Letters from Maine

Does the name Bruce Lipton sound familiar to you? Until a few years ago the only bell that it rang with me was that I had a high school classmate named Bruce Lipton. I recall that his father owned the local grocery store and he was one of the most prolific pranksters in a class with a long history of prank playing. If the name dredges up any associations for you it may because you have heard of a PhD biologist who has written and lectured extensively on epigenetics. You may have even read his most widely published book, “The Biology of Belief.” It turns out the Epigenetics Guy and my high school prankster classmate are one and the same.

After decades of separation – he is in California and I’m here in Maine – we have reconnected via Zoom mini reunions that our class has organized to combat the isolation that has descended on us with the pandemic. While I haven’t read his books, I have watched and listened to some of his podcasts and lectures. The devilish twinkle in his eye in the 1950s and 1960s has provided the scaffolding on which he has built a charismatic and persuasive presentation style.

Bruce was no dummy in school but his early career as a cell biologist doing research in stem-cell function was a surprise to all of us. But then high school reunions are often full of surprises and should serve as good reminders of the danger of profiling and pigeon-holing adolescents.

Professor Lipton’s take on epigenetics boils down to the notion that our genome should merely be considered a blueprint and not the final determinant of who we are and what illnesses befall us. His research and observations suggest to him that there are an uncountable number extragenomic factors, including environmental conditions and our belief systems, that can influence how that blueprint is read and the resulting expression of the genes we have inherited.

At face value, Bruce’s basic premise falls very close to some of the conclusions I have toyed with in an attempt to explain what I have observed doing primary care pediatrics. For example, I have trouble blaming the meteoric rise of the ADHD phenomenon on a genetic mutation. I suspect there are likely to be extragenomic forces coming into play, such as sleep deprivation and changing child-rearing practices. In my Oct. 9, 2020, Letters from Maine column I referred to a Swedish twins study that suggested children from a family with a strong history of depression were more likely to develop depression when raised in an adopted family that experienced domestic turmoil. His philosophy also fits with my sense that I have more control over my own health outcomes than many other people.

However, Professor Lipton and I part company (just philosophically that is) when he slips into hyperbole and applies what he terms as the New Biology too broadly. He may be correct that the revolutionary changes which came in the wake of Watson and Crick’s double helix discovery have resulted in a view of pathophysiology that is overly focused on what we are learning about our genome. On the other hand it is refreshing to hear someone with his charismatic and persuasive skills question the status quo.

If you haven’t listened to what he has to say I urge you to browse the Internet and sample some of his talks. I am sure you will find what he has to say stimulating. I doubt you will buy his whole package but I suspect you may find some bits you can agree with.

It still boils down to the old nature versus nurture argument. He’s all in for nurture. I’m still more comfortable straddling the fence.
 

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.

Does the name Bruce Lipton sound familiar to you? Until a few years ago the only bell that it rang with me was that I had a high school classmate named Bruce Lipton. I recall that his father owned the local grocery store and he was one of the most prolific pranksters in a class with a long history of prank playing. If the name dredges up any associations for you it may because you have heard of a PhD biologist who has written and lectured extensively on epigenetics. You may have even read his most widely published book, “The Biology of Belief.” It turns out the Epigenetics Guy and my high school prankster classmate are one and the same.

After decades of separation – he is in California and I’m here in Maine – we have reconnected via Zoom mini reunions that our class has organized to combat the isolation that has descended on us with the pandemic. While I haven’t read his books, I have watched and listened to some of his podcasts and lectures. The devilish twinkle in his eye in the 1950s and 1960s has provided the scaffolding on which he has built a charismatic and persuasive presentation style.

Bruce was no dummy in school but his early career as a cell biologist doing research in stem-cell function was a surprise to all of us. But then high school reunions are often full of surprises and should serve as good reminders of the danger of profiling and pigeon-holing adolescents.

Professor Lipton’s take on epigenetics boils down to the notion that our genome should merely be considered a blueprint and not the final determinant of who we are and what illnesses befall us. His research and observations suggest to him that there are an uncountable number extragenomic factors, including environmental conditions and our belief systems, that can influence how that blueprint is read and the resulting expression of the genes we have inherited.

At face value, Bruce’s basic premise falls very close to some of the conclusions I have toyed with in an attempt to explain what I have observed doing primary care pediatrics. For example, I have trouble blaming the meteoric rise of the ADHD phenomenon on a genetic mutation. I suspect there are likely to be extragenomic forces coming into play, such as sleep deprivation and changing child-rearing practices. In my Oct. 9, 2020, Letters from Maine column I referred to a Swedish twins study that suggested children from a family with a strong history of depression were more likely to develop depression when raised in an adopted family that experienced domestic turmoil. His philosophy also fits with my sense that I have more control over my own health outcomes than many other people.

However, Professor Lipton and I part company (just philosophically that is) when he slips into hyperbole and applies what he terms as the New Biology too broadly. He may be correct that the revolutionary changes which came in the wake of Watson and Crick’s double helix discovery have resulted in a view of pathophysiology that is overly focused on what we are learning about our genome. On the other hand it is refreshing to hear someone with his charismatic and persuasive skills question the status quo.

If you haven’t listened to what he has to say I urge you to browse the Internet and sample some of his talks. I am sure you will find what he has to say stimulating. I doubt you will buy his whole package but I suspect you may find some bits you can agree with.

It still boils down to the old nature versus nurture argument. He’s all in for nurture. I’m still more comfortable straddling the fence.
 

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.

Does the name Bruce Lipton sound familiar to you? Until a few years ago the only bell that it rang with me was that I had a high school classmate named Bruce Lipton. I recall that his father owned the local grocery store and he was one of the most prolific pranksters in a class with a long history of prank playing. If the name dredges up any associations for you it may because you have heard of a PhD biologist who has written and lectured extensively on epigenetics. You may have even read his most widely published book, “The Biology of Belief.” It turns out the Epigenetics Guy and my high school prankster classmate are one and the same.

After decades of separation – he is in California and I’m here in Maine – we have reconnected via Zoom mini reunions that our class has organized to combat the isolation that has descended on us with the pandemic. While I haven’t read his books, I have watched and listened to some of his podcasts and lectures. The devilish twinkle in his eye in the 1950s and 1960s has provided the scaffolding on which he has built a charismatic and persuasive presentation style.

Bruce was no dummy in school but his early career as a cell biologist doing research in stem-cell function was a surprise to all of us. But then high school reunions are often full of surprises and should serve as good reminders of the danger of profiling and pigeon-holing adolescents.

Professor Lipton’s take on epigenetics boils down to the notion that our genome should merely be considered a blueprint and not the final determinant of who we are and what illnesses befall us. His research and observations suggest to him that there are an uncountable number extragenomic factors, including environmental conditions and our belief systems, that can influence how that blueprint is read and the resulting expression of the genes we have inherited.

At face value, Bruce’s basic premise falls very close to some of the conclusions I have toyed with in an attempt to explain what I have observed doing primary care pediatrics. For example, I have trouble blaming the meteoric rise of the ADHD phenomenon on a genetic mutation. I suspect there are likely to be extragenomic forces coming into play, such as sleep deprivation and changing child-rearing practices. In my Oct. 9, 2020, Letters from Maine column I referred to a Swedish twins study that suggested children from a family with a strong history of depression were more likely to develop depression when raised in an adopted family that experienced domestic turmoil. His philosophy also fits with my sense that I have more control over my own health outcomes than many other people.

However, Professor Lipton and I part company (just philosophically that is) when he slips into hyperbole and applies what he terms as the New Biology too broadly. He may be correct that the revolutionary changes which came in the wake of Watson and Crick’s double helix discovery have resulted in a view of pathophysiology that is overly focused on what we are learning about our genome. On the other hand it is refreshing to hear someone with his charismatic and persuasive skills question the status quo.

If you haven’t listened to what he has to say I urge you to browse the Internet and sample some of his talks. I am sure you will find what he has to say stimulating. I doubt you will buy his whole package but I suspect you may find some bits you can agree with.

It still boils down to the old nature versus nurture argument. He’s all in for nurture. I’m still more comfortable straddling the fence.
 

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.

Finding the current domestic and global situations too disheartening to write about, I have decided for the moment to take the long view in hopes of finding something to stimulate your imaginations. It appears that we have several vaccines effective against SARS-CoV-2 if not in your hands at the moment at least in someone’s freezer or at the very least somewhere near beginning of their journey in the production pipeline. It may be a year of more but thanks to the vaccines and herd immunity there will be a time when parents may feel more comfortable about bringing their children into your office. How are you going to dial back your office routine to something even vaguely familiar?

To keep your office afloat financially you have probably been forced to adopt and adapt telemedicine strategies to your practice style. Prior to the pandemic you may have been among the few who were actively experimenting with practicing remotely. But, it is more likely that you had given little serious thought to how you would manage your patients without them being physically present.

You probably carried in your mind a list of symptoms and complaints which you had promised yourself that you would never treat without first laying eyes and hands on the patient. You may have even codified this list into a set of guidelines that you included in the office manual for your nurses, assistants, and receptionists. You may have looked askance at some of your colleagues whom you felt too often treated their patients (and yours when they were covering) based on what seemed to be scanty information gleaned from a phone call. The impropriety of this kind of clinical behavior may have even come up at staff meetings or at least been the topic of hallway discussions.

How did your list of complaints that demanded an in-person visit evolve? I suspect that in large part it was formed as you modeled the behavior of your mentors and teachers. In some cases you may have heard of tragic cases in which a child had died or suffered serious consequences of being treated without an in-person evaluation. In many cases you were following a tradition or ethic that said treating in certain circumstances without an exam just wasn’t done.

Have the realities of the pandemic forced you to alter your list of must-see-before-I’ll-treat complaints? Have you found yourself calling in antibiotic prescriptions for children with ear pain who 1 year ago you would have told to come in for an office visit? Are you treating “strep throats” without a rapid strep test or culture? How many stimulant prescriptions have you refilled for children who haven’t been reevaluated in the office in over a year? How are you going to manage the tsunami of requests for sports physicals once the junior high and high school teams are allowed to return to action? You probably won’t have the time to examine all of the sports candidates who show up in your office with crumpled forms recently retrieved from crumb-filled backpacks.

Where are you going to reset the bar as the pandemic lifts and the barriers that have prevented patients from coming to your office over the last year or year and a half recede? Have you realized that many of your office visits in prepandemic times were unnecessary? How many children with otitis really needed to be followed up with an ear recheck visit? Which children with sore throats and a fever needed to be examined? Was a yearly exam really necessary for a high school sophomore who wanted to play basketball? Has your comfort zone widened to include more patient complaints that can be managed without a face to face encounter? Where will telemedicine fit into the mix?

At some time in the next 12 months you will have to recalibrate and reset the bar. It will probably be a gradual process that in large part can be molded by the responses of the families who may have also come to realize that seeing you in the office isn’t quite as necessary as you both may have thought it was.
 

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

Finding the current domestic and global situations too disheartening to write about, I have decided for the moment to take the long view in hopes of finding something to stimulate your imaginations. It appears that we have several vaccines effective against SARS-CoV-2 if not in your hands at the moment at least in someone’s freezer or at the very least somewhere near beginning of their journey in the production pipeline. It may be a year of more but thanks to the vaccines and herd immunity there will be a time when parents may feel more comfortable about bringing their children into your office. How are you going to dial back your office routine to something even vaguely familiar?

To keep your office afloat financially you have probably been forced to adopt and adapt telemedicine strategies to your practice style. Prior to the pandemic you may have been among the few who were actively experimenting with practicing remotely. But, it is more likely that you had given little serious thought to how you would manage your patients without them being physically present.

You probably carried in your mind a list of symptoms and complaints which you had promised yourself that you would never treat without first laying eyes and hands on the patient. You may have even codified this list into a set of guidelines that you included in the office manual for your nurses, assistants, and receptionists. You may have looked askance at some of your colleagues whom you felt too often treated their patients (and yours when they were covering) based on what seemed to be scanty information gleaned from a phone call. The impropriety of this kind of clinical behavior may have even come up at staff meetings or at least been the topic of hallway discussions.

How did your list of complaints that demanded an in-person visit evolve? I suspect that in large part it was formed as you modeled the behavior of your mentors and teachers. In some cases you may have heard of tragic cases in which a child had died or suffered serious consequences of being treated without an in-person evaluation. In many cases you were following a tradition or ethic that said treating in certain circumstances without an exam just wasn’t done.

Have the realities of the pandemic forced you to alter your list of must-see-before-I’ll-treat complaints? Have you found yourself calling in antibiotic prescriptions for children with ear pain who 1 year ago you would have told to come in for an office visit? Are you treating “strep throats” without a rapid strep test or culture? How many stimulant prescriptions have you refilled for children who haven’t been reevaluated in the office in over a year? How are you going to manage the tsunami of requests for sports physicals once the junior high and high school teams are allowed to return to action? You probably won’t have the time to examine all of the sports candidates who show up in your office with crumpled forms recently retrieved from crumb-filled backpacks.

Where are you going to reset the bar as the pandemic lifts and the barriers that have prevented patients from coming to your office over the last year or year and a half recede? Have you realized that many of your office visits in prepandemic times were unnecessary? How many children with otitis really needed to be followed up with an ear recheck visit? Which children with sore throats and a fever needed to be examined? Was a yearly exam really necessary for a high school sophomore who wanted to play basketball? Has your comfort zone widened to include more patient complaints that can be managed without a face to face encounter? Where will telemedicine fit into the mix?

At some time in the next 12 months you will have to recalibrate and reset the bar. It will probably be a gradual process that in large part can be molded by the responses of the families who may have also come to realize that seeing you in the office isn’t quite as necessary as you both may have thought it was.
 

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

Finding the current domestic and global situations too disheartening to write about, I have decided for the moment to take the long view in hopes of finding something to stimulate your imaginations. It appears that we have several vaccines effective against SARS-CoV-2 if not in your hands at the moment at least in someone’s freezer or at the very least somewhere near beginning of their journey in the production pipeline. It may be a year of more but thanks to the vaccines and herd immunity there will be a time when parents may feel more comfortable about bringing their children into your office. How are you going to dial back your office routine to something even vaguely familiar?

To keep your office afloat financially you have probably been forced to adopt and adapt telemedicine strategies to your practice style. Prior to the pandemic you may have been among the few who were actively experimenting with practicing remotely. But, it is more likely that you had given little serious thought to how you would manage your patients without them being physically present.

You probably carried in your mind a list of symptoms and complaints which you had promised yourself that you would never treat without first laying eyes and hands on the patient. You may have even codified this list into a set of guidelines that you included in the office manual for your nurses, assistants, and receptionists. You may have looked askance at some of your colleagues whom you felt too often treated their patients (and yours when they were covering) based on what seemed to be scanty information gleaned from a phone call. The impropriety of this kind of clinical behavior may have even come up at staff meetings or at least been the topic of hallway discussions.

How did your list of complaints that demanded an in-person visit evolve? I suspect that in large part it was formed as you modeled the behavior of your mentors and teachers. In some cases you may have heard of tragic cases in which a child had died or suffered serious consequences of being treated without an in-person evaluation. In many cases you were following a tradition or ethic that said treating in certain circumstances without an exam just wasn’t done.

Have the realities of the pandemic forced you to alter your list of must-see-before-I’ll-treat complaints? Have you found yourself calling in antibiotic prescriptions for children with ear pain who 1 year ago you would have told to come in for an office visit? Are you treating “strep throats” without a rapid strep test or culture? How many stimulant prescriptions have you refilled for children who haven’t been reevaluated in the office in over a year? How are you going to manage the tsunami of requests for sports physicals once the junior high and high school teams are allowed to return to action? You probably won’t have the time to examine all of the sports candidates who show up in your office with crumpled forms recently retrieved from crumb-filled backpacks.

Where are you going to reset the bar as the pandemic lifts and the barriers that have prevented patients from coming to your office over the last year or year and a half recede? Have you realized that many of your office visits in prepandemic times were unnecessary? How many children with otitis really needed to be followed up with an ear recheck visit? Which children with sore throats and a fever needed to be examined? Was a yearly exam really necessary for a high school sophomore who wanted to play basketball? Has your comfort zone widened to include more patient complaints that can be managed without a face to face encounter? Where will telemedicine fit into the mix?

At some time in the next 12 months you will have to recalibrate and reset the bar. It will probably be a gradual process that in large part can be molded by the responses of the families who may have also come to realize that seeing you in the office isn’t quite as necessary as you both may have thought it was.
 

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

Do you accept new families into your practice who have already chosen to not have their children immunized? What about families who have been in your practice for several months or years? In 2016 the American Academy of Pediatrics published a clinical report in which it stated that, under some circumstances, dismissing families who refuse to vaccinate is permissible. Have you felt sufficiently supported by that statement and dismissed any families after multiple attempts at education on your part?

In a Pediatrics Perspective article in the December issue of Pediatrics, two philosophers and a physician make the argument that, while in some situations dismissing a family who refuses vaccines may be “an ethically acceptable option” refusing to accept a family with the same philosophy is not. It is an interesting paper and worth reading regardless of whether or not you already accept and continue to tolerate vaccine deniers in your practice.

The Pediatrics Perspective is certainly not the last word on the ethics of caring for families who deny their children care that we believe is critical to their health and the welfare of the community at large. There has been a lot of discussion about the issue but little has been written about how we as the physicians on the front line are coping emotionally with what the authors of the paper call the “burdens associated with treating” families who refuse to follow our guidance.

It is hard not to feel angry when a family you have invested valuable office time in discussing the benefits and safety of vaccines continues to disregard what you see as the facts. The time you have spent with them is not just income-generating time for your practice, it is time stolen from other families who are more willing to follow your recommendations. In how many visits will you continue to raise the issue? Unless I saw a glimmer of hope I would usually stop after two wasted encounters. But, the issue would still linger as the elephant in the examination room for as long as I continued to see the patient.

How have you expressed your anger? Have you been argumentative or rude? You may have been able maintain your composure and remain civil and appear caring, but I suspect the anger is still gnawing at you. And, there is still the frustration and feeling of impotence. You may have questioned your ability as an educator. You should get over that notion quickly. There is ample evidence that most vaccine deniers are not going to be convinced by even the most carefully presented information. I suggest you leave it to others to try their hands at education. Let them invest their time while you tend to the needs of your other patients. You can try being a fear monger and, while fear can be effective, you have better ways to spend your office day than telling horror stories.

If vaccine denial makes you feel powerless, you should get over that pretty quickly as well and accept the fact that you are simply an advisor. If you believe that most of the families in your practice are following your recommendations as though you had presented them on stone tablets, it is time for a wakeup call.

Finally, there is the most troubling emotion associated with vaccine refusal and that is fear, the fear of being sued. Establishing a relationship with a family is one that requires mutual trust and certainly vaccine refusal will put that trust in question, particularly if you have done a less than adequate job of hiding your anger and frustration with their unfortunate decision.

For now, vaccine refusal is just another one of those crosses that those of us in primary care must bear together wearing the best face we can put forward. That doesn’t mean we can’t share those emotions with our peers. Misery does love company.
 

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.

Do you accept new families into your practice who have already chosen to not have their children immunized? What about families who have been in your practice for several months or years? In 2016 the American Academy of Pediatrics published a clinical report in which it stated that, under some circumstances, dismissing families who refuse to vaccinate is permissible. Have you felt sufficiently supported by that statement and dismissed any families after multiple attempts at education on your part?

In a Pediatrics Perspective article in the December issue of Pediatrics, two philosophers and a physician make the argument that, while in some situations dismissing a family who refuses vaccines may be “an ethically acceptable option” refusing to accept a family with the same philosophy is not. It is an interesting paper and worth reading regardless of whether or not you already accept and continue to tolerate vaccine deniers in your practice.

The Pediatrics Perspective is certainly not the last word on the ethics of caring for families who deny their children care that we believe is critical to their health and the welfare of the community at large. There has been a lot of discussion about the issue but little has been written about how we as the physicians on the front line are coping emotionally with what the authors of the paper call the “burdens associated with treating” families who refuse to follow our guidance.

It is hard not to feel angry when a family you have invested valuable office time in discussing the benefits and safety of vaccines continues to disregard what you see as the facts. The time you have spent with them is not just income-generating time for your practice, it is time stolen from other families who are more willing to follow your recommendations. In how many visits will you continue to raise the issue? Unless I saw a glimmer of hope I would usually stop after two wasted encounters. But, the issue would still linger as the elephant in the examination room for as long as I continued to see the patient.

How have you expressed your anger? Have you been argumentative or rude? You may have been able maintain your composure and remain civil and appear caring, but I suspect the anger is still gnawing at you. And, there is still the frustration and feeling of impotence. You may have questioned your ability as an educator. You should get over that notion quickly. There is ample evidence that most vaccine deniers are not going to be convinced by even the most carefully presented information. I suggest you leave it to others to try their hands at education. Let them invest their time while you tend to the needs of your other patients. You can try being a fear monger and, while fear can be effective, you have better ways to spend your office day than telling horror stories.

If vaccine denial makes you feel powerless, you should get over that pretty quickly as well and accept the fact that you are simply an advisor. If you believe that most of the families in your practice are following your recommendations as though you had presented them on stone tablets, it is time for a wakeup call.

Finally, there is the most troubling emotion associated with vaccine refusal and that is fear, the fear of being sued. Establishing a relationship with a family is one that requires mutual trust and certainly vaccine refusal will put that trust in question, particularly if you have done a less than adequate job of hiding your anger and frustration with their unfortunate decision.

For now, vaccine refusal is just another one of those crosses that those of us in primary care must bear together wearing the best face we can put forward. That doesn’t mean we can’t share those emotions with our peers. Misery does love company.
 

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.

Do you accept new families into your practice who have already chosen to not have their children immunized? What about families who have been in your practice for several months or years? In 2016 the American Academy of Pediatrics published a clinical report in which it stated that, under some circumstances, dismissing families who refuse to vaccinate is permissible. Have you felt sufficiently supported by that statement and dismissed any families after multiple attempts at education on your part?

In a Pediatrics Perspective article in the December issue of Pediatrics, two philosophers and a physician make the argument that, while in some situations dismissing a family who refuses vaccines may be “an ethically acceptable option” refusing to accept a family with the same philosophy is not. It is an interesting paper and worth reading regardless of whether or not you already accept and continue to tolerate vaccine deniers in your practice.

The Pediatrics Perspective is certainly not the last word on the ethics of caring for families who deny their children care that we believe is critical to their health and the welfare of the community at large. There has been a lot of discussion about the issue but little has been written about how we as the physicians on the front line are coping emotionally with what the authors of the paper call the “burdens associated with treating” families who refuse to follow our guidance.

It is hard not to feel angry when a family you have invested valuable office time in discussing the benefits and safety of vaccines continues to disregard what you see as the facts. The time you have spent with them is not just income-generating time for your practice, it is time stolen from other families who are more willing to follow your recommendations. In how many visits will you continue to raise the issue? Unless I saw a glimmer of hope I would usually stop after two wasted encounters. But, the issue would still linger as the elephant in the examination room for as long as I continued to see the patient.

How have you expressed your anger? Have you been argumentative or rude? You may have been able maintain your composure and remain civil and appear caring, but I suspect the anger is still gnawing at you. And, there is still the frustration and feeling of impotence. You may have questioned your ability as an educator. You should get over that notion quickly. There is ample evidence that most vaccine deniers are not going to be convinced by even the most carefully presented information. I suggest you leave it to others to try their hands at education. Let them invest their time while you tend to the needs of your other patients. You can try being a fear monger and, while fear can be effective, you have better ways to spend your office day than telling horror stories.

If vaccine denial makes you feel powerless, you should get over that pretty quickly as well and accept the fact that you are simply an advisor. If you believe that most of the families in your practice are following your recommendations as though you had presented them on stone tablets, it is time for a wakeup call.

Finally, there is the most troubling emotion associated with vaccine refusal and that is fear, the fear of being sued. Establishing a relationship with a family is one that requires mutual trust and certainly vaccine refusal will put that trust in question, particularly if you have done a less than adequate job of hiding your anger and frustration with their unfortunate decision.

For now, vaccine refusal is just another one of those crosses that those of us in primary care must bear together wearing the best face we can put forward. That doesn’t mean we can’t share those emotions with our peers. Misery does love company.
 

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 a recent New York Times opinion article, author Aubrey Gordon claims that since a visit to her pediatrician in fourth grade she has felt like an “enemy combatant in the nation’s war on childhood obesity.” (“Leave Fat Kids Alone,” Nov. 13, 2020).

At that unfortunate encounter, she recalls being told that “You’ll be thin and beautiful ... If you can just stay the same weight.” In retrospect she feels that the comment by her well-meaning but misguided physician “planted the seeds of depression” that have plagued her ever since.

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 a recent New York Times opinion article, author Aubrey Gordon claims that since a visit to her pediatrician in fourth grade she has felt like an “enemy combatant in the nation’s war on childhood obesity.” (“Leave Fat Kids Alone,” Nov. 13, 2020).

At that unfortunate encounter, she recalls being told that “You’ll be thin and beautiful ... If you can just stay the same weight.” In retrospect she feels that the comment by her well-meaning but misguided physician “planted the seeds of depression” that have plagued her ever since.

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 a recent New York Times opinion article, author Aubrey Gordon claims that since a visit to her pediatrician in fourth grade she has felt like an “enemy combatant in the nation’s war on childhood obesity.” (“Leave Fat Kids Alone,” Nov. 13, 2020).

At that unfortunate encounter, she recalls being told that “You’ll be thin and beautiful ... If you can just stay the same weight.” In retrospect she feels that the comment by her well-meaning but misguided physician “planted the seeds of depression” that have plagued her ever since.

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.

Isolation in response to COVID-19 pandemic has driven many people to reestablish long forgotten connections between old friends and geographically distant relatives. Fed by the ease in which Zoom and other electronic miracles can bring once familiar voices and faces into our homes, we no longer need to wait until our high school or college reunions to reconnect.

The Class of 1962 at Pleasantville (N.Y.) High School has always attracted an unusually large number of attendees at its reunions, and its exuberant response to pandemic-fueled mini Zoom reunions is not surprising. With each virtual gathering we learn and relearn more about each other. I had always felt that because my birthday was in December that I was among the very youngest in my class. (New York’s school enrollment calendar cutoff is in December.) However, I recently learned that some of my classmates were even younger, having been born in the following spring.

This revelation prompted a discussion among the younger septuagenarians about whether we felt that our relative immaturity, at least as measured by the calendar, affected us. It was generally agreed that for the women, being younger seemed to present little problem. For, the men there were a few for whom immaturity put them at an athletic disadvantage. But, there was uniform agreement that social immaturity made dating an uncomfortable adventure. No one felt that his or her immaturity placed them at an academic disadvantage. Of course, all of these observations are heavily colored by the bias of those who have chosen to maintain contact with classmates.

A recent flurry of papers and commentaries about relative age at school entry and the diagnosis of attention deficit/hyperactivity disorder prompted me to ask my Zoom mates if they could recall anyone whom they would label as having exhibited the behavior we have all come to associate with ADHD (Vuori M et al. Children’s relative age and ADHD medication use: A Finnish population-based study. Pediatrics 2020 Oct. doi: 10.1542/peds.2019-4046, and Butter EM. Keeping relative age effects and ADHD care in context. Pediatrics. 2020;146[4]:e2020022798).

We could all recall classmates who struggled academically and seemed to not be paying attention. However, when one includes the hyperactivity descriptor we couldn’t recall anyone whose in-classroom physical activity drew our attention. Of course, there were many shared anecdotes about note passing, spitball throwing, and out-of-class shenanigans. But, from the perspective of behavior that disrupted the classroom there were very few. And, not surprisingly, given the intervening 6 decades, none of us could make an association between immaturity and the behavior.

While I have very few memories of what happened when I was in grade school, many of my classmates have vivid recollections of events both mundane and dramatic even as far back as first and second grade. Why do none of them recall classmates whose behavior would in current terminology be labeled as ADHD?

Were most of us that age bouncing off the walls and so there were no outliers? Were the teachers more tolerant because they expected that many children, particularly the younger ones, would be more physically active? Or, maybe we arrived at school, even those who were chronologically less mature, having already been settled down by home environments that neither fostered nor tolerated hyperactivity?

If you ask a pediatrician over the age of 70 if he or she recalls being taught anything about ADHD in medical school or seeing any children in his or her first years of practice who would fit the current diagnostic criteria, you will see them simply shrug. ADHD was simply not on our radar in the 1970s and 1980s. And it’s not because radar hadn’t been invented. We pediatricians were paying attention, and I trust in my high school classmates’ observations. I am sure there were isolated cases that could easily have been labeled as ADHD if the term had existed. But, the volume of hyperactive children a pediatrician sees today in the course of a normal office day just didn’t exist.

I have trouble believing that this dramatic increase in frequency is the result of accumulating genetic damage from Teflon cookware or climate change or air pollution. Although I am open to any serious attempt to explain the phenomenon I think we should look first into the home environment in which children are being raised. Sleep schedules, activity, and amusement opportunities as well as discipline styles – just to name a few – are far different now than before the ADHD diagnosis overtook the landscape.
 

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.

Isolation in response to COVID-19 pandemic has driven many people to reestablish long forgotten connections between old friends and geographically distant relatives. Fed by the ease in which Zoom and other electronic miracles can bring once familiar voices and faces into our homes, we no longer need to wait until our high school or college reunions to reconnect.

The Class of 1962 at Pleasantville (N.Y.) High School has always attracted an unusually large number of attendees at its reunions, and its exuberant response to pandemic-fueled mini Zoom reunions is not surprising. With each virtual gathering we learn and relearn more about each other. I had always felt that because my birthday was in December that I was among the very youngest in my class. (New York’s school enrollment calendar cutoff is in December.) However, I recently learned that some of my classmates were even younger, having been born in the following spring.

This revelation prompted a discussion among the younger septuagenarians about whether we felt that our relative immaturity, at least as measured by the calendar, affected us. It was generally agreed that for the women, being younger seemed to present little problem. For, the men there were a few for whom immaturity put them at an athletic disadvantage. But, there was uniform agreement that social immaturity made dating an uncomfortable adventure. No one felt that his or her immaturity placed them at an academic disadvantage. Of course, all of these observations are heavily colored by the bias of those who have chosen to maintain contact with classmates.

A recent flurry of papers and commentaries about relative age at school entry and the diagnosis of attention deficit/hyperactivity disorder prompted me to ask my Zoom mates if they could recall anyone whom they would label as having exhibited the behavior we have all come to associate with ADHD (Vuori M et al. Children’s relative age and ADHD medication use: A Finnish population-based study. Pediatrics 2020 Oct. doi: 10.1542/peds.2019-4046, and Butter EM. Keeping relative age effects and ADHD care in context. Pediatrics. 2020;146[4]:e2020022798).

We could all recall classmates who struggled academically and seemed to not be paying attention. However, when one includes the hyperactivity descriptor we couldn’t recall anyone whose in-classroom physical activity drew our attention. Of course, there were many shared anecdotes about note passing, spitball throwing, and out-of-class shenanigans. But, from the perspective of behavior that disrupted the classroom there were very few. And, not surprisingly, given the intervening 6 decades, none of us could make an association between immaturity and the behavior.

While I have very few memories of what happened when I was in grade school, many of my classmates have vivid recollections of events both mundane and dramatic even as far back as first and second grade. Why do none of them recall classmates whose behavior would in current terminology be labeled as ADHD?

Were most of us that age bouncing off the walls and so there were no outliers? Were the teachers more tolerant because they expected that many children, particularly the younger ones, would be more physically active? Or, maybe we arrived at school, even those who were chronologically less mature, having already been settled down by home environments that neither fostered nor tolerated hyperactivity?

If you ask a pediatrician over the age of 70 if he or she recalls being taught anything about ADHD in medical school or seeing any children in his or her first years of practice who would fit the current diagnostic criteria, you will see them simply shrug. ADHD was simply not on our radar in the 1970s and 1980s. And it’s not because radar hadn’t been invented. We pediatricians were paying attention, and I trust in my high school classmates’ observations. I am sure there were isolated cases that could easily have been labeled as ADHD if the term had existed. But, the volume of hyperactive children a pediatrician sees today in the course of a normal office day just didn’t exist.

I have trouble believing that this dramatic increase in frequency is the result of accumulating genetic damage from Teflon cookware or climate change or air pollution. Although I am open to any serious attempt to explain the phenomenon I think we should look first into the home environment in which children are being raised. Sleep schedules, activity, and amusement opportunities as well as discipline styles – just to name a few – are far different now than before the ADHD diagnosis overtook the landscape.
 

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.

Isolation in response to COVID-19 pandemic has driven many people to reestablish long forgotten connections between old friends and geographically distant relatives. Fed by the ease in which Zoom and other electronic miracles can bring once familiar voices and faces into our homes, we no longer need to wait until our high school or college reunions to reconnect.

The Class of 1962 at Pleasantville (N.Y.) High School has always attracted an unusually large number of attendees at its reunions, and its exuberant response to pandemic-fueled mini Zoom reunions is not surprising. With each virtual gathering we learn and relearn more about each other. I had always felt that because my birthday was in December that I was among the very youngest in my class. (New York’s school enrollment calendar cutoff is in December.) However, I recently learned that some of my classmates were even younger, having been born in the following spring.

This revelation prompted a discussion among the younger septuagenarians about whether we felt that our relative immaturity, at least as measured by the calendar, affected us. It was generally agreed that for the women, being younger seemed to present little problem. For, the men there were a few for whom immaturity put them at an athletic disadvantage. But, there was uniform agreement that social immaturity made dating an uncomfortable adventure. No one felt that his or her immaturity placed them at an academic disadvantage. Of course, all of these observations are heavily colored by the bias of those who have chosen to maintain contact with classmates.

A recent flurry of papers and commentaries about relative age at school entry and the diagnosis of attention deficit/hyperactivity disorder prompted me to ask my Zoom mates if they could recall anyone whom they would label as having exhibited the behavior we have all come to associate with ADHD (Vuori M et al. Children’s relative age and ADHD medication use: A Finnish population-based study. Pediatrics 2020 Oct. doi: 10.1542/peds.2019-4046, and Butter EM. Keeping relative age effects and ADHD care in context. Pediatrics. 2020;146[4]:e2020022798).

We could all recall classmates who struggled academically and seemed to not be paying attention. However, when one includes the hyperactivity descriptor we couldn’t recall anyone whose in-classroom physical activity drew our attention. Of course, there were many shared anecdotes about note passing, spitball throwing, and out-of-class shenanigans. But, from the perspective of behavior that disrupted the classroom there were very few. And, not surprisingly, given the intervening 6 decades, none of us could make an association between immaturity and the behavior.

While I have very few memories of what happened when I was in grade school, many of my classmates have vivid recollections of events both mundane and dramatic even as far back as first and second grade. Why do none of them recall classmates whose behavior would in current terminology be labeled as ADHD?

Were most of us that age bouncing off the walls and so there were no outliers? Were the teachers more tolerant because they expected that many children, particularly the younger ones, would be more physically active? Or, maybe we arrived at school, even those who were chronologically less mature, having already been settled down by home environments that neither fostered nor tolerated hyperactivity?

If you ask a pediatrician over the age of 70 if he or she recalls being taught anything about ADHD in medical school or seeing any children in his or her first years of practice who would fit the current diagnostic criteria, you will see them simply shrug. ADHD was simply not on our radar in the 1970s and 1980s. And it’s not because radar hadn’t been invented. We pediatricians were paying attention, and I trust in my high school classmates’ observations. I am sure there were isolated cases that could easily have been labeled as ADHD if the term had existed. But, the volume of hyperactive children a pediatrician sees today in the course of a normal office day just didn’t exist.

I have trouble believing that this dramatic increase in frequency is the result of accumulating genetic damage from Teflon cookware or climate change or air pollution. Although I am open to any serious attempt to explain the phenomenon I think we should look first into the home environment in which children are being raised. Sleep schedules, activity, and amusement opportunities as well as discipline styles – just to name a few – are far different now than before the ADHD diagnosis overtook the landscape.
 

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.

It’s not unusual when I run into a former patient that I am addressed as “Doctor” Wilkoff. I guess that is to be expected because when I was in practice I seldom introduced myself as Will. However, I will admit now that I never quite felt comfortable with the “Doctor” label. Today, if you addressed me as “Doctor” I would correct you and refer to myself as the “ex-Doctor Wilkoff.”

The term doctor derived from the Latin word to teach and eventually morphed into an academic title. In common parlance it is sometimes used as verb meaning to treat, e.g., “he doctored the wound.” Regardless of what academic field we are talking about, the title “doctor” has become a term of respect for someone who has spent an unusually long time learning his or her subject or craft. The holder of a doctorate, particularly in medicine, receives a rank, earned or unearned, near the top of the social hierarchy.

When I look back at more than 50 years of doing pediatrics I’m not sure that “doctor” really captures what I was up to. I will grant you that it is nice that folks want to acknowledge all those years I spent in training. But I don’t think one could say that what I did as a primary care small town pediatrician fits in with the original definition “to teach.” I did spend a few hours teaching students every so often but my primary time was spent with patients and I don’t consider what I was doing with them as teaching. There just wasn’t enough time. I had to take as a given that families who came to see me already had a basic knowledge base either as the result of their schooling, family lore, or public service announcements from the American Academy of Pediatrics.

I certainly wasn’t doing much doctoring in the sense of treating or curing disease. If one removes administering immunizations and delivery room resuscitations, I saved very few lives.

So you may ask, if not as “doctor,” how would I prefer to be labeled? Good question, but easy for me to answer. The term “coach” quickly comes to mind. As someone who played a variety of team sports there is no term that I can think of that commands more respect than “Coach.” While the term doesn’t carry the burden of a particularly long educational journey it does imply the person is wise, observant, and experienced.

There is some teaching involved but primarily a coach is going to assess the players (or in this cases the families) he is presented with and then do the best he can to guide them toward good decisions they can make themselves given their specific situations. This requires spending most of one’s time getting to know each family and understanding their strengths and limitations. One can’t coach speed to an athlete who is slow footed. And, one isn’t going to get a family that is dominated by anxiety to become bold risk takers. The best you can do is to help them learn strategies to minimize their anxieties.

A good coach can help his players learn to set reasonable goals given their skill sets. And, a good pediatrician can coach his families how to adapt their strengths and weakness to the challenges of each of their children. For example, for a physician faced with a mother-infant dyad that is struggling with breastfeeding, once the education piece is in place, it is up to him or her to function as a coach and assist the team in setting a reasonable goal that can result in a win-win for the family.

A coach must be humble, putting his or her players’ needs first and flexible enough to adjust his or her goals to define success in terms for what is best for each individual team. “Coach” may not carry the ring of authority that can come with “Doctor” but it is a role equally as challenging and rewarding.
 

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.

It’s not unusual when I run into a former patient that I am addressed as “Doctor” Wilkoff. I guess that is to be expected because when I was in practice I seldom introduced myself as Will. However, I will admit now that I never quite felt comfortable with the “Doctor” label. Today, if you addressed me as “Doctor” I would correct you and refer to myself as the “ex-Doctor Wilkoff.”

The term doctor derived from the Latin word to teach and eventually morphed into an academic title. In common parlance it is sometimes used as verb meaning to treat, e.g., “he doctored the wound.” Regardless of what academic field we are talking about, the title “doctor” has become a term of respect for someone who has spent an unusually long time learning his or her subject or craft. The holder of a doctorate, particularly in medicine, receives a rank, earned or unearned, near the top of the social hierarchy.

When I look back at more than 50 years of doing pediatrics I’m not sure that “doctor” really captures what I was up to. I will grant you that it is nice that folks want to acknowledge all those years I spent in training. But I don’t think one could say that what I did as a primary care small town pediatrician fits in with the original definition “to teach.” I did spend a few hours teaching students every so often but my primary time was spent with patients and I don’t consider what I was doing with them as teaching. There just wasn’t enough time. I had to take as a given that families who came to see me already had a basic knowledge base either as the result of their schooling, family lore, or public service announcements from the American Academy of Pediatrics.

I certainly wasn’t doing much doctoring in the sense of treating or curing disease. If one removes administering immunizations and delivery room resuscitations, I saved very few lives.

So you may ask, if not as “doctor,” how would I prefer to be labeled? Good question, but easy for me to answer. The term “coach” quickly comes to mind. As someone who played a variety of team sports there is no term that I can think of that commands more respect than “Coach.” While the term doesn’t carry the burden of a particularly long educational journey it does imply the person is wise, observant, and experienced.

There is some teaching involved but primarily a coach is going to assess the players (or in this cases the families) he is presented with and then do the best he can to guide them toward good decisions they can make themselves given their specific situations. This requires spending most of one’s time getting to know each family and understanding their strengths and limitations. One can’t coach speed to an athlete who is slow footed. And, one isn’t going to get a family that is dominated by anxiety to become bold risk takers. The best you can do is to help them learn strategies to minimize their anxieties.

A good coach can help his players learn to set reasonable goals given their skill sets. And, a good pediatrician can coach his families how to adapt their strengths and weakness to the challenges of each of their children. For example, for a physician faced with a mother-infant dyad that is struggling with breastfeeding, once the education piece is in place, it is up to him or her to function as a coach and assist the team in setting a reasonable goal that can result in a win-win for the family.

A coach must be humble, putting his or her players’ needs first and flexible enough to adjust his or her goals to define success in terms for what is best for each individual team. “Coach” may not carry the ring of authority that can come with “Doctor” but it is a role equally as challenging and rewarding.
 

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.

It’s not unusual when I run into a former patient that I am addressed as “Doctor” Wilkoff. I guess that is to be expected because when I was in practice I seldom introduced myself as Will. However, I will admit now that I never quite felt comfortable with the “Doctor” label. Today, if you addressed me as “Doctor” I would correct you and refer to myself as the “ex-Doctor Wilkoff.”

The term doctor derived from the Latin word to teach and eventually morphed into an academic title. In common parlance it is sometimes used as verb meaning to treat, e.g., “he doctored the wound.” Regardless of what academic field we are talking about, the title “doctor” has become a term of respect for someone who has spent an unusually long time learning his or her subject or craft. The holder of a doctorate, particularly in medicine, receives a rank, earned or unearned, near the top of the social hierarchy.

When I look back at more than 50 years of doing pediatrics I’m not sure that “doctor” really captures what I was up to. I will grant you that it is nice that folks want to acknowledge all those years I spent in training. But I don’t think one could say that what I did as a primary care small town pediatrician fits in with the original definition “to teach.” I did spend a few hours teaching students every so often but my primary time was spent with patients and I don’t consider what I was doing with them as teaching. There just wasn’t enough time. I had to take as a given that families who came to see me already had a basic knowledge base either as the result of their schooling, family lore, or public service announcements from the American Academy of Pediatrics.

I certainly wasn’t doing much doctoring in the sense of treating or curing disease. If one removes administering immunizations and delivery room resuscitations, I saved very few lives.

So you may ask, if not as “doctor,” how would I prefer to be labeled? Good question, but easy for me to answer. The term “coach” quickly comes to mind. As someone who played a variety of team sports there is no term that I can think of that commands more respect than “Coach.” While the term doesn’t carry the burden of a particularly long educational journey it does imply the person is wise, observant, and experienced.

There is some teaching involved but primarily a coach is going to assess the players (or in this cases the families) he is presented with and then do the best he can to guide them toward good decisions they can make themselves given their specific situations. This requires spending most of one’s time getting to know each family and understanding their strengths and limitations. One can’t coach speed to an athlete who is slow footed. And, one isn’t going to get a family that is dominated by anxiety to become bold risk takers. The best you can do is to help them learn strategies to minimize their anxieties.

A good coach can help his players learn to set reasonable goals given their skill sets. And, a good pediatrician can coach his families how to adapt their strengths and weakness to the challenges of each of their children. For example, for a physician faced with a mother-infant dyad that is struggling with breastfeeding, once the education piece is in place, it is up to him or her to function as a coach and assist the team in setting a reasonable goal that can result in a win-win for the family.

A coach must be humble, putting his or her players’ needs first and flexible enough to adjust his or her goals to define success in terms for what is best for each individual team. “Coach” may not carry the ring of authority that can come with “Doctor” but it is a role equally as challenging and rewarding.
 

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.

Regardless of who received the most electoral votes it is pretty clear that each candidate has millions of supporters, and that they are separated by only a few percentage points. I guess one could argue that so many people being able to express their opinions is healthy. However, from my side of the divide I have difficulty understanding how so many of my fellow citizens could arrive at an opinion so diametrically opposed to my own.

Since the 2016 election I have tried to read as many articles as I could find in search of an explanation for that outcome and continuing partisan support. I have never had much interest in political science because it always sounded like an oxymoron. But I am willing to listen to anyone who claims to understand how so many other citizens can see the world so differently from the way I do. It simply may be that for whatever reason one person, in this case one man, has such charismatic power that his supporters willingly abandon the moral skeleton on which their lives had been draped. Or is this us versus them primarily a chasm between the elites and the nonelites?

I don’t know much about you but the fact that you are reading this column means that, like me, you are an elite. Even if you are a woman of color and the daughter of immigrants you have taken advantage of what opportunities you have been offered, stayed in school long enough to adopt a reverence for the scientific method, and have a job that pays well because you have acquired some expertise.

Tom Nichols, a political scientist teaching at Harvard Extension School, says that “expertise is a very exclusionary idea because it’s supposed to be: Not everybody gets a vote on how to fly the plane” (Why isn’t the right more afraid of COVID-19? by Christina Pazzanese, Harvard Gazette, Oct 30, 2020) This exclusivity may in part explain the cultural trend that has eroded faith in experts in general, but particularly around issues such as climate change. Ironically, although science continues to be held in esteem in our culture, many scientists have become targets for those citizens who wish to attack authority figures.

How is it that you and I as pediatricians have avoided those attacks and the derogatory label as “so-called experts”? We are scientists and elites. But, we have expertise in areas in which people often feel a critical need.

You may live and practice in a community where many of your patients’ families don’t share your political views. But you have probably been successful at maintaining a trusting relationship with them in large part because you have cast yourself in the role of an adviser and not a dictator. And, although at times it has been difficult, you have been careful to avoid sharing your advice in a manner that sounds condescending. You have succeeded in functioning as an expert while carefully disguising yourself as a nonelite.

However, you are skating on thin ice if you venture into topics that run counter to your patients’ religious beliefs. Theda Skocpol, professor of government and psychology at Harvard University, Cambridge, Mass., has observed that studies have shown that while religious conservatives are aware of the science and don’t reject the finding, “they resent the use of experts as political authorities.” This may explain why all across this diverse country, our patients are eager for and accepting of our advice on all manners of health-related issues until we step into a swampy area that threatens their political views – such as vaccination or gun control.

With one misstep in the wrong direction, you can go from being a compassionate adviser to an elitist “so-called expert.”
 

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.

Regardless of who received the most electoral votes it is pretty clear that each candidate has millions of supporters, and that they are separated by only a few percentage points. I guess one could argue that so many people being able to express their opinions is healthy. However, from my side of the divide I have difficulty understanding how so many of my fellow citizens could arrive at an opinion so diametrically opposed to my own.

Since the 2016 election I have tried to read as many articles as I could find in search of an explanation for that outcome and continuing partisan support. I have never had much interest in political science because it always sounded like an oxymoron. But I am willing to listen to anyone who claims to understand how so many other citizens can see the world so differently from the way I do. It simply may be that for whatever reason one person, in this case one man, has such charismatic power that his supporters willingly abandon the moral skeleton on which their lives had been draped. Or is this us versus them primarily a chasm between the elites and the nonelites?

I don’t know much about you but the fact that you are reading this column means that, like me, you are an elite. Even if you are a woman of color and the daughter of immigrants you have taken advantage of what opportunities you have been offered, stayed in school long enough to adopt a reverence for the scientific method, and have a job that pays well because you have acquired some expertise.

Tom Nichols, a political scientist teaching at Harvard Extension School, says that “expertise is a very exclusionary idea because it’s supposed to be: Not everybody gets a vote on how to fly the plane” (Why isn’t the right more afraid of COVID-19? by Christina Pazzanese, Harvard Gazette, Oct 30, 2020) This exclusivity may in part explain the cultural trend that has eroded faith in experts in general, but particularly around issues such as climate change. Ironically, although science continues to be held in esteem in our culture, many scientists have become targets for those citizens who wish to attack authority figures.

How is it that you and I as pediatricians have avoided those attacks and the derogatory label as “so-called experts”? We are scientists and elites. But, we have expertise in areas in which people often feel a critical need.

You may live and practice in a community where many of your patients’ families don’t share your political views. But you have probably been successful at maintaining a trusting relationship with them in large part because you have cast yourself in the role of an adviser and not a dictator. And, although at times it has been difficult, you have been careful to avoid sharing your advice in a manner that sounds condescending. You have succeeded in functioning as an expert while carefully disguising yourself as a nonelite.

However, you are skating on thin ice if you venture into topics that run counter to your patients’ religious beliefs. Theda Skocpol, professor of government and psychology at Harvard University, Cambridge, Mass., has observed that studies have shown that while religious conservatives are aware of the science and don’t reject the finding, “they resent the use of experts as political authorities.” This may explain why all across this diverse country, our patients are eager for and accepting of our advice on all manners of health-related issues until we step into a swampy area that threatens their political views – such as vaccination or gun control.

With one misstep in the wrong direction, you can go from being a compassionate adviser to an elitist “so-called expert.”
 

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.

Regardless of who received the most electoral votes it is pretty clear that each candidate has millions of supporters, and that they are separated by only a few percentage points. I guess one could argue that so many people being able to express their opinions is healthy. However, from my side of the divide I have difficulty understanding how so many of my fellow citizens could arrive at an opinion so diametrically opposed to my own.

Since the 2016 election I have tried to read as many articles as I could find in search of an explanation for that outcome and continuing partisan support. I have never had much interest in political science because it always sounded like an oxymoron. But I am willing to listen to anyone who claims to understand how so many other citizens can see the world so differently from the way I do. It simply may be that for whatever reason one person, in this case one man, has such charismatic power that his supporters willingly abandon the moral skeleton on which their lives had been draped. Or is this us versus them primarily a chasm between the elites and the nonelites?

I don’t know much about you but the fact that you are reading this column means that, like me, you are an elite. Even if you are a woman of color and the daughter of immigrants you have taken advantage of what opportunities you have been offered, stayed in school long enough to adopt a reverence for the scientific method, and have a job that pays well because you have acquired some expertise.

Tom Nichols, a political scientist teaching at Harvard Extension School, says that “expertise is a very exclusionary idea because it’s supposed to be: Not everybody gets a vote on how to fly the plane” (Why isn’t the right more afraid of COVID-19? by Christina Pazzanese, Harvard Gazette, Oct 30, 2020) This exclusivity may in part explain the cultural trend that has eroded faith in experts in general, but particularly around issues such as climate change. Ironically, although science continues to be held in esteem in our culture, many scientists have become targets for those citizens who wish to attack authority figures.

How is it that you and I as pediatricians have avoided those attacks and the derogatory label as “so-called experts”? We are scientists and elites. But, we have expertise in areas in which people often feel a critical need.

You may live and practice in a community where many of your patients’ families don’t share your political views. But you have probably been successful at maintaining a trusting relationship with them in large part because you have cast yourself in the role of an adviser and not a dictator. And, although at times it has been difficult, you have been careful to avoid sharing your advice in a manner that sounds condescending. You have succeeded in functioning as an expert while carefully disguising yourself as a nonelite.

However, you are skating on thin ice if you venture into topics that run counter to your patients’ religious beliefs. Theda Skocpol, professor of government and psychology at Harvard University, Cambridge, Mass., has observed that studies have shown that while religious conservatives are aware of the science and don’t reject the finding, “they resent the use of experts as political authorities.” This may explain why all across this diverse country, our patients are eager for and accepting of our advice on all manners of health-related issues until we step into a swampy area that threatens their political views – such as vaccination or gun control.

With one misstep in the wrong direction, you can go from being a compassionate adviser to an elitist “so-called expert.”
 

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 the COVID-19 vaccine candidates have begun to roll off the production lines into the distribution networks by the millions, media coverage almost universally includes a still photo or video of someone receiving an injection. Ever observant, a retired lawyer friend of mine who learned to give shots when he was in the Army and again more recently while taking a wilderness survival course emailed me his concerns about what he felt were examples of poor injection technique. Included in his commentary was an Internet link in which a physician, who I suspect may have been a pediatrician, demonstrated what the physician considered proper intramuscular injection technique, which included a single-handed aspiration prior to giving the injection allowing the free hand to stabilize the patient’s – in this case a child’s – arm during the entire process.

Sean Locke/iStockphoto

I replied to my friend that I too was often troubled by what I considered to be poor injection technique. But, I said the physician in the link touting his improved technique was misguided. My understanding has been that unless the injection site is in the gluteus, there is no need aspirate prior to an intramuscular vaccine injection because the risk of intravascular injection is so small. I then confirmed this by reviewing the Centers for Disease Control and Prevention’s Vaccine Recommendations and Guidelines of the Advisory Committee on Immunization Practices, which was updated in June 2019. Included in those recommendations was the observation that the vaccine administrator does not need to wear gloves unless he or she has open lesions or is at risk from contacting the recipient’s body fluids.

My little research project into proper injection technique got me thinking about how and when I learned to give shots. Like many of the technical skills one learns in training, giving intramuscular injections is probably an example of the “see one, do one, teach one” mantra. But in the case of giving shots, I don’t recall any teaching. Do you? It was more “see a dozen and get on with it.” Or maybe you trained in an environment in which nurses gave all the injections. I hope not.

When it comes to giving immunizations to children, the art is in entering into that encounter with a calm, matter-of-fact attitude and body language, hiding the needle, firmly restraining the child, and moving quickly and smoothly. Aspirating and glove donning merely add to the drama and waste time. But how did I learn that art? No one taught me. Like many clinical skills, I watched scores of nurses and physicians, mentally logging in their tricks and mistakes that would help me craft my style.

I always felt and still feel that providing immunizations was per hour spent, the most valuable investment of my time. Doing the injecting myself was both the most efficient way to provide the service, and also emphasized the importance that I placed on the immunization. In the process of my 40-plus–year career, that included several hundred thousand patient encounters in which I gave innumerable injections. And, I egotistically assumed that I was good at it because many infants never cried, and a few children said, “That didn’t hurt.” I suspect you can make the same claim.

Injecting millions of adults with a COVID-19 vaccine, on the other hand, is a piece of cake because restraining the recipient shouldn’t factor into the scenario. However, I wonder who is going to administer all those millions of injections and who is going to train them? How many of the trainers are aware of the CDC-ACIP guidelines? Or, are they going to fall back on old techniques that lack evidence support?

From the efficiency standpoint, it probably doesn’t make much difference. The injection takes but a few seconds. Filling out the paperwork and waiting for the recipient to figure out how to expose his or her deltoid can take fifty times that long.
 

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 the COVID-19 vaccine candidates have begun to roll off the production lines into the distribution networks by the millions, media coverage almost universally includes a still photo or video of someone receiving an injection. Ever observant, a retired lawyer friend of mine who learned to give shots when he was in the Army and again more recently while taking a wilderness survival course emailed me his concerns about what he felt were examples of poor injection technique. Included in his commentary was an Internet link in which a physician, who I suspect may have been a pediatrician, demonstrated what the physician considered proper intramuscular injection technique, which included a single-handed aspiration prior to giving the injection allowing the free hand to stabilize the patient’s – in this case a child’s – arm during the entire process.

Sean Locke/iStockphoto

I replied to my friend that I too was often troubled by what I considered to be poor injection technique. But, I said the physician in the link touting his improved technique was misguided. My understanding has been that unless the injection site is in the gluteus, there is no need aspirate prior to an intramuscular vaccine injection because the risk of intravascular injection is so small. I then confirmed this by reviewing the Centers for Disease Control and Prevention’s Vaccine Recommendations and Guidelines of the Advisory Committee on Immunization Practices, which was updated in June 2019. Included in those recommendations was the observation that the vaccine administrator does not need to wear gloves unless he or she has open lesions or is at risk from contacting the recipient’s body fluids.

My little research project into proper injection technique got me thinking about how and when I learned to give shots. Like many of the technical skills one learns in training, giving intramuscular injections is probably an example of the “see one, do one, teach one” mantra. But in the case of giving shots, I don’t recall any teaching. Do you? It was more “see a dozen and get on with it.” Or maybe you trained in an environment in which nurses gave all the injections. I hope not.

When it comes to giving immunizations to children, the art is in entering into that encounter with a calm, matter-of-fact attitude and body language, hiding the needle, firmly restraining the child, and moving quickly and smoothly. Aspirating and glove donning merely add to the drama and waste time. But how did I learn that art? No one taught me. Like many clinical skills, I watched scores of nurses and physicians, mentally logging in their tricks and mistakes that would help me craft my style.

I always felt and still feel that providing immunizations was per hour spent, the most valuable investment of my time. Doing the injecting myself was both the most efficient way to provide the service, and also emphasized the importance that I placed on the immunization. In the process of my 40-plus–year career, that included several hundred thousand patient encounters in which I gave innumerable injections. And, I egotistically assumed that I was good at it because many infants never cried, and a few children said, “That didn’t hurt.” I suspect you can make the same claim.

Injecting millions of adults with a COVID-19 vaccine, on the other hand, is a piece of cake because restraining the recipient shouldn’t factor into the scenario. However, I wonder who is going to administer all those millions of injections and who is going to train them? How many of the trainers are aware of the CDC-ACIP guidelines? Or, are they going to fall back on old techniques that lack evidence support?

From the efficiency standpoint, it probably doesn’t make much difference. The injection takes but a few seconds. Filling out the paperwork and waiting for the recipient to figure out how to expose his or her deltoid can take fifty times that long.
 

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 the COVID-19 vaccine candidates have begun to roll off the production lines into the distribution networks by the millions, media coverage almost universally includes a still photo or video of someone receiving an injection. Ever observant, a retired lawyer friend of mine who learned to give shots when he was in the Army and again more recently while taking a wilderness survival course emailed me his concerns about what he felt were examples of poor injection technique. Included in his commentary was an Internet link in which a physician, who I suspect may have been a pediatrician, demonstrated what the physician considered proper intramuscular injection technique, which included a single-handed aspiration prior to giving the injection allowing the free hand to stabilize the patient’s – in this case a child’s – arm during the entire process.

Sean Locke/iStockphoto

I replied to my friend that I too was often troubled by what I considered to be poor injection technique. But, I said the physician in the link touting his improved technique was misguided. My understanding has been that unless the injection site is in the gluteus, there is no need aspirate prior to an intramuscular vaccine injection because the risk of intravascular injection is so small. I then confirmed this by reviewing the Centers for Disease Control and Prevention’s Vaccine Recommendations and Guidelines of the Advisory Committee on Immunization Practices, which was updated in June 2019. Included in those recommendations was the observation that the vaccine administrator does not need to wear gloves unless he or she has open lesions or is at risk from contacting the recipient’s body fluids.

My little research project into proper injection technique got me thinking about how and when I learned to give shots. Like many of the technical skills one learns in training, giving intramuscular injections is probably an example of the “see one, do one, teach one” mantra. But in the case of giving shots, I don’t recall any teaching. Do you? It was more “see a dozen and get on with it.” Or maybe you trained in an environment in which nurses gave all the injections. I hope not.

When it comes to giving immunizations to children, the art is in entering into that encounter with a calm, matter-of-fact attitude and body language, hiding the needle, firmly restraining the child, and moving quickly and smoothly. Aspirating and glove donning merely add to the drama and waste time. But how did I learn that art? No one taught me. Like many clinical skills, I watched scores of nurses and physicians, mentally logging in their tricks and mistakes that would help me craft my style.

I always felt and still feel that providing immunizations was per hour spent, the most valuable investment of my time. Doing the injecting myself was both the most efficient way to provide the service, and also emphasized the importance that I placed on the immunization. In the process of my 40-plus–year career, that included several hundred thousand patient encounters in which I gave innumerable injections. And, I egotistically assumed that I was good at it because many infants never cried, and a few children said, “That didn’t hurt.” I suspect you can make the same claim.

Injecting millions of adults with a COVID-19 vaccine, on the other hand, is a piece of cake because restraining the recipient shouldn’t factor into the scenario. However, I wonder who is going to administer all those millions of injections and who is going to train them? How many of the trainers are aware of the CDC-ACIP guidelines? Or, are they going to fall back on old techniques that lack evidence support?

From the efficiency standpoint, it probably doesn’t make much difference. The injection takes but a few seconds. Filling out the paperwork and waiting for the recipient to figure out how to expose his or her deltoid can take fifty times that long.
 

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 the COVID-19 pandemic continues to chug along, some communities feel it slowing to a pace at which they might feel comfortable about a return to, if not quite “business as usual,” at least “business as sort of normal-ish.” They are ready to accept a level of disease that signals they have reached a steady state. However, in other communities, the virus has picked up speed and is threatening to overwhelm the medical infrastructure. If you are in one of those fortunate and skillfully managed states in which folks are beginning to talk seriously, but with little evidence, that it is time to return to normal, it is probably far too early. Are there any metrics that could be applied to make the decision to ease restrictions more rational?

Courtesy Dr. William G. Wilkoff

Eons ago in pandemic terms, the World Health Organization in Thailand published a list of criteria to aid in determining when a community could consider lifting the limits that seemed to have been effective in halting transmission of the virus (“Transitioning to and maintaining a steady state of low-level or no transmission,” WHO, Thailand, 2020 Apr 18). While much more has been learned about the behavior of the virus since the spring of 2020, the criteria from the WHO in Thailand are worth considering.

Here is my summary of their criteria for returning to normalcy. First, virus transmission is controlled to the point that only sporadic cases and small clusters exist, and that all of these are traceable in origin. Second, health care and public health systems are in place with sufficient capacities to manage a shift from detection to treatment should the case load increase dramatically; this capacity should include detection, testing, isolation, and quarantine. Third, outbreaks in high-risk populations such as nursing homes have been minimized. Fourth, workplace prevention strategies are in place and have been demonstrated to be effective. Fifth, risk of imported cases is at manageable levels. Finally, communities are engaged.

It is hard to argue with the rationale behind each of these criteria. However, the United States is not Thailand, and just thinking about how this country would go about meeting those criteria provides a window into some of the reasons why we have done so poorly and will continue to be challenged in dealing with the pandemic.

First, notice that the criteria make no mention of a vaccine. One gets the sense that from the top down our country is banking too heavily on the effectiveness and widespread delivery of a vaccine. Even if and when a vaccine is developed and delivered, all of these criteria still must be met and kept in mind for a future pandemic.

Second, the criteria call for an effective health care system, but it is abundantly clear that the United States does not have a cohesive health care system and probably won’t for the foreseeable future. The best we can hope for is individual states cobbling together their own systems, which may in turn serve as examples for those states who haven’t had the foresight. We have had a public health system of sorts, but its credibility and effectiveness has been neutered to the point that again we must rely on each state’s ability to see through the haze and create it’s own systems for detection, testing, tracking, isolating, and quarantining – often with little help in materiel support from the federal government. The sliver of good news is that, after a bit of a stumbling start, detecting and limiting the importation of cases from abroad is being addressed.

We continue to hear and see evidence that there are segments of the population who are not engaged in the activities that we have learned are necessary to stabilize the pandemic. My sense is that those people represent a very small minority. But, it is probably large enough to make the route to a steady state on a national level long and painful. This unfortunately is to be expected in a country that was built on a framework of personal freedoms. The best you can hope for in achieving a steady state is to live in one of the states that seems to be achieving the fine balance between personal freedoms and the common good.
 

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 the COVID-19 pandemic continues to chug along, some communities feel it slowing to a pace at which they might feel comfortable about a return to, if not quite “business as usual,” at least “business as sort of normal-ish.” They are ready to accept a level of disease that signals they have reached a steady state. However, in other communities, the virus has picked up speed and is threatening to overwhelm the medical infrastructure. If you are in one of those fortunate and skillfully managed states in which folks are beginning to talk seriously, but with little evidence, that it is time to return to normal, it is probably far too early. Are there any metrics that could be applied to make the decision to ease restrictions more rational?

Courtesy Dr. William G. Wilkoff

Eons ago in pandemic terms, the World Health Organization in Thailand published a list of criteria to aid in determining when a community could consider lifting the limits that seemed to have been effective in halting transmission of the virus (“Transitioning to and maintaining a steady state of low-level or no transmission,” WHO, Thailand, 2020 Apr 18). While much more has been learned about the behavior of the virus since the spring of 2020, the criteria from the WHO in Thailand are worth considering.

Here is my summary of their criteria for returning to normalcy. First, virus transmission is controlled to the point that only sporadic cases and small clusters exist, and that all of these are traceable in origin. Second, health care and public health systems are in place with sufficient capacities to manage a shift from detection to treatment should the case load increase dramatically; this capacity should include detection, testing, isolation, and quarantine. Third, outbreaks in high-risk populations such as nursing homes have been minimized. Fourth, workplace prevention strategies are in place and have been demonstrated to be effective. Fifth, risk of imported cases is at manageable levels. Finally, communities are engaged.

It is hard to argue with the rationale behind each of these criteria. However, the United States is not Thailand, and just thinking about how this country would go about meeting those criteria provides a window into some of the reasons why we have done so poorly and will continue to be challenged in dealing with the pandemic.

First, notice that the criteria make no mention of a vaccine. One gets the sense that from the top down our country is banking too heavily on the effectiveness and widespread delivery of a vaccine. Even if and when a vaccine is developed and delivered, all of these criteria still must be met and kept in mind for a future pandemic.

Second, the criteria call for an effective health care system, but it is abundantly clear that the United States does not have a cohesive health care system and probably won’t for the foreseeable future. The best we can hope for is individual states cobbling together their own systems, which may in turn serve as examples for those states who haven’t had the foresight. We have had a public health system of sorts, but its credibility and effectiveness has been neutered to the point that again we must rely on each state’s ability to see through the haze and create it’s own systems for detection, testing, tracking, isolating, and quarantining – often with little help in materiel support from the federal government. The sliver of good news is that, after a bit of a stumbling start, detecting and limiting the importation of cases from abroad is being addressed.

We continue to hear and see evidence that there are segments of the population who are not engaged in the activities that we have learned are necessary to stabilize the pandemic. My sense is that those people represent a very small minority. But, it is probably large enough to make the route to a steady state on a national level long and painful. This unfortunately is to be expected in a country that was built on a framework of personal freedoms. The best you can hope for in achieving a steady state is to live in one of the states that seems to be achieving the fine balance between personal freedoms and the common good.
 

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 the COVID-19 pandemic continues to chug along, some communities feel it slowing to a pace at which they might feel comfortable about a return to, if not quite “business as usual,” at least “business as sort of normal-ish.” They are ready to accept a level of disease that signals they have reached a steady state. However, in other communities, the virus has picked up speed and is threatening to overwhelm the medical infrastructure. If you are in one of those fortunate and skillfully managed states in which folks are beginning to talk seriously, but with little evidence, that it is time to return to normal, it is probably far too early. Are there any metrics that could be applied to make the decision to ease restrictions more rational?

Courtesy Dr. William G. Wilkoff

Eons ago in pandemic terms, the World Health Organization in Thailand published a list of criteria to aid in determining when a community could consider lifting the limits that seemed to have been effective in halting transmission of the virus (“Transitioning to and maintaining a steady state of low-level or no transmission,” WHO, Thailand, 2020 Apr 18). While much more has been learned about the behavior of the virus since the spring of 2020, the criteria from the WHO in Thailand are worth considering.

Here is my summary of their criteria for returning to normalcy. First, virus transmission is controlled to the point that only sporadic cases and small clusters exist, and that all of these are traceable in origin. Second, health care and public health systems are in place with sufficient capacities to manage a shift from detection to treatment should the case load increase dramatically; this capacity should include detection, testing, isolation, and quarantine. Third, outbreaks in high-risk populations such as nursing homes have been minimized. Fourth, workplace prevention strategies are in place and have been demonstrated to be effective. Fifth, risk of imported cases is at manageable levels. Finally, communities are engaged.

It is hard to argue with the rationale behind each of these criteria. However, the United States is not Thailand, and just thinking about how this country would go about meeting those criteria provides a window into some of the reasons why we have done so poorly and will continue to be challenged in dealing with the pandemic.

First, notice that the criteria make no mention of a vaccine. One gets the sense that from the top down our country is banking too heavily on the effectiveness and widespread delivery of a vaccine. Even if and when a vaccine is developed and delivered, all of these criteria still must be met and kept in mind for a future pandemic.

Second, the criteria call for an effective health care system, but it is abundantly clear that the United States does not have a cohesive health care system and probably won’t for the foreseeable future. The best we can hope for is individual states cobbling together their own systems, which may in turn serve as examples for those states who haven’t had the foresight. We have had a public health system of sorts, but its credibility and effectiveness has been neutered to the point that again we must rely on each state’s ability to see through the haze and create it’s own systems for detection, testing, tracking, isolating, and quarantining – often with little help in materiel support from the federal government. The sliver of good news is that, after a bit of a stumbling start, detecting and limiting the importation of cases from abroad is being addressed.

We continue to hear and see evidence that there are segments of the population who are not engaged in the activities that we have learned are necessary to stabilize the pandemic. My sense is that those people represent a very small minority. But, it is probably large enough to make the route to a steady state on a national level long and painful. This unfortunately is to be expected in a country that was built on a framework of personal freedoms. The best you can hope for in achieving a steady state is to live in one of the states that seems to be achieving the fine balance between personal freedoms and the common good.
 

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.

To say that the pandemic has dropped us into uncharted territory is an understatement of unmeasurable proportions. Every day we learn more about it, and every day that new information brings us new challenges. COVID-19 is playing by its own set of rules. To keep pace with it societies have been forced to adapt to them, and members of those societies have had to realize that these new rules must be obeyed or be prepared to suffer the consequences.

BananaStock/Thinkstock

I’m not sure exactly when it happened but gradually over my 7 and a half decades on this planet it appears that following the rules and understanding the value of “No” have become concepts to be ignored and left to gather dust in the attics and basements of our society. The tug of war between well-considered rules and the often misinterpreted concept of freedom has been ebbing and flowing since Eve plucked a forbidden apple off that tree.

In some parts of the world, the twin skills of saying and responding to “No” have become lost arts. I think it is not by chance that, of the four books I have written for parents, the one titled “How to Say No to Your Toddler” has become the most widely distributed, having been translated into Italian, Polish, and Russian. It is only slightly comforting to learn that at least some parents understand that creating rules can be important, but realize they aren’t quite sure how go about it.

As it has become clear that social distancing and mask wearing are associated with curtailing the spread of COVID-19, state and local governments have had to bone up on their long-forgotten No-saying skills. This relearning process has been particularly painful for school administrators who may have been warned that “You’ll never be able to get first and second graders to wear masks” or that “College students just won’t obey the rules.”

Both of these cautions are based on observations by educators with years of experience and certainly have a ring of truth to them. But could it be that these pessimistic predictions reflect a society in which parents and educators have lost the talent for crafting sensible rules and linking them to enforceable and rational consequences?

As colleges throughout the country have reopened using a variety of learning and residential strategies, there have been numerous incidents that validate the gloomy predictions of student misbehavior. Smaller schools seem to be having less difficulty, which is not surprising given their relative ease in fostering a sense of community. Many schools have been forced to rollback their plans for in-person learning because students have failed to follow some very simple but unpopular rules.

In a swift and decisive response to student misbehavior, Northeastern University in Boston dismissed 11 first-year students and will not refund their tuition when officials discovered a prohibited social gathering in one of the resident facilities (“Northeastern Dismisses 11 Students for Gathering in Violation of COVID-19 Policies,” by Ian Thomsen, News at Northwestern). This response seemed to have come as a surprise to many students and parents around the country who have become accustomed a diet of warnings and minor sanctions.

Whether this action by Northeastern will trigger similar responses by other universities remains to be seen. But we can hope that it sets an example of how learning about “No” can be an important part of one’s education.
 

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.

To say that the pandemic has dropped us into uncharted territory is an understatement of unmeasurable proportions. Every day we learn more about it, and every day that new information brings us new challenges. COVID-19 is playing by its own set of rules. To keep pace with it societies have been forced to adapt to them, and members of those societies have had to realize that these new rules must be obeyed or be prepared to suffer the consequences.

BananaStock/Thinkstock

I’m not sure exactly when it happened but gradually over my 7 and a half decades on this planet it appears that following the rules and understanding the value of “No” have become concepts to be ignored and left to gather dust in the attics and basements of our society. The tug of war between well-considered rules and the often misinterpreted concept of freedom has been ebbing and flowing since Eve plucked a forbidden apple off that tree.

In some parts of the world, the twin skills of saying and responding to “No” have become lost arts. I think it is not by chance that, of the four books I have written for parents, the one titled “How to Say No to Your Toddler” has become the most widely distributed, having been translated into Italian, Polish, and Russian. It is only slightly comforting to learn that at least some parents understand that creating rules can be important, but realize they aren’t quite sure how go about it.

As it has become clear that social distancing and mask wearing are associated with curtailing the spread of COVID-19, state and local governments have had to bone up on their long-forgotten No-saying skills. This relearning process has been particularly painful for school administrators who may have been warned that “You’ll never be able to get first and second graders to wear masks” or that “College students just won’t obey the rules.”

Both of these cautions are based on observations by educators with years of experience and certainly have a ring of truth to them. But could it be that these pessimistic predictions reflect a society in which parents and educators have lost the talent for crafting sensible rules and linking them to enforceable and rational consequences?

As colleges throughout the country have reopened using a variety of learning and residential strategies, there have been numerous incidents that validate the gloomy predictions of student misbehavior. Smaller schools seem to be having less difficulty, which is not surprising given their relative ease in fostering a sense of community. Many schools have been forced to rollback their plans for in-person learning because students have failed to follow some very simple but unpopular rules.

In a swift and decisive response to student misbehavior, Northeastern University in Boston dismissed 11 first-year students and will not refund their tuition when officials discovered a prohibited social gathering in one of the resident facilities (“Northeastern Dismisses 11 Students for Gathering in Violation of COVID-19 Policies,” by Ian Thomsen, News at Northwestern). This response seemed to have come as a surprise to many students and parents around the country who have become accustomed a diet of warnings and minor sanctions.

Whether this action by Northeastern will trigger similar responses by other universities remains to be seen. But we can hope that it sets an example of how learning about “No” can be an important part of one’s education.
 

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.

To say that the pandemic has dropped us into uncharted territory is an understatement of unmeasurable proportions. Every day we learn more about it, and every day that new information brings us new challenges. COVID-19 is playing by its own set of rules. To keep pace with it societies have been forced to adapt to them, and members of those societies have had to realize that these new rules must be obeyed or be prepared to suffer the consequences.

BananaStock/Thinkstock

I’m not sure exactly when it happened but gradually over my 7 and a half decades on this planet it appears that following the rules and understanding the value of “No” have become concepts to be ignored and left to gather dust in the attics and basements of our society. The tug of war between well-considered rules and the often misinterpreted concept of freedom has been ebbing and flowing since Eve plucked a forbidden apple off that tree.

In some parts of the world, the twin skills of saying and responding to “No” have become lost arts. I think it is not by chance that, of the four books I have written for parents, the one titled “How to Say No to Your Toddler” has become the most widely distributed, having been translated into Italian, Polish, and Russian. It is only slightly comforting to learn that at least some parents understand that creating rules can be important, but realize they aren’t quite sure how go about it.

As it has become clear that social distancing and mask wearing are associated with curtailing the spread of COVID-19, state and local governments have had to bone up on their long-forgotten No-saying skills. This relearning process has been particularly painful for school administrators who may have been warned that “You’ll never be able to get first and second graders to wear masks” or that “College students just won’t obey the rules.”

Both of these cautions are based on observations by educators with years of experience and certainly have a ring of truth to them. But could it be that these pessimistic predictions reflect a society in which parents and educators have lost the talent for crafting sensible rules and linking them to enforceable and rational consequences?

As colleges throughout the country have reopened using a variety of learning and residential strategies, there have been numerous incidents that validate the gloomy predictions of student misbehavior. Smaller schools seem to be having less difficulty, which is not surprising given their relative ease in fostering a sense of community. Many schools have been forced to rollback their plans for in-person learning because students have failed to follow some very simple but unpopular rules.

In a swift and decisive response to student misbehavior, Northeastern University in Boston dismissed 11 first-year students and will not refund their tuition when officials discovered a prohibited social gathering in one of the resident facilities (“Northeastern Dismisses 11 Students for Gathering in Violation of COVID-19 Policies,” by Ian Thomsen, News at Northwestern). This response seemed to have come as a surprise to many students and parents around the country who have become accustomed a diet of warnings and minor sanctions.

Whether this action by Northeastern will trigger similar responses by other universities remains to be seen. But we can hope that it sets an example of how learning about “No” can be an important part of one’s education.
 

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.