Commentary

If you manage to struggle your way to the back of the October 2014 Pediatrics, you will find a clinical report authored by members of the American Academy of Pediatrics Section on Integrative Medicine Executive Committee and the AAP Committee on Practice and Ambulatory Medicine (Pediatrics 2014;134:830-35 [doi: 10.1542/peds.2014-2278]). Under the title Physician Health and Wellness, the authors have carved out an approach to physician burnout, not by addressing its treatment but instead addressing it from the perspective of prevention.

Although the authors refer to two systems-based initiatives that have been launched in the last several years, unfortunately they shy away from making any specific recommendations themselves.

Not surprisingly, they observe that a mentally healthy physician is usually a physically healthy physician who eats well, sleeps well, and exercises regularly. He probably has supportive friends and/or family, and knows how to partition his life in a way that allows him time for one or two pursuits that he enjoys outside of his professional activities. Unless, of course, he is one of those lucky few who derives enough enjoyment from his patients. I would add that a mentally healthy, burnout-resistant physician is one whose expectations for his life are well within his abilities and the situation in which he finds himself.

But, why not give us some specifics on how we might guide young physicians onto paths that will maximize their resistance to burnout while it is still a preventable condition? For starters, why not consider a potential medical student’s ability to make healthy lifestyle choices? How many medical school admissions officers ask about the applicant’s exercise and sleep history ... and hobbies? An urban legend has it that the admissions director where I attended medical school occasionally performed his own little stress tests by among other things, asking the interviewee to open a window that had been painted shut. His efforts may have been crude and cruel, but why not give more attention to seeking out medical students who have already demonstrated some ability to find balance in their lives?

Once in medical school, students should have mentors or coaches who are good role models of wellness and who have the commitment to meet with the students on a regular basis. Encourage medical students to keep and share with their mentors diaries that include their exercise, sleep, and dietary schedules as well as observations on their own mental health. It’s gotta be easy on a smart phone. This may sound like smothering with mothering, but the magnitude of the problem of burnout deserves a more hands-on approach.

As students approach the last 2 years of school, they should be coached on what to expect from postgraduate training and the career paths they are considering. They should be encouraged to consider their own strengths and vulnerabilities, and how these will mesh with the realities of life as a practicing physician.

In the generation just ahead of me, some of the elite house officer training programs required that their house officers be single, because the program administrators felt that the life of a house officer was not compatible with married life. I’m not suggesting that we return to those monastic days, but medical students and young physicians need to be coached on how to be more realistic when making career choices and family planning decisions. One survey noted by the authors of this report has shown that not having minor children in the home was associated with less stress.

The authors offer “mindfulness” as an avenue worthy of consideration. It is a concept that I have trouble grasping, other than seeing it as a reminder to folks to stop just going through the motions and make a broad and honest assessment of their current situations. I guess if it helps a young physician to realize that if he moved a half-hour closer to work he would gain an hour a day with his family, “mindfulness” makes sense.

Finally, this AAP clinical report ignores one of the most serious contributors to physician burnout: electronic medical records. Everyone on the front lines knows it and talks about it. But, for the decision makers it continues to be the elephant in the room. It may take someone with a heavy hand and some common sense, but with good leadership a national electronic health record system that works is within reach.

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 [email protected].

If you manage to struggle your way to the back of the October 2014 Pediatrics, you will find a clinical report authored by members of the American Academy of Pediatrics Section on Integrative Medicine Executive Committee and the AAP Committee on Practice and Ambulatory Medicine (Pediatrics 2014;134:830-35 [doi: 10.1542/peds.2014-2278]). Under the title Physician Health and Wellness, the authors have carved out an approach to physician burnout, not by addressing its treatment but instead addressing it from the perspective of prevention.

Although the authors refer to two systems-based initiatives that have been launched in the last several years, unfortunately they shy away from making any specific recommendations themselves.

Not surprisingly, they observe that a mentally healthy physician is usually a physically healthy physician who eats well, sleeps well, and exercises regularly. He probably has supportive friends and/or family, and knows how to partition his life in a way that allows him time for one or two pursuits that he enjoys outside of his professional activities. Unless, of course, he is one of those lucky few who derives enough enjoyment from his patients. I would add that a mentally healthy, burnout-resistant physician is one whose expectations for his life are well within his abilities and the situation in which he finds himself.

But, why not give us some specifics on how we might guide young physicians onto paths that will maximize their resistance to burnout while it is still a preventable condition? For starters, why not consider a potential medical student’s ability to make healthy lifestyle choices? How many medical school admissions officers ask about the applicant’s exercise and sleep history ... and hobbies? An urban legend has it that the admissions director where I attended medical school occasionally performed his own little stress tests by among other things, asking the interviewee to open a window that had been painted shut. His efforts may have been crude and cruel, but why not give more attention to seeking out medical students who have already demonstrated some ability to find balance in their lives?

Once in medical school, students should have mentors or coaches who are good role models of wellness and who have the commitment to meet with the students on a regular basis. Encourage medical students to keep and share with their mentors diaries that include their exercise, sleep, and dietary schedules as well as observations on their own mental health. It’s gotta be easy on a smart phone. This may sound like smothering with mothering, but the magnitude of the problem of burnout deserves a more hands-on approach.

As students approach the last 2 years of school, they should be coached on what to expect from postgraduate training and the career paths they are considering. They should be encouraged to consider their own strengths and vulnerabilities, and how these will mesh with the realities of life as a practicing physician.

In the generation just ahead of me, some of the elite house officer training programs required that their house officers be single, because the program administrators felt that the life of a house officer was not compatible with married life. I’m not suggesting that we return to those monastic days, but medical students and young physicians need to be coached on how to be more realistic when making career choices and family planning decisions. One survey noted by the authors of this report has shown that not having minor children in the home was associated with less stress.

The authors offer “mindfulness” as an avenue worthy of consideration. It is a concept that I have trouble grasping, other than seeing it as a reminder to folks to stop just going through the motions and make a broad and honest assessment of their current situations. I guess if it helps a young physician to realize that if he moved a half-hour closer to work he would gain an hour a day with his family, “mindfulness” makes sense.

Finally, this AAP clinical report ignores one of the most serious contributors to physician burnout: electronic medical records. Everyone on the front lines knows it and talks about it. But, for the decision makers it continues to be the elephant in the room. It may take someone with a heavy hand and some common sense, but with good leadership a national electronic health record system that works is within reach.

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 [email protected].

If you manage to struggle your way to the back of the October 2014 Pediatrics, you will find a clinical report authored by members of the American Academy of Pediatrics Section on Integrative Medicine Executive Committee and the AAP Committee on Practice and Ambulatory Medicine (Pediatrics 2014;134:830-35 [doi: 10.1542/peds.2014-2278]). Under the title Physician Health and Wellness, the authors have carved out an approach to physician burnout, not by addressing its treatment but instead addressing it from the perspective of prevention.

Although the authors refer to two systems-based initiatives that have been launched in the last several years, unfortunately they shy away from making any specific recommendations themselves.

Not surprisingly, they observe that a mentally healthy physician is usually a physically healthy physician who eats well, sleeps well, and exercises regularly. He probably has supportive friends and/or family, and knows how to partition his life in a way that allows him time for one or two pursuits that he enjoys outside of his professional activities. Unless, of course, he is one of those lucky few who derives enough enjoyment from his patients. I would add that a mentally healthy, burnout-resistant physician is one whose expectations for his life are well within his abilities and the situation in which he finds himself.

But, why not give us some specifics on how we might guide young physicians onto paths that will maximize their resistance to burnout while it is still a preventable condition? For starters, why not consider a potential medical student’s ability to make healthy lifestyle choices? How many medical school admissions officers ask about the applicant’s exercise and sleep history ... and hobbies? An urban legend has it that the admissions director where I attended medical school occasionally performed his own little stress tests by among other things, asking the interviewee to open a window that had been painted shut. His efforts may have been crude and cruel, but why not give more attention to seeking out medical students who have already demonstrated some ability to find balance in their lives?

Once in medical school, students should have mentors or coaches who are good role models of wellness and who have the commitment to meet with the students on a regular basis. Encourage medical students to keep and share with their mentors diaries that include their exercise, sleep, and dietary schedules as well as observations on their own mental health. It’s gotta be easy on a smart phone. This may sound like smothering with mothering, but the magnitude of the problem of burnout deserves a more hands-on approach.

As students approach the last 2 years of school, they should be coached on what to expect from postgraduate training and the career paths they are considering. They should be encouraged to consider their own strengths and vulnerabilities, and how these will mesh with the realities of life as a practicing physician.

In the generation just ahead of me, some of the elite house officer training programs required that their house officers be single, because the program administrators felt that the life of a house officer was not compatible with married life. I’m not suggesting that we return to those monastic days, but medical students and young physicians need to be coached on how to be more realistic when making career choices and family planning decisions. One survey noted by the authors of this report has shown that not having minor children in the home was associated with less stress.

The authors offer “mindfulness” as an avenue worthy of consideration. It is a concept that I have trouble grasping, other than seeing it as a reminder to folks to stop just going through the motions and make a broad and honest assessment of their current situations. I guess if it helps a young physician to realize that if he moved a half-hour closer to work he would gain an hour a day with his family, “mindfulness” makes sense.

Finally, this AAP clinical report ignores one of the most serious contributors to physician burnout: electronic medical records. Everyone on the front lines knows it and talks about it. But, for the decision makers it continues to be the elephant in the room. It may take someone with a heavy hand and some common sense, but with good leadership a national electronic health record system that works is within reach.

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 [email protected].

December is the time for reflection. For the last few years, I have found a great way to do that – by watching TED talks. The TED talk phenomenon is an example of how digital media enable the spread of ideas. In an effort to inspire you, both in life and in practice, I’m sharing nine of my favorite TED talks that range from digital medicine to meditation, from healthcare costs to healthcare transformation, and from happiness to introspection. Find the time in the next month or so to watch a few of these. You will be grateful for 2014 and inspired for 2015.

Stefan Larsson, “What Doctors Can Learn From Each Other,” October 2013

A physician and value-based health care advocate, Dr. Larsson argues for a paradigm shift in health care. He asks, “With our ever-increasing focus on costs, are we forgetting about the patient?” Through concrete examples, he argues that health care leaders should focus not only on quality over cost, but also that doing so will lead to overall lower costs and better care delivery.

Daniel Kraft, “Medicine’s future? There’s an app for that,” April 2011

In this fast-paced, energetic presentation, Kraft, a physician, scientist, and innovator, explores exponential technologies such as robotics and artificial intelligence, and how they are radically transforming health care. He argues that these technologies will usher in an “era of digital medicine,” (which has already begun), and will ultimately make care delivery faster, smaller, cheaper, and better.

Atul Gawande, “How do we heal medicine?” February 2012

Dr. Gawande, a Harvard surgeon, researcher, and writer, argues that health care needs fewer cowboys and more pit crews. The problem is that physicians have been trained, hired, and rewarded to be cowboys, or rugged individuals. Gawande says that medicine is obsessed with components – we want the best specialists, the best drugs, the best tests. But at what cost? He calls for medicine to be a system in which we can recognize both success and failure, and design solutions for the failures. His answer: a checklist. In a study of eight hospitals in eight different countries that implemented checklists for surgery, they found complication rates fell 35% and death rates fell 47%. The truth: As individualistic as we want to be, complexity requires group success.

Rebecca Onie, “What if our health care system kept us healthy?” June 2012

What if a physician could write a prescription for food, shelter, or heat for their patients to give them the basic resources they needed to be healthy? That’s exactly what’s happening in clinics in which Health Leads operate. Ms. Onie, a cofounder of Health Leads, has helped more than 9,000 families to receive the basic necessities for their health. She argues that this system not only allows physicians to manage patients’ diseases, but also to improve patients’ health.

Dan Pink, “The Puzzle of motivation,” July 2009

If you want your employees to work better, faster, and more creatively, then you should dangle a sweeter carrot in front of them. Right? Not so fast. In this intriguing talk, Pink blasts a hole in the belief that bigger rewards produce better results. In tasks that require heuristic thinking, larger rewards typically lead to poorer performance. Therefore, he advocates developing intrinsic motivation by focusing on autonomy, mastery, and purpose.

Matthieu Ricard, “The Habits of Happiness,” February 2004

With dozens of headlines screaming about doctor dissatisfaction, it might not be a bad idea to watch Matthieu Ricard’s video about achieving happiness. We all seek happiness and avoid suffering, yet for most us happiness comes in fleeting glimpses. What if happiness was something you could experience daily? Mr. Ricard, a French biochemist turned Buddhist monk, says you can. He believes that practicing meditation can put us in touch with our emotions (both good and bad), cultivate compassion toward others, and ultimately achieve happiness and fulfillment.

Graham Hill, “Less stuff, more happiness,” March 2011

In this video, Mr. Hill, the founder of LifeEdited, shares his story of buying a 420-square-foot apartment then designing it so it can include an office, a bed, a kitchen, and a table large enough for a dinner party of 10 people. (Spoiler alert: He gets it all.) His premise is simple: Having less stuff gives you more freedom and time, which will ultimately make room for more of the good stuff in life.

Louie Schwartzberg, “Nature. Beauty. Gratitude,” June 2011

In this beautiful and poignant video, Schwartzberg, a cinematographer who has been shooting time-lapsed flowers 24 hours a day, 7 days a week, for more than 30 years, shares his illuminating images and encourages us to more fully and mindfully connect with the people, places, and things around us. He shares two interviews about nature and gratitude, one from the perspective of a young child, the other from an elderly man. The underlying message in both is that nature’s beauty is a gift that cultivates appreciation and gratitude in us that we can then pass on to others.

OK, I’m going to include one more TED talk, which is mine. I presented “Reinventing physicians” in 2011 at TEDxPennQuarter. I hope you enjoy it.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is@dermdoc on Twitter.

December is the time for reflection. For the last few years, I have found a great way to do that – by watching TED talks. The TED talk phenomenon is an example of how digital media enable the spread of ideas. In an effort to inspire you, both in life and in practice, I’m sharing nine of my favorite TED talks that range from digital medicine to meditation, from healthcare costs to healthcare transformation, and from happiness to introspection. Find the time in the next month or so to watch a few of these. You will be grateful for 2014 and inspired for 2015.

Stefan Larsson, “What Doctors Can Learn From Each Other,” October 2013

A physician and value-based health care advocate, Dr. Larsson argues for a paradigm shift in health care. He asks, “With our ever-increasing focus on costs, are we forgetting about the patient?” Through concrete examples, he argues that health care leaders should focus not only on quality over cost, but also that doing so will lead to overall lower costs and better care delivery.

Daniel Kraft, “Medicine’s future? There’s an app for that,” April 2011

In this fast-paced, energetic presentation, Kraft, a physician, scientist, and innovator, explores exponential technologies such as robotics and artificial intelligence, and how they are radically transforming health care. He argues that these technologies will usher in an “era of digital medicine,” (which has already begun), and will ultimately make care delivery faster, smaller, cheaper, and better.

Atul Gawande, “How do we heal medicine?” February 2012

Dr. Gawande, a Harvard surgeon, researcher, and writer, argues that health care needs fewer cowboys and more pit crews. The problem is that physicians have been trained, hired, and rewarded to be cowboys, or rugged individuals. Gawande says that medicine is obsessed with components – we want the best specialists, the best drugs, the best tests. But at what cost? He calls for medicine to be a system in which we can recognize both success and failure, and design solutions for the failures. His answer: a checklist. In a study of eight hospitals in eight different countries that implemented checklists for surgery, they found complication rates fell 35% and death rates fell 47%. The truth: As individualistic as we want to be, complexity requires group success.

Rebecca Onie, “What if our health care system kept us healthy?” June 2012

What if a physician could write a prescription for food, shelter, or heat for their patients to give them the basic resources they needed to be healthy? That’s exactly what’s happening in clinics in which Health Leads operate. Ms. Onie, a cofounder of Health Leads, has helped more than 9,000 families to receive the basic necessities for their health. She argues that this system not only allows physicians to manage patients’ diseases, but also to improve patients’ health.

Dan Pink, “The Puzzle of motivation,” July 2009

If you want your employees to work better, faster, and more creatively, then you should dangle a sweeter carrot in front of them. Right? Not so fast. In this intriguing talk, Pink blasts a hole in the belief that bigger rewards produce better results. In tasks that require heuristic thinking, larger rewards typically lead to poorer performance. Therefore, he advocates developing intrinsic motivation by focusing on autonomy, mastery, and purpose.

Matthieu Ricard, “The Habits of Happiness,” February 2004

With dozens of headlines screaming about doctor dissatisfaction, it might not be a bad idea to watch Matthieu Ricard’s video about achieving happiness. We all seek happiness and avoid suffering, yet for most us happiness comes in fleeting glimpses. What if happiness was something you could experience daily? Mr. Ricard, a French biochemist turned Buddhist monk, says you can. He believes that practicing meditation can put us in touch with our emotions (both good and bad), cultivate compassion toward others, and ultimately achieve happiness and fulfillment.

Graham Hill, “Less stuff, more happiness,” March 2011

In this video, Mr. Hill, the founder of LifeEdited, shares his story of buying a 420-square-foot apartment then designing it so it can include an office, a bed, a kitchen, and a table large enough for a dinner party of 10 people. (Spoiler alert: He gets it all.) His premise is simple: Having less stuff gives you more freedom and time, which will ultimately make room for more of the good stuff in life.

Louie Schwartzberg, “Nature. Beauty. Gratitude,” June 2011

In this beautiful and poignant video, Schwartzberg, a cinematographer who has been shooting time-lapsed flowers 24 hours a day, 7 days a week, for more than 30 years, shares his illuminating images and encourages us to more fully and mindfully connect with the people, places, and things around us. He shares two interviews about nature and gratitude, one from the perspective of a young child, the other from an elderly man. The underlying message in both is that nature’s beauty is a gift that cultivates appreciation and gratitude in us that we can then pass on to others.

OK, I’m going to include one more TED talk, which is mine. I presented “Reinventing physicians” in 2011 at TEDxPennQuarter. I hope you enjoy it.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is@dermdoc on Twitter.

December is the time for reflection. For the last few years, I have found a great way to do that – by watching TED talks. The TED talk phenomenon is an example of how digital media enable the spread of ideas. In an effort to inspire you, both in life and in practice, I’m sharing nine of my favorite TED talks that range from digital medicine to meditation, from healthcare costs to healthcare transformation, and from happiness to introspection. Find the time in the next month or so to watch a few of these. You will be grateful for 2014 and inspired for 2015.

Stefan Larsson, “What Doctors Can Learn From Each Other,” October 2013

A physician and value-based health care advocate, Dr. Larsson argues for a paradigm shift in health care. He asks, “With our ever-increasing focus on costs, are we forgetting about the patient?” Through concrete examples, he argues that health care leaders should focus not only on quality over cost, but also that doing so will lead to overall lower costs and better care delivery.

Daniel Kraft, “Medicine’s future? There’s an app for that,” April 2011

In this fast-paced, energetic presentation, Kraft, a physician, scientist, and innovator, explores exponential technologies such as robotics and artificial intelligence, and how they are radically transforming health care. He argues that these technologies will usher in an “era of digital medicine,” (which has already begun), and will ultimately make care delivery faster, smaller, cheaper, and better.

Atul Gawande, “How do we heal medicine?” February 2012

Dr. Gawande, a Harvard surgeon, researcher, and writer, argues that health care needs fewer cowboys and more pit crews. The problem is that physicians have been trained, hired, and rewarded to be cowboys, or rugged individuals. Gawande says that medicine is obsessed with components – we want the best specialists, the best drugs, the best tests. But at what cost? He calls for medicine to be a system in which we can recognize both success and failure, and design solutions for the failures. His answer: a checklist. In a study of eight hospitals in eight different countries that implemented checklists for surgery, they found complication rates fell 35% and death rates fell 47%. The truth: As individualistic as we want to be, complexity requires group success.

Rebecca Onie, “What if our health care system kept us healthy?” June 2012

What if a physician could write a prescription for food, shelter, or heat for their patients to give them the basic resources they needed to be healthy? That’s exactly what’s happening in clinics in which Health Leads operate. Ms. Onie, a cofounder of Health Leads, has helped more than 9,000 families to receive the basic necessities for their health. She argues that this system not only allows physicians to manage patients’ diseases, but also to improve patients’ health.

Dan Pink, “The Puzzle of motivation,” July 2009

If you want your employees to work better, faster, and more creatively, then you should dangle a sweeter carrot in front of them. Right? Not so fast. In this intriguing talk, Pink blasts a hole in the belief that bigger rewards produce better results. In tasks that require heuristic thinking, larger rewards typically lead to poorer performance. Therefore, he advocates developing intrinsic motivation by focusing on autonomy, mastery, and purpose.

Matthieu Ricard, “The Habits of Happiness,” February 2004

With dozens of headlines screaming about doctor dissatisfaction, it might not be a bad idea to watch Matthieu Ricard’s video about achieving happiness. We all seek happiness and avoid suffering, yet for most us happiness comes in fleeting glimpses. What if happiness was something you could experience daily? Mr. Ricard, a French biochemist turned Buddhist monk, says you can. He believes that practicing meditation can put us in touch with our emotions (both good and bad), cultivate compassion toward others, and ultimately achieve happiness and fulfillment.

Graham Hill, “Less stuff, more happiness,” March 2011

In this video, Mr. Hill, the founder of LifeEdited, shares his story of buying a 420-square-foot apartment then designing it so it can include an office, a bed, a kitchen, and a table large enough for a dinner party of 10 people. (Spoiler alert: He gets it all.) His premise is simple: Having less stuff gives you more freedom and time, which will ultimately make room for more of the good stuff in life.

Louie Schwartzberg, “Nature. Beauty. Gratitude,” June 2011

In this beautiful and poignant video, Schwartzberg, a cinematographer who has been shooting time-lapsed flowers 24 hours a day, 7 days a week, for more than 30 years, shares his illuminating images and encourages us to more fully and mindfully connect with the people, places, and things around us. He shares two interviews about nature and gratitude, one from the perspective of a young child, the other from an elderly man. The underlying message in both is that nature’s beauty is a gift that cultivates appreciation and gratitude in us that we can then pass on to others.

OK, I’m going to include one more TED talk, which is mine. I presented “Reinventing physicians” in 2011 at TEDxPennQuarter. I hope you enjoy it.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is@dermdoc on Twitter.

When your pager vibrates at 7 o’clock in the morning, it is unlikely to be alerting you of good news. It may be a parent who assumes that because his child’s medical home has evening office hours that there will be a receptionist sitting there at sunup to help him make an appointment for a nonurgent complaint. Or, it may be a call from a parent who knows that she doesn’t have a medical emergency on her hands, but who would like your advice about whether she should take a day off from work or send her child to day care.

But, an uncomfortable number of daybreak calls come from parents with what eventually turns out to be a desperately ill child. I have witnessed those scenarios often enough that even though I am retired, I break into a cold sweat when the home phone rings anytime between 6 and 7 in the morning.

A study from Wake Forest University, Winston-Salem, N.C., published in the November 2014 issue of Pediatrics, supports my long-standing discomfort with patients who present in the early morning. (McCrory et al. “Off-Hours Admission to Pediatric Intensive Care and Mortality,” Pediatrics 2014;134:e1345-e1353 [doi: 10.1542/peds.2014-1071]). In a retrospective study of nearly a quarter of a million admissions to 99 perinatal ICUs over a 3-year period, the investigators discovered that admission in off-hours and weekends “does not independently increase the odds of mortality.”

However, they found that admission from 6 to 11 in the morning is “associated with an increased risk of death.” This may not have been the result the investigators were expecting, and their analyses don’t suggest a cause. In the discussion portion of the paper, they offer some explanations that are in sync with my observations. First, ICUs are generally fully staffed 24-7-365. While the lights maybe dimmed slightly, there is seldom a diurnal variation in the attentiveness and quality of the caregivers in an ICU. Contrast this to an ordinary medical/surgical floor on which the staffing levels drop precipitously when the sun goes down. The skeletal staff is usually working in the dark, resorting to flashlights and ankle-level lighting to make their observations. And ... things are missed. Things like skin-color changes and the quality of respirations that become obvious when the morning shift arrives and the lights go on. “Holy s**t! This patient needs to be in the PICU!” And, the PICU now receives a patient at 7:30 a.m. who has a greater odds of mortality because the illness has percolated in the dark overnight.

The same phenomenon occurs in the outpatient setting. At night, sleep deprivation may cloud a parent’s observational skills. The lights in the bedroom may have been left off in hopes of keeping the child more comfortable. The parent may have called the doctor and been shunted to a triage nurse who is unfamiliar with the family and whose algorithm fails at a critical branch point. Or, the call may have been fielded by an answering service that is more interested in protecting its client’s sleep than serving the needs of the caller.

Or the parent may have spoken to the doctor early in the evening, but was hesitant to call again and wake her when the child’s condition changed. House officers can fall into the same trap when their misplaced concern about the sleep needs of the physician to whom they report prevents them from making a critical call for help.

Again, the result is that when the sun comes up, a child whose illness might have been more easily managed in the PICU at 2:30 a.m. doesn’t arrive in the unit until those deadly hours between 6 a.m. and 11 a.m. While there may be diurnal variations in the inherent mortality of some pathological conditions, this study from North Carolina suggests that when the lights go out, critical observations go unmade and so do wise decisions.

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 [email protected].

When your pager vibrates at 7 o’clock in the morning, it is unlikely to be alerting you of good news. It may be a parent who assumes that because his child’s medical home has evening office hours that there will be a receptionist sitting there at sunup to help him make an appointment for a nonurgent complaint. Or, it may be a call from a parent who knows that she doesn’t have a medical emergency on her hands, but who would like your advice about whether she should take a day off from work or send her child to day care.

But, an uncomfortable number of daybreak calls come from parents with what eventually turns out to be a desperately ill child. I have witnessed those scenarios often enough that even though I am retired, I break into a cold sweat when the home phone rings anytime between 6 and 7 in the morning.

A study from Wake Forest University, Winston-Salem, N.C., published in the November 2014 issue of Pediatrics, supports my long-standing discomfort with patients who present in the early morning. (McCrory et al. “Off-Hours Admission to Pediatric Intensive Care and Mortality,” Pediatrics 2014;134:e1345-e1353 [doi: 10.1542/peds.2014-1071]). In a retrospective study of nearly a quarter of a million admissions to 99 perinatal ICUs over a 3-year period, the investigators discovered that admission in off-hours and weekends “does not independently increase the odds of mortality.”

However, they found that admission from 6 to 11 in the morning is “associated with an increased risk of death.” This may not have been the result the investigators were expecting, and their analyses don’t suggest a cause. In the discussion portion of the paper, they offer some explanations that are in sync with my observations. First, ICUs are generally fully staffed 24-7-365. While the lights maybe dimmed slightly, there is seldom a diurnal variation in the attentiveness and quality of the caregivers in an ICU. Contrast this to an ordinary medical/surgical floor on which the staffing levels drop precipitously when the sun goes down. The skeletal staff is usually working in the dark, resorting to flashlights and ankle-level lighting to make their observations. And ... things are missed. Things like skin-color changes and the quality of respirations that become obvious when the morning shift arrives and the lights go on. “Holy s**t! This patient needs to be in the PICU!” And, the PICU now receives a patient at 7:30 a.m. who has a greater odds of mortality because the illness has percolated in the dark overnight.

The same phenomenon occurs in the outpatient setting. At night, sleep deprivation may cloud a parent’s observational skills. The lights in the bedroom may have been left off in hopes of keeping the child more comfortable. The parent may have called the doctor and been shunted to a triage nurse who is unfamiliar with the family and whose algorithm fails at a critical branch point. Or, the call may have been fielded by an answering service that is more interested in protecting its client’s sleep than serving the needs of the caller.

Or the parent may have spoken to the doctor early in the evening, but was hesitant to call again and wake her when the child’s condition changed. House officers can fall into the same trap when their misplaced concern about the sleep needs of the physician to whom they report prevents them from making a critical call for help.

Again, the result is that when the sun comes up, a child whose illness might have been more easily managed in the PICU at 2:30 a.m. doesn’t arrive in the unit until those deadly hours between 6 a.m. and 11 a.m. While there may be diurnal variations in the inherent mortality of some pathological conditions, this study from North Carolina suggests that when the lights go out, critical observations go unmade and so do wise decisions.

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 [email protected].

When your pager vibrates at 7 o’clock in the morning, it is unlikely to be alerting you of good news. It may be a parent who assumes that because his child’s medical home has evening office hours that there will be a receptionist sitting there at sunup to help him make an appointment for a nonurgent complaint. Or, it may be a call from a parent who knows that she doesn’t have a medical emergency on her hands, but who would like your advice about whether she should take a day off from work or send her child to day care.

But, an uncomfortable number of daybreak calls come from parents with what eventually turns out to be a desperately ill child. I have witnessed those scenarios often enough that even though I am retired, I break into a cold sweat when the home phone rings anytime between 6 and 7 in the morning.

A study from Wake Forest University, Winston-Salem, N.C., published in the November 2014 issue of Pediatrics, supports my long-standing discomfort with patients who present in the early morning. (McCrory et al. “Off-Hours Admission to Pediatric Intensive Care and Mortality,” Pediatrics 2014;134:e1345-e1353 [doi: 10.1542/peds.2014-1071]). In a retrospective study of nearly a quarter of a million admissions to 99 perinatal ICUs over a 3-year period, the investigators discovered that admission in off-hours and weekends “does not independently increase the odds of mortality.”

However, they found that admission from 6 to 11 in the morning is “associated with an increased risk of death.” This may not have been the result the investigators were expecting, and their analyses don’t suggest a cause. In the discussion portion of the paper, they offer some explanations that are in sync with my observations. First, ICUs are generally fully staffed 24-7-365. While the lights maybe dimmed slightly, there is seldom a diurnal variation in the attentiveness and quality of the caregivers in an ICU. Contrast this to an ordinary medical/surgical floor on which the staffing levels drop precipitously when the sun goes down. The skeletal staff is usually working in the dark, resorting to flashlights and ankle-level lighting to make their observations. And ... things are missed. Things like skin-color changes and the quality of respirations that become obvious when the morning shift arrives and the lights go on. “Holy s**t! This patient needs to be in the PICU!” And, the PICU now receives a patient at 7:30 a.m. who has a greater odds of mortality because the illness has percolated in the dark overnight.

The same phenomenon occurs in the outpatient setting. At night, sleep deprivation may cloud a parent’s observational skills. The lights in the bedroom may have been left off in hopes of keeping the child more comfortable. The parent may have called the doctor and been shunted to a triage nurse who is unfamiliar with the family and whose algorithm fails at a critical branch point. Or, the call may have been fielded by an answering service that is more interested in protecting its client’s sleep than serving the needs of the caller.

Or the parent may have spoken to the doctor early in the evening, but was hesitant to call again and wake her when the child’s condition changed. House officers can fall into the same trap when their misplaced concern about the sleep needs of the physician to whom they report prevents them from making a critical call for help.

Again, the result is that when the sun comes up, a child whose illness might have been more easily managed in the PICU at 2:30 a.m. doesn’t arrive in the unit until those deadly hours between 6 a.m. and 11 a.m. While there may be diurnal variations in the inherent mortality of some pathological conditions, this study from North Carolina suggests that when the lights go out, critical observations go unmade and so do wise decisions.

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 [email protected].

Two years ago, I saw a young man in my office who had decided not to return to college after his freshman year. He had been a very good high school hockey player, and I asked him what he was doing now to stay fit. He replied that he had joined a fitness facility, part of a national franchise system, and “I’m going on the Paleo Diet.” As I was among the clueless at that time, I quizzed him about his diet.

He told me that it was an attempt to duplicate the diet of our ancestors prior to the development of agriculture (thought to be about 10,000 years ago). This meant no processed food, no dairy products, no grains or legumes, no refined sugars. Lean meat, nuts, fruits, and low-starch vegetables were okay.

When I saw him for a follow-up visit 2 months later, I asked how he was doing with what I called his “caveman diet.” He said, “I lasted about 6 weeks, but I’m still working out four times a week.” It turns out that while my patient had drifted away from his paleolithic diet, enough other people have climbed on the bandwagon that there are now a couple of magazines devoted what has broadened beyond diet to what could be called a paleo lifestyle.

Devotees of the live-like-our-ancestors movement hope to avoid the “diseases of civilization by exercising frequently, particularly doing things that mimic our ancestors activities such as running, jumping, climbing, and throwing. A committed paleo person should wear a minimum of clothes and try to go barefoot as often as possible. He should have frequent contact with nature and get plenty of sun exposure for his source of vitamin D. His sleep patterns should be in sync with the sun cycle, and he should avoid stress by simplifying and downsizing his life.

This sounds like a lifestyle most toddlers strive for everyday. They prefer to run around nude and shoeless, climb just for fun, and throw anything within reach. It got me wondering what paleo parenting might be look like. Certainly, it would begin with breastfeeding. But, for how long? I don’t think we know the answer to that. It may not have been as long some breastfeeding advocates believe.

I suspect young children are smart enough to find shade in the middle of day to take a nap if we allow them. My obsession with the hazards of sleep deprivation makes the paleo’s attempt to link sleep to the sun cycle particularly appealing. It would benefit parents as well as the children for them to all go to bed when the sun went down. Paleo parenting would mean no TV. What a concept!

Of course, there are several flies in this ancestral ointment. First, I suspect that our prehistoric ancestors seldom lived into their fourth decade. How many of the “diseases of civilization” are simply the effect of aging on bodies that were not genetically engineered for longevity? How much do we really know about the diet and lifestyle of our paleo ancestors? Carbon isotope studies and microscopic analysis of ancient stool samples are pretty scanty evidence.

And, why choose to set our target to emulate before the development of agriculture? Some grain and a few root vegetables aren’t going to send our children on the road to obesity if they are active and getting adequate amounts of sleep.

There can be many advantages to adopting an “ancestral lifestyle,” but we don’t have to peel the onion all the way back to prehistory to reap the benefits. Heck, I bet if we rolled back to pretelevision, we would be a much healthier society.

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 [email protected].

Two years ago, I saw a young man in my office who had decided not to return to college after his freshman year. He had been a very good high school hockey player, and I asked him what he was doing now to stay fit. He replied that he had joined a fitness facility, part of a national franchise system, and “I’m going on the Paleo Diet.” As I was among the clueless at that time, I quizzed him about his diet.

He told me that it was an attempt to duplicate the diet of our ancestors prior to the development of agriculture (thought to be about 10,000 years ago). This meant no processed food, no dairy products, no grains or legumes, no refined sugars. Lean meat, nuts, fruits, and low-starch vegetables were okay.

When I saw him for a follow-up visit 2 months later, I asked how he was doing with what I called his “caveman diet.” He said, “I lasted about 6 weeks, but I’m still working out four times a week.” It turns out that while my patient had drifted away from his paleolithic diet, enough other people have climbed on the bandwagon that there are now a couple of magazines devoted what has broadened beyond diet to what could be called a paleo lifestyle.

Devotees of the live-like-our-ancestors movement hope to avoid the “diseases of civilization by exercising frequently, particularly doing things that mimic our ancestors activities such as running, jumping, climbing, and throwing. A committed paleo person should wear a minimum of clothes and try to go barefoot as often as possible. He should have frequent contact with nature and get plenty of sun exposure for his source of vitamin D. His sleep patterns should be in sync with the sun cycle, and he should avoid stress by simplifying and downsizing his life.

This sounds like a lifestyle most toddlers strive for everyday. They prefer to run around nude and shoeless, climb just for fun, and throw anything within reach. It got me wondering what paleo parenting might be look like. Certainly, it would begin with breastfeeding. But, for how long? I don’t think we know the answer to that. It may not have been as long some breastfeeding advocates believe.

I suspect young children are smart enough to find shade in the middle of day to take a nap if we allow them. My obsession with the hazards of sleep deprivation makes the paleo’s attempt to link sleep to the sun cycle particularly appealing. It would benefit parents as well as the children for them to all go to bed when the sun went down. Paleo parenting would mean no TV. What a concept!

Of course, there are several flies in this ancestral ointment. First, I suspect that our prehistoric ancestors seldom lived into their fourth decade. How many of the “diseases of civilization” are simply the effect of aging on bodies that were not genetically engineered for longevity? How much do we really know about the diet and lifestyle of our paleo ancestors? Carbon isotope studies and microscopic analysis of ancient stool samples are pretty scanty evidence.

And, why choose to set our target to emulate before the development of agriculture? Some grain and a few root vegetables aren’t going to send our children on the road to obesity if they are active and getting adequate amounts of sleep.

There can be many advantages to adopting an “ancestral lifestyle,” but we don’t have to peel the onion all the way back to prehistory to reap the benefits. Heck, I bet if we rolled back to pretelevision, we would be a much healthier society.

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 [email protected].

Two years ago, I saw a young man in my office who had decided not to return to college after his freshman year. He had been a very good high school hockey player, and I asked him what he was doing now to stay fit. He replied that he had joined a fitness facility, part of a national franchise system, and “I’m going on the Paleo Diet.” As I was among the clueless at that time, I quizzed him about his diet.

He told me that it was an attempt to duplicate the diet of our ancestors prior to the development of agriculture (thought to be about 10,000 years ago). This meant no processed food, no dairy products, no grains or legumes, no refined sugars. Lean meat, nuts, fruits, and low-starch vegetables were okay.

When I saw him for a follow-up visit 2 months later, I asked how he was doing with what I called his “caveman diet.” He said, “I lasted about 6 weeks, but I’m still working out four times a week.” It turns out that while my patient had drifted away from his paleolithic diet, enough other people have climbed on the bandwagon that there are now a couple of magazines devoted what has broadened beyond diet to what could be called a paleo lifestyle.

Devotees of the live-like-our-ancestors movement hope to avoid the “diseases of civilization by exercising frequently, particularly doing things that mimic our ancestors activities such as running, jumping, climbing, and throwing. A committed paleo person should wear a minimum of clothes and try to go barefoot as often as possible. He should have frequent contact with nature and get plenty of sun exposure for his source of vitamin D. His sleep patterns should be in sync with the sun cycle, and he should avoid stress by simplifying and downsizing his life.

This sounds like a lifestyle most toddlers strive for everyday. They prefer to run around nude and shoeless, climb just for fun, and throw anything within reach. It got me wondering what paleo parenting might be look like. Certainly, it would begin with breastfeeding. But, for how long? I don’t think we know the answer to that. It may not have been as long some breastfeeding advocates believe.

I suspect young children are smart enough to find shade in the middle of day to take a nap if we allow them. My obsession with the hazards of sleep deprivation makes the paleo’s attempt to link sleep to the sun cycle particularly appealing. It would benefit parents as well as the children for them to all go to bed when the sun went down. Paleo parenting would mean no TV. What a concept!

Of course, there are several flies in this ancestral ointment. First, I suspect that our prehistoric ancestors seldom lived into their fourth decade. How many of the “diseases of civilization” are simply the effect of aging on bodies that were not genetically engineered for longevity? How much do we really know about the diet and lifestyle of our paleo ancestors? Carbon isotope studies and microscopic analysis of ancient stool samples are pretty scanty evidence.

And, why choose to set our target to emulate before the development of agriculture? Some grain and a few root vegetables aren’t going to send our children on the road to obesity if they are active and getting adequate amounts of sleep.

There can be many advantages to adopting an “ancestral lifestyle,” but we don’t have to peel the onion all the way back to prehistory to reap the benefits. Heck, I bet if we rolled back to pretelevision, we would be a much healthier society.

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 [email protected].

As the most common form of cancer in the United States,¹ dermatologists often focus on treating the physical aspects of skin cancer, but it is equally important to consider the consequences that this disease has on a patient’s quality of life (QOL). Health is a dynamic process, encompassing one’s physical, emotional, and psychosocial well-being. There are a number of ways to measure health outcomes including mortality, morbidity, health status, and QOL. In recent years, health-related QOL (HRQOL) outcomes in dermatology have become increasingly important to clinical practice and may become factors in quality measurement or reimbursement.

Understanding a patient’s HRQOL allows health care providers to better evaluate the burden of disease and disability associated with skin cancer and its treatment. Clinical severity is not always able to capture the extent to which a disease affects one’s life.² Furthermore, physician estimation of disease severity is not always consistent with patient-reported outcomes.³ As such, clinical questionnaires may be invaluable tools capable of objectively reporting a patient’s perception of improvement in health, which may affect how a dermatologist approaches treatment, discussion, and maintenance.

Nonmelanoma Skin Cancer

Most nonmelanoma skin cancer (NMSC) occurs in readily visible areas, namely the head and neck. Surgical treatment minimizes recurrence and complication rates. Nonmelanoma skin cancer has a low mortality and a high cure rate if diagnosed early; therefore, it may be difficult to assess treatment efficacy on cure rates alone. The amalgamation of anxiety associated with the diagnosis, aesthetic and functional concerns regarding treatment, and long-term consequences including fear of future skin cancer may have a lasting effect on an individual’s psychosocial relationships and underscores the need for QOL studies.

Most generic QOL and dermatology-specific QOL instruments fail to accurately detect the concerns of patients with NMSC.^4-6 Generic QOL measures used for skin cancer patients report scores of patients that were similar to population norms,⁴ suggesting that these tools may fail to appropriately assess unique QOL concerns among individuals with skin cancer. Furthermore, dermatology-specific instruments have been reported to be insensitive to specific appearance-related concerns of patients with NMSC, likely because skin cancer patients made up a small percentage of the initial population in their design.^4,7 Nevertheless, dermatology-specific instruments may be suitable depending on the objectives of the study.⁸

Recently, skin cancer–specific QOL instruments have been developed to fill the paucity of appropriate tools for this population. These questionnaires include the Facial Skin Cancer Index, Skin Cancer Index, and the Skin Cancer Quality of Life Impact Tool.⁷ The Skin Cancer Index is a 15-item questionnaire validated in patients undergoing Mohs micrographic surgery and has been used to assess behavior modification and risk perceptions in NMSC patients. Importantly, it does ask the patient if he/she is worried about scarring. The Facial Skin Cancer Index and the Skin Cancer Quality of Life Impact Tool do not take into account detailed aesthetic concerns regarding facial disfigurement and scarring or expectations of reconstruction.⁷ It may be prudent to assess these areas with supplemental scales.

Melanoma

Melanoma, the third most common skin cancer, is highly aggressive and can affect young and middle-aged patients. Because the mortality associated with later-stage melanoma is greater, the QOL impact of melanoma differs from NMSC. There are also 3 distinct periods of melanoma HRQOL impact: diagnosis, treatment, and follow-up. Approximately 30% of patients diagnosed with melanoma report high levels of psychological distress.⁹ The psychosocial effects of a melanoma diagnosis are longitudinal, as there is a high survival rate in early disease but also an increased future risk for melanoma, affecting future behaviors and overall QOL. The diagnosis of melanoma also affects family members due to the increased risk among first-degree relatives. After removal of deeper melanoma, the patient remains at risk for disease progression, which can have a profound impact on his/her social and professional activities and overall lifestyle. There may be a role for longitudinal QOL assessments to monitor changes over time and direct ongoing therapy.

The proportion of patients with melanoma who report high levels of impairment in QOL is comparable to that seen in other malignancies.¹⁰ Generic QOL instruments have found that melanoma patients have medium to high levels of distress and substantial improvement in HRQOL has been achieved with cognitive-behavioral intervention.¹¹ Quality-of-life studies also have shown levels of distress are highest at initial diagnosis and immediately following treatment.¹² In a randomized surgical trial, patients with a larger excision margin had poorer mental and physical function scores on assessment.¹³ Skin-specific QOL instruments have been used in studies of patients with melanoma and found that postmelanoma surveillance did not impact QOL. Also, women experienced greater improvements in QOL over time after reporting lower scores immediately postsurgery.¹³

The FACT-melanoma (Functional Assessment of Cancer Therapy) is a melanoma-specific HRQOL assessment that has been used in patients undergoing clinical trials. It has been shown to distinguish between early and advanced-stage (stages III or IV) HRQOL issues.¹⁴ Patients with early-stage melanoma are more concerned with cosmetic outcome, and those with later-stage melanoma are more concerned with morbidity and mortality associated with treatment.

Comment

Choosing the best QOL instrument depends on the specific objectives of the study. Although generic QOL questionnaires have performed poorly in studies of specific skin diseases and even dermatology-specific tools have shown limited responsiveness in skin cancer, a combination of tools may be an effective approach. However, dermatologists must be cautious when administering these valuable tools to ensure that they do not become a burdensome task for the patient.¹⁵ Although no single skin cancer–specific QOL tool is perfect, it is likely that the current questionnaires still allow for aid with appropriate patient management and comparison of treatments.¹⁶

It behooves clinicians to recognize and appreciate the value of QOL instruments as an important adjunct to treatment. These tools have shown QOL to be an independent predictor of survival among many types of cancer patients, including melanoma.¹⁰ Currently, the psychological and emotional needs of skin cancer patients often go overlooked and undetected by conventional methods. Within one’s own practice, introducing QOL assessments can improve patient self-awareness and physician awareness of matters that may have a greater impact on patient health. On a larger scale, introducing patient-reported outcome measures can affect resource allocation by identifying patient populations that may be most impacted and can give a comprehensive method for physicians to gauge treatment efficacy, leading to improved outcomes.

As the most common form of cancer in the United States,¹ dermatologists often focus on treating the physical aspects of skin cancer, but it is equally important to consider the consequences that this disease has on a patient’s quality of life (QOL). Health is a dynamic process, encompassing one’s physical, emotional, and psychosocial well-being. There are a number of ways to measure health outcomes including mortality, morbidity, health status, and QOL. In recent years, health-related QOL (HRQOL) outcomes in dermatology have become increasingly important to clinical practice and may become factors in quality measurement or reimbursement.

Understanding a patient’s HRQOL allows health care providers to better evaluate the burden of disease and disability associated with skin cancer and its treatment. Clinical severity is not always able to capture the extent to which a disease affects one’s life.² Furthermore, physician estimation of disease severity is not always consistent with patient-reported outcomes.³ As such, clinical questionnaires may be invaluable tools capable of objectively reporting a patient’s perception of improvement in health, which may affect how a dermatologist approaches treatment, discussion, and maintenance.

Nonmelanoma Skin Cancer

Most nonmelanoma skin cancer (NMSC) occurs in readily visible areas, namely the head and neck. Surgical treatment minimizes recurrence and complication rates. Nonmelanoma skin cancer has a low mortality and a high cure rate if diagnosed early; therefore, it may be difficult to assess treatment efficacy on cure rates alone. The amalgamation of anxiety associated with the diagnosis, aesthetic and functional concerns regarding treatment, and long-term consequences including fear of future skin cancer may have a lasting effect on an individual’s psychosocial relationships and underscores the need for QOL studies.

Most generic QOL and dermatology-specific QOL instruments fail to accurately detect the concerns of patients with NMSC.^4-6 Generic QOL measures used for skin cancer patients report scores of patients that were similar to population norms,⁴ suggesting that these tools may fail to appropriately assess unique QOL concerns among individuals with skin cancer. Furthermore, dermatology-specific instruments have been reported to be insensitive to specific appearance-related concerns of patients with NMSC, likely because skin cancer patients made up a small percentage of the initial population in their design.^4,7 Nevertheless, dermatology-specific instruments may be suitable depending on the objectives of the study.⁸

Recently, skin cancer–specific QOL instruments have been developed to fill the paucity of appropriate tools for this population. These questionnaires include the Facial Skin Cancer Index, Skin Cancer Index, and the Skin Cancer Quality of Life Impact Tool.⁷ The Skin Cancer Index is a 15-item questionnaire validated in patients undergoing Mohs micrographic surgery and has been used to assess behavior modification and risk perceptions in NMSC patients. Importantly, it does ask the patient if he/she is worried about scarring. The Facial Skin Cancer Index and the Skin Cancer Quality of Life Impact Tool do not take into account detailed aesthetic concerns regarding facial disfigurement and scarring or expectations of reconstruction.⁷ It may be prudent to assess these areas with supplemental scales.

Melanoma

Melanoma, the third most common skin cancer, is highly aggressive and can affect young and middle-aged patients. Because the mortality associated with later-stage melanoma is greater, the QOL impact of melanoma differs from NMSC. There are also 3 distinct periods of melanoma HRQOL impact: diagnosis, treatment, and follow-up. Approximately 30% of patients diagnosed with melanoma report high levels of psychological distress.⁹ The psychosocial effects of a melanoma diagnosis are longitudinal, as there is a high survival rate in early disease but also an increased future risk for melanoma, affecting future behaviors and overall QOL. The diagnosis of melanoma also affects family members due to the increased risk among first-degree relatives. After removal of deeper melanoma, the patient remains at risk for disease progression, which can have a profound impact on his/her social and professional activities and overall lifestyle. There may be a role for longitudinal QOL assessments to monitor changes over time and direct ongoing therapy.

The proportion of patients with melanoma who report high levels of impairment in QOL is comparable to that seen in other malignancies.¹⁰ Generic QOL instruments have found that melanoma patients have medium to high levels of distress and substantial improvement in HRQOL has been achieved with cognitive-behavioral intervention.¹¹ Quality-of-life studies also have shown levels of distress are highest at initial diagnosis and immediately following treatment.¹² In a randomized surgical trial, patients with a larger excision margin had poorer mental and physical function scores on assessment.¹³ Skin-specific QOL instruments have been used in studies of patients with melanoma and found that postmelanoma surveillance did not impact QOL. Also, women experienced greater improvements in QOL over time after reporting lower scores immediately postsurgery.¹³

The FACT-melanoma (Functional Assessment of Cancer Therapy) is a melanoma-specific HRQOL assessment that has been used in patients undergoing clinical trials. It has been shown to distinguish between early and advanced-stage (stages III or IV) HRQOL issues.¹⁴ Patients with early-stage melanoma are more concerned with cosmetic outcome, and those with later-stage melanoma are more concerned with morbidity and mortality associated with treatment.

Comment

Choosing the best QOL instrument depends on the specific objectives of the study. Although generic QOL questionnaires have performed poorly in studies of specific skin diseases and even dermatology-specific tools have shown limited responsiveness in skin cancer, a combination of tools may be an effective approach. However, dermatologists must be cautious when administering these valuable tools to ensure that they do not become a burdensome task for the patient.¹⁵ Although no single skin cancer–specific QOL tool is perfect, it is likely that the current questionnaires still allow for aid with appropriate patient management and comparison of treatments.¹⁶

It behooves clinicians to recognize and appreciate the value of QOL instruments as an important adjunct to treatment. These tools have shown QOL to be an independent predictor of survival among many types of cancer patients, including melanoma.¹⁰ Currently, the psychological and emotional needs of skin cancer patients often go overlooked and undetected by conventional methods. Within one’s own practice, introducing QOL assessments can improve patient self-awareness and physician awareness of matters that may have a greater impact on patient health. On a larger scale, introducing patient-reported outcome measures can affect resource allocation by identifying patient populations that may be most impacted and can give a comprehensive method for physicians to gauge treatment efficacy, leading to improved outcomes.

As the most common form of cancer in the United States,¹ dermatologists often focus on treating the physical aspects of skin cancer, but it is equally important to consider the consequences that this disease has on a patient’s quality of life (QOL). Health is a dynamic process, encompassing one’s physical, emotional, and psychosocial well-being. There are a number of ways to measure health outcomes including mortality, morbidity, health status, and QOL. In recent years, health-related QOL (HRQOL) outcomes in dermatology have become increasingly important to clinical practice and may become factors in quality measurement or reimbursement.

Understanding a patient’s HRQOL allows health care providers to better evaluate the burden of disease and disability associated with skin cancer and its treatment. Clinical severity is not always able to capture the extent to which a disease affects one’s life.² Furthermore, physician estimation of disease severity is not always consistent with patient-reported outcomes.³ As such, clinical questionnaires may be invaluable tools capable of objectively reporting a patient’s perception of improvement in health, which may affect how a dermatologist approaches treatment, discussion, and maintenance.

Nonmelanoma Skin Cancer

Most nonmelanoma skin cancer (NMSC) occurs in readily visible areas, namely the head and neck. Surgical treatment minimizes recurrence and complication rates. Nonmelanoma skin cancer has a low mortality and a high cure rate if diagnosed early; therefore, it may be difficult to assess treatment efficacy on cure rates alone. The amalgamation of anxiety associated with the diagnosis, aesthetic and functional concerns regarding treatment, and long-term consequences including fear of future skin cancer may have a lasting effect on an individual’s psychosocial relationships and underscores the need for QOL studies.

Most generic QOL and dermatology-specific QOL instruments fail to accurately detect the concerns of patients with NMSC.^4-6 Generic QOL measures used for skin cancer patients report scores of patients that were similar to population norms,⁴ suggesting that these tools may fail to appropriately assess unique QOL concerns among individuals with skin cancer. Furthermore, dermatology-specific instruments have been reported to be insensitive to specific appearance-related concerns of patients with NMSC, likely because skin cancer patients made up a small percentage of the initial population in their design.^4,7 Nevertheless, dermatology-specific instruments may be suitable depending on the objectives of the study.⁸

Recently, skin cancer–specific QOL instruments have been developed to fill the paucity of appropriate tools for this population. These questionnaires include the Facial Skin Cancer Index, Skin Cancer Index, and the Skin Cancer Quality of Life Impact Tool.⁷ The Skin Cancer Index is a 15-item questionnaire validated in patients undergoing Mohs micrographic surgery and has been used to assess behavior modification and risk perceptions in NMSC patients. Importantly, it does ask the patient if he/she is worried about scarring. The Facial Skin Cancer Index and the Skin Cancer Quality of Life Impact Tool do not take into account detailed aesthetic concerns regarding facial disfigurement and scarring or expectations of reconstruction.⁷ It may be prudent to assess these areas with supplemental scales.

Melanoma

Melanoma, the third most common skin cancer, is highly aggressive and can affect young and middle-aged patients. Because the mortality associated with later-stage melanoma is greater, the QOL impact of melanoma differs from NMSC. There are also 3 distinct periods of melanoma HRQOL impact: diagnosis, treatment, and follow-up. Approximately 30% of patients diagnosed with melanoma report high levels of psychological distress.⁹ The psychosocial effects of a melanoma diagnosis are longitudinal, as there is a high survival rate in early disease but also an increased future risk for melanoma, affecting future behaviors and overall QOL. The diagnosis of melanoma also affects family members due to the increased risk among first-degree relatives. After removal of deeper melanoma, the patient remains at risk for disease progression, which can have a profound impact on his/her social and professional activities and overall lifestyle. There may be a role for longitudinal QOL assessments to monitor changes over time and direct ongoing therapy.

The proportion of patients with melanoma who report high levels of impairment in QOL is comparable to that seen in other malignancies.¹⁰ Generic QOL instruments have found that melanoma patients have medium to high levels of distress and substantial improvement in HRQOL has been achieved with cognitive-behavioral intervention.¹¹ Quality-of-life studies also have shown levels of distress are highest at initial diagnosis and immediately following treatment.¹² In a randomized surgical trial, patients with a larger excision margin had poorer mental and physical function scores on assessment.¹³ Skin-specific QOL instruments have been used in studies of patients with melanoma and found that postmelanoma surveillance did not impact QOL. Also, women experienced greater improvements in QOL over time after reporting lower scores immediately postsurgery.¹³

The FACT-melanoma (Functional Assessment of Cancer Therapy) is a melanoma-specific HRQOL assessment that has been used in patients undergoing clinical trials. It has been shown to distinguish between early and advanced-stage (stages III or IV) HRQOL issues.¹⁴ Patients with early-stage melanoma are more concerned with cosmetic outcome, and those with later-stage melanoma are more concerned with morbidity and mortality associated with treatment.

Comment

Choosing the best QOL instrument depends on the specific objectives of the study. Although generic QOL questionnaires have performed poorly in studies of specific skin diseases and even dermatology-specific tools have shown limited responsiveness in skin cancer, a combination of tools may be an effective approach. However, dermatologists must be cautious when administering these valuable tools to ensure that they do not become a burdensome task for the patient.¹⁵ Although no single skin cancer–specific QOL tool is perfect, it is likely that the current questionnaires still allow for aid with appropriate patient management and comparison of treatments.¹⁶

It behooves clinicians to recognize and appreciate the value of QOL instruments as an important adjunct to treatment. These tools have shown QOL to be an independent predictor of survival among many types of cancer patients, including melanoma.¹⁰ Currently, the psychological and emotional needs of skin cancer patients often go overlooked and undetected by conventional methods. Within one’s own practice, introducing QOL assessments can improve patient self-awareness and physician awareness of matters that may have a greater impact on patient health. On a larger scale, introducing patient-reported outcome measures can affect resource allocation by identifying patient populations that may be most impacted and can give a comprehensive method for physicians to gauge treatment efficacy, leading to improved outcomes.

I take most, but not all insurances. I suspect the majority of doctors today would say the same.

I see a lot of articles about how patients who now have insurance can’t find doctors to see them. And, of course, generally this is blamed on doctors.

The problem is that people often equate insurance with health care, and they aren’t the same. If your insurance reimbursement is minimal, the odds are that no one in health care will be contracted with it. There may be a few newbie docs who figure they can make up the loss by sheer volume. As a result, they get badly overwhelmed, with long waiting-room times and a few months’ delay for appointments. As soon as they get established, they will drop the insurance. This creates a revolving door of doctors for some plans, as new docs use them to get started, then run away screaming and burned out at the first chance they get.

People often get upset and use the “You don’t care, you’re only in this for the money!” line when they find out I don’t take their insurance. My staff hears it frequently.

On the contrary, I do care. If I didn’t, I’d likely get out of medicine entirely. The fact that I’m still doing this after 16 years says that much.

But, in order to take care of people, I also have to pay my rent, staff, insurance, and all the other amounts that make up an overhead. If I can’t keep my office open, then I’m not able to help anyone.

This gets tricky, as some insurances will pay less than the amount needed for me to stay in practice. Some will argue that it’s better than nothing, but, if you’re not making enough to meet overhead, then nothing and less than the amount needed for me to stay in practice mean pretty much the same thing.

If I don’t take your insurance, I’m sorry. This has nothing to do with you. It means that company has decided not to pay me enough to cover my expenses (their decision, not mine), and so I had to drop them in order to continue helping others.

Like all other doctors, I’m forced to decide what works best for both me and the highest number of my patients. To continue caring for people, I need to stay open, and I select the insurances that will allow me to do that. I can’t be everyone’s doctor.

So please, don’t be angry if I no longer take your insurance. In a perfect world, overhead and business decisions wouldn’t play such a key role in medicine. But our world is far from perfect and always will be.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I take most, but not all insurances. I suspect the majority of doctors today would say the same.

I see a lot of articles about how patients who now have insurance can’t find doctors to see them. And, of course, generally this is blamed on doctors.

The problem is that people often equate insurance with health care, and they aren’t the same. If your insurance reimbursement is minimal, the odds are that no one in health care will be contracted with it. There may be a few newbie docs who figure they can make up the loss by sheer volume. As a result, they get badly overwhelmed, with long waiting-room times and a few months’ delay for appointments. As soon as they get established, they will drop the insurance. This creates a revolving door of doctors for some plans, as new docs use them to get started, then run away screaming and burned out at the first chance they get.

People often get upset and use the “You don’t care, you’re only in this for the money!” line when they find out I don’t take their insurance. My staff hears it frequently.

On the contrary, I do care. If I didn’t, I’d likely get out of medicine entirely. The fact that I’m still doing this after 16 years says that much.

But, in order to take care of people, I also have to pay my rent, staff, insurance, and all the other amounts that make up an overhead. If I can’t keep my office open, then I’m not able to help anyone.

This gets tricky, as some insurances will pay less than the amount needed for me to stay in practice. Some will argue that it’s better than nothing, but, if you’re not making enough to meet overhead, then nothing and less than the amount needed for me to stay in practice mean pretty much the same thing.

If I don’t take your insurance, I’m sorry. This has nothing to do with you. It means that company has decided not to pay me enough to cover my expenses (their decision, not mine), and so I had to drop them in order to continue helping others.

Like all other doctors, I’m forced to decide what works best for both me and the highest number of my patients. To continue caring for people, I need to stay open, and I select the insurances that will allow me to do that. I can’t be everyone’s doctor.

So please, don’t be angry if I no longer take your insurance. In a perfect world, overhead and business decisions wouldn’t play such a key role in medicine. But our world is far from perfect and always will be.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I take most, but not all insurances. I suspect the majority of doctors today would say the same.

I see a lot of articles about how patients who now have insurance can’t find doctors to see them. And, of course, generally this is blamed on doctors.

The problem is that people often equate insurance with health care, and they aren’t the same. If your insurance reimbursement is minimal, the odds are that no one in health care will be contracted with it. There may be a few newbie docs who figure they can make up the loss by sheer volume. As a result, they get badly overwhelmed, with long waiting-room times and a few months’ delay for appointments. As soon as they get established, they will drop the insurance. This creates a revolving door of doctors for some plans, as new docs use them to get started, then run away screaming and burned out at the first chance they get.

People often get upset and use the “You don’t care, you’re only in this for the money!” line when they find out I don’t take their insurance. My staff hears it frequently.

On the contrary, I do care. If I didn’t, I’d likely get out of medicine entirely. The fact that I’m still doing this after 16 years says that much.

But, in order to take care of people, I also have to pay my rent, staff, insurance, and all the other amounts that make up an overhead. If I can’t keep my office open, then I’m not able to help anyone.

This gets tricky, as some insurances will pay less than the amount needed for me to stay in practice. Some will argue that it’s better than nothing, but, if you’re not making enough to meet overhead, then nothing and less than the amount needed for me to stay in practice mean pretty much the same thing.

If I don’t take your insurance, I’m sorry. This has nothing to do with you. It means that company has decided not to pay me enough to cover my expenses (their decision, not mine), and so I had to drop them in order to continue helping others.

Like all other doctors, I’m forced to decide what works best for both me and the highest number of my patients. To continue caring for people, I need to stay open, and I select the insurances that will allow me to do that. I can’t be everyone’s doctor.

So please, don’t be angry if I no longer take your insurance. In a perfect world, overhead and business decisions wouldn’t play such a key role in medicine. But our world is far from perfect and always will be.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

If Maine conjures up images of pine-covered mountains and rocky coastlines, then Fort Kent won’t fit into your construct. Slumbering on the broad flat valley of the Saint John River that forms Maine’s border with Canada, the rolling farmland around this town of 4,000 would remind you more of Iowa. Aroostook County is potato country and is so unique that most Mainers refer to it simply as “The County.”

Fort Kent was originally built as a defense outpost but was seldom used. Today it is an unlikely spot for what could be one of the pivotal battles in a war that could decide our country’s future. But who in 1800 would have guessed that the small town of Gettysburg would have such a crucial role to play in American history.

And, who would imagine that a pixy-faced young woman with strawberry ringlets would be one of the heroes? But, on Halloween Day, 2014, the chief judge of the Maine District Courts ruled that Kaci Hickox was no longer to be quarantined in her home. As a nurse who had recently returned from West Africa where she had been caring for patients with Ebola, she certainly was at a higher risk for contracting the disease. But, there has been no clinical evidence that she had the disease or was contagious.

However, the governor of New Jersey, Chris Christie, ignored the facts and responded to irrational fear and isolated Ms. Hickox when she arrived from Africa in an unheated tent with little regard for her psychological comfort. With the help of her lawyer, she was allowed to travel back to Fort Kent where she had been living with her boyfriend, a nursing student. The governor of Maine, Paul LePage, reacted only slightly less irrationally than his New Jersey counterpart, and Kaci was ordered not leave her home. Negotiations for a more reasonable evidence-based arrangement broke down. And, in a brave and clever show of defiance, Kaci and her boyfriend went for a bike ride, heading away from town on the rural roads around Fort Kent. Were the state troopers following in two squad cars going to don hazmat suits to arrest the couple? Not likely, and the ride ended uneventfully. The next day Judge Charles C. Laverdiere lifted the quarantine and in his decision said that we all owed the nurse “a debt of gratitude” for her decision to treat Ebola patients.

Much of the buzz surrounding this decision has focused on the issue of Ms. Hickox’s personal freedom and even the constitutionality of her quarantine. But, more importantly, her case represents a rare victory in a key battle in a bigger war, the war between science and fear-based irrational thought. It is a war in which we have incurred too many losses. Hundreds of children have died of illnesses from which they could have been protected by immunization because their parents failed to trust the science.

Scientific thought is on the defensive. It is being poorly taught in school, and sadly a few who claim to be scientists have allowed their egos and greed to taint the results of their experiments. In the vacuum created when science has been ignored, fear and emotionally based decisions dominate.

In the case of Ebola, we all have suffered from the absence of a single voice of authority armed with evidence. It could have been the U.S. Surgeon General if the Senate hadn’t declined to confirm President Barack Obama’s appointment because of his position on gun-related issues.

However, even if we had a surgeon general, the most obvious choice for the role of defender and promoter of evidence-based decisions in a case that is so highly charged should have been the president himself. The country deserved a straight talking, look-em-in-the-eye delineation of the facts, a presentation that acknowledged that there are seldom situations in which the risk is zero, but one that reminded us that the only thing we have to fear is fear itself. However, this president’s style seems to be to step back and delegate when we need someone who will step forward and lead. The result of his abdication has been the confusing and conflicting attempts at leadership by three governors who may have been well intended, but lacked the skills and resources to address the scientific evidence.

In a battle with no general and a commander-in-chief who chose to stay in his tent, science has been rescued temporarily by a courageous young nurse and sage judge from Maine where our state motto is “Dirigo” – I lead.

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 [email protected].

If Maine conjures up images of pine-covered mountains and rocky coastlines, then Fort Kent won’t fit into your construct. Slumbering on the broad flat valley of the Saint John River that forms Maine’s border with Canada, the rolling farmland around this town of 4,000 would remind you more of Iowa. Aroostook County is potato country and is so unique that most Mainers refer to it simply as “The County.”

Fort Kent was originally built as a defense outpost but was seldom used. Today it is an unlikely spot for what could be one of the pivotal battles in a war that could decide our country’s future. But who in 1800 would have guessed that the small town of Gettysburg would have such a crucial role to play in American history.

And, who would imagine that a pixy-faced young woman with strawberry ringlets would be one of the heroes? But, on Halloween Day, 2014, the chief judge of the Maine District Courts ruled that Kaci Hickox was no longer to be quarantined in her home. As a nurse who had recently returned from West Africa where she had been caring for patients with Ebola, she certainly was at a higher risk for contracting the disease. But, there has been no clinical evidence that she had the disease or was contagious.

However, the governor of New Jersey, Chris Christie, ignored the facts and responded to irrational fear and isolated Ms. Hickox when she arrived from Africa in an unheated tent with little regard for her psychological comfort. With the help of her lawyer, she was allowed to travel back to Fort Kent where she had been living with her boyfriend, a nursing student. The governor of Maine, Paul LePage, reacted only slightly less irrationally than his New Jersey counterpart, and Kaci was ordered not leave her home. Negotiations for a more reasonable evidence-based arrangement broke down. And, in a brave and clever show of defiance, Kaci and her boyfriend went for a bike ride, heading away from town on the rural roads around Fort Kent. Were the state troopers following in two squad cars going to don hazmat suits to arrest the couple? Not likely, and the ride ended uneventfully. The next day Judge Charles C. Laverdiere lifted the quarantine and in his decision said that we all owed the nurse “a debt of gratitude” for her decision to treat Ebola patients.

Much of the buzz surrounding this decision has focused on the issue of Ms. Hickox’s personal freedom and even the constitutionality of her quarantine. But, more importantly, her case represents a rare victory in a key battle in a bigger war, the war between science and fear-based irrational thought. It is a war in which we have incurred too many losses. Hundreds of children have died of illnesses from which they could have been protected by immunization because their parents failed to trust the science.

Scientific thought is on the defensive. It is being poorly taught in school, and sadly a few who claim to be scientists have allowed their egos and greed to taint the results of their experiments. In the vacuum created when science has been ignored, fear and emotionally based decisions dominate.

In the case of Ebola, we all have suffered from the absence of a single voice of authority armed with evidence. It could have been the U.S. Surgeon General if the Senate hadn’t declined to confirm President Barack Obama’s appointment because of his position on gun-related issues.

However, even if we had a surgeon general, the most obvious choice for the role of defender and promoter of evidence-based decisions in a case that is so highly charged should have been the president himself. The country deserved a straight talking, look-em-in-the-eye delineation of the facts, a presentation that acknowledged that there are seldom situations in which the risk is zero, but one that reminded us that the only thing we have to fear is fear itself. However, this president’s style seems to be to step back and delegate when we need someone who will step forward and lead. The result of his abdication has been the confusing and conflicting attempts at leadership by three governors who may have been well intended, but lacked the skills and resources to address the scientific evidence.

In a battle with no general and a commander-in-chief who chose to stay in his tent, science has been rescued temporarily by a courageous young nurse and sage judge from Maine where our state motto is “Dirigo” – I lead.

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 [email protected].

If Maine conjures up images of pine-covered mountains and rocky coastlines, then Fort Kent won’t fit into your construct. Slumbering on the broad flat valley of the Saint John River that forms Maine’s border with Canada, the rolling farmland around this town of 4,000 would remind you more of Iowa. Aroostook County is potato country and is so unique that most Mainers refer to it simply as “The County.”

Fort Kent was originally built as a defense outpost but was seldom used. Today it is an unlikely spot for what could be one of the pivotal battles in a war that could decide our country’s future. But who in 1800 would have guessed that the small town of Gettysburg would have such a crucial role to play in American history.

And, who would imagine that a pixy-faced young woman with strawberry ringlets would be one of the heroes? But, on Halloween Day, 2014, the chief judge of the Maine District Courts ruled that Kaci Hickox was no longer to be quarantined in her home. As a nurse who had recently returned from West Africa where she had been caring for patients with Ebola, she certainly was at a higher risk for contracting the disease. But, there has been no clinical evidence that she had the disease or was contagious.

However, the governor of New Jersey, Chris Christie, ignored the facts and responded to irrational fear and isolated Ms. Hickox when she arrived from Africa in an unheated tent with little regard for her psychological comfort. With the help of her lawyer, she was allowed to travel back to Fort Kent where she had been living with her boyfriend, a nursing student. The governor of Maine, Paul LePage, reacted only slightly less irrationally than his New Jersey counterpart, and Kaci was ordered not leave her home. Negotiations for a more reasonable evidence-based arrangement broke down. And, in a brave and clever show of defiance, Kaci and her boyfriend went for a bike ride, heading away from town on the rural roads around Fort Kent. Were the state troopers following in two squad cars going to don hazmat suits to arrest the couple? Not likely, and the ride ended uneventfully. The next day Judge Charles C. Laverdiere lifted the quarantine and in his decision said that we all owed the nurse “a debt of gratitude” for her decision to treat Ebola patients.

Much of the buzz surrounding this decision has focused on the issue of Ms. Hickox’s personal freedom and even the constitutionality of her quarantine. But, more importantly, her case represents a rare victory in a key battle in a bigger war, the war between science and fear-based irrational thought. It is a war in which we have incurred too many losses. Hundreds of children have died of illnesses from which they could have been protected by immunization because their parents failed to trust the science.

Scientific thought is on the defensive. It is being poorly taught in school, and sadly a few who claim to be scientists have allowed their egos and greed to taint the results of their experiments. In the vacuum created when science has been ignored, fear and emotionally based decisions dominate.

In the case of Ebola, we all have suffered from the absence of a single voice of authority armed with evidence. It could have been the U.S. Surgeon General if the Senate hadn’t declined to confirm President Barack Obama’s appointment because of his position on gun-related issues.

However, even if we had a surgeon general, the most obvious choice for the role of defender and promoter of evidence-based decisions in a case that is so highly charged should have been the president himself. The country deserved a straight talking, look-em-in-the-eye delineation of the facts, a presentation that acknowledged that there are seldom situations in which the risk is zero, but one that reminded us that the only thing we have to fear is fear itself. However, this president’s style seems to be to step back and delegate when we need someone who will step forward and lead. The result of his abdication has been the confusing and conflicting attempts at leadership by three governors who may have been well intended, but lacked the skills and resources to address the scientific evidence.

In a battle with no general and a commander-in-chief who chose to stay in his tent, science has been rescued temporarily by a courageous young nurse and sage judge from Maine where our state motto is “Dirigo” – I lead.

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 [email protected].