Letters from Maine

The recent decisions by the United States Supreme Court (SCOTUS) declaring the current admission policies at Harvard and the University of North Carolina illegal have sent shock waves through the university and graduate school communities. In the minds of many observers, these decisions have effectively eliminated affirmative action as a tool for leveling the playing field for ethnic minorities.

However, there are some commentators who feel that affirmative action has never been as effective as others have believed. They point out that the number of students admitted to the most selective schools is very small compared with the entire nation’s collection of colleges and universities. Regardless of where you come down on the effectiveness of past affirmative action policies, the SCOTUS decision is a done deal. It’s time to move on and begin anew our search for inclusion-promoting strategies that will pass the Court’s litmus test of legality.

I count myself among those who are optimistic that there are enough of us committed individuals that a new and better version of affirmative action is just over the horizon. Some of my supporting evidence can be found in a New York Times article by Stephanie Saul describing the admissions policy at the University of California Davis Medical School. The keystone of the university’s policy is a “socioeconomic disadvantage scale” that takes into account the applicant’s life circumstances, such as parental education and family income. This ranking – on a scale of 0 to 99 – is tossed into the standard mix of grades, test scores, essays, interviews, and recommendations. It shouldn’t surprise that UC Davis is now one of the most diverse medical schools in the United States despite the fact that California voted to ban affirmative action in 1996.

The socioeconomic disadvantage scale may, in the long run, be more effective than the current affirmative action strategies that have been race based. It certainly makes more sense to me. For example, in 2020 the Medical College Admission Test (MCAT) made a significant philosophical change by broadening and deepening its focus on the social sciences. To some extent, this refocusing may have reflected the American Association of Medical Colleges’ search for more well-rounded students and, by extension, more physicians sensitive to the plight of their disadvantaged patients. By weighting the questions more toward subjects such as how bias can influence patient care, it was hoped that the newly minted physicians would view and treat patients not just as victims of illness but as multifaceted individuals who reside in an environment that may be influencing their health.

While I agree with the goal of creating physicians with a broader and more holistic view, the notion that adding questions from social science disciplines is going to achieve this goal never made much sense to me. Answering questions posed by social scientists teaching in a selective academic setting doesn’t necessarily guarantee that the applicant has a full understanding of the real-world consequences of poverty and bias.

On the other hand, an applicant’s responses to a questionnaire about the socioeconomic conditions in which she or he grew up is far more likely to unearth candidates with a deep, broad, and very personal understanding of the challenges that disadvantaged patients face. It’s another one of those been-there-know-how-it-feels kind of things. Reading a book about how to ride a bicycle cannot quite capture the challenge of balancing yourself on two thin wheels.

Whether an affirmative action plan that includes a socioeconomic scale will indeed spawn a crop of physicians who will practice customer-friendly, understanding, and sensitive medicine remains to be seen. The pathway to becoming a practicing physician takes a minimum of 6 or 7 years. Much of that education comes in the form of watching and listening to physicians who, in turn, modeled their behavior after the cohort that preceded them in a very old system, and so on. There is no guarantee that even the most sensitively selected students will remain immune to incorporating into their practice style some of the systemic bias that will inevitably surround them. But a socioeconomic disadvantage scale is certainly worth a try.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

The recent decisions by the United States Supreme Court (SCOTUS) declaring the current admission policies at Harvard and the University of North Carolina illegal have sent shock waves through the university and graduate school communities. In the minds of many observers, these decisions have effectively eliminated affirmative action as a tool for leveling the playing field for ethnic minorities.

However, there are some commentators who feel that affirmative action has never been as effective as others have believed. They point out that the number of students admitted to the most selective schools is very small compared with the entire nation’s collection of colleges and universities. Regardless of where you come down on the effectiveness of past affirmative action policies, the SCOTUS decision is a done deal. It’s time to move on and begin anew our search for inclusion-promoting strategies that will pass the Court’s litmus test of legality.

I count myself among those who are optimistic that there are enough of us committed individuals that a new and better version of affirmative action is just over the horizon. Some of my supporting evidence can be found in a New York Times article by Stephanie Saul describing the admissions policy at the University of California Davis Medical School. The keystone of the university’s policy is a “socioeconomic disadvantage scale” that takes into account the applicant’s life circumstances, such as parental education and family income. This ranking – on a scale of 0 to 99 – is tossed into the standard mix of grades, test scores, essays, interviews, and recommendations. It shouldn’t surprise that UC Davis is now one of the most diverse medical schools in the United States despite the fact that California voted to ban affirmative action in 1996.

The socioeconomic disadvantage scale may, in the long run, be more effective than the current affirmative action strategies that have been race based. It certainly makes more sense to me. For example, in 2020 the Medical College Admission Test (MCAT) made a significant philosophical change by broadening and deepening its focus on the social sciences. To some extent, this refocusing may have reflected the American Association of Medical Colleges’ search for more well-rounded students and, by extension, more physicians sensitive to the plight of their disadvantaged patients. By weighting the questions more toward subjects such as how bias can influence patient care, it was hoped that the newly minted physicians would view and treat patients not just as victims of illness but as multifaceted individuals who reside in an environment that may be influencing their health.

While I agree with the goal of creating physicians with a broader and more holistic view, the notion that adding questions from social science disciplines is going to achieve this goal never made much sense to me. Answering questions posed by social scientists teaching in a selective academic setting doesn’t necessarily guarantee that the applicant has a full understanding of the real-world consequences of poverty and bias.

On the other hand, an applicant’s responses to a questionnaire about the socioeconomic conditions in which she or he grew up is far more likely to unearth candidates with a deep, broad, and very personal understanding of the challenges that disadvantaged patients face. It’s another one of those been-there-know-how-it-feels kind of things. Reading a book about how to ride a bicycle cannot quite capture the challenge of balancing yourself on two thin wheels.

Whether an affirmative action plan that includes a socioeconomic scale will indeed spawn a crop of physicians who will practice customer-friendly, understanding, and sensitive medicine remains to be seen. The pathway to becoming a practicing physician takes a minimum of 6 or 7 years. Much of that education comes in the form of watching and listening to physicians who, in turn, modeled their behavior after the cohort that preceded them in a very old system, and so on. There is no guarantee that even the most sensitively selected students will remain immune to incorporating into their practice style some of the systemic bias that will inevitably surround them. But a socioeconomic disadvantage scale is certainly worth a try.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

The recent decisions by the United States Supreme Court (SCOTUS) declaring the current admission policies at Harvard and the University of North Carolina illegal have sent shock waves through the university and graduate school communities. In the minds of many observers, these decisions have effectively eliminated affirmative action as a tool for leveling the playing field for ethnic minorities.

However, there are some commentators who feel that affirmative action has never been as effective as others have believed. They point out that the number of students admitted to the most selective schools is very small compared with the entire nation’s collection of colleges and universities. Regardless of where you come down on the effectiveness of past affirmative action policies, the SCOTUS decision is a done deal. It’s time to move on and begin anew our search for inclusion-promoting strategies that will pass the Court’s litmus test of legality.

I count myself among those who are optimistic that there are enough of us committed individuals that a new and better version of affirmative action is just over the horizon. Some of my supporting evidence can be found in a New York Times article by Stephanie Saul describing the admissions policy at the University of California Davis Medical School. The keystone of the university’s policy is a “socioeconomic disadvantage scale” that takes into account the applicant’s life circumstances, such as parental education and family income. This ranking – on a scale of 0 to 99 – is tossed into the standard mix of grades, test scores, essays, interviews, and recommendations. It shouldn’t surprise that UC Davis is now one of the most diverse medical schools in the United States despite the fact that California voted to ban affirmative action in 1996.

The socioeconomic disadvantage scale may, in the long run, be more effective than the current affirmative action strategies that have been race based. It certainly makes more sense to me. For example, in 2020 the Medical College Admission Test (MCAT) made a significant philosophical change by broadening and deepening its focus on the social sciences. To some extent, this refocusing may have reflected the American Association of Medical Colleges’ search for more well-rounded students and, by extension, more physicians sensitive to the plight of their disadvantaged patients. By weighting the questions more toward subjects such as how bias can influence patient care, it was hoped that the newly minted physicians would view and treat patients not just as victims of illness but as multifaceted individuals who reside in an environment that may be influencing their health.

While I agree with the goal of creating physicians with a broader and more holistic view, the notion that adding questions from social science disciplines is going to achieve this goal never made much sense to me. Answering questions posed by social scientists teaching in a selective academic setting doesn’t necessarily guarantee that the applicant has a full understanding of the real-world consequences of poverty and bias.

On the other hand, an applicant’s responses to a questionnaire about the socioeconomic conditions in which she or he grew up is far more likely to unearth candidates with a deep, broad, and very personal understanding of the challenges that disadvantaged patients face. It’s another one of those been-there-know-how-it-feels kind of things. Reading a book about how to ride a bicycle cannot quite capture the challenge of balancing yourself on two thin wheels.

Whether an affirmative action plan that includes a socioeconomic scale will indeed spawn a crop of physicians who will practice customer-friendly, understanding, and sensitive medicine remains to be seen. The pathway to becoming a practicing physician takes a minimum of 6 or 7 years. Much of that education comes in the form of watching and listening to physicians who, in turn, modeled their behavior after the cohort that preceded them in a very old system, and so on. There is no guarantee that even the most sensitively selected students will remain immune to incorporating into their practice style some of the systemic bias that will inevitably surround them. But a socioeconomic disadvantage scale is certainly worth a try.

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.

Many decades ago I wrote a book I brazenly titled: “The Good Grandmother Handbook.” I had been a parent for a scant 7 or 8 years but based on my experiences in the office I felt I had accumulated enough wisdom to suggest to women in their fifth to seventh decades how they might conduct themselves around their grandchildren. Luckily, the book never got further than several hundred pages of crudely typed manuscript. This was before word processing programs had settled into the home computer industry, which was still in its infancy.

But I continue find the subject of grandparents interesting. Now, with grandchildren of my own (the oldest has just graduated from high school) and scores of peers knee deep in their own grandparenting adventures, I hope that my perspective now has a bit less of a holier-than-thou aroma.

My most recent muse-prodding event came when I stumbled across an article about the epidemiology of unintentional pediatric firearm fatalities. Looking at 10 years of data from the National Violent Death Reporting System, the investigators found that in 80% of the cases the firearm owner was a relative of the victim; in slightly more than 60% of the cases the event occurred in the victim’s home.

The data set was not granular enough to define the exact relationship between the child and relative who owned the gun. I suspect that most often the relative was a parent or an uncle or aunt. However, viewed through my septuagenarian prism, this paper prompted me to wonder in how many of these fatalities the firearm owner was a grandparent.

I have only anecdotal observations, but I can easily recall situations here in Maine in which a child has been injured by his or her grandfather’s gun. The data from the study show that pediatric fatalities are bimodal, with the majority occurring in the 1- to 5-year age group and a second peak in adolescence. The grandparent-involved cases I can recall were in the younger demographic.

Unfortunately, firearms aren’t the only threat that other grandparents and I pose to the health and safety of our grandchildren. I can remember before the development of, and the widespread use of, tamper-proof pill bottles, “grandma’s purse” overdoses were an unfortunately common occurrence.

More recently, at least here in Maine, we have been hearing more about motorized vehicle–related injuries and fatalities – grandparents backing over their grandchildren in the driveway or, more often, grandfathers (usually) taking their young grandchildren for rides on their snowmobiles, ATVs, lawn tractors, (fill in the blank). Whenever one of these events occurs, my mind quickly jumps beyond the tragic loss of life to imagining what terrible and long-lasting emotional chaos these incidents have spawned in those families.

During the pandemic, many parents and grandparents became aware of the threat that viral-spewing young children pose to the older and more vulnerable generation. On the other hand, many parents have been told that having a grandparent around can present a risk to the health and safety of their grandchildren. It can be a touchy subject in families, and grandparents may bristle at “being treated like a child” when they are reminded that children aren’t small adults and that their own behavior may be setting a bad example or putting their grandchildren at risk.

My generation had to learn how to buckle infants and toddlers into car seats because it was something that wasn’t done for our children. Fortunately, most new grandparents now already have those buckle-and-click skills and mindset. But, there are still many aspects of child safety, including firearms availability, that we must address, and our messages of caution should also target grandparents.

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.

Many decades ago I wrote a book I brazenly titled: “The Good Grandmother Handbook.” I had been a parent for a scant 7 or 8 years but based on my experiences in the office I felt I had accumulated enough wisdom to suggest to women in their fifth to seventh decades how they might conduct themselves around their grandchildren. Luckily, the book never got further than several hundred pages of crudely typed manuscript. This was before word processing programs had settled into the home computer industry, which was still in its infancy.

But I continue find the subject of grandparents interesting. Now, with grandchildren of my own (the oldest has just graduated from high school) and scores of peers knee deep in their own grandparenting adventures, I hope that my perspective now has a bit less of a holier-than-thou aroma.

My most recent muse-prodding event came when I stumbled across an article about the epidemiology of unintentional pediatric firearm fatalities. Looking at 10 years of data from the National Violent Death Reporting System, the investigators found that in 80% of the cases the firearm owner was a relative of the victim; in slightly more than 60% of the cases the event occurred in the victim’s home.

The data set was not granular enough to define the exact relationship between the child and relative who owned the gun. I suspect that most often the relative was a parent or an uncle or aunt. However, viewed through my septuagenarian prism, this paper prompted me to wonder in how many of these fatalities the firearm owner was a grandparent.

I have only anecdotal observations, but I can easily recall situations here in Maine in which a child has been injured by his or her grandfather’s gun. The data from the study show that pediatric fatalities are bimodal, with the majority occurring in the 1- to 5-year age group and a second peak in adolescence. The grandparent-involved cases I can recall were in the younger demographic.

Unfortunately, firearms aren’t the only threat that other grandparents and I pose to the health and safety of our grandchildren. I can remember before the development of, and the widespread use of, tamper-proof pill bottles, “grandma’s purse” overdoses were an unfortunately common occurrence.

More recently, at least here in Maine, we have been hearing more about motorized vehicle–related injuries and fatalities – grandparents backing over their grandchildren in the driveway or, more often, grandfathers (usually) taking their young grandchildren for rides on their snowmobiles, ATVs, lawn tractors, (fill in the blank). Whenever one of these events occurs, my mind quickly jumps beyond the tragic loss of life to imagining what terrible and long-lasting emotional chaos these incidents have spawned in those families.

During the pandemic, many parents and grandparents became aware of the threat that viral-spewing young children pose to the older and more vulnerable generation. On the other hand, many parents have been told that having a grandparent around can present a risk to the health and safety of their grandchildren. It can be a touchy subject in families, and grandparents may bristle at “being treated like a child” when they are reminded that children aren’t small adults and that their own behavior may be setting a bad example or putting their grandchildren at risk.

My generation had to learn how to buckle infants and toddlers into car seats because it was something that wasn’t done for our children. Fortunately, most new grandparents now already have those buckle-and-click skills and mindset. But, there are still many aspects of child safety, including firearms availability, that we must address, and our messages of caution should also target grandparents.

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.

Many decades ago I wrote a book I brazenly titled: “The Good Grandmother Handbook.” I had been a parent for a scant 7 or 8 years but based on my experiences in the office I felt I had accumulated enough wisdom to suggest to women in their fifth to seventh decades how they might conduct themselves around their grandchildren. Luckily, the book never got further than several hundred pages of crudely typed manuscript. This was before word processing programs had settled into the home computer industry, which was still in its infancy.

But I continue find the subject of grandparents interesting. Now, with grandchildren of my own (the oldest has just graduated from high school) and scores of peers knee deep in their own grandparenting adventures, I hope that my perspective now has a bit less of a holier-than-thou aroma.

My most recent muse-prodding event came when I stumbled across an article about the epidemiology of unintentional pediatric firearm fatalities. Looking at 10 years of data from the National Violent Death Reporting System, the investigators found that in 80% of the cases the firearm owner was a relative of the victim; in slightly more than 60% of the cases the event occurred in the victim’s home.

The data set was not granular enough to define the exact relationship between the child and relative who owned the gun. I suspect that most often the relative was a parent or an uncle or aunt. However, viewed through my septuagenarian prism, this paper prompted me to wonder in how many of these fatalities the firearm owner was a grandparent.

I have only anecdotal observations, but I can easily recall situations here in Maine in which a child has been injured by his or her grandfather’s gun. The data from the study show that pediatric fatalities are bimodal, with the majority occurring in the 1- to 5-year age group and a second peak in adolescence. The grandparent-involved cases I can recall were in the younger demographic.

Unfortunately, firearms aren’t the only threat that other grandparents and I pose to the health and safety of our grandchildren. I can remember before the development of, and the widespread use of, tamper-proof pill bottles, “grandma’s purse” overdoses were an unfortunately common occurrence.

More recently, at least here in Maine, we have been hearing more about motorized vehicle–related injuries and fatalities – grandparents backing over their grandchildren in the driveway or, more often, grandfathers (usually) taking their young grandchildren for rides on their snowmobiles, ATVs, lawn tractors, (fill in the blank). Whenever one of these events occurs, my mind quickly jumps beyond the tragic loss of life to imagining what terrible and long-lasting emotional chaos these incidents have spawned in those families.

During the pandemic, many parents and grandparents became aware of the threat that viral-spewing young children pose to the older and more vulnerable generation. On the other hand, many parents have been told that having a grandparent around can present a risk to the health and safety of their grandchildren. It can be a touchy subject in families, and grandparents may bristle at “being treated like a child” when they are reminded that children aren’t small adults and that their own behavior may be setting a bad example or putting their grandchildren at risk.

My generation had to learn how to buckle infants and toddlers into car seats because it was something that wasn’t done for our children. Fortunately, most new grandparents now already have those buckle-and-click skills and mindset. But, there are still many aspects of child safety, including firearms availability, that we must address, and our messages of caution should also target grandparents.

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.

Abdominal pain has always been among the most common complaints fielded by primary care pediatricians. Much has been written about how we clinicians should respond when one of these patients presents in our office. Obviously, we start with a good history and physical exam and then progress to whatever laboratory or imaging tests we believe will yield the most accurate diagnosis in the shortest amount of time and with the minimum risk to the patient.

However, the number of children complaining of abdominal pain who arrive at clinicians’ offices is but a mere fraction of the youngsters who have shared the complaint with their parents or caregivers. Little has been written about what is going on beneath the surface of this monstrous iceberg of pediatric abdominal pain.

A recent poll commissioned by C.S. Mott Children’s Hospital at the University of Michigan attempts to determine how Doctor Moms and Dads are handling their children’s belly pain complaints on what is truly the frontline of health care. Using a national panel of more than 2,000 parents, the investigators reviewed the responses of more than 1,000 individuals who had at least one child age 3-10.

Seventeen percent of the parents reported that their children complained of abdominal pain at least once a month. Only a bit more than 50% of these parents say they have discussed this frequent pain with their children’s providers. Less than a third of parents reported their children complain of abdominal pain only a few times a year and half the parents responded that their children rarely or never complained of a bellyache.

The survey drilled a little deeper and discovered that for the most part, parents took a thoughtful history and did a reasonably focused physical exam. More than a third of respondents felt “very confident” in their ability to recognize a serious problem. A third of parents reported that they would treat the symptoms with an over-the-counter product.

About a quarter of the parents attributed their children’s complaints to anxiety or to gain attention. In these situations, more than half of the parents said they would talk to the child about his/her concerns and/or suggest relaxation techniques or employ distraction. Only a few would allow the child to stay home from school or miss other activities. In general, it feels like Dr. Moms and Dads in the trenches are doing a pretty good job evaluating, triaging, and managing most children with abdominal pain. At least in my experience, unfortunate outcomes of pediatric abdominal pain as the result of home mismanagement are rare.

This is a nice little survey, but I don’t think it tells us much we haven’t already suspected. What we really want to know more about are those exceedingly rare but avoidable situations when parents have not managed their children’s belly pain well and the results have been tragic. Why did they wait so long to call the physician? What signs did they miss? What symptoms did they ignore or discount? Are there patterns we can better address with education?

Just as in cases of Sudden Unexplained Infant Death, investigating with sensitivity can be extremely difficult. Interviewing parents who are still processing the unexpected death of their child is something that must be done without the slightest hint of assessing blame. Sometimes that is just plain impossible. Fortunately, these cases are rare.

If we are considering launching the study that I have proposed, we must also embark on a parallel study that asks what are the systemic conditions that may have led to the tragic mismanagement of pediatric abdominal pain? When parents have been alert to children’s complaints and appearance and attempted to seek medical care, what impediments did they encounter? Was there a triage nurse or on call physician who didn’t listen, or failed to ask the right questions? Was the emergency room just too busy to allow a proper evaluation? Was there a communication problem? And, of course, there is always the money. Did the parents’ concern about paying for the evaluation blind them to their instinct to call? These are not easy questions to ask ourselves but they must be asked if we wish to bring our failure rate closer to zero and retain the trust of our patients.

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.

Abdominal pain has always been among the most common complaints fielded by primary care pediatricians. Much has been written about how we clinicians should respond when one of these patients presents in our office. Obviously, we start with a good history and physical exam and then progress to whatever laboratory or imaging tests we believe will yield the most accurate diagnosis in the shortest amount of time and with the minimum risk to the patient.

However, the number of children complaining of abdominal pain who arrive at clinicians’ offices is but a mere fraction of the youngsters who have shared the complaint with their parents or caregivers. Little has been written about what is going on beneath the surface of this monstrous iceberg of pediatric abdominal pain.

A recent poll commissioned by C.S. Mott Children’s Hospital at the University of Michigan attempts to determine how Doctor Moms and Dads are handling their children’s belly pain complaints on what is truly the frontline of health care. Using a national panel of more than 2,000 parents, the investigators reviewed the responses of more than 1,000 individuals who had at least one child age 3-10.

Seventeen percent of the parents reported that their children complained of abdominal pain at least once a month. Only a bit more than 50% of these parents say they have discussed this frequent pain with their children’s providers. Less than a third of parents reported their children complain of abdominal pain only a few times a year and half the parents responded that their children rarely or never complained of a bellyache.

The survey drilled a little deeper and discovered that for the most part, parents took a thoughtful history and did a reasonably focused physical exam. More than a third of respondents felt “very confident” in their ability to recognize a serious problem. A third of parents reported that they would treat the symptoms with an over-the-counter product.

About a quarter of the parents attributed their children’s complaints to anxiety or to gain attention. In these situations, more than half of the parents said they would talk to the child about his/her concerns and/or suggest relaxation techniques or employ distraction. Only a few would allow the child to stay home from school or miss other activities. In general, it feels like Dr. Moms and Dads in the trenches are doing a pretty good job evaluating, triaging, and managing most children with abdominal pain. At least in my experience, unfortunate outcomes of pediatric abdominal pain as the result of home mismanagement are rare.

This is a nice little survey, but I don’t think it tells us much we haven’t already suspected. What we really want to know more about are those exceedingly rare but avoidable situations when parents have not managed their children’s belly pain well and the results have been tragic. Why did they wait so long to call the physician? What signs did they miss? What symptoms did they ignore or discount? Are there patterns we can better address with education?

Just as in cases of Sudden Unexplained Infant Death, investigating with sensitivity can be extremely difficult. Interviewing parents who are still processing the unexpected death of their child is something that must be done without the slightest hint of assessing blame. Sometimes that is just plain impossible. Fortunately, these cases are rare.

If we are considering launching the study that I have proposed, we must also embark on a parallel study that asks what are the systemic conditions that may have led to the tragic mismanagement of pediatric abdominal pain? When parents have been alert to children’s complaints and appearance and attempted to seek medical care, what impediments did they encounter? Was there a triage nurse or on call physician who didn’t listen, or failed to ask the right questions? Was the emergency room just too busy to allow a proper evaluation? Was there a communication problem? And, of course, there is always the money. Did the parents’ concern about paying for the evaluation blind them to their instinct to call? These are not easy questions to ask ourselves but they must be asked if we wish to bring our failure rate closer to zero and retain the trust of our patients.

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.

Abdominal pain has always been among the most common complaints fielded by primary care pediatricians. Much has been written about how we clinicians should respond when one of these patients presents in our office. Obviously, we start with a good history and physical exam and then progress to whatever laboratory or imaging tests we believe will yield the most accurate diagnosis in the shortest amount of time and with the minimum risk to the patient.

However, the number of children complaining of abdominal pain who arrive at clinicians’ offices is but a mere fraction of the youngsters who have shared the complaint with their parents or caregivers. Little has been written about what is going on beneath the surface of this monstrous iceberg of pediatric abdominal pain.

A recent poll commissioned by C.S. Mott Children’s Hospital at the University of Michigan attempts to determine how Doctor Moms and Dads are handling their children’s belly pain complaints on what is truly the frontline of health care. Using a national panel of more than 2,000 parents, the investigators reviewed the responses of more than 1,000 individuals who had at least one child age 3-10.

Seventeen percent of the parents reported that their children complained of abdominal pain at least once a month. Only a bit more than 50% of these parents say they have discussed this frequent pain with their children’s providers. Less than a third of parents reported their children complain of abdominal pain only a few times a year and half the parents responded that their children rarely or never complained of a bellyache.

The survey drilled a little deeper and discovered that for the most part, parents took a thoughtful history and did a reasonably focused physical exam. More than a third of respondents felt “very confident” in their ability to recognize a serious problem. A third of parents reported that they would treat the symptoms with an over-the-counter product.

About a quarter of the parents attributed their children’s complaints to anxiety or to gain attention. In these situations, more than half of the parents said they would talk to the child about his/her concerns and/or suggest relaxation techniques or employ distraction. Only a few would allow the child to stay home from school or miss other activities. In general, it feels like Dr. Moms and Dads in the trenches are doing a pretty good job evaluating, triaging, and managing most children with abdominal pain. At least in my experience, unfortunate outcomes of pediatric abdominal pain as the result of home mismanagement are rare.

This is a nice little survey, but I don’t think it tells us much we haven’t already suspected. What we really want to know more about are those exceedingly rare but avoidable situations when parents have not managed their children’s belly pain well and the results have been tragic. Why did they wait so long to call the physician? What signs did they miss? What symptoms did they ignore or discount? Are there patterns we can better address with education?

Just as in cases of Sudden Unexplained Infant Death, investigating with sensitivity can be extremely difficult. Interviewing parents who are still processing the unexpected death of their child is something that must be done without the slightest hint of assessing blame. Sometimes that is just plain impossible. Fortunately, these cases are rare.

If we are considering launching the study that I have proposed, we must also embark on a parallel study that asks what are the systemic conditions that may have led to the tragic mismanagement of pediatric abdominal pain? When parents have been alert to children’s complaints and appearance and attempted to seek medical care, what impediments did they encounter? Was there a triage nurse or on call physician who didn’t listen, or failed to ask the right questions? Was the emergency room just too busy to allow a proper evaluation? Was there a communication problem? And, of course, there is always the money. Did the parents’ concern about paying for the evaluation blind them to their instinct to call? These are not easy questions to ask ourselves but they must be asked if we wish to bring our failure rate closer to zero and retain the trust of our patients.

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.

Although we continue to hear a chorus of cautions from the wise folks in the public health community, most of us and our political leaders have allowed the SARS-CoV-2 pandemic to slip quietly into the dark recesses of our been-there-done-that pile. Obviously, this failure to continue learning from our mistakes is an oversight for which we will pay dearly the next time a public health crisis requiring a coordinated effort on a national and international scale raises its ugly head.

However, there is a significant portion of the population for whom the pandemic is fresh in their minds because they are experiencing the symptoms of what they have been told is long COVID. In January 2023 the Kaiser Family Foundation reported that 15% of the U.S. population feels that at some point they have experienced the symptoms of long COVID. And 6% report that they believe they currently have long COVID.

As long ago as February of 2021, Congress gave the National Institutes of Health $1.5 billion to fund a 4-year study of the prolonged health consequence of SARS-CoV-2. Sadly, 2 years into the study we aren’t too much further along in our search for answers. The Post Acute Sequelae of SARS-CoV-2 has earned an acronym, PASC, but it continues to be little more than a laundry list of vague symptoms including shortness of breath, fatigue, fever, headaches, “brain fog,” and a variety of other neurologic problems. We seem to have slipped into the same trap we find ourselves in with conditions such as chronic Lyme disease and chronic fatigue syndrome that lack workable diagnostic criteria.

However, I have just stumbled across a study in the JAMA Network Open that hints at a partial answer. Using data collected from a prospective study of nurses, investigators based at the T.H. Chan School of Public Health at Harvard found that adherence to healthy sleep prior to infection with COVID was inversely related to PCC, or Post COVID Condition, their chosen acronym for long COVID.

After taking into account a long list of covariants, the investigators found that women with consistently healthy sleep before and after their infection had the lowest risk of PCC when compared with women with consistently unhealthy sleep.

This finding seems to be telling us is that we shouldn’t be surprised to learn that folks who were relatively less healthy prior to contracting COVID are more likely to report feeling unhealthy after the acute phase of the illness has passed. It is unclear whether this observation is because their suboptimal health prior to the infection made them more vulnerable to its aftereffects or whether this is a return to their baseline for which we have labeled long COVID.

The results of this study are particularly important because it highlights our continued failure to acknowledge the critical role of sleep in the entire wellness picture. The broader message is of equal importance and that is when we are trying to discover what is making our patients sick, we must adhere to our traditional practice of taking a good and thorough history. When a patient asks the surgeon whether he will be able to play the violin after surgery, the prudent physician will always ask whether the patient has ever played the instrument.

As with any good study, it leaves more questions than it answers. While this study addresses the vague and neurologically based symptoms of long COVID, many of which are known symptoms associated with sleep deprivation, it doesn’t address the patients with more organically based symptoms such as those who have pulmonary or renal damage acquired during the acute phase of the illness. Many of these unfortunate individuals may have entered the pandemic with already damaged or vulnerable organ systems.

Finally, it leaves a very interesting question unanswered: Can we help the long COVID patients suffering with primarily neurologic symptoms by aggressively managing their preexisting unhealthy sleep habits? Or, has the damage already been done? I suspect and certainly hope it is the former.
 

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.

Although we continue to hear a chorus of cautions from the wise folks in the public health community, most of us and our political leaders have allowed the SARS-CoV-2 pandemic to slip quietly into the dark recesses of our been-there-done-that pile. Obviously, this failure to continue learning from our mistakes is an oversight for which we will pay dearly the next time a public health crisis requiring a coordinated effort on a national and international scale raises its ugly head.

However, there is a significant portion of the population for whom the pandemic is fresh in their minds because they are experiencing the symptoms of what they have been told is long COVID. In January 2023 the Kaiser Family Foundation reported that 15% of the U.S. population feels that at some point they have experienced the symptoms of long COVID. And 6% report that they believe they currently have long COVID.

As long ago as February of 2021, Congress gave the National Institutes of Health $1.5 billion to fund a 4-year study of the prolonged health consequence of SARS-CoV-2. Sadly, 2 years into the study we aren’t too much further along in our search for answers. The Post Acute Sequelae of SARS-CoV-2 has earned an acronym, PASC, but it continues to be little more than a laundry list of vague symptoms including shortness of breath, fatigue, fever, headaches, “brain fog,” and a variety of other neurologic problems. We seem to have slipped into the same trap we find ourselves in with conditions such as chronic Lyme disease and chronic fatigue syndrome that lack workable diagnostic criteria.

However, I have just stumbled across a study in the JAMA Network Open that hints at a partial answer. Using data collected from a prospective study of nurses, investigators based at the T.H. Chan School of Public Health at Harvard found that adherence to healthy sleep prior to infection with COVID was inversely related to PCC, or Post COVID Condition, their chosen acronym for long COVID.

After taking into account a long list of covariants, the investigators found that women with consistently healthy sleep before and after their infection had the lowest risk of PCC when compared with women with consistently unhealthy sleep.

This finding seems to be telling us is that we shouldn’t be surprised to learn that folks who were relatively less healthy prior to contracting COVID are more likely to report feeling unhealthy after the acute phase of the illness has passed. It is unclear whether this observation is because their suboptimal health prior to the infection made them more vulnerable to its aftereffects or whether this is a return to their baseline for which we have labeled long COVID.

The results of this study are particularly important because it highlights our continued failure to acknowledge the critical role of sleep in the entire wellness picture. The broader message is of equal importance and that is when we are trying to discover what is making our patients sick, we must adhere to our traditional practice of taking a good and thorough history. When a patient asks the surgeon whether he will be able to play the violin after surgery, the prudent physician will always ask whether the patient has ever played the instrument.

As with any good study, it leaves more questions than it answers. While this study addresses the vague and neurologically based symptoms of long COVID, many of which are known symptoms associated with sleep deprivation, it doesn’t address the patients with more organically based symptoms such as those who have pulmonary or renal damage acquired during the acute phase of the illness. Many of these unfortunate individuals may have entered the pandemic with already damaged or vulnerable organ systems.

Finally, it leaves a very interesting question unanswered: Can we help the long COVID patients suffering with primarily neurologic symptoms by aggressively managing their preexisting unhealthy sleep habits? Or, has the damage already been done? I suspect and certainly hope it is the former.
 

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.

Although we continue to hear a chorus of cautions from the wise folks in the public health community, most of us and our political leaders have allowed the SARS-CoV-2 pandemic to slip quietly into the dark recesses of our been-there-done-that pile. Obviously, this failure to continue learning from our mistakes is an oversight for which we will pay dearly the next time a public health crisis requiring a coordinated effort on a national and international scale raises its ugly head.

However, there is a significant portion of the population for whom the pandemic is fresh in their minds because they are experiencing the symptoms of what they have been told is long COVID. In January 2023 the Kaiser Family Foundation reported that 15% of the U.S. population feels that at some point they have experienced the symptoms of long COVID. And 6% report that they believe they currently have long COVID.

As long ago as February of 2021, Congress gave the National Institutes of Health $1.5 billion to fund a 4-year study of the prolonged health consequence of SARS-CoV-2. Sadly, 2 years into the study we aren’t too much further along in our search for answers. The Post Acute Sequelae of SARS-CoV-2 has earned an acronym, PASC, but it continues to be little more than a laundry list of vague symptoms including shortness of breath, fatigue, fever, headaches, “brain fog,” and a variety of other neurologic problems. We seem to have slipped into the same trap we find ourselves in with conditions such as chronic Lyme disease and chronic fatigue syndrome that lack workable diagnostic criteria.

However, I have just stumbled across a study in the JAMA Network Open that hints at a partial answer. Using data collected from a prospective study of nurses, investigators based at the T.H. Chan School of Public Health at Harvard found that adherence to healthy sleep prior to infection with COVID was inversely related to PCC, or Post COVID Condition, their chosen acronym for long COVID.

After taking into account a long list of covariants, the investigators found that women with consistently healthy sleep before and after their infection had the lowest risk of PCC when compared with women with consistently unhealthy sleep.

This finding seems to be telling us is that we shouldn’t be surprised to learn that folks who were relatively less healthy prior to contracting COVID are more likely to report feeling unhealthy after the acute phase of the illness has passed. It is unclear whether this observation is because their suboptimal health prior to the infection made them more vulnerable to its aftereffects or whether this is a return to their baseline for which we have labeled long COVID.

The results of this study are particularly important because it highlights our continued failure to acknowledge the critical role of sleep in the entire wellness picture. The broader message is of equal importance and that is when we are trying to discover what is making our patients sick, we must adhere to our traditional practice of taking a good and thorough history. When a patient asks the surgeon whether he will be able to play the violin after surgery, the prudent physician will always ask whether the patient has ever played the instrument.

As with any good study, it leaves more questions than it answers. While this study addresses the vague and neurologically based symptoms of long COVID, many of which are known symptoms associated with sleep deprivation, it doesn’t address the patients with more organically based symptoms such as those who have pulmonary or renal damage acquired during the acute phase of the illness. Many of these unfortunate individuals may have entered the pandemic with already damaged or vulnerable organ systems.

Finally, it leaves a very interesting question unanswered: Can we help the long COVID patients suffering with primarily neurologic symptoms by aggressively managing their preexisting unhealthy sleep habits? Or, has the damage already been done? I suspect and certainly hope it is the former.
 

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.

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

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

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

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

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

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

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

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

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

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

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

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

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

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

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

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

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

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

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

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

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

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

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

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

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

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

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

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

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

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

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

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

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

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

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

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

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

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

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

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

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

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

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

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

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

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

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

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

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

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

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

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

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

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

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

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

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

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

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

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

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

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

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

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

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

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

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

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

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

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

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

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

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

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

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

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

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

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

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

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

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

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

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

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

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

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

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

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

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

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

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

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

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

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

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

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

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

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

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

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

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

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

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

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

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

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

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

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

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

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

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

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

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

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

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

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

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

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

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

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

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

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

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

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

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

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

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

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

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

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

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

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

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

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

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

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

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

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

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

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

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

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

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

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

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

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

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

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

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

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

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

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

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

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

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

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

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

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

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

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

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

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

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

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

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

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

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

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

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

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

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

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

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

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

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

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

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

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

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

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

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

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

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

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

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

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

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

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

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.