William G. Wilkoff

The receptionist usually scribbles an abbreviated version of the patient's chief complaint at the top of the billing form to give me a heads-up on the diagnostic challenge awaiting me, but Sheila was still learning the job and had left the space blank. It wasn't a big deal, but it meant I was going to enter the examining room blind.

As I eased the door open, however, my nose told me everything I needed to know before my eyes met the droopy gaze of the 12-year-old slouched on the exam table. The heavy, sweet odor told me this young man's mother was going to say her son had a sore throat, and it told me I was going to correctly predict that his rapid strep test would be positive.

Although the ears and eyes are the pediatrician's most powerful sensors, there are a few pediatric illnesses with distinctive odors that can lead the olfactorily sensitive physician to the right diagnosis. When I check the incubator each morning, I know instantly by the smell if we have a positive urine culture growing. An 8-year-old boy's smelly armpits prompt me to examine his genitalia, even though his chief complaint is a cough.

There are the 3-year-olds with bad breath and a little trickle from one nostril whose parents are surprised when I accurately anticipate that I am going to find a smelly little treasure hidden beneath a turbinate. And I must admit that I get a bit of perverse pleasure when I see the expression on the face of a squeamish parent of a 1-week-old after I lift up a previously undisturbed umbilical cord and release an invisible fetid cloud of aroma.

Other odors can alert me to a child-unfriendly home environment. When a 3-month-old smells like an ashtray, I can skip over my standard question about someone smoking. I move forward into a thorough investigation of exactly who is smoking and when and then begin looking for a remedy. The smoky smell puts me on alert for other things about the family that will put the baby at risk.

One of the most troubling odors I have encountered is alcohol on the breath of a father who had driven his child to the office for a well-child visit. This meant confronting him and then finding his wife so that she could become the designated driver. As uncomfortable as that encounter was, it did lead to a first stab at family counseling and a trip to Alcoholics Anonymous.

My nose reminds me that I live and practice in a community with socioeconomic diversity. Although they usually try to disguise their occupational odors, sometimes people just don't have enough time to do a thorough decontamination. The cattle and dairy farmers arrive with a hint of eau de barnyard, the woodcutters with a mixture of fresh sawdust and chainsaw oil. Fathers who have had to prime balky carburetors by hand to get the old family pickup truck going show up smelling of gasoline and axle grease. The lobstermen and sardine packers may arrive smelling of fish. But fortunately, we aren't too fashion conscious here in Maine, and I must rarely endure the overdoses of designer perfume that those of you in big cities encounter.

Although some of these odors are unpleasant even in small doses, the smell that bothers me the most is that of a well-cooked meal on a family when my lunch is a distant memory and dinner is still a waiting room full of patients away.

The receptionist usually scribbles an abbreviated version of the patient's chief complaint at the top of the billing form to give me a heads-up on the diagnostic challenge awaiting me, but Sheila was still learning the job and had left the space blank. It wasn't a big deal, but it meant I was going to enter the examining room blind.

As I eased the door open, however, my nose told me everything I needed to know before my eyes met the droopy gaze of the 12-year-old slouched on the exam table. The heavy, sweet odor told me this young man's mother was going to say her son had a sore throat, and it told me I was going to correctly predict that his rapid strep test would be positive.

Although the ears and eyes are the pediatrician's most powerful sensors, there are a few pediatric illnesses with distinctive odors that can lead the olfactorily sensitive physician to the right diagnosis. When I check the incubator each morning, I know instantly by the smell if we have a positive urine culture growing. An 8-year-old boy's smelly armpits prompt me to examine his genitalia, even though his chief complaint is a cough.

There are the 3-year-olds with bad breath and a little trickle from one nostril whose parents are surprised when I accurately anticipate that I am going to find a smelly little treasure hidden beneath a turbinate. And I must admit that I get a bit of perverse pleasure when I see the expression on the face of a squeamish parent of a 1-week-old after I lift up a previously undisturbed umbilical cord and release an invisible fetid cloud of aroma.

Other odors can alert me to a child-unfriendly home environment. When a 3-month-old smells like an ashtray, I can skip over my standard question about someone smoking. I move forward into a thorough investigation of exactly who is smoking and when and then begin looking for a remedy. The smoky smell puts me on alert for other things about the family that will put the baby at risk.

One of the most troubling odors I have encountered is alcohol on the breath of a father who had driven his child to the office for a well-child visit. This meant confronting him and then finding his wife so that she could become the designated driver. As uncomfortable as that encounter was, it did lead to a first stab at family counseling and a trip to Alcoholics Anonymous.

My nose reminds me that I live and practice in a community with socioeconomic diversity. Although they usually try to disguise their occupational odors, sometimes people just don't have enough time to do a thorough decontamination. The cattle and dairy farmers arrive with a hint of eau de barnyard, the woodcutters with a mixture of fresh sawdust and chainsaw oil. Fathers who have had to prime balky carburetors by hand to get the old family pickup truck going show up smelling of gasoline and axle grease. The lobstermen and sardine packers may arrive smelling of fish. But fortunately, we aren't too fashion conscious here in Maine, and I must rarely endure the overdoses of designer perfume that those of you in big cities encounter.

Although some of these odors are unpleasant even in small doses, the smell that bothers me the most is that of a well-cooked meal on a family when my lunch is a distant memory and dinner is still a waiting room full of patients away.

The receptionist usually scribbles an abbreviated version of the patient's chief complaint at the top of the billing form to give me a heads-up on the diagnostic challenge awaiting me, but Sheila was still learning the job and had left the space blank. It wasn't a big deal, but it meant I was going to enter the examining room blind.

As I eased the door open, however, my nose told me everything I needed to know before my eyes met the droopy gaze of the 12-year-old slouched on the exam table. The heavy, sweet odor told me this young man's mother was going to say her son had a sore throat, and it told me I was going to correctly predict that his rapid strep test would be positive.

Although the ears and eyes are the pediatrician's most powerful sensors, there are a few pediatric illnesses with distinctive odors that can lead the olfactorily sensitive physician to the right diagnosis. When I check the incubator each morning, I know instantly by the smell if we have a positive urine culture growing. An 8-year-old boy's smelly armpits prompt me to examine his genitalia, even though his chief complaint is a cough.

There are the 3-year-olds with bad breath and a little trickle from one nostril whose parents are surprised when I accurately anticipate that I am going to find a smelly little treasure hidden beneath a turbinate. And I must admit that I get a bit of perverse pleasure when I see the expression on the face of a squeamish parent of a 1-week-old after I lift up a previously undisturbed umbilical cord and release an invisible fetid cloud of aroma.

Other odors can alert me to a child-unfriendly home environment. When a 3-month-old smells like an ashtray, I can skip over my standard question about someone smoking. I move forward into a thorough investigation of exactly who is smoking and when and then begin looking for a remedy. The smoky smell puts me on alert for other things about the family that will put the baby at risk.

One of the most troubling odors I have encountered is alcohol on the breath of a father who had driven his child to the office for a well-child visit. This meant confronting him and then finding his wife so that she could become the designated driver. As uncomfortable as that encounter was, it did lead to a first stab at family counseling and a trip to Alcoholics Anonymous.

My nose reminds me that I live and practice in a community with socioeconomic diversity. Although they usually try to disguise their occupational odors, sometimes people just don't have enough time to do a thorough decontamination. The cattle and dairy farmers arrive with a hint of eau de barnyard, the woodcutters with a mixture of fresh sawdust and chainsaw oil. Fathers who have had to prime balky carburetors by hand to get the old family pickup truck going show up smelling of gasoline and axle grease. The lobstermen and sardine packers may arrive smelling of fish. But fortunately, we aren't too fashion conscious here in Maine, and I must rarely endure the overdoses of designer perfume that those of you in big cities encounter.

Although some of these odors are unpleasant even in small doses, the smell that bothers me the most is that of a well-cooked meal on a family when my lunch is a distant memory and dinner is still a waiting room full of patients away.

A few weeks ago I visited my favorite otolaryngologist. He's my favorite because he doesn't cut first and ask questions later. He is also very good at explaining things to parents. Bob is about my age and had already been in practice for a couple of years when I arrived in town in 1974.

My appointment was the first and last attempt to find a treatable cause for my dwindling hearing. I have long suspected that it is simply the result of years of auditory abuse, and reading the studies documenting that most pediatricians are exposed to noise levels deemed unsafe by the standards of the Occupational Safety and Health Administration only added to my suspicions. Although I feared that my difficulty catching every word in group conversations was the inevitable audiologic equivalent of presbyopia, I was in denial. I hoped that Bob could cure the problem by removing 35 years' worth of stethoscope-compacted cerumen.

After checking in with the receptionist, I spent a few minutes in his bare-bones waiting room catching up on Hollywood gossip and chatting with one of my teenage patients, who had just recovered from a bout of sinusitis-induced septicemia. When it was my turn, Bob ushered me into his small examining room and sat me down in what could have been an old barber chair. Since neither of us is a frequent attendee at hospital staff meetings, we had lots of catching up to do. The conversation ranged from children's weddings to our painful attempts at reacquiring tennis skills that had been allowed to atrophy over the last 2 decades.

After what seemed like less than 5 minutes of banter, he paused and said, “Well, the good news is that you don't have any wax in your ears. The bad news is that I bet you'll be wanting a hearing aid in a couple of years.” He then spent 10 minutes explaining the physiologic process that was eroding my hearing and what I could do to remedy the situation. We parted with an agreement to get together for some doubles in a couple of weeks.

As I climbed back into my truck for the trip home, I wondered how Bob could sound so confident about the cause of my deafness without even looking in my ears. The examination portion of the visit had flown by so quickly that I didn't remember him using an otoscope.

As I turned onto the highway, I attempted to reconstruct our encounter. He had moved so smoothly and efficiently through the exam that my focus had been on our conversation and not his invasion into every orifice in my head. I began to recall that he had not only looked in my ears, but he had also removed a small bit of cerumen and insufflated my tympanic membranes. He had looked past my turbinates, sterilized a mirror with an alcohol lamp, and taken a peek at my vocal cords. His fingers had nimbly danced over my thyroid and all the nodes above my clavicles.

As I thought about it, I realized that Bob had done an extremely thorough head and neck exam. Because of his efficiency, which came from more than 30 years of experience and the familiar surroundings of an office where every instrument was exactly where it was supposed to be, the process had taken no more than 4 or 5 minutes. Thirty years of trial and error guided his hands to find my tympanic membranes on the first pass and locate my vocal cords without triggering my gag reflex.

In the hands of an experienced clinician, a good, focused physical exam doesn't take much time. The true test of our clinical ability is not the speed at which we have learned to perform a thorough examination but what we do with the time we have saved. Do we reinvest it in the patient we have just examined by conveying to them what we have discovered in a manner that says we care? Or do we use the time we have gained through our efficiency to rush on to the next patient? Fortunately for me, Bob has chosen to do the former, and that's another reason he's my favorite.

A few weeks ago I visited my favorite otolaryngologist. He's my favorite because he doesn't cut first and ask questions later. He is also very good at explaining things to parents. Bob is about my age and had already been in practice for a couple of years when I arrived in town in 1974.

My appointment was the first and last attempt to find a treatable cause for my dwindling hearing. I have long suspected that it is simply the result of years of auditory abuse, and reading the studies documenting that most pediatricians are exposed to noise levels deemed unsafe by the standards of the Occupational Safety and Health Administration only added to my suspicions. Although I feared that my difficulty catching every word in group conversations was the inevitable audiologic equivalent of presbyopia, I was in denial. I hoped that Bob could cure the problem by removing 35 years' worth of stethoscope-compacted cerumen.

After checking in with the receptionist, I spent a few minutes in his bare-bones waiting room catching up on Hollywood gossip and chatting with one of my teenage patients, who had just recovered from a bout of sinusitis-induced septicemia. When it was my turn, Bob ushered me into his small examining room and sat me down in what could have been an old barber chair. Since neither of us is a frequent attendee at hospital staff meetings, we had lots of catching up to do. The conversation ranged from children's weddings to our painful attempts at reacquiring tennis skills that had been allowed to atrophy over the last 2 decades.

After what seemed like less than 5 minutes of banter, he paused and said, “Well, the good news is that you don't have any wax in your ears. The bad news is that I bet you'll be wanting a hearing aid in a couple of years.” He then spent 10 minutes explaining the physiologic process that was eroding my hearing and what I could do to remedy the situation. We parted with an agreement to get together for some doubles in a couple of weeks.

As I climbed back into my truck for the trip home, I wondered how Bob could sound so confident about the cause of my deafness without even looking in my ears. The examination portion of the visit had flown by so quickly that I didn't remember him using an otoscope.

As I turned onto the highway, I attempted to reconstruct our encounter. He had moved so smoothly and efficiently through the exam that my focus had been on our conversation and not his invasion into every orifice in my head. I began to recall that he had not only looked in my ears, but he had also removed a small bit of cerumen and insufflated my tympanic membranes. He had looked past my turbinates, sterilized a mirror with an alcohol lamp, and taken a peek at my vocal cords. His fingers had nimbly danced over my thyroid and all the nodes above my clavicles.

As I thought about it, I realized that Bob had done an extremely thorough head and neck exam. Because of his efficiency, which came from more than 30 years of experience and the familiar surroundings of an office where every instrument was exactly where it was supposed to be, the process had taken no more than 4 or 5 minutes. Thirty years of trial and error guided his hands to find my tympanic membranes on the first pass and locate my vocal cords without triggering my gag reflex.

In the hands of an experienced clinician, a good, focused physical exam doesn't take much time. The true test of our clinical ability is not the speed at which we have learned to perform a thorough examination but what we do with the time we have saved. Do we reinvest it in the patient we have just examined by conveying to them what we have discovered in a manner that says we care? Or do we use the time we have gained through our efficiency to rush on to the next patient? Fortunately for me, Bob has chosen to do the former, and that's another reason he's my favorite.

A few weeks ago I visited my favorite otolaryngologist. He's my favorite because he doesn't cut first and ask questions later. He is also very good at explaining things to parents. Bob is about my age and had already been in practice for a couple of years when I arrived in town in 1974.

My appointment was the first and last attempt to find a treatable cause for my dwindling hearing. I have long suspected that it is simply the result of years of auditory abuse, and reading the studies documenting that most pediatricians are exposed to noise levels deemed unsafe by the standards of the Occupational Safety and Health Administration only added to my suspicions. Although I feared that my difficulty catching every word in group conversations was the inevitable audiologic equivalent of presbyopia, I was in denial. I hoped that Bob could cure the problem by removing 35 years' worth of stethoscope-compacted cerumen.

After checking in with the receptionist, I spent a few minutes in his bare-bones waiting room catching up on Hollywood gossip and chatting with one of my teenage patients, who had just recovered from a bout of sinusitis-induced septicemia. When it was my turn, Bob ushered me into his small examining room and sat me down in what could have been an old barber chair. Since neither of us is a frequent attendee at hospital staff meetings, we had lots of catching up to do. The conversation ranged from children's weddings to our painful attempts at reacquiring tennis skills that had been allowed to atrophy over the last 2 decades.

After what seemed like less than 5 minutes of banter, he paused and said, “Well, the good news is that you don't have any wax in your ears. The bad news is that I bet you'll be wanting a hearing aid in a couple of years.” He then spent 10 minutes explaining the physiologic process that was eroding my hearing and what I could do to remedy the situation. We parted with an agreement to get together for some doubles in a couple of weeks.

As I climbed back into my truck for the trip home, I wondered how Bob could sound so confident about the cause of my deafness without even looking in my ears. The examination portion of the visit had flown by so quickly that I didn't remember him using an otoscope.

As I turned onto the highway, I attempted to reconstruct our encounter. He had moved so smoothly and efficiently through the exam that my focus had been on our conversation and not his invasion into every orifice in my head. I began to recall that he had not only looked in my ears, but he had also removed a small bit of cerumen and insufflated my tympanic membranes. He had looked past my turbinates, sterilized a mirror with an alcohol lamp, and taken a peek at my vocal cords. His fingers had nimbly danced over my thyroid and all the nodes above my clavicles.

As I thought about it, I realized that Bob had done an extremely thorough head and neck exam. Because of his efficiency, which came from more than 30 years of experience and the familiar surroundings of an office where every instrument was exactly where it was supposed to be, the process had taken no more than 4 or 5 minutes. Thirty years of trial and error guided his hands to find my tympanic membranes on the first pass and locate my vocal cords without triggering my gag reflex.

In the hands of an experienced clinician, a good, focused physical exam doesn't take much time. The true test of our clinical ability is not the speed at which we have learned to perform a thorough examination but what we do with the time we have saved. Do we reinvest it in the patient we have just examined by conveying to them what we have discovered in a manner that says we care? Or do we use the time we have gained through our efficiency to rush on to the next patient? Fortunately for me, Bob has chosen to do the former, and that's another reason he's my favorite.

Research that agrees with my anecdotal observations and supports my nonconforming practices always warms my heart, so the lead article in the December issue of Pediatrics really got my old cockles cooking.

After carefully evaluating 42 preventive interventions recommended by at least two national organizations concerned with child health, the investigators concluded that “limited direct evidence was found to support” these recommendations. So many interventions have been recommended and mandated, they also observed, that implementation of an unsupported recommendation by pediatricians could actually be harmful because it may displace “other beneficial activities” (Pediatrics 2004;114:1511–21).

What a bold and long overdue observation. Over the past 30 years, well-meaning groups from every nook and cranny of the child-oriented world have recommended that we pediatricians invest our hard-earned reputations and precious time promoting their pet ventures. It's time for us to say, “Whoa! Let's see if what you're asking us to do works.”

Even if the majority of these recommendations were well supported, their overwhelming volume would make implementation impossible even by the most efficient practitioner. When unproven interventions become mandated by state laws and regulations, those of us who dare to ignore them are vulnerable to financial penalties and, even worse, professional censure.

Obviously, this situation represents a serious challenge to our profession. We must demand that, regardless how valid they sound, all recommended interventions be evidence based.

Good research takes time, though, particularly when some of the outcomes may not be measurable until our patients reach adulthood. So what should we front-liners do for the next few decades while the researchers are gathering the evidence?

We must change our attitude toward well-child care. Health maintenance visits should be parent- and patient-driven. For too long, we and the committees that coach us have been writing the agendas for these visits.

This paternalistic attitude ignores the basic truth that our patients and their parents know best what is troubling them. Occasionally, we may need to help them articulate and focus their concerns, but it is the families and not the committees that should be writing the script for well-child visits. It's time for us to slide out from behind the steering wheel and begin riding shotgun. From our new seat on the passenger's side, we must keep our eyes on the road ahead and be prepared to warn parents when we see potholes in the path they have chosen.

We must replace our committee-driven interventions with open-ended questions that signal to parents that we are concerned about what concerns them. Then we must patiently wait for their answers. Instead of asking every family if they keep a gun in the house, we must become experts at reading body language and listening to the answers of simple questions like, “How are things going? Is your baby happy? Are you happy?” Dialogues that build on these open-ended questions will create the framework of a more valuable well-child visit.

If the parent is experienced and voices no concerns when offered the opportunity to express them, the visit may last just long enough for a good exam (though we may even find that part unnecessary) and some immunizations.

On the other hand, our apparent willingness to listen may encourage the depressed mother of a toddler to share her secret that she has been abusing the child. A well-child visit cannot be a one-size-fits-all event fabricated from a collection of committee-made parts.

We must acknowledge that the most important component of well-child care doesn't occur during the health maintenance visit. The three critical elements in keeping a child healthy are availability, availability, and availability. Parents already believe that pediatricians know a lot about children. Our challenge is to demonstrate that we care about their concerns and are eager to answer their questions not just at well-child visits, but at any time. An illness can be an excellent opportunity to get to know more about the patient and his family and to make it clear that we are good and concerned listeners.

It sounds like the medical home is the answer again.

Research that agrees with my anecdotal observations and supports my nonconforming practices always warms my heart, so the lead article in the December issue of Pediatrics really got my old cockles cooking.

After carefully evaluating 42 preventive interventions recommended by at least two national organizations concerned with child health, the investigators concluded that “limited direct evidence was found to support” these recommendations. So many interventions have been recommended and mandated, they also observed, that implementation of an unsupported recommendation by pediatricians could actually be harmful because it may displace “other beneficial activities” (Pediatrics 2004;114:1511–21).

What a bold and long overdue observation. Over the past 30 years, well-meaning groups from every nook and cranny of the child-oriented world have recommended that we pediatricians invest our hard-earned reputations and precious time promoting their pet ventures. It's time for us to say, “Whoa! Let's see if what you're asking us to do works.”

Even if the majority of these recommendations were well supported, their overwhelming volume would make implementation impossible even by the most efficient practitioner. When unproven interventions become mandated by state laws and regulations, those of us who dare to ignore them are vulnerable to financial penalties and, even worse, professional censure.

Obviously, this situation represents a serious challenge to our profession. We must demand that, regardless how valid they sound, all recommended interventions be evidence based.

Good research takes time, though, particularly when some of the outcomes may not be measurable until our patients reach adulthood. So what should we front-liners do for the next few decades while the researchers are gathering the evidence?

We must change our attitude toward well-child care. Health maintenance visits should be parent- and patient-driven. For too long, we and the committees that coach us have been writing the agendas for these visits.

This paternalistic attitude ignores the basic truth that our patients and their parents know best what is troubling them. Occasionally, we may need to help them articulate and focus their concerns, but it is the families and not the committees that should be writing the script for well-child visits. It's time for us to slide out from behind the steering wheel and begin riding shotgun. From our new seat on the passenger's side, we must keep our eyes on the road ahead and be prepared to warn parents when we see potholes in the path they have chosen.

We must replace our committee-driven interventions with open-ended questions that signal to parents that we are concerned about what concerns them. Then we must patiently wait for their answers. Instead of asking every family if they keep a gun in the house, we must become experts at reading body language and listening to the answers of simple questions like, “How are things going? Is your baby happy? Are you happy?” Dialogues that build on these open-ended questions will create the framework of a more valuable well-child visit.

If the parent is experienced and voices no concerns when offered the opportunity to express them, the visit may last just long enough for a good exam (though we may even find that part unnecessary) and some immunizations.

On the other hand, our apparent willingness to listen may encourage the depressed mother of a toddler to share her secret that she has been abusing the child. A well-child visit cannot be a one-size-fits-all event fabricated from a collection of committee-made parts.

We must acknowledge that the most important component of well-child care doesn't occur during the health maintenance visit. The three critical elements in keeping a child healthy are availability, availability, and availability. Parents already believe that pediatricians know a lot about children. Our challenge is to demonstrate that we care about their concerns and are eager to answer their questions not just at well-child visits, but at any time. An illness can be an excellent opportunity to get to know more about the patient and his family and to make it clear that we are good and concerned listeners.

It sounds like the medical home is the answer again.

Research that agrees with my anecdotal observations and supports my nonconforming practices always warms my heart, so the lead article in the December issue of Pediatrics really got my old cockles cooking.

After carefully evaluating 42 preventive interventions recommended by at least two national organizations concerned with child health, the investigators concluded that “limited direct evidence was found to support” these recommendations. So many interventions have been recommended and mandated, they also observed, that implementation of an unsupported recommendation by pediatricians could actually be harmful because it may displace “other beneficial activities” (Pediatrics 2004;114:1511–21).

What a bold and long overdue observation. Over the past 30 years, well-meaning groups from every nook and cranny of the child-oriented world have recommended that we pediatricians invest our hard-earned reputations and precious time promoting their pet ventures. It's time for us to say, “Whoa! Let's see if what you're asking us to do works.”

Even if the majority of these recommendations were well supported, their overwhelming volume would make implementation impossible even by the most efficient practitioner. When unproven interventions become mandated by state laws and regulations, those of us who dare to ignore them are vulnerable to financial penalties and, even worse, professional censure.

Obviously, this situation represents a serious challenge to our profession. We must demand that, regardless how valid they sound, all recommended interventions be evidence based.

Good research takes time, though, particularly when some of the outcomes may not be measurable until our patients reach adulthood. So what should we front-liners do for the next few decades while the researchers are gathering the evidence?

We must change our attitude toward well-child care. Health maintenance visits should be parent- and patient-driven. For too long, we and the committees that coach us have been writing the agendas for these visits.

This paternalistic attitude ignores the basic truth that our patients and their parents know best what is troubling them. Occasionally, we may need to help them articulate and focus their concerns, but it is the families and not the committees that should be writing the script for well-child visits. It's time for us to slide out from behind the steering wheel and begin riding shotgun. From our new seat on the passenger's side, we must keep our eyes on the road ahead and be prepared to warn parents when we see potholes in the path they have chosen.

We must replace our committee-driven interventions with open-ended questions that signal to parents that we are concerned about what concerns them. Then we must patiently wait for their answers. Instead of asking every family if they keep a gun in the house, we must become experts at reading body language and listening to the answers of simple questions like, “How are things going? Is your baby happy? Are you happy?” Dialogues that build on these open-ended questions will create the framework of a more valuable well-child visit.

If the parent is experienced and voices no concerns when offered the opportunity to express them, the visit may last just long enough for a good exam (though we may even find that part unnecessary) and some immunizations.

On the other hand, our apparent willingness to listen may encourage the depressed mother of a toddler to share her secret that she has been abusing the child. A well-child visit cannot be a one-size-fits-all event fabricated from a collection of committee-made parts.

We must acknowledge that the most important component of well-child care doesn't occur during the health maintenance visit. The three critical elements in keeping a child healthy are availability, availability, and availability. Parents already believe that pediatricians know a lot about children. Our challenge is to demonstrate that we care about their concerns and are eager to answer their questions not just at well-child visits, but at any time. An illness can be an excellent opportunity to get to know more about the patient and his family and to make it clear that we are good and concerned listeners.

It sounds like the medical home is the answer again.