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All the pediatricians in our office were so impressed and grateful for the article "Inhaled corticosteroids and growth: How big a dose of caution?" (March). Drs. Stempel, Pedersen, and Blaiss did an incredible job of providing a comparative review of the current literature on inhaled steroids and presented very practical information for prescribing pediatricians. Thank you all so much for this excellent resource, which we have already referred to and used as a teaching tool with our pediatric residents.
Although we sympathize with Dr. Weinberg's concern that the general pediatrician is at risk of becoming merely a triage physician for children rather than being considered the specialist in the care of children, we disagree that pediatric nurse practitioners (PNPs) are a primary cause of this malaise as he implies ("Whither the general pediatrician?" Readers' Forum, February). As of February 2002, there were approximately 10,000 PNPs in the United States. Less than 1% of NPs practice independently (Stone EL: Pediatrics 1995;96:844). There are 53,000 members of the American Academy of Pediatrics. In 1990, the vast majority (96%) of pediatric residents found immediate employment (Eaton AP et al: Pediatrics 1991;88:870). Based on the numbers alone, PNPs will not supplant the general pediatrician and are not the cause of "whither the general pediatrician."
Dr. Weinberg's statement that "care for children [provided by the pediatric nurse practitioner and the family practitioner] may not be as good, or as personalized, as that given by the general pediatrician, but it will be adequate" is also inaccurate. In 1993, a meta-analysis of 53 studies of nurse practitioners (NPs) and certified nurse midwives found that NPs provided more health promotion activities than did physicians and had higher quality-of-care measures (Brown SA et al: Nurse Practitioners and Certified Nurse-Midwives: A Meta-analysis of Studies on Nurses in Primary Care Roles, 1993). Similarly, a major government report concluded that the quality of care provided by NPs, certified nurse midwives, and physician assistants was equivalent to the quality of comparable physician services (US Congress, Office of Technology Assessment: Nurse Practitioners, Physician Assistants and Certified Nurse-Midwives: Policy Analysis, 1986).
Regarding the provision of personalized care, a comparison of content taught during health supervision visits by experienced NPs and by pediatricians indicated that NPs covered more in-depth developmental and child behavioral topics, provided more maternal support, and averaged eight minutes more per visit than experienced pediatricians (Foye H et al: Am J Dis Child 1977; 131:1170). Over the past decade, the scope of general pediatric practice expanded to include more complex child-health issues, including violence prevention and lifestyle issues such as drug and alcohol use, areas in which PNPs bring particular expertise to the pediatric office because of their nursing background. PNPs are trained to provide health promotion, health supervision, and diagnosis and treatment of common childhood illnesses; pediatricians are trained in depth in the diagnosis and treatment of childhood illnesses (Stone EL, 1995). The collaborative practice by PNPs and pediatricians is the optimal mode of pediatric primary care and is the experience of the vast majority of PNPs.
With the health-care needs of children escalating in complexity, PNPs and pediatricians need to help each other traverse the health-care crisis. Our common goal must be to provide high-quality, cost-effective pediatric care in a collaborative modelnot an adversarial one.
The author replies: I am truly sorry if I gave the impression that pediatric nurse practitioners do not give good pediatric care. That was not my intention. As the father of an excellent PNP, and having been preceptor for a number of very good PNPs, I am fully aware of how the PNP functions and of the important role the PNP fills in present-day pediatric care. Yes, most PNPs give good quality care, spend a lot of time with their patients, and are as caring as the average general pediatrician. No, the problem with the general pediatrician is within the specialty itself, and will have to be addressed and, if possible, fixed there.
I am concerned that the recommendation to use a diaper as a compress ("Warm compresses from a surprising source," Clinical Tip, February) may have an unintended consequence that is legally actionable against pediatricians: Namely, I am aware of a child, on whose behalf legal action is pending, who received a second-degree burn after using a diaper as a warm compress.
The author replies: In our litigious society, there are many examples of torts. It is simply up to the clinician to use any treatment modality safely and wisely. If there is concern that a particular parent is not going to be very careful in applying a recommendation, such as the one described in my "Clinical Tip," then I concur that it is best not to offer it. Furthermore, every new technique should be introduced with the caveat that the child's parent or caretaker receive careful education on how to carry out the proposed treatmentfrom someone who is experienced with it. Over the years, unintentional burns caused by all kinds of therapeutic modalities have been reported in journals; proper education and instruction is mandatory.
Two reputable references in support of the use of disposable diapers as warm compresses can be found online at http://18.104.22.168/search?q=cache:mhks1yVSRWcC:2g.isg.syssrc.com/non_trauma/
firstaid.htm+disposable+ diapers+as+compresses&hl=en (then click on First-Aid Kit), and at http://22.214.171.124/search?q=cache:VLPzwSEF4zYC:
Readers' Forum. Contemporary Pediatrics 2002;6:20.