Lucy M. Osborn

Cough Variant Asthma: A Review of the Clinical Literature

Cough variant asthma is an occult form of asthma of which the only sign or symptom is chronic cough. This review examines 15 clinically oriented research articles on cough variant asthma and summarizes what is known about its frequency of occurrence, clinical presentation, diagnosis, treatment, and natural history. Cough variant asthma is a common problem among all ages that frequently goes unrecognized. Pulmonary function, as measured by spirometry, is often within normal limits. Any patient with a nonproductive, nocturnal cough lasting more than two weeks, should receive an empiric trial of bronchodilators. The natural history of cough variant asthma is variable. A significant proportion of patients followed over time develop the classic signs and symptoms of asthma, whereas for many patients, cough resolves without need for further treatment.

Circumcision A Study of Current Practices

The purpose of this study was to investigate the current incidence of circumcision, the reasons governing parental decisions regarding circumcision, the immediate and later complications from the procedure, as well as genital problems occurring in uncircumcised boys. The incidence of circumcision was found not to have changed over the past five years despite the recommen dations of the American Academy of Pediatrics Task Force on Circumcision. The reasons given for circumcision reflected mostly the strength of tradition, rather than a medical approach. Four per cent of newborns experienced early complications from the procedure, whereas 13 per cent experienced later, minor complications. Problems reported in uncircumcised infants were probably variants of normal. While the results of this study add evidence for discontinuing neonatal circumcision, we strongly recommend that, if physicians dissuade parents from having their infants circumcised, they must give adequate information concerning hygiene and the slow, natural separation of the foreskin from the glans.The purpose of this study was to investigate the current incidence of circumcision, the reasons governing parental decisions regarding circumcision, the immediate and later complications from the procedure, as well as genital problems occurring in uncircumcised boys. The incidence of circumcision was found not to have changed over the past five years despite the recommendations of the American Academy of Pediatrics Task Force on Circumcision. The reasons given for circumcision reflected mostly the strength of tradition, rather than a medical approach. Four per cent of newborns experienced early complications from the procedure, whereas 13 per cent experienced later, minor complications. Problems reported in uncircumcised infants were probably variants of normal. While the results of this study and evidence for discontinuing neonatal circumcision, we strongly recommend that, if physicians dissuade parents from having their infants circumcised, they must give adequate information concerning hygiene and the slow, natural separation of the foreskin from the glans.

Recruiting and Retaining Clinician-Educators: Lessons Learned from Three Programs

Market-driven reform of the health care system in the United States has led to a demand for changes in medical education. The Sixth Report of the Council on Graduate Medical Education (COGME) states: “The growth of managed care will magnify the deficiencies of the current educational system, yet will also provide new and essential educational opportunities to improve the preparation of physicians for their future roles.”1 The report defines competencies for primary care and managed care practice, then recommends curricular reforms, including changes in the sites used for training. The COGME report further recommends: “The size, composition and competencies of the full-time faculty at medical schools and residency programs must be reviewed in order to assure that they are appropriate to train physicians for their future roles.”1 As Dr. Evan Charney points out, medical education uses an apprenticeship model.2 Specialists and subspecialists have been well served by a system that uses trained, experienced physicians who practice their specialties in appropriate settings, usually within teaching hospitals. These same elements are essential for training generalist physicians, creating the need for community-practice settings as training sites and practicing physicians as clinician-educators. As medical schools and residency training programs attempt to adapt to the nations demand for changing the physician workforce, it is evident that nowhere is the balance between specialists and generalists more skewed than in academic health centers.3 Changes in medical practice as well as medical education now mandate that more community physicians and full-time academic generalist clinician-educators be successfully incorporated into the faculty. This article outlines lessons learned in the recruitment and retention of clinician-educators using different strategies at three medical centers: the University of Utah, Emory University, and the University of Cincinnati.

The APA/HRSA Faculty Development Scholars Program: Introduction to the Supplement

BACKGROUND The purpose of this project was to improve pediatric primary care medical education by providing faculty development for full-time and community-based faculty who teach general pediatrics to medical students and/or residents in ambulatory pediatric community-based settings. Funding for the program came through an interagency agreement with the Health Resources and Services Administration (HRSA) and the Agency for Healthcare Research and Quality (AHRQ). METHODS A train-the-trainer model was used to train 112 scholars who could teach skills to general pediatric faculty across the nation. The three scholar groups focused on community-based ambulatory teaching; educational scholarship; and executive leadership. RESULTS Scholars felt well prepared to deliver faculty development programs in their home institutions and regions. They presented 599 workshops to 7989 participants during the course of the contract. More than 50% of scholars assumed positions of leadership, and most reported increased support for medical education in their local and regional environments. CONCLUSIONS This national pediatric faculty development program pioneered in the development of a new training model and should guide training of new scholars and advanced and continuing training for those who complete a basic program.

Effective well-child care

Policymakers, researchers, and clinicians have questioned the effectiveness of well-child care for many years. As the nation faces decreasing resources for health care, the cost-effectiveness of all medical interventions must be critically examined. Simultaneous provision of universal access to care and containment of costs can only be accomplished if basic benefit packages are defined in a way that confines the services available to those procedures and treatments that have proven benefit at reasonable costs. Disease prevention and health promotion are activi-

Group well-child care offers unique opportunities for patient education.

By using a group process, health educators can greatly increase the cost effectiveness of well-child care. Benefits of group care, compared with traditional well-child care, include increased time for patient education, prolonged observation of parent-child interactions, the ability to observe children with their peers, and the opportunity to employ a broad variety of teaching techniques, such as role-modeling. This paper describes the authors 15 years of experience using this model, illustrating with examples the advantages of group well-child care.

The changing role of academic health care centers in generalist education and practice support

Academic medical centers have been more compatible with the training and support of specialist and subspecialist physicians than that of their generalist colleagues. To meet the increasing demand for well-prepared generalist physicians, academic centers must change the manner in which they discharge their traditional missions of patient care, education, and training. This will require alteration of their organizational structures, changes in the allocation of resources, and an evolution of the culture of academic medicine toward one that is supportive of generalist education and practice. This paper discusses 1) the present organizational, structural, and cultural elements of the academic health care center that are inadequate for that goal; 2) a model for reorganizing academic health care centers to best achieve that goal; and 3) educational programs and technologies that promise to address the continuing educational needs of generalists.