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The Interdisciplinary Generalist Curriculum Project at the Medical College of Ohio.

The Interdisciplinary Generalist Curriculum (IGC) Project at the Medical College of Ohio sought to develop and introduce a new required preclinical community-based ambulatory experience and to incorporate existing clinically oriented courses in the first two years into one specific curriculum. The major portion of the IGC was the Introduction to Primary Care (IPC), which consisted of 180 hours of new and restructured curriculum time in the first and second years. It included a community-based ambulatory care experience involving students spending time with community-based preceptors, problem-based group discussions with two generalists of different backgrounds, patient-centered workshops in primary care during both first and second years, an in-depth experience in the first year for students who worked with preceptors for two full days, and the development of a two-day clinical assessment and feedback session just prior to entry into the third clinical year. The IGC Project progressed as planned with two major exceptions. The problem-based group discussions were difficult to coordinate with schedules of two physicians as well as the busy schedules of four students, and were adapted after the initial experience so that at least one preceptor attended each meeting. The second difficulty involved coordinating with other clinical departments to effect a true change in the culture of the institution. Nonetheless, as a result of having the IGC Project at the Medical College of Ohio, the curriculum has been revised to incorporate all of the basic IGC concepts and principles. Other results are the development of objective structured clinical examinations that are held at the end of the first and second years and institution of the primary care block in the third year, which have provided the impetus for the establishment of a clinical skills assessment center.

Curriculum↗

The Interdisciplinary Generalist Curriculum Project at the University of Illinois at Chicago College of Medicine.

The Interdisciplinary Generalist Curriculum (IGC) Project was initiated at the University of Illinois at Chicago (UI-Chicago) College of Medicine to link an ongoing longitudinal primary care experience with a didactic curriculum emphasizing generalism. The result of this educational initiative was a more extensive reform of the preclinical curriculum than originally had been planned. The IGC Project catalyzed a critical analysis of the first- and second-year curriculum that continues and that has resulted in the integration of all of the early clinical course work under a single longitudinal curriculum. The IGC Project also established a model for interdisciplinary collaboration in course and curriculum design and expanded the walls of the university to include greater numbers of community-based generalist preceptors. This modestly funded and focused educational initiative had unanticipated and far-reaching implications for educational activities throughout the College of Medicine at UI-Chicago.

Chicago↗

The treatment of patients with asthma by specialists and generalists.

The authors investigated possible differences between specialists and generalists in the intensity with which they treat patients with asthma by studying the care of 283 patients between the ages of six and 40 provided by 13 allergists and 40 randomly selected physicians in two primary care specialties: pediatrics and family practice. After excluding patients with more than one physician, allergists' patients were nearly identical to primary care physicians' patients in the frequency and duration of symptoms, and they had a similar number of asthma-related emergency room visits in the previous year and asthma-related hospitalizations in the preceding 3 years. The allergists treated their patients significantly more intensively than did the primary care physicians. Sixty-two percent of allergists' patients had received oral corticosteroids in the preceding year compared with 30% of primary care patients (P less than 0.001). More of the allergists' patients had received oral corticosteroids throughout the year (9% vs. 0%, respectively, P less than 0.01). They were also more likely to have used corticosteroid inhalers (46% vs. 19%) and a greater number of asthma medications (mean = 2.8 vs. 1.3). In a separate survey of the same physicians, using clinical vignettes, the allergists were more likely to prescribe corticosteroid tablets and inhalers. These findings suggest that specialists and generalists differ in the intensity with which they treat patients with asthma and cannot be explained by patient selection or severity differences.

Administration, Inhalation↗

Needs-based planning for generalist physicians.

OBJECTIVES: The Manitoba Centre for Health Policy and Evaluation (MCHPE) collaborated with a provincially-appointed Physician Resource Committee in an assessment of provincial physician resources. RESEARCH DESIGN: Beginning with map-based analyses of physician supply and contacts across the province, compared with the health and socioeconomic characteristics of local populations, the study moved to a needs-based, regression-based approach to physician resource planning. RESULTS: The results challenged the popular belief that Manitoba suffers from an increasing shortage of physicians. A handful of high-need, low-supply and low-use areas are identified, as is the expensive surplus of generalist physicians in Winnipeg. (Generalist physicians include general and family practitioners as well as general internists and pediatricians.) No relationship between physician supply and health characteristics of populations, or between high physician supply and low hospital use patterns were found. Given the Committee's interest in what drives high physician contact rates, analyses of visit patterns of hypertensive patients were undertaken. We found that patients who had more complex medical conditions made more contacts, but that after controlling for this and other key patient characteristics, the patient's primary care physician's patient recall rate was a strong influence on how frequently visits were made.

Adolescent↗

Who should be a stapes surgeon? An otologist or a generalist?

PURPOSE OF REVIEW: The overall experience with stapes surgery has declined, both within residency training programs, as well as in clinical practice. Does this change in the environment suggest that subspecialists rather than generalists manage patients with otosclerosis? RECENT FINDINGS: A decreasing availability of patients with clinical otosclerosis has encouraged trainees and practitioners to adopt strategies that will enable the maintenance of quality care to these patients. SUMMARY: Well trained generalists should be prepared to perform stapes surgery. Lack of experience or infrequent exposure to disease suggests that optimal care can be achieved by referring the patient to an experienced otologic surgeon.

Clinical Competence↗

Food-limitation in a generalist predator.

Investigating food-limitation in generalist predators is difficult, because they can switch to alternative prey, when one of their staple prey becomes scarce. Apart from data on the dynamics of the predator population, a robust study requires: (i) a documentation of the predator's entire prey base; and (ii) an experimental or natural situation, where profitable dietary shifts are impossible, because several preferred prey species decline simultaneously. Here, we provide a detailed description of how food-supply has limited a generalist avian top predator, the northern goshawk Accipiter gentilis. In our study area, populations of several principal goshawk prey species crashed simultaneously during 1975-2000, whereas other extrinsic factors remained essentially unchanged. The breeding and non-breeding segments of the local goshawk population declined markedly, associated with a significant increase in nest failures. Brood size of successful pairs remained unaffected by changes in prey availability. Breeding recruitment ceased at a time when potential replacement birds ('floaters') were still present, providing a rare empirical demonstration of an 'acceptance threshold' in raptor territory choice. To investigate how goshawk diet changed in response to varying food-supplies, we make novel use of an analytical tool from biodiversity research-'abundance-biomass-comparison curves' (ABC curves). With increasing levels of food-stress, the dominance of principal prey species in the diet decreased, and the number of small-bodied prey species increased, as did intra-guild predation. Our finding that breeder and non-breeder segments declined in concert is unexpected. Our results carry the management implication that, in food-limited raptor populations, externally induced breeder mortality can rapidly depress population size, as losses are no longer buffered when floaters reject breeding opportunities.

Animals↗

Specialization and habitat: spatial and environmental effects on abundance and genetic diversity of forest generalist and specialist Carabus species.

Habitat specialist species are supposed to be more susceptible to variations in local environmental characteristics than generalists. To test this hypothesis, we conducted a comparative analysis on abundance and genetic diversity of forest carabids differing in their habitat requirements. Four species were sampled in forests characterized by abiotic, landscape and biotic environmental variables. A statistical framework based on canonical correspondence analysis was used for one habitat generalist and one habitat specialist species to determine the relative contribution of environmental variables in structuring inter- and intrapopulational genetic diversity depicted by microsatellites. Our results showed that sympatric species differed in their sensitivity to environmental variables. The same variables were found to be important in analyses of abundance and genetic data. However, specialization was not related to a greater sensitivity to local environmental characteristics. The strong impact of spatial variables on genetic data suggested that genetic variation among populations would largely reflect the response of individual species to dispersal opportunities more than the effect of habitat quality.

Adaptation, Biological↗

Rural generalist nurses' perceptions of the effectiveness of their therapeutic interventions for patients with mental illness.

OBJECTIVE: To explore generalist nurses' perceptions of their efficacy in caring for mentally ill clients in rural and remote settings, and their educational needs in the area of mental health care. DESIGN: A self-administered questionnaire adapted from the Mental Health Problems Perception Questionnaire; a Likert scale used to rate the perceptions of nursing staff of their own ability to adequately treat and care for patients experiencing mental illness. SETTING: The Roma and Charleville Health Service Districts, Queensland, Australia. SUBJECTS: Nurses (Registered Nurses, Assistants in Nursing and Enrolled Nurses) in the Roma and Charleville health service districts (n = 163). MAIN OUTCOME MEASURES: Generalist nurses' perceptions regarding their therapeutic commitment, role competency and role support. RESULTS: Seventy per cent of respondents indicated that limited knowledge of mental health problems was an issue preventing nursing staff in rural and remote settings from providing optimum care to patients with mental illness. Twenty-nine per cent of respondents indicated that they had never received or undertaken training or education in relation to the care, treatment or assessment of patients with mental illness. CONCLUSION: Rural nurses do not feel competent, nor adequately supported, to deal with patients with mental health problems. In addition, the nurses' education and ongoing training do not adequately prepare them for this sphere.

Adult↗

Practice, clinical management, and financial arrangements of practicing generalists.

OBJECTIVE: To describe the practice settings, financial arrangements, and management strategies experienced by generalist physicians and identify factors associated with reporting pressure to limit referrals, pressure to see more patients, and career dissatisfaction. DESIGN: Cross-sectional mail survey. PARTICIPANTS AND SETTING: Six hundred nineteen generalist physicians (62% response rate) caring for managed care patients in 3 Minnesota health plans during 1999. MEASUREMENTS AND MAIN RESULTS: Twenty-six percent of physicians reported pressure to limit referrals. In adjusted analyses, female physicians and those who were board certified acted as gatekeepers for most of their patients, received incentives based on performance reports and quality profiles, and received direct income from capitation, and were more likely than others to report this pressure (all P <.05). Sixty-two percent reported pressure to see more patients. In adjusted analyses, this pressure was more frequent among physicians in practices owned by health systems, those using physician extenders, and among physicians paid by salary with performance adjustment or those receiving at least some capitation (all P <.05). One-quarter (24%) of physicians were dissatisfied with their career in medicine. In adjusted analyses, physicians reporting pressure to limit referrals (risk ratio, 1.12; 95% confidence interval, 1.01 to 1.19) and those reporting pressure to see more patients (risk ratio, 1.37; 95% confidence interval, 1.08 to 1.66) were more likely to be dissatisfied than other physicians. CONCLUSIONS: Pressures to limit referrals and to see more patients are common, particularly among physicians paid based on productivity or capitation, and they are associated with career dissatisfaction. Whether future changes in practice arrangements or compensation strategies can decrease such physician-reported pressures, and ultimately improve physician satisfaction, will be an important area for future study.

Adult↗

Antibiotic prescribing decisions of generalists and infectious disease specialists: thresholds for adopting new drug therapies.

The objective of this study was to examine whether physicians are willing to continue to use older antibiotics in the face of drug resistance in order to preserve newer antibiotics forfuture use. The study was a national sample of 398 generalist physicians and 429 infectious disease (ID) specialists. Clinical vignettes prompted respondents to select the level of resistance to a hypothetical older antibiotic at which they would prefer a newer antibiotic without any current resistance in the treatment of a patient with pneumococcalpneumonia. Vignettes varied in the site of care of the patient as a proxyfor variation in disease severity. Respondents significantly reduced their threshold for switching to a newer antibiotic as disease severityincreased. Generalists were more responsive to disease severity than LD specialists. Thus, the adoption of recommendations to limit overuse of newer antibiotics may be variable across clinical settings and providers, reducing the impact of these recommendations on emerging resistance.

Adult↗

Experiences of the generalist nurse caring for adolescents with mental health problems.

Mental healthcare for adolescents is currently provided in a range of settings, including general hospital wards and paediatric wards, although care of adolescents with mental health problems in general settings has not been evaluated. This descriptive study surveyed generalist nurses who provide care to adolescents with mental health problems in the general hospital setting to determine satisfaction with their abilities to provide care, challenges encountered in care provision and strategies to provide optimal care by these nurses. Participants included 30 generalist nurses (response rate of 73%) from two wards in a tertiary paediatric hospital in Queensland, Australia. The survey findings showed that 67 percent of the respondents felt inadequately prepared to care for this group and only 41 percent were satisfied with their ability to provide care. Strategies identified to improve nursing care included: enhancement of continuity of care and teamwork, provision of appropriate environmental facilities, greater support from specialist mental health nurses and further education on caring for adolescent mental health problems.

Adolescent↗

Physician choice criteria: factors influencing patient selection of generalists versus specialists.

This paper presents the results of an exploratory study designed to (1) ascertain the primary sources of information patients use when selecting physicians and (2) identify differences in patient selection factor importance by type of physician under consideration (specialists versus generalists). The results support previous research which finds word-of-mouth and physician referrals the primary sources of information. Selection factors considered important when selecting a generalist were significantly different from factors considered important when selecting a specialist. Implications of the study's findings for effective physician marketing and future research are discussed.

Adult↗

Generalist-subspecialist communication for children with chronic conditions: a regional physician survey.

OBJECTIVE: To identify target areas for interventions to improve communication between pediatric generalists (PCPs) and pediatric subspecialists (SPs) in the outpatient care of children with chronic conditions. METHODS: We constructed a 4-page mailed questionnaire probing communication practices, opinions about the role of communication in care, and perceived barriers and facilitators to PCP-SP communication in the care of children with chronic conditions. In the spring of 2001, we surveyed all 495 New England SPs who were members of the American Academy of Pediatrics (AAP) and/or SP societies and a random sample of 495 generalist AAP members in New England. Eligible were those actively providing outpatient care. Most items were rated on a 5-point scale. RESULTS: Of those eligible, 48% (412/860) completed the questionnaire. Although 98% of respondents agreed that communication was important for good care, reported practices reflected large gaps in this area. Frequent receipt (>60% of the time) of communication about an initial referral was reported by only 28% of SPs. Barriers reported as most important involved inefficiencies in telephone contact, transcription delay, and failure to keep all providers informed when >1 specialist is involved. Important facilitators included letters or phone calls at or before the time of consultation, and clear and specific referral questions from PCPs. PCPs saw communication as more of a problem than did SPs (40% vs 28%), and reported several barriers as more important. Although 86% of respondents had access to e-mail in their practices, <20% used it often. CONCLUSIONS: PCPs and SPs sharing care for children with chronic conditions are troubled by their frequent failure or inability to contact their colleagues by phone and letter. PCPs communicate less frequently than SPs yet perceive more problems with communication. Interventions to promote efficient contact between providers at or before the time of subspecialty visits can lead to improved coordination of care, which in turn may better meet the needs of families.

Child↗

The relationship between the race/ethnicity of generalist physicians and their care for underserved populations.

OBJECTIVES: The purpose of this study was to examine empirically the relationship between physicians' race or ethnicity and their care for medically underserved populations. METHODS: Generalist physicians who received the MD degree in 1983 or 1984 (n = 1581) were surveyed. The personal and background characteristics of four racial/ethnic groups of physicians were compared with the characteristics of their patients. RESULTS: When the potentially confounding variables of gender, childhood family income, childhood residence, and National Health Services Corps financial aid obligations were controlled, generalist physicians from underrepresented minorities were more likely than their nonminority counterparts to care for medically underserved populations. CONCLUSIONS: Physicians from underrepresented minorities are more likely than others to care for medically underserved populations.

Adult↗

Generalist versus specialist occupational therapists.

The issue is not generalist versus specialist, bachelor's degree versus master's degree, or even registered occupational therapist versus certified occupational therapy assistant. The issue is: What is each professional's product? What is the process by which each produces it? What knowledge, skills, and judgment do each need to competently produce the product? And, under what circumstances and conditions and at what point are each required to assure a quality product? The delineation of the requisite knowledge and skills as well as the delineation of generalist and specialist will flow from the answer to these questions.

Guidelines as Topic↗

Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice.

Coordinated care is a defining principle of primary care, but it is becoming increasingly difficult to provide as the health care delivery system in the United States becomes more complex. To guide recommendations for research and practice, the evidence about implementation of coordinated care and its benefits must be considered. On the basis of review of the published literature this article makes recommendations concerning needs for a better-developed evidence base to substantiate the value of care coordination, generalist practices to be the hub of care coordination for most patients, improved communication among clinicians, a team approach to achieve coordination, integration of patients and families as partners, and incorporation of medical informatics. Although coordination of care is central to generalist practice, it requires far more effort than physicians alone can deliver. To make policy recommendations, further work is needed to identify essential elements of care coordination and prove its effectiveness at improving health outcomes.

Interprofessional Relations↗

National Study of Internal Medicine Manpower: V. Comparison of residents in internal medicine--future generalists and subspecialists.

Questionnaire III of the National Study of internal Medicine Manpower was directed to a random sample of residents (and subspecialty fellows) in the spring of 1977. Residents were classified according to whether they sought careers as predominantly general internists (49%) or subspecialty internists (51%), and the two groups were compared. Future generalists, more often, tended to be non-Jewish, to have incurred higher debts, and to have trained in medical schools in the states where they had spent their childhoods. Training experiences also were different. Future generalists, more than subspecialists, were attracted to the field because of the ability to retain independence in their work. Subspecialists, more often, intended to have academic careers and locate in the largest cities. Although subspecialists expected greater financial rewards, neither group selected their fields on this basis. By controlling for the main criterion used to select the medical school attended, we were able to explain several factors that differentiated the two groups.

Attitude of Health Personnel↗

Choosing a specialty during a generalist initiative: a focus group study.

BACKGROUND: Virginia Commonwealth University (VCU) (as part of a three-school consortium) was 1 of 12 sites awarded a Robert Wood Johnson Generalist Physician Initiative (RWJ-GPI) grant. Given the goals of this initiative--to promote a balanced output of generalists and specialists--program planners wanted to understand how medical students made career decisions in the context of this curriculum change and the larger social environment. METHODS: Seven focus groups (average size: six members each) of second-year and fourth-year students were recruited. Groups were homogeneous with respect to subspecialty or primary care orientation and career trajectory. An experienced moderator conducted all groups. The discussions were taped and transcribed. Analysis proceeded concurrently with data gathering, using a template style and with assistance from the NUD*IST software program. RESULTS: Students from all groups hoped for control of their practice, intellectual challenge, rewarding relationships with their patients and their own families, and fair compensation for effort. They worried about their future prospects, and specialty-oriented students felt that the emphasis on primary care production was being forced on the school. All groups saw managed care as doing more harm than good for patients, and all wished for improved career counseling. DISCUSSION: The RWJ-GPI at VCU became a lightning rod for student worry and resentment at being forced into primary care specialties. The backlash phenomenon was seen at other US medical schools and is one of the postulated reasons for a decline in US student numbers matching in family practice, internal medicine, and internal medicine-pediatrics. Medical school faculty should respond with constructive, pro-student policies and programs.

Adult↗