State of Asthma Education and Management in Urban Medical Residency Training Programs

Background: Adherence to the national asthma guidelines has been shown to identify those at risk of having asthma, reduce morbidity and improve control of disease. However, these guidelines have been underutilized by physicians and is associated with stagnant, clinical asthma outcomes.  This study assessed resident physician exposure to the national guidelines, asthma knowledge and outpatient practice habits.  This is of particular concern, if such practice habits and nonadherence to these guidelines develop in the setting of medical training programs.

Methods: Residents in internal medicine (IM) and pediatrics at four urban teaching hospitals in New York City completed a survey (n=129). Questions assessed management practices, subspecialty referral patterns and asthma education in continuity clinics. 

Results: 57% of residents estimated that less than half of asthmatics are “well-controlled”, and 72% believed that less than half understand the difference between quick-relief and controller medications. 12% routinely employed validated asthma screening tests.  10% reported routinely providing written action plans, and only 40% regularly monitored peak flows. Pediatric residents were more likely to routinely use asthma action plans (p=.018), while IM residents more regularly used asthma screening tools and monitored peak flow values (p=.036 and p=0.0, respectively).  Most residents failed to utilize asthma specialists; 81% referred fewer than 1 in 4 asthmatics. 17% of referrals were sent to allergists and 81% to pulmonologists.  Only 18% of respondents reported routine citation of guidelines by clinic preceptors. Clinic preceptors were rated as the second leading source of exposure to guidelines (15%), far less common than lectures (50%). 

Conclusions: Surveyed residents were unfamiliar with National Asthma Education and Prevention Program (NAEPP) guidelines.  This is likely due to lack of exposure through lectures, rotations in asthma specialty clinics and input from clinical preceptors.  Tools available to effectively manage asthma, including asthma screening tests, objective lung data, and referrals to specialists were grossly underutilized. Training programs must make a more concerted effort to incorporate these resources in residency education and improve resident physician knowledge of asthma.