Letters from Maine

Unlike many of you, maybe even most of you, I can recall when my office records were handwritten, some would say scribbled, on pieces of paper. They were decipherable by a select few. Some veteran assistants never mastered the skill. Pages were sometimes lavishly illustrated with drawings of body parts, often because I couldn’t remember or spell the correct anatomic term. When I needed to send a referring letter to another provider I typed it myself because dictating never quite suited my personality.

When I joined a small primary care group, the computer-savvy lead physician and a programmer developed our own homegrown EHR. It relied on scanning documents, as so many of us still generated handwritten notes. Even the most vociferous Luddites among us loved the system from day 2.

However, for a variety of reasons, some defensible some just plain bad, our beloved system needed to be replaced after 7 years. We then invested in an off-the-shelf EHR system that promised more capabilities. We were told there would be a learning curve but the plateau would come quickly and we would enjoy our new electronic assistant.

You’ve lived the rest of the story. The learning curve was steep and long and the plateau was a time gobbler. I was probably the most efficient provider in the group, and after 6 months I was leaving the office an hour later than I had been and was seeing the same number of patients. Most of my coworkers were staying and/or working on the computer at home for an extra 2 hours. This change could be easily documented by speaking with our spouses and children. I understand from my colleagues who have stayed in the business that over the ensuing decade and a half since my first experience with the EHR, its insatiable appetite for a clinician’s time has not abated.

The authors of a recent article in Annals of Family Medicine offer up some advice on how this tragic situation might be brought under control. First, the investigators point out that the phenomenon of after-hours EHR work, sometimes referred to as WOW (work outside of work), has not gone unnoticed by health system administrators and vendors who develop and sell the EHRs. However, analyzing the voluminous data necessary is not any easy task and for the most part has resulted in metrics that cannot be easily applied over a variety of practice scenarios. Many health care organizations, even large ones, have simply given up and rely on the WOW data and recommendations provided by the vendors, obviously lending the situation a faint odor of conflict of interest.

The bottom line is that after a couple of decades, there is no well defined way of quantifying the time-gobbling effect of an EHR system. It would seem to me just asking the spouses and significant others of the clinicians would be sufficient. But, authors of the paper have more specific recommendations. First, they suggest that time working on the computer outside of scheduled time with patients should be separated from any other calculation of EHR usage. They encourage vendors and time-management researchers to develop standardized and validated methods for measuring active EHR use. And, finally they recommend that all EHR work done outside of time scheduled with patients be attributed to WOW. They feel that clearly labeling it work outside of work offers health care organizations a better chance of developing policies that will address the scourge of burnout.

This, unfortunately, is another tragic example of how clinicians have lost control of our work environments. The fact that 20 years have passed and there is still no standardized method for determining how much time we spend on the computer is more evidence we need to raise our voices.
 

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].

Unlike many of you, maybe even most of you, I can recall when my office records were handwritten, some would say scribbled, on pieces of paper. They were decipherable by a select few. Some veteran assistants never mastered the skill. Pages were sometimes lavishly illustrated with drawings of body parts, often because I couldn’t remember or spell the correct anatomic term. When I needed to send a referring letter to another provider I typed it myself because dictating never quite suited my personality.

When I joined a small primary care group, the computer-savvy lead physician and a programmer developed our own homegrown EHR. It relied on scanning documents, as so many of us still generated handwritten notes. Even the most vociferous Luddites among us loved the system from day 2.

However, for a variety of reasons, some defensible some just plain bad, our beloved system needed to be replaced after 7 years. We then invested in an off-the-shelf EHR system that promised more capabilities. We were told there would be a learning curve but the plateau would come quickly and we would enjoy our new electronic assistant.

You’ve lived the rest of the story. The learning curve was steep and long and the plateau was a time gobbler. I was probably the most efficient provider in the group, and after 6 months I was leaving the office an hour later than I had been and was seeing the same number of patients. Most of my coworkers were staying and/or working on the computer at home for an extra 2 hours. This change could be easily documented by speaking with our spouses and children. I understand from my colleagues who have stayed in the business that over the ensuing decade and a half since my first experience with the EHR, its insatiable appetite for a clinician’s time has not abated.

The authors of a recent article in Annals of Family Medicine offer up some advice on how this tragic situation might be brought under control. First, the investigators point out that the phenomenon of after-hours EHR work, sometimes referred to as WOW (work outside of work), has not gone unnoticed by health system administrators and vendors who develop and sell the EHRs. However, analyzing the voluminous data necessary is not any easy task and for the most part has resulted in metrics that cannot be easily applied over a variety of practice scenarios. Many health care organizations, even large ones, have simply given up and rely on the WOW data and recommendations provided by the vendors, obviously lending the situation a faint odor of conflict of interest.

The bottom line is that after a couple of decades, there is no well defined way of quantifying the time-gobbling effect of an EHR system. It would seem to me just asking the spouses and significant others of the clinicians would be sufficient. But, authors of the paper have more specific recommendations. First, they suggest that time working on the computer outside of scheduled time with patients should be separated from any other calculation of EHR usage. They encourage vendors and time-management researchers to develop standardized and validated methods for measuring active EHR use. And, finally they recommend that all EHR work done outside of time scheduled with patients be attributed to WOW. They feel that clearly labeling it work outside of work offers health care organizations a better chance of developing policies that will address the scourge of burnout.

This, unfortunately, is another tragic example of how clinicians have lost control of our work environments. The fact that 20 years have passed and there is still no standardized method for determining how much time we spend on the computer is more evidence we need to raise our voices.
 

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].

Unlike many of you, maybe even most of you, I can recall when my office records were handwritten, some would say scribbled, on pieces of paper. They were decipherable by a select few. Some veteran assistants never mastered the skill. Pages were sometimes lavishly illustrated with drawings of body parts, often because I couldn’t remember or spell the correct anatomic term. When I needed to send a referring letter to another provider I typed it myself because dictating never quite suited my personality.

When I joined a small primary care group, the computer-savvy lead physician and a programmer developed our own homegrown EHR. It relied on scanning documents, as so many of us still generated handwritten notes. Even the most vociferous Luddites among us loved the system from day 2.

However, for a variety of reasons, some defensible some just plain bad, our beloved system needed to be replaced after 7 years. We then invested in an off-the-shelf EHR system that promised more capabilities. We were told there would be a learning curve but the plateau would come quickly and we would enjoy our new electronic assistant.

You’ve lived the rest of the story. The learning curve was steep and long and the plateau was a time gobbler. I was probably the most efficient provider in the group, and after 6 months I was leaving the office an hour later than I had been and was seeing the same number of patients. Most of my coworkers were staying and/or working on the computer at home for an extra 2 hours. This change could be easily documented by speaking with our spouses and children. I understand from my colleagues who have stayed in the business that over the ensuing decade and a half since my first experience with the EHR, its insatiable appetite for a clinician’s time has not abated.

The authors of a recent article in Annals of Family Medicine offer up some advice on how this tragic situation might be brought under control. First, the investigators point out that the phenomenon of after-hours EHR work, sometimes referred to as WOW (work outside of work), has not gone unnoticed by health system administrators and vendors who develop and sell the EHRs. However, analyzing the voluminous data necessary is not any easy task and for the most part has resulted in metrics that cannot be easily applied over a variety of practice scenarios. Many health care organizations, even large ones, have simply given up and rely on the WOW data and recommendations provided by the vendors, obviously lending the situation a faint odor of conflict of interest.

The bottom line is that after a couple of decades, there is no well defined way of quantifying the time-gobbling effect of an EHR system. It would seem to me just asking the spouses and significant others of the clinicians would be sufficient. But, authors of the paper have more specific recommendations. First, they suggest that time working on the computer outside of scheduled time with patients should be separated from any other calculation of EHR usage. They encourage vendors and time-management researchers to develop standardized and validated methods for measuring active EHR use. And, finally they recommend that all EHR work done outside of time scheduled with patients be attributed to WOW. They feel that clearly labeling it work outside of work offers health care organizations a better chance of developing policies that will address the scourge of burnout.

This, unfortunately, is another tragic example of how clinicians have lost control of our work environments. The fact that 20 years have passed and there is still no standardized method for determining how much time we spend on the computer is more evidence we need to raise our voices.
 

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].

A recent study published in the journal Academic Pediatrics suggests that during health maintenance visits clinicians are giving too little attention to their patients’ sleep problems. Using a questionnaire, researchers surveyed patients’ caregivers’ concerns and observations regarding a variety of sleep problems. The investigators then reviewed the clinicians’ documentation of what transpired at the visit and found that while over 90% of the caregivers reported their child had at least one sleep related problem, only 20% of the clinicians documented the problem. And, only 12% documented a management plan regarding the sleep concerns.

I am always bit skeptical about studies that rely on clinicians’ “documentation” because clinicians are busy people and don’t always remember to record things they’ve discussed. You and I know that the lawyers’ dictum “if it wasn’t documented it didn’t happen” is rubbish. However, I still find the basic finding of this study concerning. If we are failing to ask about or even listen to caregivers’ concerns about something as important as sleep, we are missing the boat ... a very large boat.

How could this be happening? First, sleep may have fallen victim to the bloated list of topics that well-intentioned single-issue preventive health advocates have tacked on to the health maintenance visit. It’s a burden that few of us can manage without cutting corners.

However, it is more troubling to me that so many clinicians have chosen sleep as one of those corners to cut. This oversight suggests to me that too many of us have failed to realize from our own observations that sleep is incredibly important to the health of our patients ... and to ourselves.

I will admit that I am extremely sensitive to the importance of sleep. Some might say my sensitivity borders on an obsession. But, the literature is clear and becoming more voluminous every year that sleep is important to the mental health of our patients and their caregivers to things like obesity, to symptoms that suggest an attention-deficit/hyperactivity disorder, to school success, and to migraine ... to name just a few.

It may be that most of us realize the importance of sleep but feel our society has allowed itself to become so sleep deprived that there is little chance we can turn the ship around by spending just a few minutes trying help a family undo their deeply ingrained sleep unfriendly habits.

I am tempted to join those of you who see sleep depravation as a “why bother” issue. But, I’m not ready to throw in the towel. There are things that we as clinicians can do to help families address poor sleep hygiene. Even simply sharing your observations about the importance of sleep in the whole wellness picture may have an effect.

One of the benefits of retiring in the same community in which I practiced for over 40 years is that at least every month or two I encounter a parent who thanks me for sharing my views on the importance of sleep. They may not recall the little tip or two I gave them, but it seems that urging them to put sleep near the top of their lifestyle priority list has made the difference for them.

If I have failed in getting you to join me in my crusade against sleep deprivation, at least take to heart the most basic message of this study. That is that the investigators found only 20% of clinicians were addressing a concern that 90% of the caregivers shared. It happened to be sleep, but it could have been anything.

The authors of the study suggest that we need to be more assiduous in our screening for sleep problems. On the contrary. You and I know we don’t need more screening. We just need to be better listeners.

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].

A recent study published in the journal Academic Pediatrics suggests that during health maintenance visits clinicians are giving too little attention to their patients’ sleep problems. Using a questionnaire, researchers surveyed patients’ caregivers’ concerns and observations regarding a variety of sleep problems. The investigators then reviewed the clinicians’ documentation of what transpired at the visit and found that while over 90% of the caregivers reported their child had at least one sleep related problem, only 20% of the clinicians documented the problem. And, only 12% documented a management plan regarding the sleep concerns.

I am always bit skeptical about studies that rely on clinicians’ “documentation” because clinicians are busy people and don’t always remember to record things they’ve discussed. You and I know that the lawyers’ dictum “if it wasn’t documented it didn’t happen” is rubbish. However, I still find the basic finding of this study concerning. If we are failing to ask about or even listen to caregivers’ concerns about something as important as sleep, we are missing the boat ... a very large boat.

How could this be happening? First, sleep may have fallen victim to the bloated list of topics that well-intentioned single-issue preventive health advocates have tacked on to the health maintenance visit. It’s a burden that few of us can manage without cutting corners.

However, it is more troubling to me that so many clinicians have chosen sleep as one of those corners to cut. This oversight suggests to me that too many of us have failed to realize from our own observations that sleep is incredibly important to the health of our patients ... and to ourselves.

I will admit that I am extremely sensitive to the importance of sleep. Some might say my sensitivity borders on an obsession. But, the literature is clear and becoming more voluminous every year that sleep is important to the mental health of our patients and their caregivers to things like obesity, to symptoms that suggest an attention-deficit/hyperactivity disorder, to school success, and to migraine ... to name just a few.

It may be that most of us realize the importance of sleep but feel our society has allowed itself to become so sleep deprived that there is little chance we can turn the ship around by spending just a few minutes trying help a family undo their deeply ingrained sleep unfriendly habits.

I am tempted to join those of you who see sleep depravation as a “why bother” issue. But, I’m not ready to throw in the towel. There are things that we as clinicians can do to help families address poor sleep hygiene. Even simply sharing your observations about the importance of sleep in the whole wellness picture may have an effect.

One of the benefits of retiring in the same community in which I practiced for over 40 years is that at least every month or two I encounter a parent who thanks me for sharing my views on the importance of sleep. They may not recall the little tip or two I gave them, but it seems that urging them to put sleep near the top of their lifestyle priority list has made the difference for them.

If I have failed in getting you to join me in my crusade against sleep deprivation, at least take to heart the most basic message of this study. That is that the investigators found only 20% of clinicians were addressing a concern that 90% of the caregivers shared. It happened to be sleep, but it could have been anything.

The authors of the study suggest that we need to be more assiduous in our screening for sleep problems. On the contrary. You and I know we don’t need more screening. We just need to be better listeners.

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].

A recent study published in the journal Academic Pediatrics suggests that during health maintenance visits clinicians are giving too little attention to their patients’ sleep problems. Using a questionnaire, researchers surveyed patients’ caregivers’ concerns and observations regarding a variety of sleep problems. The investigators then reviewed the clinicians’ documentation of what transpired at the visit and found that while over 90% of the caregivers reported their child had at least one sleep related problem, only 20% of the clinicians documented the problem. And, only 12% documented a management plan regarding the sleep concerns.

I am always bit skeptical about studies that rely on clinicians’ “documentation” because clinicians are busy people and don’t always remember to record things they’ve discussed. You and I know that the lawyers’ dictum “if it wasn’t documented it didn’t happen” is rubbish. However, I still find the basic finding of this study concerning. If we are failing to ask about or even listen to caregivers’ concerns about something as important as sleep, we are missing the boat ... a very large boat.

How could this be happening? First, sleep may have fallen victim to the bloated list of topics that well-intentioned single-issue preventive health advocates have tacked on to the health maintenance visit. It’s a burden that few of us can manage without cutting corners.

However, it is more troubling to me that so many clinicians have chosen sleep as one of those corners to cut. This oversight suggests to me that too many of us have failed to realize from our own observations that sleep is incredibly important to the health of our patients ... and to ourselves.

I will admit that I am extremely sensitive to the importance of sleep. Some might say my sensitivity borders on an obsession. But, the literature is clear and becoming more voluminous every year that sleep is important to the mental health of our patients and their caregivers to things like obesity, to symptoms that suggest an attention-deficit/hyperactivity disorder, to school success, and to migraine ... to name just a few.

It may be that most of us realize the importance of sleep but feel our society has allowed itself to become so sleep deprived that there is little chance we can turn the ship around by spending just a few minutes trying help a family undo their deeply ingrained sleep unfriendly habits.

I am tempted to join those of you who see sleep depravation as a “why bother” issue. But, I’m not ready to throw in the towel. There are things that we as clinicians can do to help families address poor sleep hygiene. Even simply sharing your observations about the importance of sleep in the whole wellness picture may have an effect.

One of the benefits of retiring in the same community in which I practiced for over 40 years is that at least every month or two I encounter a parent who thanks me for sharing my views on the importance of sleep. They may not recall the little tip or two I gave them, but it seems that urging them to put sleep near the top of their lifestyle priority list has made the difference for them.

If I have failed in getting you to join me in my crusade against sleep deprivation, at least take to heart the most basic message of this study. That is that the investigators found only 20% of clinicians were addressing a concern that 90% of the caregivers shared. It happened to be sleep, but it could have been anything.

The authors of the study suggest that we need to be more assiduous in our screening for sleep problems. On the contrary. You and I know we don’t need more screening. We just need to be better listeners.

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].

In my most recent column (AI & U), I suggested that artificial intelligence (AI) in its most recent newsworthy iteration, the chatbot, offers some potentially useful opportunities. For example, in the short term the ability of a machine to search for the diagnostic possibilities and treatment options in a matter of seconds sounds very appealing. The skills needed to ask the chatbot the best questions and then interpret the machine’s responses would still require a medical school education. Good news for those of you worried about job security.

However, let’s look further down the road for how AI and other technological advances might change the look and feel of primary care. It is reasonable to expect that a chatbot could engage the patient in a spoken (or written) dialog in the patient’s preferred language and targeted to his/her educational level. You already deal with this kind of interaction in a primitive form when you call the customer service department of even a small company. That is if you were lucky enough to find the number buried in the company’s website.

The “system” could then perform a targeted exam using a variety of sensors. Electronic stethoscopes and tympanographic sensors already exist. While currently most sonograms are performed by trained technicians, one can envision the technology being dumbed down to a point that the patient could operate most of the sensors himself or herself, provided the patient could reach the body part in question. The camera on a basic cell phone can take an image of a skin lesion that can already be compared with a standard set of normals and abnormals. While currently a questionable lesion triggers the provider to perform a biopsy, it is possible that sensors could become so sensitive and the algorithms so clever that the biopsy would be unnecessary. The pandemic has already shown us that patients can obtain sample swabs and accurately perform simple tests in their home.

Once the “system” has made the diagnosis, it would then converse with the patient about the various treatment options and arrange follow up. One would hope that, if the “system’s” diagnosis included a fatal outcome, it would trigger a face-to-face interaction with a counselor and a team of social workers to break the bad news and provide some kind of emotional support.

Those of you who are doubting Dorothys and Thomases may be asking what about scenarios in which the patient’s chief complaint is difficulty breathing or sudden onset of weakness? Remember, I am talking about the usual 8 a.m–6 p.m. primary care office. Any patient with a possibly life-threatening complaint would be triaged by the chatbot and would be seen at some point by a real human. However, it is likely that individual’s training would not require the breadth of the typical medical school education and instead would be targeted at the most common high-risk scenarios. This higher-acuity specialist would, of course, be assisted by a chatbot.

Patients with complaints primarily associated with mental illness would be seen by humans specializing in that area. Although I suspect there are folks somewhere brainstorming on how chatbots could potentially be effective counselors.

Clearly, the future I am suggesting leaves the patient with fewer interactions with a human, and certainly very rarely with a human who has navigated what we think of today as a traditional medical school education.

Would patients accept a dehumanized type of primary care delivered by AI? Would they do it without complaint? Would they have a choice? Do you like it when you are interrogated by the prerecorded voice on the phone tree of some company’s customer service? Do you have a choice? If that interrogation was refined to the point where it saved you time and resulted in the correct answer 99% of the time would you still complain?

If patients found that most of their primary care complaints could be handled more quickly by an AI system with minimal physician intervention and that system offered a success rate of over 90% when measured by the accuracy of the diagnosis and management plan, would they complain? They may have no other choice than to complain if primary care continues to lose favor among recent medical school graduates.

And what would the patients complain about? They already complain about the current system in which they feel that the face-to-face encounters with their physician are becoming less frequent. I often hear complaints that “the doctor just looked at the computer, and he didn’t really examine me.” By which I think they sometimes mean “touched” me.

I suspect we will discover what most of us already suspect and that is there is something special about the eye-to-eye contact and tactile interaction between the physician and the patient. The osteopathic tradition clearly makes this a priority when it utilizes manipulative medicine. It may be that if primary care medicine follows the AI-paved road I have imagined it won’t be able to match the success rate of the current system. Without that human element, with or without the hands-on aspect or even if the diagnosis is correct and the management is spot on, it just won’t work as well.

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].

In my most recent column (AI & U), I suggested that artificial intelligence (AI) in its most recent newsworthy iteration, the chatbot, offers some potentially useful opportunities. For example, in the short term the ability of a machine to search for the diagnostic possibilities and treatment options in a matter of seconds sounds very appealing. The skills needed to ask the chatbot the best questions and then interpret the machine’s responses would still require a medical school education. Good news for those of you worried about job security.

However, let’s look further down the road for how AI and other technological advances might change the look and feel of primary care. It is reasonable to expect that a chatbot could engage the patient in a spoken (or written) dialog in the patient’s preferred language and targeted to his/her educational level. You already deal with this kind of interaction in a primitive form when you call the customer service department of even a small company. That is if you were lucky enough to find the number buried in the company’s website.

The “system” could then perform a targeted exam using a variety of sensors. Electronic stethoscopes and tympanographic sensors already exist. While currently most sonograms are performed by trained technicians, one can envision the technology being dumbed down to a point that the patient could operate most of the sensors himself or herself, provided the patient could reach the body part in question. The camera on a basic cell phone can take an image of a skin lesion that can already be compared with a standard set of normals and abnormals. While currently a questionable lesion triggers the provider to perform a biopsy, it is possible that sensors could become so sensitive and the algorithms so clever that the biopsy would be unnecessary. The pandemic has already shown us that patients can obtain sample swabs and accurately perform simple tests in their home.

Once the “system” has made the diagnosis, it would then converse with the patient about the various treatment options and arrange follow up. One would hope that, if the “system’s” diagnosis included a fatal outcome, it would trigger a face-to-face interaction with a counselor and a team of social workers to break the bad news and provide some kind of emotional support.

Those of you who are doubting Dorothys and Thomases may be asking what about scenarios in which the patient’s chief complaint is difficulty breathing or sudden onset of weakness? Remember, I am talking about the usual 8 a.m–6 p.m. primary care office. Any patient with a possibly life-threatening complaint would be triaged by the chatbot and would be seen at some point by a real human. However, it is likely that individual’s training would not require the breadth of the typical medical school education and instead would be targeted at the most common high-risk scenarios. This higher-acuity specialist would, of course, be assisted by a chatbot.

Patients with complaints primarily associated with mental illness would be seen by humans specializing in that area. Although I suspect there are folks somewhere brainstorming on how chatbots could potentially be effective counselors.

Clearly, the future I am suggesting leaves the patient with fewer interactions with a human, and certainly very rarely with a human who has navigated what we think of today as a traditional medical school education.

Would patients accept a dehumanized type of primary care delivered by AI? Would they do it without complaint? Would they have a choice? Do you like it when you are interrogated by the prerecorded voice on the phone tree of some company’s customer service? Do you have a choice? If that interrogation was refined to the point where it saved you time and resulted in the correct answer 99% of the time would you still complain?

If patients found that most of their primary care complaints could be handled more quickly by an AI system with minimal physician intervention and that system offered a success rate of over 90% when measured by the accuracy of the diagnosis and management plan, would they complain? They may have no other choice than to complain if primary care continues to lose favor among recent medical school graduates.

And what would the patients complain about? They already complain about the current system in which they feel that the face-to-face encounters with their physician are becoming less frequent. I often hear complaints that “the doctor just looked at the computer, and he didn’t really examine me.” By which I think they sometimes mean “touched” me.

I suspect we will discover what most of us already suspect and that is there is something special about the eye-to-eye contact and tactile interaction between the physician and the patient. The osteopathic tradition clearly makes this a priority when it utilizes manipulative medicine. It may be that if primary care medicine follows the AI-paved road I have imagined it won’t be able to match the success rate of the current system. Without that human element, with or without the hands-on aspect or even if the diagnosis is correct and the management is spot on, it just won’t work as well.

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].

In my most recent column (AI & U), I suggested that artificial intelligence (AI) in its most recent newsworthy iteration, the chatbot, offers some potentially useful opportunities. For example, in the short term the ability of a machine to search for the diagnostic possibilities and treatment options in a matter of seconds sounds very appealing. The skills needed to ask the chatbot the best questions and then interpret the machine’s responses would still require a medical school education. Good news for those of you worried about job security.

However, let’s look further down the road for how AI and other technological advances might change the look and feel of primary care. It is reasonable to expect that a chatbot could engage the patient in a spoken (or written) dialog in the patient’s preferred language and targeted to his/her educational level. You already deal with this kind of interaction in a primitive form when you call the customer service department of even a small company. That is if you were lucky enough to find the number buried in the company’s website.

The “system” could then perform a targeted exam using a variety of sensors. Electronic stethoscopes and tympanographic sensors already exist. While currently most sonograms are performed by trained technicians, one can envision the technology being dumbed down to a point that the patient could operate most of the sensors himself or herself, provided the patient could reach the body part in question. The camera on a basic cell phone can take an image of a skin lesion that can already be compared with a standard set of normals and abnormals. While currently a questionable lesion triggers the provider to perform a biopsy, it is possible that sensors could become so sensitive and the algorithms so clever that the biopsy would be unnecessary. The pandemic has already shown us that patients can obtain sample swabs and accurately perform simple tests in their home.

Once the “system” has made the diagnosis, it would then converse with the patient about the various treatment options and arrange follow up. One would hope that, if the “system’s” diagnosis included a fatal outcome, it would trigger a face-to-face interaction with a counselor and a team of social workers to break the bad news and provide some kind of emotional support.

Those of you who are doubting Dorothys and Thomases may be asking what about scenarios in which the patient’s chief complaint is difficulty breathing or sudden onset of weakness? Remember, I am talking about the usual 8 a.m–6 p.m. primary care office. Any patient with a possibly life-threatening complaint would be triaged by the chatbot and would be seen at some point by a real human. However, it is likely that individual’s training would not require the breadth of the typical medical school education and instead would be targeted at the most common high-risk scenarios. This higher-acuity specialist would, of course, be assisted by a chatbot.

Patients with complaints primarily associated with mental illness would be seen by humans specializing in that area. Although I suspect there are folks somewhere brainstorming on how chatbots could potentially be effective counselors.

Clearly, the future I am suggesting leaves the patient with fewer interactions with a human, and certainly very rarely with a human who has navigated what we think of today as a traditional medical school education.

Would patients accept a dehumanized type of primary care delivered by AI? Would they do it without complaint? Would they have a choice? Do you like it when you are interrogated by the prerecorded voice on the phone tree of some company’s customer service? Do you have a choice? If that interrogation was refined to the point where it saved you time and resulted in the correct answer 99% of the time would you still complain?

If patients found that most of their primary care complaints could be handled more quickly by an AI system with minimal physician intervention and that system offered a success rate of over 90% when measured by the accuracy of the diagnosis and management plan, would they complain? They may have no other choice than to complain if primary care continues to lose favor among recent medical school graduates.

And what would the patients complain about? They already complain about the current system in which they feel that the face-to-face encounters with their physician are becoming less frequent. I often hear complaints that “the doctor just looked at the computer, and he didn’t really examine me.” By which I think they sometimes mean “touched” me.

I suspect we will discover what most of us already suspect and that is there is something special about the eye-to-eye contact and tactile interaction between the physician and the patient. The osteopathic tradition clearly makes this a priority when it utilizes manipulative medicine. It may be that if primary care medicine follows the AI-paved road I have imagined it won’t be able to match the success rate of the current system. Without that human element, with or without the hands-on aspect or even if the diagnosis is correct and the management is spot on, it just won’t work as well.

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].

Since the November 2022 release of a much-discussed artificial intelligence (AI)-based chatbot, I have been curious what all the buzz is about. I decided to engage my well-connected software-savvy son-in-law to hear where he thought things were going.

He started by suggesting that I pose a question to the chatbot about something of which I had some current knowledge. I had recently researched the concept of primal beliefs and so we asked the chatbot to write a short essay about when an individual develops his/her primal beliefs.

In a matter of seconds the “machine” spit out a very readable document that included all the information that had taken me several hours to unearth and digest. And ... it included the references that I had determined to be valid and appropriate. It was an impressive performance to say the least.

Obviously, a technological development with this capability is sending tremors through the educational establishment. One can easily think of several human skills that an AI like this might eventually make superfluous. It will also make it increasingly difficult for educators to determine a students’ true abilities – research, synthesis, and writing to name just a few. But, of course, one could question whether we will need to teach and then test for these skills that the chatbot can perform more quickly. I’m going to leave it to the educators to struggle with that question.

In the long term you and I may find that AI is a serious threat to our existence as health care providers. In the meantime I’ve decided to focus on how we in primary care can take advantage of the wonders of the current AI technology.

My first thought is that if I were having trouble arriving at a diagnosis, I might appreciate having a chatbot to ask for help. Of course this would require that I had already taken a history, done a good exam, and ordered some obvious lab and imaging studies. It would also mean that I had decent knowledge and understanding of basic pathophysiology and was capable of thinking broadly enough to ask a question that would give me the greatest chance of getting the correct answer.

Knowing how to ask the right question is a skill that can be taught. For example, my wife is a successful and experienced online shopper but she acknowledges that when we have medical questions, I can often find the answer more quickly than she can. My relative success usually hinges on my choice of the key word(s) to begin the search, clearly the result of my medical training.

Once I have received a list of possible diagnoses from the chatbot, I must then be able to evaluate the validity and applicability of the references it has supplied. That too is a skill that can be taught. And, for the moment the critical importance of having these two skills suggests that graduating from medical school will continue to give us some job security in the face of expanding AI.

The same process I could used to coax the chatbot to arrive at a diagnosis could be applied when faced with a therapeutic question. Is surgery better than a pharmacological approach? If I need help with a dosage regimen, I could find this information online now. But, wouldn’t it be quicker and maybe better if I asked the chatbot to do the research for me and print a short essay on the pros and cons of different management approaches?

Once I’ve made the diagnosis, crafted a management plan, and now want to hand the patient a document in his/her primary language and at his/her reading skill level describing the diagnosis and giving detailed instructions to follow, this would seem to be a piece of cake for a chatbot given the appropriate commands. Hopefully I would remember to include the disclaimer that “This document was created with the help of a chatbot.”

Clearly, there is nothing to prevent our patients from asking the chatbot the same questions I have posed. And, no doubt, this will happen. It is already happening in a more cumbersome fashion when patients research their own symptoms. However, in the short term I believe we will retain the upper hand.

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].

Since the November 2022 release of a much-discussed artificial intelligence (AI)-based chatbot, I have been curious what all the buzz is about. I decided to engage my well-connected software-savvy son-in-law to hear where he thought things were going.

He started by suggesting that I pose a question to the chatbot about something of which I had some current knowledge. I had recently researched the concept of primal beliefs and so we asked the chatbot to write a short essay about when an individual develops his/her primal beliefs.

In a matter of seconds the “machine” spit out a very readable document that included all the information that had taken me several hours to unearth and digest. And ... it included the references that I had determined to be valid and appropriate. It was an impressive performance to say the least.

Obviously, a technological development with this capability is sending tremors through the educational establishment. One can easily think of several human skills that an AI like this might eventually make superfluous. It will also make it increasingly difficult for educators to determine a students’ true abilities – research, synthesis, and writing to name just a few. But, of course, one could question whether we will need to teach and then test for these skills that the chatbot can perform more quickly. I’m going to leave it to the educators to struggle with that question.

In the long term you and I may find that AI is a serious threat to our existence as health care providers. In the meantime I’ve decided to focus on how we in primary care can take advantage of the wonders of the current AI technology.

My first thought is that if I were having trouble arriving at a diagnosis, I might appreciate having a chatbot to ask for help. Of course this would require that I had already taken a history, done a good exam, and ordered some obvious lab and imaging studies. It would also mean that I had decent knowledge and understanding of basic pathophysiology and was capable of thinking broadly enough to ask a question that would give me the greatest chance of getting the correct answer.

Knowing how to ask the right question is a skill that can be taught. For example, my wife is a successful and experienced online shopper but she acknowledges that when we have medical questions, I can often find the answer more quickly than she can. My relative success usually hinges on my choice of the key word(s) to begin the search, clearly the result of my medical training.

Once I have received a list of possible diagnoses from the chatbot, I must then be able to evaluate the validity and applicability of the references it has supplied. That too is a skill that can be taught. And, for the moment the critical importance of having these two skills suggests that graduating from medical school will continue to give us some job security in the face of expanding AI.

The same process I could used to coax the chatbot to arrive at a diagnosis could be applied when faced with a therapeutic question. Is surgery better than a pharmacological approach? If I need help with a dosage regimen, I could find this information online now. But, wouldn’t it be quicker and maybe better if I asked the chatbot to do the research for me and print a short essay on the pros and cons of different management approaches?

Once I’ve made the diagnosis, crafted a management plan, and now want to hand the patient a document in his/her primary language and at his/her reading skill level describing the diagnosis and giving detailed instructions to follow, this would seem to be a piece of cake for a chatbot given the appropriate commands. Hopefully I would remember to include the disclaimer that “This document was created with the help of a chatbot.”

Clearly, there is nothing to prevent our patients from asking the chatbot the same questions I have posed. And, no doubt, this will happen. It is already happening in a more cumbersome fashion when patients research their own symptoms. However, in the short term I believe we will retain the upper hand.

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].

Since the November 2022 release of a much-discussed artificial intelligence (AI)-based chatbot, I have been curious what all the buzz is about. I decided to engage my well-connected software-savvy son-in-law to hear where he thought things were going.

He started by suggesting that I pose a question to the chatbot about something of which I had some current knowledge. I had recently researched the concept of primal beliefs and so we asked the chatbot to write a short essay about when an individual develops his/her primal beliefs.

In a matter of seconds the “machine” spit out a very readable document that included all the information that had taken me several hours to unearth and digest. And ... it included the references that I had determined to be valid and appropriate. It was an impressive performance to say the least.

Obviously, a technological development with this capability is sending tremors through the educational establishment. One can easily think of several human skills that an AI like this might eventually make superfluous. It will also make it increasingly difficult for educators to determine a students’ true abilities – research, synthesis, and writing to name just a few. But, of course, one could question whether we will need to teach and then test for these skills that the chatbot can perform more quickly. I’m going to leave it to the educators to struggle with that question.

In the long term you and I may find that AI is a serious threat to our existence as health care providers. In the meantime I’ve decided to focus on how we in primary care can take advantage of the wonders of the current AI technology.

My first thought is that if I were having trouble arriving at a diagnosis, I might appreciate having a chatbot to ask for help. Of course this would require that I had already taken a history, done a good exam, and ordered some obvious lab and imaging studies. It would also mean that I had decent knowledge and understanding of basic pathophysiology and was capable of thinking broadly enough to ask a question that would give me the greatest chance of getting the correct answer.

Knowing how to ask the right question is a skill that can be taught. For example, my wife is a successful and experienced online shopper but she acknowledges that when we have medical questions, I can often find the answer more quickly than she can. My relative success usually hinges on my choice of the key word(s) to begin the search, clearly the result of my medical training.

Once I have received a list of possible diagnoses from the chatbot, I must then be able to evaluate the validity and applicability of the references it has supplied. That too is a skill that can be taught. And, for the moment the critical importance of having these two skills suggests that graduating from medical school will continue to give us some job security in the face of expanding AI.

The same process I could used to coax the chatbot to arrive at a diagnosis could be applied when faced with a therapeutic question. Is surgery better than a pharmacological approach? If I need help with a dosage regimen, I could find this information online now. But, wouldn’t it be quicker and maybe better if I asked the chatbot to do the research for me and print a short essay on the pros and cons of different management approaches?

Once I’ve made the diagnosis, crafted a management plan, and now want to hand the patient a document in his/her primary language and at his/her reading skill level describing the diagnosis and giving detailed instructions to follow, this would seem to be a piece of cake for a chatbot given the appropriate commands. Hopefully I would remember to include the disclaimer that “This document was created with the help of a chatbot.”

Clearly, there is nothing to prevent our patients from asking the chatbot the same questions I have posed. And, no doubt, this will happen. It is already happening in a more cumbersome fashion when patients research their own symptoms. However, in the short term I believe we will retain the upper hand.

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].

A few weeks ago I asked what changes would have to occur to return urgent care to its former place under the umbrella of the primary care pediatrician. Several responses that I received and the recent story about screenings in this magazine (April 2023) have prompted me to ask the broader question of what is a pediatrician? More specifically, what is the role of a primary care pediatrician?

I think we can agree that a pediatrician is someone who has dedicated his or her training to learning about and then treating the diseases of children. There are pediatricians whose focus is on newborns. There are others who specialize by organ system or by the intensity of the disease (for example, hospitalists and ED physicians). In Great Britain, and to some extent Canada, “paediatricians” serve primarily as consultants to other health care providers. In this country, however, we tend to think of a pediatrician as a frontline primary care physician with general expertise in children. It is those providers (myself included) to whom I address my questions: “What is our role? What is our primary mission?” Are the expectations that we and others have for us realistic given the realities of 21st-century America? And, is our failure to meet some of those expectations contributing to our burnout?

Are we preventionists? I have always thought that one of the things that sets us apart from other specialties is our focus on prevention. We’ve done a pretty good job with infectious diseases thanks to vaccines and antibiotics. But, when I look at the children who grew to be obese adults under my care I have to say that I and my peers have done an abysmal job of prevention. And that is just one example.

Are we educators responsible for helping parents learn what we consider to be the best child-rearing practices? The Latin root of the word “doctor” means teacher. But, education done well is a very time-consuming process. How many of us have time in the office to really teach? Furthermore, some recent studies on managing vaccine deniers suggests that education doesn’t work with people who have long-held beliefs.

Are we data-entry clerks tasked with documenting our every professional step to validate our value to society and the correctness of our methods? It seems that there are some folks who believe we should be.

Are we screeners? TSA agents with white coats and stethoscopes responsible for screening the entire population for potential threats that weren’t obvious to our thoughtful history taking and careful physical examinations?

And finally, are we healers? If you haven’t already disabused yourself of that myth please take a moment to consider the number of cures you have orchestrated in the last 10 years.

The answer is that we can and maybe should be all of those things but we and those who advise us and support us must have reasonable expectations of how difficult it can be to be all those things to all of our patients in the real world of primary care pediatrics. We aren’t social engineers who can level every inequality nor can we orchestrate changes in a society that leans toward enabling unhealthy lifestyles.

The American Academy of Pediatrics must shoulder some of the blame for this discrepancy between expectations and reality. In the Pediatric News article on screening, Susan Kressly, MD, the chair of the American Academy of Pediatrics’s Section on Administration and Practice shares some common-sense observations on how screening can be applied thoughtfully. However, this isn’t how it is usually portrayed in the top-down rollout as each advocacy group releases its next best screening recommendations.

Faced with this clash or expectations I have always chosen to think small. I live in a small town in a small state. I look at each patient and each family, one at a time, with its strengths and its vulnerabilities as a given. I try to educate and prevent as their needs and my time allows. I screen when something makes me feel uncomfortable. Long ago I retired my aspirations as a healer and instead have focussed on being a soother.

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].

A few weeks ago I asked what changes would have to occur to return urgent care to its former place under the umbrella of the primary care pediatrician. Several responses that I received and the recent story about screenings in this magazine (April 2023) have prompted me to ask the broader question of what is a pediatrician? More specifically, what is the role of a primary care pediatrician?

I think we can agree that a pediatrician is someone who has dedicated his or her training to learning about and then treating the diseases of children. There are pediatricians whose focus is on newborns. There are others who specialize by organ system or by the intensity of the disease (for example, hospitalists and ED physicians). In Great Britain, and to some extent Canada, “paediatricians” serve primarily as consultants to other health care providers. In this country, however, we tend to think of a pediatrician as a frontline primary care physician with general expertise in children. It is those providers (myself included) to whom I address my questions: “What is our role? What is our primary mission?” Are the expectations that we and others have for us realistic given the realities of 21st-century America? And, is our failure to meet some of those expectations contributing to our burnout?

Are we preventionists? I have always thought that one of the things that sets us apart from other specialties is our focus on prevention. We’ve done a pretty good job with infectious diseases thanks to vaccines and antibiotics. But, when I look at the children who grew to be obese adults under my care I have to say that I and my peers have done an abysmal job of prevention. And that is just one example.

Are we educators responsible for helping parents learn what we consider to be the best child-rearing practices? The Latin root of the word “doctor” means teacher. But, education done well is a very time-consuming process. How many of us have time in the office to really teach? Furthermore, some recent studies on managing vaccine deniers suggests that education doesn’t work with people who have long-held beliefs.

Are we data-entry clerks tasked with documenting our every professional step to validate our value to society and the correctness of our methods? It seems that there are some folks who believe we should be.

Are we screeners? TSA agents with white coats and stethoscopes responsible for screening the entire population for potential threats that weren’t obvious to our thoughtful history taking and careful physical examinations?

And finally, are we healers? If you haven’t already disabused yourself of that myth please take a moment to consider the number of cures you have orchestrated in the last 10 years.

The answer is that we can and maybe should be all of those things but we and those who advise us and support us must have reasonable expectations of how difficult it can be to be all those things to all of our patients in the real world of primary care pediatrics. We aren’t social engineers who can level every inequality nor can we orchestrate changes in a society that leans toward enabling unhealthy lifestyles.

The American Academy of Pediatrics must shoulder some of the blame for this discrepancy between expectations and reality. In the Pediatric News article on screening, Susan Kressly, MD, the chair of the American Academy of Pediatrics’s Section on Administration and Practice shares some common-sense observations on how screening can be applied thoughtfully. However, this isn’t how it is usually portrayed in the top-down rollout as each advocacy group releases its next best screening recommendations.

Faced with this clash or expectations I have always chosen to think small. I live in a small town in a small state. I look at each patient and each family, one at a time, with its strengths and its vulnerabilities as a given. I try to educate and prevent as their needs and my time allows. I screen when something makes me feel uncomfortable. Long ago I retired my aspirations as a healer and instead have focussed on being a soother.

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].

A few weeks ago I asked what changes would have to occur to return urgent care to its former place under the umbrella of the primary care pediatrician. Several responses that I received and the recent story about screenings in this magazine (April 2023) have prompted me to ask the broader question of what is a pediatrician? More specifically, what is the role of a primary care pediatrician?

I think we can agree that a pediatrician is someone who has dedicated his or her training to learning about and then treating the diseases of children. There are pediatricians whose focus is on newborns. There are others who specialize by organ system or by the intensity of the disease (for example, hospitalists and ED physicians). In Great Britain, and to some extent Canada, “paediatricians” serve primarily as consultants to other health care providers. In this country, however, we tend to think of a pediatrician as a frontline primary care physician with general expertise in children. It is those providers (myself included) to whom I address my questions: “What is our role? What is our primary mission?” Are the expectations that we and others have for us realistic given the realities of 21st-century America? And, is our failure to meet some of those expectations contributing to our burnout?

Are we preventionists? I have always thought that one of the things that sets us apart from other specialties is our focus on prevention. We’ve done a pretty good job with infectious diseases thanks to vaccines and antibiotics. But, when I look at the children who grew to be obese adults under my care I have to say that I and my peers have done an abysmal job of prevention. And that is just one example.

Are we educators responsible for helping parents learn what we consider to be the best child-rearing practices? The Latin root of the word “doctor” means teacher. But, education done well is a very time-consuming process. How many of us have time in the office to really teach? Furthermore, some recent studies on managing vaccine deniers suggests that education doesn’t work with people who have long-held beliefs.

Are we data-entry clerks tasked with documenting our every professional step to validate our value to society and the correctness of our methods? It seems that there are some folks who believe we should be.

Are we screeners? TSA agents with white coats and stethoscopes responsible for screening the entire population for potential threats that weren’t obvious to our thoughtful history taking and careful physical examinations?

And finally, are we healers? If you haven’t already disabused yourself of that myth please take a moment to consider the number of cures you have orchestrated in the last 10 years.

The answer is that we can and maybe should be all of those things but we and those who advise us and support us must have reasonable expectations of how difficult it can be to be all those things to all of our patients in the real world of primary care pediatrics. We aren’t social engineers who can level every inequality nor can we orchestrate changes in a society that leans toward enabling unhealthy lifestyles.

The American Academy of Pediatrics must shoulder some of the blame for this discrepancy between expectations and reality. In the Pediatric News article on screening, Susan Kressly, MD, the chair of the American Academy of Pediatrics’s Section on Administration and Practice shares some common-sense observations on how screening can be applied thoughtfully. However, this isn’t how it is usually portrayed in the top-down rollout as each advocacy group releases its next best screening recommendations.

Faced with this clash or expectations I have always chosen to think small. I live in a small town in a small state. I look at each patient and each family, one at a time, with its strengths and its vulnerabilities as a given. I try to educate and prevent as their needs and my time allows. I screen when something makes me feel uncomfortable. Long ago I retired my aspirations as a healer and instead have focussed on being a soother.

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].

How old were you when you had your first job? No, not that one when the neighbors paid you to feed their goldfish while they were on vacation. I mean the one when you first saw the dreaded letters “FICA” on your pay stub and realized that “making $9.00 an hour” didn’t mean that you would be taking home $360 at the end of a 40-hour week.

Were you still in middle school or just entering high school? Was it during the summer before you entered college? Was it a positive experience? If not financially, did that job at least provide some life lessons that you have found valuable?

Among my peers in a middle class dominated small town, having a “good” summer job was somewhat of a status symbol. Few of us worked during the school year. Having family connections meant that you might be lucky enough to be hired “doing construction” and making big bucks. Most of our families didn’t “need” the money we earned. Our paychecks provided us with our first taste of what it meant do some “discretionary spending” and build a savings account. And ... it meant we weren’t hanging around the house getting into trouble. As I recall we and our parents saw working as a teenager as a win-win situation.

A recent survey done by investigators at the C.S. Mott Children’s Hospital at the University of Michigan polled parents about their thoughts about teenagers working (Parents see upsides and downsides to teen jobs, Mott Poll Report, April 17, 2023). In reviewing data from the hospital’s National Poll On Children’s Health, the researchers found that parents prioritized whether the job would fit their teens’ schedules (87%), the logistics of getting the teenager to the job (68%), and whether it would provide a learning experience (54%). Only a third listed pay rate as a consideration.

Parents reported half of their 18-year-olds had jobs, 42% aged 16-17 had jobs, and less than 10% of the 14- to 15-year-olds had jobs. Parents of teenagers with jobs felt that the work experience made a positive impact on money management (76%), self-esteem (70%), and time management (63%). On the other hand, a smaller percentage of parents reported a negative effect on sleep (16%), activities (11%), social life (11%), and grades (4%). Forty-four percent of parents of working teenagers reported that their children had experienced problems at work. These included issues of too many or too few hours, disagreements with coworkers or managers, and pay not meeting expectations.

It is interesting that although I can’t provide any data, my impression is that a much higher percentage of my peer group were working when we were younger than 18. Not surprisingly, the teenagers who are currently working distribute their income much as we had done 50 years ago.

How should we as primary care providers interpret the results of this poll? Of course they support my bias or I wouldn’t be sharing them with you. I have found that for most teenagers, a job can have a positive influence on their development and with a modest amount of parental oversight will have a minimal impact on their health and safety. As a result I have asked most teenagers at their health maintenance visits if they have any summer work plans. This survey also demonstrated that parents don’t need to be cautioned about the potential downsides. In fact, they might even benefit from the observation that the upsides of work are considerable.

The fact that nearly half of teenagers experienced workplace problems doesn’t impress me as a downside. It merely reflects reality and provides opportunities for learning and growth. With the unemployment rate at rock bottom, this is an excellent climate for teenagers to dip their toes into the working world. If they feel they are being mistreated on the job they should realize that they are in the driver’s seat. They won’t have to look very far to find a “hiring” sign in another window just down the street.
 

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].

How old were you when you had your first job? No, not that one when the neighbors paid you to feed their goldfish while they were on vacation. I mean the one when you first saw the dreaded letters “FICA” on your pay stub and realized that “making $9.00 an hour” didn’t mean that you would be taking home $360 at the end of a 40-hour week.

Were you still in middle school or just entering high school? Was it during the summer before you entered college? Was it a positive experience? If not financially, did that job at least provide some life lessons that you have found valuable?

Among my peers in a middle class dominated small town, having a “good” summer job was somewhat of a status symbol. Few of us worked during the school year. Having family connections meant that you might be lucky enough to be hired “doing construction” and making big bucks. Most of our families didn’t “need” the money we earned. Our paychecks provided us with our first taste of what it meant do some “discretionary spending” and build a savings account. And ... it meant we weren’t hanging around the house getting into trouble. As I recall we and our parents saw working as a teenager as a win-win situation.

A recent survey done by investigators at the C.S. Mott Children’s Hospital at the University of Michigan polled parents about their thoughts about teenagers working (Parents see upsides and downsides to teen jobs, Mott Poll Report, April 17, 2023). In reviewing data from the hospital’s National Poll On Children’s Health, the researchers found that parents prioritized whether the job would fit their teens’ schedules (87%), the logistics of getting the teenager to the job (68%), and whether it would provide a learning experience (54%). Only a third listed pay rate as a consideration.

Parents reported half of their 18-year-olds had jobs, 42% aged 16-17 had jobs, and less than 10% of the 14- to 15-year-olds had jobs. Parents of teenagers with jobs felt that the work experience made a positive impact on money management (76%), self-esteem (70%), and time management (63%). On the other hand, a smaller percentage of parents reported a negative effect on sleep (16%), activities (11%), social life (11%), and grades (4%). Forty-four percent of parents of working teenagers reported that their children had experienced problems at work. These included issues of too many or too few hours, disagreements with coworkers or managers, and pay not meeting expectations.

It is interesting that although I can’t provide any data, my impression is that a much higher percentage of my peer group were working when we were younger than 18. Not surprisingly, the teenagers who are currently working distribute their income much as we had done 50 years ago.

How should we as primary care providers interpret the results of this poll? Of course they support my bias or I wouldn’t be sharing them with you. I have found that for most teenagers, a job can have a positive influence on their development and with a modest amount of parental oversight will have a minimal impact on their health and safety. As a result I have asked most teenagers at their health maintenance visits if they have any summer work plans. This survey also demonstrated that parents don’t need to be cautioned about the potential downsides. In fact, they might even benefit from the observation that the upsides of work are considerable.

The fact that nearly half of teenagers experienced workplace problems doesn’t impress me as a downside. It merely reflects reality and provides opportunities for learning and growth. With the unemployment rate at rock bottom, this is an excellent climate for teenagers to dip their toes into the working world. If they feel they are being mistreated on the job they should realize that they are in the driver’s seat. They won’t have to look very far to find a “hiring” sign in another window just down the street.
 

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].

How old were you when you had your first job? No, not that one when the neighbors paid you to feed their goldfish while they were on vacation. I mean the one when you first saw the dreaded letters “FICA” on your pay stub and realized that “making $9.00 an hour” didn’t mean that you would be taking home $360 at the end of a 40-hour week.

Were you still in middle school or just entering high school? Was it during the summer before you entered college? Was it a positive experience? If not financially, did that job at least provide some life lessons that you have found valuable?

Among my peers in a middle class dominated small town, having a “good” summer job was somewhat of a status symbol. Few of us worked during the school year. Having family connections meant that you might be lucky enough to be hired “doing construction” and making big bucks. Most of our families didn’t “need” the money we earned. Our paychecks provided us with our first taste of what it meant do some “discretionary spending” and build a savings account. And ... it meant we weren’t hanging around the house getting into trouble. As I recall we and our parents saw working as a teenager as a win-win situation.

A recent survey done by investigators at the C.S. Mott Children’s Hospital at the University of Michigan polled parents about their thoughts about teenagers working (Parents see upsides and downsides to teen jobs, Mott Poll Report, April 17, 2023). In reviewing data from the hospital’s National Poll On Children’s Health, the researchers found that parents prioritized whether the job would fit their teens’ schedules (87%), the logistics of getting the teenager to the job (68%), and whether it would provide a learning experience (54%). Only a third listed pay rate as a consideration.

Parents reported half of their 18-year-olds had jobs, 42% aged 16-17 had jobs, and less than 10% of the 14- to 15-year-olds had jobs. Parents of teenagers with jobs felt that the work experience made a positive impact on money management (76%), self-esteem (70%), and time management (63%). On the other hand, a smaller percentage of parents reported a negative effect on sleep (16%), activities (11%), social life (11%), and grades (4%). Forty-four percent of parents of working teenagers reported that their children had experienced problems at work. These included issues of too many or too few hours, disagreements with coworkers or managers, and pay not meeting expectations.

It is interesting that although I can’t provide any data, my impression is that a much higher percentage of my peer group were working when we were younger than 18. Not surprisingly, the teenagers who are currently working distribute their income much as we had done 50 years ago.

How should we as primary care providers interpret the results of this poll? Of course they support my bias or I wouldn’t be sharing them with you. I have found that for most teenagers, a job can have a positive influence on their development and with a modest amount of parental oversight will have a minimal impact on their health and safety. As a result I have asked most teenagers at their health maintenance visits if they have any summer work plans. This survey also demonstrated that parents don’t need to be cautioned about the potential downsides. In fact, they might even benefit from the observation that the upsides of work are considerable.

The fact that nearly half of teenagers experienced workplace problems doesn’t impress me as a downside. It merely reflects reality and provides opportunities for learning and growth. With the unemployment rate at rock bottom, this is an excellent climate for teenagers to dip their toes into the working world. If they feel they are being mistreated on the job they should realize that they are in the driver’s seat. They won’t have to look very far to find a “hiring” sign in another window just down the street.
 

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].

A few months ago, after several months of considerable foot dragging, I wrote that I have accepted the American Academy of Pediatrics’ proclamation that we should begin to treat obesity as a disease.

While it may feel like we are just throwing in the towel, it sounds better if we admit that we may have reached the threshold beyond which total focus on prevention is not going to work.

I continue to be troubled by the lingering fear that, in declaring that obesity is a disease, we will suspend our current efforts at preventing the condition. Granted, most of these efforts at prevention have been woefully ineffective. However, I still believe that, much like ADHD, the rise in obesity in this country is a reflection of some serious flaws in our society. On the other hand, as an inveterate optimist I have not given up on the belief that we will find some yet-to-be-discovered changes in our societal fabric that will eventually turn the ship around.

With this somewhat contradictory combination of resignation and optimism in mind, I continue to seek out studies that hold some promise for prevention while we begin tinkering with the let’s-treat-it-like-a-disease approach.

I recently discovered a story about one such study from the Center for Economic and Social Research at the University of Southern California. Using data collected about adolescent dependents of military personnel, the researchers found that “exposure to a more advantageous built environment for more than 2 years was associated with lower probabilities of obesity.” Because more than half of these teenagers were living in housing that had been assigned by the military, the researchers could more easily control for a variety of factors some related to self-selection.

Interestingly, the data did not support associations between the adolescents’ diet, physical activity, or socioeconomic environments. The investigators noted that “more advantageous built environments were associated with lower consumption of unhealthy foods.” However, the study lacked the granularity to determine what segments of the built environment were most associated with the effect they were observing.

Like me, you may not be familiar with the term “built environment.” Turns out it is just exactly what we might expect – anything about the environment that is the result of human action – buildings, roadways, dams, neighborhoods – and what they do and don’t contain. For example, is the adolescent living in an environment that encourages walking or one that is overly motor vehicle–centric? Does his or her neighborhood have easily reachable grocery stores that offer a range of healthy foods or does the teenager live in a nutritional desert populated only by convenience stores? Is there ample space for outdoor physical activity?

The authors’ observation that the adolescents who benefited from living in advantageous environments had a lower consumption of unhealthy foods might suggest that access to a healthy diet might be a significant factor. For me, the take-home message is that in our search for preventive strategies we have barely scratched the surface. The observation that the associations these researchers were making was over a relatively short time span of 2 years should give us hope that if we think more broadly and creatively we may be to find solutions on a grand scale.

Over the last century we have built an environment that is clearly obesogenic. This paper offers a starting point from which we can learn which components of that environment are the most potent contributors to the obesity epidemic. Once we have that information the question remains: Can we find the political will to tear down and rebuilt?

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].

A few months ago, after several months of considerable foot dragging, I wrote that I have accepted the American Academy of Pediatrics’ proclamation that we should begin to treat obesity as a disease.

While it may feel like we are just throwing in the towel, it sounds better if we admit that we may have reached the threshold beyond which total focus on prevention is not going to work.

I continue to be troubled by the lingering fear that, in declaring that obesity is a disease, we will suspend our current efforts at preventing the condition. Granted, most of these efforts at prevention have been woefully ineffective. However, I still believe that, much like ADHD, the rise in obesity in this country is a reflection of some serious flaws in our society. On the other hand, as an inveterate optimist I have not given up on the belief that we will find some yet-to-be-discovered changes in our societal fabric that will eventually turn the ship around.

With this somewhat contradictory combination of resignation and optimism in mind, I continue to seek out studies that hold some promise for prevention while we begin tinkering with the let’s-treat-it-like-a-disease approach.

I recently discovered a story about one such study from the Center for Economic and Social Research at the University of Southern California. Using data collected about adolescent dependents of military personnel, the researchers found that “exposure to a more advantageous built environment for more than 2 years was associated with lower probabilities of obesity.” Because more than half of these teenagers were living in housing that had been assigned by the military, the researchers could more easily control for a variety of factors some related to self-selection.

Interestingly, the data did not support associations between the adolescents’ diet, physical activity, or socioeconomic environments. The investigators noted that “more advantageous built environments were associated with lower consumption of unhealthy foods.” However, the study lacked the granularity to determine what segments of the built environment were most associated with the effect they were observing.

Like me, you may not be familiar with the term “built environment.” Turns out it is just exactly what we might expect – anything about the environment that is the result of human action – buildings, roadways, dams, neighborhoods – and what they do and don’t contain. For example, is the adolescent living in an environment that encourages walking or one that is overly motor vehicle–centric? Does his or her neighborhood have easily reachable grocery stores that offer a range of healthy foods or does the teenager live in a nutritional desert populated only by convenience stores? Is there ample space for outdoor physical activity?

The authors’ observation that the adolescents who benefited from living in advantageous environments had a lower consumption of unhealthy foods might suggest that access to a healthy diet might be a significant factor. For me, the take-home message is that in our search for preventive strategies we have barely scratched the surface. The observation that the associations these researchers were making was over a relatively short time span of 2 years should give us hope that if we think more broadly and creatively we may be to find solutions on a grand scale.

Over the last century we have built an environment that is clearly obesogenic. This paper offers a starting point from which we can learn which components of that environment are the most potent contributors to the obesity epidemic. Once we have that information the question remains: Can we find the political will to tear down and rebuilt?

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].

A few months ago, after several months of considerable foot dragging, I wrote that I have accepted the American Academy of Pediatrics’ proclamation that we should begin to treat obesity as a disease.

While it may feel like we are just throwing in the towel, it sounds better if we admit that we may have reached the threshold beyond which total focus on prevention is not going to work.

I continue to be troubled by the lingering fear that, in declaring that obesity is a disease, we will suspend our current efforts at preventing the condition. Granted, most of these efforts at prevention have been woefully ineffective. However, I still believe that, much like ADHD, the rise in obesity in this country is a reflection of some serious flaws in our society. On the other hand, as an inveterate optimist I have not given up on the belief that we will find some yet-to-be-discovered changes in our societal fabric that will eventually turn the ship around.

With this somewhat contradictory combination of resignation and optimism in mind, I continue to seek out studies that hold some promise for prevention while we begin tinkering with the let’s-treat-it-like-a-disease approach.

I recently discovered a story about one such study from the Center for Economic and Social Research at the University of Southern California. Using data collected about adolescent dependents of military personnel, the researchers found that “exposure to a more advantageous built environment for more than 2 years was associated with lower probabilities of obesity.” Because more than half of these teenagers were living in housing that had been assigned by the military, the researchers could more easily control for a variety of factors some related to self-selection.

Interestingly, the data did not support associations between the adolescents’ diet, physical activity, or socioeconomic environments. The investigators noted that “more advantageous built environments were associated with lower consumption of unhealthy foods.” However, the study lacked the granularity to determine what segments of the built environment were most associated with the effect they were observing.

Like me, you may not be familiar with the term “built environment.” Turns out it is just exactly what we might expect – anything about the environment that is the result of human action – buildings, roadways, dams, neighborhoods – and what they do and don’t contain. For example, is the adolescent living in an environment that encourages walking or one that is overly motor vehicle–centric? Does his or her neighborhood have easily reachable grocery stores that offer a range of healthy foods or does the teenager live in a nutritional desert populated only by convenience stores? Is there ample space for outdoor physical activity?

The authors’ observation that the adolescents who benefited from living in advantageous environments had a lower consumption of unhealthy foods might suggest that access to a healthy diet might be a significant factor. For me, the take-home message is that in our search for preventive strategies we have barely scratched the surface. The observation that the associations these researchers were making was over a relatively short time span of 2 years should give us hope that if we think more broadly and creatively we may be to find solutions on a grand scale.

Over the last century we have built an environment that is clearly obesogenic. This paper offers a starting point from which we can learn which components of that environment are the most potent contributors to the obesity epidemic. Once we have that information the question remains: Can we find the political will to tear down and rebuilt?

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].

A couple of weeks ago I stumbled across a report of a Pew Research Center’s survey titled “Parenting in America today” (Pew Research Center. Jan. 24, 2023), which found that 40% of parents in the United States with children younger than 18 are “extremely or very worried” that at some point their children might struggle with anxiety or depression. Thirty-six percent replied that they were “somewhat” worried. This total of more than 75% represents a significant change from the 2015 Pew Center survey in which only 54% of parents were “somewhat” worried about their children’s mental health.

Prompted by these findings I began work on a column in which I planned to encourage pediatricians to think more like family physicians when we were working with children who were experiencing serious mental health problems. My primary message was going to be that we should turn more of our attention to the mental health of the anxious parents who must endure the often long and frustrating path toward effective psychiatric care for their children. This might come in the form of some simple suggestions about nonpharmacologic self-help strategies. Or, it could mean encouraging parents to seek psychiatric care or counseling for themselves as they wait for help for their child.

However, as I began that column, my thoughts kept drifting toward a broader consideration of the relationship between parents and pediatric mental health. If mental health of children is causing their parents to be anxious and depressed isn’t it just as likely that this is a bidirectional connection? This was not exactly an “aha” moment for me because it is a relationship I have considered for sometime. However, it is a concept that I have come to realize is receiving far too little attention.

There are exceptions. For example, a recent opinion piece in the New York Times by David French, “What if Kids Are Sad and Stressed Because Their Parents Are?” (March 19, 2023) echoes many of my concerns. Drawing on his experiences traveling around college campuses, Mr. French observes, “Just as parents are upset about their children’s anxiety and depression, children are anxious about their parent’s mental health.”

He notes that an August 2022 NBC News poll found that 58% of registered voters feel this country’s best days are behind it and joins me in imagining that this negative mind set is filtering down to the pediatric population. He acknowledges that there are other likely contributors to teen unhappiness including the ubiquity of smart phones, the secularization of society, and the media’s focus on the political divide. However, Mr. French wonders if the parenting style that results in childhood experiences that are dominated by adult supervision and protection may also be playing a large role.

In his conclusion, Mr. French asks us to consider “How much fear and anxiety should we import to our lives and homes?” as we adults search for an answer.

As I continued to drill down for other possible solutions, I encountered an avenue of psychological research that suggests that instead of, or in addition to, filtering out the anxiety-generating deluge of information, we begin to give some thought to how our beliefs may be coloring our perception of reality.

Jeremy D.W. Clifton, PhD, a psychologist at the University of Pennsylvania Positive Psychology Center has done extensive research on the relationship between our basic beliefs about the world (known as primal beliefs or simply primals in psychologist lingo) and how we interpret reality. For example, one of your primal beliefs may be that the world is a dangerous place. I, on the other hand, may see the world as a stimulating environment offering me endless opportunities to explore. I may see the world as an abundant resource limited only by my creativity. You, however, see it as a barren wasteland.

Dr. Clifton’s research has shown that our primals (at least those of adults) are relatively immutable through one’s lifetime and “do not appear to be the consequence of our experiences.” For example, living in a ZIP code with a high crime rate does not predict that you will see the world as a dangerous place. Nor does being affluent guarantee that an adult sees the world rich with opportunities.

It is unclear exactly when and by what process we develop our primal beliefs, but it is safe to say our parents probably play a large role. Exactly to what degree the tsunami of bad news we are allowing to inundate our children’s lives plays a role is unclear. However, it is reasonable to assume that news about climate change, school shootings, and the pandemic must be a contributor.

According to Dr. Clifton, there is some evidence that certain mind exercises, when applied diligently, can occasionally modify the primal beliefs of an individual who sees the world as dangerous and barren. Until such strategies become more readily accessible, the best we can do is acknowledge that our children are like canaries in a coal mine full of negative perceptions, then do our best to clear the air.

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].

A couple of weeks ago I stumbled across a report of a Pew Research Center’s survey titled “Parenting in America today” (Pew Research Center. Jan. 24, 2023), which found that 40% of parents in the United States with children younger than 18 are “extremely or very worried” that at some point their children might struggle with anxiety or depression. Thirty-six percent replied that they were “somewhat” worried. This total of more than 75% represents a significant change from the 2015 Pew Center survey in which only 54% of parents were “somewhat” worried about their children’s mental health.

Prompted by these findings I began work on a column in which I planned to encourage pediatricians to think more like family physicians when we were working with children who were experiencing serious mental health problems. My primary message was going to be that we should turn more of our attention to the mental health of the anxious parents who must endure the often long and frustrating path toward effective psychiatric care for their children. This might come in the form of some simple suggestions about nonpharmacologic self-help strategies. Or, it could mean encouraging parents to seek psychiatric care or counseling for themselves as they wait for help for their child.

However, as I began that column, my thoughts kept drifting toward a broader consideration of the relationship between parents and pediatric mental health. If mental health of children is causing their parents to be anxious and depressed isn’t it just as likely that this is a bidirectional connection? This was not exactly an “aha” moment for me because it is a relationship I have considered for sometime. However, it is a concept that I have come to realize is receiving far too little attention.

There are exceptions. For example, a recent opinion piece in the New York Times by David French, “What if Kids Are Sad and Stressed Because Their Parents Are?” (March 19, 2023) echoes many of my concerns. Drawing on his experiences traveling around college campuses, Mr. French observes, “Just as parents are upset about their children’s anxiety and depression, children are anxious about their parent’s mental health.”

He notes that an August 2022 NBC News poll found that 58% of registered voters feel this country’s best days are behind it and joins me in imagining that this negative mind set is filtering down to the pediatric population. He acknowledges that there are other likely contributors to teen unhappiness including the ubiquity of smart phones, the secularization of society, and the media’s focus on the political divide. However, Mr. French wonders if the parenting style that results in childhood experiences that are dominated by adult supervision and protection may also be playing a large role.

In his conclusion, Mr. French asks us to consider “How much fear and anxiety should we import to our lives and homes?” as we adults search for an answer.

As I continued to drill down for other possible solutions, I encountered an avenue of psychological research that suggests that instead of, or in addition to, filtering out the anxiety-generating deluge of information, we begin to give some thought to how our beliefs may be coloring our perception of reality.

Jeremy D.W. Clifton, PhD, a psychologist at the University of Pennsylvania Positive Psychology Center has done extensive research on the relationship between our basic beliefs about the world (known as primal beliefs or simply primals in psychologist lingo) and how we interpret reality. For example, one of your primal beliefs may be that the world is a dangerous place. I, on the other hand, may see the world as a stimulating environment offering me endless opportunities to explore. I may see the world as an abundant resource limited only by my creativity. You, however, see it as a barren wasteland.

Dr. Clifton’s research has shown that our primals (at least those of adults) are relatively immutable through one’s lifetime and “do not appear to be the consequence of our experiences.” For example, living in a ZIP code with a high crime rate does not predict that you will see the world as a dangerous place. Nor does being affluent guarantee that an adult sees the world rich with opportunities.

It is unclear exactly when and by what process we develop our primal beliefs, but it is safe to say our parents probably play a large role. Exactly to what degree the tsunami of bad news we are allowing to inundate our children’s lives plays a role is unclear. However, it is reasonable to assume that news about climate change, school shootings, and the pandemic must be a contributor.

According to Dr. Clifton, there is some evidence that certain mind exercises, when applied diligently, can occasionally modify the primal beliefs of an individual who sees the world as dangerous and barren. Until such strategies become more readily accessible, the best we can do is acknowledge that our children are like canaries in a coal mine full of negative perceptions, then do our best to clear the air.

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].

A couple of weeks ago I stumbled across a report of a Pew Research Center’s survey titled “Parenting in America today” (Pew Research Center. Jan. 24, 2023), which found that 40% of parents in the United States with children younger than 18 are “extremely or very worried” that at some point their children might struggle with anxiety or depression. Thirty-six percent replied that they were “somewhat” worried. This total of more than 75% represents a significant change from the 2015 Pew Center survey in which only 54% of parents were “somewhat” worried about their children’s mental health.

Prompted by these findings I began work on a column in which I planned to encourage pediatricians to think more like family physicians when we were working with children who were experiencing serious mental health problems. My primary message was going to be that we should turn more of our attention to the mental health of the anxious parents who must endure the often long and frustrating path toward effective psychiatric care for their children. This might come in the form of some simple suggestions about nonpharmacologic self-help strategies. Or, it could mean encouraging parents to seek psychiatric care or counseling for themselves as they wait for help for their child.

However, as I began that column, my thoughts kept drifting toward a broader consideration of the relationship between parents and pediatric mental health. If mental health of children is causing their parents to be anxious and depressed isn’t it just as likely that this is a bidirectional connection? This was not exactly an “aha” moment for me because it is a relationship I have considered for sometime. However, it is a concept that I have come to realize is receiving far too little attention.

There are exceptions. For example, a recent opinion piece in the New York Times by David French, “What if Kids Are Sad and Stressed Because Their Parents Are?” (March 19, 2023) echoes many of my concerns. Drawing on his experiences traveling around college campuses, Mr. French observes, “Just as parents are upset about their children’s anxiety and depression, children are anxious about their parent’s mental health.”

He notes that an August 2022 NBC News poll found that 58% of registered voters feel this country’s best days are behind it and joins me in imagining that this negative mind set is filtering down to the pediatric population. He acknowledges that there are other likely contributors to teen unhappiness including the ubiquity of smart phones, the secularization of society, and the media’s focus on the political divide. However, Mr. French wonders if the parenting style that results in childhood experiences that are dominated by adult supervision and protection may also be playing a large role.

In his conclusion, Mr. French asks us to consider “How much fear and anxiety should we import to our lives and homes?” as we adults search for an answer.

As I continued to drill down for other possible solutions, I encountered an avenue of psychological research that suggests that instead of, or in addition to, filtering out the anxiety-generating deluge of information, we begin to give some thought to how our beliefs may be coloring our perception of reality.

Jeremy D.W. Clifton, PhD, a psychologist at the University of Pennsylvania Positive Psychology Center has done extensive research on the relationship between our basic beliefs about the world (known as primal beliefs or simply primals in psychologist lingo) and how we interpret reality. For example, one of your primal beliefs may be that the world is a dangerous place. I, on the other hand, may see the world as a stimulating environment offering me endless opportunities to explore. I may see the world as an abundant resource limited only by my creativity. You, however, see it as a barren wasteland.

Dr. Clifton’s research has shown that our primals (at least those of adults) are relatively immutable through one’s lifetime and “do not appear to be the consequence of our experiences.” For example, living in a ZIP code with a high crime rate does not predict that you will see the world as a dangerous place. Nor does being affluent guarantee that an adult sees the world rich with opportunities.

It is unclear exactly when and by what process we develop our primal beliefs, but it is safe to say our parents probably play a large role. Exactly to what degree the tsunami of bad news we are allowing to inundate our children’s lives plays a role is unclear. However, it is reasonable to assume that news about climate change, school shootings, and the pandemic must be a contributor.

According to Dr. Clifton, there is some evidence that certain mind exercises, when applied diligently, can occasionally modify the primal beliefs of an individual who sees the world as dangerous and barren. Until such strategies become more readily accessible, the best we can do is acknowledge that our children are like canaries in a coal mine full of negative perceptions, then do our best to clear the air.

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].

Scenario: Yesterday you saw a 6-month-old infant with what appeared to be viral gastroenteritis and mild dehydration. When you called his parents today to check on his condition he was not improving despite your recommendations about his diet and oral rehydration. Should you have him brought to your office for a reevaluation, have his parents take him to the local emergency department for evaluation and probable hospital admission, or ask his parents to take him to the hospital telling them that you will call and arrange for a direct admission.

Obviously, I haven’t given you enough background information to allow you to give me an answer you are comfortable with. What time of day is it? Is it a holiday weekend? What’s the weather like? How far is it from the patient’s home to your office? To the emergency department? How is the local ED staffed? Are there hospitalists? What is their training?

Whether or not you choose to see the patient first in the office, is direct admission to the hospital an option that you are likely to choose? What steps do you take to see that it happens smoothly?

At least one-quarter of the unscheduled pediatric hospitalizations begin with a direct admission, meaning that the patients are not first evaluated in that hospital’s ED. In a recent policy statement, the American Academy of Pediatrics Committee on Hospital Care explored the pluses and minuses of direct admission and issued a list of seven recommendations. Among the concerns raised by the authors are “potential delays in initial evaluation and treatment, inconsistent admission processes, and difficulties in determining the appropriateness of patients for direct admission.” The committee makes it clear that they understand each community has it own strengths and challenges and the unique needs of each patient make it difficult to define a set of recommendations that fits all.

However, as I read through the committee’s seven recommendations, one leapt off the screen as a unifying concept that should apply in every situation. Recommendation No. 2 reads, “[There should be] clear systems of communication between members of the health care team and with families of children requiring admission.”

First, who is on this “health care team”? Are you a team member with the hospital folks – the ED nurses and doctors, the hospitalists, the floor nurses? Do you share an employer? Are you in the same town? Have your ever met them face to face? Do you do so regularly?

I assume you call the ED or the pediatric floor to arrange a direct admit? Maybe you don’t. I can recall working in situations where several infamous “local docs” would just send the patients in with a scribbled note (or not) and no phone call. Will you be speaking to folks who are even vaguely familiar with you or even your name? Do you get to speak with people who will be hands on with the patient?

Obviously, where I’m going with this is that, if you and the hospital staff are truly on the same health care team, communication should flow freely among the members and having some familiarity allows this to happen more smoothly. It can start on our end as the referring physician by making the call personally. Likewise, the receiving hospital must make frontline people available so you can speak with staff who will be working with the patient. Do you have enough information to tell the family what to expect?

Of course legible and complete records are a must. But nothing beats personal contact and a name. If you can tell a parent “I spoke to Martha, the nurse who will meet you on the floor,” that can be a giant first step forward in the healing process.

Most of us trained at hospitals that accepted direct admit patients and can remember the challenges. And most of us recall EDs that weren’t pediatric friendly. Whether our local situation favors direct admission or ED preadmission evaluation, it is our job to make the communication flow with the patient’s safety and the family’s comfort in mind.
 

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].

Scenario: Yesterday you saw a 6-month-old infant with what appeared to be viral gastroenteritis and mild dehydration. When you called his parents today to check on his condition he was not improving despite your recommendations about his diet and oral rehydration. Should you have him brought to your office for a reevaluation, have his parents take him to the local emergency department for evaluation and probable hospital admission, or ask his parents to take him to the hospital telling them that you will call and arrange for a direct admission.

Obviously, I haven’t given you enough background information to allow you to give me an answer you are comfortable with. What time of day is it? Is it a holiday weekend? What’s the weather like? How far is it from the patient’s home to your office? To the emergency department? How is the local ED staffed? Are there hospitalists? What is their training?

Whether or not you choose to see the patient first in the office, is direct admission to the hospital an option that you are likely to choose? What steps do you take to see that it happens smoothly?

At least one-quarter of the unscheduled pediatric hospitalizations begin with a direct admission, meaning that the patients are not first evaluated in that hospital’s ED. In a recent policy statement, the American Academy of Pediatrics Committee on Hospital Care explored the pluses and minuses of direct admission and issued a list of seven recommendations. Among the concerns raised by the authors are “potential delays in initial evaluation and treatment, inconsistent admission processes, and difficulties in determining the appropriateness of patients for direct admission.” The committee makes it clear that they understand each community has it own strengths and challenges and the unique needs of each patient make it difficult to define a set of recommendations that fits all.

However, as I read through the committee’s seven recommendations, one leapt off the screen as a unifying concept that should apply in every situation. Recommendation No. 2 reads, “[There should be] clear systems of communication between members of the health care team and with families of children requiring admission.”

First, who is on this “health care team”? Are you a team member with the hospital folks – the ED nurses and doctors, the hospitalists, the floor nurses? Do you share an employer? Are you in the same town? Have your ever met them face to face? Do you do so regularly?

I assume you call the ED or the pediatric floor to arrange a direct admit? Maybe you don’t. I can recall working in situations where several infamous “local docs” would just send the patients in with a scribbled note (or not) and no phone call. Will you be speaking to folks who are even vaguely familiar with you or even your name? Do you get to speak with people who will be hands on with the patient?

Obviously, where I’m going with this is that, if you and the hospital staff are truly on the same health care team, communication should flow freely among the members and having some familiarity allows this to happen more smoothly. It can start on our end as the referring physician by making the call personally. Likewise, the receiving hospital must make frontline people available so you can speak with staff who will be working with the patient. Do you have enough information to tell the family what to expect?

Of course legible and complete records are a must. But nothing beats personal contact and a name. If you can tell a parent “I spoke to Martha, the nurse who will meet you on the floor,” that can be a giant first step forward in the healing process.

Most of us trained at hospitals that accepted direct admit patients and can remember the challenges. And most of us recall EDs that weren’t pediatric friendly. Whether our local situation favors direct admission or ED preadmission evaluation, it is our job to make the communication flow with the patient’s safety and the family’s comfort in mind.
 

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].

Scenario: Yesterday you saw a 6-month-old infant with what appeared to be viral gastroenteritis and mild dehydration. When you called his parents today to check on his condition he was not improving despite your recommendations about his diet and oral rehydration. Should you have him brought to your office for a reevaluation, have his parents take him to the local emergency department for evaluation and probable hospital admission, or ask his parents to take him to the hospital telling them that you will call and arrange for a direct admission.

Obviously, I haven’t given you enough background information to allow you to give me an answer you are comfortable with. What time of day is it? Is it a holiday weekend? What’s the weather like? How far is it from the patient’s home to your office? To the emergency department? How is the local ED staffed? Are there hospitalists? What is their training?

Whether or not you choose to see the patient first in the office, is direct admission to the hospital an option that you are likely to choose? What steps do you take to see that it happens smoothly?

At least one-quarter of the unscheduled pediatric hospitalizations begin with a direct admission, meaning that the patients are not first evaluated in that hospital’s ED. In a recent policy statement, the American Academy of Pediatrics Committee on Hospital Care explored the pluses and minuses of direct admission and issued a list of seven recommendations. Among the concerns raised by the authors are “potential delays in initial evaluation and treatment, inconsistent admission processes, and difficulties in determining the appropriateness of patients for direct admission.” The committee makes it clear that they understand each community has it own strengths and challenges and the unique needs of each patient make it difficult to define a set of recommendations that fits all.

However, as I read through the committee’s seven recommendations, one leapt off the screen as a unifying concept that should apply in every situation. Recommendation No. 2 reads, “[There should be] clear systems of communication between members of the health care team and with families of children requiring admission.”

First, who is on this “health care team”? Are you a team member with the hospital folks – the ED nurses and doctors, the hospitalists, the floor nurses? Do you share an employer? Are you in the same town? Have your ever met them face to face? Do you do so regularly?

I assume you call the ED or the pediatric floor to arrange a direct admit? Maybe you don’t. I can recall working in situations where several infamous “local docs” would just send the patients in with a scribbled note (or not) and no phone call. Will you be speaking to folks who are even vaguely familiar with you or even your name? Do you get to speak with people who will be hands on with the patient?

Obviously, where I’m going with this is that, if you and the hospital staff are truly on the same health care team, communication should flow freely among the members and having some familiarity allows this to happen more smoothly. It can start on our end as the referring physician by making the call personally. Likewise, the receiving hospital must make frontline people available so you can speak with staff who will be working with the patient. Do you have enough information to tell the family what to expect?

Of course legible and complete records are a must. But nothing beats personal contact and a name. If you can tell a parent “I spoke to Martha, the nurse who will meet you on the floor,” that can be a giant first step forward in the healing process.

Most of us trained at hospitals that accepted direct admit patients and can remember the challenges. And most of us recall EDs that weren’t pediatric friendly. Whether our local situation favors direct admission or ED preadmission evaluation, it is our job to make the communication flow with the patient’s safety and the family’s comfort in mind.
 

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].

Last night I invested an hour and a half watching the first half of the Super Bowl ... because ... well, just because. As exciting as it might have been to watch, investing another 2 hours on the second half would have kept me up well past my bedtime. As I lay in bed with the thwack-thwack-thud of helmets hitting pads still reverberating in my ears, my thoughts drifted to the ever-shifting landscape of concussion management.

More than 2 decades ago, concussions were just beginning to exit the dark ages when loss of consciousness was the defining symptom or sign that most folks (and here I am including physicians) used to separate the run-of-the-mill stinger or bell-ringer from a “real” concussion.

The new era dawned with the appearance of clinics devoted to concussion management and the development of protocols that limited everything from physical exertion to reading and screen time. Schools were coaxed into subjecting their athletes to preparticipation testing sessions with the hope that creating a baseline cognitive assessment would somehow make the diagnosis and management of concussion feel more scientific. Many of the recommended management strategies were based on the intuitive but flawed notion of “brain rest.” If reading or bright lights aggravate patient’s symptoms, they should be avoided but otherwise resting the brain doesn’t seem to make sense.

Fortunately, there were, and hopefully will continue to be, clinicians willing to question hastily developed management protocols. One recent cohort study from Canada has found that, surprisingly, (to some experts), “early return to school was associated with a lower symptom burden” This association held true for both age groups the researches studied (8-12 years and 13-18 years). The authors conclude that delayed return to school “may be detrimental to recovery.” In this study, early return to school was defined as less than 3 days.

In another study, this one in the journal Pediatrics, the authors found that “the association of early screen time with postconcussion symptoms is not linear.” Their conclusion was that the best approach to clinical management of concussion should include a moderate amount of screen time.

After reading both of these studies I am heartened that we are now hearing voices suggesting a return to concussion management based on careful observation of the individual patient and common sense. A concussed brain is not a torn hamstring or a broken clavicle that under most circumstances will heal in a predictable amount of time. It is prudent to exclude the concussed patient from activities that carry a significant risk of reinjury until the symptoms have subsided. However, postconcussion symptoms are often vague and can be mistaken for or aggravated by a host of other conditions including learning disabilities, anxiety, and depression.

I hope that our experience with the COVID pandemic has taught us that removing children from school and their usual activities can have a serious negative effect on their emotional health and academic achievement. This seems to be particularly true for the young people who were already struggling to adjust to being a student. Getting out of the habit of going to school often intensifies the anxieties of an emotionally or academically challenged student. Each day away from the school atmosphere can compound the symptoms that may or may not have been triggered by the concussion.

The message here is clear that, whether we are talking about concussions or appendectomies or mononucleosis, the sooner we can return the child to something close to their old normal the more successful we will be in a helping them adjust to the new normal.

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].

Last night I invested an hour and a half watching the first half of the Super Bowl ... because ... well, just because. As exciting as it might have been to watch, investing another 2 hours on the second half would have kept me up well past my bedtime. As I lay in bed with the thwack-thwack-thud of helmets hitting pads still reverberating in my ears, my thoughts drifted to the ever-shifting landscape of concussion management.

More than 2 decades ago, concussions were just beginning to exit the dark ages when loss of consciousness was the defining symptom or sign that most folks (and here I am including physicians) used to separate the run-of-the-mill stinger or bell-ringer from a “real” concussion.

The new era dawned with the appearance of clinics devoted to concussion management and the development of protocols that limited everything from physical exertion to reading and screen time. Schools were coaxed into subjecting their athletes to preparticipation testing sessions with the hope that creating a baseline cognitive assessment would somehow make the diagnosis and management of concussion feel more scientific. Many of the recommended management strategies were based on the intuitive but flawed notion of “brain rest.” If reading or bright lights aggravate patient’s symptoms, they should be avoided but otherwise resting the brain doesn’t seem to make sense.

Fortunately, there were, and hopefully will continue to be, clinicians willing to question hastily developed management protocols. One recent cohort study from Canada has found that, surprisingly, (to some experts), “early return to school was associated with a lower symptom burden” This association held true for both age groups the researches studied (8-12 years and 13-18 years). The authors conclude that delayed return to school “may be detrimental to recovery.” In this study, early return to school was defined as less than 3 days.

In another study, this one in the journal Pediatrics, the authors found that “the association of early screen time with postconcussion symptoms is not linear.” Their conclusion was that the best approach to clinical management of concussion should include a moderate amount of screen time.

After reading both of these studies I am heartened that we are now hearing voices suggesting a return to concussion management based on careful observation of the individual patient and common sense. A concussed brain is not a torn hamstring or a broken clavicle that under most circumstances will heal in a predictable amount of time. It is prudent to exclude the concussed patient from activities that carry a significant risk of reinjury until the symptoms have subsided. However, postconcussion symptoms are often vague and can be mistaken for or aggravated by a host of other conditions including learning disabilities, anxiety, and depression.

I hope that our experience with the COVID pandemic has taught us that removing children from school and their usual activities can have a serious negative effect on their emotional health and academic achievement. This seems to be particularly true for the young people who were already struggling to adjust to being a student. Getting out of the habit of going to school often intensifies the anxieties of an emotionally or academically challenged student. Each day away from the school atmosphere can compound the symptoms that may or may not have been triggered by the concussion.

The message here is clear that, whether we are talking about concussions or appendectomies or mononucleosis, the sooner we can return the child to something close to their old normal the more successful we will be in a helping them adjust to the new normal.

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].

Last night I invested an hour and a half watching the first half of the Super Bowl ... because ... well, just because. As exciting as it might have been to watch, investing another 2 hours on the second half would have kept me up well past my bedtime. As I lay in bed with the thwack-thwack-thud of helmets hitting pads still reverberating in my ears, my thoughts drifted to the ever-shifting landscape of concussion management.

More than 2 decades ago, concussions were just beginning to exit the dark ages when loss of consciousness was the defining symptom or sign that most folks (and here I am including physicians) used to separate the run-of-the-mill stinger or bell-ringer from a “real” concussion.

The new era dawned with the appearance of clinics devoted to concussion management and the development of protocols that limited everything from physical exertion to reading and screen time. Schools were coaxed into subjecting their athletes to preparticipation testing sessions with the hope that creating a baseline cognitive assessment would somehow make the diagnosis and management of concussion feel more scientific. Many of the recommended management strategies were based on the intuitive but flawed notion of “brain rest.” If reading or bright lights aggravate patient’s symptoms, they should be avoided but otherwise resting the brain doesn’t seem to make sense.

Fortunately, there were, and hopefully will continue to be, clinicians willing to question hastily developed management protocols. One recent cohort study from Canada has found that, surprisingly, (to some experts), “early return to school was associated with a lower symptom burden” This association held true for both age groups the researches studied (8-12 years and 13-18 years). The authors conclude that delayed return to school “may be detrimental to recovery.” In this study, early return to school was defined as less than 3 days.

In another study, this one in the journal Pediatrics, the authors found that “the association of early screen time with postconcussion symptoms is not linear.” Their conclusion was that the best approach to clinical management of concussion should include a moderate amount of screen time.

After reading both of these studies I am heartened that we are now hearing voices suggesting a return to concussion management based on careful observation of the individual patient and common sense. A concussed brain is not a torn hamstring or a broken clavicle that under most circumstances will heal in a predictable amount of time. It is prudent to exclude the concussed patient from activities that carry a significant risk of reinjury until the symptoms have subsided. However, postconcussion symptoms are often vague and can be mistaken for or aggravated by a host of other conditions including learning disabilities, anxiety, and depression.

I hope that our experience with the COVID pandemic has taught us that removing children from school and their usual activities can have a serious negative effect on their emotional health and academic achievement. This seems to be particularly true for the young people who were already struggling to adjust to being a student. Getting out of the habit of going to school often intensifies the anxieties of an emotionally or academically challenged student. Each day away from the school atmosphere can compound the symptoms that may or may not have been triggered by the concussion.

The message here is clear that, whether we are talking about concussions or appendectomies or mononucleosis, the sooner we can return the child to something close to their old normal the more successful we will be in a helping them adjust to the new normal.

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].