Philip O. Ozuah

Physical activity during school in urban minority kindergarten and first-grade students

OBJECTIVES: To determine if physical activity (PA) during the school day varied by school, grade level, gender, weight status, and physical education (PE) and recess participation among urban kindergarten and first-grade students. METHODS: Cross-sectional study at 4 Bronx, NY, schools. Student PA was measured by a Yamax Digi-Walker pedometer, an objective and validated measure of PA in children. Each student wore a sealed pedometer during school for 5 consecutive days. Hierarchical models were fit to identify variables predictive of PA. RESULTS: A total of 916 had valid pedometer data (53% male, 70% Hispanic, mean age 5.98 years [SD 0.66], 45% overweight). PA varied by school (P < .0001). First-grade students took a significantly greater mean number of steps during school than kindergarten students. Overall, students took an average of 2479.7 (SD 961.8) steps/school day. PA did not differ by BMI status. Students took on average 724 more steps on PE days than on non-PE days and 490 more steps on days with outdoor recess than nonrecess days (P < .05 for both). Fewer than 1% of all students achieved lower cut points for previously published mean range of steps/school day for boys and girls. Multivariable analysis revealed higher grade level, participation in PE class, and outdoor recess as independent predictors of PA. CONCLUSIONS: PA levels were low in kindergarten and first-grade students. Future interventions incorporating classroom-based PA and outdoor recess may increase PA in resource-poor urban schools with limited PE facilities.

Tuberculin skin testing in children.

Skin testing is recommended for children at risk for this disease.

Measurement of Inhaled Corticosteroid Adherence in Inner-City, Minority Children with Persistent Asthma by Parental Report and Integrated Dose Counter

Parents often overreport adherence to asthma treatment regimens making accurate assessment of medication adherence in clinical practice difficult. This study was conducted to compare two adherence assessment methods clinicians may choose from when assessing patient inhaled corticosteroid (ICS) adherence: parental report and dose counter measurements of metered-dose inhaler (MDI) actuation. Participants included children (N = 50) with persistent asthma and their parents (N = 50). At enrollment, children received a new, marked ICS at the dose prescribed by their physician. Thirty days following enrollment, we measured ICS adherence by parental report and objectively, with a dose counter. Parental report overestimated ICS adherence when compared to dose counter. We found a statistically significant overall difference between parental report and objectively measured adherence. A dose counter that most ICS inhalers are equipped with may be a more reliable alternative measure of ICS adherence in a clinical practice setting.

Student perceptions of effectiveness of the eight step preceptor (ESP) model in the ambulatory setting

Background: Balancing consistently effective clinical teaching with quality patient care is a crucial challenge for ambulatory preceptors. Educators have developed frameworks of specific teaching behaviors to facilitate consistent, efficient precepting, but few have evaluated their effectiveness. We modified an existing precepting model by incorporating additional adult learning principles to create the Eight Step Preceptor (ESP) model. We then determined if students perceived faculty to be more effective teachers when they incorporated more ESP components into their precepting sessions. Purposes: The objective was to describe the association between faculty using the ESP behaviors during their precepting and medical students satisfaction with their learning. Methods: A trained observer timed the duration of precepting sessions in a childrens hospital ambulatory clinic between August and November 2001. Students rated faculty “teaching effectiveness,” and both students and observer rated whether faculty effectively incorporated ESP behaviors during each session. Results: Sessions lasted on average 26 ± 14 min. Faculty gave a teaching point and feedback in over 50% of the precepting sessions but did not consistently incorporate the other ESP behaviors. Faculty use of more ESP behaviors correlated significantly with greater teaching effectiveness (r = .62, p < .003) but not significantly with duration of precepting sessions. Conclusions: Students perceived faculty as more effective teachers when they incorporated more ESP behaviors while precepting. The ESP model was associated with more effective ambulatory precepting in our study.

A Classroom-Based Physical Activity Intervention for Urban Kindergarten and First-Grade Students: A Feasibility Study

BACKGROUNDnUrban elementary schools in minority communities with high obesity prevalence may have limited resources for physical education (PE) to achieve daily activity recommendations. Little is known whether integrating physical activity (PA) into classrooms can increase activity levels of students attending such schools.nnnMETHODSnWe conducted a cluster randomized, controlled trial among kindergarten and first-grade students from four Bronx, New York, schools to determine feasibility and impact of a classroom-based intervention on students PA levels. Students in two intervention schools received the Childrens Hospital at Montefiore Joining Academics and Movement (CHAM JAM), an audio CD consisting of 10-minute, education-focused aerobic activities led by teachers three times a day. PA was objectively measured by pedometer. Each subject wore a sealed pedometer during the 6-hour school day for 5 consecutive days at baseline (Time 1) and 8 weeks postintervention (Time 2). Hierarchical linear models were fit to evaluate differences in mean number of steps between the two groups.nnnRESULTSnA total of 988 students participated (intervention group, n=500; control group, n=488). There was no significant difference at baseline between the two groups on mean number of steps (2581 [standard deviation (SD), 1284] vs. 2476 [SD, 1180]; P=0.71). Eight weeks post-CHAM JAM, intervention group students took significantly greater mean number of steps than controls (2839 [SD, 1262] vs. 2545 [SD, 1153]; P=0.0048) after adjusting for baseline number of steps and other covariates (grade, gender, recess, and PE class). CHAM JAM was equally effective in gender, grade level, and BMI subgroups.nnnCONCLUSIONSnCHAM JAM significantly increased school-based PA among kindergarten and first-grade students in inner-city schools. This approach holds promise as a cost-effective means to integrate the physical and cognitive benefits of PA into high-risk schools.

Resident education and clinic efficiency.

Context and setting New medical graduates in Victoria (Australia) commence their intern year in mid-January with a 3–5 day orientation programme in their parent hospital. Orientation programmes usually comprise overly thorough didactic presentations on clinical and administrative topics given by senior staff. The only interactive components involve procedural skills teaching and hospital tours. Why the idea was necessary In 2005 we surveyed our hospital’s interns on their (self-reported) ability to perform several procedural, clinical management and administrative tasks before and after their first rotation. This showed a pre ⁄ post 59% improvement in managing administrative tasks (from a low base) compared with a 2% improvement in procedural skills (from a high base). Mid-year evaluation of our 2005 orientation showed that interns remembered only the interactive components. What was done Using the 2005 interns and their educators, we further developed the survey list to construct a set of systems-based tasks that interns should perform competently in their first weeks, including case presentation. We incorporated the tasks into a team-based contest conducted in the hospital, titled The Amazing Case Race , adapted from the CBS television programme. Clinician taskmasters ranked each team’s performance, provided necessary assistance and assessed the team presentations. The 40 interns were organised into teams of 5, ensuring that no group consisted entirely of interns who knew each other or the hospital well. Our virtual patient, Emily Brown, a widow aged 82 years with several comorbidities, was admitted from the emergency department and experienced a torrid hospital course including an endoscopy and a stay in the intensive care unit (ICU) before being discharged within 48 hours. All her investigation results and prescriptions were available on the hospital computer systems. Initial tasks included accessing the radiology system to view the patient’s chest X-ray, combining this with the clinical information to make a diagnosis of pneumonia, accessing the hospital antibiotic guidelines to decide on an antibiotic, gaining permission from the infectious diseases registrar to prescribe the chosen antibiotic, and correctly writing it on the drug chart. Later, the teams had to respond appropriately to Mrs Brown’s daughter’s angry phone call about the lack of communication about her mother’s transfer to the ICU. Other tasks included prescribing anticoagulants according to hospital policy and referring Mrs Brown for physiotherapy via Hospital in the Home. The final tasks involved the correct completion of both a discharge summary and a death certificate. Evaluation of results and impact The immediate feedback from interns and senior clinicians was very positive, with an overall score of 4.3 ⁄ 5.0 compared with a score of 3.5 ⁄ 5.0 for the 2005 programme. The positive response continued, with 95% attendance at intern education sessions all year, an increase in interns returning for Hospital medical officer 2 positions in 2007 and very few intern complaints about management or hospital systems. The Amazing Case Race provides a safe mechanism for new interns to interact successfully with hospital systems by providing team-based simulated patient care in real settings.

Reliability of adolescent standardised patients in assessing professionalism.

Context and setting The Accreditation Council for Graduate Medical Education (ACGME) requires that residency programmes in the USA institute competency-based assessments of professionalism. Many residency programmes are struggling to find ways to assess residents’ competencies in professionalism. While standardised patients (SPs) have been used extensively in medical education, it is unclear whether adolescent SPs are reliable in assessing residents in this domain of competency. Why the idea was necessary Standardised patients are among ACGME’s recommended approaches for assessing residents’ competencies in professionalism. Usually, SPs are adult actors trained to portray realistic clinical scenarios. We have found that, in contrast with adult SPs, adolescent SPs are relatively easier to recruit and less costly. However, no prior studies have validated the reliability of adolescent SPs in assessing professionalism. If found to be reliable, adolescent SPs could offer paediatric educators a new tool for achieving ACGME competency mandates. Thus, we decided to examine adolescent SPs’ reliability in assessing residents’ professionalism. What was done We conducted a prospective criterion standard study at a major academic medical centre. Twelve adolescent SPs were trained to complete checklists that assessed elements of professionalism adapted from the ACGME Outcomes Project website. A cohort of residents (n 1⁄4 18) interviewed the SPs. All interviews were directly observed by 2 trained faculty members. The SP and faculty staff completed similar checklists immediately after each encounter and were blinded to each others’ ratings. Faculty ratings were used as the criterion standard. To validate SPs’ ratings, comparisons were made between faculty and SP ratings. Interrater reliability was assessed by determining percent agreement, Kendall tau-b coefficient of concordance and Cohen’s kappa coefficient of correlation. Evaluation of results and impact Overall, 36 resident– SP interactions were analysed. Results of interrater reliability analyses revealed statistically significant high levels of correlation between faculty and SP ratings in several domains, including trust, empathy, respect and integrity. Examples of statements from the checklists and their corresponding results of interrater reliability measures are as follows: ‘I can trust this doctor’ (percentage agreement 1⁄4 100%, Kendall tau-b coefficient 1⁄4 1Æ00, kappa 1⁄4 1Æ00, P < 0Æ0001); ‘The doctor showed warmth and compassion’ (percentage agreement 1⁄4 96%, Kendall tau-b coefficient 1⁄4 0Æ89, kappa 1⁄4 0Æ85, P < 0Æ0001); ‘The doctor was respectful to me’ (percentage agreement 1⁄4 100%, Kendall tau-b coefficient 1⁄4 1Æ00, kappa 1⁄4 0Æ90, P 1⁄4 0Æ001), and ‘The doctor asked for my opinion when making decisions about my treatment’ (percentage agreement 1⁄4 85%, Kendall tau-b coefficient 1⁄4 0Æ74, kappa 1⁄4 0Æ45, P 1⁄4 0Æ003). Results of this study provide further evidence in support of the use of adolescent SPs for the assessment of professionalism. We found that there was a strong correlation between faculty and adolescent SP ratings of the domains of professionalism.

Impact of an innovative CD-ROM on ambulatory teaching

abandoned. Making changes in approaches to teaching was identified in 31 CTCs. These included improving communication skills (by spending more time on listening), enabling residents to teach students, and adopting new competency-based assessment tools and new approaches to teaching procedural skills. A total of 19 CTCs related to assessment and feedback (e.g. adopting feedback frameworks taught, giving specific or regular feedback, planning feedback). There were 15 commitments to improve the use of information technology (IT) and electronic resources (e.g. setting up a website for practice, using websites, creating lists of websites for resident or patient teaching). There were nine commitments to improve role-modelling, most of which related to demonstrating the benefits of family medicine as a career. The final five commitments focused on office management for effectiveness and error disclosure. The CTCs that the doctors were able to implement and carry out themselves (e.g. improving communication or observation of trainees) were likely to have been adopted fully or partially. By contrast, many of the 22 changes the doctors had been unable to implement or had abandoned were more complex and required additional time or the opportunity to implement. Almost half (7 ⁄ 15) of the plans for IT and electronic resources were incomplete or had been abandoned, whereas only a third (12 ⁄ 31) of plans relating to approaches to teaching had not succeeded. The CTC process provided new data with which to assess our programme because the CTCs were directly associated with the content provided. Changes were in the directions intended. Encouraging all attendees to complete their CTC forms is critical to understanding programme impact.

Assessment of residents' competency in asthma severity classification

the website; time required to participate; relevance to training; style of posting, and whether the forum represents a safe environment in which trainees can express opinions. Evaluation of results and impact A total of 27 (77%) questionnaires were returned. All trainees had Internet access, either at home or work, and found the website easy to use, with few technical difficulties. Overall, 96% felt they had adequate time to participate and felt the discussions were relevant to their training. The forum was felt to be a safe environment in which to participate and allowed improved contact with their peers. Trainees found the face-to-face group discussions valuable, but being unable to attend was the main reason for not participating in online discussion. Other factors that diminished participation were overlong postings, poor grammar and unfamiliarity with using the forum. In summary, an online discussion forum is a feasible and liked method of providing regular teaching without reducing theatre time. Potential areas to improve participation have been identified, including the provision of guidelines on the style of posting, and placing a summary of the group discussion on the forum.

Improving immigrant health education using videoconferencing

age of the experienced staff may have been a confounding factor. The experienced orthopaedic specialists rated organizational problems as a more important obstacle than did the non-experienced specialists, and this might have been related to their familiarity with the strict scheduling necessary for teleconsultation. In keeping with the perceived risks, the orthopaedic specialists seemed to be comfortable about using teleconsultation for the follow-up of patients after surgery, but not for the provision of second opinions in oncology cases. The general perception of risk may contribute to the expectation of higher professional revenues for teleconsultations in comparison with conventional outpatient revenues. In conclusion, orthopaedics has been confirmed as offering a challenge for telemedicine. Orthopaedic specialists are used to physical contact with their patients and to palpating their joints. Only for specific conditions and when patients are known to them are they ready to abandon the conventional approach. A longterm prospective study is required to investigate the diagnostic capabilities of teleconsultation for different orthopaedic pathologies.