neighbors because Brunswick was and still is a small town.

Although I was very aware of my own office visit and in-house lab charges, I was never quite sure about what the hospitals were billing for tests and x-rays that I ordered. But, I got enough "Doctor, do you know what that test cost?" calls to want to be better informed.

Many years later, when I joined a small physician-owned group, we were all still directly involved in the fee-setting process. But, as the group was engulfed by larger and larger entities, the fee schedule disappeared behind a corporate smoke screen. An article in the June 2013 Pediatrics makes it pretty clear that I was not alone in my state of ignorance. T. A. Rock et al. from the Children’s Hospital of Philadelphia reported that 71% of the general pediatric attending physicians and 75% of the pediatric residents would describe themselves as "minimally knowledgeable" or "completely unaware" of the costs, charges, and reimbursements at the hospital (Pediatrics 2013:131;1072-80).

One might argue that hospitals and large group practices are such complex entities with a variety of contractual arrangements with multiple payers that it is unreasonable for a physician to be informed about what is being charged of his or her services. Rubbish! It is unreasonable to expect a physician to become an investigative reporter in his or her spare time. But, it is time that hospitals and large groups lift the smoke screen that hangs over health care charges in this country. Everyone – patients, tax payers and not least of all providers – need to know what health care costs.

One might also argue that a physician should not consider the cost of a diagnostic test that he or she is ordering. That may have been a valid argument when malpractice suits were infrequent and inconsequential. But, now an unreasonable number of tests are ordered simply as defensive medicine. We physicians have not been good stewards of the health care dollar. Cost should not discourage us from ordering a test that is truly necessary. But, each time we click a box on the order screen we should be asking ourselves, "How much of somebody else’s money am I spending to cover my behind?"

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

Thirty years ago, I was transitioning from a two-doctor partnership to solo practice. I was desperately seeking advice about how to run a small business when I stumbled across a letter to the editor written by an older physician. He wrote that for 20 years he had pegged his office visit charge to the price of a first-class stamp ... a dollar for each penny of postage. He claimed that over 2 decades, it had allowed him to stay ahead of inflation and provided him a level of reimbursement that he felt was fair and equitable.

While at the time it seemed like a reasonable strategy, it obviously wouldn’t work now. Today, at $0.47 a stamp the United States Postal Service is losing money hand over fist. And, I don’t think there are many physicians today who are billing $47 dollars for a 99213. Although if the price of stamp reflected the real costs, that old guy’s formula might still hold up.

As long as I practiced by myself, I was acutely aware of my expenses and my charges. While most families I saw had some level of third-party coverage, there were plenty of lobsterman, carpenters, and other small business owners who were paying out of pocket. Often, on the weekend, I was the only one in the office. I had to be comfortable with saying, as I looked a parent in the eye, "If you want to pay for the visit today, it’ll be $23." Many of the families were friends and all of them were neighbors because Brunswick was and still is a small town.

Although I was very aware of my own office visit and in-house lab charges, I was never quite sure about what the hospitals were billing for tests and x-rays that I ordered. But, I got enough "Doctor, do you know what that test cost?" calls to want to be better informed.

Many years later, when I joined a small physician-owned group, we were all still directly involved in the fee-setting process. But, as the group was engulfed by larger and larger entities, the fee schedule disappeared behind a corporate smoke screen. An article in the June 2013 Pediatrics makes it pretty clear that I was not alone in my state of ignorance. T. A. Rock et al. from the Children’s Hospital of Philadelphia reported that 71% of the general pediatric attending physicians and 75% of the pediatric residents would describe themselves as "minimally knowledgeable" or "completely unaware" of the costs, charges, and reimbursements at the hospital (Pediatrics 2013:131;1072-80).

One might argue that hospitals and large group practices are such complex entities with a variety of contractual arrangements with multiple payers that it is unreasonable for a physician to be informed about what is being charged of his or her services. Rubbish! It is unreasonable to expect a physician to become an investigative reporter in his or her spare time. But, it is time that hospitals and large groups lift the smoke screen that hangs over health care charges in this country. Everyone – patients, tax payers and not least of all providers – need to know what health care costs.

One might also argue that a physician should not consider the cost of a diagnostic test that he or she is ordering. That may have been a valid argument when malpractice suits were infrequent and inconsequential. But, now an unreasonable number of tests are ordered simply as defensive medicine. We physicians have not been good stewards of the health care dollar. Cost should not discourage us from ordering a test that is truly necessary. But, each time we click a box on the order screen we should be asking ourselves, "How much of somebody else’s money am I spending to cover my behind?"

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

Thirty years ago, I was transitioning from a two-doctor partnership to solo practice. I was desperately seeking advice about how to run a small business when I stumbled across a letter to the editor written by an older physician. He wrote that for 20 years he had pegged his office visit charge to the price of a first-class stamp ... a dollar for each penny of postage. He claimed that over 2 decades, it had allowed him to stay ahead of inflation and provided him a level of reimbursement that he felt was fair and equitable.

While at the time it seemed like a reasonable strategy, it obviously wouldn’t work now. Today, at $0.47 a stamp the United States Postal Service is losing money hand over fist. And, I don’t think there are many physicians today who are billing $47 dollars for a 99213. Although if the price of stamp reflected the real costs, that old guy’s formula might still hold up.

As long as I practiced by myself, I was acutely aware of my expenses and my charges. While most families I saw had some level of third-party coverage, there were plenty of lobsterman, carpenters, and other small business owners who were paying out of pocket. Often, on the weekend, I was the only one in the office. I had to be comfortable with saying, as I looked a parent in the eye, "If you want to pay for the visit today, it’ll be $23." Many of the families were friends and all of them were neighbors because Brunswick was and still is a small town.

Although I was very aware of my own office visit and in-house lab charges, I was never quite sure about what the hospitals were billing for tests and x-rays that I ordered. But, I got enough "Doctor, do you know what that test cost?" calls to want to be better informed.

Many years later, when I joined a small physician-owned group, we were all still directly involved in the fee-setting process. But, as the group was engulfed by larger and larger entities, the fee schedule disappeared behind a corporate smoke screen. An article in the June 2013 Pediatrics makes it pretty clear that I was not alone in my state of ignorance. T. A. Rock et al. from the Children’s Hospital of Philadelphia reported that 71% of the general pediatric attending physicians and 75% of the pediatric residents would describe themselves as "minimally knowledgeable" or "completely unaware" of the costs, charges, and reimbursements at the hospital (Pediatrics 2013:131;1072-80).

One might argue that hospitals and large group practices are such complex entities with a variety of contractual arrangements with multiple payers that it is unreasonable for a physician to be informed about what is being charged of his or her services. Rubbish! It is unreasonable to expect a physician to become an investigative reporter in his or her spare time. But, it is time that hospitals and large groups lift the smoke screen that hangs over health care charges in this country. Everyone – patients, tax payers and not least of all providers – need to know what health care costs.

One might also argue that a physician should not consider the cost of a diagnostic test that he or she is ordering. That may have been a valid argument when malpractice suits were infrequent and inconsequential. But, now an unreasonable number of tests are ordered simply as defensive medicine. We physicians have not been good stewards of the health care dollar. Cost should not discourage us from ordering a test that is truly necessary. But, each time we click a box on the order screen we should be asking ourselves, "How much of somebody else’s money am I spending to cover my behind?"

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

When I was 8 and my sister was 10 months old, we were playing on the living room carpet when, suddenly and without provocation, the little creeper hit me in the mouth with a Kiwi shoe polish bottle.

I have no idea why we were playing with a shoe polish bottle, but of all the potential disasters that could have occurred, I guess a chipped central incisor was a relatively minor result. That was my first wake-up call to the destructive power lurking in the lightning-quick hands of infants and toddlers.

Unfortunately, many adults are unaware or have forgotten that their own faces can be enticing targets for babies eager to engage in tactile exploration of the environment. Scratched corneas, torn ear lobes, and mangled spectacles are the most common occurrences when relatives and strangers attempt an in-your-face style of getting acquainted. I recall meeting one grandmother who nearly lost her vision in one eye as the result of an infected infant fingernail scratch of her cornea.

We pediatricians should understand better than most people that infants can lash out without warning, but stuff happens. We might be distracted by a could-it-be-a-murmur sound coming through the stethoscope tubing. Or we may be suffering from some postlunch drowsiness and "Oops," there goes a new pair of glasses.

Given the frequency of our close encounters with infants and toddlers, one would expect that patient-inflicted injuries are quite common, but I’m not aware of any data on this kind of work-related hazard. I suspect that most of us fret more about the risk of contracting an infection from our patients than about being injured in the line of duty.

Looking back on a career that spans 4 decades, I can recall a few incidents in which I took a direct snot shot to the eye and developed conjunctivitis. I don’t remember being injured. Have I just been lucky or is there something about how I approach little patients that has protected me?

Like most of you, I have unconsciously learned some self-defense strategies along the way. For example, I got peed on quite a bit as resident, but now I always keep one eye on the penis and one hand on the flap of a diaper. I haven’t been hit in the last 30 years.

I examine patients under the age of 4 in their parents’ laps. I hold the child’s left elbow with my right hand, adjusting the grip depending on the child’s behavior. I ask the parent to hold the other elbow. When it’s time to get into the child’s face, I show the parents how to encircle the patient in a bear hug. Some parents don’t seem to realize that their role is critical to my safety, and so I must remain on alert for the first sign of a Houdini escape.

As infants become toddlers, innocent pokes of curiosity can become intentional jabs and swats. Hopefully, a low-key, gentle approach can keep these challenges to a minimum, but you know as well as I do that, when language fails them, children have few ways to respond but to strike out when they are afraid.

Have patients tried to bite me? Yes! Have they succeeded? Thankfully not.

Nowadays, my biggest safety concern when I enter an exam room is tripping as I navigate the minefield of toys scattered on the floor. I would like to hear from you about patient-inflicted injuries that you have experienced or heard about, and what strategies you may use to keep yourself intact while you examine these deceptively passive cuties.

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

When I was 8 and my sister was 10 months old, we were playing on the living room carpet when, suddenly and without provocation, the little creeper hit me in the mouth with a Kiwi shoe polish bottle.

I have no idea why we were playing with a shoe polish bottle, but of all the potential disasters that could have occurred, I guess a chipped central incisor was a relatively minor result. That was my first wake-up call to the destructive power lurking in the lightning-quick hands of infants and toddlers.

Unfortunately, many adults are unaware or have forgotten that their own faces can be enticing targets for babies eager to engage in tactile exploration of the environment. Scratched corneas, torn ear lobes, and mangled spectacles are the most common occurrences when relatives and strangers attempt an in-your-face style of getting acquainted. I recall meeting one grandmother who nearly lost her vision in one eye as the result of an infected infant fingernail scratch of her cornea.

We pediatricians should understand better than most people that infants can lash out without warning, but stuff happens. We might be distracted by a could-it-be-a-murmur sound coming through the stethoscope tubing. Or we may be suffering from some postlunch drowsiness and "Oops," there goes a new pair of glasses.

Given the frequency of our close encounters with infants and toddlers, one would expect that patient-inflicted injuries are quite common, but I’m not aware of any data on this kind of work-related hazard. I suspect that most of us fret more about the risk of contracting an infection from our patients than about being injured in the line of duty.

Looking back on a career that spans 4 decades, I can recall a few incidents in which I took a direct snot shot to the eye and developed conjunctivitis. I don’t remember being injured. Have I just been lucky or is there something about how I approach little patients that has protected me?

Like most of you, I have unconsciously learned some self-defense strategies along the way. For example, I got peed on quite a bit as resident, but now I always keep one eye on the penis and one hand on the flap of a diaper. I haven’t been hit in the last 30 years.

I examine patients under the age of 4 in their parents’ laps. I hold the child’s left elbow with my right hand, adjusting the grip depending on the child’s behavior. I ask the parent to hold the other elbow. When it’s time to get into the child’s face, I show the parents how to encircle the patient in a bear hug. Some parents don’t seem to realize that their role is critical to my safety, and so I must remain on alert for the first sign of a Houdini escape.

As infants become toddlers, innocent pokes of curiosity can become intentional jabs and swats. Hopefully, a low-key, gentle approach can keep these challenges to a minimum, but you know as well as I do that, when language fails them, children have few ways to respond but to strike out when they are afraid.

Have patients tried to bite me? Yes! Have they succeeded? Thankfully not.

Nowadays, my biggest safety concern when I enter an exam room is tripping as I navigate the minefield of toys scattered on the floor. I would like to hear from you about patient-inflicted injuries that you have experienced or heard about, and what strategies you may use to keep yourself intact while you examine these deceptively passive cuties.

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

When I was 8 and my sister was 10 months old, we were playing on the living room carpet when, suddenly and without provocation, the little creeper hit me in the mouth with a Kiwi shoe polish bottle.

I have no idea why we were playing with a shoe polish bottle, but of all the potential disasters that could have occurred, I guess a chipped central incisor was a relatively minor result. That was my first wake-up call to the destructive power lurking in the lightning-quick hands of infants and toddlers.

Unfortunately, many adults are unaware or have forgotten that their own faces can be enticing targets for babies eager to engage in tactile exploration of the environment. Scratched corneas, torn ear lobes, and mangled spectacles are the most common occurrences when relatives and strangers attempt an in-your-face style of getting acquainted. I recall meeting one grandmother who nearly lost her vision in one eye as the result of an infected infant fingernail scratch of her cornea.

We pediatricians should understand better than most people that infants can lash out without warning, but stuff happens. We might be distracted by a could-it-be-a-murmur sound coming through the stethoscope tubing. Or we may be suffering from some postlunch drowsiness and "Oops," there goes a new pair of glasses.

Given the frequency of our close encounters with infants and toddlers, one would expect that patient-inflicted injuries are quite common, but I’m not aware of any data on this kind of work-related hazard. I suspect that most of us fret more about the risk of contracting an infection from our patients than about being injured in the line of duty.

Looking back on a career that spans 4 decades, I can recall a few incidents in which I took a direct snot shot to the eye and developed conjunctivitis. I don’t remember being injured. Have I just been lucky or is there something about how I approach little patients that has protected me?

Like most of you, I have unconsciously learned some self-defense strategies along the way. For example, I got peed on quite a bit as resident, but now I always keep one eye on the penis and one hand on the flap of a diaper. I haven’t been hit in the last 30 years.

I examine patients under the age of 4 in their parents’ laps. I hold the child’s left elbow with my right hand, adjusting the grip depending on the child’s behavior. I ask the parent to hold the other elbow. When it’s time to get into the child’s face, I show the parents how to encircle the patient in a bear hug. Some parents don’t seem to realize that their role is critical to my safety, and so I must remain on alert for the first sign of a Houdini escape.

As infants become toddlers, innocent pokes of curiosity can become intentional jabs and swats. Hopefully, a low-key, gentle approach can keep these challenges to a minimum, but you know as well as I do that, when language fails them, children have few ways to respond but to strike out when they are afraid.

Have patients tried to bite me? Yes! Have they succeeded? Thankfully not.

Nowadays, my biggest safety concern when I enter an exam room is tripping as I navigate the minefield of toys scattered on the floor. I would like to hear from you about patient-inflicted injuries that you have experienced or heard about, and what strategies you may use to keep yourself intact while you examine these deceptively passive cuties.

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