Sandra F. Braganza

The Use of Complementary Therapies in Inner-City Asthmatic Children

Use of complementary/alternative medicine (CAM) has been increasing, especially among patients with a chronic illness. Although asthma is the most common chronic illness affecting children in the United States, very little is known about the use of CAM in children with asthma. Our objective was to determine the prevalence and correlates of CAM use among inner-city children with asthma. A cross-sectional survey of parents of children with asthma attending an urban health center was performed. Parents were surveyed regarding CAM use over the past year, perceived efficacy of CAM, severity of childs asthma symptoms and demographic information. Differences in proportions were tested by chi-square or Fishers exact test as appropriate. Three hundred ten parents participated, of whom 61% were Hispanic and 37% were African American. Parental mean age was 33 years and the mean age of the child was 7.2 years; 89% of parents had treated their child in the past year with some form of CAM. However, only 18% had informed a physician of doing so. The most common forms of CAM used were as follows: prayers (53%), rubs (53%), and massage (45%). Of those who used CAM, 59% perceived it to be at least as effective as pharmacotherapy, and 44% used CAM as first treatment of an asthma attack. Mild and moderate persistent asthmatics had significantly higher rates of CAM use than did mild intermittent and severe persistent asthmatics. We found a very high rate of CAM use among children with asthma in this inner-city population. Most importantly, a very high proportion of parents perceived the therapies to be effective, used them as first treatment of an acute exacerbation, and did not inform a physician of doing so. These findings have implications for the care of asthmatic children by pediatricians practicing in urban settings.

Use of Written Asthma Action Plans

Written asthma action plans (WAAPs) are recommended for children with asthma. However, limited studies have examined how parents use WAAPs. The objective of this study was to describe how parents of children with asthma use the WAAPs they receive from their child’s primary care provider and to examine their perceived effectiveness. Investigators surveyed parents of children with asthma at an inner-city academic community health center in the Bronx, New York. A structured parent survey tool was developed to collect information about parents’ use of WAAPs, and a trained physician researcher interviewed parents in person or by phone. Of 428 subjects interviewed, 27% had a WAAP in the home. Children who had a WAAP were older and more likely to have persistent asthma. Most parents reported that they kept the WAAP posted at home or in another safe place. Eighty percent believed that WAAPs were extremely useful, and 55% looked at the WAAP when their child was sick or when they needed to administer medication. Pa...

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.

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.

Resident Documentation of Social Determinants of Health: Effects of a Teaching Tool in the Outpatient Setting

Social determinants of health (SDH) significantly affect the health of children and thus, screening is important in pediatric primary care. We assessed the use of a formal social history taking tool after a 2-phase intervention. The first phase (P1) was a teaching module describing SDH and community resources and the second phase (P2) consisted of visual reminders to use the tool. Patient charts (n = 322) were reviewed pre- and postintervention. Residents had higher documentation rates of Women, Infants, and Children (WIC) program use and housing subsidies at post-P1 and at post-P(1 + 2) (WIC, P = .01 and P = .03, respectively; housing, P = .02 and P = .04, respectively), and higher documentation rates of food stamp utilization at post-P(1 + 2) (P = .04), as compared with baseline. Implementation of a simple teaching tool in the outpatient setting enabled residents to document income benefits and housing. Further studies should be done to evaluate effective teaching methods to elicit other important SDH.