To help patients control asthma the clinician must be a good listener and teacher.

Despite the fact that our understanding of asthma and its therapy has grown significantly over the last 20 years, there is ample evidence that asthma is not well controlled in many patients. Surveys in British schools have shown that as many as 50% of children who exhibit chronic symptoms of asthma are either undiagnosed or undertreated. '2 Hospital admissions and visits to the emergency department, which largely reflect failures of primary preventive care for asthma, are abundant and increasing in many countries.3 Recent studies with computerised chronolog devices that record the exact time of each actuation of a metered dose inhaler show that compliance with asthma treatment regimens is even worse than previously thought.45 Furthermore, surveys of both children and adult sufferers indicate that emotional distress caused by asthma is common in both the patient and other family members. " How can asthma be better controlled? Firstly, education is needed to help members of the public recognise asthma symptoms and encourage sufferers to seek informed medical care. Secondly, professional education is needed to help all health care providers understand and use state of the art asthma therapy in caring for their patients. Thirdly, patient education is needed to help patients and their families learn that they can manage asthma effectively and, in most cases, live active lives with little interference from symptoms. National asthma campaigns or education programmes in several countries have begun to address these problems through publication of asthma guidelines such as the International Consensus Report and other educational initiatives. There are, however, some significant barriers to changing both professional and patient behaviour that require new approaches to patient education and clinical care. Patients need to be able to follow instructions outside the clinic and comply with treatment recommendations. One major barrier to achieving this is that patient education is often thought of as the one way transfer from clinician to patient of asthma information and skills such as the use of metered dose inhalers (MDI) and peak flow meters. While this aspect of education is important, learning such skills is only one part of a more comprehensive challenge facing asthmatic patients and their families. Studies of how patients with asthma respond to their illness suggest that they face three broader tasks that have consequences for its control. " They must first decide what asthma is and what it means to them, or about them, on a very personal level. Most new asthma patients or family members quickly develop intense feelings or beliefs about the condition which affect their motivation to adhere to the therapeutic plan. These feelings may include anger, self-blame, fear, a lessened sense of self-esteem, frustration at activity limitations and, for some, refusal to accept the diagnosis of asthma. Many have inaccurate beliefs about the origin or prognosis of asthma-for example, they may think it is caused by psychological factors or is a sign of vulnerability to illness in general. Other patients have serious reservations about taking medicines, especially on a daily basis, fearing side effects, addiction, or ineffectiveness of the prescription. Most patients initially view asthma as episodic rather than chronic, and this view makes it hard for them to understand and follow instructions to take brief, patients develop beliefs about asthma which have powerful, but not necessarily helpful, effects on their attitudes towards health care, their goals for treatment, and their willingness and ability to control asthma. Such beliefs are often hidden from clinicians because pressure of time or the technical atmosphere of the clinical visit work against holding the kind of discussion needed to uncover them. The first challenge for the clinician, then, is to discover what the patient's knowledge, beliefs and feelings about asthma are, to reinforce those that are appropriate and accurate, and to begin the process of persuading the patient to change those that are not. The second task for patients is the acquisition of information and skills needed to prevent and control asthma, which also entails developing the cohfidence to use these skills appropriately. This task includes recognising and responding to symptoms of asthma, understanding the purposes of different types of medicines and learning to use them correctly, and making appropriate decisions about when to seek emergency care. Although these aspects of patient education have Peceived more attention from health care providers than any others, research suggests that many patients emerge from their contacts with clinicians ill prepared to carry out these elements of the treatment plan.6 Patients often fail to use medicines promptly once symptoms begin, and frequently stop using them too soon after remission. Many patients do not know how to decide when emergency care is needed, and the resulting anxiety adds to the psychic burden of managing asthma.7 Medications are often administered incorrectly by patients: two recent surveys showed that more than two out of three patients with asthma did not use MDIs properly.910 The correct use of an MDI is complex and is often not mastered by clinicians themselves. A recent study at a teaching hospital in New York found that paediatric residents, when asked to demonstrate inhaler technique, omitted or incorrectly performed 34% of seven key steps. " The most common errors were failure to hold one's breath for at least five seconds (54%), failure to shake the MDI before use (48%), failure to exhale before MDI use (40%), and actuating the MDI more than once during a single breath (29%). These findings suggest that clinicians need better training themselves in the key skills needed for asthma management, as well as training in effective methods for teaching these skills to patients. The third task that patients must learn is to manage key relationships so that both patient and family can live normal, active lives. For parents of children with asthma this means learning to talk with school teachers to get support for carrying out the child's treatment plan at school, or managing family relationships to minimise disruption of activities or relationships with siblings.6 For children it means learning to explain asthma to peers and overcome teasing or exclusion from games. '2 For adults with asthma it may involve talking with employers about controlling environmental irritants and using asthma medicines in the workplace. These issues are often critical to the success of a preventive treatment strategy, yet they are rarely addressed by clinicians unless patients bring them up. In the UK, the National Asthma Campaign provides materials to help schools and employers develop appropriate policies about asthma. These include the leaflet Asthma in the workplace for per685