Letters from Maine

Traditionally, as the ides of August descend upon us we expect to be bombarded with advertisements encouraging parents and students to finish up their back-to-school shopping. But, this year the question on every parent and school administrator’s mind is not which color back pack will be the most popular this year but whether a mask should be a required part of the back-to-school ensemble.

The American Academy of Pediatrics has recommended that “All students older than 2 years and all school staff should wear a mask at school” (“American Academy of Pediatrics Updates Recommendations for Opening Schools in Fall 2021.” 2021 Jul 19). The academy’s statement includes a generous list of common sense caveats but it does not include a statement that masks have been shown to be protective for children in school environments. The Centers for Disease Control and Prevention “recommends” universal indoor masking along with keeping a 3-foot separation but again fails to include any references to support the effectiveness of masks (“Guidance for COVID-19 Prevention in K-12 Schools.” 2021 Aug 5).

Not surprisingly, into this void have stepped two pairs of experts – one group purporting to have evidence that masking is effective in school environments and the other warning that masks may not only be ineffective but that they also carry some significant downsides. And, where can you find these opposing positions? Not in The Lancet. Not in the New England Journal of Medicine. We don’t have time for any of that peer-reviewed monkey business. No, this is pandemic-era science where we have an abundance of opinions and paucity of facts. You will find these opposing articles on the op-ed pages of two of this country’s major newspapers.

In the Aug. 10, 2021, edition of the New York Times you will find an article (“We Studied One Million Students. This Is What We Learned About Masking”) by two pediatricians, Kanecia Zimmerman, MD, and Danny Benjamin Jr., MD, who have “studied” a million students in North Carolina school systems and tell us universal masking is “one of the most effective and efficient strategies for preventing SARS-CoV-2 transmission in schools. These investigators write that they “believe” the low rate of in school transmission they observed in North Carolina was “because of the mask-on-mask school environment.”

However, in the next paragraph the authors admit, “Because North Carolina had a mask mandate for all K-12 schools, we could not compare masked schools with unmasked schools.” They lean instead on studies from three other states with mask mandates that also had low transmission rates and a single report of an outbreak in Israel that employed neither masking nor safe distancing.

On the other side of the divide is an article in the Wall Street Journal titled “The Case Against Masks for Children” by Marty Makary, MD, and H. Cody Meissner, MD, (2021 Aug 9). The authors, one a pediatric infectious disease specialist, argue that there is “no science behind mask mandates for children.” And, observe that, of the $46 billion spent on research grants by the National Institutes of Health, “not a single grant was dedicated to studying masking in children.”

Dr. Makary and Dr. Meissner present a variety of concerns about the effects of masking including those on the development and communication skills of young children. None of their theoretical concerns of course are supported by controlled studies. They also observe that in previous studies children seem to be less likely to transmit COVID-19 than adults. Although we all know the landscape is changing with the emergence of the delta strain. In their strongest statement the authors claim, “It is abusive to force kids who struggle with them [masks] to sacrifice for the sake of unvaccinated adults.”

So there you have it. It is a situation we have come to expect over the last 2 years – plenty of opinions and too few facts supported by controlled studies. Both pairs of authors, however, agree on two things: Vaccination should continue to be considered our primary tool in prevention and control of COVID-19. and children need to be in school. Based on nothing more than a hunch and 7 decades of hunching, I tend to side with Dr. Makary and Dr. Meissner. Depending on the situation, I suggest masking but wouldn’t mandate it for children in school.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Traditionally, as the ides of August descend upon us we expect to be bombarded with advertisements encouraging parents and students to finish up their back-to-school shopping. But, this year the question on every parent and school administrator’s mind is not which color back pack will be the most popular this year but whether a mask should be a required part of the back-to-school ensemble.

The American Academy of Pediatrics has recommended that “All students older than 2 years and all school staff should wear a mask at school” (“American Academy of Pediatrics Updates Recommendations for Opening Schools in Fall 2021.” 2021 Jul 19). The academy’s statement includes a generous list of common sense caveats but it does not include a statement that masks have been shown to be protective for children in school environments. The Centers for Disease Control and Prevention “recommends” universal indoor masking along with keeping a 3-foot separation but again fails to include any references to support the effectiveness of masks (“Guidance for COVID-19 Prevention in K-12 Schools.” 2021 Aug 5).

Not surprisingly, into this void have stepped two pairs of experts – one group purporting to have evidence that masking is effective in school environments and the other warning that masks may not only be ineffective but that they also carry some significant downsides. And, where can you find these opposing positions? Not in The Lancet. Not in the New England Journal of Medicine. We don’t have time for any of that peer-reviewed monkey business. No, this is pandemic-era science where we have an abundance of opinions and paucity of facts. You will find these opposing articles on the op-ed pages of two of this country’s major newspapers.

In the Aug. 10, 2021, edition of the New York Times you will find an article (“We Studied One Million Students. This Is What We Learned About Masking”) by two pediatricians, Kanecia Zimmerman, MD, and Danny Benjamin Jr., MD, who have “studied” a million students in North Carolina school systems and tell us universal masking is “one of the most effective and efficient strategies for preventing SARS-CoV-2 transmission in schools. These investigators write that they “believe” the low rate of in school transmission they observed in North Carolina was “because of the mask-on-mask school environment.”

However, in the next paragraph the authors admit, “Because North Carolina had a mask mandate for all K-12 schools, we could not compare masked schools with unmasked schools.” They lean instead on studies from three other states with mask mandates that also had low transmission rates and a single report of an outbreak in Israel that employed neither masking nor safe distancing.

On the other side of the divide is an article in the Wall Street Journal titled “The Case Against Masks for Children” by Marty Makary, MD, and H. Cody Meissner, MD, (2021 Aug 9). The authors, one a pediatric infectious disease specialist, argue that there is “no science behind mask mandates for children.” And, observe that, of the $46 billion spent on research grants by the National Institutes of Health, “not a single grant was dedicated to studying masking in children.”

Dr. Makary and Dr. Meissner present a variety of concerns about the effects of masking including those on the development and communication skills of young children. None of their theoretical concerns of course are supported by controlled studies. They also observe that in previous studies children seem to be less likely to transmit COVID-19 than adults. Although we all know the landscape is changing with the emergence of the delta strain. In their strongest statement the authors claim, “It is abusive to force kids who struggle with them [masks] to sacrifice for the sake of unvaccinated adults.”

So there you have it. It is a situation we have come to expect over the last 2 years – plenty of opinions and too few facts supported by controlled studies. Both pairs of authors, however, agree on two things: Vaccination should continue to be considered our primary tool in prevention and control of COVID-19. and children need to be in school. Based on nothing more than a hunch and 7 decades of hunching, I tend to side with Dr. Makary and Dr. Meissner. Depending on the situation, I suggest masking but wouldn’t mandate it for children in school.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Traditionally, as the ides of August descend upon us we expect to be bombarded with advertisements encouraging parents and students to finish up their back-to-school shopping. But, this year the question on every parent and school administrator’s mind is not which color back pack will be the most popular this year but whether a mask should be a required part of the back-to-school ensemble.

The American Academy of Pediatrics has recommended that “All students older than 2 years and all school staff should wear a mask at school” (“American Academy of Pediatrics Updates Recommendations for Opening Schools in Fall 2021.” 2021 Jul 19). The academy’s statement includes a generous list of common sense caveats but it does not include a statement that masks have been shown to be protective for children in school environments. The Centers for Disease Control and Prevention “recommends” universal indoor masking along with keeping a 3-foot separation but again fails to include any references to support the effectiveness of masks (“Guidance for COVID-19 Prevention in K-12 Schools.” 2021 Aug 5).

Not surprisingly, into this void have stepped two pairs of experts – one group purporting to have evidence that masking is effective in school environments and the other warning that masks may not only be ineffective but that they also carry some significant downsides. And, where can you find these opposing positions? Not in The Lancet. Not in the New England Journal of Medicine. We don’t have time for any of that peer-reviewed monkey business. No, this is pandemic-era science where we have an abundance of opinions and paucity of facts. You will find these opposing articles on the op-ed pages of two of this country’s major newspapers.

In the Aug. 10, 2021, edition of the New York Times you will find an article (“We Studied One Million Students. This Is What We Learned About Masking”) by two pediatricians, Kanecia Zimmerman, MD, and Danny Benjamin Jr., MD, who have “studied” a million students in North Carolina school systems and tell us universal masking is “one of the most effective and efficient strategies for preventing SARS-CoV-2 transmission in schools. These investigators write that they “believe” the low rate of in school transmission they observed in North Carolina was “because of the mask-on-mask school environment.”

However, in the next paragraph the authors admit, “Because North Carolina had a mask mandate for all K-12 schools, we could not compare masked schools with unmasked schools.” They lean instead on studies from three other states with mask mandates that also had low transmission rates and a single report of an outbreak in Israel that employed neither masking nor safe distancing.

On the other side of the divide is an article in the Wall Street Journal titled “The Case Against Masks for Children” by Marty Makary, MD, and H. Cody Meissner, MD, (2021 Aug 9). The authors, one a pediatric infectious disease specialist, argue that there is “no science behind mask mandates for children.” And, observe that, of the $46 billion spent on research grants by the National Institutes of Health, “not a single grant was dedicated to studying masking in children.”

Dr. Makary and Dr. Meissner present a variety of concerns about the effects of masking including those on the development and communication skills of young children. None of their theoretical concerns of course are supported by controlled studies. They also observe that in previous studies children seem to be less likely to transmit COVID-19 than adults. Although we all know the landscape is changing with the emergence of the delta strain. In their strongest statement the authors claim, “It is abusive to force kids who struggle with them [masks] to sacrifice for the sake of unvaccinated adults.”

So there you have it. It is a situation we have come to expect over the last 2 years – plenty of opinions and too few facts supported by controlled studies. Both pairs of authors, however, agree on two things: Vaccination should continue to be considered our primary tool in prevention and control of COVID-19. and children need to be in school. Based on nothing more than a hunch and 7 decades of hunching, I tend to side with Dr. Makary and Dr. Meissner. Depending on the situation, I suggest masking but wouldn’t mandate it for children in school.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Our emotional health and that of our patients has taken a terrible beating at the hands of the COVID-19 pandemic. Suicides, substance abuse, levels of depression, and anxiety have risen dramatically. It is tempting to believe that it is the unfortunate events alone we hear about and experience that are causing us to feel the way we do. However, James Gross, PhD, professor of psychology and director of the Stanford (Calif.) University psychophysiology laboratory said: “It is actually the thoughts that we have about the situation that are leading us to feel negative emotions or fail to feel positive emotions.” (YouTube video – https://www.youtube.com/watch?v=Ay4_L1RfkIs).

With this premise as a jumping off point, a large group of psychophysiologists at a variety of centers around the world began a study of more than 20,000 subjects in more than 87 countries and regions. Half of the subjects were exposed to a brief (about 5 min) emotional regulation strategy called “reappraisal.” All the subjects were then shown images of the COVID-19 crisis culled from news sources and were then surveyed about their emotions. The researchers discovered that those subjects exposed to the reappraisal intervention demonstrated significantly increased positive responses and significantly decreased negative responses compared to the two control groups.

Reappraisal is an intervention that encourages individuals to think differently about their current situation in hopes of improving their emotional responses. The researchers tested two different types of reappraisal: “Reconstruing,” which aims to change the way the situation is represented mentally – for example, viewing it as controllable – and “repurposing,” in which the subject is encouraged to focus on the potentially positive outcomes of the situation. In other words, reappraisal basically tries to instill a glass-half-full, silver-lining mindset. The investigators report that both reappraisal strategies were equally effective at influencing the subjects’ responses.

The authors claimed that their findings suggest that reappraisal interventions might be of value for health care and other essential workers who have demonstrated a vulnerability to emotion upheaval during the pandemic. The authors also envisioned opportunities for political and business leaders to implement national and global reappraisal–based initiatives to generate resilience on a national and even global scale.

I will admit that, although I am usually skeptical of studies aimed at quantifying emotions, I found this study interesting. After watching a half hour of television news or reading the online edition of the New York Times I think we could all use a pep talk from someone who might be able to help us look on the bright side of things. However, I doubt that a single 5-minute reappraisal intervention is going to have much lasting benefit in the face of the shear magnitude of bad news we are fed every day. Catastrophic news sells newspapers and it is unlikely that dynamic is ever going to change.

I guess we could try mandating that every half hour of network news be followed by a 5-minute session of reconstruing or repurposing. That is, if we could find someone who could consistently put a positive spin on the news of the day. Even if we could locate that one-in-a-million individual with an absolutely unshakably sunny disposition and a knack for finding silver linings, I suspect after a few weeks he or she would be labeled the arch Pollyanna and be drummed off the air.

That is not to say that we should write off the findings of this international study as a statistical quirk. It may be, but clearly these last 2 years have taken a toll on our emotions and even those of us who are congenital optimists need a pep talk from time to time. Although my forte is denial, I think I already know how to reconstrue and repurpose, but I’m ready to listen to anyone who can help me learn to do it better.

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Our emotional health and that of our patients has taken a terrible beating at the hands of the COVID-19 pandemic. Suicides, substance abuse, levels of depression, and anxiety have risen dramatically. It is tempting to believe that it is the unfortunate events alone we hear about and experience that are causing us to feel the way we do. However, James Gross, PhD, professor of psychology and director of the Stanford (Calif.) University psychophysiology laboratory said: “It is actually the thoughts that we have about the situation that are leading us to feel negative emotions or fail to feel positive emotions.” (YouTube video – https://www.youtube.com/watch?v=Ay4_L1RfkIs).

With this premise as a jumping off point, a large group of psychophysiologists at a variety of centers around the world began a study of more than 20,000 subjects in more than 87 countries and regions. Half of the subjects were exposed to a brief (about 5 min) emotional regulation strategy called “reappraisal.” All the subjects were then shown images of the COVID-19 crisis culled from news sources and were then surveyed about their emotions. The researchers discovered that those subjects exposed to the reappraisal intervention demonstrated significantly increased positive responses and significantly decreased negative responses compared to the two control groups.

Reappraisal is an intervention that encourages individuals to think differently about their current situation in hopes of improving their emotional responses. The researchers tested two different types of reappraisal: “Reconstruing,” which aims to change the way the situation is represented mentally – for example, viewing it as controllable – and “repurposing,” in which the subject is encouraged to focus on the potentially positive outcomes of the situation. In other words, reappraisal basically tries to instill a glass-half-full, silver-lining mindset. The investigators report that both reappraisal strategies were equally effective at influencing the subjects’ responses.

The authors claimed that their findings suggest that reappraisal interventions might be of value for health care and other essential workers who have demonstrated a vulnerability to emotion upheaval during the pandemic. The authors also envisioned opportunities for political and business leaders to implement national and global reappraisal–based initiatives to generate resilience on a national and even global scale.

I will admit that, although I am usually skeptical of studies aimed at quantifying emotions, I found this study interesting. After watching a half hour of television news or reading the online edition of the New York Times I think we could all use a pep talk from someone who might be able to help us look on the bright side of things. However, I doubt that a single 5-minute reappraisal intervention is going to have much lasting benefit in the face of the shear magnitude of bad news we are fed every day. Catastrophic news sells newspapers and it is unlikely that dynamic is ever going to change.

I guess we could try mandating that every half hour of network news be followed by a 5-minute session of reconstruing or repurposing. That is, if we could find someone who could consistently put a positive spin on the news of the day. Even if we could locate that one-in-a-million individual with an absolutely unshakably sunny disposition and a knack for finding silver linings, I suspect after a few weeks he or she would be labeled the arch Pollyanna and be drummed off the air.

That is not to say that we should write off the findings of this international study as a statistical quirk. It may be, but clearly these last 2 years have taken a toll on our emotions and even those of us who are congenital optimists need a pep talk from time to time. Although my forte is denial, I think I already know how to reconstrue and repurpose, but I’m ready to listen to anyone who can help me learn to do it better.

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Our emotional health and that of our patients has taken a terrible beating at the hands of the COVID-19 pandemic. Suicides, substance abuse, levels of depression, and anxiety have risen dramatically. It is tempting to believe that it is the unfortunate events alone we hear about and experience that are causing us to feel the way we do. However, James Gross, PhD, professor of psychology and director of the Stanford (Calif.) University psychophysiology laboratory said: “It is actually the thoughts that we have about the situation that are leading us to feel negative emotions or fail to feel positive emotions.” (YouTube video – https://www.youtube.com/watch?v=Ay4_L1RfkIs).

With this premise as a jumping off point, a large group of psychophysiologists at a variety of centers around the world began a study of more than 20,000 subjects in more than 87 countries and regions. Half of the subjects were exposed to a brief (about 5 min) emotional regulation strategy called “reappraisal.” All the subjects were then shown images of the COVID-19 crisis culled from news sources and were then surveyed about their emotions. The researchers discovered that those subjects exposed to the reappraisal intervention demonstrated significantly increased positive responses and significantly decreased negative responses compared to the two control groups.

Reappraisal is an intervention that encourages individuals to think differently about their current situation in hopes of improving their emotional responses. The researchers tested two different types of reappraisal: “Reconstruing,” which aims to change the way the situation is represented mentally – for example, viewing it as controllable – and “repurposing,” in which the subject is encouraged to focus on the potentially positive outcomes of the situation. In other words, reappraisal basically tries to instill a glass-half-full, silver-lining mindset. The investigators report that both reappraisal strategies were equally effective at influencing the subjects’ responses.

The authors claimed that their findings suggest that reappraisal interventions might be of value for health care and other essential workers who have demonstrated a vulnerability to emotion upheaval during the pandemic. The authors also envisioned opportunities for political and business leaders to implement national and global reappraisal–based initiatives to generate resilience on a national and even global scale.

I will admit that, although I am usually skeptical of studies aimed at quantifying emotions, I found this study interesting. After watching a half hour of television news or reading the online edition of the New York Times I think we could all use a pep talk from someone who might be able to help us look on the bright side of things. However, I doubt that a single 5-minute reappraisal intervention is going to have much lasting benefit in the face of the shear magnitude of bad news we are fed every day. Catastrophic news sells newspapers and it is unlikely that dynamic is ever going to change.

I guess we could try mandating that every half hour of network news be followed by a 5-minute session of reconstruing or repurposing. That is, if we could find someone who could consistently put a positive spin on the news of the day. Even if we could locate that one-in-a-million individual with an absolutely unshakably sunny disposition and a knack for finding silver linings, I suspect after a few weeks he or she would be labeled the arch Pollyanna and be drummed off the air.

That is not to say that we should write off the findings of this international study as a statistical quirk. It may be, but clearly these last 2 years have taken a toll on our emotions and even those of us who are congenital optimists need a pep talk from time to time. Although my forte is denial, I think I already know how to reconstrue and repurpose, but I’m ready to listen to anyone who can help me learn to do it better.

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Not surprisingly, the pandemic has torn at the already fraying fabric of many families. Cooped up away from friends and the emotional relief valve of school, even children who had been relatively easy to manage in the past have posed disciplinary challenges beyond their parents’ abilities to cope.

In a recent study from the Parenting in Context Lab of the University of Michigan (“Child Discipline During the Covid-19 Pandemic,” Family Snapshots: Life During the Pandemic, American Academy of Pediatrics, June 8 2021) researchers found that one in six parents surveyed (n = 3,000 adults) admitted to spanking. Nearly half of the parents said that they had yelled at or threatened their children.

Five out of six parents reported using what the investigators described as less harsh “positive discipline measures.” Three-quarters of these parents used “explaining” as a strategy and nearly the same number used either time-outs or sent the children to their rooms.

Again, not surprisingly, parents who had experienced at least one adverse childhood experience (ACE) were more than twice as likely to spank. And parents who reported an episode of intimate partner violence (IPV) were more likely to resort to a harsh discipline strategy (yelling, threatening, or spanking).

Over my professional career I’ve spent a lot of time thinking about discipline and I have attempted to summarize my thoughts in a book titled, “How to Say No to Your Toddler” (Simon and Schuster, 2003), that has been published in four languages. Based on my observations, trying to explain to a misbehaving child the error of his ways is generally parental time not well spent. A well-structured time-out, preferably in a separate room with a door closed, is the most effective and safest discipline strategy.

However, as in all of my books, this advice on discipline was colored by the families in my practice and the audience for which I was writing, primarily middle class and upper middle class, reasonably affluent parents who buy books. These are usually folks who have homes in which children often have their own rooms, or where at least there are multiple rooms with doors – spaces to escape when tensions rise. Few of these parents have endured ACEs. Few have they experienced – nor have their children witnessed – IPV.

My advice that parents make only threats that can be safely carried, out such as time-out, and to always follow up on threats and promises, is valid regardless of a family’s socioeconomic situation. However, when it comes to choosing a consequence, my standard recommendation of a time-out can be difficult to follow for a family of six living in a three-room apartment, particularly during pandemic-dictated restrictions and lockdowns.

Of course there are alternatives to time-outs in a separate space, including an extended hug in a parental lap, but these responses require that the parents have been able to compose themselves well enough, and that they have the time. One of the important benefits of time-outs is that they can provide parents the time and space to reassess the situation and consider their role in the conflict. The bottom line is that a time-out is the safest and most effective form of discipline, but it requires space and a parent relatively unburdened of financial or emotional stress. Families without these luxuries are left with few alternatives other than physical or verbal abuse.

The AAP’s Family Snapshot concludes with the observation that “pediatricians and pediatric health care providers can continue to play an important role in supporting positive discipline strategies.” That is a difficult assignment even in prepandemic times, but for those of you working with families who lack the space and time to defuse disciplinary tensions, it is a heroic task.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Not surprisingly, the pandemic has torn at the already fraying fabric of many families. Cooped up away from friends and the emotional relief valve of school, even children who had been relatively easy to manage in the past have posed disciplinary challenges beyond their parents’ abilities to cope.

In a recent study from the Parenting in Context Lab of the University of Michigan (“Child Discipline During the Covid-19 Pandemic,” Family Snapshots: Life During the Pandemic, American Academy of Pediatrics, June 8 2021) researchers found that one in six parents surveyed (n = 3,000 adults) admitted to spanking. Nearly half of the parents said that they had yelled at or threatened their children.

Five out of six parents reported using what the investigators described as less harsh “positive discipline measures.” Three-quarters of these parents used “explaining” as a strategy and nearly the same number used either time-outs or sent the children to their rooms.

Again, not surprisingly, parents who had experienced at least one adverse childhood experience (ACE) were more than twice as likely to spank. And parents who reported an episode of intimate partner violence (IPV) were more likely to resort to a harsh discipline strategy (yelling, threatening, or spanking).

Over my professional career I’ve spent a lot of time thinking about discipline and I have attempted to summarize my thoughts in a book titled, “How to Say No to Your Toddler” (Simon and Schuster, 2003), that has been published in four languages. Based on my observations, trying to explain to a misbehaving child the error of his ways is generally parental time not well spent. A well-structured time-out, preferably in a separate room with a door closed, is the most effective and safest discipline strategy.

However, as in all of my books, this advice on discipline was colored by the families in my practice and the audience for which I was writing, primarily middle class and upper middle class, reasonably affluent parents who buy books. These are usually folks who have homes in which children often have their own rooms, or where at least there are multiple rooms with doors – spaces to escape when tensions rise. Few of these parents have endured ACEs. Few have they experienced – nor have their children witnessed – IPV.

My advice that parents make only threats that can be safely carried, out such as time-out, and to always follow up on threats and promises, is valid regardless of a family’s socioeconomic situation. However, when it comes to choosing a consequence, my standard recommendation of a time-out can be difficult to follow for a family of six living in a three-room apartment, particularly during pandemic-dictated restrictions and lockdowns.

Of course there are alternatives to time-outs in a separate space, including an extended hug in a parental lap, but these responses require that the parents have been able to compose themselves well enough, and that they have the time. One of the important benefits of time-outs is that they can provide parents the time and space to reassess the situation and consider their role in the conflict. The bottom line is that a time-out is the safest and most effective form of discipline, but it requires space and a parent relatively unburdened of financial or emotional stress. Families without these luxuries are left with few alternatives other than physical or verbal abuse.

The AAP’s Family Snapshot concludes with the observation that “pediatricians and pediatric health care providers can continue to play an important role in supporting positive discipline strategies.” That is a difficult assignment even in prepandemic times, but for those of you working with families who lack the space and time to defuse disciplinary tensions, it is a heroic task.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Not surprisingly, the pandemic has torn at the already fraying fabric of many families. Cooped up away from friends and the emotional relief valve of school, even children who had been relatively easy to manage in the past have posed disciplinary challenges beyond their parents’ abilities to cope.

In a recent study from the Parenting in Context Lab of the University of Michigan (“Child Discipline During the Covid-19 Pandemic,” Family Snapshots: Life During the Pandemic, American Academy of Pediatrics, June 8 2021) researchers found that one in six parents surveyed (n = 3,000 adults) admitted to spanking. Nearly half of the parents said that they had yelled at or threatened their children.

Five out of six parents reported using what the investigators described as less harsh “positive discipline measures.” Three-quarters of these parents used “explaining” as a strategy and nearly the same number used either time-outs or sent the children to their rooms.

Again, not surprisingly, parents who had experienced at least one adverse childhood experience (ACE) were more than twice as likely to spank. And parents who reported an episode of intimate partner violence (IPV) were more likely to resort to a harsh discipline strategy (yelling, threatening, or spanking).

Over my professional career I’ve spent a lot of time thinking about discipline and I have attempted to summarize my thoughts in a book titled, “How to Say No to Your Toddler” (Simon and Schuster, 2003), that has been published in four languages. Based on my observations, trying to explain to a misbehaving child the error of his ways is generally parental time not well spent. A well-structured time-out, preferably in a separate room with a door closed, is the most effective and safest discipline strategy.

However, as in all of my books, this advice on discipline was colored by the families in my practice and the audience for which I was writing, primarily middle class and upper middle class, reasonably affluent parents who buy books. These are usually folks who have homes in which children often have their own rooms, or where at least there are multiple rooms with doors – spaces to escape when tensions rise. Few of these parents have endured ACEs. Few have they experienced – nor have their children witnessed – IPV.

My advice that parents make only threats that can be safely carried, out such as time-out, and to always follow up on threats and promises, is valid regardless of a family’s socioeconomic situation. However, when it comes to choosing a consequence, my standard recommendation of a time-out can be difficult to follow for a family of six living in a three-room apartment, particularly during pandemic-dictated restrictions and lockdowns.

Of course there are alternatives to time-outs in a separate space, including an extended hug in a parental lap, but these responses require that the parents have been able to compose themselves well enough, and that they have the time. One of the important benefits of time-outs is that they can provide parents the time and space to reassess the situation and consider their role in the conflict. The bottom line is that a time-out is the safest and most effective form of discipline, but it requires space and a parent relatively unburdened of financial or emotional stress. Families without these luxuries are left with few alternatives other than physical or verbal abuse.

The AAP’s Family Snapshot concludes with the observation that “pediatricians and pediatric health care providers can continue to play an important role in supporting positive discipline strategies.” That is a difficult assignment even in prepandemic times, but for those of you working with families who lack the space and time to defuse disciplinary tensions, it is a heroic task.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

You are seeing a third-grader who has been experiencing some difficulty in school and his parents are wondering if he might have attention-deficit/hyperactivity disorder. In addition to interviewing his parents and doing a complete physical exam, you solicit information from his teacher, whose report confirms his struggles and also raises the possibility of an attention-deficit disorder. While the child has never been a model student, his parents have not voiced concerns at any of his previous health maintenance visits.

The child’s mother mentions that she has heard from another mother whose son and several other boys in the class have been struggling and misbehaving. Math seems to have been a particular problem. You don’t recall seeing any other third-graders whose parents have reported recent-onset school problems. But you practice in a large community with several grade schools spread out over a large county and may not be aware of a cluster.

As you get to know this child and his family better, you decide this doesn’t feel like a textbook case of ADHD, if indeed there is such a thing. You wonder if something is going on at school but you haven’t elicited any history that suggests bullying.

The parents have not expressed any concerns about the teacher, but you are beginning to wonder whether it’s time to consider the teacher’s role in this scenario. You recall reading about an article recently published in the journal Child Development that describes a study of more than 1,500 Head Start students in which the researchers found that teachers’ self-reported depressive symptoms were directly associated with lower math skills acquisition over the academic year.

There has been little published previously on an association between depressive symptoms in a teacher and academic achievement; however, the most quoted article I could find is from 2015 in which researchers studied 523 third-graders and 17 teachers at eight Florida school districts. The investigators found that in classes taught by teachers at increased risk for depression there was a decrease in the “quality of the learning environment” as determined by trained observers who watched classroom videos. It is interesting that a new math curriculum had been introduced during the academic year in which these observations were made.

Teaching can be a tough job and I guess we shouldn’t be surprised that the Rand Corporation has reported that teachers are nearly twice as likely to experience job stress and almost three times as likely to experience depression than is the general adult population.

Even if you have a strong suspicion that a depressed teacher is contributing to your patient’s academic struggles and maybe those of his classmates, what are your options? You don’t have enough information, nor would privacy concerns allow you to speak to the school administration. Your best approach would probably be to share with the child’s parents your concern that “something” in the school environment maybe contributing to the changes they are seeing, being careful to avoid singling out the teacher as the culprit because you really have nothing more than a suspicion. If the situation worsens and more parents share their stories, some of them may be bold enough to speak to the school administration.

I have always thought that here is a role for the principal. He or she may be aware of the teacher’s fragility and may be taking steps to correct the problem – but at a minimum, a visit to the classroom to get a sense for the “quality of the learning environment” would be in order.

Unfortunately, because mental health diagnoses continue to carry a stigma, it is very unlikely that a situation like this will resolve quickly to the benefit of the teacher or your patient and his classmates.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

You are seeing a third-grader who has been experiencing some difficulty in school and his parents are wondering if he might have attention-deficit/hyperactivity disorder. In addition to interviewing his parents and doing a complete physical exam, you solicit information from his teacher, whose report confirms his struggles and also raises the possibility of an attention-deficit disorder. While the child has never been a model student, his parents have not voiced concerns at any of his previous health maintenance visits.

The child’s mother mentions that she has heard from another mother whose son and several other boys in the class have been struggling and misbehaving. Math seems to have been a particular problem. You don’t recall seeing any other third-graders whose parents have reported recent-onset school problems. But you practice in a large community with several grade schools spread out over a large county and may not be aware of a cluster.

As you get to know this child and his family better, you decide this doesn’t feel like a textbook case of ADHD, if indeed there is such a thing. You wonder if something is going on at school but you haven’t elicited any history that suggests bullying.

The parents have not expressed any concerns about the teacher, but you are beginning to wonder whether it’s time to consider the teacher’s role in this scenario. You recall reading about an article recently published in the journal Child Development that describes a study of more than 1,500 Head Start students in which the researchers found that teachers’ self-reported depressive symptoms were directly associated with lower math skills acquisition over the academic year.

There has been little published previously on an association between depressive symptoms in a teacher and academic achievement; however, the most quoted article I could find is from 2015 in which researchers studied 523 third-graders and 17 teachers at eight Florida school districts. The investigators found that in classes taught by teachers at increased risk for depression there was a decrease in the “quality of the learning environment” as determined by trained observers who watched classroom videos. It is interesting that a new math curriculum had been introduced during the academic year in which these observations were made.

Teaching can be a tough job and I guess we shouldn’t be surprised that the Rand Corporation has reported that teachers are nearly twice as likely to experience job stress and almost three times as likely to experience depression than is the general adult population.

Even if you have a strong suspicion that a depressed teacher is contributing to your patient’s academic struggles and maybe those of his classmates, what are your options? You don’t have enough information, nor would privacy concerns allow you to speak to the school administration. Your best approach would probably be to share with the child’s parents your concern that “something” in the school environment maybe contributing to the changes they are seeing, being careful to avoid singling out the teacher as the culprit because you really have nothing more than a suspicion. If the situation worsens and more parents share their stories, some of them may be bold enough to speak to the school administration.

I have always thought that here is a role for the principal. He or she may be aware of the teacher’s fragility and may be taking steps to correct the problem – but at a minimum, a visit to the classroom to get a sense for the “quality of the learning environment” would be in order.

Unfortunately, because mental health diagnoses continue to carry a stigma, it is very unlikely that a situation like this will resolve quickly to the benefit of the teacher or your patient and his classmates.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

You are seeing a third-grader who has been experiencing some difficulty in school and his parents are wondering if he might have attention-deficit/hyperactivity disorder. In addition to interviewing his parents and doing a complete physical exam, you solicit information from his teacher, whose report confirms his struggles and also raises the possibility of an attention-deficit disorder. While the child has never been a model student, his parents have not voiced concerns at any of his previous health maintenance visits.

The child’s mother mentions that she has heard from another mother whose son and several other boys in the class have been struggling and misbehaving. Math seems to have been a particular problem. You don’t recall seeing any other third-graders whose parents have reported recent-onset school problems. But you practice in a large community with several grade schools spread out over a large county and may not be aware of a cluster.

As you get to know this child and his family better, you decide this doesn’t feel like a textbook case of ADHD, if indeed there is such a thing. You wonder if something is going on at school but you haven’t elicited any history that suggests bullying.

The parents have not expressed any concerns about the teacher, but you are beginning to wonder whether it’s time to consider the teacher’s role in this scenario. You recall reading about an article recently published in the journal Child Development that describes a study of more than 1,500 Head Start students in which the researchers found that teachers’ self-reported depressive symptoms were directly associated with lower math skills acquisition over the academic year.

There has been little published previously on an association between depressive symptoms in a teacher and academic achievement; however, the most quoted article I could find is from 2015 in which researchers studied 523 third-graders and 17 teachers at eight Florida school districts. The investigators found that in classes taught by teachers at increased risk for depression there was a decrease in the “quality of the learning environment” as determined by trained observers who watched classroom videos. It is interesting that a new math curriculum had been introduced during the academic year in which these observations were made.

Teaching can be a tough job and I guess we shouldn’t be surprised that the Rand Corporation has reported that teachers are nearly twice as likely to experience job stress and almost three times as likely to experience depression than is the general adult population.

Even if you have a strong suspicion that a depressed teacher is contributing to your patient’s academic struggles and maybe those of his classmates, what are your options? You don’t have enough information, nor would privacy concerns allow you to speak to the school administration. Your best approach would probably be to share with the child’s parents your concern that “something” in the school environment maybe contributing to the changes they are seeing, being careful to avoid singling out the teacher as the culprit because you really have nothing more than a suspicion. If the situation worsens and more parents share their stories, some of them may be bold enough to speak to the school administration.

I have always thought that here is a role for the principal. He or she may be aware of the teacher’s fragility and may be taking steps to correct the problem – but at a minimum, a visit to the classroom to get a sense for the “quality of the learning environment” would be in order.

Unfortunately, because mental health diagnoses continue to carry a stigma, it is very unlikely that a situation like this will resolve quickly to the benefit of the teacher or your patient and his classmates.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Some days it feels like more than half of the journal articles I encounter report data suggesting that poverty is associated with some disease entity. I realize that young postgraduates are under some pressure to publish, but I’m ready for a break. I and most pediatricians already know, or at least have assumed, that in general and with few exceptions unwellness and poverty are closely linked. Whether that association is causal or not is a more interesting question. The answer, I suspect, depends on which health condition we are talking about. For the moment I think we should assume that poverty is more likely a major contributor and not merely a fellow traveler of poor health.

Some other questions: What are we as pediatricians expected to do about poverty? Is awareness sufficient? Should I be content with having an elevated awareness that a certain patient has a given disease because I know his family is economically challenged? Or, conversely, should I be satisfied that I have asked about a family’s economic distress when I have just diagnosed a child with asthma? The answer to those questions is a very personal one for each of us to ponder and may depend on where we feel we can best invest our time and skill set.

Like me, you may feel that the focus of your professional life is better spent diagnosing and treating the collateral damage of poverty and addressing economic inequities in your philanthropic activities and your choices at the polls. On the other hand, you may choose to use your public persona as a physician to more actively address poverty whether it is on a local, national, or global stage. There is no correct answer and a hybrid may work best for you.

On the other hand, while you agree that there is some link between poverty and unwellness, perhaps the issue is overblown and we should pay more attention to other factors such as the sad state of the family in both disadvantaged and advantaged populations. Maybe if we worked harder to foster and support two-parent families the drag of economic disadvantage would be reduced.

I recently encountered a study that explores this very question. Christina Cross, PhD, a postdoctoral fellow in the department of sociology at Harvard University, reports on her soon-to-be-published study of a nationally representative sample in which she found that, using a selection of academic metrics including earned grades, likelihood of grade repetition, and rates of suspension, in low-income families there was no difference in achievement between Black youth raised in single-parent households and Black youth raised in two-parent households. However, in well-off families, Black youth raised in two-parent households had better academic metrics. (“Why living in a two-parent home isn’t a cure-all for Black students.” Christina Cross. The Harvard Gazette. 2021 Jun 3).

I guess few of us are surprised that living in a two-parent household can provide a child with some advantages. However, it is disappointing and again not surprising that poverty can rob a child of these advantages. While it may make us feel like we are doing something when we offer counseling that promotes two-family households, this may be no more valuable than supporting apple pie and motherhood. Dr. Cross concludes that President Biden’s proposed American Families Plan is more likely to succeed than those focused on counseling because it will offer direct financial support with its tax credits and subsidies.*

Let’s hope she is correct.

* This story was updated on July 6, 2021. 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Some days it feels like more than half of the journal articles I encounter report data suggesting that poverty is associated with some disease entity. I realize that young postgraduates are under some pressure to publish, but I’m ready for a break. I and most pediatricians already know, or at least have assumed, that in general and with few exceptions unwellness and poverty are closely linked. Whether that association is causal or not is a more interesting question. The answer, I suspect, depends on which health condition we are talking about. For the moment I think we should assume that poverty is more likely a major contributor and not merely a fellow traveler of poor health.

Some other questions: What are we as pediatricians expected to do about poverty? Is awareness sufficient? Should I be content with having an elevated awareness that a certain patient has a given disease because I know his family is economically challenged? Or, conversely, should I be satisfied that I have asked about a family’s economic distress when I have just diagnosed a child with asthma? The answer to those questions is a very personal one for each of us to ponder and may depend on where we feel we can best invest our time and skill set.

Like me, you may feel that the focus of your professional life is better spent diagnosing and treating the collateral damage of poverty and addressing economic inequities in your philanthropic activities and your choices at the polls. On the other hand, you may choose to use your public persona as a physician to more actively address poverty whether it is on a local, national, or global stage. There is no correct answer and a hybrid may work best for you.

On the other hand, while you agree that there is some link between poverty and unwellness, perhaps the issue is overblown and we should pay more attention to other factors such as the sad state of the family in both disadvantaged and advantaged populations. Maybe if we worked harder to foster and support two-parent families the drag of economic disadvantage would be reduced.

I recently encountered a study that explores this very question. Christina Cross, PhD, a postdoctoral fellow in the department of sociology at Harvard University, reports on her soon-to-be-published study of a nationally representative sample in which she found that, using a selection of academic metrics including earned grades, likelihood of grade repetition, and rates of suspension, in low-income families there was no difference in achievement between Black youth raised in single-parent households and Black youth raised in two-parent households. However, in well-off families, Black youth raised in two-parent households had better academic metrics. (“Why living in a two-parent home isn’t a cure-all for Black students.” Christina Cross. The Harvard Gazette. 2021 Jun 3).

I guess few of us are surprised that living in a two-parent household can provide a child with some advantages. However, it is disappointing and again not surprising that poverty can rob a child of these advantages. While it may make us feel like we are doing something when we offer counseling that promotes two-family households, this may be no more valuable than supporting apple pie and motherhood. Dr. Cross concludes that President Biden’s proposed American Families Plan is more likely to succeed than those focused on counseling because it will offer direct financial support with its tax credits and subsidies.*

Let’s hope she is correct.

* This story was updated on July 6, 2021. 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Some days it feels like more than half of the journal articles I encounter report data suggesting that poverty is associated with some disease entity. I realize that young postgraduates are under some pressure to publish, but I’m ready for a break. I and most pediatricians already know, or at least have assumed, that in general and with few exceptions unwellness and poverty are closely linked. Whether that association is causal or not is a more interesting question. The answer, I suspect, depends on which health condition we are talking about. For the moment I think we should assume that poverty is more likely a major contributor and not merely a fellow traveler of poor health.

Some other questions: What are we as pediatricians expected to do about poverty? Is awareness sufficient? Should I be content with having an elevated awareness that a certain patient has a given disease because I know his family is economically challenged? Or, conversely, should I be satisfied that I have asked about a family’s economic distress when I have just diagnosed a child with asthma? The answer to those questions is a very personal one for each of us to ponder and may depend on where we feel we can best invest our time and skill set.

Like me, you may feel that the focus of your professional life is better spent diagnosing and treating the collateral damage of poverty and addressing economic inequities in your philanthropic activities and your choices at the polls. On the other hand, you may choose to use your public persona as a physician to more actively address poverty whether it is on a local, national, or global stage. There is no correct answer and a hybrid may work best for you.

On the other hand, while you agree that there is some link between poverty and unwellness, perhaps the issue is overblown and we should pay more attention to other factors such as the sad state of the family in both disadvantaged and advantaged populations. Maybe if we worked harder to foster and support two-parent families the drag of economic disadvantage would be reduced.

I recently encountered a study that explores this very question. Christina Cross, PhD, a postdoctoral fellow in the department of sociology at Harvard University, reports on her soon-to-be-published study of a nationally representative sample in which she found that, using a selection of academic metrics including earned grades, likelihood of grade repetition, and rates of suspension, in low-income families there was no difference in achievement between Black youth raised in single-parent households and Black youth raised in two-parent households. However, in well-off families, Black youth raised in two-parent households had better academic metrics. (“Why living in a two-parent home isn’t a cure-all for Black students.” Christina Cross. The Harvard Gazette. 2021 Jun 3).

I guess few of us are surprised that living in a two-parent household can provide a child with some advantages. However, it is disappointing and again not surprising that poverty can rob a child of these advantages. While it may make us feel like we are doing something when we offer counseling that promotes two-family households, this may be no more valuable than supporting apple pie and motherhood. Dr. Cross concludes that President Biden’s proposed American Families Plan is more likely to succeed than those focused on counseling because it will offer direct financial support with its tax credits and subsidies.*

Let’s hope she is correct.

* This story was updated on July 6, 2021. 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Burnout is seldom the result of a single factor. It is more often a tragic case of death by a thousand cuts: a balky user-unfriendly electronic medical record system, administrative pressure to see more patients and the resulting frustration of not being able to provide the care you feel they deserve, an overemphasis on documentation or you won’t get paid, the dark cloud of malpractice always overhead, and of course the difficult balance between family responsibilities and work. It often boils down to feeling that there aren’t enough hours in the day to get everything done and still have time to recharge your physical and psychological batteries.

A recent report in the Harvard Business School newsletter, Working Knowledge (“Commuting Hurts Productivity and Your Best Talent Suffers Most.” Lane Lambert. 2021 Mar 30) describes an interesting study by Andy Wu, assistant professor of business administration, in which he discovered that, for every 10 kilometers of commuting distance, there was a decrease in the productivity of high-tech inventors as measured by the number of patents registered by their companies. The quality of their inventions declined even more (7%) for each additional 10 kilometers of commute.

You might question the relevance of these findings with your work in an outpatient clinic, but a conscientious physician is also an inventor and a creator. Every patient, even those with what sounds like a routine complaint, presents a novel collection of management challenges. The best physicians treat their profession as an art and must be invent solutions on the fly.

There is abundant evidence that commuting also can have a negative effect on the physical and mental health of workers. (“The astonishing human potential wasted on commutes.” The Washington Post .Christopher Ingraham. 2016 Feb 25). Watching my father walk into the house after an hour-long train ride out of the city and listening to him grumble created an image that influenced every decision I made about where my wife and I would live and work.

Did I benefit from the luxury of growing up in a small suburban community? Of course I did and I shall be forever grateful for the sacrifice my father made to allow that to happen. But, I promised myself that, while I would make sacrifices for my family, a long or unpleasant commute was not going to be on that list. For a few years I tolerated a 10- to 12-minute car commute (three stoplights) but asked to dissolve the partnership because even that 9-mile ride was too much for me and instead spent the bulk of my 40-year career a 10-minute bike ride from my office and the two hospitals. It meant we didn’t have a view of the ocean or a gentleman’s farm but we had an extra hour together as a family and I arrived at work and at home happy.

The pandemic has been a wake-up call for many of the fortunate folks who have found that they can work from home, eliminating what may have been a time-gobbling commute that was creating more stress than they may have realized. Even if telemedicine continues to maintain some postpandemic presence, I suspect that most physicians will continue to be faced with the challenge of traveling to an office or hospital.

If work is losing some of its luster and/or you are arriving home grumpy from a long day in the office, it is easy to blame an insensitive office administrator or the clunky electronic medical record system ... they deserve it. But, it may be the journey and not just the destination that is the contributing to the problem. I realize that rethinking the decision about where one lives can be painful and the options may be limited. However, I hope that at least some of you can rethink the role your journey is playing in your life.

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Burnout is seldom the result of a single factor. It is more often a tragic case of death by a thousand cuts: a balky user-unfriendly electronic medical record system, administrative pressure to see more patients and the resulting frustration of not being able to provide the care you feel they deserve, an overemphasis on documentation or you won’t get paid, the dark cloud of malpractice always overhead, and of course the difficult balance between family responsibilities and work. It often boils down to feeling that there aren’t enough hours in the day to get everything done and still have time to recharge your physical and psychological batteries.

A recent report in the Harvard Business School newsletter, Working Knowledge (“Commuting Hurts Productivity and Your Best Talent Suffers Most.” Lane Lambert. 2021 Mar 30) describes an interesting study by Andy Wu, assistant professor of business administration, in which he discovered that, for every 10 kilometers of commuting distance, there was a decrease in the productivity of high-tech inventors as measured by the number of patents registered by their companies. The quality of their inventions declined even more (7%) for each additional 10 kilometers of commute.

You might question the relevance of these findings with your work in an outpatient clinic, but a conscientious physician is also an inventor and a creator. Every patient, even those with what sounds like a routine complaint, presents a novel collection of management challenges. The best physicians treat their profession as an art and must be invent solutions on the fly.

There is abundant evidence that commuting also can have a negative effect on the physical and mental health of workers. (“The astonishing human potential wasted on commutes.” The Washington Post .Christopher Ingraham. 2016 Feb 25). Watching my father walk into the house after an hour-long train ride out of the city and listening to him grumble created an image that influenced every decision I made about where my wife and I would live and work.

Did I benefit from the luxury of growing up in a small suburban community? Of course I did and I shall be forever grateful for the sacrifice my father made to allow that to happen. But, I promised myself that, while I would make sacrifices for my family, a long or unpleasant commute was not going to be on that list. For a few years I tolerated a 10- to 12-minute car commute (three stoplights) but asked to dissolve the partnership because even that 9-mile ride was too much for me and instead spent the bulk of my 40-year career a 10-minute bike ride from my office and the two hospitals. It meant we didn’t have a view of the ocean or a gentleman’s farm but we had an extra hour together as a family and I arrived at work and at home happy.

The pandemic has been a wake-up call for many of the fortunate folks who have found that they can work from home, eliminating what may have been a time-gobbling commute that was creating more stress than they may have realized. Even if telemedicine continues to maintain some postpandemic presence, I suspect that most physicians will continue to be faced with the challenge of traveling to an office or hospital.

If work is losing some of its luster and/or you are arriving home grumpy from a long day in the office, it is easy to blame an insensitive office administrator or the clunky electronic medical record system ... they deserve it. But, it may be the journey and not just the destination that is the contributing to the problem. I realize that rethinking the decision about where one lives can be painful and the options may be limited. However, I hope that at least some of you can rethink the role your journey is playing in your life.

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Burnout is seldom the result of a single factor. It is more often a tragic case of death by a thousand cuts: a balky user-unfriendly electronic medical record system, administrative pressure to see more patients and the resulting frustration of not being able to provide the care you feel they deserve, an overemphasis on documentation or you won’t get paid, the dark cloud of malpractice always overhead, and of course the difficult balance between family responsibilities and work. It often boils down to feeling that there aren’t enough hours in the day to get everything done and still have time to recharge your physical and psychological batteries.

A recent report in the Harvard Business School newsletter, Working Knowledge (“Commuting Hurts Productivity and Your Best Talent Suffers Most.” Lane Lambert. 2021 Mar 30) describes an interesting study by Andy Wu, assistant professor of business administration, in which he discovered that, for every 10 kilometers of commuting distance, there was a decrease in the productivity of high-tech inventors as measured by the number of patents registered by their companies. The quality of their inventions declined even more (7%) for each additional 10 kilometers of commute.

You might question the relevance of these findings with your work in an outpatient clinic, but a conscientious physician is also an inventor and a creator. Every patient, even those with what sounds like a routine complaint, presents a novel collection of management challenges. The best physicians treat their profession as an art and must be invent solutions on the fly.

There is abundant evidence that commuting also can have a negative effect on the physical and mental health of workers. (“The astonishing human potential wasted on commutes.” The Washington Post .Christopher Ingraham. 2016 Feb 25). Watching my father walk into the house after an hour-long train ride out of the city and listening to him grumble created an image that influenced every decision I made about where my wife and I would live and work.

Did I benefit from the luxury of growing up in a small suburban community? Of course I did and I shall be forever grateful for the sacrifice my father made to allow that to happen. But, I promised myself that, while I would make sacrifices for my family, a long or unpleasant commute was not going to be on that list. For a few years I tolerated a 10- to 12-minute car commute (three stoplights) but asked to dissolve the partnership because even that 9-mile ride was too much for me and instead spent the bulk of my 40-year career a 10-minute bike ride from my office and the two hospitals. It meant we didn’t have a view of the ocean or a gentleman’s farm but we had an extra hour together as a family and I arrived at work and at home happy.

The pandemic has been a wake-up call for many of the fortunate folks who have found that they can work from home, eliminating what may have been a time-gobbling commute that was creating more stress than they may have realized. Even if telemedicine continues to maintain some postpandemic presence, I suspect that most physicians will continue to be faced with the challenge of traveling to an office or hospital.

If work is losing some of its luster and/or you are arriving home grumpy from a long day in the office, it is easy to blame an insensitive office administrator or the clunky electronic medical record system ... they deserve it. But, it may be the journey and not just the destination that is the contributing to the problem. I realize that rethinking the decision about where one lives can be painful and the options may be limited. However, I hope that at least some of you can rethink the role your journey is playing in your life.

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

As the protective effect of the vaccines becomes increasingly apparent, a large number of school systems are beginning to return to prepandemic in-school learning. But anecdotal reports from around the country are making it clear that some children or their families are hesitant to return to the old norm of face to face learning (Goldstein D. “Schools Are Open, but Many Families Remain Hesitant to Return.” New York Times. 2021 May 9). The possible explanations for this hesitancy include a broad list that goes well beyond the obvious concern about the child contracting COVID-19.

I hear from my grandchildren that remote learning has for the most part been unpleasant and lacked the rigor of their in-class experiences. But, they admit that they have found that, in some situations, they prefer the environment at home because it is less distracting. They also acknowledge that, while they miss seeing their friends, at times the isolation has allowed them to be more efficient. Of course, their observations must be viewed in light of their personalities and the support provided by their parents. For these motivated teenagers, the bottom line is that they would prefer to be in school.

However, for the children who have always been a bit ambivalent about school either because they were anxious in social situations or because they found the academics too challenging, one can easily understand why they might prefer to remain in a less-intimidating home environment. For them, missing their friends may have little draw because they may not have had any friends. And, the negative feedback and bullying they have received at school is too overwhelming. A teenager for whom the pandemic has offered the out-of-school free time to explore her independence, feel more like an adult, and enjoy the benefits of having a job may be hesitant to return to the restrictions imposed by what she sees as the childishness of in-school learning.

Compounding the problem is the risk avoidance posture of some school systems and the hesitancy of some teachers to return to an environment that they continue to view as unsafe despite the evidence of the effectiveness of the vaccines and the minimal threat of in-school spread. It is going to be interesting to see how school administrators and politicians deal with this level of institutional hesitancy. Some schools may take what might be considered a hard-line approach and eliminate remote learning completely.

Regardless of how swiftly and thoughtfully schools return to in-class learning, a large number of children will eventually be faced with the stark reality of returning to a place in which they had felt painfully uncomfortable in the past. Pediatricians must be prepared to see this current wave of school hesitancy morph into a full-fledged tsunami of school refusals.

Successful management of a family whose child finds school too challenging emotionally has always required a combination of careful attention to the possible medical causes of the child’s complaints, consultation with a mental health practitioner, and thoughtful coordination with educators sensitive to the child’s school-generated distress.

It has never been easy to reassure the family of a child with frequent headaches or belly pain that his symptoms have no physical basis and then gently point out that the stress of school attendance may be a contributing factor. Some families who buy into the association may be fortunate enough to be able to offer their child home schooling as a solution to school refusal. But this strategy often requires that one parent remain home and has the temperament and the skills to teach.

Now that we have all seen that remote learning has the potential to work in a crisis, will some parents begin to demand it for their children with school refusal? Who will pay for it? I think you and I would prefer to see a solution that targeted therapeutic interventions aimed at getting the child back in school. But you and I also know those strategies don’t always work.

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

As the protective effect of the vaccines becomes increasingly apparent, a large number of school systems are beginning to return to prepandemic in-school learning. But anecdotal reports from around the country are making it clear that some children or their families are hesitant to return to the old norm of face to face learning (Goldstein D. “Schools Are Open, but Many Families Remain Hesitant to Return.” New York Times. 2021 May 9). The possible explanations for this hesitancy include a broad list that goes well beyond the obvious concern about the child contracting COVID-19.

I hear from my grandchildren that remote learning has for the most part been unpleasant and lacked the rigor of their in-class experiences. But, they admit that they have found that, in some situations, they prefer the environment at home because it is less distracting. They also acknowledge that, while they miss seeing their friends, at times the isolation has allowed them to be more efficient. Of course, their observations must be viewed in light of their personalities and the support provided by their parents. For these motivated teenagers, the bottom line is that they would prefer to be in school.

However, for the children who have always been a bit ambivalent about school either because they were anxious in social situations or because they found the academics too challenging, one can easily understand why they might prefer to remain in a less-intimidating home environment. For them, missing their friends may have little draw because they may not have had any friends. And, the negative feedback and bullying they have received at school is too overwhelming. A teenager for whom the pandemic has offered the out-of-school free time to explore her independence, feel more like an adult, and enjoy the benefits of having a job may be hesitant to return to the restrictions imposed by what she sees as the childishness of in-school learning.

Compounding the problem is the risk avoidance posture of some school systems and the hesitancy of some teachers to return to an environment that they continue to view as unsafe despite the evidence of the effectiveness of the vaccines and the minimal threat of in-school spread. It is going to be interesting to see how school administrators and politicians deal with this level of institutional hesitancy. Some schools may take what might be considered a hard-line approach and eliminate remote learning completely.

Regardless of how swiftly and thoughtfully schools return to in-class learning, a large number of children will eventually be faced with the stark reality of returning to a place in which they had felt painfully uncomfortable in the past. Pediatricians must be prepared to see this current wave of school hesitancy morph into a full-fledged tsunami of school refusals.

Successful management of a family whose child finds school too challenging emotionally has always required a combination of careful attention to the possible medical causes of the child’s complaints, consultation with a mental health practitioner, and thoughtful coordination with educators sensitive to the child’s school-generated distress.

It has never been easy to reassure the family of a child with frequent headaches or belly pain that his symptoms have no physical basis and then gently point out that the stress of school attendance may be a contributing factor. Some families who buy into the association may be fortunate enough to be able to offer their child home schooling as a solution to school refusal. But this strategy often requires that one parent remain home and has the temperament and the skills to teach.

Now that we have all seen that remote learning has the potential to work in a crisis, will some parents begin to demand it for their children with school refusal? Who will pay for it? I think you and I would prefer to see a solution that targeted therapeutic interventions aimed at getting the child back in school. But you and I also know those strategies don’t always work.

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

As the protective effect of the vaccines becomes increasingly apparent, a large number of school systems are beginning to return to prepandemic in-school learning. But anecdotal reports from around the country are making it clear that some children or their families are hesitant to return to the old norm of face to face learning (Goldstein D. “Schools Are Open, but Many Families Remain Hesitant to Return.” New York Times. 2021 May 9). The possible explanations for this hesitancy include a broad list that goes well beyond the obvious concern about the child contracting COVID-19.

I hear from my grandchildren that remote learning has for the most part been unpleasant and lacked the rigor of their in-class experiences. But, they admit that they have found that, in some situations, they prefer the environment at home because it is less distracting. They also acknowledge that, while they miss seeing their friends, at times the isolation has allowed them to be more efficient. Of course, their observations must be viewed in light of their personalities and the support provided by their parents. For these motivated teenagers, the bottom line is that they would prefer to be in school.

However, for the children who have always been a bit ambivalent about school either because they were anxious in social situations or because they found the academics too challenging, one can easily understand why they might prefer to remain in a less-intimidating home environment. For them, missing their friends may have little draw because they may not have had any friends. And, the negative feedback and bullying they have received at school is too overwhelming. A teenager for whom the pandemic has offered the out-of-school free time to explore her independence, feel more like an adult, and enjoy the benefits of having a job may be hesitant to return to the restrictions imposed by what she sees as the childishness of in-school learning.

Compounding the problem is the risk avoidance posture of some school systems and the hesitancy of some teachers to return to an environment that they continue to view as unsafe despite the evidence of the effectiveness of the vaccines and the minimal threat of in-school spread. It is going to be interesting to see how school administrators and politicians deal with this level of institutional hesitancy. Some schools may take what might be considered a hard-line approach and eliminate remote learning completely.

Regardless of how swiftly and thoughtfully schools return to in-class learning, a large number of children will eventually be faced with the stark reality of returning to a place in which they had felt painfully uncomfortable in the past. Pediatricians must be prepared to see this current wave of school hesitancy morph into a full-fledged tsunami of school refusals.

Successful management of a family whose child finds school too challenging emotionally has always required a combination of careful attention to the possible medical causes of the child’s complaints, consultation with a mental health practitioner, and thoughtful coordination with educators sensitive to the child’s school-generated distress.

It has never been easy to reassure the family of a child with frequent headaches or belly pain that his symptoms have no physical basis and then gently point out that the stress of school attendance may be a contributing factor. Some families who buy into the association may be fortunate enough to be able to offer their child home schooling as a solution to school refusal. But this strategy often requires that one parent remain home and has the temperament and the skills to teach.

Now that we have all seen that remote learning has the potential to work in a crisis, will some parents begin to demand it for their children with school refusal? Who will pay for it? I think you and I would prefer to see a solution that targeted therapeutic interventions aimed at getting the child back in school. But you and I also know those strategies don’t always work.

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

One of the top stories in the local newspaper recently described an unfortunate incident in which a previously healthy 19-month-old baby was found unresponsive and apneic in a crib at her day-care center. She was successfully resuscitated by the daycare provider but is now blind, has seizures, and no longer walks or talks. According to the day care owner, the child had not settled down during rest time and her talking was preventing the other children from sleeping. This apparently had happened before and the day-care provider had successfully resorted to triple wrapping the child in a blanket and placing her in a crib in a separate room. The day-care provider had checked on the child once and noted she was snoring. When the child failed to wake after the expected interval of time she was found face down with her head partially covered by a pillow.

An investigation of the day-care center is ongoing and no reports or prior violations, warnings, or license suspensions have surfaced at this point. The day-care provider has been charged with aggravated assault and endangering the welfare of a child. The charges could carry a prison sentence of 30 years.

As I reread this very sad story I began wondering how this tragedy is going to unfold in the next months and years. We can assume one young life has already been permanently damaged. Her family will have to deal with the consequences of this event for decades or longer. What about the day-care provider? I hope we can assume that she intended no harm to the child nor had she ignored prior warnings or training about swaddling. Nor does this lapse in judgment fit a previous pattern of behavior. Regardless of what the courts decide she will carry some degree of guilt for the foreseeable future. The day-care center has been closed voluntarily and given that Maine is a small state where word travels fast it is unlikely that it will ever reopen.

Can we imagine any good coming out of this tragedy? It may be that with luck and diligent therapies that the little girl will be able to lead a life she finds rewarding and gives others some pleasure. It is possible that some individuals involved in her life – her parents or therapists – will find the devotion to her care brings new meaning to their lives.

Will the day-care provider find a new career or a cause that can help her restore some of the self worth she may have lost in the wake of the event? Or, will a protracted course through the legal system take its devastating toll on her life and marriage? It is unlikely that she will spend anywhere near 30 years in prison, if any at all. Will the child’s family sue this small family day-care center? It is hard to imagine they will recover anything more than a tiny fraction of the lifetime costs of this child’s care.

It is also unlikely that the message that swaddling children old enough to turn over carries a significant risk will go beyond one or two more stories in the local Maine newspapers. If this child’s father had been a professional football player or her mother had been an actress or U.S. Senator this tragic turn of events could possibly have stirred enough waters to grab national attention, spawn a foundation, or even result in legislation. But, she appears to come from a family with modest means without claims to notoriety. There is no flawed product to ban. She is a victim of ignorance and our failure to educate. As a result, her tragedy and those of thousands of other children will do little more than accumulate as unfortunate statistics.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

One of the top stories in the local newspaper recently described an unfortunate incident in which a previously healthy 19-month-old baby was found unresponsive and apneic in a crib at her day-care center. She was successfully resuscitated by the daycare provider but is now blind, has seizures, and no longer walks or talks. According to the day care owner, the child had not settled down during rest time and her talking was preventing the other children from sleeping. This apparently had happened before and the day-care provider had successfully resorted to triple wrapping the child in a blanket and placing her in a crib in a separate room. The day-care provider had checked on the child once and noted she was snoring. When the child failed to wake after the expected interval of time she was found face down with her head partially covered by a pillow.

An investigation of the day-care center is ongoing and no reports or prior violations, warnings, or license suspensions have surfaced at this point. The day-care provider has been charged with aggravated assault and endangering the welfare of a child. The charges could carry a prison sentence of 30 years.

As I reread this very sad story I began wondering how this tragedy is going to unfold in the next months and years. We can assume one young life has already been permanently damaged. Her family will have to deal with the consequences of this event for decades or longer. What about the day-care provider? I hope we can assume that she intended no harm to the child nor had she ignored prior warnings or training about swaddling. Nor does this lapse in judgment fit a previous pattern of behavior. Regardless of what the courts decide she will carry some degree of guilt for the foreseeable future. The day-care center has been closed voluntarily and given that Maine is a small state where word travels fast it is unlikely that it will ever reopen.

Can we imagine any good coming out of this tragedy? It may be that with luck and diligent therapies that the little girl will be able to lead a life she finds rewarding and gives others some pleasure. It is possible that some individuals involved in her life – her parents or therapists – will find the devotion to her care brings new meaning to their lives.

Will the day-care provider find a new career or a cause that can help her restore some of the self worth she may have lost in the wake of the event? Or, will a protracted course through the legal system take its devastating toll on her life and marriage? It is unlikely that she will spend anywhere near 30 years in prison, if any at all. Will the child’s family sue this small family day-care center? It is hard to imagine they will recover anything more than a tiny fraction of the lifetime costs of this child’s care.

It is also unlikely that the message that swaddling children old enough to turn over carries a significant risk will go beyond one or two more stories in the local Maine newspapers. If this child’s father had been a professional football player or her mother had been an actress or U.S. Senator this tragic turn of events could possibly have stirred enough waters to grab national attention, spawn a foundation, or even result in legislation. But, she appears to come from a family with modest means without claims to notoriety. There is no flawed product to ban. She is a victim of ignorance and our failure to educate. As a result, her tragedy and those of thousands of other children will do little more than accumulate as unfortunate statistics.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

One of the top stories in the local newspaper recently described an unfortunate incident in which a previously healthy 19-month-old baby was found unresponsive and apneic in a crib at her day-care center. She was successfully resuscitated by the daycare provider but is now blind, has seizures, and no longer walks or talks. According to the day care owner, the child had not settled down during rest time and her talking was preventing the other children from sleeping. This apparently had happened before and the day-care provider had successfully resorted to triple wrapping the child in a blanket and placing her in a crib in a separate room. The day-care provider had checked on the child once and noted she was snoring. When the child failed to wake after the expected interval of time she was found face down with her head partially covered by a pillow.

An investigation of the day-care center is ongoing and no reports or prior violations, warnings, or license suspensions have surfaced at this point. The day-care provider has been charged with aggravated assault and endangering the welfare of a child. The charges could carry a prison sentence of 30 years.

As I reread this very sad story I began wondering how this tragedy is going to unfold in the next months and years. We can assume one young life has already been permanently damaged. Her family will have to deal with the consequences of this event for decades or longer. What about the day-care provider? I hope we can assume that she intended no harm to the child nor had she ignored prior warnings or training about swaddling. Nor does this lapse in judgment fit a previous pattern of behavior. Regardless of what the courts decide she will carry some degree of guilt for the foreseeable future. The day-care center has been closed voluntarily and given that Maine is a small state where word travels fast it is unlikely that it will ever reopen.

Can we imagine any good coming out of this tragedy? It may be that with luck and diligent therapies that the little girl will be able to lead a life she finds rewarding and gives others some pleasure. It is possible that some individuals involved in her life – her parents or therapists – will find the devotion to her care brings new meaning to their lives.

Will the day-care provider find a new career or a cause that can help her restore some of the self worth she may have lost in the wake of the event? Or, will a protracted course through the legal system take its devastating toll on her life and marriage? It is unlikely that she will spend anywhere near 30 years in prison, if any at all. Will the child’s family sue this small family day-care center? It is hard to imagine they will recover anything more than a tiny fraction of the lifetime costs of this child’s care.

It is also unlikely that the message that swaddling children old enough to turn over carries a significant risk will go beyond one or two more stories in the local Maine newspapers. If this child’s father had been a professional football player or her mother had been an actress or U.S. Senator this tragic turn of events could possibly have stirred enough waters to grab national attention, spawn a foundation, or even result in legislation. But, she appears to come from a family with modest means without claims to notoriety. There is no flawed product to ban. She is a victim of ignorance and our failure to educate. As a result, her tragedy and those of thousands of other children will do little more than accumulate as unfortunate statistics.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

It’s pretty clear that, at least globally, we have not reached a steady state with the SARS-COV-2 virus. And here in the United States we should remain concerned that if we can’t convince our vaccine-hesitant population to step forward for their shots, this country may slide back into dangerous instability. Despite these uncertainties, it may be time to polish up the old retrospectoscope again and see what the last year and a half has taught us.

Although it took us too long to discover the reality, it is now pretty clear that the virus is spread in the air and by close personal contact, especially indoors. There continues to be some misplaced over-attention to surface cleaning, but for the most part, the bulk of the population seems to have finally gotten the picture. We are of course still plagued by our own impatience and the unfortunate mix of politics and the disagreement about how personal freedom and the common good can coexist.

A year ago, while we were still on the steep part of the learning curve and the specter of the unknown hung over us like a dark cloud, schools and colleges faced a myriad of challenges as they considered how to safely educate their students. Faced with a relative vacuum in leadership from the federal government, school boards and college administrators were left to interpret the trickle of information that filtered down from the media. Many turned for help to hired consultants and a variety of state and local health departments, all of whom were relying on the same information sources that were available to all of us – sources that often were neither peer reviewed nor based on hard facts. In this land that prides itself on free speech, we were all college administrators, local school board members, and parents basing our decision on the same smorgasbord of information that was frequently self-contradictory.

As I look around at the school systems and colleges with which I have some familiarity it has been interesting to observe how their responses to this hodgepodge of opinion and guesstimates have fallen into two basic categories. Some institutions seem to have been primarily motivated by risk avoidance and others appeared to have struggled to maintain their focus on how best to carry out their primary mission of educating their students.

This dichotomy is not surprising. Institutions are composed of people and people naturally self-sort themselves into pessimists and optimists. When a study is published without peer review suggesting that within schools transmission of the virus between children is unusual the optimist may use the scrap of information to support her decision to craft a hybrid system that includes an abundance of in-class experience. The pessimist will probably observe that it was only one study and instead be more concerned about the number of multi-system-inflammatory syndrome cases reported among children in New York City. He will be far less likely to abandon his all-remote learning system.

There is risk inherent in any decision-making process, including incurring a greater risk by failing to make any decision. The person whose primary focus is on avoiding any risk often shuts off the process of creative thinking and problem solving. At the end of the day, the risk avoider may have achieved his goal with a policy that includes aggressive closings but has fallen far short of his primary mission of educating students.

Here in New England there are several examples of small colleges that have managed to create more normal on-campus educational environments. To my knowledge, their experience with case numbers is no worse and may even be better than that of schools of similar size and geographic siting that chose more restrictive policies. You could argue that the less restrictive schools were just lucky. But my hunch is that the institutions that were able to put risk in perspective and remain focused on their mission were able to navigate the uncharted waters more creatively. The bottom line is that we aren’t talking about right or wrong decisions but grouped together they should provide a foundation to build on for the next turmoil.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

It’s pretty clear that, at least globally, we have not reached a steady state with the SARS-COV-2 virus. And here in the United States we should remain concerned that if we can’t convince our vaccine-hesitant population to step forward for their shots, this country may slide back into dangerous instability. Despite these uncertainties, it may be time to polish up the old retrospectoscope again and see what the last year and a half has taught us.

Although it took us too long to discover the reality, it is now pretty clear that the virus is spread in the air and by close personal contact, especially indoors. There continues to be some misplaced over-attention to surface cleaning, but for the most part, the bulk of the population seems to have finally gotten the picture. We are of course still plagued by our own impatience and the unfortunate mix of politics and the disagreement about how personal freedom and the common good can coexist.

A year ago, while we were still on the steep part of the learning curve and the specter of the unknown hung over us like a dark cloud, schools and colleges faced a myriad of challenges as they considered how to safely educate their students. Faced with a relative vacuum in leadership from the federal government, school boards and college administrators were left to interpret the trickle of information that filtered down from the media. Many turned for help to hired consultants and a variety of state and local health departments, all of whom were relying on the same information sources that were available to all of us – sources that often were neither peer reviewed nor based on hard facts. In this land that prides itself on free speech, we were all college administrators, local school board members, and parents basing our decision on the same smorgasbord of information that was frequently self-contradictory.

As I look around at the school systems and colleges with which I have some familiarity it has been interesting to observe how their responses to this hodgepodge of opinion and guesstimates have fallen into two basic categories. Some institutions seem to have been primarily motivated by risk avoidance and others appeared to have struggled to maintain their focus on how best to carry out their primary mission of educating their students.

This dichotomy is not surprising. Institutions are composed of people and people naturally self-sort themselves into pessimists and optimists. When a study is published without peer review suggesting that within schools transmission of the virus between children is unusual the optimist may use the scrap of information to support her decision to craft a hybrid system that includes an abundance of in-class experience. The pessimist will probably observe that it was only one study and instead be more concerned about the number of multi-system-inflammatory syndrome cases reported among children in New York City. He will be far less likely to abandon his all-remote learning system.

There is risk inherent in any decision-making process, including incurring a greater risk by failing to make any decision. The person whose primary focus is on avoiding any risk often shuts off the process of creative thinking and problem solving. At the end of the day, the risk avoider may have achieved his goal with a policy that includes aggressive closings but has fallen far short of his primary mission of educating students.

Here in New England there are several examples of small colleges that have managed to create more normal on-campus educational environments. To my knowledge, their experience with case numbers is no worse and may even be better than that of schools of similar size and geographic siting that chose more restrictive policies. You could argue that the less restrictive schools were just lucky. But my hunch is that the institutions that were able to put risk in perspective and remain focused on their mission were able to navigate the uncharted waters more creatively. The bottom line is that we aren’t talking about right or wrong decisions but grouped together they should provide a foundation to build on for the next turmoil.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

It’s pretty clear that, at least globally, we have not reached a steady state with the SARS-COV-2 virus. And here in the United States we should remain concerned that if we can’t convince our vaccine-hesitant population to step forward for their shots, this country may slide back into dangerous instability. Despite these uncertainties, it may be time to polish up the old retrospectoscope again and see what the last year and a half has taught us.

Although it took us too long to discover the reality, it is now pretty clear that the virus is spread in the air and by close personal contact, especially indoors. There continues to be some misplaced over-attention to surface cleaning, but for the most part, the bulk of the population seems to have finally gotten the picture. We are of course still plagued by our own impatience and the unfortunate mix of politics and the disagreement about how personal freedom and the common good can coexist.

A year ago, while we were still on the steep part of the learning curve and the specter of the unknown hung over us like a dark cloud, schools and colleges faced a myriad of challenges as they considered how to safely educate their students. Faced with a relative vacuum in leadership from the federal government, school boards and college administrators were left to interpret the trickle of information that filtered down from the media. Many turned for help to hired consultants and a variety of state and local health departments, all of whom were relying on the same information sources that were available to all of us – sources that often were neither peer reviewed nor based on hard facts. In this land that prides itself on free speech, we were all college administrators, local school board members, and parents basing our decision on the same smorgasbord of information that was frequently self-contradictory.

As I look around at the school systems and colleges with which I have some familiarity it has been interesting to observe how their responses to this hodgepodge of opinion and guesstimates have fallen into two basic categories. Some institutions seem to have been primarily motivated by risk avoidance and others appeared to have struggled to maintain their focus on how best to carry out their primary mission of educating their students.

This dichotomy is not surprising. Institutions are composed of people and people naturally self-sort themselves into pessimists and optimists. When a study is published without peer review suggesting that within schools transmission of the virus between children is unusual the optimist may use the scrap of information to support her decision to craft a hybrid system that includes an abundance of in-class experience. The pessimist will probably observe that it was only one study and instead be more concerned about the number of multi-system-inflammatory syndrome cases reported among children in New York City. He will be far less likely to abandon his all-remote learning system.

There is risk inherent in any decision-making process, including incurring a greater risk by failing to make any decision. The person whose primary focus is on avoiding any risk often shuts off the process of creative thinking and problem solving. At the end of the day, the risk avoider may have achieved his goal with a policy that includes aggressive closings but has fallen far short of his primary mission of educating students.

Here in New England there are several examples of small colleges that have managed to create more normal on-campus educational environments. To my knowledge, their experience with case numbers is no worse and may even be better than that of schools of similar size and geographic siting that chose more restrictive policies. You could argue that the less restrictive schools were just lucky. But my hunch is that the institutions that were able to put risk in perspective and remain focused on their mission were able to navigate the uncharted waters more creatively. The bottom line is that we aren’t talking about right or wrong decisions but grouped together they should provide a foundation to build on for the next turmoil.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I suspect that very few of you chose to go into pediatrics as part of a get-rich-quick scheme. But, like me, you may have assumed that by going into medicine you would always have a job buffered from the erratic winds of the economy, an assumption that it turns out did not take into account the risk of a global pandemic.

I also bet that if you chose to subspecialize it was not because you felt you might make more money. I and most of the lay public have always naively assumed that specialists generally make more money because … well, because they spent more time training. You, on the other hand, may have discovered belatedly that becoming a pediatric subspecialist isn’t as lucrative as you thought it might be.

It turns out that, when subjected to some standard money-crunching exercises, the lifetime earning potential of most pediatric subspecialists falls significantly behind that of general pediatricians. In a paper published in the April 2021 issue of Pediatrics, investigators from the departments of neurology and pediatric neurology at Johns Hopkins University have reported that, with the exception of three hospital-based, procedure-oriented specialties (cardiology, critical care, and neonatology) the earning time lost during training is usually not recouped over the course of a subspecialist’s career. This observation may be explained in many cases by the fact that the income generated by most subspecialists is similar to and not greater than that of general pediatricians. Even when the income of a subspecialist is greater, it is generally not enough to allow for catch up for the earning power lost during training. The researchers observed this effect both in academic and nonacademic settings.

It is possible that, as the results of this study become more widely distributed, more pediatricians in training will begin to think a bit more about the bottom line when they are considering fellowship training. I suspect that drift is already underway, and if it continues, we will find more subspecialties experiencing shortages. And the importance of this lack of subspecialists on both a local and national level is not something to ignore.

The authors discuss several possible solutions. One option might be to shorten the subspecialty training period. Obviously, this would raise some concerns about quality. Another might be for the government to begin a program in which student loans were selectively forgiven based on a physician’s decision to pursue a subspecialty that is experiencing a shortage.

Another option might be to subsidize the income of some subspecialists. Although this might have a similar effect as loan forgiveness, as a physician with a longstanding pride in being a generalist I would hate to see subspecialists guaranteed a higher income merely because of the narrower mix of patients they have chosen to see. I have always felt that the challenge faced by a primary care generalist who must be prepared to deal with the breadth of complaints that present themselves at the door is at least as great and in many cases greater than that of a specialist whose patients to a large extent have been presorted.

Another solution that comes to mind is that, instead of shortening fellowship programs, one could restructure basic pediatric training programs to allow physicians who have already chosen to become subspecialists to enter a fellowship program after 2 years of house officer training. Restructuring of this magnitude would not be as simple as lopping off the last year of house officer training. It would require tailoring each physician’s shortened prefellowship learning experience to maximize his or her exposure to clinical situations that will be most relevant to the anticipated subspecialty they have chosen. A plan like this also assumes that a significant number of recent medical school graduates will be ready to make choices during their internship that will channel them into careers that will span decades.

Becoming a generalist was an easy decision for me. Any of the subspecialties I was considering would have meant I would have had to live and work in or near a high-density population. I am and always have been a small town kind of guy.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I suspect that very few of you chose to go into pediatrics as part of a get-rich-quick scheme. But, like me, you may have assumed that by going into medicine you would always have a job buffered from the erratic winds of the economy, an assumption that it turns out did not take into account the risk of a global pandemic.

I also bet that if you chose to subspecialize it was not because you felt you might make more money. I and most of the lay public have always naively assumed that specialists generally make more money because … well, because they spent more time training. You, on the other hand, may have discovered belatedly that becoming a pediatric subspecialist isn’t as lucrative as you thought it might be.

It turns out that, when subjected to some standard money-crunching exercises, the lifetime earning potential of most pediatric subspecialists falls significantly behind that of general pediatricians. In a paper published in the April 2021 issue of Pediatrics, investigators from the departments of neurology and pediatric neurology at Johns Hopkins University have reported that, with the exception of three hospital-based, procedure-oriented specialties (cardiology, critical care, and neonatology) the earning time lost during training is usually not recouped over the course of a subspecialist’s career. This observation may be explained in many cases by the fact that the income generated by most subspecialists is similar to and not greater than that of general pediatricians. Even when the income of a subspecialist is greater, it is generally not enough to allow for catch up for the earning power lost during training. The researchers observed this effect both in academic and nonacademic settings.

It is possible that, as the results of this study become more widely distributed, more pediatricians in training will begin to think a bit more about the bottom line when they are considering fellowship training. I suspect that drift is already underway, and if it continues, we will find more subspecialties experiencing shortages. And the importance of this lack of subspecialists on both a local and national level is not something to ignore.

The authors discuss several possible solutions. One option might be to shorten the subspecialty training period. Obviously, this would raise some concerns about quality. Another might be for the government to begin a program in which student loans were selectively forgiven based on a physician’s decision to pursue a subspecialty that is experiencing a shortage.

Another option might be to subsidize the income of some subspecialists. Although this might have a similar effect as loan forgiveness, as a physician with a longstanding pride in being a generalist I would hate to see subspecialists guaranteed a higher income merely because of the narrower mix of patients they have chosen to see. I have always felt that the challenge faced by a primary care generalist who must be prepared to deal with the breadth of complaints that present themselves at the door is at least as great and in many cases greater than that of a specialist whose patients to a large extent have been presorted.

Another solution that comes to mind is that, instead of shortening fellowship programs, one could restructure basic pediatric training programs to allow physicians who have already chosen to become subspecialists to enter a fellowship program after 2 years of house officer training. Restructuring of this magnitude would not be as simple as lopping off the last year of house officer training. It would require tailoring each physician’s shortened prefellowship learning experience to maximize his or her exposure to clinical situations that will be most relevant to the anticipated subspecialty they have chosen. A plan like this also assumes that a significant number of recent medical school graduates will be ready to make choices during their internship that will channel them into careers that will span decades.

Becoming a generalist was an easy decision for me. Any of the subspecialties I was considering would have meant I would have had to live and work in or near a high-density population. I am and always have been a small town kind of guy.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I suspect that very few of you chose to go into pediatrics as part of a get-rich-quick scheme. But, like me, you may have assumed that by going into medicine you would always have a job buffered from the erratic winds of the economy, an assumption that it turns out did not take into account the risk of a global pandemic.

I also bet that if you chose to subspecialize it was not because you felt you might make more money. I and most of the lay public have always naively assumed that specialists generally make more money because … well, because they spent more time training. You, on the other hand, may have discovered belatedly that becoming a pediatric subspecialist isn’t as lucrative as you thought it might be.

It turns out that, when subjected to some standard money-crunching exercises, the lifetime earning potential of most pediatric subspecialists falls significantly behind that of general pediatricians. In a paper published in the April 2021 issue of Pediatrics, investigators from the departments of neurology and pediatric neurology at Johns Hopkins University have reported that, with the exception of three hospital-based, procedure-oriented specialties (cardiology, critical care, and neonatology) the earning time lost during training is usually not recouped over the course of a subspecialist’s career. This observation may be explained in many cases by the fact that the income generated by most subspecialists is similar to and not greater than that of general pediatricians. Even when the income of a subspecialist is greater, it is generally not enough to allow for catch up for the earning power lost during training. The researchers observed this effect both in academic and nonacademic settings.

It is possible that, as the results of this study become more widely distributed, more pediatricians in training will begin to think a bit more about the bottom line when they are considering fellowship training. I suspect that drift is already underway, and if it continues, we will find more subspecialties experiencing shortages. And the importance of this lack of subspecialists on both a local and national level is not something to ignore.

The authors discuss several possible solutions. One option might be to shorten the subspecialty training period. Obviously, this would raise some concerns about quality. Another might be for the government to begin a program in which student loans were selectively forgiven based on a physician’s decision to pursue a subspecialty that is experiencing a shortage.

Another option might be to subsidize the income of some subspecialists. Although this might have a similar effect as loan forgiveness, as a physician with a longstanding pride in being a generalist I would hate to see subspecialists guaranteed a higher income merely because of the narrower mix of patients they have chosen to see. I have always felt that the challenge faced by a primary care generalist who must be prepared to deal with the breadth of complaints that present themselves at the door is at least as great and in many cases greater than that of a specialist whose patients to a large extent have been presorted.

Another solution that comes to mind is that, instead of shortening fellowship programs, one could restructure basic pediatric training programs to allow physicians who have already chosen to become subspecialists to enter a fellowship program after 2 years of house officer training. Restructuring of this magnitude would not be as simple as lopping off the last year of house officer training. It would require tailoring each physician’s shortened prefellowship learning experience to maximize his or her exposure to clinical situations that will be most relevant to the anticipated subspecialty they have chosen. A plan like this also assumes that a significant number of recent medical school graduates will be ready to make choices during their internship that will channel them into careers that will span decades.

Becoming a generalist was an easy decision for me. Any of the subspecialties I was considering would have meant I would have had to live and work in or near a high-density population. I am and always have been a small town kind of guy.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].