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Clarifying medical uses of marijuana

In the Eye on Washington section of Updates in the May issue, the first sentence of the item on the medical uses of marijuana is misleading: "The Institute of Medicine issued a favorable report on the medical uses of marijuana, specifically for treating pain, nausea, and weight loss associated with AIDS." In fact, the IOM report states specifically that "marijuana's future as medicine does not involve smoking it." The report goes on to say that "there is no compelling evidence that marijuana should be used to treat glaucoma and little evidence for treating migraines. Medical marijuana should only be used in short-term trials, the goal of which should not be to develop marijuana as a licensed drug. Purified components of marijuana, not the plant itself, hold potential for treating pain, chemotherapy-induced nausea and vomiting and AIDS­wasting syndromes."

Richard Schwartz, MD

Vienna, VA

The editor of Updates replies: I thank Dr. Schwartz for drawing attention to an important omission in the way Eye on Washington reported the Institute of Medicine's study. The IOM cautioned that the benefits of smoking marijuana were limited because the smoke was so toxic the true benefits of marijuana would be realized only with alternative methods for delivering its active components. The researchers recommended the government pay for research to speed development of such products but also suggest that until such products become available people who do not respond to other therapy be permitted to smoke marijuana.

Judith Asch-Goodkin

Treating croup

The excellent "Viral croup: Current diagnosis and treatment" (February) brought to mind the following questions:

  • Clarification of the two different doses mentioned for different epinephrines. One mention (page 148) is of a 5 mL dose of l-epinephrine at 1:1000. Table 2 refers to 0.5 mL of 2.25% racemic epinephrine. Are these doses correct? Are both doses diluted with normal saline? Do they have an equivalent effect?

  • Can the budesonide metered dose inhaler be used for croup with a spacer and mask instead of nebulized budesonide?

I enjoy Contemporary Pediatrics and always read it cover to cover. It is right on target for the general pediatrician.

Ada Hess, MD

Kew Gardens Hills, NY

The author replies: The two doses are approximately equal and are correct. A dose of 5 mL of l-epinephrine at 1:1000 dilution is 0.005 mg of epinephrine. The dose may be further diluted with saline to reduce its irritating effect when it is given by nebulization. A dose of 0.25 mL to 0.75 mL of a 2.25% solution of racemic epinephrine is 0.005 to 0.017 mg, respectively. Several mL of normal saline may be used for nebulization.

With regard to using the budesonide metered dose inhaler with a spacer and mask for patients with croup, this mode of delivering medication to patients with croup has not been studied and so should not be used. As of now, oral dexamethasone at a dose of 0.15 mg/kg would seem to be the easiest and least expensive way to treat patients with croup.

Ellen R. Wald, MD
Pittsburgh, PA

Are med-peds a threat to pediatricians?

I read "The medicine-pediatric physician: Past, present, and future" (March) with interest. Without doubt med-peds physicians can provide cost-effective and high-quality primary care. Whether med-peds can be used to their fullest potential depends, however, on the resolution of issues that my colleagues and I face every day as we try to combine the practice of two separate primary care specialties. Here are some of the issues we med-peds face:

  • Our facility, a 550-bed community hospital with several residency programs, does not allow for active membership in more than one department. Typically, the med-peds physician has active membership status in internal medicine and affiliate privileges in pediatrics. In practice, we attend meetings in both pediatrics and internal medicine. Only attendance at the internal medicine meetings counts toward maintaining our active medical staff status, however.

  • Although we feel fully accepted by the internal medicine staff, we have all sensed at one time or another a subtle, but real, lack of acceptance by the Department of Pediatrics. The department often indicates that we lack sufficient training to provide comprehensive care of children. But we are pediatricians! Although taking care of adults as well as children reduces the number of infants and children in our practice, the decrease in volume does not decrease our dedication to pediatrics.

  • Coverage of a med-peds practice is problematic unless the physician is part of a multispecialty group practice. Family practice physicians can cover adult and pediatric patients, but internal medicine and pediatric colleagues are required for critical care and special care nursery patients.

Broadly trained med-peds physicians are a great resource for cost-effective care in today's health-care environment. To fulfill their potential, however, med-peds must be accepted and supported by their colleagues. Although competition for patients has increased, collaboration among primary physicians offers the best hope for delivering comprehensive care and advocacy for infants and children. In addition, consumers need to be educated about this new breed of physician. The public must understand that the med-peds doctor has the unique training and ability to provide truly total care. As one of the advertisements for our practice says, "It's like having two doctors in one."

Toby Jacobowitz, MD

Ann Arbor, MI

The author says, "As we proceed into the next century, the specialty of medicine-pediatrics is poised to play a central role in medical practice." He states that these physicians "are probably better suited than any other primary care specialists to integrate all components of health care." I would like the author's view of the implications of this role for the pediatrician? Will we be driven out by med-peds? How can we best work together?

Hari C. Sachs, MD

Rockville, MD

The author replies: Dealing with the dichotomy Dr. Jacobwitz describes requires establishing lines of communication so as to change outdated policies that don't address the concept of a hybrid specialist. With the support of the American Academy of Pediatrics, the American College of Physicians, and the American Medical Association, med-peds physicians can educate hospital administrators, insurers, and the public about the diverse potential of the med-peds physician. I suggest that Dr. Jacobwitz share the Contemporary Pediatrics article with hospital administrators, since it describes what the med-peds physician has accomplished as an internist and as a pediatrican.

Collaboration with local practitioners is required to find coverage for med-peds physicians. By sharing integrated call coverage among single-specialty practices, all the participating physicians reduce their call schedules. In small towns, family physicians and med-peds physicians may share inpatient coverage equally. In larger towns, the med-peds physician may provide more inpatient and consultative services, which the practice could offset by integrating protected time into the med-peds physician's daily schedule to provide these services. Many alternative scenarios also are possible.

Dr. Sachs asks about the implications for the pediatrician of med-peds' central role in medical practice. Along with providing health maintenance, acute care, and tertiary care to both children and adults, the med-peds physician is prepared to apply the concepts of anticipatory guidance to adults (an unfamiliar concept for internists) and secondary prevention (less experienced by pediatricians) to children with chronic pediatric illness as well as to serve as a consultant to the pediatrician or the internist. The pediatrician encounters diseases commonly seen by the internist, such as deep vein thrombosis, pulmonary embolism, and hypertension, and the opportunity to use a med-peds colleague as a medicine consultant will optimize management of patients with these conditions.

Will the med-peds physician drive out the pediatrician? Absolutely not! Collaborative practice between the med-peds physician and the pediatrician increases the potential for the pediatrician to be "driven into" providing more pediatric care by attracting adolescents and families who want to be cared for in the same group practice. As to how pediatricians and med-peds physicians can best work together, the key is to relate to one another as consultants, partners, and colleagues so as to allow patients to maintain a continuum of care across a lifetime.

Gary M. Onady, MD, PhD
Dayton, OH

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Letters to the Editor
Contemporary Pediatrics
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E-mail address: cpletters@medec.com

We reserve the right to edit letters for clarity and length.

Iris Rosendahl. Letters. Contemporary Pediatrics 1999;8:19.

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