Commentary

Peer review is the filter that determines what is published in the scientific literature and what is not allowed to see the light of day. It has been considered "the gatekeeper of science." In modern times, peer review has consisted of a journal editor sending a submitted article to a limited number of experts in the field who then judge its worth for publication. Many specialists see reviewing manuscripts as a service to their profession, put considerable effort into their analysis, and provide extensive comments on revisions needed to strengthen papers.

However, the value of this venerable process as it is presently constituted has been questioned by numerous critics. Because manuscripts are reviewed by a limited number of often rival scientists in a highly specialized field, the practice is prone to bias. Innovation may be stifled when reviewers reject outlier concepts that may be correct but that do not fit into the mainstream of thought. Critiques are often superficial as they are performed by otherwise busy individuals who receive no compensation for their efforts. Finally, journal editors are given undue power in the process. Not only do they make the final decision to publish or reject a manuscript, they are also responsible for selecting reviewers and are then free to ignore or accept their recommendations.

These criticisms of this time-honored system have led to a strong impetus for change. Coincident with the motivation for modifying this essential component of the publication process have been technological advancements that are facilitating new approaches. The Internet has provided a mechanism for making peer review a more open, inclusive process with any member of the scientific community who so desires having the opportunity to contribute to the evaluation of published work. A recent incident highlights how uninvited, but valuable, input from the wider scientific community can rapidly and effectively improve the accuracy of the literature.

On July 2, 2014, National Public Radio’s Morning Edition broadcast "Easy method for making stem cells was too good to be true" and a New York Times headline proclaimed "Stem cell research papers are retracted." In January 2014, Haruko Obokata of the RIKEN Centre for Developmental Biology in Japan published an innovative and considerably simpler method of producing stem cells than extracting them from embryos or making them from skin cells in a complicated and prolonged process (Nature 2014;505: 641-7). At the time of publication, the work was viewed by many to be potentially Nobel Prize-worthy research—that is, until the stem cell research community chimed in with its extensive and detailed post-publication peer review.

A number of research groups questioned Obokata’s conclusions. Some even attempted to replicate the experiments, but with no success. Soon the critics’ findings and opinions appeared on a variety of websites and blogs, including the Nature website. The RIKEN Centre took notice and appointed a committee to investigate the research. The committee found that Obokata had manipulated her data on at least two occasions and concluded that she had participated in research misconduct. Pressure mounted, which led to the recent voluntary retraction of the article by its authors.

This case represents an extreme outcome resulting from a failure of pre-publication vetting followed by a successful post-hoc peer review. But it demonstrates how the emerging and more comprehensive means of evaluating published research is rapidly working its way into the fabric of how science and the reporting of it operate. It would be ideal if this extensive vetting of potentially important research could be done prior to rather than after its release to the general public. Physics academicians have accomplished this by posting their research papers as pre-prints on-line for their colleagues to evaluate. Only after a successful conclusion of this process is a work deemed acceptable for entry into the physics literature. Submission of biomedical research to a similar process has a significant downside in that new, possibly harmful therapies, not yet peer-reviewed, could be adopted by practitioners and/or patients before their time. However, some modification of it will likely evolve and lead to a more accurate assessment of submitted work than the present process allows.

How publications are valued is also being modified thanks to the omnibus means of rapid communication allowed by an ever-expanding Internet. Bibliometrics, most notably the number of times an article is subsequently cited in print, has been the mainstay in determining the value of individual articles. The journal impact factor, which has historically been the main measure of a journal\'s standing compared to that of others in its field, is derived from the aggregate of citations for all articles over a period of time. With the advent of the Internet, a new set of alternative metrics (altmetrics) is now contributing to the evaluation of published work. While print citations take years to accumulate, article downloads, mentions on Facebook, number of tweets on Twitter, and numerous other altmetrics have the considerable advantage of immediacy and can be logged by any reader, not only those authors who decide to subsequently cite certain publications. Although these new metrics are unlikely to replace traditional citations in assigning value to individual articles, along with them, they will be helpful in determining what must be read to maintain currency in one’s specialty.

So, readers of the surgical literature feel your newly found power and exert it. You along with your colleagues around the globe can, and in fact have an obligation to, play a role in determining what is worth reading from an ever-expanding volume of new information. Many eyes will almost certainly be better than relying solely on the opinions of a chosen few.

Dr. Rikkers is Editor in Chief of ACS Surgery News.

Peer review is the filter that determines what is published in the scientific literature and what is not allowed to see the light of day. It has been considered "the gatekeeper of science." In modern times, peer review has consisted of a journal editor sending a submitted article to a limited number of experts in the field who then judge its worth for publication. Many specialists see reviewing manuscripts as a service to their profession, put considerable effort into their analysis, and provide extensive comments on revisions needed to strengthen papers.

However, the value of this venerable process as it is presently constituted has been questioned by numerous critics. Because manuscripts are reviewed by a limited number of often rival scientists in a highly specialized field, the practice is prone to bias. Innovation may be stifled when reviewers reject outlier concepts that may be correct but that do not fit into the mainstream of thought. Critiques are often superficial as they are performed by otherwise busy individuals who receive no compensation for their efforts. Finally, journal editors are given undue power in the process. Not only do they make the final decision to publish or reject a manuscript, they are also responsible for selecting reviewers and are then free to ignore or accept their recommendations.

These criticisms of this time-honored system have led to a strong impetus for change. Coincident with the motivation for modifying this essential component of the publication process have been technological advancements that are facilitating new approaches. The Internet has provided a mechanism for making peer review a more open, inclusive process with any member of the scientific community who so desires having the opportunity to contribute to the evaluation of published work. A recent incident highlights how uninvited, but valuable, input from the wider scientific community can rapidly and effectively improve the accuracy of the literature.

On July 2, 2014, National Public Radio’s Morning Edition broadcast "Easy method for making stem cells was too good to be true" and a New York Times headline proclaimed "Stem cell research papers are retracted." In January 2014, Haruko Obokata of the RIKEN Centre for Developmental Biology in Japan published an innovative and considerably simpler method of producing stem cells than extracting them from embryos or making them from skin cells in a complicated and prolonged process (Nature 2014;505: 641-7). At the time of publication, the work was viewed by many to be potentially Nobel Prize-worthy research—that is, until the stem cell research community chimed in with its extensive and detailed post-publication peer review.

A number of research groups questioned Obokata’s conclusions. Some even attempted to replicate the experiments, but with no success. Soon the critics’ findings and opinions appeared on a variety of websites and blogs, including the Nature website. The RIKEN Centre took notice and appointed a committee to investigate the research. The committee found that Obokata had manipulated her data on at least two occasions and concluded that she had participated in research misconduct. Pressure mounted, which led to the recent voluntary retraction of the article by its authors.

This case represents an extreme outcome resulting from a failure of pre-publication vetting followed by a successful post-hoc peer review. But it demonstrates how the emerging and more comprehensive means of evaluating published research is rapidly working its way into the fabric of how science and the reporting of it operate. It would be ideal if this extensive vetting of potentially important research could be done prior to rather than after its release to the general public. Physics academicians have accomplished this by posting their research papers as pre-prints on-line for their colleagues to evaluate. Only after a successful conclusion of this process is a work deemed acceptable for entry into the physics literature. Submission of biomedical research to a similar process has a significant downside in that new, possibly harmful therapies, not yet peer-reviewed, could be adopted by practitioners and/or patients before their time. However, some modification of it will likely evolve and lead to a more accurate assessment of submitted work than the present process allows.

How publications are valued is also being modified thanks to the omnibus means of rapid communication allowed by an ever-expanding Internet. Bibliometrics, most notably the number of times an article is subsequently cited in print, has been the mainstay in determining the value of individual articles. The journal impact factor, which has historically been the main measure of a journal\'s standing compared to that of others in its field, is derived from the aggregate of citations for all articles over a period of time. With the advent of the Internet, a new set of alternative metrics (altmetrics) is now contributing to the evaluation of published work. While print citations take years to accumulate, article downloads, mentions on Facebook, number of tweets on Twitter, and numerous other altmetrics have the considerable advantage of immediacy and can be logged by any reader, not only those authors who decide to subsequently cite certain publications. Although these new metrics are unlikely to replace traditional citations in assigning value to individual articles, along with them, they will be helpful in determining what must be read to maintain currency in one’s specialty.

So, readers of the surgical literature feel your newly found power and exert it. You along with your colleagues around the globe can, and in fact have an obligation to, play a role in determining what is worth reading from an ever-expanding volume of new information. Many eyes will almost certainly be better than relying solely on the opinions of a chosen few.

Dr. Rikkers is Editor in Chief of ACS Surgery News.

Peer review is the filter that determines what is published in the scientific literature and what is not allowed to see the light of day. It has been considered "the gatekeeper of science." In modern times, peer review has consisted of a journal editor sending a submitted article to a limited number of experts in the field who then judge its worth for publication. Many specialists see reviewing manuscripts as a service to their profession, put considerable effort into their analysis, and provide extensive comments on revisions needed to strengthen papers.

However, the value of this venerable process as it is presently constituted has been questioned by numerous critics. Because manuscripts are reviewed by a limited number of often rival scientists in a highly specialized field, the practice is prone to bias. Innovation may be stifled when reviewers reject outlier concepts that may be correct but that do not fit into the mainstream of thought. Critiques are often superficial as they are performed by otherwise busy individuals who receive no compensation for their efforts. Finally, journal editors are given undue power in the process. Not only do they make the final decision to publish or reject a manuscript, they are also responsible for selecting reviewers and are then free to ignore or accept their recommendations.

These criticisms of this time-honored system have led to a strong impetus for change. Coincident with the motivation for modifying this essential component of the publication process have been technological advancements that are facilitating new approaches. The Internet has provided a mechanism for making peer review a more open, inclusive process with any member of the scientific community who so desires having the opportunity to contribute to the evaluation of published work. A recent incident highlights how uninvited, but valuable, input from the wider scientific community can rapidly and effectively improve the accuracy of the literature.

On July 2, 2014, National Public Radio’s Morning Edition broadcast "Easy method for making stem cells was too good to be true" and a New York Times headline proclaimed "Stem cell research papers are retracted." In January 2014, Haruko Obokata of the RIKEN Centre for Developmental Biology in Japan published an innovative and considerably simpler method of producing stem cells than extracting them from embryos or making them from skin cells in a complicated and prolonged process (Nature 2014;505: 641-7). At the time of publication, the work was viewed by many to be potentially Nobel Prize-worthy research—that is, until the stem cell research community chimed in with its extensive and detailed post-publication peer review.

A number of research groups questioned Obokata’s conclusions. Some even attempted to replicate the experiments, but with no success. Soon the critics’ findings and opinions appeared on a variety of websites and blogs, including the Nature website. The RIKEN Centre took notice and appointed a committee to investigate the research. The committee found that Obokata had manipulated her data on at least two occasions and concluded that she had participated in research misconduct. Pressure mounted, which led to the recent voluntary retraction of the article by its authors.

This case represents an extreme outcome resulting from a failure of pre-publication vetting followed by a successful post-hoc peer review. But it demonstrates how the emerging and more comprehensive means of evaluating published research is rapidly working its way into the fabric of how science and the reporting of it operate. It would be ideal if this extensive vetting of potentially important research could be done prior to rather than after its release to the general public. Physics academicians have accomplished this by posting their research papers as pre-prints on-line for their colleagues to evaluate. Only after a successful conclusion of this process is a work deemed acceptable for entry into the physics literature. Submission of biomedical research to a similar process has a significant downside in that new, possibly harmful therapies, not yet peer-reviewed, could be adopted by practitioners and/or patients before their time. However, some modification of it will likely evolve and lead to a more accurate assessment of submitted work than the present process allows.

How publications are valued is also being modified thanks to the omnibus means of rapid communication allowed by an ever-expanding Internet. Bibliometrics, most notably the number of times an article is subsequently cited in print, has been the mainstay in determining the value of individual articles. The journal impact factor, which has historically been the main measure of a journal\'s standing compared to that of others in its field, is derived from the aggregate of citations for all articles over a period of time. With the advent of the Internet, a new set of alternative metrics (altmetrics) is now contributing to the evaluation of published work. While print citations take years to accumulate, article downloads, mentions on Facebook, number of tweets on Twitter, and numerous other altmetrics have the considerable advantage of immediacy and can be logged by any reader, not only those authors who decide to subsequently cite certain publications. Although these new metrics are unlikely to replace traditional citations in assigning value to individual articles, along with them, they will be helpful in determining what must be read to maintain currency in one’s specialty.

So, readers of the surgical literature feel your newly found power and exert it. You along with your colleagues around the globe can, and in fact have an obligation to, play a role in determining what is worth reading from an ever-expanding volume of new information. Many eyes will almost certainly be better than relying solely on the opinions of a chosen few.

Dr. Rikkers is Editor in Chief of ACS Surgery News.

During a recent interview on public radio, the CEO of one of Maine’s small hospitals (we have only one hospital that might qualify as not small) observed that the implementation of the Affordable Care Act had already resulted in a decrease in the length of hospital stay and shifted some of the health care utilization away from his hospital. These changes have been reflected in decreased revenue for his institution. This in turn was making it difficult for it to subsidize the outpatient practices it had purchased. He added that over the last several years, outpatient medicine was not sustainable without subsidies.

We hear a lot these days about sustainability, but I had never considered outpatient pediatrics in terms of sustainability. But as I thought more about it, I realized that on several levels that primary care pediatrics had frequently had to adjust when its resources had been unable to keep up with demand.

Fifty years ago, outpatient pediatrics was comfortably sustainable, at least from the profit and loss perspective. Most practices were solo, owner-operated enterprises. Real estate was cheap, and many physicians practiced out of their homes. Overhead costs were low. There were no expensive immunizations to stockpile and then, as now, most pediatricians didn’t require much in the way of high tech equipment to make diagnoses. And certainly there were no costly computer systems to purchase and invest valuable time in learning to operate.

If there was something unsustainable about solo practice, it was the issue of coverage. A surprising number of physicians were able to find a balance between being available to their patients and having enough time and energy for personal restoration and a family. However, over time, an increasing number of physicians found solo practice unsustainable. They simply ran out of emotional capital. The solution was to join together in groups. This provided an answer to the on-call issue and offered the promise of an improved financial balance sheet. Business consultants preached the economy of scale. A group could buy things like toilet paper at a discount, and group members could share support staff, saving on payroll.

But it turns out that seeing patients in an outpatient setting doesn’t follow the rules of economy of scale that apply to a factory cranking out widgets. Physicians practice with different levels of efficiency. They are often independent-minded individuals for whom sharing overhead is a difficult concept to grasp. Sometimes, the result is an unsustainable dynamic in which the overhead of the less-efficient members dictates the overhead for the group. As groups grow bigger, even the physicians who understood how to run an office efficiently surrender control to business managers who may not understand medicine. The overhead continues to rise.

The result can be a tense and unsustainable atmosphere with the business manager saying, "You need to bring in more money by doing more studies and/or seeing more patients." The physicians respond, "But doing more procedures doesn’t translate into good medicine. And neither does seeing too many patients."

Even groups that had been able to craft a sustainable model began to face threat from third-party payers whose preferred provider lists that could change year to year might exclude them. This threat of instability created an unsustainable situation in which a practice could no longer count on having a panel of patients large enough to be profitable. The result was often selling out to an even larger entity.

On top of these scenarios consider the rising cost of college and medical school, and the reality that even the best electronic medical record systems adds at least 5 minutes to the physician’s time investment in each office visit. It is surprising that young people still choose primary care.

Is there hope for this bleak picture of unsustainability? I’m not sure, but there is clearly enough fat and waste in our health care system that a redistribution of resources toward primary care could make it sustainable and improve the quality.

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].

During a recent interview on public radio, the CEO of one of Maine’s small hospitals (we have only one hospital that might qualify as not small) observed that the implementation of the Affordable Care Act had already resulted in a decrease in the length of hospital stay and shifted some of the health care utilization away from his hospital. These changes have been reflected in decreased revenue for his institution. This in turn was making it difficult for it to subsidize the outpatient practices it had purchased. He added that over the last several years, outpatient medicine was not sustainable without subsidies.

We hear a lot these days about sustainability, but I had never considered outpatient pediatrics in terms of sustainability. But as I thought more about it, I realized that on several levels that primary care pediatrics had frequently had to adjust when its resources had been unable to keep up with demand.

Fifty years ago, outpatient pediatrics was comfortably sustainable, at least from the profit and loss perspective. Most practices were solo, owner-operated enterprises. Real estate was cheap, and many physicians practiced out of their homes. Overhead costs were low. There were no expensive immunizations to stockpile and then, as now, most pediatricians didn’t require much in the way of high tech equipment to make diagnoses. And certainly there were no costly computer systems to purchase and invest valuable time in learning to operate.

If there was something unsustainable about solo practice, it was the issue of coverage. A surprising number of physicians were able to find a balance between being available to their patients and having enough time and energy for personal restoration and a family. However, over time, an increasing number of physicians found solo practice unsustainable. They simply ran out of emotional capital. The solution was to join together in groups. This provided an answer to the on-call issue and offered the promise of an improved financial balance sheet. Business consultants preached the economy of scale. A group could buy things like toilet paper at a discount, and group members could share support staff, saving on payroll.

But it turns out that seeing patients in an outpatient setting doesn’t follow the rules of economy of scale that apply to a factory cranking out widgets. Physicians practice with different levels of efficiency. They are often independent-minded individuals for whom sharing overhead is a difficult concept to grasp. Sometimes, the result is an unsustainable dynamic in which the overhead of the less-efficient members dictates the overhead for the group. As groups grow bigger, even the physicians who understood how to run an office efficiently surrender control to business managers who may not understand medicine. The overhead continues to rise.

The result can be a tense and unsustainable atmosphere with the business manager saying, "You need to bring in more money by doing more studies and/or seeing more patients." The physicians respond, "But doing more procedures doesn’t translate into good medicine. And neither does seeing too many patients."

Even groups that had been able to craft a sustainable model began to face threat from third-party payers whose preferred provider lists that could change year to year might exclude them. This threat of instability created an unsustainable situation in which a practice could no longer count on having a panel of patients large enough to be profitable. The result was often selling out to an even larger entity.

On top of these scenarios consider the rising cost of college and medical school, and the reality that even the best electronic medical record systems adds at least 5 minutes to the physician’s time investment in each office visit. It is surprising that young people still choose primary care.

Is there hope for this bleak picture of unsustainability? I’m not sure, but there is clearly enough fat and waste in our health care system that a redistribution of resources toward primary care could make it sustainable and improve the quality.

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].

During a recent interview on public radio, the CEO of one of Maine’s small hospitals (we have only one hospital that might qualify as not small) observed that the implementation of the Affordable Care Act had already resulted in a decrease in the length of hospital stay and shifted some of the health care utilization away from his hospital. These changes have been reflected in decreased revenue for his institution. This in turn was making it difficult for it to subsidize the outpatient practices it had purchased. He added that over the last several years, outpatient medicine was not sustainable without subsidies.

We hear a lot these days about sustainability, but I had never considered outpatient pediatrics in terms of sustainability. But as I thought more about it, I realized that on several levels that primary care pediatrics had frequently had to adjust when its resources had been unable to keep up with demand.

Fifty years ago, outpatient pediatrics was comfortably sustainable, at least from the profit and loss perspective. Most practices were solo, owner-operated enterprises. Real estate was cheap, and many physicians practiced out of their homes. Overhead costs were low. There were no expensive immunizations to stockpile and then, as now, most pediatricians didn’t require much in the way of high tech equipment to make diagnoses. And certainly there were no costly computer systems to purchase and invest valuable time in learning to operate.

If there was something unsustainable about solo practice, it was the issue of coverage. A surprising number of physicians were able to find a balance between being available to their patients and having enough time and energy for personal restoration and a family. However, over time, an increasing number of physicians found solo practice unsustainable. They simply ran out of emotional capital. The solution was to join together in groups. This provided an answer to the on-call issue and offered the promise of an improved financial balance sheet. Business consultants preached the economy of scale. A group could buy things like toilet paper at a discount, and group members could share support staff, saving on payroll.

But it turns out that seeing patients in an outpatient setting doesn’t follow the rules of economy of scale that apply to a factory cranking out widgets. Physicians practice with different levels of efficiency. They are often independent-minded individuals for whom sharing overhead is a difficult concept to grasp. Sometimes, the result is an unsustainable dynamic in which the overhead of the less-efficient members dictates the overhead for the group. As groups grow bigger, even the physicians who understood how to run an office efficiently surrender control to business managers who may not understand medicine. The overhead continues to rise.

The result can be a tense and unsustainable atmosphere with the business manager saying, "You need to bring in more money by doing more studies and/or seeing more patients." The physicians respond, "But doing more procedures doesn’t translate into good medicine. And neither does seeing too many patients."

Even groups that had been able to craft a sustainable model began to face threat from third-party payers whose preferred provider lists that could change year to year might exclude them. This threat of instability created an unsustainable situation in which a practice could no longer count on having a panel of patients large enough to be profitable. The result was often selling out to an even larger entity.

On top of these scenarios consider the rising cost of college and medical school, and the reality that even the best electronic medical record systems adds at least 5 minutes to the physician’s time investment in each office visit. It is surprising that young people still choose primary care.

Is there hope for this bleak picture of unsustainability? I’m not sure, but there is clearly enough fat and waste in our health care system that a redistribution of resources toward primary care could make it sustainable and improve the quality.

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].

Pediatricians tend to be rather easygoing or at least to survive they must learn to appear calm. It is our job to keep our heads when all about us are losing theirs. However, there are certain words that can rattle even the most apparently unflappable pediatrician. For example, when a parent or nurse says a child is "grunting," I begin to get twitchy. I drop everything I’m doing, and that child receives all of my professional attention.

"Lethargic" used to be one of those pulse-quickening words for me, but over the years, it began to lose some of its coronary-tightening qualities. I had always considered "lethargic" to be a rather ominous descriptor. But, people seem to apply the term to children who were merely sleepy, listless, or just plain unmotivated. It took me a decade or two of rushing to bedsides or opening the office in the middle of the night to see a "lethargic" child who turned out, in my vocabulary, to be just a bit "droopy" or unusually quiet but not seriously ill.

I found that to minimize the number of false alarms, I just needed to ask more questions to flesh out the child’s appearance and determine what had prompted the caller to use the "L" word. "Lethargy" seemed to mean too many different things to too many people to be of much use as a descriptor. Nonetheless, I still feel twinges of fear when I hear the word. When I encounter it in a nurse’s progress note, I always feel the need to counter it in my own note by providing a more specific description of the child’s condition.

A recent study in Pediatric Emergency Care (Webb, T. et al. 2014;30: 151-6) mirrors my experience with "lethargy." In a retrospective chart review of 272 patients aged 0-6 months, the investigators found that only 12.5% of the children who were described as having poor feeding or lethargy had a condition that required intervention. Infants who were feverish, hypothermic, or less than 35 weeks’ gestation were excluded from the study. However, infants that were described as appearing "ill" were much more likely to require intervention.

So what does a pediatrician mean when she or he describes a child as "ill looking" or "sick looking?" That is the $64,000 question (actually $560,000 in today’s dollars). We could generate a list that include abnormal vital signs, a spectrum of colors from pale to blue, and some neurologic observations, but a child looking sick or ill (and here I mean sick at level of needing immediate attention and probably intervention) is a gestalt.

Knowing when a child is seriously ill is a skill that is difficult to teach and can only come with seeing scores, and scores, and scores of children with a variety of conditions. The physician in training may not necessarily be directly involved with the care of those children, but she or he should have been close enough long enough to feel, see, smell, and hear what is going on. House officers and students should be encouraged to seek out as many of these chances to see sick and well children as they can to sharpen this skill. A mentor may help by pointing out a certain finding or collection of findings that are useful in forming the impression that this is a seriously ill child. But, it is a mistake to focus on one or two observations and not to emphasize the total picture. The ability to correctly determine that a child is desperately ill requires that the physician be able to see the trees, but not ignore the forest.

While most parents have that special sense when things are terribly wrong, we have all witnessed tragic situations when a focus on the thermometer has blurred the bigger picture that the child is desperately ill. Unfortunately, I have seen cases when a physician or nurse has been similarly deceived by a normal vital sign or laboratory result and failed to step back, look at the child, and say to themselves, "But, this child looks sick."

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].

Pediatricians tend to be rather easygoing or at least to survive they must learn to appear calm. It is our job to keep our heads when all about us are losing theirs. However, there are certain words that can rattle even the most apparently unflappable pediatrician. For example, when a parent or nurse says a child is "grunting," I begin to get twitchy. I drop everything I’m doing, and that child receives all of my professional attention.

"Lethargic" used to be one of those pulse-quickening words for me, but over the years, it began to lose some of its coronary-tightening qualities. I had always considered "lethargic" to be a rather ominous descriptor. But, people seem to apply the term to children who were merely sleepy, listless, or just plain unmotivated. It took me a decade or two of rushing to bedsides or opening the office in the middle of the night to see a "lethargic" child who turned out, in my vocabulary, to be just a bit "droopy" or unusually quiet but not seriously ill.

I found that to minimize the number of false alarms, I just needed to ask more questions to flesh out the child’s appearance and determine what had prompted the caller to use the "L" word. "Lethargy" seemed to mean too many different things to too many people to be of much use as a descriptor. Nonetheless, I still feel twinges of fear when I hear the word. When I encounter it in a nurse’s progress note, I always feel the need to counter it in my own note by providing a more specific description of the child’s condition.

A recent study in Pediatric Emergency Care (Webb, T. et al. 2014;30: 151-6) mirrors my experience with "lethargy." In a retrospective chart review of 272 patients aged 0-6 months, the investigators found that only 12.5% of the children who were described as having poor feeding or lethargy had a condition that required intervention. Infants who were feverish, hypothermic, or less than 35 weeks’ gestation were excluded from the study. However, infants that were described as appearing "ill" were much more likely to require intervention.

So what does a pediatrician mean when she or he describes a child as "ill looking" or "sick looking?" That is the $64,000 question (actually $560,000 in today’s dollars). We could generate a list that include abnormal vital signs, a spectrum of colors from pale to blue, and some neurologic observations, but a child looking sick or ill (and here I mean sick at level of needing immediate attention and probably intervention) is a gestalt.

Knowing when a child is seriously ill is a skill that is difficult to teach and can only come with seeing scores, and scores, and scores of children with a variety of conditions. The physician in training may not necessarily be directly involved with the care of those children, but she or he should have been close enough long enough to feel, see, smell, and hear what is going on. House officers and students should be encouraged to seek out as many of these chances to see sick and well children as they can to sharpen this skill. A mentor may help by pointing out a certain finding or collection of findings that are useful in forming the impression that this is a seriously ill child. But, it is a mistake to focus on one or two observations and not to emphasize the total picture. The ability to correctly determine that a child is desperately ill requires that the physician be able to see the trees, but not ignore the forest.

While most parents have that special sense when things are terribly wrong, we have all witnessed tragic situations when a focus on the thermometer has blurred the bigger picture that the child is desperately ill. Unfortunately, I have seen cases when a physician or nurse has been similarly deceived by a normal vital sign or laboratory result and failed to step back, look at the child, and say to themselves, "But, this child looks sick."

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].

Pediatricians tend to be rather easygoing or at least to survive they must learn to appear calm. It is our job to keep our heads when all about us are losing theirs. However, there are certain words that can rattle even the most apparently unflappable pediatrician. For example, when a parent or nurse says a child is "grunting," I begin to get twitchy. I drop everything I’m doing, and that child receives all of my professional attention.

"Lethargic" used to be one of those pulse-quickening words for me, but over the years, it began to lose some of its coronary-tightening qualities. I had always considered "lethargic" to be a rather ominous descriptor. But, people seem to apply the term to children who were merely sleepy, listless, or just plain unmotivated. It took me a decade or two of rushing to bedsides or opening the office in the middle of the night to see a "lethargic" child who turned out, in my vocabulary, to be just a bit "droopy" or unusually quiet but not seriously ill.

I found that to minimize the number of false alarms, I just needed to ask more questions to flesh out the child’s appearance and determine what had prompted the caller to use the "L" word. "Lethargy" seemed to mean too many different things to too many people to be of much use as a descriptor. Nonetheless, I still feel twinges of fear when I hear the word. When I encounter it in a nurse’s progress note, I always feel the need to counter it in my own note by providing a more specific description of the child’s condition.

A recent study in Pediatric Emergency Care (Webb, T. et al. 2014;30: 151-6) mirrors my experience with "lethargy." In a retrospective chart review of 272 patients aged 0-6 months, the investigators found that only 12.5% of the children who were described as having poor feeding or lethargy had a condition that required intervention. Infants who were feverish, hypothermic, or less than 35 weeks’ gestation were excluded from the study. However, infants that were described as appearing "ill" were much more likely to require intervention.

So what does a pediatrician mean when she or he describes a child as "ill looking" or "sick looking?" That is the $64,000 question (actually $560,000 in today’s dollars). We could generate a list that include abnormal vital signs, a spectrum of colors from pale to blue, and some neurologic observations, but a child looking sick or ill (and here I mean sick at level of needing immediate attention and probably intervention) is a gestalt.

Knowing when a child is seriously ill is a skill that is difficult to teach and can only come with seeing scores, and scores, and scores of children with a variety of conditions. The physician in training may not necessarily be directly involved with the care of those children, but she or he should have been close enough long enough to feel, see, smell, and hear what is going on. House officers and students should be encouraged to seek out as many of these chances to see sick and well children as they can to sharpen this skill. A mentor may help by pointing out a certain finding or collection of findings that are useful in forming the impression that this is a seriously ill child. But, it is a mistake to focus on one or two observations and not to emphasize the total picture. The ability to correctly determine that a child is desperately ill requires that the physician be able to see the trees, but not ignore the forest.

While most parents have that special sense when things are terribly wrong, we have all witnessed tragic situations when a focus on the thermometer has blurred the bigger picture that the child is desperately ill. Unfortunately, I have seen cases when a physician or nurse has been similarly deceived by a normal vital sign or laboratory result and failed to step back, look at the child, and say to themselves, "But, this child looks sick."

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].

The sage, bearded, middle-aged doctor stood at the lectern in the auditorium in front of the young, eager, restless interns who were ready to begin their first day of training post medical school. Had smartphones existed at the time, we would have held ours high, recording the speech that would launch us into our careers.

"I have only one bit of advice: Drink lots of water."

That’s it? No words of encouragement like, Go out there and save lives? Study hard? Don’t kill anyone?

Sometimes the simplest advice is the best advice.

Being an intern is like running a marathon. You don’t have time to eat. You don’t have time to sleep. You’re tired all the time. And you feel like you’re stuck at Heartbreak Hill – will this nightmare ever end? So my advice to interns is the same – drink lots of water, and you will make it to the finish line. Take care of yourself, because you won’t be able to help others if your basic needs are not met. And when you are pushed to the limit, sometimes you have to step back and laugh at life’s absurdities.

The hospital where I spent endless days and nights had a beautiful exterior, its white neo-Gothic structure towering over the East River in Manhattan. The inside was another story – it was downright rundown. This was 25 years ago, and I imagine it has gone through a major renovation since that time.

The patients’ rooms had air conditioning units, but the hallways and nurses stations were like furnaces. I thought I was in Dante’s Inferno. My internship began in July, so I drank lots of water. A bit of advice: Never get sick in July when the interns are starting.

I didn’t kill anyone those 2 months on the internal medicine unit, and I was relieved to go to another hospital nearby to work on the neurology unit. At least there was central air conditioning. But the nicer environment did not make up for a toxic atmosphere. The female nurses seemed to have an allergy to the female interns, because when we approached to ask for help they would run to the open arms of the male interns.

Worse yet, a well-known neurologist yelled at me loud and long, following me down the hallway, waving his arms, his comb-over coming undone. He was the doctor in charge on the unit, and I had respectfully brought up the idea of a change in treatment plan, a less medically aggressive and more palliative approach for a suffering patient with end-stage cancer. This doctor carried on as if I were some kind of serial killer instead of a caring doctor.

The unit was so depressing that I would read "Anna Karenina" to cheer myself up.

The next 6 months of training were heavenly in comparison because I was working on medical-psychiatric units in a freestanding psychiatric hospital in Westchester County, N.Y. This hospital would provide my 3-year psychiatry residency training after internship. Frederick Law Olmsted, the architect of Central Park, had designed the hospital’s grounds, which had rolling hills with walking trails lined by beautiful oak, maple, and sycamore trees.

The geriatric psychiatric unit was interesting and tough – we treated many patients with Parkinson’s disease and dementia. One time, in a meeting with a supervising psychiatrist in her office, I cried because the patients reminded me of my grandparents, who had dementia. The psychiatrist glared at me after this demonstration of countertransference with a response that could only be called disgust and hate. I turned off the tears and my emotions as well. And I drank a lot of water.

I spent my last 2 months back in Manhattan doing internal medicine. By then the interns and residents were complete burnouts and were especially foul tempered. One of the interns kicked his foot through a glass door after being tormented by a resident. We had had enough.

Despite drinking water, I was worn down and developed a 103° fever. I did not come into work for a day or two. This was unacceptable. The resident thought I was faking the fever, and I had to get a doctor’s note to document my illness.

I remember the last day of internship. It was one of the best days of my life. Water became my friend again. On my way to the basement of the hospital to turn in my beeper – the ugly black box that was attached to my pants and went off at all hours day and night – I made a stop at the ladies room. I pulled down my pants and the beeper fell into the toilet. The beeper sizzled and then was silent. I swear it was an accident, but I did laugh out loud.

I fished out the beeper and attempted to dry it off with a paper towel, but it kept dripping water. I think I killed it.

I brought the beeper to a clerk, and she gave me a nasty look like it was not the first time this had happened. Then I walked out of the hospital on a beautiful summer day and strolled down the lovely avenue on my way to a celebratory dinner with my husband, who had finished his internship as well. And I drank lots of water.

Dr. Morris is a psychiatrist at the University of Florida Counseling and Wellness Center in Gainesville and has provided clinical care to University of Florida students for the last 20 years. Her areas of specialty include depression, eating disorders, and anxiety disorders.

The sage, bearded, middle-aged doctor stood at the lectern in the auditorium in front of the young, eager, restless interns who were ready to begin their first day of training post medical school. Had smartphones existed at the time, we would have held ours high, recording the speech that would launch us into our careers.

"I have only one bit of advice: Drink lots of water."

That’s it? No words of encouragement like, Go out there and save lives? Study hard? Don’t kill anyone?

Sometimes the simplest advice is the best advice.

Being an intern is like running a marathon. You don’t have time to eat. You don’t have time to sleep. You’re tired all the time. And you feel like you’re stuck at Heartbreak Hill – will this nightmare ever end? So my advice to interns is the same – drink lots of water, and you will make it to the finish line. Take care of yourself, because you won’t be able to help others if your basic needs are not met. And when you are pushed to the limit, sometimes you have to step back and laugh at life’s absurdities.

The hospital where I spent endless days and nights had a beautiful exterior, its white neo-Gothic structure towering over the East River in Manhattan. The inside was another story – it was downright rundown. This was 25 years ago, and I imagine it has gone through a major renovation since that time.

The patients’ rooms had air conditioning units, but the hallways and nurses stations were like furnaces. I thought I was in Dante’s Inferno. My internship began in July, so I drank lots of water. A bit of advice: Never get sick in July when the interns are starting.

I didn’t kill anyone those 2 months on the internal medicine unit, and I was relieved to go to another hospital nearby to work on the neurology unit. At least there was central air conditioning. But the nicer environment did not make up for a toxic atmosphere. The female nurses seemed to have an allergy to the female interns, because when we approached to ask for help they would run to the open arms of the male interns.

Worse yet, a well-known neurologist yelled at me loud and long, following me down the hallway, waving his arms, his comb-over coming undone. He was the doctor in charge on the unit, and I had respectfully brought up the idea of a change in treatment plan, a less medically aggressive and more palliative approach for a suffering patient with end-stage cancer. This doctor carried on as if I were some kind of serial killer instead of a caring doctor.

The unit was so depressing that I would read "Anna Karenina" to cheer myself up.

The next 6 months of training were heavenly in comparison because I was working on medical-psychiatric units in a freestanding psychiatric hospital in Westchester County, N.Y. This hospital would provide my 3-year psychiatry residency training after internship. Frederick Law Olmsted, the architect of Central Park, had designed the hospital’s grounds, which had rolling hills with walking trails lined by beautiful oak, maple, and sycamore trees.

The geriatric psychiatric unit was interesting and tough – we treated many patients with Parkinson’s disease and dementia. One time, in a meeting with a supervising psychiatrist in her office, I cried because the patients reminded me of my grandparents, who had dementia. The psychiatrist glared at me after this demonstration of countertransference with a response that could only be called disgust and hate. I turned off the tears and my emotions as well. And I drank a lot of water.

I spent my last 2 months back in Manhattan doing internal medicine. By then the interns and residents were complete burnouts and were especially foul tempered. One of the interns kicked his foot through a glass door after being tormented by a resident. We had had enough.

Despite drinking water, I was worn down and developed a 103° fever. I did not come into work for a day or two. This was unacceptable. The resident thought I was faking the fever, and I had to get a doctor’s note to document my illness.

I remember the last day of internship. It was one of the best days of my life. Water became my friend again. On my way to the basement of the hospital to turn in my beeper – the ugly black box that was attached to my pants and went off at all hours day and night – I made a stop at the ladies room. I pulled down my pants and the beeper fell into the toilet. The beeper sizzled and then was silent. I swear it was an accident, but I did laugh out loud.

I fished out the beeper and attempted to dry it off with a paper towel, but it kept dripping water. I think I killed it.

I brought the beeper to a clerk, and she gave me a nasty look like it was not the first time this had happened. Then I walked out of the hospital on a beautiful summer day and strolled down the lovely avenue on my way to a celebratory dinner with my husband, who had finished his internship as well. And I drank lots of water.

Dr. Morris is a psychiatrist at the University of Florida Counseling and Wellness Center in Gainesville and has provided clinical care to University of Florida students for the last 20 years. Her areas of specialty include depression, eating disorders, and anxiety disorders.

The sage, bearded, middle-aged doctor stood at the lectern in the auditorium in front of the young, eager, restless interns who were ready to begin their first day of training post medical school. Had smartphones existed at the time, we would have held ours high, recording the speech that would launch us into our careers.

"I have only one bit of advice: Drink lots of water."

That’s it? No words of encouragement like, Go out there and save lives? Study hard? Don’t kill anyone?

Sometimes the simplest advice is the best advice.

Being an intern is like running a marathon. You don’t have time to eat. You don’t have time to sleep. You’re tired all the time. And you feel like you’re stuck at Heartbreak Hill – will this nightmare ever end? So my advice to interns is the same – drink lots of water, and you will make it to the finish line. Take care of yourself, because you won’t be able to help others if your basic needs are not met. And when you are pushed to the limit, sometimes you have to step back and laugh at life’s absurdities.

The hospital where I spent endless days and nights had a beautiful exterior, its white neo-Gothic structure towering over the East River in Manhattan. The inside was another story – it was downright rundown. This was 25 years ago, and I imagine it has gone through a major renovation since that time.

The patients’ rooms had air conditioning units, but the hallways and nurses stations were like furnaces. I thought I was in Dante’s Inferno. My internship began in July, so I drank lots of water. A bit of advice: Never get sick in July when the interns are starting.

I didn’t kill anyone those 2 months on the internal medicine unit, and I was relieved to go to another hospital nearby to work on the neurology unit. At least there was central air conditioning. But the nicer environment did not make up for a toxic atmosphere. The female nurses seemed to have an allergy to the female interns, because when we approached to ask for help they would run to the open arms of the male interns.

Worse yet, a well-known neurologist yelled at me loud and long, following me down the hallway, waving his arms, his comb-over coming undone. He was the doctor in charge on the unit, and I had respectfully brought up the idea of a change in treatment plan, a less medically aggressive and more palliative approach for a suffering patient with end-stage cancer. This doctor carried on as if I were some kind of serial killer instead of a caring doctor.

The unit was so depressing that I would read "Anna Karenina" to cheer myself up.

The next 6 months of training were heavenly in comparison because I was working on medical-psychiatric units in a freestanding psychiatric hospital in Westchester County, N.Y. This hospital would provide my 3-year psychiatry residency training after internship. Frederick Law Olmsted, the architect of Central Park, had designed the hospital’s grounds, which had rolling hills with walking trails lined by beautiful oak, maple, and sycamore trees.

The geriatric psychiatric unit was interesting and tough – we treated many patients with Parkinson’s disease and dementia. One time, in a meeting with a supervising psychiatrist in her office, I cried because the patients reminded me of my grandparents, who had dementia. The psychiatrist glared at me after this demonstration of countertransference with a response that could only be called disgust and hate. I turned off the tears and my emotions as well. And I drank a lot of water.

I spent my last 2 months back in Manhattan doing internal medicine. By then the interns and residents were complete burnouts and were especially foul tempered. One of the interns kicked his foot through a glass door after being tormented by a resident. We had had enough.

Despite drinking water, I was worn down and developed a 103° fever. I did not come into work for a day or two. This was unacceptable. The resident thought I was faking the fever, and I had to get a doctor’s note to document my illness.

I remember the last day of internship. It was one of the best days of my life. Water became my friend again. On my way to the basement of the hospital to turn in my beeper – the ugly black box that was attached to my pants and went off at all hours day and night – I made a stop at the ladies room. I pulled down my pants and the beeper fell into the toilet. The beeper sizzled and then was silent. I swear it was an accident, but I did laugh out loud.

I fished out the beeper and attempted to dry it off with a paper towel, but it kept dripping water. I think I killed it.

I brought the beeper to a clerk, and she gave me a nasty look like it was not the first time this had happened. Then I walked out of the hospital on a beautiful summer day and strolled down the lovely avenue on my way to a celebratory dinner with my husband, who had finished his internship as well. And I drank lots of water.

Dr. Morris is a psychiatrist at the University of Florida Counseling and Wellness Center in Gainesville and has provided clinical care to University of Florida students for the last 20 years. Her areas of specialty include depression, eating disorders, and anxiety disorders.

Have you ever used "The Doctor Trick"?

Of course you have. You probably call it something else, though. Like a light saber, it must be used with respect and care. Overuse will render it worthless, but sometimes you don’t have a choice.

"The Doctor Trick" – as a friend in residency called it – is using your title as an excuse to leave.

I remember the first time I did it. It was in residency, and I’d somehow been dragged to a Halloween party I didn’t really want to be at. Not only that, but it had a $15 cover charge. After getting in and realizing that I’d prefer having my fingernails pulled out, I went back to the door. I showed the cashier my hospital ID and receipt indicating I’d been there less than 5 minutes. I told her I’d been called to the hospital for an emergency. She gave me my money back, and I thanked her and left.

Granted, she was under no obligation to do that, but it didn’t hurt to ask. As my dad would say: "The worst they can do is say no."

So I’ve used it here and there over time, typically as an excuse to leave a party, meeting, or pretty much any event where I’m looking for a way out. I’ve never used it to try and get better seats, or a table by the window. To me, that falls on the entitled side, and usually people will say no anyway.

It’s kept in check by knowing that overuse will, like the boy who cried wolf, render it useless. There’s also a fear that abusing it will bring bad karma from the feared "Call Gods" who will punish you next time you’re on.

That said, it still provides a convenient excuse to get out of, or away from, meetings, in-laws, school boards, and other happenings you’d rather avoid.

Membership, as they say, has its privileges.

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

Have you ever used "The Doctor Trick"?

Of course you have. You probably call it something else, though. Like a light saber, it must be used with respect and care. Overuse will render it worthless, but sometimes you don’t have a choice.

"The Doctor Trick" – as a friend in residency called it – is using your title as an excuse to leave.

I remember the first time I did it. It was in residency, and I’d somehow been dragged to a Halloween party I didn’t really want to be at. Not only that, but it had a $15 cover charge. After getting in and realizing that I’d prefer having my fingernails pulled out, I went back to the door. I showed the cashier my hospital ID and receipt indicating I’d been there less than 5 minutes. I told her I’d been called to the hospital for an emergency. She gave me my money back, and I thanked her and left.

Granted, she was under no obligation to do that, but it didn’t hurt to ask. As my dad would say: "The worst they can do is say no."

So I’ve used it here and there over time, typically as an excuse to leave a party, meeting, or pretty much any event where I’m looking for a way out. I’ve never used it to try and get better seats, or a table by the window. To me, that falls on the entitled side, and usually people will say no anyway.

It’s kept in check by knowing that overuse will, like the boy who cried wolf, render it useless. There’s also a fear that abusing it will bring bad karma from the feared "Call Gods" who will punish you next time you’re on.

That said, it still provides a convenient excuse to get out of, or away from, meetings, in-laws, school boards, and other happenings you’d rather avoid.

Membership, as they say, has its privileges.

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

Have you ever used "The Doctor Trick"?

Of course you have. You probably call it something else, though. Like a light saber, it must be used with respect and care. Overuse will render it worthless, but sometimes you don’t have a choice.

"The Doctor Trick" – as a friend in residency called it – is using your title as an excuse to leave.

I remember the first time I did it. It was in residency, and I’d somehow been dragged to a Halloween party I didn’t really want to be at. Not only that, but it had a $15 cover charge. After getting in and realizing that I’d prefer having my fingernails pulled out, I went back to the door. I showed the cashier my hospital ID and receipt indicating I’d been there less than 5 minutes. I told her I’d been called to the hospital for an emergency. She gave me my money back, and I thanked her and left.

Granted, she was under no obligation to do that, but it didn’t hurt to ask. As my dad would say: "The worst they can do is say no."

So I’ve used it here and there over time, typically as an excuse to leave a party, meeting, or pretty much any event where I’m looking for a way out. I’ve never used it to try and get better seats, or a table by the window. To me, that falls on the entitled side, and usually people will say no anyway.

It’s kept in check by knowing that overuse will, like the boy who cried wolf, render it useless. There’s also a fear that abusing it will bring bad karma from the feared "Call Gods" who will punish you next time you’re on.

That said, it still provides a convenient excuse to get out of, or away from, meetings, in-laws, school boards, and other happenings you’d rather avoid.

Membership, as they say, has its privileges.

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