Network News Excerpts
(EXCERPTS TAKEN FROM THE SPRING 2001
EDITION OF THE NETWORK NEWS)
From the Director
By Mort Wasserman, MD, MPH
A Sign of the Times
PROS research recently was featured on the cover of Time Magazine
(Time, 2000) and subsequently on the front page of the New York Times
(New York Times, 2001). In the October 30th issue cover article ("Early
Puberty: Why Girls are Growing Up Faster"), Time reported on
the findings of the PROS Secondary Sexual Characteristics (SSC) study
(Herman-Giddens, et al., 1997) and the subsequent fall-out from that
work. As many of you recall, that PROS study indicated that girls are
entering puberty at an earlier age than described in pediatric textbooks.
Unfortunately, the Time writers failed to mention PROS by name
in the article, which focused on possible causes for and implications
of the study's findings. I wrote to the editor and pointed out that
the reporters had overlooked a key story with an additional headline
- "Busy Pediatric Practitioners Band Together with Scientist Colleagues
to Make an Important Discovery." The editor was not persuaded
by my argument and Time never published my letter. The New
York Times front page article, "Doubters Fault Theory Finding
Earlier Puberty" (which also failed to mention PROS by name), was
a very provocative piece in which the reporter depicted a raging furor
among pediatric endocrinologists over the accuracy and meaning of the
PROS findings.
PROS conducted the SSC study because (1) a curious clinician wondered
if girls weren't beginning puberty earlier than was stated in the textbooks
and (2) the National Health and Nutrition Examination Survey (NHANES),
which routinely studies statistically representative samples
of the general population in order to assess questions of this sort,
had addressed the issue but only for a smaller age range of girls, ages
8-12. As opposed to a statistically representative sample, SSC
study subjects were a convenience sample of girls seen at pediatric
visits that required complete physical examinations. The SSC study has
been criticized for the nature of the sample, but as NHANES has no plans
to undertake a study that would confirm or refute the wider-age-range
PROS findings, and as such the SSC study data remain the best available
on the subject. Interestingly, preliminary (and as yet unpublished)
analyses of the 8-12 year old groups for which the SSC study and NHANES
samples do overlap suggest a high degree of correlation in pubertal
stages between the two samples. If these results are verified, it will
lend further credence to the PROS findings.
Now, in an interesting twist, PROS is being called upon to confirm
or refute results of a recent NHANES study of the emergence of puberty
in young boys! A preliminary analysis of NHANES data on puberty in boys
done by SSC Principal Investigator Marcia Herman-Giddens, DrPH and colleagues
suggests that boys too are entering puberty earlier. However, unlike
the case with girls, this runs counter to the impression of many pediatric
clinicians, and members of NHANES own investigative team have questioned
whether the examinations done to assess puberty were accurate (personal
communication from Dr Herman-Giddens).
As those who were involved in the study will recall, PROS practitioners
who participated in the SSC study were trained using a specially-prepared
manual (Herman-Giddens, et al., 1995) and passed a test in order to
qualify to collect data. This kind of meticulous training, combined
with the trusting relationship between PROS practitioners and their
patients, could allow for more complete and accurate exams than might
be obtained by an examiner from a government study. For this reason,
Dr Herman-Giddens and PROS Puerto Rico Coordinator Dr Carlos Bourdony
will be presenting the possibility of a boys SSC study to the assembled
PROS Coordinators in March.
Whether or not this boys SSC study ever comes to pass (and I hope it
does), two facts remain. First, PROS practitioners are capable of producing
new knowledge that is front-page news in the world's most famous magazines
and newspapers. Second, PROS is having one heck of a time getting its
name in print!!
References
Herman-Giddens ME, Slora EJ, Wasserman RC, Bourdony CJ, Bhapkar
MV, Koch GG,
Hasemeier CM. Secondary sexual characteristics and menses in young girls
seen in office practice: a study from the Pediatric Research in Office
Settings (PROS) network. Pediatrics 1997; 99:505-512.
Herman-Giddens, ME and Bourdony, CJ. Assessment of Sexual Maturity
Stages in Girls, American Academy of Pediatrics, Elk Grove Village,
IL, 1995
New York Times, February 20, 2001.
Time, October 30, 2000.
From The Steering Committee Chair
By Gordon Glade, MD
Do Doctors Get Better with Age?
Do you remember when you first realized that the knowledge you gained
in residency did not jive with what was being practiced in your community?
I recall a senior pediatrician telling me that I didn't need the fancy
asthma protocols that I had brought with me from residency." You
really should just use Marax." I quickly found a PDR to learn that Marax
was a fixed dose combination of ephedrine sulfate, hydroxyzine, theophylline,
and alcohol." So why should I use Marax?" I asked (instead of the carefully
titrated doses of theophylline I had learned to prescribe). "It's been
around for a long time and has worked great for my patients," he replied.
There were very good doctors in my town who couldn't stand to spend
the patient's money for a throat culture or a urine culture when a shot
of penicillin or a few days of ampicillin would help the patient with
pharyngitis or a UTI and "probably wouldn't hurt." Patients were admitted
to the hospital simply to be observed and acetaminophen and aspirin
were being alternated every two hours for fever. The standard of care
in my community was largely defined by physicians with twenty or more
years of experience. When I asked a senior pediatrician in a nearby
community how he decided when to adapt a new treatment he said, "Never
be the first one to give a new drug or try a new procedure; but, on
the other hand, never be the last either."
Now that I have been in practice for twenty years, I wonder what kind
of standard of care I am setting for the new doctors. How should I balance
what I think I have learned from experience with what the latest new
thing is. How do I decide when to change my routine?
PROS has taught me to keep asking the question "What are the data to
support what I am doing?" I know that sometimes there is no data but
if I don't at least ask the question "Why?" I risk drifting into habits
much like those that greeted me when I opened my practice. Each time
a new cephalosporin came out it the 80s and 90s, my best defense against
the onslaught of detail men was "Why?" or "Show me the data." In the
past year, without this defense I would be more bewildered than I am
with the many new faces on methylphenidate for ADHD.
On the other hand, sometimes there is data. If so, we should be moving
more quickly to adapting evidence-based guidelines. For example, in
our county our cost for caring for a child with bronchiolitis is much
higher than the rest of the state. We should be moving more quickly
away from traditional hospitalizations for oxygen and nebulized bronchodilators.
After all there are data and guidelines (at least for what doesn't work).
The older I get the more challenging it is to achieve balance in
my life. Adopting new ideas too early...too late. What's the best
thing to do? Read the literature, know evidence-based guidelines,
don't be swayed by fancy-schmancy drug salesmen or parents who just
need a little education; ask the questions, participate in PROS projects
to find some answers. Or maybe do my own in-office research project.
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