Letters to the Editor
Article Outline
Dear Editor
I believe we are currently in the infancy of electronic medical records (EMRs), just beginning to realize their potential. As an EMR instructor for AHPs and MDs, I can see how the end-users continually develop and improve in their use of the EMR. Initially, use of an EMR is time-consuming, and I do believe the focus is more on the computer and data entry than it is on the patient. This does pass as the end-user becomes more comfortable with the system and learns the tips and tricks that streamline use of the EMR, allowing the practitioner to spend more time with the patient. Eventually, I think EMRs are going to be rich depositories for health and illness information.
Thank you for your interesting pro-con article (Point/Counterpoint, “Are Electronic Health Records a Barrier to Nurse Practitioner Student Learning?” April 2010) on EMRs.
Debbie Pronitis, MSN, RNDallas, TX
Dear Editor
In response to the recent letter submitted by Janna Willhaus, CPNP, from Prairie Village, Kansas (April 2010), regarding her concerns of retail clinics treating pediatric patients, I was certainly shocked by some of her observations. As a family nurse practitioner I have treated many pediatric patients in my retail practice without incident. Many of our patients do not have a medical home, but we have an extensive referral network. In addition, it is our practice to make telephone contact in 48 hours to talk with the parents or guardians on the progress a child is making and to answer any questions they may have. This practice is done for all of our patients!
Our treatment plans are quite extensive, and if a child has a medical home, he or she is encouraged to follow up with a primary provider within 48-72 hours if symptoms worsen. We also have protocols in place regarding sharing medical information that are HIPAA compliant and medical information may be sent to the primary provider at the request of the guardian. In addition, every child that I see has height and weight done and plotted on growth charts. If there is concern, it is discussed at the time of the initial visit.
The problem with improper diagnoses and treatment recommendations is not unique to the pediatric population or retail clinics. I have many patients that are seen in my clinic that have been treated by their primary provider and use our services because they are not getting better for a variety of reasons. I certainly have respect for Ms. Willhaus' concerns, but I also must state that the quality of care received by primary providers can be “hit or miss” just as well. Also, any provider who cannot tell the difference between tachycardia and wheezes/ronchi should not be practicing!
John J. Malek, PhD, MSN, FNP-CLas Vegas, NV
Dear Editor
I am writing in response to the letter to the editor from Janna Willhaus, CPNP, in April 2010 journal. I feel she was very harsh on the retail clinic nurse practitioners. I can only speak for myself, but we send every pediatrician a letter the next day. We also call the patients' family to check on the child the very next day. One of the issues that we find in our clinic is that the parents bring the kids to us because they cannot get into their pediatrician for over “a week.” I feel that, if they were so worried about the children, they would see the sick patient within 24 hours. I certainly do not feel that the care they receive is “hit and miss.” What an insult to her colleagues. I work in a retail clinic that an ENT opened, and I have great resources. I feel that our patients get excellent care. Most of the children want to come back to see me and not their regular pediatrician. Maybe the primary practice pediatricians and NPs are a little threatened by us.
Kolleen Dayton, C-FNP, C-WHNPWheeling, WV
Dear Editor
The article on teen contraception in the April issue is very good, and the author does a good job of presenting practical questions to ask teenagers. I would like to correct one statement that she makes in the article. She states, “However any IUD method is not appropriate for someone who has not had a pregnancy.” This is incorrect. The World Health Organization lists only two contraindications: current cervicitis and pelvic inflammatory disease in the past 3 months. They list it as a category two, saying that the benefits of an IUD outweigh the risks in a nulliparous woman. Contraceptive Technology (19th edition) also does not list it as a contraindication. Because of the small size of the uterus and the small diameter of the cervical canal, it may be more difficult to insert an IUD, and the rate of expulsion is higher, but it is not contraindicated in a nulliparous woman. Thank you for your attention to this matter.
Sheryl Shantz, FNPYuma, AZ
Dear Editor
In the article “Teen Contraception,” author Linda Sullivan states, “Any IUD method is not appropriate for someone who has not had a pregnancy.”1 This statement is contrary to both current evidence and clinical guidelines.
There are two main issues that are important to address. The first issue is that intrauterine devices (IUDs) are safe to use in nulliparous women. In a retrospective cohort study of 461 women, Veldhuis, Vos, and Lagro-Janssen found no statistically significant difference in complications from IUD placement and use between nulliparous and parous women.2 It has become common practice for clinicians to insert IUDs in nulliparous women. The World Health Organization guidelines state that IUDs can safely be used in nulliparous women but may require closer follow-up.33
The second issue is that IUDs are safe and often an appropriate contraceptive choice in adolescent females. In a systematic review, Deans and Grimes state, “IUDs should be offered as a first-line contraception to all women—including adolescents who may have difficulty with methods requiring ongoing compliance.”4 Finally, the American College of Obstetricians & Gynecologists Committee Opinion supports the use of IUDs in adolescent females, regardless of parity, as first-line contraception.5
In conclusion, IUDs are a safe and effective method of contraception for adolescents, and nurse practitioners should not hesitate to consider their use in this population.
Anne E. Cavett, BSN, MSN/MPH(c)Meghan E. Greeley, BSN, MSN/MPH(c)Shirley E. Van Zandt, MS, MPH, CRNP
Dear Editor
I noted that your article on teen contraception stated, “Any IUD method is not appropriate for someone who has not had a pregnancy.” This information is inaccurate. “Intrauterine Contraceptives: A Review of Uses, Side Effects, and Candidates” (Shimoni N, Seminars in Reproductive Medicine. Update on Contraception. March 2010;28[2]:118-125) states that both IUDs (Mirena and Paragard) are appropriate for use in nulliparous women. The World Health Organization (WHO) also promotes IUD use in nulliparous women. It is a widely accepted standard of care in family planning clinics to use IUDs in nulliparous women. I was concerned to see outdated information reported in a journal of your caliber; hopefully, you can clarify this information for your readers.
Jill Antell, PNP
Author's Response
Regarding the use of IUDs in nulliparous women, I thank the readers for their comments. In fact the comments are correct in that the IUD is no longer contraindicated in nulliparous women. The official guidelines governing the use of the IUD as a method of contraception have changed.
Linda Sullivan, RN, BC, DSN
References
- . Teen contraception: darned if you do darned if you don't . J Nurs Pract . 2010;6(4):274–278
- . Complications of the intrauterine device in nulliparous and parous women . Europ J Gen Pract . 2004;10:82–87
- . Medical eligibility criteria for contraceptive use . Available at www.who.int/reproductivehealth/publications/family_planning/9789241563888/en 2009; Accessed May 8, 2010.
- . Intrauterine devices for adolescents: a systematic review . Contraception . 2009;79:418–423
- American College of Obstetricians & Gynecologists Committee Opinion No. 392, December 2007. Intrauterine device and adolescents . Obstet Gynecol . 2007;110:1493–1495
Editor's Note: The following letters refer to the article “Teen Contraception: Darned if You Do and Darned if You Don't” in the April 2010 issue.
PII: S1555-4155(10)00294-1
doi:10.1016/j.nurpra.2010.05.013
