Letters from Maine

My first civilian job after finishing my training was as an associate and eventually a partner of a pediatrician whose office was in a wing of his large 19th-century home. The pediatrician in the neighboring town had his office in a small house next to his home. This model of small one- or two -provider offices in or nearby their homes was replicated up and down the coast. After 7 years, the 12-minute drive from my home to the office became intolerable and I asked to dissolve what was otherwise a successful partnership. I opened a one-provider office with a 6-minute bike ride commute and my wife served as the billing clerk and bookkeeper.

Those next 10 years of solo practice were the most rewarding, both economically and professionally. Eventually faced with the need to add another provider, I reluctantly joined a recently formed group of primary care physicians who, like me, had been running one- or two-provider offices often with spouses as support staff — basically Mom and Pop operations. However, the group was gradually absorbed by increasingly larger entities and our practices that once were as individual as our personalities became homogenized. Neither my patients nor I liked the new feel of the office.

Still pining for that small office vibe, I continue to wonder if it could be scaled up and adapted to today’s healthcare realities. I recently read a New York Times article describing how a pediatrician has launched such a practice model into the uncharted waters of Greater New York City.

At age 34, Dr. Michel Cohen, a Moroccan-French émigré, opened his storefront pediatric practice in 1994. The upper story housed his loft apartment. A self-described “hippie doctor,” Dr. Cohen developed a following based on his book on parenting and publicity surrounding his role in the even more popular book on French-style parenting titled Bringing up Bebe by Pamela Druckerman. By 2009 his practice had grown to three small storefront offices. However, they weren’t sufficiently profitable. He decided to shun the distractions of his celebrity practice trappings and instead focus on growth, hoping that the gravitas associated with even more office locations would allow him to offer better service and improve the bottom line. Sort of an “economy of scale” notion applied to the small office setting.

He now has 48 offices having added 12 new sites last year with 5 more planned for next year. These are all one- or two-physician installations with two exam rooms per provider. The offices are bright and colorful, focused on appealing to a child’s taste. The furniture is blond wood, most of it based on Dr. Cohen’s designs and in some cases handmade. Current staffing is 112 physicians and nurse practitioners and volume exceeds 100,000 visits per year.

The volume has allowed the practice to add a user-friendly patient portal and offer an after-hours call-in option. The larger volume means that staffing can be more easily adjusted to illness and vacations. The goal is to have the practitioners become identified with their sites and the patients assigned to them whenever possible. Uniformity in office designs allow a provider filling in from another site to easily find supplies and function within a familiar system.

While the sites have generally served upscale gentrified neighborhoods, the practice has recently expanded to less affluent areas and accepts Medicaid. Dr. Cohen’s dream is to expand his network nationally as a nonprofit in which low-income sites would be subsidized by the more profitable offices. A previous attempt at expansion with two offices in Southern California did not work out because the time zone difference didn’t mesh well with the Internet portal.

Wanting to hear a firsthand account from a family on how the Tribeca Pediatric system works, I contacted a neighbor who has recently moved his young family here to Brunswick. His impression was generally positive. He gave high marks to the patient portal for the ability to get school and camp forms and vaccination records quickly. Appointments made electronically was a plus, although the after-hours response time sometimes took an hour or two. He would have preferred to see their assigned provider for a higher percentage of visits, but this seems to be a common complaint even in systems with the greatest availability. Care was dispensed efficiently but didn’t seem to be overly rushed.

In the NY Times article there is one complaint by a former provider who felt she was getting burned out by the system and leaned on 10 minutes for sick visits and 20 minutes for well visits. Personally, I don’t see this as a problem. The length of a visit and the quality of the care are not always related. Given good support services and an efficiently run office, those slot guidelines seem very reasonable, realizing that a skilled clinician must have already learned to adjust his or her pace to the realities of the patient mix. However, as the pediatric sick population has leaned more toward behavioral and mental health problems, a primary care practice should be offering some option for these patients either in-house or with reliable referral relationships. Although the NY Times article doesn’t provide any numbers, it does mention that the providers are generally young and there is some turnover, possibly as providers use the practice as a “stepping stone.”

To some extent Dr. Cohen’s success seems to be the result of his real estate acumen and business sense. Because the majority of recent medical school graduates enter the work force with a substantial debt, it is difficult to imagine that a young physician would have Dr. Cohen’s entrepreneurial passion. However, clearly his success, at least in the short term, demonstrates that there is a substantial percentage of both patients and providers who prefer small personalized offices if given the option. It will be interesting to see if and how Tribeca Pediatrics expands and whether any of the larger existing networks attempt to imitate it.

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.

My first civilian job after finishing my training was as an associate and eventually a partner of a pediatrician whose office was in a wing of his large 19th-century home. The pediatrician in the neighboring town had his office in a small house next to his home. This model of small one- or two -provider offices in or nearby their homes was replicated up and down the coast. After 7 years, the 12-minute drive from my home to the office became intolerable and I asked to dissolve what was otherwise a successful partnership. I opened a one-provider office with a 6-minute bike ride commute and my wife served as the billing clerk and bookkeeper.

Those next 10 years of solo practice were the most rewarding, both economically and professionally. Eventually faced with the need to add another provider, I reluctantly joined a recently formed group of primary care physicians who, like me, had been running one- or two-provider offices often with spouses as support staff — basically Mom and Pop operations. However, the group was gradually absorbed by increasingly larger entities and our practices that once were as individual as our personalities became homogenized. Neither my patients nor I liked the new feel of the office.

Still pining for that small office vibe, I continue to wonder if it could be scaled up and adapted to today’s healthcare realities. I recently read a New York Times article describing how a pediatrician has launched such a practice model into the uncharted waters of Greater New York City.

At age 34, Dr. Michel Cohen, a Moroccan-French émigré, opened his storefront pediatric practice in 1994. The upper story housed his loft apartment. A self-described “hippie doctor,” Dr. Cohen developed a following based on his book on parenting and publicity surrounding his role in the even more popular book on French-style parenting titled Bringing up Bebe by Pamela Druckerman. By 2009 his practice had grown to three small storefront offices. However, they weren’t sufficiently profitable. He decided to shun the distractions of his celebrity practice trappings and instead focus on growth, hoping that the gravitas associated with even more office locations would allow him to offer better service and improve the bottom line. Sort of an “economy of scale” notion applied to the small office setting.

He now has 48 offices having added 12 new sites last year with 5 more planned for next year. These are all one- or two-physician installations with two exam rooms per provider. The offices are bright and colorful, focused on appealing to a child’s taste. The furniture is blond wood, most of it based on Dr. Cohen’s designs and in some cases handmade. Current staffing is 112 physicians and nurse practitioners and volume exceeds 100,000 visits per year.

The volume has allowed the practice to add a user-friendly patient portal and offer an after-hours call-in option. The larger volume means that staffing can be more easily adjusted to illness and vacations. The goal is to have the practitioners become identified with their sites and the patients assigned to them whenever possible. Uniformity in office designs allow a provider filling in from another site to easily find supplies and function within a familiar system.

While the sites have generally served upscale gentrified neighborhoods, the practice has recently expanded to less affluent areas and accepts Medicaid. Dr. Cohen’s dream is to expand his network nationally as a nonprofit in which low-income sites would be subsidized by the more profitable offices. A previous attempt at expansion with two offices in Southern California did not work out because the time zone difference didn’t mesh well with the Internet portal.

Wanting to hear a firsthand account from a family on how the Tribeca Pediatric system works, I contacted a neighbor who has recently moved his young family here to Brunswick. His impression was generally positive. He gave high marks to the patient portal for the ability to get school and camp forms and vaccination records quickly. Appointments made electronically was a plus, although the after-hours response time sometimes took an hour or two. He would have preferred to see their assigned provider for a higher percentage of visits, but this seems to be a common complaint even in systems with the greatest availability. Care was dispensed efficiently but didn’t seem to be overly rushed.

In the NY Times article there is one complaint by a former provider who felt she was getting burned out by the system and leaned on 10 minutes for sick visits and 20 minutes for well visits. Personally, I don’t see this as a problem. The length of a visit and the quality of the care are not always related. Given good support services and an efficiently run office, those slot guidelines seem very reasonable, realizing that a skilled clinician must have already learned to adjust his or her pace to the realities of the patient mix. However, as the pediatric sick population has leaned more toward behavioral and mental health problems, a primary care practice should be offering some option for these patients either in-house or with reliable referral relationships. Although the NY Times article doesn’t provide any numbers, it does mention that the providers are generally young and there is some turnover, possibly as providers use the practice as a “stepping stone.”

To some extent Dr. Cohen’s success seems to be the result of his real estate acumen and business sense. Because the majority of recent medical school graduates enter the work force with a substantial debt, it is difficult to imagine that a young physician would have Dr. Cohen’s entrepreneurial passion. However, clearly his success, at least in the short term, demonstrates that there is a substantial percentage of both patients and providers who prefer small personalized offices if given the option. It will be interesting to see if and how Tribeca Pediatrics expands and whether any of the larger existing networks attempt to imitate it.

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.

My first civilian job after finishing my training was as an associate and eventually a partner of a pediatrician whose office was in a wing of his large 19th-century home. The pediatrician in the neighboring town had his office in a small house next to his home. This model of small one- or two -provider offices in or nearby their homes was replicated up and down the coast. After 7 years, the 12-minute drive from my home to the office became intolerable and I asked to dissolve what was otherwise a successful partnership. I opened a one-provider office with a 6-minute bike ride commute and my wife served as the billing clerk and bookkeeper.

Those next 10 years of solo practice were the most rewarding, both economically and professionally. Eventually faced with the need to add another provider, I reluctantly joined a recently formed group of primary care physicians who, like me, had been running one- or two-provider offices often with spouses as support staff — basically Mom and Pop operations. However, the group was gradually absorbed by increasingly larger entities and our practices that once were as individual as our personalities became homogenized. Neither my patients nor I liked the new feel of the office.

Still pining for that small office vibe, I continue to wonder if it could be scaled up and adapted to today’s healthcare realities. I recently read a New York Times article describing how a pediatrician has launched such a practice model into the uncharted waters of Greater New York City.

At age 34, Dr. Michel Cohen, a Moroccan-French émigré, opened his storefront pediatric practice in 1994. The upper story housed his loft apartment. A self-described “hippie doctor,” Dr. Cohen developed a following based on his book on parenting and publicity surrounding his role in the even more popular book on French-style parenting titled Bringing up Bebe by Pamela Druckerman. By 2009 his practice had grown to three small storefront offices. However, they weren’t sufficiently profitable. He decided to shun the distractions of his celebrity practice trappings and instead focus on growth, hoping that the gravitas associated with even more office locations would allow him to offer better service and improve the bottom line. Sort of an “economy of scale” notion applied to the small office setting.

He now has 48 offices having added 12 new sites last year with 5 more planned for next year. These are all one- or two-physician installations with two exam rooms per provider. The offices are bright and colorful, focused on appealing to a child’s taste. The furniture is blond wood, most of it based on Dr. Cohen’s designs and in some cases handmade. Current staffing is 112 physicians and nurse practitioners and volume exceeds 100,000 visits per year.

The volume has allowed the practice to add a user-friendly patient portal and offer an after-hours call-in option. The larger volume means that staffing can be more easily adjusted to illness and vacations. The goal is to have the practitioners become identified with their sites and the patients assigned to them whenever possible. Uniformity in office designs allow a provider filling in from another site to easily find supplies and function within a familiar system.

While the sites have generally served upscale gentrified neighborhoods, the practice has recently expanded to less affluent areas and accepts Medicaid. Dr. Cohen’s dream is to expand his network nationally as a nonprofit in which low-income sites would be subsidized by the more profitable offices. A previous attempt at expansion with two offices in Southern California did not work out because the time zone difference didn’t mesh well with the Internet portal.

Wanting to hear a firsthand account from a family on how the Tribeca Pediatric system works, I contacted a neighbor who has recently moved his young family here to Brunswick. His impression was generally positive. He gave high marks to the patient portal for the ability to get school and camp forms and vaccination records quickly. Appointments made electronically was a plus, although the after-hours response time sometimes took an hour or two. He would have preferred to see their assigned provider for a higher percentage of visits, but this seems to be a common complaint even in systems with the greatest availability. Care was dispensed efficiently but didn’t seem to be overly rushed.

In the NY Times article there is one complaint by a former provider who felt she was getting burned out by the system and leaned on 10 minutes for sick visits and 20 minutes for well visits. Personally, I don’t see this as a problem. The length of a visit and the quality of the care are not always related. Given good support services and an efficiently run office, those slot guidelines seem very reasonable, realizing that a skilled clinician must have already learned to adjust his or her pace to the realities of the patient mix. However, as the pediatric sick population has leaned more toward behavioral and mental health problems, a primary care practice should be offering some option for these patients either in-house or with reliable referral relationships. Although the NY Times article doesn’t provide any numbers, it does mention that the providers are generally young and there is some turnover, possibly as providers use the practice as a “stepping stone.”

To some extent Dr. Cohen’s success seems to be the result of his real estate acumen and business sense. Because the majority of recent medical school graduates enter the work force with a substantial debt, it is difficult to imagine that a young physician would have Dr. Cohen’s entrepreneurial passion. However, clearly his success, at least in the short term, demonstrates that there is a substantial percentage of both patients and providers who prefer small personalized offices if given the option. It will be interesting to see if and how Tribeca Pediatrics expands and whether any of the larger existing networks attempt to imitate it.

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 this February’s issue of the journal Pediatrics there is an interesting paper that explores the demographics and sleep environments of the more than 8000 sudden unexpected infant death (SUID) victims who died in the United States between 2011 and 2020. The authors’ broad conclusion was “Most SUID, regardless of sleep location, had multiple unsafe sleep factors present demonstrating the need for comprehensive sleep counseling for every family at every encounter.”

From the perspective of a former busy primary care physician I shudder when I read a statement this broad because it doesn’t acknowledge the realities of my professional life. A sentence containing “comprehensive” and two “every’s” won’t be taken seriously by most of the practicing pediatricians I know. However, there is an abundance of information generated by these investigators that could help a pediatrician target his advice to the individual families in his practice without having to resort to time-consuming comprehensive counseling, which is likely to sound like just so much chatter to families overwhelmed by the new challenge of raising a child.

For example, nearly 60% of SUID cases were sharing a sleep surface when they died, and surface-sharing infants were more likely to not have a crib in their home. It seems to me that one should start with the simple question, “Do your have a crib in your home ... in all the homes where the baby will sleep?” And, it should be asked in the hospital prior to discharge.

In 1993, our second-born daughter went home from a teaching hospital in a cardboard box. So did all of her nursery mates. It was decorated with a stork motif and had served as her bassinet. Since early in the last century, families in Finland have been offered a similar box filled with baby supplies. Shrinkflation has caused a scale back in its contents, but the box itself has remained as a safe and inexpensive sleep surface for income-challenged families.

Many babies in this country are put to sleep in a variety of places as they are shuttled around to where the inexpensive childcare is available. Offering families as many boxes as they need may avoid the tragedy of their infant smothering on Aunt Louise’s couch or Cousin Martha’s bed littered with pillows. This is particularly important in a family with multiples (twins, triplets, etc.) who are overrepresented in the SUID population. The opening question about crib availability is likely to alert the healthcare provider to a social situation dominated by poverty that may include lower parental education and a higher likelihood of residential insecurity, all of which are associated with surface-sharing.

The authors observe “surface-sharing in and of itself may not be what caregiver education should focus on.” A simple cardboard box, however, is not a sleep surface likely to be shared with an adult.

For the families for whom surface-sharing is a choice and not a necessity, the investigators encourage us to engage families on their motivation for surface-sharing. This is a discussion that clinicians should be initiating, regardless of our concern of SUID prevention, by simply asking “How are you and your baby sleeping?” Is the baby being nursed to sleep? Where? While the authors acknowledge that their raw data did not allow them to make any observations on a relationship between surface-sharing and breastfeeding, my anecdotal observations have found an unfortunate number of mothers who have become human pacifiers for their babies and are co-sleeping. This association can result in a sleep-deprived parent(s) with unhealthy consequences. Although it can be difficult to uncouple breastfeeding from settling, early intervention triggered by asking a simple question can improve the chances of resolution.

Although I may quibble with the wording of authors’ final conclusion, this is an excellent paper worth looking at. SUID while infrequent and for the most part still mysterious is a tragedy that we should be able to prevent.

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 this February’s issue of the journal Pediatrics there is an interesting paper that explores the demographics and sleep environments of the more than 8000 sudden unexpected infant death (SUID) victims who died in the United States between 2011 and 2020. The authors’ broad conclusion was “Most SUID, regardless of sleep location, had multiple unsafe sleep factors present demonstrating the need for comprehensive sleep counseling for every family at every encounter.”

From the perspective of a former busy primary care physician I shudder when I read a statement this broad because it doesn’t acknowledge the realities of my professional life. A sentence containing “comprehensive” and two “every’s” won’t be taken seriously by most of the practicing pediatricians I know. However, there is an abundance of information generated by these investigators that could help a pediatrician target his advice to the individual families in his practice without having to resort to time-consuming comprehensive counseling, which is likely to sound like just so much chatter to families overwhelmed by the new challenge of raising a child.

For example, nearly 60% of SUID cases were sharing a sleep surface when they died, and surface-sharing infants were more likely to not have a crib in their home. It seems to me that one should start with the simple question, “Do your have a crib in your home ... in all the homes where the baby will sleep?” And, it should be asked in the hospital prior to discharge.

In 1993, our second-born daughter went home from a teaching hospital in a cardboard box. So did all of her nursery mates. It was decorated with a stork motif and had served as her bassinet. Since early in the last century, families in Finland have been offered a similar box filled with baby supplies. Shrinkflation has caused a scale back in its contents, but the box itself has remained as a safe and inexpensive sleep surface for income-challenged families.

Many babies in this country are put to sleep in a variety of places as they are shuttled around to where the inexpensive childcare is available. Offering families as many boxes as they need may avoid the tragedy of their infant smothering on Aunt Louise’s couch or Cousin Martha’s bed littered with pillows. This is particularly important in a family with multiples (twins, triplets, etc.) who are overrepresented in the SUID population. The opening question about crib availability is likely to alert the healthcare provider to a social situation dominated by poverty that may include lower parental education and a higher likelihood of residential insecurity, all of which are associated with surface-sharing.

The authors observe “surface-sharing in and of itself may not be what caregiver education should focus on.” A simple cardboard box, however, is not a sleep surface likely to be shared with an adult.

For the families for whom surface-sharing is a choice and not a necessity, the investigators encourage us to engage families on their motivation for surface-sharing. This is a discussion that clinicians should be initiating, regardless of our concern of SUID prevention, by simply asking “How are you and your baby sleeping?” Is the baby being nursed to sleep? Where? While the authors acknowledge that their raw data did not allow them to make any observations on a relationship between surface-sharing and breastfeeding, my anecdotal observations have found an unfortunate number of mothers who have become human pacifiers for their babies and are co-sleeping. This association can result in a sleep-deprived parent(s) with unhealthy consequences. Although it can be difficult to uncouple breastfeeding from settling, early intervention triggered by asking a simple question can improve the chances of resolution.

Although I may quibble with the wording of authors’ final conclusion, this is an excellent paper worth looking at. SUID while infrequent and for the most part still mysterious is a tragedy that we should be able to prevent.

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 this February’s issue of the journal Pediatrics there is an interesting paper that explores the demographics and sleep environments of the more than 8000 sudden unexpected infant death (SUID) victims who died in the United States between 2011 and 2020. The authors’ broad conclusion was “Most SUID, regardless of sleep location, had multiple unsafe sleep factors present demonstrating the need for comprehensive sleep counseling for every family at every encounter.”

From the perspective of a former busy primary care physician I shudder when I read a statement this broad because it doesn’t acknowledge the realities of my professional life. A sentence containing “comprehensive” and two “every’s” won’t be taken seriously by most of the practicing pediatricians I know. However, there is an abundance of information generated by these investigators that could help a pediatrician target his advice to the individual families in his practice without having to resort to time-consuming comprehensive counseling, which is likely to sound like just so much chatter to families overwhelmed by the new challenge of raising a child.

For example, nearly 60% of SUID cases were sharing a sleep surface when they died, and surface-sharing infants were more likely to not have a crib in their home. It seems to me that one should start with the simple question, “Do your have a crib in your home ... in all the homes where the baby will sleep?” And, it should be asked in the hospital prior to discharge.

In 1993, our second-born daughter went home from a teaching hospital in a cardboard box. So did all of her nursery mates. It was decorated with a stork motif and had served as her bassinet. Since early in the last century, families in Finland have been offered a similar box filled with baby supplies. Shrinkflation has caused a scale back in its contents, but the box itself has remained as a safe and inexpensive sleep surface for income-challenged families.

Many babies in this country are put to sleep in a variety of places as they are shuttled around to where the inexpensive childcare is available. Offering families as many boxes as they need may avoid the tragedy of their infant smothering on Aunt Louise’s couch or Cousin Martha’s bed littered with pillows. This is particularly important in a family with multiples (twins, triplets, etc.) who are overrepresented in the SUID population. The opening question about crib availability is likely to alert the healthcare provider to a social situation dominated by poverty that may include lower parental education and a higher likelihood of residential insecurity, all of which are associated with surface-sharing.

The authors observe “surface-sharing in and of itself may not be what caregiver education should focus on.” A simple cardboard box, however, is not a sleep surface likely to be shared with an adult.

For the families for whom surface-sharing is a choice and not a necessity, the investigators encourage us to engage families on their motivation for surface-sharing. This is a discussion that clinicians should be initiating, regardless of our concern of SUID prevention, by simply asking “How are you and your baby sleeping?” Is the baby being nursed to sleep? Where? While the authors acknowledge that their raw data did not allow them to make any observations on a relationship between surface-sharing and breastfeeding, my anecdotal observations have found an unfortunate number of mothers who have become human pacifiers for their babies and are co-sleeping. This association can result in a sleep-deprived parent(s) with unhealthy consequences. Although it can be difficult to uncouple breastfeeding from settling, early intervention triggered by asking a simple question can improve the chances of resolution.

Although I may quibble with the wording of authors’ final conclusion, this is an excellent paper worth looking at. SUID while infrequent and for the most part still mysterious is a tragedy that we should be able to prevent.

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 can’t remember where I heard it. Maybe I made it up myself. But, one definition of a family is a group of folks with whom you share your genes and germs. In that same vein, one could define daycare as a group of germ-sharing children. Of course that’s news to almost no one. Parents who decide, or are forced, to send their children to daycare expect that those children will get more colds, “stomach flu,” and ear infections than the children who spend their days in isolation at home. Everyone from the pediatrician to the little old lady next door has warned parents of the inevitable reality of daycare. Of course there are upsides that parents can cling to, including increased socialization and the hope that getting sick young will build a more robust immunity in the long run.

However, there has been little research exploring the nuances of the germ sharing that we all know is happening in these and other social settings.

A team of evolutionary biologists at Harvard is working to better define the “social microbiome” and its “role in individuals’ susceptibility to, and resilience against, both communicable and noncommunicable diseases.” These researchers point out that while we harbor our own unique collection of microbes, we share those with the microbiomes of the people with whom we interact socially. They report that studies by other investigators have shown that residents of a household share a significant proportion of their gastrointestinal flora. There are other studies that have shown that villages can be identified by their own social biome. There are few social settings more intimately involved in microbe sharing than daycares. I have a friends who calls them “petri dishes.”

The biologists point out that antibiotic-resistant microbes can become part of an individual’s microbiome and can be shared with other individuals in their social group, who can then go on and share them in a different social environment. Imagine there is one popular physician in a community whose sense of antibiotic stewardship is, shall we say, somewhat lacking. By inappropriately prescribing antibiotics to a child or two in a daycare, he may be altering the social biome in that daycare, which could then jeopardize the health of all the children and eventually their own home-based social biomes, that may include an immune deficient individual.

The researchers also remind us that different cultures and countries may have different antibiotic usage patterns. Does this mean I am taking a risk by traveling in these “culture-dependent transmission landscapes”? Am I more likely to encounter an antibiotic-resistant microbe when I am visiting a country whose healthcare providers are less prudent prescribers?

However, as these evolutionary biologists point out, not all shared microbes are bad. There is some evidence in animals that individuals can share microbes that have been found to “increase resilience against colitis or improve their responsiveness to cancer therapy.” If a microbe can contribute to a disease that was once considered to be “noncommunicable,” we may need to redefine “communicable” in the light this more nuanced view of the social biome.

It became standard practice during the COVID pandemic to test dormitory and community sewage water to determine the level of infection. Can sewage water be used as a proxy for a social biome? If a parent is lucky enough to have a choice of daycares, would knowing each facility’s biome, as reflected in an analysis of its sewage effluent, help him or her decide? Should a daycare ask for a stool sample from each child before accepting him or her? Seems like this would raise some privacy issues, not to mention the logistical messiness of the process. As we learn more about social biomes, can we imagine a time when a daycare or country or region might proudly advertise itself as having the healthiest spectrum of microbes in its sewage system?

Communal living certainly has its benefits, not just for children but also adults as we realize how loneliness is eating its way into our society. However, living in close social contact means that, for better or worse, we will be reconfiguring our own personal biomes thanks to the inevitable gifts from our cohabitants.

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 can’t remember where I heard it. Maybe I made it up myself. But, one definition of a family is a group of folks with whom you share your genes and germs. In that same vein, one could define daycare as a group of germ-sharing children. Of course that’s news to almost no one. Parents who decide, or are forced, to send their children to daycare expect that those children will get more colds, “stomach flu,” and ear infections than the children who spend their days in isolation at home. Everyone from the pediatrician to the little old lady next door has warned parents of the inevitable reality of daycare. Of course there are upsides that parents can cling to, including increased socialization and the hope that getting sick young will build a more robust immunity in the long run.

However, there has been little research exploring the nuances of the germ sharing that we all know is happening in these and other social settings.

A team of evolutionary biologists at Harvard is working to better define the “social microbiome” and its “role in individuals’ susceptibility to, and resilience against, both communicable and noncommunicable diseases.” These researchers point out that while we harbor our own unique collection of microbes, we share those with the microbiomes of the people with whom we interact socially. They report that studies by other investigators have shown that residents of a household share a significant proportion of their gastrointestinal flora. There are other studies that have shown that villages can be identified by their own social biome. There are few social settings more intimately involved in microbe sharing than daycares. I have a friends who calls them “petri dishes.”

The biologists point out that antibiotic-resistant microbes can become part of an individual’s microbiome and can be shared with other individuals in their social group, who can then go on and share them in a different social environment. Imagine there is one popular physician in a community whose sense of antibiotic stewardship is, shall we say, somewhat lacking. By inappropriately prescribing antibiotics to a child or two in a daycare, he may be altering the social biome in that daycare, which could then jeopardize the health of all the children and eventually their own home-based social biomes, that may include an immune deficient individual.

The researchers also remind us that different cultures and countries may have different antibiotic usage patterns. Does this mean I am taking a risk by traveling in these “culture-dependent transmission landscapes”? Am I more likely to encounter an antibiotic-resistant microbe when I am visiting a country whose healthcare providers are less prudent prescribers?

However, as these evolutionary biologists point out, not all shared microbes are bad. There is some evidence in animals that individuals can share microbes that have been found to “increase resilience against colitis or improve their responsiveness to cancer therapy.” If a microbe can contribute to a disease that was once considered to be “noncommunicable,” we may need to redefine “communicable” in the light this more nuanced view of the social biome.

It became standard practice during the COVID pandemic to test dormitory and community sewage water to determine the level of infection. Can sewage water be used as a proxy for a social biome? If a parent is lucky enough to have a choice of daycares, would knowing each facility’s biome, as reflected in an analysis of its sewage effluent, help him or her decide? Should a daycare ask for a stool sample from each child before accepting him or her? Seems like this would raise some privacy issues, not to mention the logistical messiness of the process. As we learn more about social biomes, can we imagine a time when a daycare or country or region might proudly advertise itself as having the healthiest spectrum of microbes in its sewage system?

Communal living certainly has its benefits, not just for children but also adults as we realize how loneliness is eating its way into our society. However, living in close social contact means that, for better or worse, we will be reconfiguring our own personal biomes thanks to the inevitable gifts from our cohabitants.

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 can’t remember where I heard it. Maybe I made it up myself. But, one definition of a family is a group of folks with whom you share your genes and germs. In that same vein, one could define daycare as a group of germ-sharing children. Of course that’s news to almost no one. Parents who decide, or are forced, to send their children to daycare expect that those children will get more colds, “stomach flu,” and ear infections than the children who spend their days in isolation at home. Everyone from the pediatrician to the little old lady next door has warned parents of the inevitable reality of daycare. Of course there are upsides that parents can cling to, including increased socialization and the hope that getting sick young will build a more robust immunity in the long run.

However, there has been little research exploring the nuances of the germ sharing that we all know is happening in these and other social settings.

A team of evolutionary biologists at Harvard is working to better define the “social microbiome” and its “role in individuals’ susceptibility to, and resilience against, both communicable and noncommunicable diseases.” These researchers point out that while we harbor our own unique collection of microbes, we share those with the microbiomes of the people with whom we interact socially. They report that studies by other investigators have shown that residents of a household share a significant proportion of their gastrointestinal flora. There are other studies that have shown that villages can be identified by their own social biome. There are few social settings more intimately involved in microbe sharing than daycares. I have a friends who calls them “petri dishes.”

The biologists point out that antibiotic-resistant microbes can become part of an individual’s microbiome and can be shared with other individuals in their social group, who can then go on and share them in a different social environment. Imagine there is one popular physician in a community whose sense of antibiotic stewardship is, shall we say, somewhat lacking. By inappropriately prescribing antibiotics to a child or two in a daycare, he may be altering the social biome in that daycare, which could then jeopardize the health of all the children and eventually their own home-based social biomes, that may include an immune deficient individual.

The researchers also remind us that different cultures and countries may have different antibiotic usage patterns. Does this mean I am taking a risk by traveling in these “culture-dependent transmission landscapes”? Am I more likely to encounter an antibiotic-resistant microbe when I am visiting a country whose healthcare providers are less prudent prescribers?

However, as these evolutionary biologists point out, not all shared microbes are bad. There is some evidence in animals that individuals can share microbes that have been found to “increase resilience against colitis or improve their responsiveness to cancer therapy.” If a microbe can contribute to a disease that was once considered to be “noncommunicable,” we may need to redefine “communicable” in the light this more nuanced view of the social biome.

It became standard practice during the COVID pandemic to test dormitory and community sewage water to determine the level of infection. Can sewage water be used as a proxy for a social biome? If a parent is lucky enough to have a choice of daycares, would knowing each facility’s biome, as reflected in an analysis of its sewage effluent, help him or her decide? Should a daycare ask for a stool sample from each child before accepting him or her? Seems like this would raise some privacy issues, not to mention the logistical messiness of the process. As we learn more about social biomes, can we imagine a time when a daycare or country or region might proudly advertise itself as having the healthiest spectrum of microbes in its sewage system?

Communal living certainly has its benefits, not just for children but also adults as we realize how loneliness is eating its way into our society. However, living in close social contact means that, for better or worse, we will be reconfiguring our own personal biomes thanks to the inevitable gifts from our cohabitants.

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 wrote about a fledgling program here in Maine in which some emergency room physicians were being outfitted with equipment and communications gear that would allow them to respond on the fly to emergencies in the field when they weren’t working in the hospital. I questioned the rationale of using in-house personnel, already in short supply, for the few situations in which trained EMT personnel would usually be called. At the same time, I promised to return to the broader subject of the role of physicians as first responders in a future letter. And, here it is.

Have you ever been on a plane or at a large public gathering and the public addressed system crackled, “Is there a doctor on board” or in the audience? Or have you been on the highway and come upon a fresh accident in which it appears that there may have been injuries? Or at a youth soccer game in which a player has been injured and is still on the ground?

How do you usually respond in situations like this? Do you immediately identify yourself as a physician? Or, do you routinely shy away from involvement? What thoughts run through your head?

Do you feel your training and experience with emergencies is so outdated that you doubt you could be of any assistance? Has your practice become so specialized that you aren’t comfortable with anything outside of your specialty? Maybe getting involved is likely to throw your already tight travel schedule into disarray? Or are you afraid that should something go wrong while you were helping out you could be sued?

Keeping in mind that I am a retired septuagenarian pediatrician more than a decade removed from active practice, I would describe my usual response to these situations as “attentive hovering.” I position myself to have a good view of the victim and watch to see if there are any other responders. Either because of their personality or their experience, often there is someone who steps forward to help. Trained EMTs seem to have no hesitancy going into action. If I sense things aren’t going well, or the victim is a child, I will identify myself as a retired pediatrician and offer my assistance. Even if the response given by others seems appropriate, I may still eventually identify myself, maybe to lend an air of legitimacy to the process.

What are the roots of my hesitancy? I have found that I generally have little to add when there is a trained first responder on hand. They have been-there-and-done-that far more recently than I have. They know how to stabilize potential or obvious fractures. They know how to position the victim for transport. Even when I am in an environment where my medical background is already known, I yield to the more recently experienced first responders.

I don’t particularly worry about being sued. Every state has Good Samaritan laws. Although the laws vary from state to state, here in Maine I feel comfortable with the good sense of my fellow citizens. I understand if you live or practice in a more litigious environment you may be more concerned. On an airplane there is the Aviation Medical Assistant Act, which became law in 1998, and provides us with some extra protection.

What if there is a situation in which even with my outdated skills I seem to be the only show in town? Fortunately, that situation hasn’t occurred for me in quite a few years, but the odds are that one might occur. In almost 1 out of 600 airline flights, there is an inflight emergency. I tend to hang out with other septuagenarians and octogenarians doing active things. And I frequent youth athletic events where there is unlikely to be a first responder assigned to the event.

Should I be doing more to update my skills? It’s been a while since I refreshed by CPR techniques. I can’t recall the last time I handled a defibrillator. Should I be learning more about exsanguination prevention techniques?

Every so often there are some rumblings to mandate that all physicians should be required to update these first responder skills to maintain their license or certification. That wouldn’t cover those of us who are retired or who no longer practice medicine. And, I’m not sure we need to add another layer to the system. I think there are enough of us out there who would like to add ourselves to the first responder population, maybe not as fully trained experts but as folks who would like to be more ready to help by updating old or seldom-used skills.

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 wrote about a fledgling program here in Maine in which some emergency room physicians were being outfitted with equipment and communications gear that would allow them to respond on the fly to emergencies in the field when they weren’t working in the hospital. I questioned the rationale of using in-house personnel, already in short supply, for the few situations in which trained EMT personnel would usually be called. At the same time, I promised to return to the broader subject of the role of physicians as first responders in a future letter. And, here it is.

Have you ever been on a plane or at a large public gathering and the public addressed system crackled, “Is there a doctor on board” or in the audience? Or have you been on the highway and come upon a fresh accident in which it appears that there may have been injuries? Or at a youth soccer game in which a player has been injured and is still on the ground?

How do you usually respond in situations like this? Do you immediately identify yourself as a physician? Or, do you routinely shy away from involvement? What thoughts run through your head?

Do you feel your training and experience with emergencies is so outdated that you doubt you could be of any assistance? Has your practice become so specialized that you aren’t comfortable with anything outside of your specialty? Maybe getting involved is likely to throw your already tight travel schedule into disarray? Or are you afraid that should something go wrong while you were helping out you could be sued?

Keeping in mind that I am a retired septuagenarian pediatrician more than a decade removed from active practice, I would describe my usual response to these situations as “attentive hovering.” I position myself to have a good view of the victim and watch to see if there are any other responders. Either because of their personality or their experience, often there is someone who steps forward to help. Trained EMTs seem to have no hesitancy going into action. If I sense things aren’t going well, or the victim is a child, I will identify myself as a retired pediatrician and offer my assistance. Even if the response given by others seems appropriate, I may still eventually identify myself, maybe to lend an air of legitimacy to the process.

What are the roots of my hesitancy? I have found that I generally have little to add when there is a trained first responder on hand. They have been-there-and-done-that far more recently than I have. They know how to stabilize potential or obvious fractures. They know how to position the victim for transport. Even when I am in an environment where my medical background is already known, I yield to the more recently experienced first responders.

I don’t particularly worry about being sued. Every state has Good Samaritan laws. Although the laws vary from state to state, here in Maine I feel comfortable with the good sense of my fellow citizens. I understand if you live or practice in a more litigious environment you may be more concerned. On an airplane there is the Aviation Medical Assistant Act, which became law in 1998, and provides us with some extra protection.

What if there is a situation in which even with my outdated skills I seem to be the only show in town? Fortunately, that situation hasn’t occurred for me in quite a few years, but the odds are that one might occur. In almost 1 out of 600 airline flights, there is an inflight emergency. I tend to hang out with other septuagenarians and octogenarians doing active things. And I frequent youth athletic events where there is unlikely to be a first responder assigned to the event.

Should I be doing more to update my skills? It’s been a while since I refreshed by CPR techniques. I can’t recall the last time I handled a defibrillator. Should I be learning more about exsanguination prevention techniques?

Every so often there are some rumblings to mandate that all physicians should be required to update these first responder skills to maintain their license or certification. That wouldn’t cover those of us who are retired or who no longer practice medicine. And, I’m not sure we need to add another layer to the system. I think there are enough of us out there who would like to add ourselves to the first responder population, maybe not as fully trained experts but as folks who would like to be more ready to help by updating old or seldom-used skills.

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 wrote about a fledgling program here in Maine in which some emergency room physicians were being outfitted with equipment and communications gear that would allow them to respond on the fly to emergencies in the field when they weren’t working in the hospital. I questioned the rationale of using in-house personnel, already in short supply, for the few situations in which trained EMT personnel would usually be called. At the same time, I promised to return to the broader subject of the role of physicians as first responders in a future letter. And, here it is.

Have you ever been on a plane or at a large public gathering and the public addressed system crackled, “Is there a doctor on board” or in the audience? Or have you been on the highway and come upon a fresh accident in which it appears that there may have been injuries? Or at a youth soccer game in which a player has been injured and is still on the ground?

How do you usually respond in situations like this? Do you immediately identify yourself as a physician? Or, do you routinely shy away from involvement? What thoughts run through your head?

Do you feel your training and experience with emergencies is so outdated that you doubt you could be of any assistance? Has your practice become so specialized that you aren’t comfortable with anything outside of your specialty? Maybe getting involved is likely to throw your already tight travel schedule into disarray? Or are you afraid that should something go wrong while you were helping out you could be sued?

Keeping in mind that I am a retired septuagenarian pediatrician more than a decade removed from active practice, I would describe my usual response to these situations as “attentive hovering.” I position myself to have a good view of the victim and watch to see if there are any other responders. Either because of their personality or their experience, often there is someone who steps forward to help. Trained EMTs seem to have no hesitancy going into action. If I sense things aren’t going well, or the victim is a child, I will identify myself as a retired pediatrician and offer my assistance. Even if the response given by others seems appropriate, I may still eventually identify myself, maybe to lend an air of legitimacy to the process.

What are the roots of my hesitancy? I have found that I generally have little to add when there is a trained first responder on hand. They have been-there-and-done-that far more recently than I have. They know how to stabilize potential or obvious fractures. They know how to position the victim for transport. Even when I am in an environment where my medical background is already known, I yield to the more recently experienced first responders.

I don’t particularly worry about being sued. Every state has Good Samaritan laws. Although the laws vary from state to state, here in Maine I feel comfortable with the good sense of my fellow citizens. I understand if you live or practice in a more litigious environment you may be more concerned. On an airplane there is the Aviation Medical Assistant Act, which became law in 1998, and provides us with some extra protection.

What if there is a situation in which even with my outdated skills I seem to be the only show in town? Fortunately, that situation hasn’t occurred for me in quite a few years, but the odds are that one might occur. In almost 1 out of 600 airline flights, there is an inflight emergency. I tend to hang out with other septuagenarians and octogenarians doing active things. And I frequent youth athletic events where there is unlikely to be a first responder assigned to the event.

Should I be doing more to update my skills? It’s been a while since I refreshed by CPR techniques. I can’t recall the last time I handled a defibrillator. Should I be learning more about exsanguination prevention techniques?

Every so often there are some rumblings to mandate that all physicians should be required to update these first responder skills to maintain their license or certification. That wouldn’t cover those of us who are retired or who no longer practice medicine. And, I’m not sure we need to add another layer to the system. I think there are enough of us out there who would like to add ourselves to the first responder population, maybe not as fully trained experts but as folks who would like to be more ready to help by updating old or seldom-used skills.

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.

Blue Hill is a small idyllic town a little less than two and a half hours Down East the coast from where I am sitting here in Harpswell. Thanks to gentrification it tends to lean left politically, but like the rest of Maine most folks in the surrounding communities often don’t know or care much about their neighbor’s party affiliation. Its library, founded in 1796, is well funded and a source of civic pride.

One day a couple of years ago, the library director received a donated book from a patron. Although he personally didn’t agree with the book’s message, he felt it deserved a space in their collection dealing with the subject. What happened in the wake of this donation is an ugly tale. Some community members objected to the book and asked that it be removed from the shelves, or at least kept under the desk and loaned out only on request.

The objectors, many of whom knew the director, were confrontational. The collections committee unanimously supported his decision. Some committee members also received similar responses from community members. Remember, this is a small town.

A request for support sent to the American Library Association was basically ignored. Over the next 2 years things have quieted, but fractured friendships and relationships in this quiet coastal Maine town have not been repaired. However, as the librarian has observed, “intellectual freedom or the freedom of speech isn’t there just to protect the ideas that we like.”

While the title of the book may feel inflammatory to some, every publisher hopes to grab the market’s attention with a hot title. The cause of this sad situation in Blue Hill was not a white supremacist’s polemic offering specific ways to create genocide. This was a book suggesting that gender dysphoria presenting in adolescence may have multiple causes and raises concerns about the wisdom of the pace of some gender-affirming care.

Clearly the topic of gender dysphoria in adolescence has become a third rail that must be approached with caution or completely avoided. A recent opinion piece in the New York Times provides even more concerning examples of this peril. Again, the eye-catching title of the article — As Kids, They Thought They Were Trans. They No Longer Do — draws in the audience eager to read about some unfortunate individuals who have regretted their decision to transition and are now detransitioning.

If you are interested in hearing anecdotal evidence and opinions supporting the notion that there is such a thing as rapid-onset gender dysphoria, I suggest you read the entire piece. However, the article’s most troubling message for me comes when I read about the professionals who were former gender-related care providers who left the field because of “pushback, the accusations of being transphobic, from being pro-assessment and wanting a more thorough process.”

One therapist trained in gender-affirming care who began to have doubts about the model and spoke out in favor of a more measured approach was investigated by her licensing board after transgender advocates threatened to report her. Ultimately, her case was dismissed, but she continues to fear for her safety.

Gender-related healthcare is another sad example of how in this country it is the noise coming from the advocates on the extremes of the issue that is drowning out the “vast ideological middle” that is seeking civil and rational discussions.

In this situation there are those who want to make it illegal for the healthcare providers to help patients who might benefit from transitioning. On the other end of the spectrum are those advocates who are unwilling to acknowledge that there may be some adolescents with what has been called by some “rapid-onset gender dysphoria.”

The landscape on which this tragedy is being played out is changing so quickly that there will be no correct answers in the short term. There just isn’t enough data. However, there is enough anecdotal evidence from professionals who were and still are practicing gender-related care to raise a concern that something is happening in the adolescent population that suggests some individuals with gender dysphoria should be managed in a different way than the currently accepted gender-affirming model. The size of this subgroup is up for debate and we may never learn it because of reporting bias and privacy concerns.

The American Academy of Pediatrics has recently authorized a systematic review of gender-affirming care. I hope that, like the librarian in Blue Hill, it will have the courage to include all the evidence available even though, as we have seen here in Maine, some of it may spark a firestorm of vehement responses.

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.

Blue Hill is a small idyllic town a little less than two and a half hours Down East the coast from where I am sitting here in Harpswell. Thanks to gentrification it tends to lean left politically, but like the rest of Maine most folks in the surrounding communities often don’t know or care much about their neighbor’s party affiliation. Its library, founded in 1796, is well funded and a source of civic pride.

One day a couple of years ago, the library director received a donated book from a patron. Although he personally didn’t agree with the book’s message, he felt it deserved a space in their collection dealing with the subject. What happened in the wake of this donation is an ugly tale. Some community members objected to the book and asked that it be removed from the shelves, or at least kept under the desk and loaned out only on request.

The objectors, many of whom knew the director, were confrontational. The collections committee unanimously supported his decision. Some committee members also received similar responses from community members. Remember, this is a small town.

A request for support sent to the American Library Association was basically ignored. Over the next 2 years things have quieted, but fractured friendships and relationships in this quiet coastal Maine town have not been repaired. However, as the librarian has observed, “intellectual freedom or the freedom of speech isn’t there just to protect the ideas that we like.”

While the title of the book may feel inflammatory to some, every publisher hopes to grab the market’s attention with a hot title. The cause of this sad situation in Blue Hill was not a white supremacist’s polemic offering specific ways to create genocide. This was a book suggesting that gender dysphoria presenting in adolescence may have multiple causes and raises concerns about the wisdom of the pace of some gender-affirming care.

Clearly the topic of gender dysphoria in adolescence has become a third rail that must be approached with caution or completely avoided. A recent opinion piece in the New York Times provides even more concerning examples of this peril. Again, the eye-catching title of the article — As Kids, They Thought They Were Trans. They No Longer Do — draws in the audience eager to read about some unfortunate individuals who have regretted their decision to transition and are now detransitioning.

If you are interested in hearing anecdotal evidence and opinions supporting the notion that there is such a thing as rapid-onset gender dysphoria, I suggest you read the entire piece. However, the article’s most troubling message for me comes when I read about the professionals who were former gender-related care providers who left the field because of “pushback, the accusations of being transphobic, from being pro-assessment and wanting a more thorough process.”

One therapist trained in gender-affirming care who began to have doubts about the model and spoke out in favor of a more measured approach was investigated by her licensing board after transgender advocates threatened to report her. Ultimately, her case was dismissed, but she continues to fear for her safety.

Gender-related healthcare is another sad example of how in this country it is the noise coming from the advocates on the extremes of the issue that is drowning out the “vast ideological middle” that is seeking civil and rational discussions.

In this situation there are those who want to make it illegal for the healthcare providers to help patients who might benefit from transitioning. On the other end of the spectrum are those advocates who are unwilling to acknowledge that there may be some adolescents with what has been called by some “rapid-onset gender dysphoria.”

The landscape on which this tragedy is being played out is changing so quickly that there will be no correct answers in the short term. There just isn’t enough data. However, there is enough anecdotal evidence from professionals who were and still are practicing gender-related care to raise a concern that something is happening in the adolescent population that suggests some individuals with gender dysphoria should be managed in a different way than the currently accepted gender-affirming model. The size of this subgroup is up for debate and we may never learn it because of reporting bias and privacy concerns.

The American Academy of Pediatrics has recently authorized a systematic review of gender-affirming care. I hope that, like the librarian in Blue Hill, it will have the courage to include all the evidence available even though, as we have seen here in Maine, some of it may spark a firestorm of vehement responses.

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.

Blue Hill is a small idyllic town a little less than two and a half hours Down East the coast from where I am sitting here in Harpswell. Thanks to gentrification it tends to lean left politically, but like the rest of Maine most folks in the surrounding communities often don’t know or care much about their neighbor’s party affiliation. Its library, founded in 1796, is well funded and a source of civic pride.

One day a couple of years ago, the library director received a donated book from a patron. Although he personally didn’t agree with the book’s message, he felt it deserved a space in their collection dealing with the subject. What happened in the wake of this donation is an ugly tale. Some community members objected to the book and asked that it be removed from the shelves, or at least kept under the desk and loaned out only on request.

The objectors, many of whom knew the director, were confrontational. The collections committee unanimously supported his decision. Some committee members also received similar responses from community members. Remember, this is a small town.

A request for support sent to the American Library Association was basically ignored. Over the next 2 years things have quieted, but fractured friendships and relationships in this quiet coastal Maine town have not been repaired. However, as the librarian has observed, “intellectual freedom or the freedom of speech isn’t there just to protect the ideas that we like.”

While the title of the book may feel inflammatory to some, every publisher hopes to grab the market’s attention with a hot title. The cause of this sad situation in Blue Hill was not a white supremacist’s polemic offering specific ways to create genocide. This was a book suggesting that gender dysphoria presenting in adolescence may have multiple causes and raises concerns about the wisdom of the pace of some gender-affirming care.

Clearly the topic of gender dysphoria in adolescence has become a third rail that must be approached with caution or completely avoided. A recent opinion piece in the New York Times provides even more concerning examples of this peril. Again, the eye-catching title of the article — As Kids, They Thought They Were Trans. They No Longer Do — draws in the audience eager to read about some unfortunate individuals who have regretted their decision to transition and are now detransitioning.

If you are interested in hearing anecdotal evidence and opinions supporting the notion that there is such a thing as rapid-onset gender dysphoria, I suggest you read the entire piece. However, the article’s most troubling message for me comes when I read about the professionals who were former gender-related care providers who left the field because of “pushback, the accusations of being transphobic, from being pro-assessment and wanting a more thorough process.”

One therapist trained in gender-affirming care who began to have doubts about the model and spoke out in favor of a more measured approach was investigated by her licensing board after transgender advocates threatened to report her. Ultimately, her case was dismissed, but she continues to fear for her safety.

Gender-related healthcare is another sad example of how in this country it is the noise coming from the advocates on the extremes of the issue that is drowning out the “vast ideological middle” that is seeking civil and rational discussions.

In this situation there are those who want to make it illegal for the healthcare providers to help patients who might benefit from transitioning. On the other end of the spectrum are those advocates who are unwilling to acknowledge that there may be some adolescents with what has been called by some “rapid-onset gender dysphoria.”

The landscape on which this tragedy is being played out is changing so quickly that there will be no correct answers in the short term. There just isn’t enough data. However, there is enough anecdotal evidence from professionals who were and still are practicing gender-related care to raise a concern that something is happening in the adolescent population that suggests some individuals with gender dysphoria should be managed in a different way than the currently accepted gender-affirming model. The size of this subgroup is up for debate and we may never learn it because of reporting bias and privacy concerns.

The American Academy of Pediatrics has recently authorized a systematic review of gender-affirming care. I hope that, like the librarian in Blue Hill, it will have the courage to include all the evidence available even though, as we have seen here in Maine, some of it may spark a firestorm of vehement responses.

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.

When I was an intern and junior resident there was a fellow house officer who seemed to be a magnet for out-of-hospital emergencies. There were a couple of car accidents, a baby to be delivered, an elderly neighbor with alarming chest pain, and a little old lady with syncope, plus a few playground incidents that required more than a little on-site tending and triage. It got to the point where he felt he needed to raid the hospital supply closets to build himself a proper emergency kit.

Envious of his excitement I, of course, followed suit. However, my well-appointed plastic tackle box remained unopened on the floor behind the driver’s seat in my car. Sure, there were Band-Aids to be dispensed from time to time but mostly I was the on-site reassurer and triage consultant at the playground. I almost never suggested a trip to the emergency room. No little old ladies crumpled to the floor in front of me in the checkout line at the grocery store. No distracted teenage drivers plowed into telephone poles anywhere within earshot.

When I began my practice here on the midcoast of Maine, my protective aura traveled with me. I went looking for excitement by signing on as the team physician for the local high school football team. But, other than a few minor concussions, which in those days we “treated” with a “sit on the bench for awhile and I’ll ask you a few questions,” my first responder experiences continued to be boringly undramatic. Not even any obvious dislocations or angulated fractures on the playground or athletic fields I frequented.

My professional adventures were confined to the hospital, where every physician regardless of specialty training was required to take a shift covering the emergency room. Talk about a situation looking for trouble. The concept of physicians with specialty training in emergency room medicine had not yet occurred to anyone in rural Maine. Although there were anxiety-provoking nights waiting for the disasters to arrive, somehow the shit never hit the fan while I was on duty.

Finally, after several more years of this bad (or good) fortune I was on a bike ride out in the country alone on a back road and came upon a fresh single-vehicle-single-occupant accident. Steam and smoke coming out of the engine compartment, the young driver slumped over the steering wheel. I was able to pry the door open but couldn’t find a pulse. I thumped him three times on the chest and eventually could detect a pulse and he began to stir. When the ambulance arrived I dragged my bike into the back of the ambulance with me and monitored him on the way to the hospital. He did fine, only to die in another accident a few years later.

A recent article in one of our local newspapers described a fledgling program in which three emergency room physicians are being equipped with supplies and communication links that will allow them to respond to emergent situations in the field. The program is currently seeking to extend its funding for another year. Its advocates argue that the need is twofold. There is currently a regional shortage of fully trained first responder EMTs. And having an extra pair of hands in the field could ease the burden of the already overutilized emergency rooms.

I am sure the physicians who have signed on to become first responders are passionate about the need and probably enjoy the excitement of in-the-field professional experiences, much as my fellow house officer did. However, were I sitting on the committee that controls the funding of programs like this I would want to take a step back and consider whether using primary care physicians, who are already in short supply, as first responders made sense. Some of the scenarios may be dramatic and the physician’s contribution may be life saving. But I suspect in the long run these headline-making stories will be few and far between.

The argument that putting physicians in the field will make a significant dent in the emergency room overutilization crisis we have in this country doesn’t hold water. Extending outpatient office hours, education, and improved phone triage to name just a few would have a bigger impact. I suspect there are other countries and even some counties in this country that may already use physicians as first responders. It just doesn’t seem to be a model that will work well given the realities in most semirural and suburban locales.

The real question that must wait for another Letters From Maine column is how well prepared should all of us who have graduated from medical school be to function as first responders. There are thousands of us out there who initially had the training and could, with some updating, become a valuable source of first-responders. Where do issues like continuing education requirements and Good Samaritan protection fit into the equation? The answers in a future Letter.

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.

When I was an intern and junior resident there was a fellow house officer who seemed to be a magnet for out-of-hospital emergencies. There were a couple of car accidents, a baby to be delivered, an elderly neighbor with alarming chest pain, and a little old lady with syncope, plus a few playground incidents that required more than a little on-site tending and triage. It got to the point where he felt he needed to raid the hospital supply closets to build himself a proper emergency kit.

Envious of his excitement I, of course, followed suit. However, my well-appointed plastic tackle box remained unopened on the floor behind the driver’s seat in my car. Sure, there were Band-Aids to be dispensed from time to time but mostly I was the on-site reassurer and triage consultant at the playground. I almost never suggested a trip to the emergency room. No little old ladies crumpled to the floor in front of me in the checkout line at the grocery store. No distracted teenage drivers plowed into telephone poles anywhere within earshot.

When I began my practice here on the midcoast of Maine, my protective aura traveled with me. I went looking for excitement by signing on as the team physician for the local high school football team. But, other than a few minor concussions, which in those days we “treated” with a “sit on the bench for awhile and I’ll ask you a few questions,” my first responder experiences continued to be boringly undramatic. Not even any obvious dislocations or angulated fractures on the playground or athletic fields I frequented.

My professional adventures were confined to the hospital, where every physician regardless of specialty training was required to take a shift covering the emergency room. Talk about a situation looking for trouble. The concept of physicians with specialty training in emergency room medicine had not yet occurred to anyone in rural Maine. Although there were anxiety-provoking nights waiting for the disasters to arrive, somehow the shit never hit the fan while I was on duty.

Finally, after several more years of this bad (or good) fortune I was on a bike ride out in the country alone on a back road and came upon a fresh single-vehicle-single-occupant accident. Steam and smoke coming out of the engine compartment, the young driver slumped over the steering wheel. I was able to pry the door open but couldn’t find a pulse. I thumped him three times on the chest and eventually could detect a pulse and he began to stir. When the ambulance arrived I dragged my bike into the back of the ambulance with me and monitored him on the way to the hospital. He did fine, only to die in another accident a few years later.

A recent article in one of our local newspapers described a fledgling program in which three emergency room physicians are being equipped with supplies and communication links that will allow them to respond to emergent situations in the field. The program is currently seeking to extend its funding for another year. Its advocates argue that the need is twofold. There is currently a regional shortage of fully trained first responder EMTs. And having an extra pair of hands in the field could ease the burden of the already overutilized emergency rooms.

I am sure the physicians who have signed on to become first responders are passionate about the need and probably enjoy the excitement of in-the-field professional experiences, much as my fellow house officer did. However, were I sitting on the committee that controls the funding of programs like this I would want to take a step back and consider whether using primary care physicians, who are already in short supply, as first responders made sense. Some of the scenarios may be dramatic and the physician’s contribution may be life saving. But I suspect in the long run these headline-making stories will be few and far between.

The argument that putting physicians in the field will make a significant dent in the emergency room overutilization crisis we have in this country doesn’t hold water. Extending outpatient office hours, education, and improved phone triage to name just a few would have a bigger impact. I suspect there are other countries and even some counties in this country that may already use physicians as first responders. It just doesn’t seem to be a model that will work well given the realities in most semirural and suburban locales.

The real question that must wait for another Letters From Maine column is how well prepared should all of us who have graduated from medical school be to function as first responders. There are thousands of us out there who initially had the training and could, with some updating, become a valuable source of first-responders. Where do issues like continuing education requirements and Good Samaritan protection fit into the equation? The answers in a future Letter.

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.

When I was an intern and junior resident there was a fellow house officer who seemed to be a magnet for out-of-hospital emergencies. There were a couple of car accidents, a baby to be delivered, an elderly neighbor with alarming chest pain, and a little old lady with syncope, plus a few playground incidents that required more than a little on-site tending and triage. It got to the point where he felt he needed to raid the hospital supply closets to build himself a proper emergency kit.

Envious of his excitement I, of course, followed suit. However, my well-appointed plastic tackle box remained unopened on the floor behind the driver’s seat in my car. Sure, there were Band-Aids to be dispensed from time to time but mostly I was the on-site reassurer and triage consultant at the playground. I almost never suggested a trip to the emergency room. No little old ladies crumpled to the floor in front of me in the checkout line at the grocery store. No distracted teenage drivers plowed into telephone poles anywhere within earshot.

When I began my practice here on the midcoast of Maine, my protective aura traveled with me. I went looking for excitement by signing on as the team physician for the local high school football team. But, other than a few minor concussions, which in those days we “treated” with a “sit on the bench for awhile and I’ll ask you a few questions,” my first responder experiences continued to be boringly undramatic. Not even any obvious dislocations or angulated fractures on the playground or athletic fields I frequented.

My professional adventures were confined to the hospital, where every physician regardless of specialty training was required to take a shift covering the emergency room. Talk about a situation looking for trouble. The concept of physicians with specialty training in emergency room medicine had not yet occurred to anyone in rural Maine. Although there were anxiety-provoking nights waiting for the disasters to arrive, somehow the shit never hit the fan while I was on duty.

Finally, after several more years of this bad (or good) fortune I was on a bike ride out in the country alone on a back road and came upon a fresh single-vehicle-single-occupant accident. Steam and smoke coming out of the engine compartment, the young driver slumped over the steering wheel. I was able to pry the door open but couldn’t find a pulse. I thumped him three times on the chest and eventually could detect a pulse and he began to stir. When the ambulance arrived I dragged my bike into the back of the ambulance with me and monitored him on the way to the hospital. He did fine, only to die in another accident a few years later.

A recent article in one of our local newspapers described a fledgling program in which three emergency room physicians are being equipped with supplies and communication links that will allow them to respond to emergent situations in the field. The program is currently seeking to extend its funding for another year. Its advocates argue that the need is twofold. There is currently a regional shortage of fully trained first responder EMTs. And having an extra pair of hands in the field could ease the burden of the already overutilized emergency rooms.

I am sure the physicians who have signed on to become first responders are passionate about the need and probably enjoy the excitement of in-the-field professional experiences, much as my fellow house officer did. However, were I sitting on the committee that controls the funding of programs like this I would want to take a step back and consider whether using primary care physicians, who are already in short supply, as first responders made sense. Some of the scenarios may be dramatic and the physician’s contribution may be life saving. But I suspect in the long run these headline-making stories will be few and far between.

The argument that putting physicians in the field will make a significant dent in the emergency room overutilization crisis we have in this country doesn’t hold water. Extending outpatient office hours, education, and improved phone triage to name just a few would have a bigger impact. I suspect there are other countries and even some counties in this country that may already use physicians as first responders. It just doesn’t seem to be a model that will work well given the realities in most semirural and suburban locales.

The real question that must wait for another Letters From Maine column is how well prepared should all of us who have graduated from medical school be to function as first responders. There are thousands of us out there who initially had the training and could, with some updating, become a valuable source of first-responders. Where do issues like continuing education requirements and Good Samaritan protection fit into the equation? The answers in a future Letter.

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

In a recent issue of Pediatric News, the Child Psychiatry Consult column featured an excellent discussion by Dr. David Rettew of some new research into a possible association between excessive crying in infancy and emotional problems later in childhood. This longitudinal study of almost 5,000 children included an assessment at 3 months and an MRI at age 10, which found that the infants who were excessive criers also had smaller amygdala. While the orders of magnitude of the researchers’ observations is small, it is interesting that the mothers of excessive criers were slightly more likely to experience mental health problems.

Dr. Rettew wisely cautions us to take note of this study’s findings but avoid overreacting. If indeed excessive crying in infancy is a marker for future problems, at the moment we may want to increase our efforts in helping parents improve their parenting skills using a nonjudgmental approach.

Using Dr. Rettew’s sage advice as a leaping off point, I will add the reminder that we must continue to meet head on the venerable myth that “colic” is a gastrointestinal problem. We must promise to never code out a parental complaint as “colic.” If we want to label it “excessive crying of infancy,” that’s one thing, but using “colic” only serves to perpetuate the myth and all the old, and sometimes dangerous, remedies that continue to cling to it.

Whether we use the term “colicky behavior” or call it “excessive crying,” we must remember these are merely descriptive terms. We have not made a diagnosis and are obligated to keep our minds open to serious and life-threatening conditions that make infants cry excessively — aberrant coronary arteries and urinary obstructions to name just two.

I can’t leave the phenomenon of colic without adding a nickel to the two cents I have already gifted you. When I was in medical school, I am sure I was told something about the amygdala. But, I suspect that I was only expected to recall where it lived. In the 50+ years since that brief encounter, other folks have learned much more. Prompted by this study, I searched what is known about small amygdala. Turns out that sleep deprivation has been associated with smaller amygdala, as has episodic migraine headaches, both in adults.

Regular readers of Letters from Maine can already smell where this is going. For decades I have believed that both excessive crying in infancy and episodic migraine in children are associated with, and my bias would say “caused” by, sleep deprivation. We learned from this study that mothers of excessively crying infants are more likely to have mental health problems. And, I will add that at least one study has shown that mothers and fathers of excessively crying infants are more likely to suffer from migraines.

Whether you join me in my biased interpretation isn’t important. What this study tells us is that there is likely to be something going on in infancy that may be a marker for future mental health problems. Were these children born with small or vulnerable amygdala? Did poor sleep hygiene contribute to the problem by interfering with the growth of their amygdala? I can envision studies that could provide some clarity. I’m not sure many parents would agree to have their happy and well-slept 3-month-olds slid into an MRI tube to serve as controls. But, I wouldn’t be surprised that we could find a sizable number of sleep deprived and frazzled parents of colicky infants who would agree if we told them it might help find an answer.
 

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

In a recent issue of Pediatric News, the Child Psychiatry Consult column featured an excellent discussion by Dr. David Rettew of some new research into a possible association between excessive crying in infancy and emotional problems later in childhood. This longitudinal study of almost 5,000 children included an assessment at 3 months and an MRI at age 10, which found that the infants who were excessive criers also had smaller amygdala. While the orders of magnitude of the researchers’ observations is small, it is interesting that the mothers of excessive criers were slightly more likely to experience mental health problems.

Dr. Rettew wisely cautions us to take note of this study’s findings but avoid overreacting. If indeed excessive crying in infancy is a marker for future problems, at the moment we may want to increase our efforts in helping parents improve their parenting skills using a nonjudgmental approach.

Using Dr. Rettew’s sage advice as a leaping off point, I will add the reminder that we must continue to meet head on the venerable myth that “colic” is a gastrointestinal problem. We must promise to never code out a parental complaint as “colic.” If we want to label it “excessive crying of infancy,” that’s one thing, but using “colic” only serves to perpetuate the myth and all the old, and sometimes dangerous, remedies that continue to cling to it.

Whether we use the term “colicky behavior” or call it “excessive crying,” we must remember these are merely descriptive terms. We have not made a diagnosis and are obligated to keep our minds open to serious and life-threatening conditions that make infants cry excessively — aberrant coronary arteries and urinary obstructions to name just two.

I can’t leave the phenomenon of colic without adding a nickel to the two cents I have already gifted you. When I was in medical school, I am sure I was told something about the amygdala. But, I suspect that I was only expected to recall where it lived. In the 50+ years since that brief encounter, other folks have learned much more. Prompted by this study, I searched what is known about small amygdala. Turns out that sleep deprivation has been associated with smaller amygdala, as has episodic migraine headaches, both in adults.

Regular readers of Letters from Maine can already smell where this is going. For decades I have believed that both excessive crying in infancy and episodic migraine in children are associated with, and my bias would say “caused” by, sleep deprivation. We learned from this study that mothers of excessively crying infants are more likely to have mental health problems. And, I will add that at least one study has shown that mothers and fathers of excessively crying infants are more likely to suffer from migraines.

Whether you join me in my biased interpretation isn’t important. What this study tells us is that there is likely to be something going on in infancy that may be a marker for future mental health problems. Were these children born with small or vulnerable amygdala? Did poor sleep hygiene contribute to the problem by interfering with the growth of their amygdala? I can envision studies that could provide some clarity. I’m not sure many parents would agree to have their happy and well-slept 3-month-olds slid into an MRI tube to serve as controls. But, I wouldn’t be surprised that we could find a sizable number of sleep deprived and frazzled parents of colicky infants who would agree if we told them it might help find an answer.
 

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

In a recent issue of Pediatric News, the Child Psychiatry Consult column featured an excellent discussion by Dr. David Rettew of some new research into a possible association between excessive crying in infancy and emotional problems later in childhood. This longitudinal study of almost 5,000 children included an assessment at 3 months and an MRI at age 10, which found that the infants who were excessive criers also had smaller amygdala. While the orders of magnitude of the researchers’ observations is small, it is interesting that the mothers of excessive criers were slightly more likely to experience mental health problems.

Dr. Rettew wisely cautions us to take note of this study’s findings but avoid overreacting. If indeed excessive crying in infancy is a marker for future problems, at the moment we may want to increase our efforts in helping parents improve their parenting skills using a nonjudgmental approach.

Using Dr. Rettew’s sage advice as a leaping off point, I will add the reminder that we must continue to meet head on the venerable myth that “colic” is a gastrointestinal problem. We must promise to never code out a parental complaint as “colic.” If we want to label it “excessive crying of infancy,” that’s one thing, but using “colic” only serves to perpetuate the myth and all the old, and sometimes dangerous, remedies that continue to cling to it.

Whether we use the term “colicky behavior” or call it “excessive crying,” we must remember these are merely descriptive terms. We have not made a diagnosis and are obligated to keep our minds open to serious and life-threatening conditions that make infants cry excessively — aberrant coronary arteries and urinary obstructions to name just two.

I can’t leave the phenomenon of colic without adding a nickel to the two cents I have already gifted you. When I was in medical school, I am sure I was told something about the amygdala. But, I suspect that I was only expected to recall where it lived. In the 50+ years since that brief encounter, other folks have learned much more. Prompted by this study, I searched what is known about small amygdala. Turns out that sleep deprivation has been associated with smaller amygdala, as has episodic migraine headaches, both in adults.

Regular readers of Letters from Maine can already smell where this is going. For decades I have believed that both excessive crying in infancy and episodic migraine in children are associated with, and my bias would say “caused” by, sleep deprivation. We learned from this study that mothers of excessively crying infants are more likely to have mental health problems. And, I will add that at least one study has shown that mothers and fathers of excessively crying infants are more likely to suffer from migraines.

Whether you join me in my biased interpretation isn’t important. What this study tells us is that there is likely to be something going on in infancy that may be a marker for future mental health problems. Were these children born with small or vulnerable amygdala? Did poor sleep hygiene contribute to the problem by interfering with the growth of their amygdala? I can envision studies that could provide some clarity. I’m not sure many parents would agree to have their happy and well-slept 3-month-olds slid into an MRI tube to serve as controls. But, I wouldn’t be surprised that we could find a sizable number of sleep deprived and frazzled parents of colicky infants who would agree if we told them it might help find an answer.
 

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

Since very few of us practice medicine without being either an employer or an employee, we should probably be paying more attention to research in industrial and employee relations, not an area most of us have studied. One of the hot topics for employers in these days of low unemployment is the question of whether to offer free wellness-enhancing programs companywide.

Almost by definition anything “free” has a good public relations aura surrounding it. Recent surveys have shown that a large chunk of the population is feeling stressed. If your boss is offering you a free opportunity to help you feel better about yourself, he/she must understand at least a bit of what you are going through.

From the employer’s standpoint these programs offer the potential for a double win. On one hand, offering a free well-being program is a perk the company can tout as it competes in the tight market for new employees. On the other hand, if the program is effective then the employees will be happier. And we all know that happy workers are more productive and less likely to leave and feed the expensive cycle of hiring and training new workers to replace the unhappy and disgruntled workers who have quit. Even if the employer’s total focus is on the company’s bottom line, offering a wellness program should pay a dividend.

Well ... this may be one of those situations where wishful thinking isn’t going to work. A recent study published in Industrial Relations Journal suggests that these well-being programs, which include employee mental services, may not be living up to their promise. In this large study of nearly 50,00 workers in the United Kingdom, the researcher discovered that workers who had been offered coaching and relaxation classes, internet-based apps, and courses in time management and financial health were “no better off” than their coworkers who had not participated in these programs. In fact, training programs in stress management and resilience appeared to possibly have had a negative effect.

In a New York Times article about this study, the British researcher recommends that employers who are interested in improving their worker’s mental health should turn their attention to “core organizational practices” meaning pay scales, work schedules, and performance reviews.

Not surprisingly, this study has raised some controversy. There are a lot of people invested emotionally and in some cases financially in programs similar to the ones that appeared to be ineffective in this study. Critics argue the study was too short, or too small, or failed to select programs with a proven track record.

Even given these potential flaws, physicians, particularly those who of us who feel they approaching burnout, should take this investigator’s message seriously. Certainly some of us could be doing a better job of building resilience into our lifestyles and may be helped by the kind of well-being programs tested in this study. However, the biggest contribution to the burnout phenomenon is coming from the work environments that are asking too much of even the most resilient among us. This study makes it clear that if healthcare system administrators truly want to help us address burnout, they must make serious and substantive changes in their “core organizational practices” including work schedules, time-gobbling electronic systems, and short staffing. Trotting out a few feel-good mindfulness programs is not going to do the job.

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

Since very few of us practice medicine without being either an employer or an employee, we should probably be paying more attention to research in industrial and employee relations, not an area most of us have studied. One of the hot topics for employers in these days of low unemployment is the question of whether to offer free wellness-enhancing programs companywide.

Almost by definition anything “free” has a good public relations aura surrounding it. Recent surveys have shown that a large chunk of the population is feeling stressed. If your boss is offering you a free opportunity to help you feel better about yourself, he/she must understand at least a bit of what you are going through.

From the employer’s standpoint these programs offer the potential for a double win. On one hand, offering a free well-being program is a perk the company can tout as it competes in the tight market for new employees. On the other hand, if the program is effective then the employees will be happier. And we all know that happy workers are more productive and less likely to leave and feed the expensive cycle of hiring and training new workers to replace the unhappy and disgruntled workers who have quit. Even if the employer’s total focus is on the company’s bottom line, offering a wellness program should pay a dividend.

Well ... this may be one of those situations where wishful thinking isn’t going to work. A recent study published in Industrial Relations Journal suggests that these well-being programs, which include employee mental services, may not be living up to their promise. In this large study of nearly 50,00 workers in the United Kingdom, the researcher discovered that workers who had been offered coaching and relaxation classes, internet-based apps, and courses in time management and financial health were “no better off” than their coworkers who had not participated in these programs. In fact, training programs in stress management and resilience appeared to possibly have had a negative effect.

In a New York Times article about this study, the British researcher recommends that employers who are interested in improving their worker’s mental health should turn their attention to “core organizational practices” meaning pay scales, work schedules, and performance reviews.

Not surprisingly, this study has raised some controversy. There are a lot of people invested emotionally and in some cases financially in programs similar to the ones that appeared to be ineffective in this study. Critics argue the study was too short, or too small, or failed to select programs with a proven track record.

Even given these potential flaws, physicians, particularly those who of us who feel they approaching burnout, should take this investigator’s message seriously. Certainly some of us could be doing a better job of building resilience into our lifestyles and may be helped by the kind of well-being programs tested in this study. However, the biggest contribution to the burnout phenomenon is coming from the work environments that are asking too much of even the most resilient among us. This study makes it clear that if healthcare system administrators truly want to help us address burnout, they must make serious and substantive changes in their “core organizational practices” including work schedules, time-gobbling electronic systems, and short staffing. Trotting out a few feel-good mindfulness programs is not going to do the job.

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

Since very few of us practice medicine without being either an employer or an employee, we should probably be paying more attention to research in industrial and employee relations, not an area most of us have studied. One of the hot topics for employers in these days of low unemployment is the question of whether to offer free wellness-enhancing programs companywide.

Almost by definition anything “free” has a good public relations aura surrounding it. Recent surveys have shown that a large chunk of the population is feeling stressed. If your boss is offering you a free opportunity to help you feel better about yourself, he/she must understand at least a bit of what you are going through.

From the employer’s standpoint these programs offer the potential for a double win. On one hand, offering a free well-being program is a perk the company can tout as it competes in the tight market for new employees. On the other hand, if the program is effective then the employees will be happier. And we all know that happy workers are more productive and less likely to leave and feed the expensive cycle of hiring and training new workers to replace the unhappy and disgruntled workers who have quit. Even if the employer’s total focus is on the company’s bottom line, offering a wellness program should pay a dividend.

Well ... this may be one of those situations where wishful thinking isn’t going to work. A recent study published in Industrial Relations Journal suggests that these well-being programs, which include employee mental services, may not be living up to their promise. In this large study of nearly 50,00 workers in the United Kingdom, the researcher discovered that workers who had been offered coaching and relaxation classes, internet-based apps, and courses in time management and financial health were “no better off” than their coworkers who had not participated in these programs. In fact, training programs in stress management and resilience appeared to possibly have had a negative effect.

In a New York Times article about this study, the British researcher recommends that employers who are interested in improving their worker’s mental health should turn their attention to “core organizational practices” meaning pay scales, work schedules, and performance reviews.

Not surprisingly, this study has raised some controversy. There are a lot of people invested emotionally and in some cases financially in programs similar to the ones that appeared to be ineffective in this study. Critics argue the study was too short, or too small, or failed to select programs with a proven track record.

Even given these potential flaws, physicians, particularly those who of us who feel they approaching burnout, should take this investigator’s message seriously. Certainly some of us could be doing a better job of building resilience into our lifestyles and may be helped by the kind of well-being programs tested in this study. However, the biggest contribution to the burnout phenomenon is coming from the work environments that are asking too much of even the most resilient among us. This study makes it clear that if healthcare system administrators truly want to help us address burnout, they must make serious and substantive changes in their “core organizational practices” including work schedules, time-gobbling electronic systems, and short staffing. Trotting out a few feel-good mindfulness programs is not going to do the job.

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

On a recent rainy afternoon I was speed skimming through the pile of publications sitting on the floor next to my Grampy’s chair. A bright patch of color jumped off the gray background of the printed page forcing me to pause and consider the content.

In the right upper corner was a photograph of an attractive Black woman nursing her baby. Her bare arms suggested she might be slightly overweight. She wore a simple off-white head wrap and smiled broadly as she played with her infant’s fingers. The image was a reproduction of a WIC poster encouraging women to take advantage of the program’s breastfeeding support services. The accompanying article from American Academy of Pediatrics offered ten strategies for achieving breastfeeding equity.

United States Department of Agriculture

I must admit that I tend to shy away from discussions of equity because I’ve seldom found them very informative. However, the engaging image of this Black woman breastfeeding led me to read beyond the title.

The first of the strategies listed was “Check you biases.” I will certainly admit to having biases. We all have biases and see and interpret the world through lenses ground and tinted by our experiences and the environment we have inhabited. In the case of breastfeeding, I wasn’t sure where my biases lay. Maybe one of mine is reflected in a hesitancy to actively promote exclusive breastfeeding for the first 6 months. I prefer a more nuanced approach adjusted to the unique needs and limitations of each family. But I decided to chase down the Implicit Association Test (IAT) suggested in the article. I couldn’t make that link work, but found a long list of subjects on the Harvard Implicit Association Test website. None dealt with breastfeeding, so I chose the one described as Black/White.

If, like me, you have never had your implicit biases assessed by taking an IAT, you might find it interesting. Probably took me about 15 minutes using my laptop. There are a lot of demographic questions then some rapid-fire exercises in which you must provide your first response to a barrage of photos of faces and words. At times I sensed that the test makers were trying to trick me into making associations that I didn’t want to make by the order in which the exercises were presented. At the end I was told that I was a little slow in associating Black faces with positive words.

I’m not sure what this means. After doing a little internet searching I learned that one of the criticisms of the IAT is that, while it may hint at a bias, it is really more important whether you cut with or across that bias. If I acknowledge that where and how I grew up may have left me with some implicit biases, it is more important that I make a strong and honest effort to act independently of those biases.

In full disclosure I must tell you that there was one Black girl in my high school of a thousand students. I have lived and practiced in Maine for 50 years. At less than 2%, we are sixth from the bottom in Black population among other states. However, in the last 5 or 6 years here in Brunswick we have welcomed a large infusion of asylum seekers who come predominantly from Black African countries.

Skimming through the rest of the article, I found it hard to argue with the remaining nine recommendations for promoting breastfeeding, although most of them we not terribly applicable to small community practices. The photo of the Black woman nursing her baby at the top of the page remains as the primary message. The fact that I was drawn to that image is a testament to several of my biases and another example of a picture being worth far more than a thousand words.

I suspect that I’m not alone in appreciating the uniqueness of that image. Until recently, the standard photos of a mother breastfeeding have used trim White women as their models. I suspect and hope this poster will be effective in encouraging Black women to nurse. I urge you all to hang it in your office as a reminder to you and your staff of your biases and assumptions. Don’t bother to take the Implicit Association Test unless you’re retired and have 15 minutes to burn on a rainy afternoon.

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

On a recent rainy afternoon I was speed skimming through the pile of publications sitting on the floor next to my Grampy’s chair. A bright patch of color jumped off the gray background of the printed page forcing me to pause and consider the content.

In the right upper corner was a photograph of an attractive Black woman nursing her baby. Her bare arms suggested she might be slightly overweight. She wore a simple off-white head wrap and smiled broadly as she played with her infant’s fingers. The image was a reproduction of a WIC poster encouraging women to take advantage of the program’s breastfeeding support services. The accompanying article from American Academy of Pediatrics offered ten strategies for achieving breastfeeding equity.

United States Department of Agriculture

I must admit that I tend to shy away from discussions of equity because I’ve seldom found them very informative. However, the engaging image of this Black woman breastfeeding led me to read beyond the title.

The first of the strategies listed was “Check you biases.” I will certainly admit to having biases. We all have biases and see and interpret the world through lenses ground and tinted by our experiences and the environment we have inhabited. In the case of breastfeeding, I wasn’t sure where my biases lay. Maybe one of mine is reflected in a hesitancy to actively promote exclusive breastfeeding for the first 6 months. I prefer a more nuanced approach adjusted to the unique needs and limitations of each family. But I decided to chase down the Implicit Association Test (IAT) suggested in the article. I couldn’t make that link work, but found a long list of subjects on the Harvard Implicit Association Test website. None dealt with breastfeeding, so I chose the one described as Black/White.

If, like me, you have never had your implicit biases assessed by taking an IAT, you might find it interesting. Probably took me about 15 minutes using my laptop. There are a lot of demographic questions then some rapid-fire exercises in which you must provide your first response to a barrage of photos of faces and words. At times I sensed that the test makers were trying to trick me into making associations that I didn’t want to make by the order in which the exercises were presented. At the end I was told that I was a little slow in associating Black faces with positive words.

I’m not sure what this means. After doing a little internet searching I learned that one of the criticisms of the IAT is that, while it may hint at a bias, it is really more important whether you cut with or across that bias. If I acknowledge that where and how I grew up may have left me with some implicit biases, it is more important that I make a strong and honest effort to act independently of those biases.

In full disclosure I must tell you that there was one Black girl in my high school of a thousand students. I have lived and practiced in Maine for 50 years. At less than 2%, we are sixth from the bottom in Black population among other states. However, in the last 5 or 6 years here in Brunswick we have welcomed a large infusion of asylum seekers who come predominantly from Black African countries.

Skimming through the rest of the article, I found it hard to argue with the remaining nine recommendations for promoting breastfeeding, although most of them we not terribly applicable to small community practices. The photo of the Black woman nursing her baby at the top of the page remains as the primary message. The fact that I was drawn to that image is a testament to several of my biases and another example of a picture being worth far more than a thousand words.

I suspect that I’m not alone in appreciating the uniqueness of that image. Until recently, the standard photos of a mother breastfeeding have used trim White women as their models. I suspect and hope this poster will be effective in encouraging Black women to nurse. I urge you all to hang it in your office as a reminder to you and your staff of your biases and assumptions. Don’t bother to take the Implicit Association Test unless you’re retired and have 15 minutes to burn on a rainy afternoon.

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

On a recent rainy afternoon I was speed skimming through the pile of publications sitting on the floor next to my Grampy’s chair. A bright patch of color jumped off the gray background of the printed page forcing me to pause and consider the content.

In the right upper corner was a photograph of an attractive Black woman nursing her baby. Her bare arms suggested she might be slightly overweight. She wore a simple off-white head wrap and smiled broadly as she played with her infant’s fingers. The image was a reproduction of a WIC poster encouraging women to take advantage of the program’s breastfeeding support services. The accompanying article from American Academy of Pediatrics offered ten strategies for achieving breastfeeding equity.

United States Department of Agriculture

I must admit that I tend to shy away from discussions of equity because I’ve seldom found them very informative. However, the engaging image of this Black woman breastfeeding led me to read beyond the title.

The first of the strategies listed was “Check you biases.” I will certainly admit to having biases. We all have biases and see and interpret the world through lenses ground and tinted by our experiences and the environment we have inhabited. In the case of breastfeeding, I wasn’t sure where my biases lay. Maybe one of mine is reflected in a hesitancy to actively promote exclusive breastfeeding for the first 6 months. I prefer a more nuanced approach adjusted to the unique needs and limitations of each family. But I decided to chase down the Implicit Association Test (IAT) suggested in the article. I couldn’t make that link work, but found a long list of subjects on the Harvard Implicit Association Test website. None dealt with breastfeeding, so I chose the one described as Black/White.

If, like me, you have never had your implicit biases assessed by taking an IAT, you might find it interesting. Probably took me about 15 minutes using my laptop. There are a lot of demographic questions then some rapid-fire exercises in which you must provide your first response to a barrage of photos of faces and words. At times I sensed that the test makers were trying to trick me into making associations that I didn’t want to make by the order in which the exercises were presented. At the end I was told that I was a little slow in associating Black faces with positive words.

I’m not sure what this means. After doing a little internet searching I learned that one of the criticisms of the IAT is that, while it may hint at a bias, it is really more important whether you cut with or across that bias. If I acknowledge that where and how I grew up may have left me with some implicit biases, it is more important that I make a strong and honest effort to act independently of those biases.

In full disclosure I must tell you that there was one Black girl in my high school of a thousand students. I have lived and practiced in Maine for 50 years. At less than 2%, we are sixth from the bottom in Black population among other states. However, in the last 5 or 6 years here in Brunswick we have welcomed a large infusion of asylum seekers who come predominantly from Black African countries.

Skimming through the rest of the article, I found it hard to argue with the remaining nine recommendations for promoting breastfeeding, although most of them we not terribly applicable to small community practices. The photo of the Black woman nursing her baby at the top of the page remains as the primary message. The fact that I was drawn to that image is a testament to several of my biases and another example of a picture being worth far more than a thousand words.

I suspect that I’m not alone in appreciating the uniqueness of that image. Until recently, the standard photos of a mother breastfeeding have used trim White women as their models. I suspect and hope this poster will be effective in encouraging Black women to nurse. I urge you all to hang it in your office as a reminder to you and your staff of your biases and assumptions. Don’t bother to take the Implicit Association Test unless you’re retired and have 15 minutes to burn on a rainy afternoon.

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.

With the flip of the calendar a few short weeks ago, gyms and fitness centers began ramping up their advertising campaigns in hopes of attracting the horde of resolution makers searching for a place where they can inject some exercise into their sedentary lives. A recent survey by C.S. Mott’s Children’s Hospital found that even young people are setting health-related goals with more than half of the parents of 11- to 18-year-olds reporting their children were setting personal goals for themselves. More than 40% of the young people listed more exercise as a target.

However, our personal and professional experiences have taught us that achieving goals, particularly when it comes to exercise, is far more difficult than setting the target. Finding an exercise buddy can be an important motivator on the days when just lacing up one’s sneakers is a stumbling block. Investing in a gym membership and sweating with a peer group can help. However, it is an investment that rarely pays a dividend. Exercise isn’t fun for everyone. For adults, showing up at a gym may be just one more reminder of how they have already lost their competitive edge over their leaner and fitter peers. If they aren’t lucky enough to find a sport or activity that they enjoy, the loneliness of the long-distance runner has little appeal.

A recent study on children in the United Kingdom suggests that at least when it comes to teens and young adults we as physicians may actually have been making things worse for our obese patients by urging them to accept unrealistic activity goals. While it is already known that sedentary time is responsible for 70% of the total increase in cholesterol as children advance to young adulthood an unqualified recommendation for more exercise may not be the best advice.

In an interview with the study author, Andre O. Agbaje MD, MPH, said that in his large study population “light physical activity outperforms moderate to vigorous physical activity by five to eight times in lowering lipids”. While we may be surprised by this counterintuitive finding, Dr. Agbaje points out that an increase in sedentariness from 6 to 9 hours per day translates into a loss of 3 hours of light physical activity. In other words if you’re not sedentary you must be standing at attention or engaged in some light activity.

In my experience, and I suspect yours, it is difficult to get adults to do something, particularly if that something involves exerting energy, even a small amount of energy. The general admonishment of “be more active” is often met with a blank stare and the sometimes unspoken question “Like what?”

You could fall into a bottomless trap with them by suggesting a long list of activities, many of which are probably ones you do or would enjoy but don’t happen to fit with any of their interests or capabilities. Your chances of hitting on a perfect activity that the patient will attempt, let alone adopt, is very slim. Those of you with more patience than I have may choose to persist with this strategy. You could argue that even if the patient only dabbles briefly in one of your recommended activities, this is a minor victory worth celebrating. Who knows? The brief jolt of energy they received from this activity may prompt them to seek and find something else that works.

My interpretation of Dr. Agbaje’s findings is this: If we are going to suggest more activity, aim low. Don’t even mention the heavily weighted words “sport” or “exercise,” which are likely to dredge up bad memories. For adults, “Go shopping” or “Visit a friend” may be sufficient to at least get the person off the couch and on their feet and moving, even if very briefly.

The second message from this study applies more to children and adolescents and is one of those unusual instances in which a negative intervention may be more effective than a positive approach. Acknowledging that we are likely to have difficulty finding even a light activity that the child enjoys, why not pivot to the other side of the equation? Make a list of the child’s primary sedentary “activities.” Then suggest the parents put the child on a couch potato diet by immediately cutting in half the time he or she spends being sedentary. By definition, this will automatically increase his or her light physical activity by 50%. According to Dr. Agbaje’s data, this should be more effective in lowering lipids than in the unlikely event of finding a moderate activity the child accepts.

You can argue that the child will hound his or her parents unmercifully asking to be entertained. This may be true and this persistent complaining will be more likely to come from the older the child and the longer that the child has been allowed to be sedentary. Although the child may appear to have lost the ability to self amuse, I contend this isn’t a permanent loss and, with parental help, self-generated activity is a skill that can be regained if sedentary behavior is curtailed. This is another example of how saying “No!” in the right circumstances is often the most effective remedy for an unhealthy situation. I would never claim saying “No” is easy and helping parents to learn how to say “No” is one of our most difficult challenges. But, nothing else seems to be working.
 

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.

With the flip of the calendar a few short weeks ago, gyms and fitness centers began ramping up their advertising campaigns in hopes of attracting the horde of resolution makers searching for a place where they can inject some exercise into their sedentary lives. A recent survey by C.S. Mott’s Children’s Hospital found that even young people are setting health-related goals with more than half of the parents of 11- to 18-year-olds reporting their children were setting personal goals for themselves. More than 40% of the young people listed more exercise as a target.

However, our personal and professional experiences have taught us that achieving goals, particularly when it comes to exercise, is far more difficult than setting the target. Finding an exercise buddy can be an important motivator on the days when just lacing up one’s sneakers is a stumbling block. Investing in a gym membership and sweating with a peer group can help. However, it is an investment that rarely pays a dividend. Exercise isn’t fun for everyone. For adults, showing up at a gym may be just one more reminder of how they have already lost their competitive edge over their leaner and fitter peers. If they aren’t lucky enough to find a sport or activity that they enjoy, the loneliness of the long-distance runner has little appeal.

A recent study on children in the United Kingdom suggests that at least when it comes to teens and young adults we as physicians may actually have been making things worse for our obese patients by urging them to accept unrealistic activity goals. While it is already known that sedentary time is responsible for 70% of the total increase in cholesterol as children advance to young adulthood an unqualified recommendation for more exercise may not be the best advice.

In an interview with the study author, Andre O. Agbaje MD, MPH, said that in his large study population “light physical activity outperforms moderate to vigorous physical activity by five to eight times in lowering lipids”. While we may be surprised by this counterintuitive finding, Dr. Agbaje points out that an increase in sedentariness from 6 to 9 hours per day translates into a loss of 3 hours of light physical activity. In other words if you’re not sedentary you must be standing at attention or engaged in some light activity.

In my experience, and I suspect yours, it is difficult to get adults to do something, particularly if that something involves exerting energy, even a small amount of energy. The general admonishment of “be more active” is often met with a blank stare and the sometimes unspoken question “Like what?”

You could fall into a bottomless trap with them by suggesting a long list of activities, many of which are probably ones you do or would enjoy but don’t happen to fit with any of their interests or capabilities. Your chances of hitting on a perfect activity that the patient will attempt, let alone adopt, is very slim. Those of you with more patience than I have may choose to persist with this strategy. You could argue that even if the patient only dabbles briefly in one of your recommended activities, this is a minor victory worth celebrating. Who knows? The brief jolt of energy they received from this activity may prompt them to seek and find something else that works.

My interpretation of Dr. Agbaje’s findings is this: If we are going to suggest more activity, aim low. Don’t even mention the heavily weighted words “sport” or “exercise,” which are likely to dredge up bad memories. For adults, “Go shopping” or “Visit a friend” may be sufficient to at least get the person off the couch and on their feet and moving, even if very briefly.

The second message from this study applies more to children and adolescents and is one of those unusual instances in which a negative intervention may be more effective than a positive approach. Acknowledging that we are likely to have difficulty finding even a light activity that the child enjoys, why not pivot to the other side of the equation? Make a list of the child’s primary sedentary “activities.” Then suggest the parents put the child on a couch potato diet by immediately cutting in half the time he or she spends being sedentary. By definition, this will automatically increase his or her light physical activity by 50%. According to Dr. Agbaje’s data, this should be more effective in lowering lipids than in the unlikely event of finding a moderate activity the child accepts.

You can argue that the child will hound his or her parents unmercifully asking to be entertained. This may be true and this persistent complaining will be more likely to come from the older the child and the longer that the child has been allowed to be sedentary. Although the child may appear to have lost the ability to self amuse, I contend this isn’t a permanent loss and, with parental help, self-generated activity is a skill that can be regained if sedentary behavior is curtailed. This is another example of how saying “No!” in the right circumstances is often the most effective remedy for an unhealthy situation. I would never claim saying “No” is easy and helping parents to learn how to say “No” is one of our most difficult challenges. But, nothing else seems to be working.
 

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.

With the flip of the calendar a few short weeks ago, gyms and fitness centers began ramping up their advertising campaigns in hopes of attracting the horde of resolution makers searching for a place where they can inject some exercise into their sedentary lives. A recent survey by C.S. Mott’s Children’s Hospital found that even young people are setting health-related goals with more than half of the parents of 11- to 18-year-olds reporting their children were setting personal goals for themselves. More than 40% of the young people listed more exercise as a target.

However, our personal and professional experiences have taught us that achieving goals, particularly when it comes to exercise, is far more difficult than setting the target. Finding an exercise buddy can be an important motivator on the days when just lacing up one’s sneakers is a stumbling block. Investing in a gym membership and sweating with a peer group can help. However, it is an investment that rarely pays a dividend. Exercise isn’t fun for everyone. For adults, showing up at a gym may be just one more reminder of how they have already lost their competitive edge over their leaner and fitter peers. If they aren’t lucky enough to find a sport or activity that they enjoy, the loneliness of the long-distance runner has little appeal.

A recent study on children in the United Kingdom suggests that at least when it comes to teens and young adults we as physicians may actually have been making things worse for our obese patients by urging them to accept unrealistic activity goals. While it is already known that sedentary time is responsible for 70% of the total increase in cholesterol as children advance to young adulthood an unqualified recommendation for more exercise may not be the best advice.

In an interview with the study author, Andre O. Agbaje MD, MPH, said that in his large study population “light physical activity outperforms moderate to vigorous physical activity by five to eight times in lowering lipids”. While we may be surprised by this counterintuitive finding, Dr. Agbaje points out that an increase in sedentariness from 6 to 9 hours per day translates into a loss of 3 hours of light physical activity. In other words if you’re not sedentary you must be standing at attention or engaged in some light activity.

In my experience, and I suspect yours, it is difficult to get adults to do something, particularly if that something involves exerting energy, even a small amount of energy. The general admonishment of “be more active” is often met with a blank stare and the sometimes unspoken question “Like what?”

You could fall into a bottomless trap with them by suggesting a long list of activities, many of which are probably ones you do or would enjoy but don’t happen to fit with any of their interests or capabilities. Your chances of hitting on a perfect activity that the patient will attempt, let alone adopt, is very slim. Those of you with more patience than I have may choose to persist with this strategy. You could argue that even if the patient only dabbles briefly in one of your recommended activities, this is a minor victory worth celebrating. Who knows? The brief jolt of energy they received from this activity may prompt them to seek and find something else that works.

My interpretation of Dr. Agbaje’s findings is this: If we are going to suggest more activity, aim low. Don’t even mention the heavily weighted words “sport” or “exercise,” which are likely to dredge up bad memories. For adults, “Go shopping” or “Visit a friend” may be sufficient to at least get the person off the couch and on their feet and moving, even if very briefly.

The second message from this study applies more to children and adolescents and is one of those unusual instances in which a negative intervention may be more effective than a positive approach. Acknowledging that we are likely to have difficulty finding even a light activity that the child enjoys, why not pivot to the other side of the equation? Make a list of the child’s primary sedentary “activities.” Then suggest the parents put the child on a couch potato diet by immediately cutting in half the time he or she spends being sedentary. By definition, this will automatically increase his or her light physical activity by 50%. According to Dr. Agbaje’s data, this should be more effective in lowering lipids than in the unlikely event of finding a moderate activity the child accepts.

You can argue that the child will hound his or her parents unmercifully asking to be entertained. This may be true and this persistent complaining will be more likely to come from the older the child and the longer that the child has been allowed to be sedentary. Although the child may appear to have lost the ability to self amuse, I contend this isn’t a permanent loss and, with parental help, self-generated activity is a skill that can be regained if sedentary behavior is curtailed. This is another example of how saying “No!” in the right circumstances is often the most effective remedy for an unhealthy situation. I would never claim saying “No” is easy and helping parents to learn how to say “No” is one of our most difficult challenges. But, nothing else seems to be working.
 

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.