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 children's 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.

The residency program in social medicine of Montefiore Medical Center: 37 years of mission-driven, interdisciplinary training in primary care, population health, and social medicine.

Founded in 1970 to train physicians to practice in community health centers and underserved areas, the Residency Program in Social Medicine (RPSM) of Montefiore Medical Center, Bronx, New York, has graduated 562 board-eligible family physicians, general internists, and pediatricians whose careers fulfill this mission. The RPSM was a model for federal funding for primary care residency programs and has received Title VII grants during most of its history. The RPSM has tailored its mission and structured its curriculum to promote a community and population orientation and to provide the requisite knowledge and skills for integrating social medicine into clinical practice. Six unique hallmarks of RPSM training are (1) mission-oriented resident recruitment/selection and self-management, (2) interdisciplinary collaborative training among primary care professionals, (3) community-health-center-based and community-oriented primary care education, (4) biopsychosocial and ecological family systems curriculum, (5) the social medicine core curriculum and projects, and (6) grant support through Title VII. These hallmark curricular, training, and funding elements, in which population health is deeply embedded, have been carefully evaluated, regularly revised, and empirically validated since the program's inception. Practice outcomes for RPSM graduates as leaders in and advocates for population health and the care of underserved communities are described and discussed in this case study.

Residents' asthma communication skills in announced versus unannounced standardized patient exercises.

OBJECTIVE: The aim of this study was to test the hypothesis that pediatric residents would display similar levels of asthma interpersonal and communication skills in announced versus unannounced adolescent standardized patient (SP) encounters. METHODS: We conducted a prospective repeat measures experimental study at a pediatric residency program at an inner-city children's hospital. A cohort of residents (N = 18) was subjected at random to 3 SP exercises: announced and being directly observed by faculty, announced and not observed by faculty, and unannounced and unobserved. Six adolescent SPs were trained to complete checklists that included items like asthma daytime and nighttime symptoms, exercise-induced symptoms, triggers, and asthma education. For the unannounced exercises, SPs were inserted into residents' regularly scheduled clinics. Standardized patients rated residents immediately following each exercise. Residents were rated by faculty following the observed encounter. Faculty rating validated SP ratings on the observed encounter. Differences in proportions of categorical variables were tested by chi-square analyses. RESULTS: Fifty-four resident-SP encounters were analyzed. Residents consistently displayed significantly lower levels of desired behaviors in interpersonal and communication skills in the unannounced SP encounters on 10 of 14 checklist items. For example, residents asked about exercise-induced symptoms 90% of the time in announced/observed encounters versus 95% in announced/unobserved encounters versus 72% in unannounced/unobserved encounters (P = .001). There were no significant differences in residents' behaviors in the announced SP exercises (whether observed or unobserved). CONCLUSION: In this study, residents demonstrated lower levels of asthma communication skills during unannounced SP exercises. By using unannounced SPs, we were able to assess residents' interpersonal and communication skills in real clinical settings.

Improving medical student feedback with a clinical encounter card.

OBJECTIVE: We previously developed a Clinical Encounter Card (CEC) for use in medical student feedback. However, no prior studies have investigated the effectiveness of the CEC. The objective of our study was to determine whether use of the CEC would increase medical students' perception of the feedback they received. METHODS: We conducted a time-series repeated-measures experimental study at a pediatric clerkship site. The study included a crossover design with experimental and control arms. Third-year medical students on the ambulatory rotations were the experimental arm, and inpatient students were the control arm. Students and faculty in the experimental arm received the CEC, which listed 7 feedback domains: history and interviewing, physical examination, oral presentation, written notes, patient assessment, management plan, and professionalism. We used a 10-point Likert-type scale to record responses of students weekly regarding their perceptions of having received feedback in the 7 domains. Multivariate analysis of variance for repeat measures tested mean differences in continuous variables, and Mann-Whitney U rank order sum tested ordinal rank differences. RESULTS: We received 504 reports from students regarding the feedback they received. We found statistically significant improvements in 6 feedback domains for experimental subjects: history/interviewing, physical examination, oral presentation, written notes, patient assessment, and management plan. There was no improvement in feedback received about professionalism. CONCLUSIONS: Use of the CEC resulted in students' perceiving increased feedback as evidenced by significant improvements in several medical student feedback domains.

Oral rehydration therapy: is anyone drinking?

OBJECTIVES: To examine attitudes toward the use of oral rehydration therapy (ORT) by pediatric emergency medicine physicians before and after being given recent data that might affect their practice and to see if there is a difference in responses based upon year of graduation from medical school. METHODS: A national survey of all members of the American Academy of Pediatrics' Section on Emergency Medicine was conducted. Respondents were asked about their use of ORT for mild, moderate, and severe dehydration, and then presented with data refuting the concern for longer emergency department length of stay with ORT. Participants were then asked about their knowledge of, agreement with, and reaction to these data. Demographic information, such as board eligibility and year of graduation from medical school, was also obtained. The graduates were plotted on a distribution curve by year of graduation, and the group was split into thirds. RESULTS: The response rate was 59%. Before being presented with new data, earlier medical school graduates used ORT 86% for mild and 33% for moderate dehydration, whereas recent graduates used ORT 95% for mild dehydration and 55% for moderate dehydration. Overall, only 23% of physicians were familiar with the new data, but 80% agreed with the new data, and 83% would now incorporate ORT into their practice. Although the earliest graduates were as familiar with the new data as recent graduates (24% vs. 19%), they were less likely to agree with the new data (74% vs. 90%) and to incorporate ORT into practice (75% vs. 92%). CONCLUSIONS: When pediatric emergency medicine physicians are presented with data refuting the perceived barrier of prolonged time for the use of ORT, more practitioners reported that they would use ORT for mild to moderate dehydration. However, a substantial number, especially those who graduated medical school earliest, would maintain their current practice. Additional barriers need to be explored.

Health literacy among English-speaking parents in a poor urban setting.

We surveyed English-speaking parents attending an inner-city health center. Subjects read the label on a bottle of liquid medicine and 1) demonstrated how much medicine they should give, 2) stated how many times a day they should give the medicine, and 3) stated when they should give the next dose. We calculated adjusted odds ratios to test for the likelihood of incorrect medication dosing for subjects with and without demographic risk factors. Three hundred twenty six subjects participated. Overall, 252 (77%) demonstrated incorrect medication dosing. Medication dosing was more likely to be incorrect among young parents (AOR 2.45; CI 1.14, 5.26), immigrants (AOR 2.27; CI 1.04, 4.96), subjects without a high school degree (AOR 2.05; CI 1.04,4.05), and those who did not recall ever having been shown how to use a medicine dropper (AOR 1.79; CI 1.01,3.19). Implications for practice are discussed.

Availability of Spanish prescription labels.

The research team conducted a cross-sectional telephone survey of all pharmacies in the Bronx, New York (99.4% participation rate) to determine availability of Spanish prescription labels. One hundred twenty five pharmacies (78%) were small independent pharmacies; 36 (22%) were large-chain pharmacies. Overall, 111 (69%) stated that they could provide prescription labels in Spanish. Overall, for all the pharmacy ZIP codes, the mean proportion of the population that was Spanish-speaking was 46.8% (range 11% to 71.6%). Seventy-eight (48%) pharmacies were located in areas where more than 50% of the population were Spanish-speaking, 48 (30%) were located in areas with 25.1-50% Spanish-speakers, and 35 (22%) were in areas with up to 25% Spanish-speakers. Small independent pharmacies were more likely than large chain pharmacies to provide prescription labels in Spanish (71% vs. 61%, p=0.25). All the pharmacists commented that a patient must specifically request a Spanish prescription label in order to receive one. Pharmacies located in areas with the highest proportion of Spanish speakers were more likely to provide prescription labels in Spanish (82% vs. 62% vs. 49%; p=.001). Of the 111 pharmacies that could provide Spanish labels, 95 (86%) used a computer program to perform the translation and 16(14%) used a lay employee. Of pharmacies using a computer program, only one had a Spanish-speaking pharmacist who could check and correct the computer translations.

Health literacy among Spanish-speaking Latino parents with limited English proficiency.

BACKGROUND: Health literacy measures the degree to which individuals understand health information. It has not been studied among parents with limited English proficiency (LEP). OBJECTIVE: We aimed to determine how well Spanish-speaking Latino parents with LEP understood the written instructions accompanying a routinely prescribed medication. DESIGN AND METHODS: We conducted a cross-sectional survey of parents of young children. We showed subjects a medicine bottle with an English prescription label and a Spanish drug information sheet (DIS). Subjects demonstrated how much medicine they would give and stated how often they would give it (Medication Dosing). Then they answered 5 questions regarding information from the DIS (DIS comprehension). We coded responses dichotomously as correct or incorrect. We compared Medication Dosing and DIS comprehension by age, comfort with speaking English, birthplace, number of years in the United States, and education. Regression analyses were performed to adjust for these potential confounders. RESULTS: Of 100 participants, 22% correctly dosed the medication; 29% correctly answered all questions regarding the Spanish DIS. Of subjects comfortable speaking English, 50% correctly demonstrated the amount of medicine to give. Overall, higher education and comfort speaking English were associated with better Medication Dosing. Higher education and birth in South America were associated with better DIS comprehension. CONCLUSIONS: Few parents with LEP were able to understand routinely dispensed written medication instructions. Pediatricians should not assume that Spanish-speaking Latino parents who are comfortable speaking English will understand a prescription label written in English, or that Latino parents who speak Spanish will understand drug information written in Spanish.

A classroom-based physical activity intervention for urban kindergarten and first-grade students: a feasibility study.

BACKGROUND: Urban 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. METHODS: We 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 Children's 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. RESULTS: A 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. CONCLUSIONS: CHAM 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.

Use of complementary therapy by adolescents with asthma.

BACKGROUND: About 40% of adult Americans use complementary or alternative medicine (CAM) for health problems. OBJECTIVE: To determine the prevalence of reported use of CAM in a population of urban adolescents with asthma. DESIGN/METHODS: We used a multistaged, stratified sample approach at an inner-city high school. An asthma screening survey was administered to 3800 registered students, aged 13 to 18 years. We identified a subset of 200 respondents who answered yes to each of the following questions: (1) Does your physician think that you have asthma? (2) Do your parents think that you have asthma? (3) Do you think that you have asthma? A self-completion questionnaire was administered to a sample drawn from this cohort. Differences in proportion were tested by chi( 2) analyses. RESULTS: Of the 160 participants, 63% were female, 68% were Hispanic, 26% were African American, 33% had weekly symptoms, and 14% had daily symptoms. Overall, 80% of participants reported using CAM for asthma. The most commonly reported CAM included rubs (74%), herbal teas (39%), prayer (37%), massage (36%), and Jarabe 7 syrup (24%). Subjects with daily or weekly symptoms were more likely to use CAM for each episode of asthma (72% vs 51%; P =.005). The 61% of subjects who had a family member who used CAM were more likely to use CAM again (84% vs 39%; P<.001). Of the respondents, 59% reported that CAM was effective. Subjects who perceived CAM to be effective were more likely to use it again (96% vs 22%; P<.001). CONCLUSIONS: Most adolescents with asthma in this study used CAM. The prevalence of CAM use in this study population was twice the national average for adults.

Ambulatory rounds: a venue for evidence-based medicine.

OBJECTIVE: The format of inpatient morning reports and ward rounds is infrequently applied in ambulatory medical education. Published reports, however, suggest that this format provides for learner-centered, case-based discussions rather than topic-based lectures in the ambulatory setting.(1) We developed an ambulatory morning report with the specific objective of enhancing evidence-based medical inquiry among our pediatrics housestaff. DESCRIPTION: We developed a pediatric encounter form (PEF) by adapting and modifying an instrument described by Paccione et al.(2) The PEF was to be used by residents to document pertinent information and unanswered questions about patients seen during each ambulatory clinic session. Prompts were provided for documenting the patient's primary complaints, the patient's disposition, and questions that the resident needed answered. The PEF was piloted among a group of residents and faculty. The final version incorporated both resident and faculty input. Each resident was asked to complete a PEF for a maximum of two patients per clinic session. We did not direct residents as to what types of questions to formulate. All completed forms were maintained in a central folder. Next, we instituted a one-hour "Ambulatory Rounds" seminar once a week at lunch-time. During these seminars, faculty selected PEF cases from the previous week for discussion. Residents presented the cases and discussed the reasons behind the formulation of their questions. Faculty facilitated and guided residents toward resources for answering their questions. Faculty also helped residents to reformulate their questions to reflect an evidence-based medicine approach. At the end of each seminar, residents elected to research specific questions and present brief reports at the next seminar. To test the hypothesis that residents will formulate a higher proportion of evidence-based medicine (EBM) questions over time, we collected and analyzed 445 questions asked by 12 residents between July 2000 and August 2001. We categorized questions into EBM and non-EBM questions based on faculty assessment. We performed a trend analysis using chi-square to compare questions from July 2000 (as reference value) with the six-month periods of August 2000 to January 2001 and February to August 2001. By the end of the observation period, the proportion of EBM questions had significantly increased from 13% in July 2000 to 28% in the first six-month period and 59% in the second six-month period (p < 0.001). DISCUSSION: We describe a new application of outpatient morning reports. This format has been very well received. Housestaff gave the ambulatory rounds an average rating of 4.3 (out of 5) on a Likert scale. Our experience suggests that this format not only provides a forum for case-based learning but can be successfully used to enhance the principles of evidence-based medicine among residents.

Mercury exposure in an urban pediatric population.

OBJECTIVE: To determine the prevalence of elevated urinary mercury (Hg), as a marker of exposure, in a population of children drawn from an inner-city community with documented access to elemental mercury. METHODS: A prospective consecutive patient series was conducted from November 1998 to January 1999 at an inner-city clinic in New York. Anonymous urine specimens from subjects (aged 1-18 years) were collected in mercury-free containers, split, acidified with 1:100 hydrochloric acid, and frozen. Cold-vapor atomic absorption spectrofluorometric assays were conducted simultaneously at laboratories at the University of Washington and the New York City Department of Health. RESULTS: We enrolled 100 children (mean age 9.4 years; 62% male; 55% Hispanic; and 43% African American). Assay results from both laboratories were strongly correlated (r = 0.8, P <.0001). Mean urinary Hg was 1.08 +/- 1.82 microg/L. The 95th percentile for urinary Hg was 2.8 microg/L (range 0.2 to 11.7 microg/L). Five subjects had Hg levels above 5 microg/L. CONCLUSION: We found that 5% of subjects had unsuspected elevated urinary Hg levels. This finding, in a group of inner-city minority children, strongly supports the need for further investigation of the sources of mercury exposure in this population.

Rubbing ointments and asthma morbidity in adolescents.

OBJECTIVE: To determine the relationship between the use of rubbing ointments and asthma morbidity in adolescents. DESIGN: Cross-sectional study. SETTINGS/LOCATION: Inner-city high school in the Bronx, New York. SUBJECTS: 165 adolescents with asthma. OUTCOME MEASURES: Asthma morbidity, defined as emergency department (ED) use for asthma in the past year and over the lifetime. RESULTS: While 127 (77%) of subjects used albuterol as the first treatment for their last asthma attack, 18 (11%) used rubbing ointments. The rubs and albuterol groups were similar in asthma severity, mean age, gender, and ethnicity. However, subjects in the the rubs group were less likely than subjects in the albuterol group to have made an ED visit over the past 12 months or over their lifetime. Regression analysis revealed that, after controlling for asthma severity, use of rubs independently predicted less lifetime ED use. CONCLUSIONS: After controlling for asthma severity, use of rubs by adolescents with asthma was associated with lower asthma morbidity as measured by ED use.

Screening children for tuberculosis based on residence in a high-prevalence inner-city community.

In January 1994, the Committee on Infectious Diseases of the American Academy of Pediatrics (AAP) published detailed guidelines on tuberculin skin testing of children. These guidelines required mandatory screening of all children residing in high-prevalence communities. In February 1996, the AAP published updated and revised guidelines that allowed for targeted screening of such children based on epidemiologic risk of acquiring tuberculosis. We report on an assessment of the effectiveness of mandatory screening for tuberculosis in a high prevalence community.

Smoking cessation counseling by pediatricians in an inner-city setting.

OBJECTIVE: To assess mothers' perceptions of pediatrician-provided smoking cessation counseling. DESIGN: Cross-sectional, descriptive study. SETTING: Waiting rooms of five ambulatory pediatric clinics in the Bronx, NY. PARTICIPANTS: Convenience sample of 115 mothers. MAIN OUTCOME MEASURES: A structured questionnaire assessed the smoking history of the subject, presence or absence of environmental tobacco smoke(ETS)-related conditions in the subject's youngest child, and extent of smoking cessation counseling by the pediatrician. Subjects were asked whether they had been 1) asked about smoking; 2) advised about the risks of ETS exposure; 3) assisted in smoking cessation; and 4) arranged for a follow-up appointment to discuss smoking cessation. RESULTS: Overall, 73% of mothers reported being asked about smoking by their child's pediatrician, and 50% reported being advised about the effects of ETS exposure. Of the 26 smokers in the sample, only two reported being assisted in smoking cessation. None reported being arranged for a follow-up appointment. Mothers of children with ETS-related conditions reported a higher rate of assessment for smoking status (ask: 85% vs. 63%, p =.01; advise: 57% vs. 43%, p =.19). CONCLUSIONS: Mothers in our setting report a high level of inquiry into their tobacco use, especially when they have children with ETS-related conditions. While they also report receiving advice about the risks of ETS exposure, smokers are very infrequently assisted in smoking cessation.

Exposure to Reach Out and Read and vocabulary outcomes in inner city preschoolers.

To examine the association between exposure to Reach Out and Read and vocabulary outcomes in children, a consecutive sample of 200 parent/child pairs was studied at two inner-city health centers. Children at clinic A were exposed to Reach Out and Read, a clinic-based literacy intervention, for 3 years at the time of the study; children at clinic B were unexposed. Main outcome measures were the "Expressive and Receptive One Word Picture Vocabulary Tests" to measure vocabulary in the children and the "Home Literacy Orientation" scale and "READ" subscale of the STIMQ, to measure book-sharing activities. A total of 200 subjects participated, and the mean age of children was 3.8 years. Demographic characteristics were comparable for both clinics at baseline. Exposed children scored higher on receptive vocabulary (81.5 vs. 74.3; p = 0.005). They also scored higher on both the Home Literacy Orientation scale (4.3 vs. 3.3; p = 0.002) and the STIMQ-READ (12.6 vs. 11.0; p = 0.056). There were no differences in expressive vocabulary scores between the two sites (79.5 vs. 77.5; p = 0.26). In conclusion, we found a positive association between exposure to Reach Out and Read and better receptive vocabulary scores. We also found higher scores for Reach Out and Read-exposed children on measures of home reading activities.