Rotation in a Smoking Cessation Clinic Improves Nicotine Dependence Treatment Provided by First-Year Internal Medicine Trainees.

BACKGROUND AND OBJECTIVES: Over 70% of smokers visit a physician annually, and physicians are well-positioned to assist patients in smoking cessation. Residency offers the ideal setting to train physicians in best practices for treatment of nicotine dependence. We hypothesized that experiential learning during a smoking cessation medical clinic (SCMC) rotation would be associated with an improvement in smoking cessation practice of internal medicine (IM) interns in outpatient primary care and inpatient settings. METHODS: This was a prospective study performed at a large university-affiliated hospital. Forty IM interns rotated through SCMC. After a lecture on nicotine addiction and treatment, interns treated SCMC patients under direct supervision of an attending pulmonologist. Interns' smoking cessation practices before and after SCMC rotation were evaluated through chart review over 1 year. Upon study completion, a survey to assess confidence was administered. Paired t tests measured changes in rates of identifying smokers, offering pharmacological treatment and counseling. RESULTS: A total of 5,622 outpatient and 683 inpatient charts of interns' encounters with patients were reviewed. Following SCMC rotation, there was an increase in identifying active smokers (7.1% versus 18.7%), prescribing therapy for smoking cessation (6.5% versus 18.0%), and providing counseling (30.9% versus 42.3%) to outpatients. For inpatients, there was an increase in nicotine replacement during admission (12.9% versus 37.4%) and prescription of therapy upon discharge (5.7% versus 16.1%). Interns reported confidence in providing appropriate counseling and treatment. CONCLUSIONS: SCMC experience positively impacted smoking cessation treatment by IM interns, causing a measurable change in their practice.

Environmental improvements brought by the legal interventions in the homes of poorly controlled inner-city adult asthmatic patients: a proof-of-concept study.

OBJECTIVES: Domestic contamination with mold, cockroaches, rodents, and dust worsens asthma severity. This violates warranty of habitability laws in most of the states, but patients often find it beyond their means to remedy their housing situation. We aimed to study the effect of a medical-legal collaborative intervention to force landlords into providing better living conditions for patients with poorly controlled asthma. METHODS: We retrospectively studied charts of adult patients aged 18 years or older with poorly controlled asthma (moderate or severe persistent) despite maximum medical therapy. Additionally, patients had self-reported domestic allergen exposures such as mold, cockroaches, mice or rats, and dust. The patients received legal assistance to improve their domestic environments, including fixing leaks, exterminating pests, or providing a different apartment. Post-intervention change in peak expiratory flow rate (PEFR), asthma severity class, medications, emergency department (ED) visits, hospitalizations, and requirement for systemic steroids for symptom control was assessed. RESULTS: Data were available for 12 patients (9-12 months pre-intervention and 6-12 months post-intervention). Analysis of paired data revealed that mean PEFR rose by 38.6 LPM (95% CI: 9.9-67.3; p = .014). The number of ED visits and hospital admissions declined from 22 ED visits and 11 admissions to 2 ED visits and 1 admission (91% reduction), respectively. Of the 11 patients requiring systemic steroids, only three required these post-intervention. All patients had reductions in the dose and/or number of medications. During post-intervention, 11 (91.7%) patients dropped ≥2 classes in asthma severity. CONCLUSIONS: Medical-legal collaboration is highly effective in improving the control of inner-city asthmatics by effecting improvements in the domestic environment.