William G. Wilkoff, MD

I am not planning on having a headstone on my grave, or even having a grave for that matter. However, if my heirs decide to ignore my wishes and opt for some pithy observation chiseled into a tastefully sized granite block, I suspect they might choose “He always knew which way the wind was blowing ... but wasn’t so sure about the tides.” Which aptly describes both my navigational deficiencies they have observed here over my six decades on the Maine coast as well as my general inability to predict the future. Nonetheless, I am going to throw caution to the wind and take this opportunity to ponder where obesity in this country will go over the next couple of decades.

In March of last year the London-based World Obesity Federation published its World Obesity Atlas. In the summary the authors predict that based on current trends “obesity will cost the global economy of US $4 trillion of potential income in 2035, nearly 3% of current global domestic product (GDP).” They envision the “rising prevalence of obesity to be steepest among children and adolescents rising from 10% to 20% of the world’s boys during the period 2029 to 2035, and rising fro 8% to 18% of the world’s girls.”

Wilkoff_William_G_2_web.jpg

These dire predictions assume no significant measures to reverse this trajectory such as universal health coverage. Nor do the authors attempt to predict the effect of the growing use of GLP-1 agonists. This omission is surprising and somewhat refreshing given the fact that the project was funded by an unrestricted grant from Novo Nordisk, a major producer of one of these drugs.

Unfortunately, I think it is unlikely that over the next couple of decades any large countries who do not already have a functioning universal health care system will find the political will to develop one capable of reversing the trend toward obesity. Certainly, I don’t see it in the cards for this country.

On the other hand, I can foresee the availability and ease of administration for GLP-1 agonists and similar drugs improving over the near term. However, the cost and availability will continue to widen the separation between the haves and the have-nots, both globally and within each country. This will mean that the countries and population subgroups that already experience the bulk of the economic and health consequences of obesity will continue to shoulder an outsized burden of this “disease.”

It is unclear how much this widening of the fat-getting-fatter dynamic will add to the global and national political unrest that already seems to be tracking the effects of climate change. However, I can’t imaging it is going to be a calming or uniting force.

Narrowing our focus from an international to an individual resource-rich country such as the United States, let’s consider what the significant growth in availability and affordability of GLP-1 agonist drugs will mean. There will certainly be short-term improvements in the morbidity and mortality of some of the obesity related diseases. However, for other conditions it may take longer than two decades for us to notice an effect. While it is tempting to consider these declines as a financial boon for the country that already spends a high percentage of its GDP on healthcare. However, as the well-known Saturday Night Live pundit Roseanne Roseannadanna often observed, ”it’s always something ... if it’s not one thing it’s another.” There may be other non-obesity conditions that surge to fill the gap, leaving us still with a substantial financial burden for healthcare.

Patients taking GLP-1 agonists lose weight because they feel full and eat less food. While currently the number of patients taking these drugs is relatively small, the effect on this country’s food consumption is too small to calculate. However, let’s assume that 20 years from now half of the obese patients are taking appetite blunting medication. Using today’s statistics this means that 50 million adults will be eating significantly less food. Will the agriculturists have gradually adjusted to produce less food? Will this mean there is more food for the those experiencing “food insecurity”? I doubt it. Most food insecurity seems to be a problem of distribution and inequality, not supply.

Physicians now caution patients taking GLP-1 agonists to eat a healthy and balanced diet. When the drugs are more commonly available, will this caution be heeded by the majority? Will we see a population that may no longer be obese but nonetheless malnourished because of bad choices?

And, finally, in a similar vein, will previously obese individuals suddenly or gradually begin to be more physically active once the appetite blunting medicines have helped them lose weight? Here, I have my doubts. Of course, some leaner individuals begin to take advantage of their new body morphology. But, I fear that old sedentary habits will die very slowly for most, and not at all for many. We have built a vehicle-centric society in which being physically active requires making a conscious effort. Electronic devices and sedentary entertainment options are not going to disappear just because a significant percentage of the population is no longer obese.

So there you have it. I suspect that I am correct about which way some of the winds are blowing as the obesity becomes moves into its treatable “disease” phase. But, as always, I haven’t a clue which way the tide is running.
 

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

I am not planning on having a headstone on my grave, or even having a grave for that matter. However, if my heirs decide to ignore my wishes and opt for some pithy observation chiseled into a tastefully sized granite block, I suspect they might choose “He always knew which way the wind was blowing ... but wasn’t so sure about the tides.” Which aptly describes both my navigational deficiencies they have observed here over my six decades on the Maine coast as well as my general inability to predict the future. Nonetheless, I am going to throw caution to the wind and take this opportunity to ponder where obesity in this country will go over the next couple of decades.

In March of last year the London-based World Obesity Federation published its World Obesity Atlas. In the summary the authors predict that based on current trends “obesity will cost the global economy of US $4 trillion of potential income in 2035, nearly 3% of current global domestic product (GDP).” They envision the “rising prevalence of obesity to be steepest among children and adolescents rising from 10% to 20% of the world’s boys during the period 2029 to 2035, and rising fro 8% to 18% of the world’s girls.”

Wilkoff_William_G_2_web.jpg

These dire predictions assume no significant measures to reverse this trajectory such as universal health coverage. Nor do the authors attempt to predict the effect of the growing use of GLP-1 agonists. This omission is surprising and somewhat refreshing given the fact that the project was funded by an unrestricted grant from Novo Nordisk, a major producer of one of these drugs.

Unfortunately, I think it is unlikely that over the next couple of decades any large countries who do not already have a functioning universal health care system will find the political will to develop one capable of reversing the trend toward obesity. Certainly, I don’t see it in the cards for this country.

On the other hand, I can foresee the availability and ease of administration for GLP-1 agonists and similar drugs improving over the near term. However, the cost and availability will continue to widen the separation between the haves and the have-nots, both globally and within each country. This will mean that the countries and population subgroups that already experience the bulk of the economic and health consequences of obesity will continue to shoulder an outsized burden of this “disease.”

It is unclear how much this widening of the fat-getting-fatter dynamic will add to the global and national political unrest that already seems to be tracking the effects of climate change. However, I can’t imaging it is going to be a calming or uniting force.

Narrowing our focus from an international to an individual resource-rich country such as the United States, let’s consider what the significant growth in availability and affordability of GLP-1 agonist drugs will mean. There will certainly be short-term improvements in the morbidity and mortality of some of the obesity related diseases. However, for other conditions it may take longer than two decades for us to notice an effect. While it is tempting to consider these declines as a financial boon for the country that already spends a high percentage of its GDP on healthcare. However, as the well-known Saturday Night Live pundit Roseanne Roseannadanna often observed, ”it’s always something ... if it’s not one thing it’s another.” There may be other non-obesity conditions that surge to fill the gap, leaving us still with a substantial financial burden for healthcare.

Patients taking GLP-1 agonists lose weight because they feel full and eat less food. While currently the number of patients taking these drugs is relatively small, the effect on this country’s food consumption is too small to calculate. However, let’s assume that 20 years from now half of the obese patients are taking appetite blunting medication. Using today’s statistics this means that 50 million adults will be eating significantly less food. Will the agriculturists have gradually adjusted to produce less food? Will this mean there is more food for the those experiencing “food insecurity”? I doubt it. Most food insecurity seems to be a problem of distribution and inequality, not supply.

Physicians now caution patients taking GLP-1 agonists to eat a healthy and balanced diet. When the drugs are more commonly available, will this caution be heeded by the majority? Will we see a population that may no longer be obese but nonetheless malnourished because of bad choices?

And, finally, in a similar vein, will previously obese individuals suddenly or gradually begin to be more physically active once the appetite blunting medicines have helped them lose weight? Here, I have my doubts. Of course, some leaner individuals begin to take advantage of their new body morphology. But, I fear that old sedentary habits will die very slowly for most, and not at all for many. We have built a vehicle-centric society in which being physically active requires making a conscious effort. Electronic devices and sedentary entertainment options are not going to disappear just because a significant percentage of the population is no longer obese.

So there you have it. I suspect that I am correct about which way some of the winds are blowing as the obesity becomes moves into its treatable “disease” phase. But, as always, I haven’t a clue which way the tide is running.
 

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

I am not planning on having a headstone on my grave, or even having a grave for that matter. However, if my heirs decide to ignore my wishes and opt for some pithy observation chiseled into a tastefully sized granite block, I suspect they might choose “He always knew which way the wind was blowing ... but wasn’t so sure about the tides.” Which aptly describes both my navigational deficiencies they have observed here over my six decades on the Maine coast as well as my general inability to predict the future. Nonetheless, I am going to throw caution to the wind and take this opportunity to ponder where obesity in this country will go over the next couple of decades.

In March of last year the London-based World Obesity Federation published its World Obesity Atlas. In the summary the authors predict that based on current trends “obesity will cost the global economy of US $4 trillion of potential income in 2035, nearly 3% of current global domestic product (GDP).” They envision the “rising prevalence of obesity to be steepest among children and adolescents rising from 10% to 20% of the world’s boys during the period 2029 to 2035, and rising fro 8% to 18% of the world’s girls.”

Wilkoff_William_G_2_web.jpg

These dire predictions assume no significant measures to reverse this trajectory such as universal health coverage. Nor do the authors attempt to predict the effect of the growing use of GLP-1 agonists. This omission is surprising and somewhat refreshing given the fact that the project was funded by an unrestricted grant from Novo Nordisk, a major producer of one of these drugs.

Unfortunately, I think it is unlikely that over the next couple of decades any large countries who do not already have a functioning universal health care system will find the political will to develop one capable of reversing the trend toward obesity. Certainly, I don’t see it in the cards for this country.

On the other hand, I can foresee the availability and ease of administration for GLP-1 agonists and similar drugs improving over the near term. However, the cost and availability will continue to widen the separation between the haves and the have-nots, both globally and within each country. This will mean that the countries and population subgroups that already experience the bulk of the economic and health consequences of obesity will continue to shoulder an outsized burden of this “disease.”

It is unclear how much this widening of the fat-getting-fatter dynamic will add to the global and national political unrest that already seems to be tracking the effects of climate change. However, I can’t imaging it is going to be a calming or uniting force.

Narrowing our focus from an international to an individual resource-rich country such as the United States, let’s consider what the significant growth in availability and affordability of GLP-1 agonist drugs will mean. There will certainly be short-term improvements in the morbidity and mortality of some of the obesity related diseases. However, for other conditions it may take longer than two decades for us to notice an effect. While it is tempting to consider these declines as a financial boon for the country that already spends a high percentage of its GDP on healthcare. However, as the well-known Saturday Night Live pundit Roseanne Roseannadanna often observed, ”it’s always something ... if it’s not one thing it’s another.” There may be other non-obesity conditions that surge to fill the gap, leaving us still with a substantial financial burden for healthcare.

Patients taking GLP-1 agonists lose weight because they feel full and eat less food. While currently the number of patients taking these drugs is relatively small, the effect on this country’s food consumption is too small to calculate. However, let’s assume that 20 years from now half of the obese patients are taking appetite blunting medication. Using today’s statistics this means that 50 million adults will be eating significantly less food. Will the agriculturists have gradually adjusted to produce less food? Will this mean there is more food for the those experiencing “food insecurity”? I doubt it. Most food insecurity seems to be a problem of distribution and inequality, not supply.

Physicians now caution patients taking GLP-1 agonists to eat a healthy and balanced diet. When the drugs are more commonly available, will this caution be heeded by the majority? Will we see a population that may no longer be obese but nonetheless malnourished because of bad choices?

And, finally, in a similar vein, will previously obese individuals suddenly or gradually begin to be more physically active once the appetite blunting medicines have helped them lose weight? Here, I have my doubts. Of course, some leaner individuals begin to take advantage of their new body morphology. But, I fear that old sedentary habits will die very slowly for most, and not at all for many. We have built a vehicle-centric society in which being physically active requires making a conscious effort. Electronic devices and sedentary entertainment options are not going to disappear just because a significant percentage of the population is no longer obese.

So there you have it. I suspect that I am correct about which way some of the winds are blowing as the obesity becomes moves into its treatable “disease” phase. But, as always, I haven’t a clue which way the tide is running.
 

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 story in a recent edition of this newspaper reported on a disturbing, but not surprising, study by a third-year pediatric resident at the University of California, Davis, School of Medicine. Looking at just the Preparticipaton Physical Evaluations (PPEs) she could find at her institution, Tammy Ng, MD, found that only slightly more than a quarter “addressed all the criteria” on the American Academy of Pediatrics (AAP) standardized form. Although more than half included inquiries about respiratory symptoms, less than half contained questions about a cardiovascular history. The lack of consistency across all the forms reviewed was the most dramatic finding.

Having participated in more than my share of PPEs as a school physician, a primary care pediatrician, and a multi-sport high school and college athlete, I was not surprised by Dr. Ng’s findings. In high school my teammates and I considered our trip to see Old Doctor Hinds (not his real name) in the second week of August “a joke.” A few of us with “white coat” hypertension, like myself, had to be settled down and have our blood pressure retaken. But other than that wrinkle, we all passed. The football coach had his own eyeball screening tool and wouldn’t allow kids he thought were too small to play football.

Wilkoff_William_G_2_web.jpg

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 story in a recent edition of this newspaper reported on a disturbing, but not surprising, study by a third-year pediatric resident at the University of California, Davis, School of Medicine. Looking at just the Preparticipaton Physical Evaluations (PPEs) she could find at her institution, Tammy Ng, MD, found that only slightly more than a quarter “addressed all the criteria” on the American Academy of Pediatrics (AAP) standardized form. Although more than half included inquiries about respiratory symptoms, less than half contained questions about a cardiovascular history. The lack of consistency across all the forms reviewed was the most dramatic finding.

Having participated in more than my share of PPEs as a school physician, a primary care pediatrician, and a multi-sport high school and college athlete, I was not surprised by Dr. Ng’s findings. In high school my teammates and I considered our trip to see Old Doctor Hinds (not his real name) in the second week of August “a joke.” A few of us with “white coat” hypertension, like myself, had to be settled down and have our blood pressure retaken. But other than that wrinkle, we all passed. The football coach had his own eyeball screening tool and wouldn’t allow kids he thought were too small to play football.

Wilkoff_William_G_2_web.jpg

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 story in a recent edition of this newspaper reported on a disturbing, but not surprising, study by a third-year pediatric resident at the University of California, Davis, School of Medicine. Looking at just the Preparticipaton Physical Evaluations (PPEs) she could find at her institution, Tammy Ng, MD, found that only slightly more than a quarter “addressed all the criteria” on the American Academy of Pediatrics (AAP) standardized form. Although more than half included inquiries about respiratory symptoms, less than half contained questions about a cardiovascular history. The lack of consistency across all the forms reviewed was the most dramatic finding.

Having participated in more than my share of PPEs as a school physician, a primary care pediatrician, and a multi-sport high school and college athlete, I was not surprised by Dr. Ng’s findings. In high school my teammates and I considered our trip to see Old Doctor Hinds (not his real name) in the second week of August “a joke.” A few of us with “white coat” hypertension, like myself, had to be settled down and have our blood pressure retaken. But other than that wrinkle, we all passed. The football coach had his own eyeball screening tool and wouldn’t allow kids he thought were too small to play football.

Wilkoff_William_G_2_web.jpg

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.

Among the more unheralded examples of collateral damage of the COVID epidemic is chronic absenteeism. A recent NPR/Ipsos poll found that parents ranked chronic absenteeism last in a list of 12 school-related concerns. Only 5% listed it first.

This is surprising and concerning, given that prior to the pandemic the rate of chronic absenteeism nationwide was 15%, but during the 2021-22 school year this doubled to 30% and it has not declined. In fact, in some states the chronic absenteeism rate is 40%. In 2020 8 million students were chronically absent. This number is now over 14 million. Chronic absenteeism is a metric defined as a student absent for 15 days or more, which comes out to around 10% of the school year. Chronic absenteeism has been used as a predictor of the student dropout rate.

Wilkoff_William_G_2_web.jpg

The initial contribution of the pandemic is easily explained, as parents were understandably concerned about sending their children into an environment that might cause disease, or at least bring the disease home to a more vulnerable family member. The reasons behind the trend’s persistence are a bit more complicated.

Family schedules initially disrupted by the pandemic have settled back into a pattern that may make it more difficult for a child to get to school. Day care and work schedules may have changed, but not yet readjusted to sync with the school schedule.

In the simplest terms, children and their families may have simply fallen out of the habit of going to school. For children (and maybe their parents) who had always struggled with an unresolved separation anxiety, the time at home — or at least not in school — came as a relief. Which, in turn, meant that any gains in dealing with the anxiety have been undone. The child who was already struggling academically or socially found being at home much less challenging. It’s not surprising that he/she might resist climbing back in the academic saddle.

It is very likely that a significant contributor to the persistent trend in chronic absenteeism is what social scientists call “norm erosion.” Not just children, but families may have developed an attitude that time spent in school just isn’t as valuable as they once believed, or were at least told that it was. There seems to be more parents questioning what their children are being taught in school. The home schooling movement existed before the pandemic. Its roots may be growing under the surface in the form of general skepticism about the importance of school in the bigger scheme of things. The home schooling movement was ready to blossom when the COVID pandemic triggered school closures. We hoped and dreamed that remote learning would be just as good as in-person school. We now realize that, in most cases, that was wishful thinking.

It feels as though a “Perfect Attendance Record” may have lost the cachet it once had. During the pandemic anyone claiming to have never missed a day at school lost that gold star. Did opening your computer every day to watch a remote learning session count for anything?

The threshold for allowing a child to stay home from school may be reaching a historic low. Families seem to regard the school schedule as a guideline that can easily be ignored when planning a vacation. Take little brother out of school to attend big brother’s lacrosse playoff game, not to worry if the youngster misses school days for a trip.

Who is responsible for reversing the trend? Teachers already know it is a serious problem. They view attendance as important. Maybe educators could make school more appealing. But to whom? Sounds like this message should be targeted at the parents. Would stiff penalties for parents whose children are chronically absent help? Would demanding a note from a physician after a certain number of absences help? It might. But, are pediatricians and educators ready to take on one more task in which parents have dropped the ball?

An unknown percentage of chronically absent children are missing school because of a previously unrecognized or inadequately treated mental health condition or learning disability. Involving physicians in a community’s response to chronic absenteeism may be the first step in getting a child back on track. If socioeconomic factors are contributing to a child’s truancy, the involvement of social service agencies may be the answer.

I have a friend who is often asked to address graduating classes at both the high school and college level. One of his standard pieces of advice, whether it be about school or a workplace you may not be in love with, is to at least “show up.” The family that treats school attendance as optional is likely to produce adults who take a similarly nonchalant attitude toward their employment opportunities — with unfortunate results.
 

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.

Among the more unheralded examples of collateral damage of the COVID epidemic is chronic absenteeism. A recent NPR/Ipsos poll found that parents ranked chronic absenteeism last in a list of 12 school-related concerns. Only 5% listed it first.

This is surprising and concerning, given that prior to the pandemic the rate of chronic absenteeism nationwide was 15%, but during the 2021-22 school year this doubled to 30% and it has not declined. In fact, in some states the chronic absenteeism rate is 40%. In 2020 8 million students were chronically absent. This number is now over 14 million. Chronic absenteeism is a metric defined as a student absent for 15 days or more, which comes out to around 10% of the school year. Chronic absenteeism has been used as a predictor of the student dropout rate.

Wilkoff_William_G_2_web.jpg

The initial contribution of the pandemic is easily explained, as parents were understandably concerned about sending their children into an environment that might cause disease, or at least bring the disease home to a more vulnerable family member. The reasons behind the trend’s persistence are a bit more complicated.

Family schedules initially disrupted by the pandemic have settled back into a pattern that may make it more difficult for a child to get to school. Day care and work schedules may have changed, but not yet readjusted to sync with the school schedule.

In the simplest terms, children and their families may have simply fallen out of the habit of going to school. For children (and maybe their parents) who had always struggled with an unresolved separation anxiety, the time at home — or at least not in school — came as a relief. Which, in turn, meant that any gains in dealing with the anxiety have been undone. The child who was already struggling academically or socially found being at home much less challenging. It’s not surprising that he/she might resist climbing back in the academic saddle.

It is very likely that a significant contributor to the persistent trend in chronic absenteeism is what social scientists call “norm erosion.” Not just children, but families may have developed an attitude that time spent in school just isn’t as valuable as they once believed, or were at least told that it was. There seems to be more parents questioning what their children are being taught in school. The home schooling movement existed before the pandemic. Its roots may be growing under the surface in the form of general skepticism about the importance of school in the bigger scheme of things. The home schooling movement was ready to blossom when the COVID pandemic triggered school closures. We hoped and dreamed that remote learning would be just as good as in-person school. We now realize that, in most cases, that was wishful thinking.

It feels as though a “Perfect Attendance Record” may have lost the cachet it once had. During the pandemic anyone claiming to have never missed a day at school lost that gold star. Did opening your computer every day to watch a remote learning session count for anything?

The threshold for allowing a child to stay home from school may be reaching a historic low. Families seem to regard the school schedule as a guideline that can easily be ignored when planning a vacation. Take little brother out of school to attend big brother’s lacrosse playoff game, not to worry if the youngster misses school days for a trip.

Who is responsible for reversing the trend? Teachers already know it is a serious problem. They view attendance as important. Maybe educators could make school more appealing. But to whom? Sounds like this message should be targeted at the parents. Would stiff penalties for parents whose children are chronically absent help? Would demanding a note from a physician after a certain number of absences help? It might. But, are pediatricians and educators ready to take on one more task in which parents have dropped the ball?

An unknown percentage of chronically absent children are missing school because of a previously unrecognized or inadequately treated mental health condition or learning disability. Involving physicians in a community’s response to chronic absenteeism may be the first step in getting a child back on track. If socioeconomic factors are contributing to a child’s truancy, the involvement of social service agencies may be the answer.

I have a friend who is often asked to address graduating classes at both the high school and college level. One of his standard pieces of advice, whether it be about school or a workplace you may not be in love with, is to at least “show up.” The family that treats school attendance as optional is likely to produce adults who take a similarly nonchalant attitude toward their employment opportunities — with unfortunate results.
 

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.

Among the more unheralded examples of collateral damage of the COVID epidemic is chronic absenteeism. A recent NPR/Ipsos poll found that parents ranked chronic absenteeism last in a list of 12 school-related concerns. Only 5% listed it first.

This is surprising and concerning, given that prior to the pandemic the rate of chronic absenteeism nationwide was 15%, but during the 2021-22 school year this doubled to 30% and it has not declined. In fact, in some states the chronic absenteeism rate is 40%. In 2020 8 million students were chronically absent. This number is now over 14 million. Chronic absenteeism is a metric defined as a student absent for 15 days or more, which comes out to around 10% of the school year. Chronic absenteeism has been used as a predictor of the student dropout rate.

Wilkoff_William_G_2_web.jpg

The initial contribution of the pandemic is easily explained, as parents were understandably concerned about sending their children into an environment that might cause disease, or at least bring the disease home to a more vulnerable family member. The reasons behind the trend’s persistence are a bit more complicated.

Family schedules initially disrupted by the pandemic have settled back into a pattern that may make it more difficult for a child to get to school. Day care and work schedules may have changed, but not yet readjusted to sync with the school schedule.

In the simplest terms, children and their families may have simply fallen out of the habit of going to school. For children (and maybe their parents) who had always struggled with an unresolved separation anxiety, the time at home — or at least not in school — came as a relief. Which, in turn, meant that any gains in dealing with the anxiety have been undone. The child who was already struggling academically or socially found being at home much less challenging. It’s not surprising that he/she might resist climbing back in the academic saddle.

It is very likely that a significant contributor to the persistent trend in chronic absenteeism is what social scientists call “norm erosion.” Not just children, but families may have developed an attitude that time spent in school just isn’t as valuable as they once believed, or were at least told that it was. There seems to be more parents questioning what their children are being taught in school. The home schooling movement existed before the pandemic. Its roots may be growing under the surface in the form of general skepticism about the importance of school in the bigger scheme of things. The home schooling movement was ready to blossom when the COVID pandemic triggered school closures. We hoped and dreamed that remote learning would be just as good as in-person school. We now realize that, in most cases, that was wishful thinking.

It feels as though a “Perfect Attendance Record” may have lost the cachet it once had. During the pandemic anyone claiming to have never missed a day at school lost that gold star. Did opening your computer every day to watch a remote learning session count for anything?

The threshold for allowing a child to stay home from school may be reaching a historic low. Families seem to regard the school schedule as a guideline that can easily be ignored when planning a vacation. Take little brother out of school to attend big brother’s lacrosse playoff game, not to worry if the youngster misses school days for a trip.

Who is responsible for reversing the trend? Teachers already know it is a serious problem. They view attendance as important. Maybe educators could make school more appealing. But to whom? Sounds like this message should be targeted at the parents. Would stiff penalties for parents whose children are chronically absent help? Would demanding a note from a physician after a certain number of absences help? It might. But, are pediatricians and educators ready to take on one more task in which parents have dropped the ball?

An unknown percentage of chronically absent children are missing school because of a previously unrecognized or inadequately treated mental health condition or learning disability. Involving physicians in a community’s response to chronic absenteeism may be the first step in getting a child back on track. If socioeconomic factors are contributing to a child’s truancy, the involvement of social service agencies may be the answer.

I have a friend who is often asked to address graduating classes at both the high school and college level. One of his standard pieces of advice, whether it be about school or a workplace you may not be in love with, is to at least “show up.” The family that treats school attendance as optional is likely to produce adults who take a similarly nonchalant attitude toward their employment opportunities — with unfortunate results.
 

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

I am going to guess that if we asked 500,000 adults in this country if they felt that children and adolescents were spending too much time on their smartphones, we would elicit almost uniform agreement that, yes indeed, smartphone use is gobbling up too much time from our young people. And, the adults would volunteer a long laundry list of all the bad consequences this overuse was generating. If you ask this same sample of adults if they too were spending too much time on their smartphones they would answer yes and, again, give you a list of the problems they feel are the result of this overuse.

We might begin to find a scattering of responses if we ask the adults when a child is too young to have his/her own cell phone. But, they would all agree that “young children” weren’t ready to be trusted with a cell phone. The “when” they were ready would be up for discussion. However, I suspect we might see a clustering around age 10 years. The reality is that despite what the majority may believe, a 2022 survey found that 42% of children have a cell phone by age 10, 71% by age 12, and 91% by age 14.

Wilkoff_William_G_2_web.jpg

So, it would appear that, while we believe there can be significant downsides to having a cell phone, we are having great difficulty in policing ourselves and creating limits for our children. Does cell phone use qualify as an addiction, or is it just another example of how adults have lost the ability to say “no” to themselves and to their children?

When it comes to cell phones in school, the situation gets increasingly murky. The teachers I speak with are very clear that cell phones are creating problems for both the academic and the social experiences of their students. One teacher referred me to an article from the Norwegian Institute of Public Health, which found that banning cell phones in school decreased the incidence of psychological symptoms and diseases in girls. Bullying decreased in both genders and the girls’ GPA scores improved. In schools with cell phone bans, girls were more likely to choose and attend academic track programs, an effect which was more pronounced in young women with lower socioeconomic backgrounds. But, the if, when, and how to institute smartphone bans in school is complicated.

On one front, the movement toward cell phone bans in school has been given a major boost with the publication and publicity of a new book titled The Anxious Generation by social psychologist Jonathan Haidt, PhD. The New York University professor sees the GenZ’ers as experiencing a tsunami of mental health challenges including anxiety, self-harm, and suicide. And, he lays much of the blame for this situation on cell phone use.

He is optimistic about turning the tide because he claims that everywhere he speaks about the problem he says “I feel that I’m pushing on open doors.” Comparing the phenomenon to the collapse of the Berlin Wall, Dr. Haidt says “When you have a system that everyone hates, and then you have a way to escape it, it can change in a year.”

I wish I could share in his optimism, although I did just encounter a news story in the Portland paper describing a national program called “Wait Until 8th,” which is being considered by a parents’ group here in Maine.

The usual suspects have their own predictable take on the issue. The House and Senate have proposed a study on the use of cell phones in elementary and secondary schools and a pilot program awarding grants to some schools to create mobile device–free environments. Sounds like a momentum killer to me.

Not surprisingly, the issue of cell phone bans in school has taken on a bit of a political odor. The National Parents Union reports in a very small and inadequately described sample that 56% of parents are against total school bans. In the accompanying press release, the organizations offers an extensive list of concerns parents have reported — many cite the need to remain in contact with their children throughout the day. One has to wonder how often these concerns are a reflection of unresolved separation anxiety.

The American Academy of Pediatrics has rolled out a “5 Cs” framework that pediatricians can use to discuss media use with families. As usual, the thought is that talking about a problem is going to somehow convince parents to do what they already know is the correct action. And, of course, pediatricians have plenty of time to initiate this discussion of the obvious.

A recent study from the Department of Pediatrics at University of California, San Francisco, has found that parental monitoring, limit setting, and modeling good screen use behavior (my bolding) are the most effective strategies for reducing adolescent screen time. Using screen time allowances as a reward or punishment does not seem to be effective.

So there you have it. It looks like cell phone overuse, particularly in school, is something most of us see as a problem deserving an immediate solution. However, despite Dr. Haidt’s optimism about a seismic turnaround, I suspect it will more likely be guerrilla warfare — one family, one school, or one school district at a time.
 

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

I am going to guess that if we asked 500,000 adults in this country if they felt that children and adolescents were spending too much time on their smartphones, we would elicit almost uniform agreement that, yes indeed, smartphone use is gobbling up too much time from our young people. And, the adults would volunteer a long laundry list of all the bad consequences this overuse was generating. If you ask this same sample of adults if they too were spending too much time on their smartphones they would answer yes and, again, give you a list of the problems they feel are the result of this overuse.

We might begin to find a scattering of responses if we ask the adults when a child is too young to have his/her own cell phone. But, they would all agree that “young children” weren’t ready to be trusted with a cell phone. The “when” they were ready would be up for discussion. However, I suspect we might see a clustering around age 10 years. The reality is that despite what the majority may believe, a 2022 survey found that 42% of children have a cell phone by age 10, 71% by age 12, and 91% by age 14.

Wilkoff_William_G_2_web.jpg

So, it would appear that, while we believe there can be significant downsides to having a cell phone, we are having great difficulty in policing ourselves and creating limits for our children. Does cell phone use qualify as an addiction, or is it just another example of how adults have lost the ability to say “no” to themselves and to their children?

When it comes to cell phones in school, the situation gets increasingly murky. The teachers I speak with are very clear that cell phones are creating problems for both the academic and the social experiences of their students. One teacher referred me to an article from the Norwegian Institute of Public Health, which found that banning cell phones in school decreased the incidence of psychological symptoms and diseases in girls. Bullying decreased in both genders and the girls’ GPA scores improved. In schools with cell phone bans, girls were more likely to choose and attend academic track programs, an effect which was more pronounced in young women with lower socioeconomic backgrounds. But, the if, when, and how to institute smartphone bans in school is complicated.

On one front, the movement toward cell phone bans in school has been given a major boost with the publication and publicity of a new book titled The Anxious Generation by social psychologist Jonathan Haidt, PhD. The New York University professor sees the GenZ’ers as experiencing a tsunami of mental health challenges including anxiety, self-harm, and suicide. And, he lays much of the blame for this situation on cell phone use.

He is optimistic about turning the tide because he claims that everywhere he speaks about the problem he says “I feel that I’m pushing on open doors.” Comparing the phenomenon to the collapse of the Berlin Wall, Dr. Haidt says “When you have a system that everyone hates, and then you have a way to escape it, it can change in a year.”

I wish I could share in his optimism, although I did just encounter a news story in the Portland paper describing a national program called “Wait Until 8th,” which is being considered by a parents’ group here in Maine.

The usual suspects have their own predictable take on the issue. The House and Senate have proposed a study on the use of cell phones in elementary and secondary schools and a pilot program awarding grants to some schools to create mobile device–free environments. Sounds like a momentum killer to me.

Not surprisingly, the issue of cell phone bans in school has taken on a bit of a political odor. The National Parents Union reports in a very small and inadequately described sample that 56% of parents are against total school bans. In the accompanying press release, the organizations offers an extensive list of concerns parents have reported — many cite the need to remain in contact with their children throughout the day. One has to wonder how often these concerns are a reflection of unresolved separation anxiety.

The American Academy of Pediatrics has rolled out a “5 Cs” framework that pediatricians can use to discuss media use with families. As usual, the thought is that talking about a problem is going to somehow convince parents to do what they already know is the correct action. And, of course, pediatricians have plenty of time to initiate this discussion of the obvious.

A recent study from the Department of Pediatrics at University of California, San Francisco, has found that parental monitoring, limit setting, and modeling good screen use behavior (my bolding) are the most effective strategies for reducing adolescent screen time. Using screen time allowances as a reward or punishment does not seem to be effective.

So there you have it. It looks like cell phone overuse, particularly in school, is something most of us see as a problem deserving an immediate solution. However, despite Dr. Haidt’s optimism about a seismic turnaround, I suspect it will more likely be guerrilla warfare — one family, one school, or one school district at a time.
 

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

I am going to guess that if we asked 500,000 adults in this country if they felt that children and adolescents were spending too much time on their smartphones, we would elicit almost uniform agreement that, yes indeed, smartphone use is gobbling up too much time from our young people. And, the adults would volunteer a long laundry list of all the bad consequences this overuse was generating. If you ask this same sample of adults if they too were spending too much time on their smartphones they would answer yes and, again, give you a list of the problems they feel are the result of this overuse.

We might begin to find a scattering of responses if we ask the adults when a child is too young to have his/her own cell phone. But, they would all agree that “young children” weren’t ready to be trusted with a cell phone. The “when” they were ready would be up for discussion. However, I suspect we might see a clustering around age 10 years. The reality is that despite what the majority may believe, a 2022 survey found that 42% of children have a cell phone by age 10, 71% by age 12, and 91% by age 14.

Wilkoff_William_G_2_web.jpg

So, it would appear that, while we believe there can be significant downsides to having a cell phone, we are having great difficulty in policing ourselves and creating limits for our children. Does cell phone use qualify as an addiction, or is it just another example of how adults have lost the ability to say “no” to themselves and to their children?

When it comes to cell phones in school, the situation gets increasingly murky. The teachers I speak with are very clear that cell phones are creating problems for both the academic and the social experiences of their students. One teacher referred me to an article from the Norwegian Institute of Public Health, which found that banning cell phones in school decreased the incidence of psychological symptoms and diseases in girls. Bullying decreased in both genders and the girls’ GPA scores improved. In schools with cell phone bans, girls were more likely to choose and attend academic track programs, an effect which was more pronounced in young women with lower socioeconomic backgrounds. But, the if, when, and how to institute smartphone bans in school is complicated.

On one front, the movement toward cell phone bans in school has been given a major boost with the publication and publicity of a new book titled The Anxious Generation by social psychologist Jonathan Haidt, PhD. The New York University professor sees the GenZ’ers as experiencing a tsunami of mental health challenges including anxiety, self-harm, and suicide. And, he lays much of the blame for this situation on cell phone use.

He is optimistic about turning the tide because he claims that everywhere he speaks about the problem he says “I feel that I’m pushing on open doors.” Comparing the phenomenon to the collapse of the Berlin Wall, Dr. Haidt says “When you have a system that everyone hates, and then you have a way to escape it, it can change in a year.”

I wish I could share in his optimism, although I did just encounter a news story in the Portland paper describing a national program called “Wait Until 8th,” which is being considered by a parents’ group here in Maine.

The usual suspects have their own predictable take on the issue. The House and Senate have proposed a study on the use of cell phones in elementary and secondary schools and a pilot program awarding grants to some schools to create mobile device–free environments. Sounds like a momentum killer to me.

Not surprisingly, the issue of cell phone bans in school has taken on a bit of a political odor. The National Parents Union reports in a very small and inadequately described sample that 56% of parents are against total school bans. In the accompanying press release, the organizations offers an extensive list of concerns parents have reported — many cite the need to remain in contact with their children throughout the day. One has to wonder how often these concerns are a reflection of unresolved separation anxiety.

The American Academy of Pediatrics has rolled out a “5 Cs” framework that pediatricians can use to discuss media use with families. As usual, the thought is that talking about a problem is going to somehow convince parents to do what they already know is the correct action. And, of course, pediatricians have plenty of time to initiate this discussion of the obvious.

A recent study from the Department of Pediatrics at University of California, San Francisco, has found that parental monitoring, limit setting, and modeling good screen use behavior (my bolding) are the most effective strategies for reducing adolescent screen time. Using screen time allowances as a reward or punishment does not seem to be effective.

So there you have it. It looks like cell phone overuse, particularly in school, is something most of us see as a problem deserving an immediate solution. However, despite Dr. Haidt’s optimism about a seismic turnaround, I suspect it will more likely be guerrilla warfare — one family, one school, or one school district at a time.
 

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.

Early education is right up there with motherhood and apple pie as unarguable positive concepts. How could exposing young children to a school-like atmosphere not be a benefit, particularly in communities dominated by socioeconomic challenges? While there are some questions about the value of playing Mozart to infants, early education in the traditional sense continues to be viewed as a key strategy for providing young children a preschool foundation on which a successful academic career can be built. Several oft-cited randomized controlled trials have fueled both private and public interest and funding.

However, a recent commentary published in Science suggests that all programs are “not unequivocally positive and much more research is needed.” “Worrisome results in Tennessee,” “Success in Boston,” and “Largely null results for Headstart” are just a few of the article’s section titles and convey a sense of the inconsistency the investigators found as they reviewed early education systems around the country.

Wilkoff_William_G_2_web.jpg

While there may be some politicians who may attempt to use the results of this investigation as a reason to cancel public funding of underperforming early education programs, the authors avoid this baby-and-the-bathwater conclusion. Instead, they urge more rigorous research “to understand how effective programs can be designed and implemented.”

The kind of re-thinking and brainstorming these investigators suggest takes time. While we’re waiting for this process to gain traction, this might be a good time to consider some of the benefits of early education that we don’t usually consider when our focus is on academic metrics.

A recent paper in Children’s Health Care by investigators at the Boston University Medical Center and School of Medicine considered the diet of children attending preschool. Looking at the dietary records of more than 300 children attending 30 childcare centers, the researchers found that the children’s diets before arrival at daycare was less healthy than while they were in daycare. “The hour after pickup appeared to be the least healthful” of any of the time periods surveyed. Of course, we will all conjure up images of what this chaotic post-daycare pickup may look like and cut the harried parents and grandparents some slack when it comes to nutritional choices. However, the bottom line is that for the group of children surveyed being in preschool or daycare protected them from a less healthy diet they were being provided outside of school hours.

Our recent experience with pandemic-related school closures provides more evidence that being in school was superior to any remote experience academically. School-age children and adolescents gained weight when school closures were the norm. Play patterns for children shifted from outdoor play to indoor play — often dominated by more sedentary video games. Both fatal and non-fatal gun-related injuries surged during the pandemic and, by far, the majority of these occur in the home and not at school.

Stepping back to look at this broader picture that includes diet, physical activity, and safety — not to mention the benefits of socialization — leads one to arrive at the unfortunate conclusion that for many children in this country, being at home is considerably less healthy than being in school. Of course there will be those who point to the belief that schools are petri dishes putting children at greater risk for respiratory infections. On the other hand, we must accept that schools haven’t proved to be a major factor in the spread of COVID that many had feared.

The authors of the study in Science are certainly correct in recommending a more thorough investigation into the academic benefits of preschool education. However, we must keep in mind that preschool offers an environment that can be a positive influence on young children.

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.

Early education is right up there with motherhood and apple pie as unarguable positive concepts. How could exposing young children to a school-like atmosphere not be a benefit, particularly in communities dominated by socioeconomic challenges? While there are some questions about the value of playing Mozart to infants, early education in the traditional sense continues to be viewed as a key strategy for providing young children a preschool foundation on which a successful academic career can be built. Several oft-cited randomized controlled trials have fueled both private and public interest and funding.

However, a recent commentary published in Science suggests that all programs are “not unequivocally positive and much more research is needed.” “Worrisome results in Tennessee,” “Success in Boston,” and “Largely null results for Headstart” are just a few of the article’s section titles and convey a sense of the inconsistency the investigators found as they reviewed early education systems around the country.

Wilkoff_William_G_2_web.jpg

While there may be some politicians who may attempt to use the results of this investigation as a reason to cancel public funding of underperforming early education programs, the authors avoid this baby-and-the-bathwater conclusion. Instead, they urge more rigorous research “to understand how effective programs can be designed and implemented.”

The kind of re-thinking and brainstorming these investigators suggest takes time. While we’re waiting for this process to gain traction, this might be a good time to consider some of the benefits of early education that we don’t usually consider when our focus is on academic metrics.

A recent paper in Children’s Health Care by investigators at the Boston University Medical Center and School of Medicine considered the diet of children attending preschool. Looking at the dietary records of more than 300 children attending 30 childcare centers, the researchers found that the children’s diets before arrival at daycare was less healthy than while they were in daycare. “The hour after pickup appeared to be the least healthful” of any of the time periods surveyed. Of course, we will all conjure up images of what this chaotic post-daycare pickup may look like and cut the harried parents and grandparents some slack when it comes to nutritional choices. However, the bottom line is that for the group of children surveyed being in preschool or daycare protected them from a less healthy diet they were being provided outside of school hours.

Our recent experience with pandemic-related school closures provides more evidence that being in school was superior to any remote experience academically. School-age children and adolescents gained weight when school closures were the norm. Play patterns for children shifted from outdoor play to indoor play — often dominated by more sedentary video games. Both fatal and non-fatal gun-related injuries surged during the pandemic and, by far, the majority of these occur in the home and not at school.

Stepping back to look at this broader picture that includes diet, physical activity, and safety — not to mention the benefits of socialization — leads one to arrive at the unfortunate conclusion that for many children in this country, being at home is considerably less healthy than being in school. Of course there will be those who point to the belief that schools are petri dishes putting children at greater risk for respiratory infections. On the other hand, we must accept that schools haven’t proved to be a major factor in the spread of COVID that many had feared.

The authors of the study in Science are certainly correct in recommending a more thorough investigation into the academic benefits of preschool education. However, we must keep in mind that preschool offers an environment that can be a positive influence on young children.

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.

Early education is right up there with motherhood and apple pie as unarguable positive concepts. How could exposing young children to a school-like atmosphere not be a benefit, particularly in communities dominated by socioeconomic challenges? While there are some questions about the value of playing Mozart to infants, early education in the traditional sense continues to be viewed as a key strategy for providing young children a preschool foundation on which a successful academic career can be built. Several oft-cited randomized controlled trials have fueled both private and public interest and funding.

However, a recent commentary published in Science suggests that all programs are “not unequivocally positive and much more research is needed.” “Worrisome results in Tennessee,” “Success in Boston,” and “Largely null results for Headstart” are just a few of the article’s section titles and convey a sense of the inconsistency the investigators found as they reviewed early education systems around the country.

Wilkoff_William_G_2_web.jpg

While there may be some politicians who may attempt to use the results of this investigation as a reason to cancel public funding of underperforming early education programs, the authors avoid this baby-and-the-bathwater conclusion. Instead, they urge more rigorous research “to understand how effective programs can be designed and implemented.”

The kind of re-thinking and brainstorming these investigators suggest takes time. While we’re waiting for this process to gain traction, this might be a good time to consider some of the benefits of early education that we don’t usually consider when our focus is on academic metrics.

A recent paper in Children’s Health Care by investigators at the Boston University Medical Center and School of Medicine considered the diet of children attending preschool. Looking at the dietary records of more than 300 children attending 30 childcare centers, the researchers found that the children’s diets before arrival at daycare was less healthy than while they were in daycare. “The hour after pickup appeared to be the least healthful” of any of the time periods surveyed. Of course, we will all conjure up images of what this chaotic post-daycare pickup may look like and cut the harried parents and grandparents some slack when it comes to nutritional choices. However, the bottom line is that for the group of children surveyed being in preschool or daycare protected them from a less healthy diet they were being provided outside of school hours.

Our recent experience with pandemic-related school closures provides more evidence that being in school was superior to any remote experience academically. School-age children and adolescents gained weight when school closures were the norm. Play patterns for children shifted from outdoor play to indoor play — often dominated by more sedentary video games. Both fatal and non-fatal gun-related injuries surged during the pandemic and, by far, the majority of these occur in the home and not at school.

Stepping back to look at this broader picture that includes diet, physical activity, and safety — not to mention the benefits of socialization — leads one to arrive at the unfortunate conclusion that for many children in this country, being at home is considerably less healthy than being in school. Of course there will be those who point to the belief that schools are petri dishes putting children at greater risk for respiratory infections. On the other hand, we must accept that schools haven’t proved to be a major factor in the spread of COVID that many had feared.

The authors of the study in Science are certainly correct in recommending a more thorough investigation into the academic benefits of preschool education. However, we must keep in mind that preschool offers an environment that can be a positive influence on young children.

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.

No matter where one looks for the statistics, no matter what words one chooses to describe it, this country has a child and adolescent mental health crisis. Almost 20% of young people in the 3-17 age bracket have a mental, emotional, developmental, or behavioral disorder. COVID-19 has certainly exacerbated the problem, but the downward trend in the mental health of this nation has been going on for decades.

The voices calling for more services to address the problem are getting more numerous and louder. But, what exactly should those services look like and who should be delivering them?

Wilkoff_William_G_2_web.jpg

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.

No matter where one looks for the statistics, no matter what words one chooses to describe it, this country has a child and adolescent mental health crisis. Almost 20% of young people in the 3-17 age bracket have a mental, emotional, developmental, or behavioral disorder. COVID-19 has certainly exacerbated the problem, but the downward trend in the mental health of this nation has been going on for decades.

The voices calling for more services to address the problem are getting more numerous and louder. But, what exactly should those services look like and who should be delivering them?

Wilkoff_William_G_2_web.jpg

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.

No matter where one looks for the statistics, no matter what words one chooses to describe it, this country has a child and adolescent mental health crisis. Almost 20% of young people in the 3-17 age bracket have a mental, emotional, developmental, or behavioral disorder. COVID-19 has certainly exacerbated the problem, but the downward trend in the mental health of this nation has been going on for decades.

The voices calling for more services to address the problem are getting more numerous and louder. But, what exactly should those services look like and who should be delivering them?

Wilkoff_William_G_2_web.jpg

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

I have already shared with you that healthcare systems value panel size and productivity when they are considering primary care physician compensation. Your employers also know that the market won’t bear a substantial price increase for the procedure-poor practice style typical of primary care. You know that the relative value unit (RVU) system for calculating complexity of service is time consuming and discourages the inclusion of customer-friendly short visits that could allow an efficient provider to see more patients. Unfortunately, there is little hope that RVUs will become more PCP-friendly in the near future.

However, before leaving the topic of value and moving on to a consideration of quality, I can’t resist sharing some thoughts about efficiency and time management.

Wilkoff_William_G_2_web.jpg

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

I have already shared with you that healthcare systems value panel size and productivity when they are considering primary care physician compensation. Your employers also know that the market won’t bear a substantial price increase for the procedure-poor practice style typical of primary care. You know that the relative value unit (RVU) system for calculating complexity of service is time consuming and discourages the inclusion of customer-friendly short visits that could allow an efficient provider to see more patients. Unfortunately, there is little hope that RVUs will become more PCP-friendly in the near future.

However, before leaving the topic of value and moving on to a consideration of quality, I can’t resist sharing some thoughts about efficiency and time management.

Wilkoff_William_G_2_web.jpg

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

I have already shared with you that healthcare systems value panel size and productivity when they are considering primary care physician compensation. Your employers also know that the market won’t bear a substantial price increase for the procedure-poor practice style typical of primary care. You know that the relative value unit (RVU) system for calculating complexity of service is time consuming and discourages the inclusion of customer-friendly short visits that could allow an efficient provider to see more patients. Unfortunately, there is little hope that RVUs will become more PCP-friendly in the near future.

However, before leaving the topic of value and moving on to a consideration of quality, I can’t resist sharing some thoughts about efficiency and time management.

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 Part 2 of this series on PCP Compensation, I concluded by saying that it is possible, maybe even likely, that growing your panel size will further endanger your health. When you share this concern with your boss, based purely on economic principles, he or she should answer, “How about charging more per visit?” However, your boss knows that third-party payers are going to look askance at that simple strategy. He or she may then suggest that you make each visit worth more to justify the increased charge.

Here is where the topic of Relative Value Units (RVUs) raises its ugly head.

Before the invention of “health insurance,” when the patient paid for his or her own office visits, it was an unspoken negotiation between patient and physician that decided the value of the care.

When third-party payers first came on the scene, the value of the visit was based roughly on the time spent with the patient. Coupling time spent with value gave no credit to more experienced or skilled physicians who were more efficient at managing their patients. If, on average, it took me 10 minutes to effectively manage an ear infection and my younger associate 20 minutes, should he or she be paid twice as much as I’m paid?

But, value spent on a crude estimate of time spent was a system ripe for abuse.

I have no way of knowing what other physicians were doing, but I suspect I was not alone in factoring my own assessment of “complexity” into the calculation when deciding what to bill for a visit, giving only a passing glance at the recommended time-based definitions of short, standard, and complex visits. The payers then began demanding a more definable method of determining complexity. The result was the RVU, the labor-intensive, but no more accurate, system in which the provider must build a case to defend his or her charges.

Unfortunately, the institution of the RVU system was a major contributor to the death of the short visit. The extra work required to submit and defend the coding of any visit meant that, from a strictly clerical point of view, the short visit became as costly to the business to process as a more complex visit. The result was that every astute business consultant worth his or her salt would begin with the recommendation to “Code up!” Do whatever it takes to build your case for a more complex visit even though it may be a stretch. (It would certainly mean a lot more time-gobbling documenting.) Stop doing short visits. They are your loss leaders.

Before there were RVUs, there was a way physicians could be profitable and include short visits in their schedule. But it meant the provider had to be efficient. But patients generally don’t like going to follow-up visits they see as needless. And, more often than not, the patients are correct. However, patients love the same-day availability that an abundance of short visits in a primary care provider’s schedule can offer. The patient who knows that he or she won’t have to wait weeks or months to see the provider is far less likely to show up at a visit with a laundry list as long as their arm of problems and questions they have saved up while they were waiting to get an appointment. It used to be possible to provide efficient and profitable care by including short visits in a PCP’s schedule. Whether it can still be done under the current RVU system is unclear and probably doubtful.

In the last and final Letter in this series, we will begin with a brief look at efficiency and a PCP’s contribution to overhead before exploring the more difficult subject of defining the quality of a provider’s care and how this could relate to compensation.
 

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 Part 2 of this series on PCP Compensation, I concluded by saying that it is possible, maybe even likely, that growing your panel size will further endanger your health. When you share this concern with your boss, based purely on economic principles, he or she should answer, “How about charging more per visit?” However, your boss knows that third-party payers are going to look askance at that simple strategy. He or she may then suggest that you make each visit worth more to justify the increased charge.

Here is where the topic of Relative Value Units (RVUs) raises its ugly head.

Before the invention of “health insurance,” when the patient paid for his or her own office visits, it was an unspoken negotiation between patient and physician that decided the value of the care.

When third-party payers first came on the scene, the value of the visit was based roughly on the time spent with the patient. Coupling time spent with value gave no credit to more experienced or skilled physicians who were more efficient at managing their patients. If, on average, it took me 10 minutes to effectively manage an ear infection and my younger associate 20 minutes, should he or she be paid twice as much as I’m paid?

But, value spent on a crude estimate of time spent was a system ripe for abuse.

I have no way of knowing what other physicians were doing, but I suspect I was not alone in factoring my own assessment of “complexity” into the calculation when deciding what to bill for a visit, giving only a passing glance at the recommended time-based definitions of short, standard, and complex visits. The payers then began demanding a more definable method of determining complexity. The result was the RVU, the labor-intensive, but no more accurate, system in which the provider must build a case to defend his or her charges.

Unfortunately, the institution of the RVU system was a major contributor to the death of the short visit. The extra work required to submit and defend the coding of any visit meant that, from a strictly clerical point of view, the short visit became as costly to the business to process as a more complex visit. The result was that every astute business consultant worth his or her salt would begin with the recommendation to “Code up!” Do whatever it takes to build your case for a more complex visit even though it may be a stretch. (It would certainly mean a lot more time-gobbling documenting.) Stop doing short visits. They are your loss leaders.

Before there were RVUs, there was a way physicians could be profitable and include short visits in their schedule. But it meant the provider had to be efficient. But patients generally don’t like going to follow-up visits they see as needless. And, more often than not, the patients are correct. However, patients love the same-day availability that an abundance of short visits in a primary care provider’s schedule can offer. The patient who knows that he or she won’t have to wait weeks or months to see the provider is far less likely to show up at a visit with a laundry list as long as their arm of problems and questions they have saved up while they were waiting to get an appointment. It used to be possible to provide efficient and profitable care by including short visits in a PCP’s schedule. Whether it can still be done under the current RVU system is unclear and probably doubtful.

In the last and final Letter in this series, we will begin with a brief look at efficiency and a PCP’s contribution to overhead before exploring the more difficult subject of defining the quality of a provider’s care and how this could relate to compensation.
 

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 Part 2 of this series on PCP Compensation, I concluded by saying that it is possible, maybe even likely, that growing your panel size will further endanger your health. When you share this concern with your boss, based purely on economic principles, he or she should answer, “How about charging more per visit?” However, your boss knows that third-party payers are going to look askance at that simple strategy. He or she may then suggest that you make each visit worth more to justify the increased charge.

Here is where the topic of Relative Value Units (RVUs) raises its ugly head.

Before the invention of “health insurance,” when the patient paid for his or her own office visits, it was an unspoken negotiation between patient and physician that decided the value of the care.

When third-party payers first came on the scene, the value of the visit was based roughly on the time spent with the patient. Coupling time spent with value gave no credit to more experienced or skilled physicians who were more efficient at managing their patients. If, on average, it took me 10 minutes to effectively manage an ear infection and my younger associate 20 minutes, should he or she be paid twice as much as I’m paid?

But, value spent on a crude estimate of time spent was a system ripe for abuse.

I have no way of knowing what other physicians were doing, but I suspect I was not alone in factoring my own assessment of “complexity” into the calculation when deciding what to bill for a visit, giving only a passing glance at the recommended time-based definitions of short, standard, and complex visits. The payers then began demanding a more definable method of determining complexity. The result was the RVU, the labor-intensive, but no more accurate, system in which the provider must build a case to defend his or her charges.

Unfortunately, the institution of the RVU system was a major contributor to the death of the short visit. The extra work required to submit and defend the coding of any visit meant that, from a strictly clerical point of view, the short visit became as costly to the business to process as a more complex visit. The result was that every astute business consultant worth his or her salt would begin with the recommendation to “Code up!” Do whatever it takes to build your case for a more complex visit even though it may be a stretch. (It would certainly mean a lot more time-gobbling documenting.) Stop doing short visits. They are your loss leaders.

Before there were RVUs, there was a way physicians could be profitable and include short visits in their schedule. But it meant the provider had to be efficient. But patients generally don’t like going to follow-up visits they see as needless. And, more often than not, the patients are correct. However, patients love the same-day availability that an abundance of short visits in a primary care provider’s schedule can offer. The patient who knows that he or she won’t have to wait weeks or months to see the provider is far less likely to show up at a visit with a laundry list as long as their arm of problems and questions they have saved up while they were waiting to get an appointment. It used to be possible to provide efficient and profitable care by including short visits in a PCP’s schedule. Whether it can still be done under the current RVU system is unclear and probably doubtful.

In the last and final Letter in this series, we will begin with a brief look at efficiency and a PCP’s contribution to overhead before exploring the more difficult subject of defining the quality of a provider’s care and how this could relate to compensation.
 

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 last column, I began to explore the factors affecting the compensation of primary care providers (PCPs). I described two apparent economic paradoxes. First, while most healthcare systems consider their primary care segments as loss leaders, they continue to seek and hire more PCPs. The second is while PCPs are in short supply, most of them feel that they are underpaid. Supply and demand doesn’t seem to be making them more valuable in the economic sense. The explanations for these nonintuitive observations are first, healthcare systems need the volume of patients stored in the practices of even unprofitable primary care physicians to feed the high-profit specialties in their businesses. Second, there is a limit to how large a gap between revenue and overhead the systems can accept for their primary care practices. Not surprisingly, this means that system administrators must continue to nudge those PCP practices closer toward profitability, usually by demanding higher productivity.

As I did in my last letter, I will continue to lean on a discussion for PCP compensation by a large international management consulting firm I found on the internet. I am not condoning the consultant’s advice, but merely using it as a scaffolding on which to hang the rather squishy topics of time, clinical quality, and patient satisfaction. I only intend to ask questions, and I promise no answers.

First, let me make it clear that I am defining PCPs as providers who are on a performance-based pathway, which is by far the most prevalent model. A fixed-salary arrangement hasn’t made sense to me since I was a 17-year-old lifeguard paid by the hour for sitting by a pool. Had I been paid by the rescue, I would have finished the summer empty handed. A fixed salary provided me a sense of security, but it offered no path for advancement and was boring as hell. The primary care provider I am talking about has an interest in developing relationships with his/her patients, building a practice, and offering some degree of continuity. In other words, I am not considering providers working in walk-in clinics as PCPs.
 

Size Matters

My high-powered management consultant is recommending to his healthcare system management clients that they emphasize panel size component as they craft their compensation packages for PCPs. Maybe even to the point of giving it more weight than the productivity piece. This, of course, makes perfect business sense if the primary value of a PCP to the system lies in the patients he/she brings into the system.

What does this emphasis on size mean for you as a provider? If your boss is following my consultant’s advice, then you would want to be growing your panel size to improve your compensation. You could do this by a marketing plan that makes you more popular. But, I can hear you muttering that you never wanted to be a contestant in a popularity contest. Although I must say that historically this was a fact of life in any community when new providers came to town.

A provider can choose his/her own definition of popularity. You can let it be known that you are a liberal prescription writer and fill your practice with drug-seeking patients. Or you could promote customer-friendly schedules and behaviors in your office staff. And, of course, you can simply exude an aura of caring, which has always been an effective practice-building tool.

On the other hand, you may believe that you have more patients than you can handle. You may fear that growing your practice runs the risk of putting the quality of your patients’ care and your own physical and mental health at risk.

Theoretically, you could keep your panel size unchanged and increase your productivity to enhance your value and therefore your compensation. In the next part of this miniseries we’ll look at the stumbling blocks that can make increasing productivity difficult.
 

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 last column, I began to explore the factors affecting the compensation of primary care providers (PCPs). I described two apparent economic paradoxes. First, while most healthcare systems consider their primary care segments as loss leaders, they continue to seek and hire more PCPs. The second is while PCPs are in short supply, most of them feel that they are underpaid. Supply and demand doesn’t seem to be making them more valuable in the economic sense. The explanations for these nonintuitive observations are first, healthcare systems need the volume of patients stored in the practices of even unprofitable primary care physicians to feed the high-profit specialties in their businesses. Second, there is a limit to how large a gap between revenue and overhead the systems can accept for their primary care practices. Not surprisingly, this means that system administrators must continue to nudge those PCP practices closer toward profitability, usually by demanding higher productivity.

As I did in my last letter, I will continue to lean on a discussion for PCP compensation by a large international management consulting firm I found on the internet. I am not condoning the consultant’s advice, but merely using it as a scaffolding on which to hang the rather squishy topics of time, clinical quality, and patient satisfaction. I only intend to ask questions, and I promise no answers.

First, let me make it clear that I am defining PCPs as providers who are on a performance-based pathway, which is by far the most prevalent model. A fixed-salary arrangement hasn’t made sense to me since I was a 17-year-old lifeguard paid by the hour for sitting by a pool. Had I been paid by the rescue, I would have finished the summer empty handed. A fixed salary provided me a sense of security, but it offered no path for advancement and was boring as hell. The primary care provider I am talking about has an interest in developing relationships with his/her patients, building a practice, and offering some degree of continuity. In other words, I am not considering providers working in walk-in clinics as PCPs.
 

Size Matters

My high-powered management consultant is recommending to his healthcare system management clients that they emphasize panel size component as they craft their compensation packages for PCPs. Maybe even to the point of giving it more weight than the productivity piece. This, of course, makes perfect business sense if the primary value of a PCP to the system lies in the patients he/she brings into the system.

What does this emphasis on size mean for you as a provider? If your boss is following my consultant’s advice, then you would want to be growing your panel size to improve your compensation. You could do this by a marketing plan that makes you more popular. But, I can hear you muttering that you never wanted to be a contestant in a popularity contest. Although I must say that historically this was a fact of life in any community when new providers came to town.

A provider can choose his/her own definition of popularity. You can let it be known that you are a liberal prescription writer and fill your practice with drug-seeking patients. Or you could promote customer-friendly schedules and behaviors in your office staff. And, of course, you can simply exude an aura of caring, which has always been an effective practice-building tool.

On the other hand, you may believe that you have more patients than you can handle. You may fear that growing your practice runs the risk of putting the quality of your patients’ care and your own physical and mental health at risk.

Theoretically, you could keep your panel size unchanged and increase your productivity to enhance your value and therefore your compensation. In the next part of this miniseries we’ll look at the stumbling blocks that can make increasing productivity difficult.
 

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 last column, I began to explore the factors affecting the compensation of primary care providers (PCPs). I described two apparent economic paradoxes. First, while most healthcare systems consider their primary care segments as loss leaders, they continue to seek and hire more PCPs. The second is while PCPs are in short supply, most of them feel that they are underpaid. Supply and demand doesn’t seem to be making them more valuable in the economic sense. The explanations for these nonintuitive observations are first, healthcare systems need the volume of patients stored in the practices of even unprofitable primary care physicians to feed the high-profit specialties in their businesses. Second, there is a limit to how large a gap between revenue and overhead the systems can accept for their primary care practices. Not surprisingly, this means that system administrators must continue to nudge those PCP practices closer toward profitability, usually by demanding higher productivity.

As I did in my last letter, I will continue to lean on a discussion for PCP compensation by a large international management consulting firm I found on the internet. I am not condoning the consultant’s advice, but merely using it as a scaffolding on which to hang the rather squishy topics of time, clinical quality, and patient satisfaction. I only intend to ask questions, and I promise no answers.

First, let me make it clear that I am defining PCPs as providers who are on a performance-based pathway, which is by far the most prevalent model. A fixed-salary arrangement hasn’t made sense to me since I was a 17-year-old lifeguard paid by the hour for sitting by a pool. Had I been paid by the rescue, I would have finished the summer empty handed. A fixed salary provided me a sense of security, but it offered no path for advancement and was boring as hell. The primary care provider I am talking about has an interest in developing relationships with his/her patients, building a practice, and offering some degree of continuity. In other words, I am not considering providers working in walk-in clinics as PCPs.
 

Size Matters

My high-powered management consultant is recommending to his healthcare system management clients that they emphasize panel size component as they craft their compensation packages for PCPs. Maybe even to the point of giving it more weight than the productivity piece. This, of course, makes perfect business sense if the primary value of a PCP to the system lies in the patients he/she brings into the system.

What does this emphasis on size mean for you as a provider? If your boss is following my consultant’s advice, then you would want to be growing your panel size to improve your compensation. You could do this by a marketing plan that makes you more popular. But, I can hear you muttering that you never wanted to be a contestant in a popularity contest. Although I must say that historically this was a fact of life in any community when new providers came to town.

A provider can choose his/her own definition of popularity. You can let it be known that you are a liberal prescription writer and fill your practice with drug-seeking patients. Or you could promote customer-friendly schedules and behaviors in your office staff. And, of course, you can simply exude an aura of caring, which has always been an effective practice-building tool.

On the other hand, you may believe that you have more patients than you can handle. You may fear that growing your practice runs the risk of putting the quality of your patients’ care and your own physical and mental health at risk.

Theoretically, you could keep your panel size unchanged and increase your productivity to enhance your value and therefore your compensation. In the next part of this miniseries we’ll look at the stumbling blocks that can make increasing productivity difficult.
 

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

I recently read an op-ed piece in which the author wondered if any young people entering the practice of medicine felt that they were answering a “calling.” I suspect that there will continue to be, and will always be, idealists whose primary motivation for choosing medicine is that they will be healing the sick or at least providing comfort to the suffering. I occasionally hear that about a former patient who has been inspired by a personal or familial experience with a serious illness.

Unfortunately, I suspect those who feel called are the providers most likely to feel discouraged and frustrated by the current state of primary care. Luckily, I never felt a calling. For me, primary care pediatrics was a job. One that l felt obligated to perform to the best of my ability. Mine was not a calling but an inherited philosophy that work in itself was virtuous. A work ethic, if you will. Pediatrics offered the additional reward that, if well done, it might help some parents and their children feel a little better.

Fifty years ago I was not alone in treating medicine as a job. Most physicians were self-employed. Although there were exceptions like Albert Schweitzer, even those of us with a calling had to obey the basic rules of business as it applied to medicine. We were employer and employee and had to understand the critical factors of overhead, profit, and loss.

I have burdened you with this little history recitation not to suggest that things were better in the good old days, but to provide a stepping stone into the murky and uncomfortable topic of primary care physician (PCP) compensation. Because almost three quarters of you work for a hospital, health system, or corporate entity, I am going to illuminate our journey by leaning on the advice of an international company with 7000 employees and revenue of 2.5 billion dollars that considers itself a “global leader” in management consulting. Your employer is listening to some management consultant and it may help us to view your compensation from someone on their side of the table.

First, you should be aware that “most health systems lose money on their primary care operations — up to $200,000 or more per primary care physician.” This may help explain why despite being in short supply, you and most PCPs feel undervalued. However, if we are such losers, we must provide something(s) that the systems are seeking. It is likely that the system is looking to tout its ability to provide comprehensive care and demonstrate that it has a patient base broad enough to warrant attention and provide bargaining leverage on volume discounts.

The system also may want to minimize competition by absorbing the remaining PCPs in the community into their system. With you outside of the system, it had less control over your compensation than it does when you are under its umbrella.

Your employer may want to grow and feed its specialty care network, and it sees PCPs as having the fuel stored in their patient volume to do just that. In simplest and most cynical terms, the systems are willing to take a loss on us less profitable high-volume grunts in order to reap the profits of the lower-volume high-profitability specialties and subspecialties.

So that’s why you as a PCP have any value at all to a large healthcare system. But, it means that to maintain your value to the system you must continue to provide the volume it anticipates and needs. While the system may have been willing to accept some degrees of unprofitability when it hired you, there are limits. And, we shouldn’t be surprised if they continue to urge or demand that we narrow the gap between the revenue we generate and the costs that we incur, ie, our overhead.

In Part 2 of this series, I’m going to discuss the collateral damage that occurs when volume and overhead collide in an environment that claims to be committed to patient care.

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

I recently read an op-ed piece in which the author wondered if any young people entering the practice of medicine felt that they were answering a “calling.” I suspect that there will continue to be, and will always be, idealists whose primary motivation for choosing medicine is that they will be healing the sick or at least providing comfort to the suffering. I occasionally hear that about a former patient who has been inspired by a personal or familial experience with a serious illness.

Unfortunately, I suspect those who feel called are the providers most likely to feel discouraged and frustrated by the current state of primary care. Luckily, I never felt a calling. For me, primary care pediatrics was a job. One that l felt obligated to perform to the best of my ability. Mine was not a calling but an inherited philosophy that work in itself was virtuous. A work ethic, if you will. Pediatrics offered the additional reward that, if well done, it might help some parents and their children feel a little better.

Fifty years ago I was not alone in treating medicine as a job. Most physicians were self-employed. Although there were exceptions like Albert Schweitzer, even those of us with a calling had to obey the basic rules of business as it applied to medicine. We were employer and employee and had to understand the critical factors of overhead, profit, and loss.

I have burdened you with this little history recitation not to suggest that things were better in the good old days, but to provide a stepping stone into the murky and uncomfortable topic of primary care physician (PCP) compensation. Because almost three quarters of you work for a hospital, health system, or corporate entity, I am going to illuminate our journey by leaning on the advice of an international company with 7000 employees and revenue of 2.5 billion dollars that considers itself a “global leader” in management consulting. Your employer is listening to some management consultant and it may help us to view your compensation from someone on their side of the table.

First, you should be aware that “most health systems lose money on their primary care operations — up to $200,000 or more per primary care physician.” This may help explain why despite being in short supply, you and most PCPs feel undervalued. However, if we are such losers, we must provide something(s) that the systems are seeking. It is likely that the system is looking to tout its ability to provide comprehensive care and demonstrate that it has a patient base broad enough to warrant attention and provide bargaining leverage on volume discounts.

The system also may want to minimize competition by absorbing the remaining PCPs in the community into their system. With you outside of the system, it had less control over your compensation than it does when you are under its umbrella.

Your employer may want to grow and feed its specialty care network, and it sees PCPs as having the fuel stored in their patient volume to do just that. In simplest and most cynical terms, the systems are willing to take a loss on us less profitable high-volume grunts in order to reap the profits of the lower-volume high-profitability specialties and subspecialties.

So that’s why you as a PCP have any value at all to a large healthcare system. But, it means that to maintain your value to the system you must continue to provide the volume it anticipates and needs. While the system may have been willing to accept some degrees of unprofitability when it hired you, there are limits. And, we shouldn’t be surprised if they continue to urge or demand that we narrow the gap between the revenue we generate and the costs that we incur, ie, our overhead.

In Part 2 of this series, I’m going to discuss the collateral damage that occurs when volume and overhead collide in an environment that claims to be committed to patient care.

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

I recently read an op-ed piece in which the author wondered if any young people entering the practice of medicine felt that they were answering a “calling.” I suspect that there will continue to be, and will always be, idealists whose primary motivation for choosing medicine is that they will be healing the sick or at least providing comfort to the suffering. I occasionally hear that about a former patient who has been inspired by a personal or familial experience with a serious illness.

Unfortunately, I suspect those who feel called are the providers most likely to feel discouraged and frustrated by the current state of primary care. Luckily, I never felt a calling. For me, primary care pediatrics was a job. One that l felt obligated to perform to the best of my ability. Mine was not a calling but an inherited philosophy that work in itself was virtuous. A work ethic, if you will. Pediatrics offered the additional reward that, if well done, it might help some parents and their children feel a little better.

Fifty years ago I was not alone in treating medicine as a job. Most physicians were self-employed. Although there were exceptions like Albert Schweitzer, even those of us with a calling had to obey the basic rules of business as it applied to medicine. We were employer and employee and had to understand the critical factors of overhead, profit, and loss.

I have burdened you with this little history recitation not to suggest that things were better in the good old days, but to provide a stepping stone into the murky and uncomfortable topic of primary care physician (PCP) compensation. Because almost three quarters of you work for a hospital, health system, or corporate entity, I am going to illuminate our journey by leaning on the advice of an international company with 7000 employees and revenue of 2.5 billion dollars that considers itself a “global leader” in management consulting. Your employer is listening to some management consultant and it may help us to view your compensation from someone on their side of the table.

First, you should be aware that “most health systems lose money on their primary care operations — up to $200,000 or more per primary care physician.” This may help explain why despite being in short supply, you and most PCPs feel undervalued. However, if we are such losers, we must provide something(s) that the systems are seeking. It is likely that the system is looking to tout its ability to provide comprehensive care and demonstrate that it has a patient base broad enough to warrant attention and provide bargaining leverage on volume discounts.

The system also may want to minimize competition by absorbing the remaining PCPs in the community into their system. With you outside of the system, it had less control over your compensation than it does when you are under its umbrella.

Your employer may want to grow and feed its specialty care network, and it sees PCPs as having the fuel stored in their patient volume to do just that. In simplest and most cynical terms, the systems are willing to take a loss on us less profitable high-volume grunts in order to reap the profits of the lower-volume high-profitability specialties and subspecialties.

So that’s why you as a PCP have any value at all to a large healthcare system. But, it means that to maintain your value to the system you must continue to provide the volume it anticipates and needs. While the system may have been willing to accept some degrees of unprofitability when it hired you, there are limits. And, we shouldn’t be surprised if they continue to urge or demand that we narrow the gap between the revenue we generate and the costs that we incur, ie, our overhead.

In Part 2 of this series, I’m going to discuss the collateral damage that occurs when volume and overhead collide in an environment that claims to be committed to patient care.

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.