Perspective: Entering uncharted waters: navigating the transition from trainee to career for the nonphysician clinician-scientist.

The transition from trainee to career clinician-scientist can be a stressful and challenging time, particularly for those entering the less established role of nonphysician clinician-scientist. These individuals are typically PhD-prepared clinicians in the allied health professions, who have either a formal or informal joint appointment between a clinical institution and an academic or research institution. The often poorly defined boundaries and expectations of these developing roles can pose additional challenges for the trainee-to-career transition.It is important for these trainees to consider what they want and need in a position in order to be successful, productive, and fulfilled in both their professional and personal lives. It is also critical for potential employers, whether academic or clinical (or a combination of both), to be fully aware of the supports and tools necessary to recruit and retain new nonphysician clinician-scientists. Issues of relevance to the trainee and the employer include finding and negotiating a position; the importance of mentorship; the value of effective time management, particularly managing clinical and academic time commitments; and achieving work-life balance. Attention to these issues, by both the trainee and those in a position to hire them, will facilitate a smooth transition to the nonphysician clinician-scientist role and ultimately contribute to individual and organizational success.

A children's asthma education program: Roaring Adventures of Puff (RAP), improves quality of life.

BACKGROUND: It is postulated that children with asthma who receive an interactive, comprehensive education program would improve their quality of life, asthma management and asthma control compared with children receiving usual care. OBJECTIVE: To assess the feasibility and impact of 'Roaring Adventures of Puff' (RAP), a six-week childhood asthma education program administered by health professionals in schools. METHODS: Thirty-four schools from three health regions in Alberta were randomly assigned to receive either the RAP asthma program (intervention group) or usual care (control group). Baseline measurements from parent and child were taken before the intervention, and at six and 12 months. RESULTS: The intervention group had more smoke exposure at baseline. Participants lost to follow-up had more asthma symptoms. Improvements were significantly greater in the RAP intervention group from baseline to six months than in the control group in terms of parent's perceived understanding and ability to cope with and control asthma, and overall quality of life (P<0.05). On follow-up, doctor visits were reduced in the control group. CONCLUSION: A multilevel, comprehensive, school-based asthma program is feasible, and modestly improved asthma management and quality of life outcomes. An interactive group education program offered to children with asthma at their school has merit as a practical, cost-effective, peer-supportive approach to improve health outcomes.

A child's asthma quality of life rating does not significantly influence management of their asthma.

BACKGROUND: Children of parents who perceive their children have increased asthma severity use more medical services and reliever medication. METHODS: A randomized control trial of the Roaring Adventures of Puff (RAP) education program was completed among 287 grade 2-5 children with asthma. Parents and children completed a quality of life (QOL) questionnaire pre-intervention, 6 and 12 months post-intervention. We hypothesized that RAP altered how parent's assessed their child's QOL with a resultant change in asthma management. RESULTS: Pre-intervention, parents rated their child's overall QOL higher than their child (parent 5.41 [95% CI 5.24, 5.58] vs. child 4.54 [95% CI 4.32, 4.75]; P < 0.001: paired t-test). For every point increase in the parent's overall QOL score, the child was 36% less likely to receive inhaled corticosteroids in the prior 2 weeks (OR 0.64, 95% CI 0.46, 0.88; P = 0.024) and 46% less likely to have missed school due to asthma in the prior 6 months (OR 0.54, 95% CI 0.36, 0.82; P = 0.016: logistic regression). The child's QOL assessment, beyond that provided by their parent, was not associated with the asthma management outcomes examined. The RAP program decreased parent's symptoms QOL assessment by an improvement of 0.45 on a 7-point scale greater than control at 6 months (95% CI -0.81, -0.09; P = 0.06). Moreover, the RAP interaction on parent symptoms rating was important in determining whether the child received a short-acting beta-agonist in the prior 2 weeks (P = 0.05). CONCLUSIONS: Parent's QOL perception, and not the child's, is associated with asthma management. RAP decreased the parent's QOL symptoms assessment and was important in determining the child's asthma management.

Urban and rural differences in the management of asthma amongst primary care physicians in Alberta.

BACKGROUND: Inconsistencies in rural and urban health care exist; however, little has been done to evaluate the potential differences in asthma management. OBJECTIVE: To compare asthma management in rural versus urban primary care physician practices. METHODS: Forty-two of 136 consenting primary care physicians were randomly selected for chart review. The charts of 3072 patients diagnosed with asthma based on the ICD-9 Classification of Diseases were reviewed. RESULTS: Standards of asthma care were compared between rural and urban primary care physicians. 2671 patients (87%) were cared for by urban physicians and 401 patients (13%) by rural physicians. Greater proportions of male and pediatric patients were found in the rural group. Rural patients made more emergency department or hospital visits than urban patients. Rural physicians performed more pulmonary function tests and made more referrals to other healthcare specialists. Urban patients had more asthma symptoms and triggers documented and used peak flow monitoring more often. Urban physicians provided more asthma education and prescribed more oral corticosteroids and antibiotics. Overall, rates of referral, use of spirometry and use of written action plans were low globally. CONCLUSIONS: Our study indicates that the management of asthma in the rural settings is comparable to that of urban settings. Improvements in the areas of pulmonary function testing, asthma education and use of written action plans are necessary in both settings.

Asthma control and management in the community: indices in 1997 compared with indices in 2002.

OBJECTIVE: To determine whether there was any change in indices of asthma control in population-based samples of patients with asthma between 1997 and 2002. DESIGN: We examined asthma control and treatment in the community using two cross-sectional studies carried out 5 years apart in 1997 and 2002. Pharmacists handed out the questionnaires to patients with asthma; patients completed the questionnaires themselves. SETTING: Community pharmacies in Alberta. PARTICIPANTS: Patients with physician-confirmed asthma attending pharmacies to fill prescriptions for asthma medications. MAIN OUTCOME MEASURE: Asthma control. RESULTS: In 1997 and 2002, 301 and 340 completed questionnaires were received, respectively. Mean age of respondents was 42 and 39 years and the female-to-male ratio was 1.3:1 and 1.4:1, respectively. Overall asthma control was achieved by 27% (1997) and 31% (2002) of subjects, a non-significant change. Regular inhaled corticosteroid use was reported by 63% (1997) and 65% (2002) of subjects; mean daily dose of inhaled corticosteroids reported decreased from 920 mug in 1997 to 765 mug in 2002 (P < .02), which might reflect adoption of the newer guideline recommendation for lower-dose inhaled corticosteroids in combination therapy rather than a decrease in severity of asthma. Fewer respondents reported being hospitalized for asthma in 2002 (P = .02). Self-management plans were used by 7% and 5% of subjects in 1997 and 2002, respectively. CONCLUSION: In general, asthma control and use of inhaled corticosteroids was similar in 1997 and 2002. There was no evidence that patient education on asthma had increased. Asthma control was poor in 1997 and had not improved by 2002.

Management of asthma among community-based primary care physicians.

BACKGROUND: Despite significant improvements in asthma treatment and the dissemination of national and international guidelines for asthma management, there are ongoing concerns that suboptimal care is being provided for patients with asthma. OBJECTIVE: To determine the current practice patterns of asthma care among primary care physicians. DESIGN: A cross-sectional study. SETTING: Province of Alberta, Canada (population: 3 million people). PARTICIPANTS: Patients, 5 years of age or older, who had a physician's diagnosis of asthma, and had at least two visits for asthma between 1996 and 2001. MEASUREMENT AND RESULTS: Charts of 3072 distinct patients (from 45 unique primary care physicians) were reviewed. Previous emergency department visits or hospitalizations were experienced by 20% of the sample. A total of 25% of patients had documented evidence that they had performed spirometry. More than half of the patients had no documented evidence that they had received any form of asthma education; only 2% of the charts indicated that patients received a written action plan. Two thirds of the patients were prescribed an inhaled steroid within 6 months of the last clinic visit. CONCLUSIONS: Our study indicates a gap in the provision of asthma education, written action plans, and spirometric testing for patients diagnosed with asthma among primary care physicians.

The costs of implementing the 1999 Canadian Asthma Consensus Guidelines recommendation of asthma education and spirometry for the family physician.

BACKGROUND: National and international asthma guidelines recommend that patients with asthma be provided with asthma education and spirometry as a component of enhanced asthma care. The cost of implementing these interventions in family physician practices is not known. OBJECTIVE: The objective of the present study was to determine the cost of providing recommended asthma care to adult patients in the family practice setting. METHODS: The present study was conducted using three scenarios of care in family practice. Small, medium and large asthmatic patient populations were used. The incremental costs of implementing enhanced asthma care based on the Canadian Asthma Consensus Guidelines, including the provision of spirometry and asthma education in both group and individual sessions, and the resources required for these interventions were calculated for each scenario. RESULTS: For a physician with 50 asthmatic patients, the cost of providing enhanced asthma care with spirometry and group education sessions was approximately 78 dollars per patient in the first year of implementation. For individual sessions, the cost increased to 100 dollars per patient for the first year. If the physician had 100 asthmatic patients, the per patient cost would decrease; however, the overall cost of the program would be 7,000 dollars. CONCLUSIONS: The costs of providing enhanced asthma care are significant. In most cases, physicians are inadequately reimbursed (or not reimbursed) for these interventions. In light of the evidence of the effectiveness of these interventions, health insurance plans should consider adding these services to fee schedules.

Alberta Strategy to Help Manage Asthma (ASTHMA): a provincial initiative to improve outcomes for individuals with asthma.

As society struggles with escalating healthcare costs, and a general increase in the prevalence as well as the morbidity of common chronic conditions such as asthma and diabetes, patient health management programs offer new opportunities to improve the process of care, create efficiencies in the healthcare system and enhance the outcomes of patients suffering from these conditions.

Spirometric findings among school-aged First Nations children on a reserve: a pilot study.

BACKGROUND: Asthma and chronic obstructive pulmonary disease (COPD) are increasing concerns for First Nations peoples in Canada. Although hospital utilization for asthma and COPD among First Nations peoples has been increasing, the prevalence of asthma or wheezing is comparable to national averages. OBJECTIVES: A pilot study was conducted to determine the prevalence of impaired lung function in school-aged First Nations children. PATIENTS AND METHODS: A First Nations community in northern Alberta was selected to participate. Consent forms and a school health survey were completed by parents or guardians. Children with consent completed spirometry at school, and results were compared with predicted values. RESULTS: A total of 36 children participated (response rate 70.6%). Of these, 19.4% of parents reported that their child had received a physician diagnosis of asthma at some point in their life; only 28.6% had a parental report of still having asthma. Parents smoked in 73.1% of the children's homes. The mean (+/- SD) percentage of forced expiratory volume in 1 s (FEV1) over forced vital capacity (FVC) was 82.6%+/-6.9% (94.4%+/-0.08% of predicted). Evidence of airflow obstruction was found in 25% of the children. Parental report of the child ever having asthma was associated with impaired lung function (OR 3.20; P=0.033). Children in a home with reported mold exposure were less likely to have impaired lung function (OR 0.68; P=0.030). CONCLUSIONS: Many children in this study already have established airflow obstruction and may be at increased risk for asthma or COPD. Exposure to mold appeared to be protective. Further research is needed to evaluate the lung health concerns of this population.