Your Voice

Questioning the data on outcomes and satisfaction with PNP care

In "The 40-year story of PNP caregiving-still being written" (August 2005), the authors claim that "80% of health-care issues seen in a primary care pediatric office can be managed by a PNP without a significant difference in health-related outcomes." But the reference for this statement (Mundinger MO, Kane RL, Lenz ER, et al: Primary care outcomes in patients treated by nurse practitioners or physicians: A randomized trial. JAMA 2000;283:59) has nothing to do with pediatric care. That study examines the care of 1,316 adults (90% Hispanic, 77% women), 806 of whom were cared for by Spanish-speaking NPs. Also, the principal results centered on patient satisfaction and the study was conducted for just one year-too soon to make sweeping judgments about quality of care.

John DelGiorno, MDBlackwood, N.J.

Readers may be interested to know that Mundinger's work has been validated for an additional two years (Primary care outcomes in patients treated by nurse practitioners or physicians: Two-year follow-up. Med Care Res Rev 2004;61:332). This study reports results of the two-year follow-up phase of a randomized study comparing outcomes of patients assigned to an NP or a physician primary care practice. In the sample of 406 adults, "no differences were found between the groups in health status, disease-specific physiologic measures, satisfaction or use of specialist, emergency room or inpatient services. ... The results are consistent with the 6-month findings and with a growing body of evidence that the quality of primary care delivered by nurse practitioners is equivalent to that [delivered] by physicians."

Rosemary Liguori, RN, PhD, CPNP, and colleagues

Bedwetting dishonesty can't be justified

In "Clinical tips for helping patients overcome bedwetting" (September 2005), Howard J. Bennett, MD, provided helpful pointers. However, I believe that two of the tips-"Make plans to avoid embarrassment" and "Help children who don't want to go on sleepovers"-outlined, essentially, lies that our patients can tell to their friends.

Dr. Bennett indicates that we should ask our bedwetting patients to make up a cousin, a UTI, a vomiting illness, or a big day the next day to evade potential questions about pull-ups, mattress pads, or sleepovers. I don't believe that pediatricians should model dishonesty, and we certainly should not encourage it. It is important to protect children from embarrassment, but having the pediatrician help make up lies is not the answer. Parents and patients should be conscientious about putting pull-ups and mattress pads away when friends visit; when an unanticipated question arises, a matter-of-fact answer will downplay the issue.

I also think that parents who prohibit sleepovers should be praised, not put in a bad light. The potential for inappropriate touching-by either an adult or another child at the sleepover-is a growing concern. No parent or pediatrician should feel the need to make excuses for protecting a child.

Michael K. Visick, MDLogan, Utah

Author reply: Nocturnal enuresis is not a serious medical condition, but it can be very difficult to live with. Because of their wetting, these children may become socially isolated and emotionally distressed and may have low self-esteem.^1,2

I have dealt with a number of situations in which friends, schoolmates, or siblings discovered a child's enuresis. Most people are sympathetic, but that is not always the case. I have seen children teased and laughed at-even blackmailed-because of bedwetting. Such consequences pose a significant risk to a child's psychological well-being.