William G. Wilkoff, MD

As we begin to find our way in the new world of obesity management, questions continue to surface more quickly than answers. This isn’t surprising, as we are being asked to view obesity as a disease when for decades the general consensus has been that overweight people are simply will power deficient.

Are the new drugs as effective as we are told by the patients and physicians who have had some experience using and prescribing them? Will they continue to be effective in the very long run? Will their safety record hold up over time? And for those of us in pediatrics, what will be their role for children? As a group we tend to be cautious about drugs that haven’t been thoroughly tested in children. How many years will it take before we feel comfortable with obesity drugs? And, of course, we should be asking ourselves the same questions about bariatric surgery.

Fortunately, while the media spotlight has been focused on the treatment arm of our obesity strategy, there are still some folks looking at what has been up to now the discouraging prospects for prevention. The U.S. Preventive Services Task Force (USPSTF) has recently released a draft of its recommendations that includes evidence supporting the effectiveness of “intensive behavioral interventions” (defined as a minimum of 26 hours of counseling). In reviewing data from nearly 60 randomized controlled trials, which included more than 10,000 children, the task force found that when beginning as early as age 6, a package including healthy eating education, physical activity, and behavioral change support could be effective in helping the children achieve healthy weight and an improved quality of life. It should be noted that the USPSTF gave the intervention package only a B grade, which means that the agency found evidence of high certainty of a moderate benefit over an unspecified time period. Certainly, not a ringing endorsement.

While I think we must applaud the diligent efforts of the task force and its commitment to prevention, I fear that the strategy is too little too late. That being said, I am willing to accept the idea that targeting age 6 for intensive counseling may qualify for the better-late-than-never category. The task force acknowledges that procuring the resources given our already understaffed mental health clinics is going to be difficult and expensive. I would add that it will be so costly in time and money as to be unrealistic.

Based on my observations of thousands of children, the scaffolding of habits, diet, and preference for inactivity that underly obesity has already been laid by age 6. Are we prepared to shoulder our already overburdened school systems in an attempt to reconfigure this foundation of an obesogenic lifestyle? An effort on this scale after children have been sent off to first grade is doomed to failure.

A recent review of data reported by the CDC and reviewed in the journal Pediatrics reveals that about 2% of children receiving federal assistance from the WIC program are severely obese. It is probably safe to say that these preschoolers represent just the tip of a very concerning iceberg.

By waiting until age 6, we would increase the risk of further stigmatizing the obese child. What will he tell his peers when he is taken out of school or misses a playdate because he has to meet with his “obesity counselor”?

If we are going to take obesity prevention seriously and spend time and money in counseling, doesn’t it make more sense to invest this effort on the parents and the home situation when the child is still under their influence? We must be prepared to unwrap and employ an “intensive behavioral package” the first time we see evidence that the child’s growth chart is heading in an unhealthy direction.

This won’t always be easy. I can recall seeing a 4-year-old whose weight had risen dramatically from her previous curve in the year since her 3-year checkup. The answer became obvious when I discovered that her grandmother, for whom baking was a passion, had taken over as her daycare provider. Arriving at a solution that kept the family on speaking terms took some tact, but it was one of my rare successes in obesity prevention. And, it worked because of early intervention.

Thank you USPSTF, but 6 years is too late.

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 pdnews@mdedge.com.

As we begin to find our way in the new world of obesity management, questions continue to surface more quickly than answers. This isn’t surprising, as we are being asked to view obesity as a disease when for decades the general consensus has been that overweight people are simply will power deficient.

Are the new drugs as effective as we are told by the patients and physicians who have had some experience using and prescribing them? Will they continue to be effective in the very long run? Will their safety record hold up over time? And for those of us in pediatrics, what will be their role for children? As a group we tend to be cautious about drugs that haven’t been thoroughly tested in children. How many years will it take before we feel comfortable with obesity drugs? And, of course, we should be asking ourselves the same questions about bariatric surgery.

Fortunately, while the media spotlight has been focused on the treatment arm of our obesity strategy, there are still some folks looking at what has been up to now the discouraging prospects for prevention. The U.S. Preventive Services Task Force (USPSTF) has recently released a draft of its recommendations that includes evidence supporting the effectiveness of “intensive behavioral interventions” (defined as a minimum of 26 hours of counseling). In reviewing data from nearly 60 randomized controlled trials, which included more than 10,000 children, the task force found that when beginning as early as age 6, a package including healthy eating education, physical activity, and behavioral change support could be effective in helping the children achieve healthy weight and an improved quality of life. It should be noted that the USPSTF gave the intervention package only a B grade, which means that the agency found evidence of high certainty of a moderate benefit over an unspecified time period. Certainly, not a ringing endorsement.

While I think we must applaud the diligent efforts of the task force and its commitment to prevention, I fear that the strategy is too little too late. That being said, I am willing to accept the idea that targeting age 6 for intensive counseling may qualify for the better-late-than-never category. The task force acknowledges that procuring the resources given our already understaffed mental health clinics is going to be difficult and expensive. I would add that it will be so costly in time and money as to be unrealistic.

Based on my observations of thousands of children, the scaffolding of habits, diet, and preference for inactivity that underly obesity has already been laid by age 6. Are we prepared to shoulder our already overburdened school systems in an attempt to reconfigure this foundation of an obesogenic lifestyle? An effort on this scale after children have been sent off to first grade is doomed to failure.

A recent review of data reported by the CDC and reviewed in the journal Pediatrics reveals that about 2% of children receiving federal assistance from the WIC program are severely obese. It is probably safe to say that these preschoolers represent just the tip of a very concerning iceberg.

By waiting until age 6, we would increase the risk of further stigmatizing the obese child. What will he tell his peers when he is taken out of school or misses a playdate because he has to meet with his “obesity counselor”?

If we are going to take obesity prevention seriously and spend time and money in counseling, doesn’t it make more sense to invest this effort on the parents and the home situation when the child is still under their influence? We must be prepared to unwrap and employ an “intensive behavioral package” the first time we see evidence that the child’s growth chart is heading in an unhealthy direction.

This won’t always be easy. I can recall seeing a 4-year-old whose weight had risen dramatically from her previous curve in the year since her 3-year checkup. The answer became obvious when I discovered that her grandmother, for whom baking was a passion, had taken over as her daycare provider. Arriving at a solution that kept the family on speaking terms took some tact, but it was one of my rare successes in obesity prevention. And, it worked because of early intervention.

Thank you USPSTF, but 6 years is too late.

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 pdnews@mdedge.com.

As we begin to find our way in the new world of obesity management, questions continue to surface more quickly than answers. This isn’t surprising, as we are being asked to view obesity as a disease when for decades the general consensus has been that overweight people are simply will power deficient.

Are the new drugs as effective as we are told by the patients and physicians who have had some experience using and prescribing them? Will they continue to be effective in the very long run? Will their safety record hold up over time? And for those of us in pediatrics, what will be their role for children? As a group we tend to be cautious about drugs that haven’t been thoroughly tested in children. How many years will it take before we feel comfortable with obesity drugs? And, of course, we should be asking ourselves the same questions about bariatric surgery.

Fortunately, while the media spotlight has been focused on the treatment arm of our obesity strategy, there are still some folks looking at what has been up to now the discouraging prospects for prevention. The U.S. Preventive Services Task Force (USPSTF) has recently released a draft of its recommendations that includes evidence supporting the effectiveness of “intensive behavioral interventions” (defined as a minimum of 26 hours of counseling). In reviewing data from nearly 60 randomized controlled trials, which included more than 10,000 children, the task force found that when beginning as early as age 6, a package including healthy eating education, physical activity, and behavioral change support could be effective in helping the children achieve healthy weight and an improved quality of life. It should be noted that the USPSTF gave the intervention package only a B grade, which means that the agency found evidence of high certainty of a moderate benefit over an unspecified time period. Certainly, not a ringing endorsement.

While I think we must applaud the diligent efforts of the task force and its commitment to prevention, I fear that the strategy is too little too late. That being said, I am willing to accept the idea that targeting age 6 for intensive counseling may qualify for the better-late-than-never category. The task force acknowledges that procuring the resources given our already understaffed mental health clinics is going to be difficult and expensive. I would add that it will be so costly in time and money as to be unrealistic.

Based on my observations of thousands of children, the scaffolding of habits, diet, and preference for inactivity that underly obesity has already been laid by age 6. Are we prepared to shoulder our already overburdened school systems in an attempt to reconfigure this foundation of an obesogenic lifestyle? An effort on this scale after children have been sent off to first grade is doomed to failure.

A recent review of data reported by the CDC and reviewed in the journal Pediatrics reveals that about 2% of children receiving federal assistance from the WIC program are severely obese. It is probably safe to say that these preschoolers represent just the tip of a very concerning iceberg.

By waiting until age 6, we would increase the risk of further stigmatizing the obese child. What will he tell his peers when he is taken out of school or misses a playdate because he has to meet with his “obesity counselor”?

If we are going to take obesity prevention seriously and spend time and money in counseling, doesn’t it make more sense to invest this effort on the parents and the home situation when the child is still under their influence? We must be prepared to unwrap and employ an “intensive behavioral package” the first time we see evidence that the child’s growth chart is heading in an unhealthy direction.

This won’t always be easy. I can recall seeing a 4-year-old whose weight had risen dramatically from her previous curve in the year since her 3-year checkup. The answer became obvious when I discovered that her grandmother, for whom baking was a passion, had taken over as her daycare provider. Arriving at a solution that kept the family on speaking terms took some tact, but it was one of my rare successes in obesity prevention. And, it worked because of early intervention.

Thank you USPSTF, but 6 years is too late.

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 pdnews@mdedge.com.

You’re familiar with DIY and DUI, but what associations do the initials DEI trigger in your thought processor? Your college is probably influenced by it. So is your medical school, as are many of the businesses whose advertisements bombard you on television and the internet. Your professional association is definitely involved with it.

In the words of one newspaper columnist, DEI is an “ideological framework” whose most recognizable buzz words are “diversity,” “equity,” and “inclusion.” In the case of the American Academy of Pediatrics (AAP), DEI has taken the form of a hiring philosophy that accepts and respects its responsibility to create a workplace “where each person can fully contribute to the shared mission without discrimination or intimidation and each person is respected, supported, and provided the equal opportunity, regardless of race, ethnicity, ancestry, national origin, religion, gender, marital status, sexual orientation, gender identity, or expression age, veteran status, immigration status, or disability.”.

As an organization representing its members, the AAP has issued a statement: “Celebrating the diversity of children and families and promoting nurturing, inclusive environments means actively opposing intolerance, bigotry, bias and discrimination” Further, the AAP says it is committed to using policy, advocacy, and education to encourage inclusivity and cultural effectiveness for all.”. Included in its recommendations to fulfill this commitment are efforts to diversify the pediatric workforce and eliminate race-based medicine.

For the AAP, its commitment to diversity, equity, and inclusion seems to be a good fit. The first line of its mission statement — “to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents and young adults” — is well focused and one that its members can agree upon. However, we are beginning to see and hear that on some college and university campuses DEI has worn out its welcome.

In academia, the decision to include a broad mix of students and faculty with diverse backgrounds and at the same time provide opportunities equitably has hit some serious bumps in the road. It’s unclear how much the chaos in the Middle East is to blame, However, for several years there have been unfortunate campus incidents when the invitation of controversial guest speakers has laid bare the widely different interpretations of exactly what “free speech” means.

From its hazy inception, DEI has been missing one key ingredient — commonality. If we are going to actively seek to include individuals from a variety of backgrounds, encourage them to celebrate their diversity, and offer them equitable opportunities, then at the same time we must make it clear that our overriding goal is to seek and encourage the civil discussion of what we all have in common. Neglecting this additional step of promoting commonality is a grave mistake.

One mustn’t be surprised that a group of individuals from diverse backgrounds will have differing opinions. Finding common ground will predictably be a challenge, but it can be done. It requires compromise and a commitment to civil discussion. Regrettably, DEI as a framework places so much emphasis on the individual and diversity that the critical concept of commonality has been lost. Ironically, true inclusion and equity can’t occur without a reverence for commonality.

The AAP has done a good job of folding DEI into fulfilling the first sentence of its mission statement. However, it must not lose sight of the critical ingredient of commonality as it seeks to “support the professional needs of its members” (the second sentence of its mission). Despite a general agreement on the goal of providing care for all children, there are differences of opinion among its members when it comes to some of the details. The confusing topic of gender-affirmative care comes to mind. I am confident that as a group of thoughtful professionals, even in the face of wide differences, we can see the way to civil and productive discussions in the search for commonality.

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 pdnews@mdedge.com.

You’re familiar with DIY and DUI, but what associations do the initials DEI trigger in your thought processor? Your college is probably influenced by it. So is your medical school, as are many of the businesses whose advertisements bombard you on television and the internet. Your professional association is definitely involved with it.

In the words of one newspaper columnist, DEI is an “ideological framework” whose most recognizable buzz words are “diversity,” “equity,” and “inclusion.” In the case of the American Academy of Pediatrics (AAP), DEI has taken the form of a hiring philosophy that accepts and respects its responsibility to create a workplace “where each person can fully contribute to the shared mission without discrimination or intimidation and each person is respected, supported, and provided the equal opportunity, regardless of race, ethnicity, ancestry, national origin, religion, gender, marital status, sexual orientation, gender identity, or expression age, veteran status, immigration status, or disability.”.

As an organization representing its members, the AAP has issued a statement: “Celebrating the diversity of children and families and promoting nurturing, inclusive environments means actively opposing intolerance, bigotry, bias and discrimination” Further, the AAP says it is committed to using policy, advocacy, and education to encourage inclusivity and cultural effectiveness for all.”. Included in its recommendations to fulfill this commitment are efforts to diversify the pediatric workforce and eliminate race-based medicine.

For the AAP, its commitment to diversity, equity, and inclusion seems to be a good fit. The first line of its mission statement — “to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents and young adults” — is well focused and one that its members can agree upon. However, we are beginning to see and hear that on some college and university campuses DEI has worn out its welcome.

In academia, the decision to include a broad mix of students and faculty with diverse backgrounds and at the same time provide opportunities equitably has hit some serious bumps in the road. It’s unclear how much the chaos in the Middle East is to blame, However, for several years there have been unfortunate campus incidents when the invitation of controversial guest speakers has laid bare the widely different interpretations of exactly what “free speech” means.

From its hazy inception, DEI has been missing one key ingredient — commonality. If we are going to actively seek to include individuals from a variety of backgrounds, encourage them to celebrate their diversity, and offer them equitable opportunities, then at the same time we must make it clear that our overriding goal is to seek and encourage the civil discussion of what we all have in common. Neglecting this additional step of promoting commonality is a grave mistake.

One mustn’t be surprised that a group of individuals from diverse backgrounds will have differing opinions. Finding common ground will predictably be a challenge, but it can be done. It requires compromise and a commitment to civil discussion. Regrettably, DEI as a framework places so much emphasis on the individual and diversity that the critical concept of commonality has been lost. Ironically, true inclusion and equity can’t occur without a reverence for commonality.

The AAP has done a good job of folding DEI into fulfilling the first sentence of its mission statement. However, it must not lose sight of the critical ingredient of commonality as it seeks to “support the professional needs of its members” (the second sentence of its mission). Despite a general agreement on the goal of providing care for all children, there are differences of opinion among its members when it comes to some of the details. The confusing topic of gender-affirmative care comes to mind. I am confident that as a group of thoughtful professionals, even in the face of wide differences, we can see the way to civil and productive discussions in the search for commonality.

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 pdnews@mdedge.com.

You’re familiar with DIY and DUI, but what associations do the initials DEI trigger in your thought processor? Your college is probably influenced by it. So is your medical school, as are many of the businesses whose advertisements bombard you on television and the internet. Your professional association is definitely involved with it.

In the words of one newspaper columnist, DEI is an “ideological framework” whose most recognizable buzz words are “diversity,” “equity,” and “inclusion.” In the case of the American Academy of Pediatrics (AAP), DEI has taken the form of a hiring philosophy that accepts and respects its responsibility to create a workplace “where each person can fully contribute to the shared mission without discrimination or intimidation and each person is respected, supported, and provided the equal opportunity, regardless of race, ethnicity, ancestry, national origin, religion, gender, marital status, sexual orientation, gender identity, or expression age, veteran status, immigration status, or disability.”.

As an organization representing its members, the AAP has issued a statement: “Celebrating the diversity of children and families and promoting nurturing, inclusive environments means actively opposing intolerance, bigotry, bias and discrimination” Further, the AAP says it is committed to using policy, advocacy, and education to encourage inclusivity and cultural effectiveness for all.”. Included in its recommendations to fulfill this commitment are efforts to diversify the pediatric workforce and eliminate race-based medicine.

For the AAP, its commitment to diversity, equity, and inclusion seems to be a good fit. The first line of its mission statement — “to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents and young adults” — is well focused and one that its members can agree upon. However, we are beginning to see and hear that on some college and university campuses DEI has worn out its welcome.

In academia, the decision to include a broad mix of students and faculty with diverse backgrounds and at the same time provide opportunities equitably has hit some serious bumps in the road. It’s unclear how much the chaos in the Middle East is to blame, However, for several years there have been unfortunate campus incidents when the invitation of controversial guest speakers has laid bare the widely different interpretations of exactly what “free speech” means.

From its hazy inception, DEI has been missing one key ingredient — commonality. If we are going to actively seek to include individuals from a variety of backgrounds, encourage them to celebrate their diversity, and offer them equitable opportunities, then at the same time we must make it clear that our overriding goal is to seek and encourage the civil discussion of what we all have in common. Neglecting this additional step of promoting commonality is a grave mistake.

One mustn’t be surprised that a group of individuals from diverse backgrounds will have differing opinions. Finding common ground will predictably be a challenge, but it can be done. It requires compromise and a commitment to civil discussion. Regrettably, DEI as a framework places so much emphasis on the individual and diversity that the critical concept of commonality has been lost. Ironically, true inclusion and equity can’t occur without a reverence for commonality.

The AAP has done a good job of folding DEI into fulfilling the first sentence of its mission statement. However, it must not lose sight of the critical ingredient of commonality as it seeks to “support the professional needs of its members” (the second sentence of its mission). Despite a general agreement on the goal of providing care for all children, there are differences of opinion among its members when it comes to some of the details. The confusing topic of gender-affirmative care comes to mind. I am confident that as a group of thoughtful professionals, even in the face of wide differences, we can see the way to civil and productive discussions in the search for commonality.

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 pdnews@mdedge.com.

Organized labor seems to be experiencing a rebirth of sorts. In October 2022 a strike by railroad workers was averted when a tentative agreement about wages, working conditions, health insurance, and medical leave was hammered out. This past fall, strikes by auto workers that threatened to paralyze the big three manufacturers have now been resolved with agreements that meet many of the workers’ demands. The President even made an appearance on a picket line. Baristas at coffee shops, screenwriters, and actors have all been involved in work actions around the country.

While the health care industry has been relatively immune to threatened work stoppages, there are a growing number of hospitals and clinics where nurses and physicians are exploring the possibility of organizing to give themselves a stronger voice in how health care is being delivered. The realities that come when you transition from owner to employee are finally beginning to sink in for physicians, whether they are specialists or primary care providers.

One of the most significant efforts toward unionization recently occurred in Minnesota and Wisconsin. About 400 physicians and 150 physician’s assistants and nurse practitioners employed at Allina Health System voted to unionize and join the Doctors Council.

In an interview with Jacobin, a publication that offers a socialist perspective, three of the providers involved in the process that led to the vote shared their observations. The physicians claim that the first steps toward unionization came after multiple efforts to work with the Allina’s administration were rebuffed. As primary care physicians, their initial demands focused on getting help with hiring staffing and getting support with paperwork and administrative obligations.

The organizers complained that while Medicare hoped to bolster primary care by paying the providers more, the funds went to the companies, who then distributed them in a way that often did little to help the overworked providers. In addition to achieving a more equitable distribution of the monies, one of the organizers sees unionization as a way to provide a layer of protection when providers feel they must speak out about situations which clearly put quality of care at risk.

The organizers say the idea of unionization has been particularly appealing to the younger providers who are feeling threatened by burnout. When these new physicians look to their older coworkers for advice, they often find that the seasoned employees are as stressed as they are. Realizing that things aren’t going to improve with time, acting now to strengthen their voices sounds appealing.

With the vote for unionization behind them, the organizers are now ready to formulate a prioritized list of demands. Those of you who are regular readers of Letters from Maine know that I have been urging primary care physicians to find their voices. Unfortunately, unionization seems to be becoming a more common fall-back strategy when other avenues have failed to reach a sympathetic ear in the corporate boardrooms.

As more unions form, it will be interesting to see how the organizers structure their demands and job actions. While walkouts and strikes can certainly be effective in gaining attention, that attention can carry a risk of counter productivity sometimes by alienating patients, who should become allies.

Since an unsustainable burden of paperwork and administrative demands seems to be at the top of everyone’s priority list, it might make sense to adopt this message as a scaffolding on which to built a work action. Instead of walking off the job or marching on a picket line, why not stay in the hospital and continue to see patients but only for part of the work day. The remainder of the day would be spent doing all the clerical work that has become so onerous.

Providers would agree to see patients in the mornings, saving up the clerical work and administrative obligations for the afternoon. The definition of “morning” could vary depending on local conditions.

The important message to the public and the patients would be that the providers were not abandoning them by walking out. The patients’ access to face-to-face care was being limited not because the doctors didn’t want to see them but because the providers were being forced to accept other responsibilities by the administration. The physicians would always be on site in case of a crisis, but until reasonable demands for support from the company were met, a certain portion of the providers’ day would be spent doing things not directly related to face-to-face patient care. This burden of meaningless work is the reality as it stands already. Why not organize it in a way that makes it startlingly visible to the patients and the public.

There would be no video clips of physicians walking the picket lines carrying signs. Any images released to the media would be of empty waiting rooms while providers sat hunched over their computers or talking on the phone to insurance companies.

The strategy needs a catchy phrase like “a paperwork-in” but I’m still struggling with a name. Let me know if you have a better one or even a better strategy.
 

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 pdnews@mdedge.com.

Organized labor seems to be experiencing a rebirth of sorts. In October 2022 a strike by railroad workers was averted when a tentative agreement about wages, working conditions, health insurance, and medical leave was hammered out. This past fall, strikes by auto workers that threatened to paralyze the big three manufacturers have now been resolved with agreements that meet many of the workers’ demands. The President even made an appearance on a picket line. Baristas at coffee shops, screenwriters, and actors have all been involved in work actions around the country.

While the health care industry has been relatively immune to threatened work stoppages, there are a growing number of hospitals and clinics where nurses and physicians are exploring the possibility of organizing to give themselves a stronger voice in how health care is being delivered. The realities that come when you transition from owner to employee are finally beginning to sink in for physicians, whether they are specialists or primary care providers.

One of the most significant efforts toward unionization recently occurred in Minnesota and Wisconsin. About 400 physicians and 150 physician’s assistants and nurse practitioners employed at Allina Health System voted to unionize and join the Doctors Council.

In an interview with Jacobin, a publication that offers a socialist perspective, three of the providers involved in the process that led to the vote shared their observations. The physicians claim that the first steps toward unionization came after multiple efforts to work with the Allina’s administration were rebuffed. As primary care physicians, their initial demands focused on getting help with hiring staffing and getting support with paperwork and administrative obligations.

The organizers complained that while Medicare hoped to bolster primary care by paying the providers more, the funds went to the companies, who then distributed them in a way that often did little to help the overworked providers. In addition to achieving a more equitable distribution of the monies, one of the organizers sees unionization as a way to provide a layer of protection when providers feel they must speak out about situations which clearly put quality of care at risk.

The organizers say the idea of unionization has been particularly appealing to the younger providers who are feeling threatened by burnout. When these new physicians look to their older coworkers for advice, they often find that the seasoned employees are as stressed as they are. Realizing that things aren’t going to improve with time, acting now to strengthen their voices sounds appealing.

With the vote for unionization behind them, the organizers are now ready to formulate a prioritized list of demands. Those of you who are regular readers of Letters from Maine know that I have been urging primary care physicians to find their voices. Unfortunately, unionization seems to be becoming a more common fall-back strategy when other avenues have failed to reach a sympathetic ear in the corporate boardrooms.

As more unions form, it will be interesting to see how the organizers structure their demands and job actions. While walkouts and strikes can certainly be effective in gaining attention, that attention can carry a risk of counter productivity sometimes by alienating patients, who should become allies.

Since an unsustainable burden of paperwork and administrative demands seems to be at the top of everyone’s priority list, it might make sense to adopt this message as a scaffolding on which to built a work action. Instead of walking off the job or marching on a picket line, why not stay in the hospital and continue to see patients but only for part of the work day. The remainder of the day would be spent doing all the clerical work that has become so onerous.

Providers would agree to see patients in the mornings, saving up the clerical work and administrative obligations for the afternoon. The definition of “morning” could vary depending on local conditions.

The important message to the public and the patients would be that the providers were not abandoning them by walking out. The patients’ access to face-to-face care was being limited not because the doctors didn’t want to see them but because the providers were being forced to accept other responsibilities by the administration. The physicians would always be on site in case of a crisis, but until reasonable demands for support from the company were met, a certain portion of the providers’ day would be spent doing things not directly related to face-to-face patient care. This burden of meaningless work is the reality as it stands already. Why not organize it in a way that makes it startlingly visible to the patients and the public.

There would be no video clips of physicians walking the picket lines carrying signs. Any images released to the media would be of empty waiting rooms while providers sat hunched over their computers or talking on the phone to insurance companies.

The strategy needs a catchy phrase like “a paperwork-in” but I’m still struggling with a name. Let me know if you have a better one or even a better strategy.
 

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 pdnews@mdedge.com.

Organized labor seems to be experiencing a rebirth of sorts. In October 2022 a strike by railroad workers was averted when a tentative agreement about wages, working conditions, health insurance, and medical leave was hammered out. This past fall, strikes by auto workers that threatened to paralyze the big three manufacturers have now been resolved with agreements that meet many of the workers’ demands. The President even made an appearance on a picket line. Baristas at coffee shops, screenwriters, and actors have all been involved in work actions around the country.

While the health care industry has been relatively immune to threatened work stoppages, there are a growing number of hospitals and clinics where nurses and physicians are exploring the possibility of organizing to give themselves a stronger voice in how health care is being delivered. The realities that come when you transition from owner to employee are finally beginning to sink in for physicians, whether they are specialists or primary care providers.

One of the most significant efforts toward unionization recently occurred in Minnesota and Wisconsin. About 400 physicians and 150 physician’s assistants and nurse practitioners employed at Allina Health System voted to unionize and join the Doctors Council.

In an interview with Jacobin, a publication that offers a socialist perspective, three of the providers involved in the process that led to the vote shared their observations. The physicians claim that the first steps toward unionization came after multiple efforts to work with the Allina’s administration were rebuffed. As primary care physicians, their initial demands focused on getting help with hiring staffing and getting support with paperwork and administrative obligations.

The organizers complained that while Medicare hoped to bolster primary care by paying the providers more, the funds went to the companies, who then distributed them in a way that often did little to help the overworked providers. In addition to achieving a more equitable distribution of the monies, one of the organizers sees unionization as a way to provide a layer of protection when providers feel they must speak out about situations which clearly put quality of care at risk.

The organizers say the idea of unionization has been particularly appealing to the younger providers who are feeling threatened by burnout. When these new physicians look to their older coworkers for advice, they often find that the seasoned employees are as stressed as they are. Realizing that things aren’t going to improve with time, acting now to strengthen their voices sounds appealing.

With the vote for unionization behind them, the organizers are now ready to formulate a prioritized list of demands. Those of you who are regular readers of Letters from Maine know that I have been urging primary care physicians to find their voices. Unfortunately, unionization seems to be becoming a more common fall-back strategy when other avenues have failed to reach a sympathetic ear in the corporate boardrooms.

As more unions form, it will be interesting to see how the organizers structure their demands and job actions. While walkouts and strikes can certainly be effective in gaining attention, that attention can carry a risk of counter productivity sometimes by alienating patients, who should become allies.

Since an unsustainable burden of paperwork and administrative demands seems to be at the top of everyone’s priority list, it might make sense to adopt this message as a scaffolding on which to built a work action. Instead of walking off the job or marching on a picket line, why not stay in the hospital and continue to see patients but only for part of the work day. The remainder of the day would be spent doing all the clerical work that has become so onerous.

Providers would agree to see patients in the mornings, saving up the clerical work and administrative obligations for the afternoon. The definition of “morning” could vary depending on local conditions.

The important message to the public and the patients would be that the providers were not abandoning them by walking out. The patients’ access to face-to-face care was being limited not because the doctors didn’t want to see them but because the providers were being forced to accept other responsibilities by the administration. The physicians would always be on site in case of a crisis, but until reasonable demands for support from the company were met, a certain portion of the providers’ day would be spent doing things not directly related to face-to-face patient care. This burden of meaningless work is the reality as it stands already. Why not organize it in a way that makes it startlingly visible to the patients and the public.

There would be no video clips of physicians walking the picket lines carrying signs. Any images released to the media would be of empty waiting rooms while providers sat hunched over their computers or talking on the phone to insurance companies.

The strategy needs a catchy phrase like “a paperwork-in” but I’m still struggling with a name. Let me know if you have a better one or even a better strategy.
 

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 pdnews@mdedge.com.

A few weeks ago I shared by concerns about the dwindling numbers of primary care physicians. The early exodus of practicing providers and an obvious disinterest by future physicians in what they see as the unpalatable work/life balance of frontline hands-on medicine are among the causes.

A recent study published in the journal Pediatrics highlights personal finance as a contributor to the drain on the primary care workforce. The investigators found “high self-reported educational debt ($200,000 to < $300,000) was positively associated with training in a positive lifetime earnings potential subspecialty.” In other words, why would a physician who was burdened with student loans enter a subspecialty that would limit his or her ability to pay it off? I suspect that money has always been a factor in career selection, but the ballooning cost of college and medical school has certainly not nudged graduates toward the low lifetime earnings potential of primary care pediatrics.

Another recently released survey adds the perspective of current medical school students to the murky future of the primary health care workforce. The Clinician of the Future 2023: Education Edition, published by Elsevier Health, reports on insights of more than 2,000 nursing and medical school student from around the world. The headline shocker was that while across the board a not surprising 12% of medical students were considering quitting their studies, in the United States this number was 25%.

Overall, more than 60% of the students worried about their future income, how workforce shortages would effect them and whether they would join the ranks of those clinicians suffering from burnout. While the students surveyed acknowledged that artificial intelligence could have some negative repercussions, 62% were excited about its use in their education. Similarly, they anticipated the positive contribution of digital technology while acknowledging its potential downsides.

Given the current mental health climate in this country, I was not surprised that almost a quarter of medical students in this country are considering quitting school. I would like to see a larger sample surveyed and repeated over time. But, the discrepancy between the United States and the rest of the world is troubling.

The number that really jumped out at me was that 54% of medical students (nurses, 62%) viewed “ their current studies as a stepping-stone toward a broader career in health care.” As an example, the authors quoted one medical student who plans to “look for other possibilities where I don’t directly treat patients.”

Whether this disinterest in direct patient care is an attitude that preceded their entry into medical school or a change reflecting a major reversal induced by the realty of face-to-face patient encounters in school was not addressed in the survey. I think the general population would be surprised and maybe disappointed to learn that half the students in medical school weren’t planning on seeing patients.

I went off to medical school with a rather naive Norman Rockwellian view of a physician. I was a little surprised that a few of my classmates seemed to be gravitating toward administrative and research careers, but by far most of us were heading toward opportunities that would place us face to face with patients. Some would become specialists but primary care still had an appeal for many of us.

In my last letter about primary care training, I suggested that traditional medical school was probably a poor investment for the person who shares a bit of my old-school image of the primary care physician. In addition to cost and the time invested, the curriculum would likely be overly broad and deep and not terribly applicable to the patient mix he or she would eventually be seeing. This global survey may suggest that medical students have already discovered, or are just now discovering, this mismatch between medical school and the realities of primary care.

Our challenge is to first deal with deterrent of student debt and then to develop a new, affordable and efficient pathway to primary care that attracts those people who are looking for a face to face style of medicine on the front line. The patients know we need specialists and administrators but they also want a bit more of Norman Rockwell.
 

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 pdnews@mdedge.com.

A few weeks ago I shared by concerns about the dwindling numbers of primary care physicians. The early exodus of practicing providers and an obvious disinterest by future physicians in what they see as the unpalatable work/life balance of frontline hands-on medicine are among the causes.

A recent study published in the journal Pediatrics highlights personal finance as a contributor to the drain on the primary care workforce. The investigators found “high self-reported educational debt ($200,000 to < $300,000) was positively associated with training in a positive lifetime earnings potential subspecialty.” In other words, why would a physician who was burdened with student loans enter a subspecialty that would limit his or her ability to pay it off? I suspect that money has always been a factor in career selection, but the ballooning cost of college and medical school has certainly not nudged graduates toward the low lifetime earnings potential of primary care pediatrics.

Another recently released survey adds the perspective of current medical school students to the murky future of the primary health care workforce. The Clinician of the Future 2023: Education Edition, published by Elsevier Health, reports on insights of more than 2,000 nursing and medical school student from around the world. The headline shocker was that while across the board a not surprising 12% of medical students were considering quitting their studies, in the United States this number was 25%.

Overall, more than 60% of the students worried about their future income, how workforce shortages would effect them and whether they would join the ranks of those clinicians suffering from burnout. While the students surveyed acknowledged that artificial intelligence could have some negative repercussions, 62% were excited about its use in their education. Similarly, they anticipated the positive contribution of digital technology while acknowledging its potential downsides.

Given the current mental health climate in this country, I was not surprised that almost a quarter of medical students in this country are considering quitting school. I would like to see a larger sample surveyed and repeated over time. But, the discrepancy between the United States and the rest of the world is troubling.

The number that really jumped out at me was that 54% of medical students (nurses, 62%) viewed “ their current studies as a stepping-stone toward a broader career in health care.” As an example, the authors quoted one medical student who plans to “look for other possibilities where I don’t directly treat patients.”

Whether this disinterest in direct patient care is an attitude that preceded their entry into medical school or a change reflecting a major reversal induced by the realty of face-to-face patient encounters in school was not addressed in the survey. I think the general population would be surprised and maybe disappointed to learn that half the students in medical school weren’t planning on seeing patients.

I went off to medical school with a rather naive Norman Rockwellian view of a physician. I was a little surprised that a few of my classmates seemed to be gravitating toward administrative and research careers, but by far most of us were heading toward opportunities that would place us face to face with patients. Some would become specialists but primary care still had an appeal for many of us.

In my last letter about primary care training, I suggested that traditional medical school was probably a poor investment for the person who shares a bit of my old-school image of the primary care physician. In addition to cost and the time invested, the curriculum would likely be overly broad and deep and not terribly applicable to the patient mix he or she would eventually be seeing. This global survey may suggest that medical students have already discovered, or are just now discovering, this mismatch between medical school and the realities of primary care.

Our challenge is to first deal with deterrent of student debt and then to develop a new, affordable and efficient pathway to primary care that attracts those people who are looking for a face to face style of medicine on the front line. The patients know we need specialists and administrators but they also want a bit more of Norman Rockwell.
 

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 pdnews@mdedge.com.

A few weeks ago I shared by concerns about the dwindling numbers of primary care physicians. The early exodus of practicing providers and an obvious disinterest by future physicians in what they see as the unpalatable work/life balance of frontline hands-on medicine are among the causes.

A recent study published in the journal Pediatrics highlights personal finance as a contributor to the drain on the primary care workforce. The investigators found “high self-reported educational debt ($200,000 to < $300,000) was positively associated with training in a positive lifetime earnings potential subspecialty.” In other words, why would a physician who was burdened with student loans enter a subspecialty that would limit his or her ability to pay it off? I suspect that money has always been a factor in career selection, but the ballooning cost of college and medical school has certainly not nudged graduates toward the low lifetime earnings potential of primary care pediatrics.

Another recently released survey adds the perspective of current medical school students to the murky future of the primary health care workforce. The Clinician of the Future 2023: Education Edition, published by Elsevier Health, reports on insights of more than 2,000 nursing and medical school student from around the world. The headline shocker was that while across the board a not surprising 12% of medical students were considering quitting their studies, in the United States this number was 25%.

Overall, more than 60% of the students worried about their future income, how workforce shortages would effect them and whether they would join the ranks of those clinicians suffering from burnout. While the students surveyed acknowledged that artificial intelligence could have some negative repercussions, 62% were excited about its use in their education. Similarly, they anticipated the positive contribution of digital technology while acknowledging its potential downsides.

Given the current mental health climate in this country, I was not surprised that almost a quarter of medical students in this country are considering quitting school. I would like to see a larger sample surveyed and repeated over time. But, the discrepancy between the United States and the rest of the world is troubling.

The number that really jumped out at me was that 54% of medical students (nurses, 62%) viewed “ their current studies as a stepping-stone toward a broader career in health care.” As an example, the authors quoted one medical student who plans to “look for other possibilities where I don’t directly treat patients.”

Whether this disinterest in direct patient care is an attitude that preceded their entry into medical school or a change reflecting a major reversal induced by the realty of face-to-face patient encounters in school was not addressed in the survey. I think the general population would be surprised and maybe disappointed to learn that half the students in medical school weren’t planning on seeing patients.

I went off to medical school with a rather naive Norman Rockwellian view of a physician. I was a little surprised that a few of my classmates seemed to be gravitating toward administrative and research careers, but by far most of us were heading toward opportunities that would place us face to face with patients. Some would become specialists but primary care still had an appeal for many of us.

In my last letter about primary care training, I suggested that traditional medical school was probably a poor investment for the person who shares a bit of my old-school image of the primary care physician. In addition to cost and the time invested, the curriculum would likely be overly broad and deep and not terribly applicable to the patient mix he or she would eventually be seeing. This global survey may suggest that medical students have already discovered, or are just now discovering, this mismatch between medical school and the realities of primary care.

Our challenge is to first deal with deterrent of student debt and then to develop a new, affordable and efficient pathway to primary care that attracts those people who are looking for a face to face style of medicine on the front line. The patients know we need specialists and administrators but they also want a bit more of Norman Rockwell.
 

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 pdnews@mdedge.com.

I suspect that, like me, you were saddened, but maybe not shocked, to learn that firearm-related fatalities have recently surpassed motor vehicle–related fatalities as the leading cause of death among children. For those of us living in Maine, this revelation came at a particularly difficult time. The body of the presumed shooter in the Lewiston massacre was found less than 10 miles from where I am writing you this letter. There is a good chance he may have been a former patient of mine, but I no longer have access to my records to confirm that.

This reshuffling at the top of the list of mortality causes is just one example of the shifting trends that have occurred in pediatric fatality statistics. In a recent analysis of the Centers for Disease Control and Prevention statistics published in Pediatrics investigators discovered that while, in general, fatal injuries have increased over the study period (2011-2021) nonfatal injuries have decreased.

We should no longer be surprised to learn that firearm-related deaths increased more than 87%. Fatal drug poisoning was up 133% and suffocation-related deaths increased 12.5% over that 10-year period. Given this profile of fatalities, it shouldn’t surprise us that nonfatal injuries due to firearms, poisoning, and self-harm also increased.

However, nonfatal injuries in other broad categories decreased: falls were down 52.8%, overexertion 63%, struck by [something or someone] 47.3%, motor vehicle occupant 36.7%, and cut pierce 36.7%. Nonfatal drownings were unchanged.
 

Diverging trends

Fatal injuries are up and nonfatal injuries are down. What are we to make of these diverging trends? I suspect that when it comes to both firearms and drug poisonings, both fatal and nonfatal, children are now living in an environment in which the sheer volume of guns and drugs have grown the point, and will continue to grow, that contact and its consequences will continue to increase until we reach a saturation point at some unpredictable point in the future. There still may be some opportunities to curb the flow of drugs. But, I am afraid when it comes to firearms, that ship has sailed. We may have a chance to curb assault weapons, but hand guns have become ubiquitous to the point that they will continue to be a threat to children.

The increase in self-harm injuries is clearly a reflection of the increase in pediatric and adolescent mental health disturbances, which in turn is a reflection of the gloom hanging over the population in general.

But, what’s going on with the decrease in nonfatal injuries caused by falls, overexertion, struck by, and cut pierce? Is this a bit of sunshine in an otherwise cloudy picture? The authors of the paper see it as a reflection of our “public health interventions targeting pediatric safety partnered with technological advancement and legislative requirements.” Maybe when we are talking about booster seats and other automotive safety advancements. But I’m not so sure we should be too vigorous as we pat ourselves on the back.

On the other hand, aren’t these decreases in injuries related to activity just more evidence of our increasingly sedentary pediatric population? Falling off the couch seldom creates an injury that generates an ED statistic. Myopia and obesity related to excess screen time doesn’t trigger data points in this study. Overexertion injuries are down. We already know the consequences of underexertion are up.

I’m not sure we need to cut back on our efforts at injury prevention but I worry that we may run the risk of discouraging healthy activity if we aren’t careful with our voices of caution.

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 pdnews@mdedge.com.

I suspect that, like me, you were saddened, but maybe not shocked, to learn that firearm-related fatalities have recently surpassed motor vehicle–related fatalities as the leading cause of death among children. For those of us living in Maine, this revelation came at a particularly difficult time. The body of the presumed shooter in the Lewiston massacre was found less than 10 miles from where I am writing you this letter. There is a good chance he may have been a former patient of mine, but I no longer have access to my records to confirm that.

This reshuffling at the top of the list of mortality causes is just one example of the shifting trends that have occurred in pediatric fatality statistics. In a recent analysis of the Centers for Disease Control and Prevention statistics published in Pediatrics investigators discovered that while, in general, fatal injuries have increased over the study period (2011-2021) nonfatal injuries have decreased.

We should no longer be surprised to learn that firearm-related deaths increased more than 87%. Fatal drug poisoning was up 133% and suffocation-related deaths increased 12.5% over that 10-year period. Given this profile of fatalities, it shouldn’t surprise us that nonfatal injuries due to firearms, poisoning, and self-harm also increased.

However, nonfatal injuries in other broad categories decreased: falls were down 52.8%, overexertion 63%, struck by [something or someone] 47.3%, motor vehicle occupant 36.7%, and cut pierce 36.7%. Nonfatal drownings were unchanged.
 

Diverging trends

Fatal injuries are up and nonfatal injuries are down. What are we to make of these diverging trends? I suspect that when it comes to both firearms and drug poisonings, both fatal and nonfatal, children are now living in an environment in which the sheer volume of guns and drugs have grown the point, and will continue to grow, that contact and its consequences will continue to increase until we reach a saturation point at some unpredictable point in the future. There still may be some opportunities to curb the flow of drugs. But, I am afraid when it comes to firearms, that ship has sailed. We may have a chance to curb assault weapons, but hand guns have become ubiquitous to the point that they will continue to be a threat to children.

The increase in self-harm injuries is clearly a reflection of the increase in pediatric and adolescent mental health disturbances, which in turn is a reflection of the gloom hanging over the population in general.

But, what’s going on with the decrease in nonfatal injuries caused by falls, overexertion, struck by, and cut pierce? Is this a bit of sunshine in an otherwise cloudy picture? The authors of the paper see it as a reflection of our “public health interventions targeting pediatric safety partnered with technological advancement and legislative requirements.” Maybe when we are talking about booster seats and other automotive safety advancements. But I’m not so sure we should be too vigorous as we pat ourselves on the back.

On the other hand, aren’t these decreases in injuries related to activity just more evidence of our increasingly sedentary pediatric population? Falling off the couch seldom creates an injury that generates an ED statistic. Myopia and obesity related to excess screen time doesn’t trigger data points in this study. Overexertion injuries are down. We already know the consequences of underexertion are up.

I’m not sure we need to cut back on our efforts at injury prevention but I worry that we may run the risk of discouraging healthy activity if we aren’t careful with our voices of caution.

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 pdnews@mdedge.com.

I suspect that, like me, you were saddened, but maybe not shocked, to learn that firearm-related fatalities have recently surpassed motor vehicle–related fatalities as the leading cause of death among children. For those of us living in Maine, this revelation came at a particularly difficult time. The body of the presumed shooter in the Lewiston massacre was found less than 10 miles from where I am writing you this letter. There is a good chance he may have been a former patient of mine, but I no longer have access to my records to confirm that.

This reshuffling at the top of the list of mortality causes is just one example of the shifting trends that have occurred in pediatric fatality statistics. In a recent analysis of the Centers for Disease Control and Prevention statistics published in Pediatrics investigators discovered that while, in general, fatal injuries have increased over the study period (2011-2021) nonfatal injuries have decreased.

We should no longer be surprised to learn that firearm-related deaths increased more than 87%. Fatal drug poisoning was up 133% and suffocation-related deaths increased 12.5% over that 10-year period. Given this profile of fatalities, it shouldn’t surprise us that nonfatal injuries due to firearms, poisoning, and self-harm also increased.

However, nonfatal injuries in other broad categories decreased: falls were down 52.8%, overexertion 63%, struck by [something or someone] 47.3%, motor vehicle occupant 36.7%, and cut pierce 36.7%. Nonfatal drownings were unchanged.
 

Diverging trends

Fatal injuries are up and nonfatal injuries are down. What are we to make of these diverging trends? I suspect that when it comes to both firearms and drug poisonings, both fatal and nonfatal, children are now living in an environment in which the sheer volume of guns and drugs have grown the point, and will continue to grow, that contact and its consequences will continue to increase until we reach a saturation point at some unpredictable point in the future. There still may be some opportunities to curb the flow of drugs. But, I am afraid when it comes to firearms, that ship has sailed. We may have a chance to curb assault weapons, but hand guns have become ubiquitous to the point that they will continue to be a threat to children.

The increase in self-harm injuries is clearly a reflection of the increase in pediatric and adolescent mental health disturbances, which in turn is a reflection of the gloom hanging over the population in general.

But, what’s going on with the decrease in nonfatal injuries caused by falls, overexertion, struck by, and cut pierce? Is this a bit of sunshine in an otherwise cloudy picture? The authors of the paper see it as a reflection of our “public health interventions targeting pediatric safety partnered with technological advancement and legislative requirements.” Maybe when we are talking about booster seats and other automotive safety advancements. But I’m not so sure we should be too vigorous as we pat ourselves on the back.

On the other hand, aren’t these decreases in injuries related to activity just more evidence of our increasingly sedentary pediatric population? Falling off the couch seldom creates an injury that generates an ED statistic. Myopia and obesity related to excess screen time doesn’t trigger data points in this study. Overexertion injuries are down. We already know the consequences of underexertion are up.

I’m not sure we need to cut back on our efforts at injury prevention but I worry that we may run the risk of discouraging healthy activity if we aren’t careful with our voices of caution.

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 pdnews@mdedge.com.

“On which side of the bed did you get up this morning?” Obviously, your inquisitor assumes that to avoid clumsily crawling over your sleeping partner you always get up on the side with the table stacked with unread books.

You know as well as I do that you have just received a totally undisguised comment on your recent behavior that has been several shades less than cheery. You may have already sensed your own grumpiness. Do you have an explanation? Did the commute leave you with a case of unresolved road rage? Did you wake up feeling unrested? How often does that happen? Do you think you are getting enough sleep?

A few weeks ago I wrote a Letters From Maine column in which I shared a study suggesting that the regularity of an individual’s sleep pattern may, in many cases, be more important than his or her total number of hours slept. In that same column I wrote that sleep scientists don’t as yet have a good definition of sleep irregularity, nor can they give us any more than a broad range for the total number of hours a person needs to maintain wellness.

How do you determine whether you are getting enough sleep? Do you keep a chart of how many times you were asked which side of the bed you got up on in a week? Or is it how you feel in the morning? Is it when you instantly doze off any time you sit down in a quiet place?

Although many adults are clueless (or in denial) that they are sleep deprived, generally if you ask them and take a brief history they will tell you. On the other hand, determining when a child, particularly one who is preverbal, is sleep deprived is a bit more difficult. Asking the patient isn’t going to give you the answer. You must rely on parental observations. And, to some extent, this can be difficult because parents are, by definition, learning on the job. They may not realize the symptoms and behaviors they are seeing in their child are the result of sleep deficiency.

Over the last half century of observing children, I have developed a very low threshold for diagnosing sleep deprivation. Basically, any child who is cranky and not obviously sick is overtired until proven otherwise. For example, colic does not appear on my frequently used, or in fact ever used, list of diagnoses. Colicky is an adjective that I may use to describe some episodic pain or behavior, but colic as a working diagnosis? Never.

When presented with a child who has already been diagnosed with “colic” by its aunt or the lady next door, this is when the astute pediatrician must be at his or her best. If a thorough history, including sleep pattern, yields no obvious evidence of illness, the next step should be some sleep coaching. However, this is where the “until proven otherwise” thing becomes important, because not providing close follow-up and continuing to keep an open mind for the less likely coexisting conditions can be dangerous and certainly not in the patient’s best interest.

For the older child crankiness, temper tantrums, mood disorders and signs and symptoms often (some might say too often) associated with attention-deficit disorder should trigger an immediate investigation of sleep habits and appropriate advice. Less well-known conditions associated with sleep deprivation are migraine and nocturnal leg pains, often mislabeled as growing pains.

The physicians planning on using sleep as a therapeutic modality is going to quickly run into several challenges. First is convincing the parents, the patient, and the family that the condition is to a greater or lesser degree the result of sleep deprivation. Because sleep is still underappreciated as a component of wellness, this is often not an easy sell.

Second, everyone must accept that altering sleep patterns regardless of age is often not easy and will not be achieved in 1 night or 2. Keeping up the drumbeat of encouragement with close follow-up is critical. Parents must be continually reminded that sleep is being used as a medicine and the dose is not measured in hours. The improvement in symptoms will tell us when enough is enough.

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 pdnews@mdedge.com.

“On which side of the bed did you get up this morning?” Obviously, your inquisitor assumes that to avoid clumsily crawling over your sleeping partner you always get up on the side with the table stacked with unread books.

You know as well as I do that you have just received a totally undisguised comment on your recent behavior that has been several shades less than cheery. You may have already sensed your own grumpiness. Do you have an explanation? Did the commute leave you with a case of unresolved road rage? Did you wake up feeling unrested? How often does that happen? Do you think you are getting enough sleep?

A few weeks ago I wrote a Letters From Maine column in which I shared a study suggesting that the regularity of an individual’s sleep pattern may, in many cases, be more important than his or her total number of hours slept. In that same column I wrote that sleep scientists don’t as yet have a good definition of sleep irregularity, nor can they give us any more than a broad range for the total number of hours a person needs to maintain wellness.

How do you determine whether you are getting enough sleep? Do you keep a chart of how many times you were asked which side of the bed you got up on in a week? Or is it how you feel in the morning? Is it when you instantly doze off any time you sit down in a quiet place?

Although many adults are clueless (or in denial) that they are sleep deprived, generally if you ask them and take a brief history they will tell you. On the other hand, determining when a child, particularly one who is preverbal, is sleep deprived is a bit more difficult. Asking the patient isn’t going to give you the answer. You must rely on parental observations. And, to some extent, this can be difficult because parents are, by definition, learning on the job. They may not realize the symptoms and behaviors they are seeing in their child are the result of sleep deficiency.

Over the last half century of observing children, I have developed a very low threshold for diagnosing sleep deprivation. Basically, any child who is cranky and not obviously sick is overtired until proven otherwise. For example, colic does not appear on my frequently used, or in fact ever used, list of diagnoses. Colicky is an adjective that I may use to describe some episodic pain or behavior, but colic as a working diagnosis? Never.

When presented with a child who has already been diagnosed with “colic” by its aunt or the lady next door, this is when the astute pediatrician must be at his or her best. If a thorough history, including sleep pattern, yields no obvious evidence of illness, the next step should be some sleep coaching. However, this is where the “until proven otherwise” thing becomes important, because not providing close follow-up and continuing to keep an open mind for the less likely coexisting conditions can be dangerous and certainly not in the patient’s best interest.

For the older child crankiness, temper tantrums, mood disorders and signs and symptoms often (some might say too often) associated with attention-deficit disorder should trigger an immediate investigation of sleep habits and appropriate advice. Less well-known conditions associated with sleep deprivation are migraine and nocturnal leg pains, often mislabeled as growing pains.

The physicians planning on using sleep as a therapeutic modality is going to quickly run into several challenges. First is convincing the parents, the patient, and the family that the condition is to a greater or lesser degree the result of sleep deprivation. Because sleep is still underappreciated as a component of wellness, this is often not an easy sell.

Second, everyone must accept that altering sleep patterns regardless of age is often not easy and will not be achieved in 1 night or 2. Keeping up the drumbeat of encouragement with close follow-up is critical. Parents must be continually reminded that sleep is being used as a medicine and the dose is not measured in hours. The improvement in symptoms will tell us when enough is enough.

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 pdnews@mdedge.com.

“On which side of the bed did you get up this morning?” Obviously, your inquisitor assumes that to avoid clumsily crawling over your sleeping partner you always get up on the side with the table stacked with unread books.

You know as well as I do that you have just received a totally undisguised comment on your recent behavior that has been several shades less than cheery. You may have already sensed your own grumpiness. Do you have an explanation? Did the commute leave you with a case of unresolved road rage? Did you wake up feeling unrested? How often does that happen? Do you think you are getting enough sleep?

A few weeks ago I wrote a Letters From Maine column in which I shared a study suggesting that the regularity of an individual’s sleep pattern may, in many cases, be more important than his or her total number of hours slept. In that same column I wrote that sleep scientists don’t as yet have a good definition of sleep irregularity, nor can they give us any more than a broad range for the total number of hours a person needs to maintain wellness.

How do you determine whether you are getting enough sleep? Do you keep a chart of how many times you were asked which side of the bed you got up on in a week? Or is it how you feel in the morning? Is it when you instantly doze off any time you sit down in a quiet place?

Although many adults are clueless (or in denial) that they are sleep deprived, generally if you ask them and take a brief history they will tell you. On the other hand, determining when a child, particularly one who is preverbal, is sleep deprived is a bit more difficult. Asking the patient isn’t going to give you the answer. You must rely on parental observations. And, to some extent, this can be difficult because parents are, by definition, learning on the job. They may not realize the symptoms and behaviors they are seeing in their child are the result of sleep deficiency.

Over the last half century of observing children, I have developed a very low threshold for diagnosing sleep deprivation. Basically, any child who is cranky and not obviously sick is overtired until proven otherwise. For example, colic does not appear on my frequently used, or in fact ever used, list of diagnoses. Colicky is an adjective that I may use to describe some episodic pain or behavior, but colic as a working diagnosis? Never.

When presented with a child who has already been diagnosed with “colic” by its aunt or the lady next door, this is when the astute pediatrician must be at his or her best. If a thorough history, including sleep pattern, yields no obvious evidence of illness, the next step should be some sleep coaching. However, this is where the “until proven otherwise” thing becomes important, because not providing close follow-up and continuing to keep an open mind for the less likely coexisting conditions can be dangerous and certainly not in the patient’s best interest.

For the older child crankiness, temper tantrums, mood disorders and signs and symptoms often (some might say too often) associated with attention-deficit disorder should trigger an immediate investigation of sleep habits and appropriate advice. Less well-known conditions associated with sleep deprivation are migraine and nocturnal leg pains, often mislabeled as growing pains.

The physicians planning on using sleep as a therapeutic modality is going to quickly run into several challenges. First is convincing the parents, the patient, and the family that the condition is to a greater or lesser degree the result of sleep deprivation. Because sleep is still underappreciated as a component of wellness, this is often not an easy sell.

Second, everyone must accept that altering sleep patterns regardless of age is often not easy and will not be achieved in 1 night or 2. Keeping up the drumbeat of encouragement with close follow-up is critical. Parents must be continually reminded that sleep is being used as a medicine and the dose is not measured in hours. The improvement in symptoms will tell us when enough is enough.

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 pdnews@mdedge.com.

I, like every pediatrician I know, believe that breast milk is the best nutrition for human newborns. Its balance of nutritive elements and its role in preventing of a wide range of illnesses are so great that we are still learning the extent of their magnitude. It just makes sense that a mother’s milk is most well suited for her baby.

I am a bit less unambiguous about breastfeeding. By that I mean the process of providing breast milk to an infant directly from its mother’s breast. Before you yank my AAP membership card, let me make it clear that I think every woman should consider breastfeeding her infant. But we must accept that in a few situations, even with help from caring and enlightened health care providers and family members, breastfeeding doesn’t work as well as we would have hoped. Fortunately, there are alternatives.

My reservations about the process are few, and until recently I have had an unwaveringly positive attitude toward the safety of breast milk. The cause of my little bit of uncertainty arrived in a recent study by two researchers at the Dana Farber Institute in Boston, in which the investigators examining the health histories of more than 150,000 women found that those who were breastfed incurred a 23% greater risk of developing colorectal cancer when they reached adulthood. A younger cohort within that larger group had a dramatic 40% increased risk of developing high-risk cancer before reaching age 55.

The population the investigators studied came from the large Nurses’ Health Study II, a well-known repository of longitudinal health data. The researchers reported that they included biometric data and a large collection of lifestyle factors including smoking, alcohol intake, and diet in their calculations. However, breastfeeding continued to register the highest association. Interestingly, the investigators found that women who were breastfed for 9 months or longer had twice the risk of colorectal cancer as those who breastfed for from 4 to 8 months.

The study population was all women and predominantly white. However, in the general population it is the non-Hispanic white population that is experiencing the greatest increase in incidence. Of course, the study could not answer whether this association with breastfeeding also existed in minority populations.

The researchers suspect that what they are seeing is a reflection of the Westernization of the American lifestyle. One of the researchers is interested in the gut biome of infants and plans to further the investigation in that direction. Could some substance from the environment be concentrating in breast milk? Or is something missing in breast milk? She points out that, while formulas are generally fortified with vitamin D, breast milk is not.

As concerning as the results of this study may sound, the authors are very careful to urge mothers to continue to breastfeed and choose it as their first choice for feeding their babies. I have been pleasantly surprised that this study has not gotten widespread media attention because bad news travels fast. I have chosen to share it with you because at some point you may begin getting questions from concerned parents.

While apparently well done, this study is just the beginning. Like any good research, it poses more questions than it answers. For us as pediatricians it means we should continue to recommend breast milk as the first food. But, we must stay alert as further research looks deeper into this association.

We should also take advantage of our special access to young parents, a demographic that less frequently sees a physician for preventive care. For whatever reason colorectal cancer is occurring at younger ages. When we have the opportunity we should be reminding 40-year-olds not to wait until age 50 to screen for colorectal cancer, particularly if they have a family history of the disease.

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 pdnews@mdedge.com.

I, like every pediatrician I know, believe that breast milk is the best nutrition for human newborns. Its balance of nutritive elements and its role in preventing of a wide range of illnesses are so great that we are still learning the extent of their magnitude. It just makes sense that a mother’s milk is most well suited for her baby.

I am a bit less unambiguous about breastfeeding. By that I mean the process of providing breast milk to an infant directly from its mother’s breast. Before you yank my AAP membership card, let me make it clear that I think every woman should consider breastfeeding her infant. But we must accept that in a few situations, even with help from caring and enlightened health care providers and family members, breastfeeding doesn’t work as well as we would have hoped. Fortunately, there are alternatives.

My reservations about the process are few, and until recently I have had an unwaveringly positive attitude toward the safety of breast milk. The cause of my little bit of uncertainty arrived in a recent study by two researchers at the Dana Farber Institute in Boston, in which the investigators examining the health histories of more than 150,000 women found that those who were breastfed incurred a 23% greater risk of developing colorectal cancer when they reached adulthood. A younger cohort within that larger group had a dramatic 40% increased risk of developing high-risk cancer before reaching age 55.

The population the investigators studied came from the large Nurses’ Health Study II, a well-known repository of longitudinal health data. The researchers reported that they included biometric data and a large collection of lifestyle factors including smoking, alcohol intake, and diet in their calculations. However, breastfeeding continued to register the highest association. Interestingly, the investigators found that women who were breastfed for 9 months or longer had twice the risk of colorectal cancer as those who breastfed for from 4 to 8 months.

The study population was all women and predominantly white. However, in the general population it is the non-Hispanic white population that is experiencing the greatest increase in incidence. Of course, the study could not answer whether this association with breastfeeding also existed in minority populations.

The researchers suspect that what they are seeing is a reflection of the Westernization of the American lifestyle. One of the researchers is interested in the gut biome of infants and plans to further the investigation in that direction. Could some substance from the environment be concentrating in breast milk? Or is something missing in breast milk? She points out that, while formulas are generally fortified with vitamin D, breast milk is not.

As concerning as the results of this study may sound, the authors are very careful to urge mothers to continue to breastfeed and choose it as their first choice for feeding their babies. I have been pleasantly surprised that this study has not gotten widespread media attention because bad news travels fast. I have chosen to share it with you because at some point you may begin getting questions from concerned parents.

While apparently well done, this study is just the beginning. Like any good research, it poses more questions than it answers. For us as pediatricians it means we should continue to recommend breast milk as the first food. But, we must stay alert as further research looks deeper into this association.

We should also take advantage of our special access to young parents, a demographic that less frequently sees a physician for preventive care. For whatever reason colorectal cancer is occurring at younger ages. When we have the opportunity we should be reminding 40-year-olds not to wait until age 50 to screen for colorectal cancer, particularly if they have a family history of the disease.

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 pdnews@mdedge.com.

I, like every pediatrician I know, believe that breast milk is the best nutrition for human newborns. Its balance of nutritive elements and its role in preventing of a wide range of illnesses are so great that we are still learning the extent of their magnitude. It just makes sense that a mother’s milk is most well suited for her baby.

I am a bit less unambiguous about breastfeeding. By that I mean the process of providing breast milk to an infant directly from its mother’s breast. Before you yank my AAP membership card, let me make it clear that I think every woman should consider breastfeeding her infant. But we must accept that in a few situations, even with help from caring and enlightened health care providers and family members, breastfeeding doesn’t work as well as we would have hoped. Fortunately, there are alternatives.

My reservations about the process are few, and until recently I have had an unwaveringly positive attitude toward the safety of breast milk. The cause of my little bit of uncertainty arrived in a recent study by two researchers at the Dana Farber Institute in Boston, in which the investigators examining the health histories of more than 150,000 women found that those who were breastfed incurred a 23% greater risk of developing colorectal cancer when they reached adulthood. A younger cohort within that larger group had a dramatic 40% increased risk of developing high-risk cancer before reaching age 55.

The population the investigators studied came from the large Nurses’ Health Study II, a well-known repository of longitudinal health data. The researchers reported that they included biometric data and a large collection of lifestyle factors including smoking, alcohol intake, and diet in their calculations. However, breastfeeding continued to register the highest association. Interestingly, the investigators found that women who were breastfed for 9 months or longer had twice the risk of colorectal cancer as those who breastfed for from 4 to 8 months.

The study population was all women and predominantly white. However, in the general population it is the non-Hispanic white population that is experiencing the greatest increase in incidence. Of course, the study could not answer whether this association with breastfeeding also existed in minority populations.

The researchers suspect that what they are seeing is a reflection of the Westernization of the American lifestyle. One of the researchers is interested in the gut biome of infants and plans to further the investigation in that direction. Could some substance from the environment be concentrating in breast milk? Or is something missing in breast milk? She points out that, while formulas are generally fortified with vitamin D, breast milk is not.

As concerning as the results of this study may sound, the authors are very careful to urge mothers to continue to breastfeed and choose it as their first choice for feeding their babies. I have been pleasantly surprised that this study has not gotten widespread media attention because bad news travels fast. I have chosen to share it with you because at some point you may begin getting questions from concerned parents.

While apparently well done, this study is just the beginning. Like any good research, it poses more questions than it answers. For us as pediatricians it means we should continue to recommend breast milk as the first food. But, we must stay alert as further research looks deeper into this association.

We should also take advantage of our special access to young parents, a demographic that less frequently sees a physician for preventive care. For whatever reason colorectal cancer is occurring at younger ages. When we have the opportunity we should be reminding 40-year-olds not to wait until age 50 to screen for colorectal cancer, particularly if they have a family history of the disease.

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 pdnews@mdedge.com.

This country faces a broad and frightening rogues’ gallery of challenges to its health. From the recent revelation that gunshots are the leading cause of death in children to the opioid epidemic to the overworked and discouraged health care providers, the crises are so numerous it is hard to choose where we should be investing what little political will we can muster. And, where do these disasters fit against a landscape raked by natural and climate change–triggered catastrophes? How do we even begin to triage our vocabulary as we are trying to label them?

The lead article in October’s journal Pediatrics makes a heroic effort to place pediatric obesity into this pantheon of health disasters. The authors of this Pediatrics Perspective ask a simple question: Should the United States declare pediatric obesity a public health emergency? They have wisely chosen to narrow the question to the pediatric population as being a more realistic target and one that is more likely to pay bigger dividends over time.

While acknowledging that obesity prevention strategies have been largely ineffective to this point, the authors are also concerned that despite the promising development of treatment strategies, the rollout of these therapies is likely to be uneven because of funding and disparities in health care delivery.

After reviewing pros and cons for an emergency declaration, they came to the conclusion that despite the scope of the problem and the fact that health emergencies have been declared for conditions effecting fewer individuals, now is not the time. The authors observed that a declaration may serve only to hype “the problem without offering tangible solutions.” Even when as yet to be discovered effective therapies become available, the time lag before measurable improvement is likely to be so delayed that “catastrophizing” pediatric obesity may be just another exercise in wolf-crying.
 

A closer look

While I applaud the authors for their courage in addressing this question and their decision to discourage an emergency declaration, a few of their observations deserve a closer look. First, they are legitimately concerned that any health policy must be careful not to further perpetuate the stigmatization of children with obesity. However, they feel the recognition by all stakeholders “that obesity is a genetically and biologically driven disease are essential.” While I have supported the disease designation as a pragmatic strategy to move things forward, I would prefer their statement to read “obesity can be ... “ I don’t think we have mined the data deep enough to determine how many out of a cohort of a million obese children from across a wide span of socioeconomic strata have become obese primarily as a result of decisions made by school departments, parents, and governmental entities – all of which had the resources to make healthier decisions but failed to do so.

While a majority of the population may believe that obesity is a “condition of choice,” I think they would be more likely to support the political will for action if they saw data that acknowledges that yes, obesity can be a condition of choice, but here are the circumstances in which choice can and can’t make a difference. Language must always be chosen carefully to minimize stigmatization. However, remember we are not pointing fingers at victims; we are instead looking for teaching moments in which adults can learn to make better choices for the children under their care who are too young to make their own.

Finally, as the authors of this Pediatric Perspectives considered cons of a declaration of health care emergency, they raised the peculiarly American concern of personal autonomy. As they pointed out, there are unfortunate examples in this country in which efforts to limit personal choice have backfired and well-meaning and potentially effective methods for limiting unhealthy behaviors have been eliminated in the name of personal freedom. I’m not sure how we manage this except to wait and be judicious as we move forward addressing pediatric obesity on a national scale. I urge you to take a few minutes to read this perspective. It is a topic worth considering.
 

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 pdnews@mdedge.com.

This country faces a broad and frightening rogues’ gallery of challenges to its health. From the recent revelation that gunshots are the leading cause of death in children to the opioid epidemic to the overworked and discouraged health care providers, the crises are so numerous it is hard to choose where we should be investing what little political will we can muster. And, where do these disasters fit against a landscape raked by natural and climate change–triggered catastrophes? How do we even begin to triage our vocabulary as we are trying to label them?

The lead article in October’s journal Pediatrics makes a heroic effort to place pediatric obesity into this pantheon of health disasters. The authors of this Pediatrics Perspective ask a simple question: Should the United States declare pediatric obesity a public health emergency? They have wisely chosen to narrow the question to the pediatric population as being a more realistic target and one that is more likely to pay bigger dividends over time.

While acknowledging that obesity prevention strategies have been largely ineffective to this point, the authors are also concerned that despite the promising development of treatment strategies, the rollout of these therapies is likely to be uneven because of funding and disparities in health care delivery.

After reviewing pros and cons for an emergency declaration, they came to the conclusion that despite the scope of the problem and the fact that health emergencies have been declared for conditions effecting fewer individuals, now is not the time. The authors observed that a declaration may serve only to hype “the problem without offering tangible solutions.” Even when as yet to be discovered effective therapies become available, the time lag before measurable improvement is likely to be so delayed that “catastrophizing” pediatric obesity may be just another exercise in wolf-crying.
 

A closer look

While I applaud the authors for their courage in addressing this question and their decision to discourage an emergency declaration, a few of their observations deserve a closer look. First, they are legitimately concerned that any health policy must be careful not to further perpetuate the stigmatization of children with obesity. However, they feel the recognition by all stakeholders “that obesity is a genetically and biologically driven disease are essential.” While I have supported the disease designation as a pragmatic strategy to move things forward, I would prefer their statement to read “obesity can be ... “ I don’t think we have mined the data deep enough to determine how many out of a cohort of a million obese children from across a wide span of socioeconomic strata have become obese primarily as a result of decisions made by school departments, parents, and governmental entities – all of which had the resources to make healthier decisions but failed to do so.

While a majority of the population may believe that obesity is a “condition of choice,” I think they would be more likely to support the political will for action if they saw data that acknowledges that yes, obesity can be a condition of choice, but here are the circumstances in which choice can and can’t make a difference. Language must always be chosen carefully to minimize stigmatization. However, remember we are not pointing fingers at victims; we are instead looking for teaching moments in which adults can learn to make better choices for the children under their care who are too young to make their own.

Finally, as the authors of this Pediatric Perspectives considered cons of a declaration of health care emergency, they raised the peculiarly American concern of personal autonomy. As they pointed out, there are unfortunate examples in this country in which efforts to limit personal choice have backfired and well-meaning and potentially effective methods for limiting unhealthy behaviors have been eliminated in the name of personal freedom. I’m not sure how we manage this except to wait and be judicious as we move forward addressing pediatric obesity on a national scale. I urge you to take a few minutes to read this perspective. It is a topic worth considering.
 

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 pdnews@mdedge.com.

This country faces a broad and frightening rogues’ gallery of challenges to its health. From the recent revelation that gunshots are the leading cause of death in children to the opioid epidemic to the overworked and discouraged health care providers, the crises are so numerous it is hard to choose where we should be investing what little political will we can muster. And, where do these disasters fit against a landscape raked by natural and climate change–triggered catastrophes? How do we even begin to triage our vocabulary as we are trying to label them?

The lead article in October’s journal Pediatrics makes a heroic effort to place pediatric obesity into this pantheon of health disasters. The authors of this Pediatrics Perspective ask a simple question: Should the United States declare pediatric obesity a public health emergency? They have wisely chosen to narrow the question to the pediatric population as being a more realistic target and one that is more likely to pay bigger dividends over time.

While acknowledging that obesity prevention strategies have been largely ineffective to this point, the authors are also concerned that despite the promising development of treatment strategies, the rollout of these therapies is likely to be uneven because of funding and disparities in health care delivery.

After reviewing pros and cons for an emergency declaration, they came to the conclusion that despite the scope of the problem and the fact that health emergencies have been declared for conditions effecting fewer individuals, now is not the time. The authors observed that a declaration may serve only to hype “the problem without offering tangible solutions.” Even when as yet to be discovered effective therapies become available, the time lag before measurable improvement is likely to be so delayed that “catastrophizing” pediatric obesity may be just another exercise in wolf-crying.
 

A closer look

While I applaud the authors for their courage in addressing this question and their decision to discourage an emergency declaration, a few of their observations deserve a closer look. First, they are legitimately concerned that any health policy must be careful not to further perpetuate the stigmatization of children with obesity. However, they feel the recognition by all stakeholders “that obesity is a genetically and biologically driven disease are essential.” While I have supported the disease designation as a pragmatic strategy to move things forward, I would prefer their statement to read “obesity can be ... “ I don’t think we have mined the data deep enough to determine how many out of a cohort of a million obese children from across a wide span of socioeconomic strata have become obese primarily as a result of decisions made by school departments, parents, and governmental entities – all of which had the resources to make healthier decisions but failed to do so.

While a majority of the population may believe that obesity is a “condition of choice,” I think they would be more likely to support the political will for action if they saw data that acknowledges that yes, obesity can be a condition of choice, but here are the circumstances in which choice can and can’t make a difference. Language must always be chosen carefully to minimize stigmatization. However, remember we are not pointing fingers at victims; we are instead looking for teaching moments in which adults can learn to make better choices for the children under their care who are too young to make their own.

Finally, as the authors of this Pediatric Perspectives considered cons of a declaration of health care emergency, they raised the peculiarly American concern of personal autonomy. As they pointed out, there are unfortunate examples in this country in which efforts to limit personal choice have backfired and well-meaning and potentially effective methods for limiting unhealthy behaviors have been eliminated in the name of personal freedom. I’m not sure how we manage this except to wait and be judicious as we move forward addressing pediatric obesity on a national scale. I urge you to take a few minutes to read this perspective. It is a topic worth considering.
 

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 pdnews@mdedge.com.

In discussions between health care providers and patients, the words “regularity” and “irregularity” come up primarily in reference to either constipation or menstrual cycles. However, the participants in a recent panel convened by the National Sleep Foundation think we should also be discussing irregularity when we are discussing sleep with our patients.

The sleep experts on the panel began by considering 40,000 papers that directly or tangentially dealt with the topic of irregular sleep patterns. The reviewers uncovered numerous references to an association between sleep irregularity and a wide variety of adverse health outcomes, including obesity and metabolic disorders, hypertension and other cardiovascular disorders, and elevations in several inflammatory markers. Not surprisingly, the investigators also found an abundance of references supporting an association between irregular sleep and a suite of mental health problems, including depression, mood disorders, lower self esteem, poor academic performance, and deficits in attention. For example, several of the studies the panel reviewed found that in college students, GPA was lower when their sleep pattern was irregular. There were some papers that found no significant association between irregular sleep and other adverse health outcomes, but none of the studies demonstrated an association with better or improved health outcomes.

There is currently no universally accepted definition of an irregular sleep pattern. The experts pointed to some papers that used a standard deviation of 1 hour from the patient’s usual bed time determined by averaging over an interval measured in weeks. You and I shouldn’t be surprised that irregular sleep is unhealthy, but the breadth of the panel’s findings is impressive.

Although it has been long in coming, sleep is finally beginning to get some attention by the media. The focus is usually on the optimal number of hours we need each night. This panel’s findings suggest that total sleep time is only part of the story, and may even be less important than the regularity of our sleep patterns.

For those of us in pediatrics, the place where irregularity raises its ugly head is with teenagers and weekends. Although the numbers are far from clear, the question remains of how effective is catch-up sleep after a week of too-early mornings and too-late bedtimes for the chronically under-slept adolescent.

In some studies in which patients had the demonstrable effects of sleep deprivation (e.g., metabolic and cardiovascular) there was some improvement when weekend sleep was extended by 1 or 2 hours, but none beyond 2 hours.

The panel’s findings, while certainly significant, merely add weight and nuance to the existing evidence of importance of sleep and the damage done by sleep deprivation. As one of the panel members has said, “Sleep is the third pillar of health, equally important as diet and exercise, if not more.” However, this message is not getting out, or at least it is not being heeded. Like obesity, our efforts as advisers to our patients isn’t working. Unfortunately, this is because our advice is often whispered and given halfheartedly.

There was some evidence of improvement as a result of the pandemic, when those fortunate enough to be able to work from home were taking advantage of the flexibility in their schedules and getting more sleep. But health care providers certainly can’t take responsibility for what was an accident of nature.

Those of you who have been reading Letters from Maine for the last 3 decades may tire of my beating the tired horse of sleep deprivation. But I will not be deterred. I see very little evidence among health care professionals in taking the importance of sleep seriously. Sure, they may include it buried in the list of potential contributors to their patient’s complaint, but I see very little effort to move it higher on their list of priorities and almost no movement toward making substantive recommendations and then reinforcing them with follow-up.

Like obesity, sleep deprivation is a societal problem. We can lay some of the blame on Thomas Edison, but until we as health care professionals take sleep deprivation seriously, we will be undertreating and mistreating our patients who would benefit from a serious discussion of their sleep habits. Until that time you will continue to read columns like this one when I encounter significant studies on the importance of sleep.

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 pdnews@mdedge.com.

In discussions between health care providers and patients, the words “regularity” and “irregularity” come up primarily in reference to either constipation or menstrual cycles. However, the participants in a recent panel convened by the National Sleep Foundation think we should also be discussing irregularity when we are discussing sleep with our patients.

The sleep experts on the panel began by considering 40,000 papers that directly or tangentially dealt with the topic of irregular sleep patterns. The reviewers uncovered numerous references to an association between sleep irregularity and a wide variety of adverse health outcomes, including obesity and metabolic disorders, hypertension and other cardiovascular disorders, and elevations in several inflammatory markers. Not surprisingly, the investigators also found an abundance of references supporting an association between irregular sleep and a suite of mental health problems, including depression, mood disorders, lower self esteem, poor academic performance, and deficits in attention. For example, several of the studies the panel reviewed found that in college students, GPA was lower when their sleep pattern was irregular. There were some papers that found no significant association between irregular sleep and other adverse health outcomes, but none of the studies demonstrated an association with better or improved health outcomes.

There is currently no universally accepted definition of an irregular sleep pattern. The experts pointed to some papers that used a standard deviation of 1 hour from the patient’s usual bed time determined by averaging over an interval measured in weeks. You and I shouldn’t be surprised that irregular sleep is unhealthy, but the breadth of the panel’s findings is impressive.

Although it has been long in coming, sleep is finally beginning to get some attention by the media. The focus is usually on the optimal number of hours we need each night. This panel’s findings suggest that total sleep time is only part of the story, and may even be less important than the regularity of our sleep patterns.

For those of us in pediatrics, the place where irregularity raises its ugly head is with teenagers and weekends. Although the numbers are far from clear, the question remains of how effective is catch-up sleep after a week of too-early mornings and too-late bedtimes for the chronically under-slept adolescent.

In some studies in which patients had the demonstrable effects of sleep deprivation (e.g., metabolic and cardiovascular) there was some improvement when weekend sleep was extended by 1 or 2 hours, but none beyond 2 hours.

The panel’s findings, while certainly significant, merely add weight and nuance to the existing evidence of importance of sleep and the damage done by sleep deprivation. As one of the panel members has said, “Sleep is the third pillar of health, equally important as diet and exercise, if not more.” However, this message is not getting out, or at least it is not being heeded. Like obesity, our efforts as advisers to our patients isn’t working. Unfortunately, this is because our advice is often whispered and given halfheartedly.

There was some evidence of improvement as a result of the pandemic, when those fortunate enough to be able to work from home were taking advantage of the flexibility in their schedules and getting more sleep. But health care providers certainly can’t take responsibility for what was an accident of nature.

Those of you who have been reading Letters from Maine for the last 3 decades may tire of my beating the tired horse of sleep deprivation. But I will not be deterred. I see very little evidence among health care professionals in taking the importance of sleep seriously. Sure, they may include it buried in the list of potential contributors to their patient’s complaint, but I see very little effort to move it higher on their list of priorities and almost no movement toward making substantive recommendations and then reinforcing them with follow-up.

Like obesity, sleep deprivation is a societal problem. We can lay some of the blame on Thomas Edison, but until we as health care professionals take sleep deprivation seriously, we will be undertreating and mistreating our patients who would benefit from a serious discussion of their sleep habits. Until that time you will continue to read columns like this one when I encounter significant studies on the importance of sleep.

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 pdnews@mdedge.com.

In discussions between health care providers and patients, the words “regularity” and “irregularity” come up primarily in reference to either constipation or menstrual cycles. However, the participants in a recent panel convened by the National Sleep Foundation think we should also be discussing irregularity when we are discussing sleep with our patients.

The sleep experts on the panel began by considering 40,000 papers that directly or tangentially dealt with the topic of irregular sleep patterns. The reviewers uncovered numerous references to an association between sleep irregularity and a wide variety of adverse health outcomes, including obesity and metabolic disorders, hypertension and other cardiovascular disorders, and elevations in several inflammatory markers. Not surprisingly, the investigators also found an abundance of references supporting an association between irregular sleep and a suite of mental health problems, including depression, mood disorders, lower self esteem, poor academic performance, and deficits in attention. For example, several of the studies the panel reviewed found that in college students, GPA was lower when their sleep pattern was irregular. There were some papers that found no significant association between irregular sleep and other adverse health outcomes, but none of the studies demonstrated an association with better or improved health outcomes.

There is currently no universally accepted definition of an irregular sleep pattern. The experts pointed to some papers that used a standard deviation of 1 hour from the patient’s usual bed time determined by averaging over an interval measured in weeks. You and I shouldn’t be surprised that irregular sleep is unhealthy, but the breadth of the panel’s findings is impressive.

Although it has been long in coming, sleep is finally beginning to get some attention by the media. The focus is usually on the optimal number of hours we need each night. This panel’s findings suggest that total sleep time is only part of the story, and may even be less important than the regularity of our sleep patterns.

For those of us in pediatrics, the place where irregularity raises its ugly head is with teenagers and weekends. Although the numbers are far from clear, the question remains of how effective is catch-up sleep after a week of too-early mornings and too-late bedtimes for the chronically under-slept adolescent.

In some studies in which patients had the demonstrable effects of sleep deprivation (e.g., metabolic and cardiovascular) there was some improvement when weekend sleep was extended by 1 or 2 hours, but none beyond 2 hours.

The panel’s findings, while certainly significant, merely add weight and nuance to the existing evidence of importance of sleep and the damage done by sleep deprivation. As one of the panel members has said, “Sleep is the third pillar of health, equally important as diet and exercise, if not more.” However, this message is not getting out, or at least it is not being heeded. Like obesity, our efforts as advisers to our patients isn’t working. Unfortunately, this is because our advice is often whispered and given halfheartedly.

There was some evidence of improvement as a result of the pandemic, when those fortunate enough to be able to work from home were taking advantage of the flexibility in their schedules and getting more sleep. But health care providers certainly can’t take responsibility for what was an accident of nature.

Those of you who have been reading Letters from Maine for the last 3 decades may tire of my beating the tired horse of sleep deprivation. But I will not be deterred. I see very little evidence among health care professionals in taking the importance of sleep seriously. Sure, they may include it buried in the list of potential contributors to their patient’s complaint, but I see very little effort to move it higher on their list of priorities and almost no movement toward making substantive recommendations and then reinforcing them with follow-up.

Like obesity, sleep deprivation is a societal problem. We can lay some of the blame on Thomas Edison, but until we as health care professionals take sleep deprivation seriously, we will be undertreating and mistreating our patients who would benefit from a serious discussion of their sleep habits. Until that time you will continue to read columns like this one when I encounter significant studies on the importance of sleep.

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 pdnews@mdedge.com.

“The doctor won’t see you now.”

The editor of the alumni magazine had succeeded in getting my attention. The shock value of the headline hooked me and I was drawn in to chase down the research. A study by a team of researchers at Harvard Medical School has published a study in the British Medical Journal revealing that “from 2013 to 2019 the share of U.S. health care visits delivered by nonphysicians such as nurse practitioners or physician assistants increased from 14% to 26%.” In other words, at more than a quarter of the health care visits in this country the patient is not seen by a physician. The percent seen by advanced-practice providers varied by complaint and specialty. For example, 47% of patients with a respiratory complaint saw a nurse practitioner or physicians assistant, while for an eye condition only 13% were seen by an advanced-practice provider. However, overall the increase was dramatic.

It doesn’t require much deep thinking to come up with some explanations for this shift in provider involvement. It boils down to supply and demand. Compared with other similar nations, we have fewer physicians. Physicians are leaving the profession for a variety of reasons, including disappointment with their work-life balance and a sense that too much of their day is devoted to meaningless work with user unfriendly computer systems.

The number of nurse practitioners and physician assistants is growing faster than that of physicians. In fact it has been predicted that over the next 2 decades advanced-practice providers will increase by more than 50% while the physician pool will grow by less than 5%.

We can mull over the how-we-got-here ad infinitum, but this recent study suggests that we had better hustle and invest some time rethinking the role of a physician and how we should adapt our education system to better prepare for those choosing the path through medical school. This mirror gazing is particularly critical for those of us doing primary care.

While in years past I often heard a discontented grumble from patients that “I was ‘only’ seen by the nurse practitioner,” this complaint has become much less frequent as patients have gained more experience with advanced-practice providers and have begun to accept the new reality and see the change as inevitable.

When someone tells me that their daughter or nephew or second cousin is planning on becoming a doctor, I pause and listen patiently as they go on proudly about it before asking if the young person has considered becoming a physician assistant. I say, “Ya know, if I were 60 years younger I think I would bypass medical school and become a nurse practitioner because they get to do all the cool things that I enjoyed about seeing patients. Sure, my mother wouldn’t have been able to introduce me as her son the doctor. But, my parents and I would have spent less time and money on my training, and I would have had less administrative hassle heaped on me once I went into practice.”

The essence of good primary care is Availability, Continuity, and Expertise. The first two attributes aren’t taught in medical school and rely on commitment and having enough bodies to deliver the care. When it comes to expertise, how important is the broad and deep education of traditional medical school when the provider is seeing the relatively narrow spectrum of bread-and-butter everyday complaints that fill the day for most primary care providers? Particularly, when the population has already been preselected by age, geography, and socioeconomic factors.

The usual argument against my assertion is that a higher-priced and more arduous education pathway better provides the physician with the tools to deal with the outliers, the diagnostic enigmas. My reply is that any good provider regardless of his or her years spent in training is taught to first admit what they don’t know. When faced with an enigma, call a consultant or, in the near future, access a Chatbot.

If the natural market and economic forces continue to drive the growth of advanced-practice providers, what role(s) remains for the medical school–trained primary care provider? Does she or he remain the leader of a team of providers? Does she or he still see patients and somehow remain the first among equals?

While patients seem to be warming to the notion of seeing a nonphysician provider, I often still hear the complaint but “I see a different provider every time I go to the office.” Continuity is one of those three keystones of quality primary care. It is not incompatible with a team concept of care delivery, but it does require a commitment to the concept and creative scheduling that allows the patient to see the same provider at almost every visit. I’m not sure where having a first-among-equals provider fits into that scheme. Is it just one more “different” provider?

Maybe the medical school–trained provider becomes a consultant physician, much as the British and Canadian systems seem to work. She or he would see patients only after the advanced primary care provider has done an evaluation and is unsure of the next step. Would this be at the same site or electronically? Is there a time lag? In my old-school interpretation, if the visit is not the same day or maybe the next day then it doesn’t satisfy my Availability requirement of primary care.

I’m beginning to believe that the best role for the medical school–trained primary care specialist is someone who has a broad and deep understanding of the organizational issues around primary care. Primarily an educator who generally doesn’t see patients but instead trains advanced primary care providers, organizes them into teams that function to provide care in a timely fashion that emphasizes Continuity, and then performs ongoing, real time assessments to assure that care provided is at the highest level of Expertise.

It sounds like an interesting and challenging job description requiring a deep and broad education. Just not one that appeals to me. I would rather be a nurse practitioner or physician’s assistant who is on the front line and hands on.

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 pdnews@mdedge.com

“The doctor won’t see you now.”

The editor of the alumni magazine had succeeded in getting my attention. The shock value of the headline hooked me and I was drawn in to chase down the research. A study by a team of researchers at Harvard Medical School has published a study in the British Medical Journal revealing that “from 2013 to 2019 the share of U.S. health care visits delivered by nonphysicians such as nurse practitioners or physician assistants increased from 14% to 26%.” In other words, at more than a quarter of the health care visits in this country the patient is not seen by a physician. The percent seen by advanced-practice providers varied by complaint and specialty. For example, 47% of patients with a respiratory complaint saw a nurse practitioner or physicians assistant, while for an eye condition only 13% were seen by an advanced-practice provider. However, overall the increase was dramatic.

It doesn’t require much deep thinking to come up with some explanations for this shift in provider involvement. It boils down to supply and demand. Compared with other similar nations, we have fewer physicians. Physicians are leaving the profession for a variety of reasons, including disappointment with their work-life balance and a sense that too much of their day is devoted to meaningless work with user unfriendly computer systems.

The number of nurse practitioners and physician assistants is growing faster than that of physicians. In fact it has been predicted that over the next 2 decades advanced-practice providers will increase by more than 50% while the physician pool will grow by less than 5%.

We can mull over the how-we-got-here ad infinitum, but this recent study suggests that we had better hustle and invest some time rethinking the role of a physician and how we should adapt our education system to better prepare for those choosing the path through medical school. This mirror gazing is particularly critical for those of us doing primary care.

While in years past I often heard a discontented grumble from patients that “I was ‘only’ seen by the nurse practitioner,” this complaint has become much less frequent as patients have gained more experience with advanced-practice providers and have begun to accept the new reality and see the change as inevitable.

When someone tells me that their daughter or nephew or second cousin is planning on becoming a doctor, I pause and listen patiently as they go on proudly about it before asking if the young person has considered becoming a physician assistant. I say, “Ya know, if I were 60 years younger I think I would bypass medical school and become a nurse practitioner because they get to do all the cool things that I enjoyed about seeing patients. Sure, my mother wouldn’t have been able to introduce me as her son the doctor. But, my parents and I would have spent less time and money on my training, and I would have had less administrative hassle heaped on me once I went into practice.”

The essence of good primary care is Availability, Continuity, and Expertise. The first two attributes aren’t taught in medical school and rely on commitment and having enough bodies to deliver the care. When it comes to expertise, how important is the broad and deep education of traditional medical school when the provider is seeing the relatively narrow spectrum of bread-and-butter everyday complaints that fill the day for most primary care providers? Particularly, when the population has already been preselected by age, geography, and socioeconomic factors.

The usual argument against my assertion is that a higher-priced and more arduous education pathway better provides the physician with the tools to deal with the outliers, the diagnostic enigmas. My reply is that any good provider regardless of his or her years spent in training is taught to first admit what they don’t know. When faced with an enigma, call a consultant or, in the near future, access a Chatbot.

If the natural market and economic forces continue to drive the growth of advanced-practice providers, what role(s) remains for the medical school–trained primary care provider? Does she or he remain the leader of a team of providers? Does she or he still see patients and somehow remain the first among equals?

While patients seem to be warming to the notion of seeing a nonphysician provider, I often still hear the complaint but “I see a different provider every time I go to the office.” Continuity is one of those three keystones of quality primary care. It is not incompatible with a team concept of care delivery, but it does require a commitment to the concept and creative scheduling that allows the patient to see the same provider at almost every visit. I’m not sure where having a first-among-equals provider fits into that scheme. Is it just one more “different” provider?

Maybe the medical school–trained provider becomes a consultant physician, much as the British and Canadian systems seem to work. She or he would see patients only after the advanced primary care provider has done an evaluation and is unsure of the next step. Would this be at the same site or electronically? Is there a time lag? In my old-school interpretation, if the visit is not the same day or maybe the next day then it doesn’t satisfy my Availability requirement of primary care.

I’m beginning to believe that the best role for the medical school–trained primary care specialist is someone who has a broad and deep understanding of the organizational issues around primary care. Primarily an educator who generally doesn’t see patients but instead trains advanced primary care providers, organizes them into teams that function to provide care in a timely fashion that emphasizes Continuity, and then performs ongoing, real time assessments to assure that care provided is at the highest level of Expertise.

It sounds like an interesting and challenging job description requiring a deep and broad education. Just not one that appeals to me. I would rather be a nurse practitioner or physician’s assistant who is on the front line and hands on.

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 pdnews@mdedge.com

“The doctor won’t see you now.”

The editor of the alumni magazine had succeeded in getting my attention. The shock value of the headline hooked me and I was drawn in to chase down the research. A study by a team of researchers at Harvard Medical School has published a study in the British Medical Journal revealing that “from 2013 to 2019 the share of U.S. health care visits delivered by nonphysicians such as nurse practitioners or physician assistants increased from 14% to 26%.” In other words, at more than a quarter of the health care visits in this country the patient is not seen by a physician. The percent seen by advanced-practice providers varied by complaint and specialty. For example, 47% of patients with a respiratory complaint saw a nurse practitioner or physicians assistant, while for an eye condition only 13% were seen by an advanced-practice provider. However, overall the increase was dramatic.

It doesn’t require much deep thinking to come up with some explanations for this shift in provider involvement. It boils down to supply and demand. Compared with other similar nations, we have fewer physicians. Physicians are leaving the profession for a variety of reasons, including disappointment with their work-life balance and a sense that too much of their day is devoted to meaningless work with user unfriendly computer systems.

The number of nurse practitioners and physician assistants is growing faster than that of physicians. In fact it has been predicted that over the next 2 decades advanced-practice providers will increase by more than 50% while the physician pool will grow by less than 5%.

We can mull over the how-we-got-here ad infinitum, but this recent study suggests that we had better hustle and invest some time rethinking the role of a physician and how we should adapt our education system to better prepare for those choosing the path through medical school. This mirror gazing is particularly critical for those of us doing primary care.

While in years past I often heard a discontented grumble from patients that “I was ‘only’ seen by the nurse practitioner,” this complaint has become much less frequent as patients have gained more experience with advanced-practice providers and have begun to accept the new reality and see the change as inevitable.

When someone tells me that their daughter or nephew or second cousin is planning on becoming a doctor, I pause and listen patiently as they go on proudly about it before asking if the young person has considered becoming a physician assistant. I say, “Ya know, if I were 60 years younger I think I would bypass medical school and become a nurse practitioner because they get to do all the cool things that I enjoyed about seeing patients. Sure, my mother wouldn’t have been able to introduce me as her son the doctor. But, my parents and I would have spent less time and money on my training, and I would have had less administrative hassle heaped on me once I went into practice.”

The essence of good primary care is Availability, Continuity, and Expertise. The first two attributes aren’t taught in medical school and rely on commitment and having enough bodies to deliver the care. When it comes to expertise, how important is the broad and deep education of traditional medical school when the provider is seeing the relatively narrow spectrum of bread-and-butter everyday complaints that fill the day for most primary care providers? Particularly, when the population has already been preselected by age, geography, and socioeconomic factors.

The usual argument against my assertion is that a higher-priced and more arduous education pathway better provides the physician with the tools to deal with the outliers, the diagnostic enigmas. My reply is that any good provider regardless of his or her years spent in training is taught to first admit what they don’t know. When faced with an enigma, call a consultant or, in the near future, access a Chatbot.

If the natural market and economic forces continue to drive the growth of advanced-practice providers, what role(s) remains for the medical school–trained primary care provider? Does she or he remain the leader of a team of providers? Does she or he still see patients and somehow remain the first among equals?

While patients seem to be warming to the notion of seeing a nonphysician provider, I often still hear the complaint but “I see a different provider every time I go to the office.” Continuity is one of those three keystones of quality primary care. It is not incompatible with a team concept of care delivery, but it does require a commitment to the concept and creative scheduling that allows the patient to see the same provider at almost every visit. I’m not sure where having a first-among-equals provider fits into that scheme. Is it just one more “different” provider?

Maybe the medical school–trained provider becomes a consultant physician, much as the British and Canadian systems seem to work. She or he would see patients only after the advanced primary care provider has done an evaluation and is unsure of the next step. Would this be at the same site or electronically? Is there a time lag? In my old-school interpretation, if the visit is not the same day or maybe the next day then it doesn’t satisfy my Availability requirement of primary care.

I’m beginning to believe that the best role for the medical school–trained primary care specialist is someone who has a broad and deep understanding of the organizational issues around primary care. Primarily an educator who generally doesn’t see patients but instead trains advanced primary care providers, organizes them into teams that function to provide care in a timely fashion that emphasizes Continuity, and then performs ongoing, real time assessments to assure that care provided is at the highest level of Expertise.

It sounds like an interesting and challenging job description requiring a deep and broad education. Just not one that appeals to me. I would rather be a nurse practitioner or physician’s assistant who is on the front line and hands on.

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 pdnews@mdedge.com